End Sleepless Nights

By Harris McIlwain, M.D., and Debra Fulghum, M.S.

Sleep deprivation was written all over Christina’s face. Until she started treatment for fibromyalgia (FM), this 47 year-old woman lived for months with dark circles under her eyes from lack of restful sleep. Christina made it a point to be in bed by 9:00 each night, but then tossed and turned until sunrise and always felt too tired to go to work the next day. Like Christina, the majority of FM patients are fatigued, even after sleeping for ten hours at night. One woman said, “I go to bed tired and feel tired all night. I awaken tired, then I feel tired the next day.”

Patients complain that no matter how long they sleep, it is never restful. Their sleep may be interrupted by frequent awakening, that is, becoming awake enough that they remember these times the next day. Even more common are awakenings that are not enough to remember but that definitely break up their deep sleep. Most patients tell of waking up day after day feeling exhausted. They feel more tired in the morning, and many have great difficulty in concentrating during the day, just as in other situations where sleep is disrupted.

Because obtaining restful sleep is a crucial problem with this disease, it is helpful to understand the characteristics of normal sleep and how this differs from the sleep experienced by FM patients.

Understanding the Stages of Sleep

Studies have demonstrated that we have a built-in cycle of sleep-wake times along with many other cyclic variations in bodily functions, such as glandular secretions, body temperature, heart rate, blood pressure, and bronchial function. These intrinsic cycles are controlled by a group of nerve cells called a circadian pacemaker. This pacemaker is closely related to parts of the retina (in the back of the eye) and the hypothalamus in the brain.

The circadian cycle is actually 25 hours long. Since the cycle is longer than the 24-hour day, some factor must serve to synchronize the body’s pacemaker with the external clock time. These are cues from the environment called zeitgebers (from German, meaning “time givers”). The most important and powerful one is light. The hormone most closely linked to the circadian system is melatonin, which is made by the pineal gland in another part of the brain. Melatonin has been shown to synchronize the sleep-wake cycle to 24 hours in some blind subjects who were otherwise unable to live on a 24-hour day.

In adults, sleep is made up of distinct types or stages with specific characteristics defined by brain waves, eye movements, and muscle tension. The two broad categories of sleep include rapid eye movement (REM) and non-rapid eye movement sleep (NREM). It is during REM sleep that that we have almost all our dreams. (Arousals from this stage of sleep are usually associated with recall of vivid imagery.) In NREM sleep, there are four difference stages – 1, 2, 3, and 4 – characterized by different combinations of brain waves, eye movements, and reduced but not absent muscle tension. In FM, stages 3 and 4 NREM sleep are of the most importance. These stages are defined by relatively large, slow brain waves (delta waves), absent eye movements, and reduced muscle tension. Other names for these stages are “slow-wave sleep” or “delta sleep.”

About 60 years ago, it was recognized that sleep intensity is reflected by the amount of delta sleep. The depth of sleep is correlated with this stage, and it is from delta sleep that arousal is most difficult. The wake state is associated with small, variable, but mostly rapid (seven to eleven cycles per second) brain waves called alpha waves. There are quick, alert eye movements along with variable, generally high tension in the muscles.

The stages of sleep are distributed through the normal sleep period in a particular pattern. Sleep onset usually is within five to twenty minutes of going to bed. After the start of sleep, there is a cycling though stages 1 to 4 approximately every 45 to 90 minutes with REM sleep punctuating each cycle at about 60 to 90-minute intervals. Delta sleep occurs mostly in the first third of the night and makes up about 10 to 20 percent of total nocturnal sleep in normal young adults, whereas REM sleep takes place predominantly during the last third of the night’s sleep.

The percentage of delta sleep is affected by age, amount of prior sleep, and various diseases. Delta sleep decreases with age and may be absent in healthy, elderly males. Sleep deprivation increases the rapidity of the onset of delta sleep and its portion of total sleep time.

Young children have particularly large proportions of delta sleep, which increases if they are sleep-deprived. This explains why it is frequently difficult to wake children. Elderly people have smaller proportions of delta sleep, which is why they are easily aroused by environmental noise. Medical problems, such as obstructive sleep apnea, periodic leg movements during sleep, and FM may affect the quantity and quality of delta sleep. This in turn probably accounts in some measure for the feeling of fatigue experienced by people suffering from these maladies.

Fibromyalgia and Sleep

About 20 years ago, researchers in Toronto discovered that patients with FM had NREM stages of sleep “contaminated” by an intercurrent alpha rhythm (like that of wakefulness). But whether the sleep disturbance caused the FM symptoms or was secondary to the disease itself could not be determined.

This group of investigators went on to show that healthy subjects selectively deprived of delta sleep by being exposed to noise developed periods of delta sleep mixed with alpha waves.

Interestingly, when deprived of delta sleep these people experienced some musculoskeletal discomfort and mood symptoms similar to those of the patients with FM. These data suggested that the stage 4 sleep disturbance caused the appearance of the achiness or pain and mood symptoms.

However, it was felt that the effect of delta sleep disturbance on symptoms might be determined by examining the physical and psychological characteristics of the healthy subjects. Their subjects were younger than the patient population with FM and free from illnesses and psychological problems, but they were not particularly physically fit. Yet they had the symptoms of FM when put through the sleep-deprivation process. Their relatively sedentary lifestyle may have been significant, because most reports have pointed to the positive influence of exercise on delta sleep.

Sleep disturbances can be triggered in patients by physical or emotional trauma or by a metabolic or other medical problem. Poor sleep can lead to fatigue with resultant diminished exercise causing worsened physical fitness and the establishment of a vicious cycle of inactivity and sleep disturbance with physical and mood-related symptoms. These problems could help lead to the development of FM.

Hormones and Sleep

An interesting study published in the Journal of Clinical Endocrinology and Metabolism (April 2001) revealed that men seem to become more sensitive to the stimulating effects of corticotropin-releasing hormone (CRH) as they get older. This hormone plays a key role in how your body responds to stress. If you are aroused, you will have higher levels of CRH.

In the study, researchers evaluated the sleep habits of twelve middle-aged men and twelve young men over four nights. On one night, the men all received CRH ten minutes after they were asleep. Both groups of men produced higher levels of stress hormones in response to the CRH.

While younger men produced higher levels of cortisol (the main stress hormone involved in the “fight or flight” response), middle-aged men stayed awake longer. They also had less slow-wave or deep sleep than did the younger men, showing that middle-aged men may have an increased vulnerability to stress hormones. This, in part, may explain why insomnia increases in middle age as a result of these dysfunctional sleep mechanisms caused by arousal-producing stress hormones. There are also studies showing that people who spend less time in slow-wave sleep are more prone to depression.

Because of the effects of estrogen on a woman’s sleep pattern, it’s more difficult to study women and sleep. Still, for those women who find it difficult to sleep during premenstrual time, you have great company. Studies show that women have more awakenings, sleep disturbances, and vivid dreams during the premenstrual time than the rest of the month. Some women report having fatigue, no matter how long they stay in bed. Menstrual symptoms such as bloating, headache, abdominal cramps, food cravings, irritability, and emotional changes all appear to contribute to the inability to get sound sleep. These problems generally disappear a few days after menstruation begins.

For women in perimenopause or just prior to menopause, the declining levels of the hormone estradiol may increase your chance of poor sleep. In an intriguing study at the University of Pennsylvania Medical Center in Philadelphia published in Obstetrics and Gynecology (September 2001), researchers followed 436 women age 35 to 49 over a two-year period. About 17 percent of the women reported suffering from poor sleep throughout the entire study period.

While researchers blamed anxiety, depression, and caffeine consumption as factors that disturbed the women’s sleep, they also identified low estradiol levels and hot flashes in older women aged 45 to 49 as responsible for the sleepless nights, even though all women were experiencing regular menstrual cycles and had not yet entered menopause. The study concluded that the decline in estradiol that occurs with ovarian aging might be associated with poor sleep in women. This sleep deprivation results in daytime fatigue and irritability and can even lead to feelings of depression – all symptoms of fibromyalgia syndrome, too.

These studies can help you see the unique link between hormones, age, poor sleep, and the varied symptoms that can result. Use the information to assess your own bedtime habits and then use the suggestions that follow to resolve your sleep problems associated with FM.

Accurate Diagnosis is Essential for Proper Therapy

Many of the symptoms that FM patients experience are shared by those with other sleep disorders. For example, some patients with obstructive sleep apnea, intermittent blockages of the upper airway at the back of the tongue, which occurs in 2 percent of women and 4 percent of men who are 30 to 60 years old, also complain of unrefreshing sleep and “hurting all over” upon arising in the morning. They also have a history of snoring and other symptoms, including morning headaches, dry mouth, and an increased tendency to doze off during the day. Some patients with sleep apnea have high blood pressure.

If your doctor suspects that your sleep disorder may have a different cause, he or she may recommend that you have a sleep study. Sleep studies, called polysomnography, include an electroencephalogram (EEG), which measures the electrical activity of the brain, as well as the monitoring of oxygen levels, movements of the chest wall and abdomen, and nasal and oral airflow.

A sleep study may show apnea (periods without breathing), manifested by absent airflow at nose and mouth in conjunction with ongoing respiratory muscle efforts shown by movement of chest wall and abdomen. An apnea may cause decreases in blood oxygen levels. Sleep is often interrupted at the end of the apnea by awakening. This breaking up of continuous sleep is a major cause of daytime fatigue and sleepiness. Periodic leg movements during sleep, also known as nocturnal myoclonus, may also be associated with alpha intrusions and are a common cause of sleep interruptions. These sleep disorders require specific therapy.

Editor’s note: To purchase a copy of The Fibromyalgia Handbook, 3rd Edition: A 7-Step Program to Halt and Even Reverse Fibromyalgia, please visit Fibromyalgia Handbook, 3rd Edition.

© 2003 Harris McIlwain, M.D., and Debra Fulghum, M.S. All rights reserved. Reprinted with permission. For further information:

Harris H. McIlwain, M.D., C.M.D.
Tampa Medical Group Research
4700 N. Habana Ave., Suite 303
Tampa, Florida 33614

Website: www.tampamedicalgroup.com