Right now on Refocused, we’re talking all about sleep, the science behind it and why it is so important for us.
What does it take to get good sleep? What happens while we are sleeping? What obstacles are we up against when it comes to having good sleep hygiene? How does life and the changes we’ve seen as humans play a role in our sleep patterns?
We’re diving into all of that with two sleep experts, Dr. Stephen Lange and Dr. Sanford Auerbach.
- Dr. Stephen Lange is a psychologist who focuses on sleep and ADHD, and also provides healthcare services to the U.S. Coast Guard as a Coast Guard Auxiliarist.
- Dr. Sanford Auerbach is the director of Boston Medical Center’s Sleep Disorders Center, as well as an associate professor of neurology, psychiatry and behavioral neurosciences at Boston University Chobanian & Avedisian School of Medicine.
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Lindsay Guentzel (00:00):
Welcome back to Refocused, a podcast all about Attention Deficit Hyperactivity Disorder. My name is Lindsay Guentzel, and today we’re talking all about sleep and the ADHD brain.
That’s Ocean One, one of the settings from the sleep sound machine my boyfriend got me for my birthday in March. And yes, I asked for it. We’ve only been using it a couple of weeks, and I should probably knock on wood before even saying this, but I’ve noticed I’m waking up less throughout the night, which is great and something I hope continues because sleep and I have a complicated relationship right now. We have for a while, although it hasn’t always been this way. In fact, I remember when I was in high school and even early on in college when I could not only sleep through the night, but sleep in to crazy times of the day like 10:00 in the morning.
My older sisters, who were staring to realize that the sleep problems our parents had were starting to show up in their own lives, it’s that point in life when you realize the power of genetics for better or worse, I remember them saying to me, “One day, you aren’t going to sleep. So, enjoy it while you can.” And well, those days showed up a lot quicker than I had anticipated. What does it take to get good sleep? And why is it so important? We’re going to talk about that today and then next week too. We’ll explore why getting adequate sleep can be both more important for people with ADHD, and at the same time more difficult for us.
See, the frustrating thing is, we’ll never know the actual statistics of how many people with ADHD also struggle with getting good, healthy sleep because we’ll never know how many people actually have ADHD. But I do know I’m in good company when it comes to sleep problems simply from the conversations we’ve had on this podcast, like the one I had with Emily Chen back in October for Refocus Together.
Emily Chen (02:33):
I found a therapist. I’m very lucky in that my therapist really quickly caught on to the fact that I had some executive dysfunction going on. A couple of sessions in, she also discovered that my sleep hygiene was abysmal. And so, I spent that session being like, “Wait, so you’re not supposed to read in bed for long periods of time? Bed times are real? Really, they’re not fake?” But during the session, just in passing, she said, “Oh you know, people with ADHD often have sleep problems.” I just completely ignored that. That didn’t even register in my brain.
So, I got in the car to go home and was just like, “La-de-da-da,” and was like, “Wait, why did my therapist say that?” So I Google searched ADHD on my phone and went down the list and just like, “Nah, no. Nah, nah, nah. I try so hard. Yeah, uh-uh. Nope, not me.”
Lindsay Guentzel (03:25):
Isn’t it funny how what we need to learn doesn’t seem to land regardless of how in-our-face it is, until we’re ready to hear it? Emily’s hardly alone. Sleep, and the concern over how sleep affects a person with ADHD, I don’t feel like it comes up in the first wave of symptoms you learn about after you’re diagnosed. Yeah, there’s a lot of things to learn about when you’re first diagnosed. But something that has such an impact on your life, like sleep, you’d think it would maybe be brought up. Maybe you’d get a pamphlet or something when you leave the doctor’s office.
Luckily, there is work being done to increase the awareness on how ADHD can impact sleep. Organizations like CHAD and Attitude Magazine, I even hosted a webinar on sleep last fall for ADHD online that we’re going to share bits and pieces of over the next two episodes. I’m honored and really excited that Refocus gets to play a small part in increasing the awareness over how big of an issue this actually is for the neuro diverse community. Because sleep is important. All caps, underlined and bold, with so many exclamation points.
According to the National Institutes of Health, sleep deficiency can be incredibly detrimental to both our brains and our bodies. It is linked to a variety of chronic health issues, including heart disease, kidney disease, high blood pressure, diabetes, stroke, obesity, and depression. Sleep deprivation is also one of the leading causes for car accidents, and is linked to an increased risk for injury in adults, teens, and children. Add in ADHD, and it is a whole other ballgame.
In this January 2023 piece for Attitude Magazine, ADHD and sleep problems, this is why you’re always tired. Dr. William Dodson said because sleep problems tend to show up later in life, it has made it really difficult to fit issues with sleep into the diagnostic criteria set in the DSM for ADHD. I mean, I know I was diagnosed at almost 35, but I remember having a really hard time as a kid staying in bed, waking up constantly from really scary, realistic dreams, sleepwalking, all things that I still deal with in life. While I’m not a sleep expert, I’m guessing those early behaviors would have raised some flags.
But again, like so much with ADHD, we didn’t know. For people with ADHD, finding a healthy balance with sleep can be a complicated equation. It’s something I dove into with Dr. Steven Lange last year during that webinar I mentioned that we hosted together, Is Your ADHD Making You Count Sheep to Fall Asleep? Here’s how I set things up for Dr. Lange. Take ADHD out of the equation. When we look at sleep and the magnitude that it has on our life, what are we talking about? Consider this your two minute crash course on the importance.
Dr. Steven Lange (06:19):
Sleep is essential. We need sleep. There are a number of theories why, and they’re all theories because we don’t really have enough knowledge to be able to say definitively all the things that sleep does for us. One of the things it does for us is conserves energy. We’re not expending energy while we’re sleeping. The brain is very alive and very active while we’re sleeping, and we think of it as rest, but the brain is still working. It’s working on consolidating memory, and on consolidating learning.
We use dream sleep to work our emotional lives and emotional struggles that we’re having. We also need sleep as a way of repairing our organs, including our brain. Our brain kind of washes itself of toxins while we sleep. There are a couple of mechanisms that take place while we’re sleeping that just is like a wash cycle for our brains. Without that, our brains are living in a toxic everything. So, sleep is essential. All problems with sleep are really the sleep-wake problems, because what we notice not only is whether or not we’re sleeping at night, but how awake and alert we are during the day, and whether we’re able to function effectively during the day.
Biologically, we’re set up to be night sleepers, and we’re set up to be active during the day. We’re diurnal, as opposed to bats which are nocturnal. Bats are hunting during the night, sleeping during the day. We are hunting during the day, and sleeping during the night. The daily rhythms of light and dark really regulate our sleep. There’s a piece of our brain that reacts to light and put through our eyes. It’s not our regular visual system where we’re able to recognize people and things, and letters, and numbers. It’s a separate visual system that just registers light and dark.
When it’s dark, that visual system and the little piece of brain tissue called a suprachiasmatic nucleus, where it ends up, when it’s dark that piece of tissue allows us to produce melatonin, which is the sleep hormone. When it’s light out, that piece of brain tissue suppresses melatonin, and that’s what keeps us from sleeping when it’s light out. We function best when we’re aligned with the natural cycles of light and dark.
Lindsay Guentzel (08:36):
Dr. Lange studied psychology at Lehigh University before receiving his PhD from Fordham University. Before earning is doctorate, he worked as a school psychologist in New York City and New Jersey. Since then, he’s worked in hospitals, prisons, addiction treatment centers, as well as in his own private practice. He and I, and likely you since you’re listening to this podcast, all have something in common.
Dr. Steven Lange (09:00):
I have ADHD. I knew that when I was maybe six or seven years old. I didn’t know what it was called. The adults didn’t know what was going on with me either. They just knew they were frustrated. I knew I was frustrating them. My journey to becoming a psychologist had to do with understanding that the adults did not know what to do with me, they did not know how to help me, and I was going to find a way to become an adult who understood and could help.
Lindsay Guentzel (09:29):
Obviously, there’s so much for us to talk about when it comes to sleep and ADHD, but I also thought this might be a great time to back a little bit. We’re always told sleep is important, but how many of us actually take that to heart? When it comes to getting good sleep, what are we working against, and what should we be aware of? If you start by looking back at how we sleep, a lot of has changed. I’ll let Dr. Lange set the scene for you.
Dr. Steven Lange (09:58):
Just settle back and imagine life in a previous century, kind of Little House on the Prairie. You have no artificial light. No light bulbs. No electricity. So, you slept during the night and you woke up at dawn. You were already in early morning aligned with the natural cycle of day and night with light and darkness. You worked and expended physical effort and mental effort all day, except for lunch. When it was dusk, you came in, you at dinner, and you had dim light. Candle light or lamp light, or the hearth. As those burn down, you would quiet yourselves down. The family would sew, or weave, or talk, or sing, or play music. It was a very settled, relaxed time.
Then when all the lights were extinguished, no more embers, the candles burned out, the lamps burned out, you went to bed. How many people do you think in that kind of agricultural world in maybe the 1800s, let’s say 1850, had sleep problems? I am sure that there was no insomnia. Why? Because people were aligned with the natural cycle of light and darkness. They were also working hard all day. They were expending calories. They were expending energy. They were moving their bodies, and they were using their minds.
Lindsay Guentzel (11:35):
Now let me ask you, when was the last time you experienced that? For most of us, that’s just never going to be something that ever happens.
Dr. Steven Lange (11:44):
We live in a very different world. First, we live in a 24 hour a day world. You can do anything you want 24 hours a day. They used to call New York City “the city that never sleeps.” Now, none of us ever sleep. There are people who literally sleep with their phones on their chest waiting for that phone call from work. Unless you’re a neurosurgeon or a trauma surgeon, I’m not sure why you would want to do that. We can order food at 3:00 in the morning. We can go online and talk to other people at 3:00 in the morning. They can trade stocks at 3:00 in the morning. We can do our banking at 3:00 in the morning.
So, we are not aligned with the day/night cycle. Electronic communication devices help us do that. They’re ever present. They’re on our minds even if we’re not using them. We know where they are, if they’re on our nightstand, in our pocket, wherever. They are interrupting our thinking constantly. We work in artificial light, so while in an agricultural society in the 1850s, people had sunlight on their faces, which is what we’re adapted to, what we evolved to use to keep us awake. In artificial light, we’re never really in full sunlight, and we’re never really in full darkness.
As a result, we are in perpetual twilight, which is why at 2:00 in the afternoon, after lunch and your circadian rhythms are kind of at a low point in general, you begin to feel tired between 2:00 and 4:00 in the afternoon. You have not had natural sunlight, and you may not have moved your body. If you have a very physical job, you are much better off than a job like mine where I sit and I listen, and I talk, and I read, and I write. If you’re sedentary, it is very, very difficult to expand the energy and have the movement necessary to fall asleep.
If you are a child, that means you need recess. If you are an adult, it means you need recess. If you eat lunch at your desk, if you don’t get up and walk outside your building, you are undermining your sleep that night. Everybody needs recess. Everybody needs light on their face during the day. Everybody needs some movement during the day. At night, because we have artificial light, our light is no different than it is during the day. So, unless we go to some effort to dim our lights during the evening, there’s no difference for us between dusk and mid-afternoon.
So, we want to begin to dim our houses, our homes, our apartments as we get closer to bedtime. We also have to wind down and become less active or calm. Okay, so I go to work, I come home. I haven’t seen my family all day. I haven’t seen my dog or my cat all day. So now I’m really excited, and we’re playing, and we’re doing things. When my kids were small, we were going to football practice and soccer practice. We were getting all charged up between dinner and bedtime. Then it’s harder to fall sleep.
In a perfect world, between dinner and bedtime, you want to become less active, you want to become calmer. Do not use that time for conflict. Do not argue with your kids about their school work between dinner and bedtime. Do not argue with your spouse, your partner between dinner and bedtime. Do all that kind of stuff when it’s light out.
Lindsay Guentzel (15:18):
As I’ve mentioned, there is a lot for us to explore when it comes to sleep. The unfortunate reality is, we aren’t going to get to all of it in two podcast episodes regardless of how hard I try. But we’ve started the conversation and we’re going to continue talking about it. I struggled with this idea that I had to have everything figured out before I shared any of it with you, which is another lovely ADHD conundrum you’ve likely dealt with yourself.
In order to keep moving forward on the topic of sleep and ADHD, we actually need to go back, back to that wash cycle Dr. Lange mentioned when he started explaining the importance of sleep.
Dr. Steven Lange (15:56):
The wash cycle has to do with three different parts. One is, our brains are bathed in cerebral spinal fluid. When you sleep, the spaces between, the neurons, our brain cells, kind of open up and it allows for a freer flow of cerebral spinal fluid. That actually washes away toxins. The second is our blood flow increases, and that kind of does the same thing. The third part is, we burn a lot of sugar, so our brain is working. That seems to be part of the wash cycle too, that activity is somehow connected to the cleanup that the blood is taking away toxins, and the cerebral spinal fluid is taking away toxins.
Lindsay Guentzel (16:38):
You guys, I am very intrigued by this wash cycle. Not to make this all about me, although I’m fairly confident many of you will also be able to relate to this, but here’s what concerns me about this wash cycle and one of the reasons why I’m so fascinated by it. I wake up a lot throughout the night, to go to the bathroom, have a drink of water, contemplate all of my poor choices in life. So, it had me wondering…
So let’s say our brain is a dishwasher, and I know that if start my dishwasher it goes through different cycles to get to the end. I know that if I open the dishwasher midway through, it stops there. Do we know, does the brain pick up where it left off? Or does it start over and everything that was missed the night before doesn’t get cleaned, so to speak?
Dr. Steven Lange (17:25):
That is a great question. When I used to teach psychology to graduate students, when somebody asked a question like that, I would say, “That’s an awesome question. Can you come back next week and give us the answer?” I can tell you how the watch cycle works, but I can’t tell you… I don’t know the answer to that question. That’s a nice little question.
Lindsay Guentzel (17:41):
Challenge accepted. Surprising no one, I am still all about those brownie points. Here’s where we’re going to put a pin in my conversation with Dr. Lange just a for a minute. We’ll come back to Steven during next week’s episode, when we’re going to spend pretty much the entire show talking specifically about ADHD and sleep. In order to answer this very important question, I have to bring in another sleep expert. As we started plotting how we were going to share all this incredible information with you guys, we thought why don’t we take this opportunity and dive into just sleep for a little bit?
Sleep feels like one of those things that we just do as humans, but I don’t know that many of us actually go back and ever kind of dive into the importance of sleep, or why humans need sleep. So, consider this next portion of today’s episode as a little workshop I think we can all benefit from. To find the answer to my wash cycle dishwasher conundrum, I connected with a team at Boston Medical Center and was introduced to Dr. Sanford Auerbach.
Dr. Auerbach is the Director of Boston Medical Center’s Sleep Disorder Center, an American Academy of Sleep Medicine accredited facility, as well as an Associate Professor of Neurology, Psychiatry, and Behavioral Neurosciences at Boston University Chobanian & Avedisian School of Medicine
I’m curious about the sleep cycle, and kind of this idea of the sleep wash, and what is happening with the brain. The question that I have about it is, one, what’s happening during that process? Let’s say you’re somebody who wakes up a lot and get up to go to the bathroom, when I go back to sleep does my body pick back up where it left off, or are you starting over? Or do we know what’s happening in those scenarios?
Dr. Sanford Auerbach (19:26):
There are a couple of different things. When you get up in the middle of the night for reason and then come back to sleep, it’s not like you necessarily pick up exactly where you left off. But pretty much, you can think of it as being a more or less a complete process by the end of the night. There’s this balance back and forth of the different stages of sleep that people go through, and the processes they go through. You can have a little awakening here or there. In fact, most people do have short awakenings through the course of the night.
As I mentioned before, they may not always remember them, but they go through the course of the night. They’re just not always aware of them. Some people be too obsessed by it, and then if they have a short awakening, will stay up the rest of the night worried about the fact that they woke up. I usually think of it a process through the course of the night. It’s not actually the case that if you wake up in the middle of a dream and you go back to sleep, it’s not necessarily the case that you’re going to go right back to the exact spot in that dream to finish up. Perhaps sometimes people can do that.
It is interesting that during the course of sleep there are these active processes that go on to clear away some of the substances that accumulated in the brain, sort of the waste products of the brain that have accumulated through the course of the day while you’re active and doing things. Then there’s a clearance system that’s built in that’s particularly active at night when we’re asleep. It starts to be very important for our normal day type of function, and not only for our daytime function, but also perhaps to play a role in the later development of problems.
Disorders like Alzheimer’s disease, which is fairly common, so they know there’s similar kinds of disorders. There’s a buildup over time of certain elements, certain toxic elements, thought to be toxic elements, that will accumulate over time. But there’s an active cleaning process that goes on at night while we’re asleep. Perhaps more in certain stages of sleep than other stages of sleep, but certainly it’s something that goes on through the course of the night. Sleep is very important.
Lindsay Guentzel (21:23):
All right, so a little relief for those of us who agonize over the amount of time awake we see on our smartwatches every morning. Dr. Auerbach echoed a lot of what Dr. Lange shared regarding the importance of sleep. I’ll be honest, when he talked about all of the work that goes on while we’re sleeping, I don’t quite know that I knew that, or if I knew that, that I took it into account when thinking about how I view sleep in my life. Despite being snuggled up in a comfy bed wearing things that feel good against our skin, sleep is not a passive process.
There’s a lot of oxygen repair that goes on throughout the night, what Dr. Auerbach referred to as “offline information processing”, which helps us function better throughout the day. He also added, and this is something that plays off of what Dr. Lange talked about when we look back at the history of sleep, sleeping at night was also at one point a protective mechanism. Think about it. You used to not be able to function at night, and you definitely wouldn’t be going out to do stuff, moving around at night. It was dangerous.
You wouldn’t go wandering around into the forest in the middle of the night. If you think about it that way, sleeping has helped humans stay out of trouble. So, what are some of the key factors involved when it comes to falling asleep? How much sleep do we need? You may have popped a melatonin before to speed up the falling sleep process, but did you actually know we produce our own melatonin?
I dove into all of that during my time chatting with Dr. Auerbach, and we’re going to get to that right now. Wrapping up with the perfect segue into next week’s episode, looking at the connection between having ADHD and struggling with sleep.
I’d like to talk about falling asleep, which I think for some people it either comes really easily or it’s terrible.
Dr. Sanford Auerbach (23:17):
There are a couple of key things to falling asleep. One of them is, sleep deprivation, that we wake up in the morning, we’re active during the day, we accumulate all this sleep deprivation. Translate it into a sleep drive. By the end of the day when we’re ready to go to sleep, we have this built-up tendency to want to fall asleep. We’re limiting how much we can stay away without sleeping. That’s the one factor, that sleep drive. How much sleep we need to function normally, it certainly changes as we get older.
Obviously, infants and young children, a lot more sleep. As we get older, we reach this plateau about how much we sleep. There’s some variation from individual to individual. That may even vary according to the time of the year, cycle of the month perhaps, but or less we have that set need. The second this is timing. There’s a timing system involved in sleep. We have a built-in clock, a circadian clock. Sleep is sometimes thought of as being a circadian system, meaning that we wake up in the morning and then go to sleep at night, and then 24 hours later we’re awake again.
It’s built on this 24 hour clock that alternates between this wakeful and sleep premises times. If you try to sleep at times when your clock is not geared up for it, then it’s much more difficult to sleep, just like it’s a little more difficult to stay awake when your clock is in that downside. It’s much what happens to people who are jet-lagged. The optimum [inaudible 00:24:37] jet jag. In fact, jet lag is exactly that. We fool our clock because we suddenly make a couple jumps in time zones and we’re trying to function in a different time zone than what our clock… There’s a lag time before that catches up.
So, we want to be able to get the timing system down. Some people find it easier to sleep during the day than others, but biologically we have [inaudible 00:24:57] bias. The third factor is you want to be able to have your body ready to relax. To transition into sleep, you need to relax. There are so many factors that go into that, what we eat and drink can play a role in this. Caffeine, just as an example, will make it more difficult to sleep. Then again, there’s a lot of individual variability.
We want to make sure the sleeping environment is proper for sleep. In general, most people use a slightly cool area, it’s a cool environment, free of extraneous stimulation. They want to keep it low as… You want to make sure that sleeping area is removed from the hub of all the chaos that goes on in your day. Again, there’s a lot of individual variation, what makes you relax. You have to tailor it to the individual. The three key things, one is having that sleep drive in sync. Number two is having the timing system right. And number three is being able to adequately relax to transition into sleep.
Certainly, there’s a balance with all of these three factors. Now I’m assuming that we’re not dealing with other kinds of medical issues that may intervene with all of this. There are other medical conditions. People have pain problems and so forth that may interfere with this. I’m assuming that’s not the case. And, that the patient doesn’t also have other sleep disorders that we deal with in the sleep clinic. We see people who have very specific sleep disorders that may limit or make it difficult to fall asleep, Restless Leg Syndrome, for instance, and other kinds of disorders that we see.
Lindsay Guentzel (26:22):
When we’re talking about restless sleep, is there a way to define it? Or is it something that is very broad and can be different for every single person?
Dr. Sanford Auerbach (26:30):
Yes, I think it can be very broad when people talk about restless sleep. We see also things in the clinic about gets defined as “restless sleep”. Sometimes, I have to confess, when I see patients I always ask them about their sleep patterns, when they fall sleep, when they wake up in the night and so forth, and get as much of that information as we can. Yet, I also know that as individuals we’re not always very good at knowing exactly how much we sleep. We see those mistakes all the time. We see people who think they sleep soundly, and yet when we look at their sleep studies they have many multiple awakenings throughout the night that they just don’t remember.
Some of it’s as simple as the fact that you have to wake up for five or six minutes to remember that you woke up. We also see the other part of it as well. We’ll see people who come and don’t think they sleep at all, and then when we look at their sleep measurements it may not be totally normal sleep, but they sleep for five or six hours. The other day, somebody came up to me and said, “Oh, you’re going to have to repeat the study.” I said, “What do you mean repeat the study?” She said, “I only slept 15 minutes.” I said, “Well, maybe 20.” Then we looked at the sleep study and in fact she had slept five, six hours through the course of the night.
So, people’s perception of how much they sleep always has to be taken into consideration. It’s hard to predict. That’s sometimes why we do those sleep studies. Restless sleep means a lot of different things to different people, and it’s their perception. In fact, it’s one of the reasons why when we address people’s sleep problems and sleep needs, I’m much more impressed by how they function during the day. That’s the key, if you can get enough sleep that you’re functioning at your optimal level during the day, that’s what the goal is.
Lindsay Guentzel (28:07):
You mentioned waking up and needing to be awake long enough to realize that you’ve woken up in the middle of the night. But waking up in the morning can be difficult, especially if you’re someone who hits the snooze button, if you don’t have a regular routine in the morning. What is it about that morning time with waking up that is so important and so critical to not only establishing routines, but as you mentioned, to help you feel good throughout the day?
Dr. Sanford Auerbach (28:32):
Some people are more morning people and some people are more evening people. That’s very hard to undo. Yet within that context, it’s adherence to those things that we’ve already talked about, making sure that you have a regular sleep pattern, that you can figure out for yourself how many hours of sleep do you need to function? For some people, it may be six. Some people may be seven and a half, eight hours. So, it can vary a little bit. How much do you need, number one. Number two, what is your clock?
This can vary from person to person, and we can actually do things to help modify our clock. Having a regular pattern is probably key, and not going to bed at 9:00 one night and 2:00 AM the next night. As much as you can, if you adhere to a regular routine schedule. Number three, that key that I mentioned before about making sure there’s an adequate amount of relaxation to go to sleep, and separate yourself from all those stresses of the day. Stress is a key thing. Stress is good for the business. It’s good for the sleep business. Not very good for people’s sleep.
Lindsay Guentzel (29:30):
I think we’ve always hoped that if we got a bad night’s sleep the night before, that we’d make up for it. I’m wondering, what is the answer to that? Can you ever get yourself out of sleep debt, or are you starting over every single day?
Dr. Sanford Auerbach (29:45):
It used to be thought that for every hour that you lost that you’d have to pay back that hour. But I think our bodies are a little more efficient in terms of being able to build it up. It is true though that our sleep debt is cumulative. If you’re behind from one night by an hour or a couple of hours, it’s not like that goes away the next day, or the next two days. You are a bit behind until you try to sleep some more. Most typically, that’s why this typical sort of pattern that a lot of people follow is during the course of the week they do cheat a little bit and short themselves on some sleep during the week, and then may catch up on a weekend or something when they have the opportunity. That’s reflexive of that. That needs to be paid back. Maybe not necessarily in full, but certainly you have to make some allowances for that.
Lindsay Guentzel (30:31):
I want to ask about technology, because a few things that you’ve mentioned, jet lag, the introduction of flights, we can talk about even electricity, being able to have lights on at night and not being connected to the sun setting or the sun coming up. We have much more flexibility with that. Then of course, technology, phones, our computers, being able to watch things at home and stay up late, how have you seen the advancing of technology and how sleep problems have changed throughout your career?
Dr. Sanford Auerbach (31:02):
They’re tied into each other. I’ve always thought that one of the things that really spurs on a lot of sleep… There are certain sleep disorders that we see that are perhaps independent of the technology, like some of the sleep breathing disorders. Sleep Apnea is a very common disorder that we see. Although, that’s also probably related somewhat to lifestyle. As people gain weight, they’re at greater tendency to develop those types of problems. One of the things about our technology is that with the advances in technology seems for perhaps for a variety of reasons, it seems to increase in the average weight of the population and therefore increases the Sleep Apnea that we see.
The other part is, things we’ve been talking about all along here, which is that we’re enabled, and when we’re enabled people take advantage of it either one way or the other, and people stay up later. They have more things to do that they can do at night, and people do that. Even moreso than that, it’s thought that perhaps another role is the kind of lighting that we use. That’s why people are very concerned about the blue light, which will affect this clock system and perhaps make it more difficult for some people at least to fall asleep easily at night.
So, it’s the amount of light and the kinds of light that we’re exposed to, not just the day but at night as well. It gets to both ends, both night and in the morning time. And so, it’s interesting, as powerful as it is, there are certain things this whole discussion about there’s a problem between Daylight Savings and Daylight Savings Time, and Daylight Standard Time, and the changes in the clocks and so forth. That too has a major impact on health. It oftentimes is overlooked, and it’s why some people are very interested in trying to abolish those clock changes. So, the clock changes the light we’re exposed to.
You mentioned the jet lag. That’s a fairly modern concept of being able to travel that many time zones in such quick time your clock can’t keep up. The whole thing, all of this in some ways, builds up and stress is a major issue in all of our sleep problems.
Lindsay Guentzel (32:57):
I want to ask about melatonin, because it’s something my mom introduced me to forever ago, and it was one of those things where it was like, “Hi, this will help you sleep.” So, I would take five milligrams at night, and it does help me calm down. I have, knock on wood, pretty decent sleep right now. What is melatonin to begin with? How does taking a supplement help some people at night?
Dr. Sanford Auerbach (33:21):
Melatonin is a very interesting substance. We produce our own melatonin in our body, and it’s very much involved in our sleep system in a couple of different ways. It’s involved in this back and forth of the circadian rhythm that I mentioned before, the clock. At night, presumably with the darkness and as we fall asleep, there’s an increased production in melatonin. Then in the morning, perhaps related to light exposure, activities, and a bunch of other things, it starts to disappear.
So, our melatonin is naturally produced in our brains, and it’s involved in two ways. Some of the melatonin can affect this clock system, and it can also just help promote sleep. It has those two sorts of mechanisms. It’s in general, like any other thing, for some people it may have some side effects, but in general it’s thought to be relatively safe. In some people, it works very well. It’s interesting, it doesn’t work for everybody when they take it, but some patients that we see who can take some melatonin, and it sounds like you’re one of them, does very well with it and it’s not been a problem, and take advantage of that.
It’s difficult. It’s one of those things that you don’t need a prescription for it. There’s no incentive a lot of times to do those pivotal trials, those clinical trials to get on top of how well it works, why it works, who it works on more than others. A lot of the funding isn’t tied to it. If it was a propriety thing and much more expensive, then the more involved in funding to help spearhead some of that research. It’s interesting, the people where it works very easily oftentimes we don’t see them because they don’t come in.
Lindsay Guentzel (35:01):
That’s a great segue because I wanted to know what should prompt somebody to reach out to a sleep expert, or to pursue a sleep study?
Dr. Sanford Auerbach (35:09):
If there’s a suspicion that they’re having difficulties with their sleep, and there are two pieces to that, one is they’re having difficulties falling sleep and staying asleep, and getting an adequate night of sleep. When I say “adequate”, enough sleep that you’re functioning optimally during the day. That’s the number one key. There’s one potential exception to that. There are some people who have sleep-related breathing disorder. They think they’re sleeping. From their perception, they’re sleeping well.
The major culprit there is something called Obstructive Sleep Apnea. In the very simple terms, what happens is when your muscles relax [inaudible 00:35:46] at night, the airway tends to collapse. Oftentimes, there’s vibrations as you’re breathing in and out, so there’s a lot of noise which is snoring. Then there’s disruptions in the breathing through the night. It’s interesting, some of our patients come in and they come in because they’re very tired and they’re sleepy. They can’t get enough sleep, and they’re dozing off inappropriately during the day.
Some of our patients come in because they have very loud snoring, and so the bed partner chases them in, or some combination of those things. It also, if not managed properly, it’s thought to be a risk factor for developing other medical situations. I think that over the years physicians should become much more aware of these other situations, and so they’re more likely to refer you in to a fresh sleep study if they see the development of some medical problems. Or at least be suspicious of a sleep-related breathing disorder.
The two major sources of patients that we see, one of the sleeping-related breathing disorders, the Obstructive Sleep Apnea, and the other people who have insomnia. The insomnia patients usually get to see us on their own accord because they don’t feel good during the day. Most of time, if somebody sleeps say five hours a night, but feels great during the day and functions fine, and has no problems during the day, they don’t come to see us. It’s only the people whose sleeping five hours at night and don’t feel good during the day that come to see us. That’s the key.
Lindsay Guentzel (37:04):
I want to ask, and I know it’s not your area of expertise, but the podcast is about ADHD. One of the things that I’ve noticed now since my diagnosis two years ago is that the exhaustion I felt middle of the day was probably tied to the lack of dopamine in my brain and not necessarily the fact that I was sleeping terribly, because I haven’t changed really much in my sleep routine. Now that I’m properly medicated, I can make it through the day.
And so I’m curious, when we talk about sleep issues and all of their factors playing a role, have you seen anything with ADHD? Do you have patients who come in? Is this something that… Again, going off of the melatonin, it feels like we just don’t know a lot.
Dr. Sanford Auerbach (37:40):
I think that the link between sleep and ADHD is maybe more than even you suspect perhaps. We see this a little bit more in children, some children certainly who become sleep-deprived in either by virtue of not having the chance to sleep enough or by having some other sleep disorder that makes their sleep more inefficient, one of the ways in which that can manifest is in a disorder that looks like ADHD. Sleep deprivation can trigger that kind of response in patients. Sleep deprivation and ADHD do in some ways overlap a little more.
Another interesting thing that I’ve seen over the years, there’s a particular disorder that we see where patients develop excessive sleepiness. In other words, they do get a good night of sleep, yet during the day they’re still sleepy. They call them Central Disorders or Hypersomnia, where people just need more sleep. One is called Narcolepsy or Idiopathic Hypersomnia. I’ve seen several patients over the years, usually young adults, where they come in [inaudible 00:38:39] sleep issue. We diagnose them and they have narcolepsy. But they also, interestingly enough, have been diagnosed with ADHD.
As children, that’s always been intriguing. Oftentimes, the problem is that the treatment for one overlaps with the treatment for the other. You have these two disorders, one comes off as hyperactivity, one comes off as sleepiness, and oftentimes wonder, what is the exact connection? It may be a mixture of different things. Is it that you really had that narcolepsy all along and it was just mislabeled as ADHD? Or was it that they’re just both caused by similar problems? It’s a very interesting relationship between the two, but it’s something that we oftentimes encounter.
Lindsay Guentzel (39:19):
Last thing I want to ask, when we talk about sleep and the importance it plays in our lives, where are you most concerned with where things are headed or what we’re not addressing?
Dr. Sanford Auerbach (39:31):
I always think of it as there being two parts to that. One, it seems to me that… The one thing I’ve mentioned several times is the role of stress. The thing about sleep is, that doesn’t seem to be getting any better. Life doesn’t seem to becoming less stressful as time goes by. That has a direct impact on sleep. I can tell in our clinic when different world stressors come and go, the complaints of insomnia start to spike. The second part, which I think is very closely related, I don’t think that we still don’t pay enough attention to sleep.
I think physicians are slowly starting to perhaps become more attuned to it, but oftentimes I think in the medical profession not enough attention is paid to sleep, and not enough energy, and not enough resources are devoted to make sure that people sleep well. It affects everything. The thing that concerns me is not enough focus is placed on it sometimes.
Lindsay Guentzel (40:26):
So, my major takeaways from my convos with Dr. Lange and Dr. Auerbach are this, our brains are actually very busy at night. One of my jobs as the owner of said brain is to get things set up so it can be as productive as possible. That includes getting more natural light on my face, having a routine that includes relaxation, and probably not mindless scrolling on my phone, and reducing the amount of stress in my life. I’ll be honest, I didn’t know sleep was so much work.
I’m truly so appreciative of both Dr. Lange and Dr. Auerbach for sharing their time and expertise with us on Refocused, and we’re going to hear from both of them again next week as we continue the conversation on sleep and ADHD. We’ll talk about the different stages of sleep, the importance of sleep hygiene, and why we should start creating our own, don’t feel bad it you don’t have your sleep hygiene on lockdown because like Emily, mine is also abysmal.
We’ll dive further into the importance of getting outside during the day. Dr. Lange even shares his prescription for good sleep, and I’m guessing it might surprise a lot of you. In the meantime, if you’re a person with ADHD who has figured out this whole sleep hygiene nighttime routine part of adulting, I would love to hear what works for you and share it on the next episode. Super simple, send me an email, message me on social, record a voice memo on your phone and carrier pigeon it on over, or email it.
You can find the show on social @RefocusedPod, and you can email us directly, [email protected] Like I said, I want to share these on the next episode, April 13th. So, send them over now, please and thank you. Another note, after the episode on April 13th, we’ll be back to our regularly scheduled Monday morning episodes on April 17th, and if you’ve subscribed to Refocus you’ll get each episode delivered right into your favorite podcast app every time we release a new episode.
Here’s where I also remind you, rating and reviewing is a free and easy way to support the work we’re doing, as well as sharing our show on social media. When you do, make sure to tag us @RefocusedPod and @LindsayGuentzel.
Refocused is a collaboration between me, Lindsay Guentzel, and ADHD Online, a telemedicine mental healthcare company that provides affordable and accessible ADHD assessments and treatment plans, including medication management and teletherapy. A huge thanks to our Managing Editor, Sarah Platenitis, who was instrumental in building these conversations on sleep. She’s the yin to my ADHD brain yang, and we’re so lucky to have her on the team.
Our Coordinating Producer, Phil Rodeman, does everything in his power to keep me on track. It is a monster responsibility, and I’m so happy he came out of retirement to give podcast life a go.
Al Chaplain is our go-to for all things social media, and I love what she’s been creating for us. Make sure to give it a like over @RefocusedPod.
A big thanks to Mason Nelly over at DEKSIA in Grand Rapids, Michigan for all of his help in getting our videos ready to share with you guys.
Refocused couldn’t happen without my partners-turned-friends at ADHD Online. High-fives and hugs to the ones that I bug the most, Keith Boswell, Claudia Gotti, Melanie Mile, Suzanne Spruitt, Trisha Merchandeni, as well as the entire team at ADHD Online and then Tavi Health.
I foolishly missed acknowledging them last week, but they need to get some credit for the incredible work that they did on our live panel audio, getting it ready for the podcast realm, Eric and Amanda Romani at EXR Sounds and Vision. I am so grateful to have sound engineers I trust that I can turn to. Thank you guys so much.
Our show art is created by Sissy Ye of Berlin Gray, and our music was created by Louie Ingles, singer/songwriter from Perth, Australia who was diagnosed with ADHD in 2020 at the age of 39. Links to all of the partners we work with are available in the show notes.
To connect with the show or with me, you can find us online @RefocusedPod as well as @LindsayGuentzel. You can email the show directly, [email protected]. That’s [email protected]dPod.com. Remember, on the next show we’re continuing our conversation on sleep, and please, if you have some genius ADHD sleep hygiene hack, we would love to hear about it. Record a voice memo and send it to us on social media @RefocusedPod, or through email at RefocusedPod.com.
Take care of yourselves, and please, in an effort to reduce the unbelievable amount of stress we all carry around with us unnecessarily, be a little kinder to yourself this week.