Category Archives: Work and Society

How can escaping into virtual reality improve healthcare?

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You slowly creep towards the door while being acutely aware that the slightest sound will get you caught. As you reach for the handle and steadily open the large wooden door you hear a slight creak. Suddenly, the expansive and exposed wall to your right explodes in a flurry of shrapnel, wallpaper and dust. A figure starts to emerge from the wound in the wall and stares directly at you with a terrifying smile. You’ve been found out…

Virtual reality isn’t always quite so terrifying but the above example reminds us that the virtual world has the capacity to make us believe what is thrust directly in front of us. The fear is real and the experience is one which mimics the experience of navigating a trap ridden residence. Besides terrifying us and fuelling visions of humanity being locked in a virtual world to escape the real one, what is the future of virtual reality? Well, one emerging area appears to be concerned with improving mental health.

Use of virtual reality to treat mental health difficulties

Psychosis, a cardinal symptom of schizophrenia, is the presence of delusions and hallucinations which can cause considerable distress. Delusions can take many forms and the nature of these seem to be tied to the diagnosis present (e.g. bipolar disorder, depression or schizophrenia). One delusion common to those diagnosed with schizophrenia is paranoia which can, understandably, cause significant distress and impairment in an individual’s life. However, what if we could challenge the paranoid thoughts of those experiencing psychosis and illustrate their unfounded nature? A real-world setting is likely to be too anxiety-provoking for obvious reasons but what if we could recreate paranoia-inducing environments in the relative safety of virtual reality?

This is exactly what a group at the University of Oxford led by Professor Daniel Freeman has explored in their study for the British Journal of Psychiatry last year. They exposed individuals with persecutory delusions (e.g. paranoid thoughts) to one of two mock real-life setting through virtual reality and asked them to do one of two things. One group was simply exposed to the virtual environment and asked to simply experience the situation. The effect of this on their their paranoia was assessed. The second group, by contrast, was asked to drop their guard, stop using their safety behaviours, and actively put their paranoid thoughts to the test (e.g. Do people in this environment see me as an easy target and do they actually do things to belittle me?). This second condition was known as the cognitive therapy group as they were encouraged to actively re-evaluate their delusions in the safe confines of the virtual environment.

There were 30 participants tested and they were randomised to either an exposure or cognitive therapy condition. They were tested in a real-life setting initially, then gradually introduced to the virtual reality environment, and then finally tested in the real life setting once again. At each point participants were tested before and after their immersion to either real-life or virtual reality on a scale assessing the conviction and distress of paranoid thoughts. As a test of ‘credibility’ the participants were also asked whether they believed the virtual reality setting would help them overcome their paranoid thoughts. Participants were tested in one of two different virtual reality settings. The first setting was a typical one for any Londoner: a tube journey. The second was a lift which the participant walked into and could inspect the other passengers.

So, what did they find? They found that there was a significant and large reduction in conviction and distress of delusions following the cognitive therapy group’s immersion into the virtual environments. Interestingly, these findings also carried over to the real-world setting. On average, they found a reduction in scores of around 20% for the cognitive therapy vs the exposure virtual reality condition. This suggested that getting individuals with paranoid delusions to test out their threat beliefs in a safe environment had the impact of reducing their paranoia. This should be considered in light of the difficulty to achieve this in a real life setting due to considerable anxiety and stress. This suggests that virtual reality is a simple and effective way to combat threat beliefs in paranoia.

However, this was only completed over a single day and the long-term impacts of using virtual reality is this way are currently unknown. Is there a dose-dependent effect of VR on threat beliefs? How long do the therapeutic gains last for? Are there individuals for whom this works better or worse? Are there any unintended side effects of using VR for multiple sessions in a patient population? And many other questions which remain to be answered. Psychosis is not the only field where virtual reality has started to prove its worth in treatment and research but anxiety, depression and eating disorders are also highlighted in the recent review by Professor Freeman earlier this year.

It should be noted that virtual reality is by no means only being realised within mental health but it is starting to be used extensively within physical healthcare too. VR provides an optimal way to train new surgeons, doctors, and nurses in medical procedures. This is what current research is exploring and virtual reality is only one avenue. Augmented reality is becoming more common and apps such as VR in the OR allow us to witness surgical procedures in an interactive manner from the comfort of your own home.

Basic Science and Mechanisms Research

So, there appears to be promise for using virtual reality as a way to deliver therapy but what about research more basic, mechanistic, research (e.g. what causes paranoid thinking in the first place)? Surely if we can create a convincing setting then we could start to study how threat beliefs are generated, in the case of psychosis, or understand what might reduce of exacerbate mental health difficulties in general. In an earlier study conducted in 2003, Prof. Freeman showed that paranoid thoughts could be seen in a virtual reality setting with healthy individuals. In their early foray into the use of VR they found that a small number of participants in their sample attributed hostility towards the avatars present in the environment. The researchers argued that this showed that VR could be used to study paranoia and provide a more realistic environment to test predictors of paranoia in a social setting.

Finally, because we can treat these virtual realities as realistic and convincing, they provide a great landscape in which to explore situations which might prove difficult for those at risk for certain mental illnesses. This allows researchers to test out hypotheses without unnecessarily exposing participants to a threatening situation, and with the ease of removing the headset instantly if the situation becomes distressing. For example, it would be possible to further probe the effect of sleep on mood and how this might contribute to mental health difficulties through the use of virtual reality. Now, as with any science, the worth of the study is not dependent on how flashy the toys are which are used but the strength of the research question and design. Although VR may strike some as flashy, it is useful in that it provides a way to recreate reality but in the controlled and safe confines of the lab. VR may currently be synonymous with jump scares and large price tags it is also being used to improve the health of the public. The widespread use of VR across healthcare settings is still a while off. For now, we shall just have to be content with scaring ourselves senseless with Resident Evil and other horror games.

References

Freeman, D., Bradley, J., Antley, A., Bourke, E., DeWeever, N., Evans, N., … & Slater, M. (2016). Virtual reality in the treatment of persecutory delusions: randomised controlled experimental study testing how to reduce delusional conviction. The British Journal of Psychiatry, 209 (1), 62-67.

Freeman, D., Reeve, S., Robinson, A., Ehlers, A., Clark, D., Spanlang, B., & Slater, M. (2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 1-8.

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Virtual Reality (Header)

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Filed under Psychology, Schizophrenia, Work and Society

Trauma, Tetris and Memory: A Cheap Way to Reduce the Impact of Intrusive Memories

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What if I was to tell you that playing video games can be good for you? That despite derision and their use in political point scoring, games such as Tetris and Candy Crush could one day be used to help people deal with traumatic events in their lives? You might be initially sceptical but there is growing evidence to support this. Although not a new idea, Tetris has been shown to be useful in reducing the uncontrollable intrusions associated with a traumatic experience.

So, how can we use a video game such as Tetris to interfere with traumatic memories? Well, in much the same way that you would interfere with any memory. As you create a new memory and have converted all the constituent parts into a form which the brain can understand, it goes through a period of consolidation. That is where the memory is stored within your brain so you are able to recall it at a later point. Now if we interfere with the memory during this period of consolidation it is less likely that we will recall said memory. For example, if we can provide some competition for the neural real estate the original memory is vying for then we can weaken the strength of that original memory. It seems to be important that the type of memory is relatively specific and needs to match the original memory’s modality (e.g. a visual-spatial task needs another visual-spatial task to compete with it effectively). This is essentially where Tetris comes in. The authors argued that if both the trauma memory and Tetris rely on the same visual-spatial resources then you can reduce the intrusiveness of the initial trauma memory.

This is exactly what Emily Holmes at the University of Oxford and her collaborators found in studies conducted over the past eight years. If you ask a participant to play Tetris 30 minutes after a lab-controlled trauma induction you can reduce the impact of the traumatic memory compared to a control condition. These early studies showed that, at least in the lab, you could interfere with traumatic memories in a therapeutic way by reducing their intrusive nature. Although they were not carried out in a naturalistic setting they provided evidence that the proposed mechanism existed and could be manipulated. It is also key to keep in mind that this study showed that playing Tetris reduced specifically the intrusiveness of the traumatic memories and not the deliberate recall memory for the event. As the uncontrollable nature of the traumatic memory is a source of considerable distress in PTSD it is important that any intervention can have a targeted effect. What about evidence for the use of Tetris to deal with naturally occurring trauma outside of the lab? This is where their latest study, published in Molecular Psychiatry, last week comes into play (it’s open access so you can read the full article yourself here).

In a small-scale naturalistic study in Oxford, Emily Holmes, and colleagues at the Karolinska Institute in Sweden, examined individuals in A&E who had recently (within 6 hours) experienced a motor accident as a driver, passenger or pedestrian.  They randomised 71 eligible participants to either an intervention or control condition to test the real-life application of their previous findings. In the intervention condition, participants were asked to recall the traumatic event initially and to then spend at least 10 minutes (maximum 20 minutes) playing Tetris. By contrast, the control condition asked participants to write down all the activities they carried out during their time in A&E (e.g. completing a crossword, speaking to a friend, etc.). Participants were assessed at one week and one month following either the control or intervention task. During the initial week participants were required to complete a daily diary of the number of intrusive memories they experienced which were related to the trauma (e.g. motor accident). The participants were instructed not to report “memories recalled deliberately or general verbal thoughts”. The number of intrusions provided a primary way to assess the success of the use of the intervention (memory cue and Tetris).

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So, what did the researchers find? Primarily, they showed that the use of Tetris and memory recall was an effective intervention. The number of intrusions was significantly reduced in the intervention group after one week (9 intrusions on average) compared to the control condition (23 intrusions on average). Furthermore, they also found that the intervention group also reported significantly less distress after one week. However, this reduction in distress did not remain when participants were followed up after one month. To supplement this data, the authors also asked the participants about their subjective experience of using the intervention. Their reports were positive and it was apparent that they appreciated the distraction from the accident which playing Tetris offered. One participant highlighted this clearly with, “it certainly took my mind off of it at a time when I probably would have sat brooding and feeling very sorry for myself…”. Another participant, who had not played Tetris before, was keen to keep playing it following the allotted 20 minutes. The intervention thus proved to be both feasible and acceptable.

Together, these findings support the usefulness and viability of using Tetris to combat intrusive traumatic memories in a real-life setting. The reduction in the number of intrusions following a natural traumatic event (e.g. motor accident) supports the intervention and suggests it could be a low-cost, easy to administer, therapy. As the authors highlight in the paper, waiting times in A&E can be as long as 4 hours and this would be an ideal time to target individuals who have experienced a traumatic accident. As a well-tolerated, and simple, intervention it seems ideal. However, this study is simply the beginning of translating Tetris, or similar aproaches, into the realms of clinical practice. Although this trial did not show an effect on distress at a one month follow-up, a larger trial may be better suited to pick out subtle effects for longer periods of time. Furthermore, additional doses of the intervention may also prove effective as a ‘booster’ to the initial dose. As any good piece of research, this trial raises more questions and exciting avenues for further study.

Alongside the compelling results, why should we be so excited about this research? It provides clear evidence that marrying cognitive neuroscience and clinical practice are vital for progress in both fields. It is still early days for this collaborative approach but hopefully this soon blossoms into a powerful and fruitful relationship. Basic science studies can be blamed for being too distant from the disorders and clinical fields they are trying to unpick and affect. However, with a greater understanding of the mechanisms at work behind mental distress we can develop novel therapies, like the use of Tetris, to target them and help real people. Personally, that is one of the amazing things about research and one of the reasons why I fell in love with science in the first place. More work is needed to validate these findings but, at least for the time being, they provide you with a great retort to anyone who claims video games are good for nothing. To quote Emily Holmes’ original Tetris paper in 2009, “…clearly not all computer games are bad for you.”

ResearchBlogging.org

Iyadurai, L., Blackwell, S., Meiser-Stedman, R., Watson, P., Bonsall, M., Geddes, J., Nobre, A., & Holmes, E. (2017). Preventing intrusive memories after trauma via a brief intervention involving Tetris computer game play in the emergency department: a proof-of-concept randomized controlled trial Molecular Psychiatry DOI: 10.1038/mp.2017.23

Additional References:

Holmes, E. A., James, E. L., Coode-Bate, T., & Deeprose, C. (2009). Can playing the computer game “Tetris” reduce the build-up of flashbacks for trauma? A proposal from cognitive science. PloS one, 4(1), e4153.
Chicago

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Tetris (Header)

Tetris Building (Body)

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How Might Escaping Technology Help Improve Our Sleep Problems?

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“Won’t someone please think of the children?!”

Besides infancy, we don’t initially think of sleep as a big problem in childhood. Yet, a slew of recent articles have highlighted that insomnia and other sleep problems are not simply an issue of adulthood. A BBC Panorama documentary released last week commented on the surge in problems with sleep in children. Although there were a number of culprits identified for this increase in the problems with children’s sleep, one key point was technology and later exposure to artificial light.

We are all glued to our smartphones, laptops, and Fitbits. Modern artificial lighting allows us to work and entertain ourselves further into the night than natural light permits but the normality surrounding their use before bed is negatively influencing sleep. As people are educated more about the effects of technology on sleep, these issues should hopefully reduce but whether education can effect this change is uncertain. The question remains: How can we improve sleep without dragging people away from technology? One love-it or hate-it option may be camping.

Last month, a research group led by Kenneth Wright carried out two studies which examined how artificial light interferes with our natural sleep rhythms and our body’s concept of day and night. Study one assessed the sleep of participants firstly during artificial lighting and then natural lighting during the winter. The second study attempted to understand the impact of weekend camping on sleep. The researchers studied sleep by asking them to wear a watch to track movements and by tracking changes in a hormone called melatonin. Melatonin is released prior to sleep, reaches a midpoint during the first half of sleep and dips as you wake up. During the day, it is only detectable at trace levels because in the presence of light melatonin’s production is inhibited. This, in part, explains why we feel tired and want to go to bed at night rather than during the day. As a result, melatonin serves as a useful and precise marker of the internal biological night (i.e. when the body feels we should be sleeping).

The first study had participants spend a week, during winter, camping with no artificial light (e.g. torches or phones) and then a week in their normal, modern, environment which served as a baseline. Participants’ melatonin levels were measured during sleep after about 6 days of the modern environment and after 6 days of the natural light, camping, condition.

This initial study found that the internal biological night (e.g. melatonin onset, midpoint, and offset) is affected by seasonal fluctuations. Specifically, internal biological night is longer during winter and shorter during the summer. In the camping condition, melatonin onset and sleep onset were around 2 hours earlier compared to the modern, artificially lit, condition. However, melatonin offset and sleep offset were similar between camping and baseline. When comparing the winter data to previously collected summer data, the melatonin onset was earlier and melatonin offset was significantly later in the winter condition. More specifically, they showed a four-hour difference in internal biological night between winter and summer. However, there were no change in internal biological night between summer and winter offset when comparing the artificial light conditions. The modern, artificially lit, environment had extinguished the seasonal fluctuations in melatonin and sleep patterns.

The second study then went on to assess whether weekend exposure to natural light (i.e. camping) could help reduce the effects of social jet lag – the mismatch between the time you wake up during the weekday and weekend. We tend to delay our sleep during the weekend and this contributes to why it is so hard to wake up on a Monday morning. In this study, fourteen participants were first tested in their normal, artificially lit, environment and their melatonin levels during the night (onset, midpoint and offset) were assessed. Participants were then separated to a camping condition (n=9; natural light) or normal condition (n=5; artificial light).

What did they find? For the camping condition, the time at which participants went to sleep and woke up were similar between weekday and weekend. However, for the artificial light condition the onset of sleep was found to be delayed by almost 2 hours and participants woke up around an hour and a half later during the weekend compared to the weekday. People were staying up later and waking up later during the weekend presumably when they didn’t have work. Overall sleep duration and efficiency were similar across and within both groups. So, participants were not sleeping for longer under artificial light but were delaying their sleep schedule.

What about the data for internal biological night? In the camping condition, melatonin onset and midpoint were about an hour earlier during the weekend compared to weekday despite there being no changes in sleep timing. Interestingly, changes in melatonin were not only seen in the camping condition but also the modern setting. Melatonin onset, midpoint and offset were delayed by about an hour compared to the weekday for the modern, artificial light, condition. This is problematic if you have to get up earlier on the Monday morning for work and is linked to what we know as social jet lag. If you feel sleepier later and want to wake up later then you may find yourself being groggy and sleep deprived during the week.

Yet, when participants went camping over the weekend, they did not see a shift in their sleep onset or offset, and their biological night became advanced (started earlier) slightly. This suggests that weekend exposure to natural light (e.g. camping) may help diminish the negative effects of living in the current, high-paced, environment we currently have. The small sample size and short sampling period makes it hard to draw definite conclusions from this study but it does highlight that artificial lighting is having a definable impact on our sleep and the biochemistry underpinning it. It also provides some preliminary evidence of the biological impact of social jet lag.

You may, quite rightly, think that the results of this study are rather obvious: we stay up later during the weekend and our biology is going to follow suit unless we hike out to the middle of nowhere for the weekend. However, it highlighted the biological impact of our modern, well-lit, environment on our body’s internal clock. We know that using our devices before bed are generally bad for sleep but very few of us actually do anything about this. We may try to adopt better bedtime habits but this may be thwarted by technology (e.g. using a kindle to read just before bed)

Also, it is key to remember that light is not the only regulator of our sleep rhythms and in societies not exposed to artificial light the key determinant of the sleep cycle is temperature. This should make us think about not a single factor (i.e. light) but a multitude of issues may cause issues with our sleep. Interestingly, such individuals in cultures not exposed to artificial light also reported problems with insomnia but at a reduced rate than reported in modern society.

Nonetheless, light from devices, rich in low-wavelength blue-light, resets our biological clocks and inhibits the release of melatonin. As a result, we feel sleepier later even though we still have to get up at the same time and go to school, college or work. The recurrent sleep deprivation can in turn lower our mood, concentration and put us at increased risk of illness and metabolic disorders. Now, it is unlikely that the rise of childhood sleep problems can be fixed by wrenching tablets from children and throwing them out into the wilderness every Friday until Sunday. Nonetheless, we can think about what these devices are doing to our sleep – at the very least when we’re sleeping poorly to begin with.

Inquisitive Tortoise

 

ResearchBlogging.orgStothard ER, McHill AW, Depner CM, Birks BR, Moehlman TM, Ritchie HK, Guzzetti JR, Chinoy ED, LeBourgeois MK, Axelsson J, & Wright KP Jr (2017). Circadian Entrainment to the Natural Light-Dark Cycle across Seasons and the Weekend. Current biology : CB, 27 (4), 508-513 PMID: 28162893

 

Additional References:

Chang, A. M., Aeschbach, D., Duffy, J. F., & Czeisler, C. A. (2015). Evening use of light-emitting eReaders negatively affects sleep, circadian timing, and next-morning alertness. Proceedings of the National Academy of Sciences, 112(4), 1232-1237.

Yetish, G., Kaplan, H., Gurven, M., Wood, B., Pontzer, H., Manger, P. R., … & Siegel, J. M. (2015). Natural sleep and its seasonal variations in three pre-industrial societies. Current Biology, 25(21), 2862-2868.

 

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What Have Fairy Tales Got to Do With Sleep Medicine?

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“Fairy tales? That’s the best you could think of to drag people in?”

“What’s wrong with it? It’s accurate…”

“I dunno man, you used to be all about the science. Now this feels all click-bait territory *shudders*”

“…”

By fairy tales, I am of course referring to sleeping beauty. Not a champion of feminist thought, this story tells the tale of a young woman who awaits the kiss of a prince to awaken her from an eternal slumber. Although there is no disorder which makes you sleep indefinitely there is a close contender with something called Kleine-Levin syndrome (KLS) – also known as ‘sleeping beauty’ syndrome.

What is Kleine-Levin syndrome?

Kleine-Levin syndrome is an episodic and extremely rare sleep disorder whereby the individual goes through periods of excessive sleepiness (hypersomnia). We all go through periods of feeling exhausted and may find ourselves sleeping for that bit longer. Maybe in extreme cases we’ve found that we’ve spent the whole day in bed fast asleep (thanks new year’s). However, imagine spending up to 20 hours a day asleep for weeks, or even months with no indication when you’ll ‘wake up’ and go back to normal. You miss school, friends, hobbies, and significant portions of your life as your teenage years drifts steadily away. Your dreams seem more real than reality and you lose interest in everything around you. This is a taste of what those with KLS experience and have to deal with.

Other than spending most of the day asleep, sufferers also experience memory, speech, and comprehension problems. In addition, hallucinations, derealisation (feeling as if in a dream), hypersexuality and megaphagia (increased eating behaviour) and paranoia also co-occur with the sleep and cognitive symptoms. It usually tends to emerge around adolescence and usually runs its course over about 8 years (with individual variability). Unsurprisingly, KLS causes significant disruption to academic performance, social lives, and sometimes memory of affected individuals.

What is its prevalence?

It is such a rare disorder that it has been difficult to get an accurate representation of its prevalence. We do know is that it is more prevalent in males but it seems to persist for longer in females for yet unknown reason. Some studies claim the prevalence is as low as 1 in a million but there is little research to support this number. Due to its rarity, most of our available knowledge on this study has been gained through case studies.

What causes this disorder?

This is uncertain although there is research attempting to shed light on this enigmatic illness. A systematic review carried out just over a decade ago found that in over 40% of reported cases, the first episode of KL-syndrome was preceded by an infection or fever. However, in 39% of cases there was no obvious precipitating trigger and the same lack of trigger is found in 84% of subsequent episodes of KL-syndrome. Although onset tends to occur during the latter months of the year, there is no strong argument for why this might be the case. Moreover, the disease may appear to disappear with little understanding why the symptoms disappear.

The link between infections and KLS has led some to argue that it may have an immune-system cause. However, there is little evidence for a link between dysfunctional immune functioning and KLS. Researchers have found some support for a link between certain types of hypersomnia and autoimmunity disorders but it is still unclear whether this extends to KLS.

A study by Dr. Jing Wang and colleagues at the Binzhou Medical University Hospital examined a large group of individuals with KLS (N=44) to identify potential markers of KLS. They found that a large subset of these individuals (N=34) were found to have reductions in a chemical called orexin in their cerebrospinal fluid (CSF) during a relapse compared to a period of remission. Orexin is a neurochemical which is important for wakefulness and is reduced in another disorder characterised by hypersomnia – narcolepsy. However, levels of orexin were not as low as those seen in narcolepsy. Interestingly, this cohort also showed a similar pattern of viral infection preceding the initial episode of hypersomnia / KLS.

Treatment

Again, it should come with little surprise that there are limited treatment options for those with KLS. One route is to reduce the fatigue through stimulants. However, this approach is not effective for other symptoms of the disorder. A different approach is to treat KLS using a mood stabiliser, lithium, which has shown some promise in reducing the length and frequency of episodes, and in reducing the behavioural symptoms. However, evidence for the efficacy of this treatment is limited and it forms one of many possible pharmacological treatments which require wider study.

Difficulties in Diagnosis

This is an extremely rare disorder and not many will have had experience with this diagnosis. However, it is treated with scepticism from some physicians and the general public. Some see it as laziness or not unusual for adolescents and students to sleep for most of the day. It is also not unusual for an individual with KLS to be given a diagnosis of depression in light of similar symptoms to an unknowing physician. A diagnosis of KLS can be laborious to reach as it will be given after identifying whether the individual’s symptoms are not better explained by a whole host of other diagnoses or causes. We have known about this disorder for more than a century and yet we have no convincing theory for why it occurs or how to treat it.

Although there is a lot we don’t know about KLS there is still active research determined to better understand and treat this disorder. If you’re interested in learning more about what it’s like to live with this illness this documentary is a good start.

Inquisitive Tortoise

References:

Arnulf, I., Zeitzer, J. M., File, J., Farber, N., & Mignot, E. (2005). Kleine–Levin syndrome: a systematic review of 186 cases in the literature. Brain,128(12), 2763-2776.

Barateau, L., Lopez, R., Arnulf, I., Lecendreux, M., Franco, P., Drouot, X., … & Dauvilliers, Y. (2017). Comorbidity between central disorders of hypersomnolence and immune-based disorders. Neurology, 88(1), 93-100.

Kornum, B. R., Rico, T., Lin, L., Huang, Y. S., Arnulf, I., Jennum, P., & Mignot, E. (2015). Serum cytokine levels in Kleine–Levin syndrome. Sleep medicine, 16(8), 961-965.

Leu-Semenescu, S., Le Corvec, T., Groos, E., Lavault, S., Golmard, J. L., & Arnulf, I. (2015). Lithium therapy in Kleine-Levin syndrome An open-label, controlled study in 130 patients. Neurology, 85(19), 1655-1662.

Poppe, M., Friebel, D., Reuner, U., Todt, H., Koch, R., & Heubner, G. (2003). The Kleine-Levin Syndrome. Neuropediatrics, 34(03), 113-119.

Wang, J. Y., Han, F., Dong, S. X., Li, J., An, P., Zhang, X. Z., … & Yan, H. (2016). Cerebrospinal Fluid Orexin A Levels and Autonomic Function in Kleine-Levin Syndrome. Sleep, 39(4), 855.

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Sleeping Beauty (Header)

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Juggling sleep with work: what are the long-term effects?

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It’s 6am again. The unrelenting tone from your bedside table reminds you it’s time to roll out of your duvet cocoon and get ready to face the working world. You swat your shrieking phone as it gets louder and more persistent. A quick swipe of the screen and you notice the day. It’s Friday.

A relieved smile spreads across your face.

Well, at least tomorrow means a lie-in.

The typical working week for most will involve dragging ourselves out of our warm, cosy beds and forcing our legs to make the long cold trek to the bathroom. Yet, we know that come the weekend we will be able to catch up, even briefly, on the sleep denied to us during the week. Although we will moan to friends and colleagues, our society seems perfectly content with depriving ourselves of sleep during the working week only to catch it up during the weekend. We would likely prefer a few minutes (or hours) more in the morning, but many of us don’t consider this practice as detrimental to our health. The shift from short to long sleep is considered a part of life.

This is far from sensible as the effects of sleep deprivation are well known, even if you don’t spend your days buried in journals with helpful names such as ‘Sleep’.

There is a name (there always is) for the shifting of sleep patterns throughout the working week – social jet lag. This refers to the changes in our sleep timing and duration depending on when we’re working (e.g. sleeping less on workdays and more on free days), and how this can confuse our internal clocks which try to keep our sleep patterns regular and predictable. These are the same internal clocks which influence whether you are an owl or a lark – an evening or morning person. This misalignment affects people differently, and it is not hard to see why night owls, who want to sleep later and wake up later, may suffer more.

Social jet lag is a problem for society. It is associated with depression, an increased risk for heart disease, more frequent smoking, and increased stimulant use in general. Understandably, the effects seen from sleep deprivation, including difficulties in concentration, memory, social functioning and mood, are also associated with social jet lag.

Despite the mental and physical health issues reported, the available data had been largely correlational. This makes it hard to draw definite conclusions on whether society’s current schedule of sleep is bad for us in the long-term.

However, a recent study published earlier this year has attempted to address this.  A team of researchers at the University of Harvard sought to understand whether repetitive patterns of sleep restriction and catch-up sleep have a negative impact on our health and wellbeing, or whether we may simply get used to it.

More specifically, they wanted to try to work out whether there is a difference in our own subjective view of this sleep pattern and how our body, behind the scenes, might respond in terms of stress and immune functioning. Do we adapt to the sleep loss in both domains? Previous evidence suggested we might not but this hadn’t been convincingly tested over a long period until now.

To assess these questions, they recruited 14 participants who were studied in a controlled hospital setting over three weeks. During each week, the participants spent 5 days sleeping for 4 hours and 2 days sleeping for 8 hours. After a few months, the same participants were invited back to conduct the same experiment sleeping for 8 hours each day over the 25-day experiment. The results of each were compared to try to understand the impact of the working week’s sleep patterns.

The group asked participants about how sleepy they felt, their perceived effort to do anything, and how stressed they felt each day at 4 hour intervals throughout the study. Alongside this, objective measures of stress and immune functioning were also assessed via blood samples collected on 7 of the 25 study days. Specifically, they looked at the levels of a chemical messenger of the immune system known to promote inflammation, interleukin-6, and the levels (total and stability) of cortisol, a hormone released in response to stress (amongst other factors).

The participants’ diet and exercise were controlled to reduce the impact of these variables, and they could have visitors to reduce the impact of isolation, and deviation from normal routines, where possible.

So, what did they find?

Over the three weeks, when participants were restricted to only 4 hours’ sleep they (unsurprisingly) felt sleepier and reported a greater effort to do anything compared to when than when they could sleep for 8 hours (e.g. during the weekend in the restricted condition and every day for the control condition). Interestingly, the ‘effort to do anything’ ratings became increasingly similar for the restricted and control condition over the three weeks, and participants reported no extra stress when asked to halve their sleep to 4 hours for the restriction condition. Overall, this suggests that participants, although sleepy, were subjectively fine with the simulated typical work sleep pattern. There was even evidence that participants started to adapt as their reported effort to carry out tasks diminished by the third week of only 4 hours sleep.

By contrast, the objective results showed a less optimistic picture. The researchers found an increased dysregulation of cortisol as the weeks of sleep restriction went on, and an increase in morning cortisol compared to the control condition. However, both returned to normal following recovery sleep at the weekends. In terms of immune system functioning, unstimulated IL-6 levels were significantly higher for the first week of sleep restriction and then remained elevated but non-significantly so compared to the control condition. For the stimulated IL-6 levels, these were significantly elevated during the week for the second and third week of the restriction condition compared to the control.

These results highlight that although participants seemed to be no more stressed subjectively in depriving themselves of sleep during the week, it seems that this pattern of sleep was not something the body simply ‘gets used to’. Instead it seems that the body still shows an increase in the inflammatory marker IL-6, increased cortisol upon awakening, increased dysregulation of cortisol, and inhibition of IL-6 in the presence of cortisol-like molecule. This hints at a heightened stress and immune response which, importantly, does not appear to adapt to the effects of chronic sleep loss during the week. Although recovery sleep during the weekend mitigated this effect somewhat, there was some evidence to suggest that two days was not enough to return immune functioning (stimulated IL-6) back to normal.

You may be thinking that increases in IL-6 and increased inhibition of IL-6 seem counter-intuitive, but the authors had a potential explanation. They highlighted that this may be the product of a particularly active immune response following chronic sleep to deal with its physiological effects (i.e. the increased sensitivity to cortisol’s effect is lessened due to a need to remove toxins built up in the brain).

In addition, you may also want to argue that 4 hours sleep during the week is hardly typical of most people’s work schedule, and that this experiment is far from representative of real life. However, this is a weak argument as the effects of sleep deprivation have already shown to be cumulative. It is more likely that losing an hour or two during the workday has negative effects but over longer periods than are suggested by this study.

So, it seems that even though we may consider depriving ourselves of sleep during the week manageable, and even get used to it, the same cannot be said for our body. This study suggests that we don’t get used to sleep loss during the working week. Moreover, recovery sleep during the weekends may not be enough to compensate for a week of fighting our internal clocks.

Although this study only examined a small number of people and a small number of specific measures, it still highlights the persistent effects of restricted sleep on our immune and stress systems. It also provides some hints as to how we may be able to successfully convince ourselves that this pattern of sleep is not detrimental to our health. If we feel subjectively okay, if not slightly lethargic, about this lifestyle then there would be no immediate drive to change it – at an individual or society level.

Granted, necessity and an inability to pay the bills may also be powering this too…

Inquisitive Tortoise

References:

Rutters, F., Lemmens, S. G., Adam, T. C., Bremmer, M. A., Elders, P. J., Nijpels, G., & Dekker, J. M. (2014). Is social jetlag associated with an adverse endocrine, behavioral, and cardiovascular risk profile?. Journal of biological rhythms, 0748730414550199.

Simpson, N. S., Diolombi, M., Scott-Sutherland, J., Yang, H., Bhatt, V., Gautam, S., … & Haack, M. (2016). Repeating patterns of sleep restriction and recovery: Do we get used to it?. Brain, Behavior, and Immunity.

Van Dongen, H. P., Maislin, G., Mullington, J. M., & Dinges, D. F. (2003). The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. SLEEP-NEW YORK THEN WESTCHESTER-, 26(2), 117-129.

van Leeuwen, W. M., Lehto, M., Karisola, P., Lindholm, H., Luukkonen, R., Sallinen, M., … & Alenius, H. (2009). Sleep restriction increases the risk of developing cardiovascular diseases by augmenting proinflammatory responses through IL-17 and CRP. PloS one, 4(2).

Extra Reading:

http://www.huffingtonpost.com/margaux-mcgrath/social-jet-lag-and-sleep_b_7842074.html

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