The Mysteries of Sleep

By Dr. Margaret Rappaport

The inability to adequately sustain sleep at night has been recognized as a problem from earliest time. History, literature and medical science are replete with examples of disorderly sleep due to factors inside people and circumstances and situations outside of them. The array of insomnias and parasomnias are sufficient to result in many sleepless nights. So pervasive are the problems of sleep, we know all of them by name, if not reputation.

Difficulty Initiating & Maintaining Sleep

Insomnias are problems of initiating and maintaining sleep. They are manifested as restlessness, tossing and turning, over stimulation such as planning and worrying, a shortened sleep period, excessive mental alertness, and awakening to eat or go to the bathroom. Subjectively, they are a complaint of insufficient, inadequate or non-restorative sleep. Some disturbance of daytime function, such as fatigue, moodiness or impaired performance is always a feature of the insomnias.

Insomnias can be further classified into sleep initiation difficulty, sleep maintenance problems and events resulting in premature awakening. They can occur as a transient, short term, or chronic disturbance. Most importantly, the insomnias are not a specific illness or disease, but rather, a symptom of either specified or unknown origin.

Sleep Mysteries & Sleep Science

Despite being very common sleep complaints; the insomnias and the parasomnias are not well understood. Their familiar names belie the fact that they are the “mysteries of the sleep”, just as baffling as the unknown wonders of the sea. Remarkably, even now, what is known about the human brain, awake or asleep, is equitable with what mariners in the 15th century knew about the earth’s oceans!

What is known about the insomnias and how they are treated is useful to discuss, since they are the most common sleep complaints. Surveys and epidemiological studies report their prevalence. They indicate that 30 to 35% of people complain of some difficulty sleeping in the current year and as many as 50% have experienced insomnia at some time in their lives. Between 15 and 20% of them characterize their sleep problems as severe or constant. Sleep maintenance is reported to be the most frequent problem, followed by difficulty falling asleep, and then early morning waking. However, these different types of insomnia often occur in the same individual.

Several demographic trends emerge from studies, as well. First, complaints of insomnia increase with age. Older adults have more trouble maintaining sleep; younger adjust have a greater problem falling asleep. Second, women of all ages have more sleep complaints than men. This phenomenon is particularly interesting because scientific sleep studies generally disclose greater sleep pathology in men. Third, complaints of insomnia are more common in lower socioeconomic groups. Fourth, insomnia is associated with increased complaints of tension, worry, stress and depression.

Studies have also addressed the consequences of insomnia. The results indicate that insomniacs and good sleepers did not differ in most measures of performance, but poor sleepers receive fewer promotions, remained a lower pay levels in their jobs, had higher attrition in jobs and more frequent hospitalizations. Prospective data from the American Cancer Society reveal an even more fascinating association. Habitually short sleep durations are significantly related to increased mortality, across all age ranges.

Treatment For Sleep Problems

Not surprisingly, a variety of treatments have been aimed at the insomnias. The major types of treatment include pharmaceutical agents, behavioral techniques, relaxation instruction and psychological approaches.

Pharmaceuticals, such as barbiturates and benzodiazepines, most commonly known as sedative-hypnotics, are often prescribed to treat insomnia. However, they can themselves be a frequent source of insomnia complaints through mechanisms of tolerance and withdrawal. For this reason, people sometimes seek an alternative treatment.

Behavioral treatments focus on sleep hygiene that promotes awareness of the rituals or habits associated with sleep and the conditions of the sleep environment. This type of treatment helps reinforce bed/bedroom as a controlled stimulus for sleeping by limiting sleep incompatible behaviors. Sleep restriction is used to limit the time spent in bed in order to increase the efficiency of sleep.

Relaxation treatment teaches systematic tensing and relaxing of muscle groups. Biofeedback training that reinforces specific brain wave patterns is used in some instances. Autogenic training teaches relaxation by coupling pleasant visual images with relaxing body sensations such as warmth or heaviness. Paradoxical intention instructs the individual to concentrate on staying awake, in order to reduce performance anxiety related to falling asleep.

Psychological treatments include cognitive therapy that explores assumptions and beliefs about sleep and insomnia. It then provides factual information and more relational explanations. Psychotherapy, or general talk therapy, focuses on conflicts, life coping styles, and defense mechanisms as a way to uncover and treat underlying problems.

From a treatment perspective, it might seem as though people could enjoy perfect sleep, if only they work hard enough at it. Perhaps that is the case. Yet, despite the best efforts, each of us may eventually confront insomnia. We can save ourselves a lot of time, energy and misplaced guilt by learning as much as we can about the aspects of sleep we can reasonably hope to master. Just as we attempt to bring order to our households, workplaces and social lives, so should we gain mastery over our limbs by exercising, our bodily functions through sensible nutrition, our impulses, and our emotions by acquiring a discipline of slumber.