Searching for a good night's sleep

Photos by Erin VernonIt's 9:30 on a Thursday night. I'm sitting on a straight-back chair in a room that could be in a budget hotel, except for the overhead fluorescent lights that flatten everything with their persistent, white pressure. Don, a buzz-cut technician wearing blue scrubs and a back brace, has rolled my pajama pants up above my knees. He's built like a nose tackle and crouches in front of me, gently abrading the skin on my shins and attaching electrodes. He's been working on me for almost 20 minutes, attaching wires to my scalp, my chest. He is intent and quick. As he works he makes incessant, hyper-caffeinated small talk about himself, his family, the weather. It's hard to get a word in edgewise and we rarely make eye contact. This makes me feel like some obscure object of desire. But all Don wants to do is watch me sleep.

This ritual Don and I are engaged in is intended to monitor and measure my sleep patterns in order to determine if I have a sleep disorder. Don works for SleepCor, a national franchise accredited by the American Academy of Sleep Medicine specializing in helping people attain what appears to be an increasingly rare commodity in our society: a good night's sleep.

We're at SleepCor's Midwest regional center, an unobtrusive building in the midst of a futuristically sterile office park on the Northwestside of town. I was asked to check in at 8:30, so after polishing off an Ethiopian dinner and a couple glasses of wine with a colleague, I dutifully pull into a virtually empty parking lot and, overnight bag in hand, press the buzzer for admittance.

I've never thought of myself as having a sleep disorder, but I have to admit that sleep has been a source of some anxiety for as long as I can remember. When I was a child I went through a spell where I was afraid of the dark, and around junior high I can remember a lot of sleepless nights fraught with concerns about what I thought might happen at school the next day. At times during adulthood, work and various other life passages have prompted a fair share of tossing and turning; for about four years I, like a fair number of others I've discovered, conditioned my bedtimes with a hit of Benadryl as a kind of pre-emptive strike against insomnia. It worked, but played havoc with my prostate, so I quit.

At the time of my appointment at SleepCor, I was actually sleeping pretty well - and without reliance on any of the myriad forms of drowse-inducing media commonly available. But if my sleeping is OK, I'm still fascinated by sleep itself. On the one hand, we all need it and tend to get sick without enough of it. That doesn't keep sleep from seeming like a burden we have to bear, a hiatus that keeps us from being as productive as we might like to be. "Wake up!" we say by way of exhorting people to do more, be more. Founding father Ben Franklin noted that the early bird catches the worm. In a 24/7 world, being a sleepyhead can seem downright un-American.

The study of sleep

Before checking in to SleepCor to have my sleeping assessed, I spoke with one of the clinic's resident physicians, Dr. Nancy Spencer, who has spent over a decade studying sleep disorders. Blonde and birdlike, Spencer speaks of sleep with equal parts authority and enthusiasm. She entered the field through the study of epilepsy, working with patients who suffered from recurrent seizures and experienced abnormal behaviors at night. Over the years, she says, questions continued to mount about what these night disorders might be.

During the past 10 to 20 years, doctors have found that answers might lie in the study of sleep itself. Sleep disorders can be divided into four broad categories. Hypersomnias (derived from the Latin, somnus, to sleep) apply to disorders that cause people to be too sleepy through the day when they should, or would rather be, awake.

Insomnia, the second category, is the most common disorder; it means you can"t sleep. About 30 percent of us will experience insomnia during our lifetimes. Circadian rhythm disorders account for the third major type of sleep disorder. Our circadian clocks tell us when we should be sleeping or awake. Some of these disorders are intrinsic to the brain - the clock is damaged in some way - others are due to our being out of synch with our environment. Jet lag and shift work are two ways you can mess with your circadian clock.

Parasomnias - disorders of arousal - constitute the final category. These might include sleepwalking or, most severe, sleep terrors. "In our society I think we have the biggest stake in hypersomnias," Spencer observes, "because if you're too sleepy during the day what might happen? A third of our trucking accidents are due to falling asleep behind the wheel. If one is sleepy during the day they could hurt themselves or others." Obstructive sleep apnea is a common hypersomnia.

Four percent of American men and 2 percent of American women suffer from it, making sleep apnea as common as asthma. Nevertheless, Spencer says, it is under-recognized and under-treated. "Somebody comes into the doctor and says, "I feel fatigued." A lot of people conflate fatigue with sleepiness. But these are different." Fatigue is associated with sore and tired muscles. But falling asleep while watching TV, in the middle of a conversation or while waiting for a traffic light to change is sleepiness. "Doctors need to pull that history out," Spencer says, adding, "What is the reason why this person feels so sleepy?" Snoring, accompanied by gasping and periods where seconds go by and no breathing takes place are signs of sleep apnea.

"What"s happening is that a person will be sleeping and they"ll snore," Spencer explains. "Snoring is already partial obstruction of the upper airway. So they"re snoring and then they completely obstruct. The brain will try to keep working to breathe. There will be persistence of respiratory effort. But after a few moments, the brain sends an adrenaline signal down, saying, "Wake up! Take a deep breath."

" The person briefly awakens, blows open their airway and falls back to sleep. All this happens so briefly it's not remembered, but a few moments later snoring resumes and the cycle begins again - and can occur dozens of times through the course of a night. The next day, a person with sleep apnea is predictably exhausted. They did not have consolidated sleep the night before," Spencer concludes.

Common as sleep apnea may be, Spencer believes that America is practically awash in what she calls Insufficient Sleep Syndrome. "That's probably the No. 1 hypersomnia in our country. "It's a myth that we all need eight hours of sleep," Spencer says. "That's actually average. Most of us need between eight and nine - and most of us don't get that. Each brain is individual and how much sleep each of us needs can vary. Just like you were born with blue eyes, you were born with a particular sleep requirement that was specific to you."

Studies, according to Spencer, have compared people who have curtailed their sleep requirement by two hours a night for seven nights with people who are legally intoxicated. When placed on a driving course, the sleepyheads' psycho-motor vigilance and reflex times are as impaired as drinkers with 0.08 to 0.1 percent alcohol in their veins.

"Most studies show we know when we're sleepy," the doctor says. "But the errors that we make are the same as when we're intoxicated. We make errors of omission. We don't realize we're making mistakes - and that's the tragedy. Our society encourages shaving off sleep to show how productive and worthy we are." She points out that the Challenger accident, the Exxon Valdez oil spill and Three Mile Island nuclear meltdown can all be traced back to workers who were on extra or double shifts and made crucial mistakes.

How we sleep

Two processes affect how we sleep: our circadian rhythms and homeostatic sleep pressure. Circadian rhythms emanate from the brain's hypothalamus. Very sensitive to light, the circadian drive for wakefulness typically kicks in at about 5 a.m. and lasts throughout the day with a slight dip around 3 in the afternoon. This drive falls off at 10 or 11 p.m., allowing us to fall asleep.

Meanwhile, during the course of our waking, homeostatic sleep pressure is building up. It is at its strongest point at night, when circadian wakefulness is weakest. This combination allows us to fall asleep. It's a cycle that's repeated with the dawning of each day. But our circadian rhythms are subject to other changes within us as we grow and age.

Teen-agers' circadian clocks are often physiologically delayed. Instead of being sleepy at 10 or 11, they can be wide awake until 2, 3 or even 4 a.m. "There's nothing wrong with the consolidation or quality of their sleep," Spencer says. "It's perfectly normal." The problem is that school schedules generally require teens to be up by 6 in the morning. "Nobody gets the amount of sleep they need with four hours. Physiologically it's just not proper. Some of them are driving to school, aren't they? How dangerous do you think that is with a youngster who's walking around with this sleep debt that they're accumulating? It's been said that many of the accidents teen-agers have are in the morning. It's not surprising. They're driving during the last half of their sleep period."

By the same token, the elderly often experience what's called Advanced Sleep Phase Syndrome, where their circadian rhythms are advanced. This means they get sleepy around 7 or 8 in the evening and wake up at 3. Doctors sometimes mistake this early rising for depression. Although waking up when the rest of the world is asleep can be a lonely experience, Spencer hastens to say it isn't pathological. "The person had a nice, normal sleep - it's just they fell asleep too early."

Getting to sleep

Some of us can be so anxious to catch up on sleep - to pay down our sleep debt - that we self-medicate with booze and/or antihistamines ý la Benadryl. Spencer insists both are counterproductive. Alcohol promotes sleepiness but as the liver metabolizes booze it also fragments sleep. It's not uncommon for drinkers to awaken around 3 a.m. with terrible dreams from having their REM (Rapid Eye Movement) sleep sabotaged. As for antihistamines, Spencer quotes her medical school mentor: "If you want to give someone an antihistamine to help them sleep, you might as well tape it to their forehead."

In fact, Spencer generally avoids recommending medications for people with insomnia, preferring to rely instead on behavior modification techniques called Stimulus Control Therapy (SCT). While some people have a predisposition to insomnia and are aroused 24 hours a day, "Most people who have insomnia have learned to associate the bed with not sleeping. SCT gives the patient back control over their sleep."

There are, it turns out, a few basic techniques and principles to keep in mind when trying to overcome sleeplessness. First, try not to go to bed until you're sleepy. If you're awake for more than 20 minutes, go to another room and do something passive or soothing, like meditation, in low light until drowsy. Use your bed for sleep and sex and that's it - no TV watching, no eating, no computer, no working. Arise at the same time each morning and don't take naps.

"We don't need to use medications very often if the person is educated about why they have insomnia and how to treat it," Spencer says. "Insomnia really isn't a diagnosis. It's actually a symptom. And the No. 1 reason people have that symptom is something psychological."

There's also the society we've made for ourselves. "I think we have a 24-hour society," Spencer observes. "I think it encourages this sense of the work ethic and it also encourages people to stay up later, get up earlier, do that work, take care of the kids, and it tolerates this sense of pushing through the sleep need. It's a badge of honor. You hear people say, "I just got six hours of sleep and look at me, I'm still kickin'."

So what constitutes "a good night"s sleep? You feel rested when you wake up in the morning. And you get through the day without feeling excessively drowsy. It doesn"t sound very clinical, but that's it.

Abducted by aliens

The question is, can a good night's sleep be had at a sleep clinic? By the time Don, my technician, is through preparing me for what feels like ritual sacrifice, I have a sheaf of wires hanging off me that's as thick as the sweet spot on a Louisville Slugger baseball bat. And that's not all.

After Don turns down the covers and I climb into bed, sensors are inserted in my nostrils and a plastic clip about the size of a clothes pin with a red light on its tip is attached to my right index finger. The purpose of these gadgets is to monitor my vital signs - from brain waves to the amount of oxygen saturation in my blood.

Suddenly, that Ethiopian dinner I enjoyed earlier in the evening is making a claim on my attention and it occurs to me that going to the bathroom might be difficult. Don reassures me. If I have to go all I have to do is wave. He'll be watching me on a television monitor in another room and will come in and disconnect me so I can trundle down the hall to the toilet. Rather than comforting, the reminder that every move I make is being videotaped only serves to accentuate the voyeuristic quality of this experience.

Shortly after Don leaves and the lights are turned out, he speaks to me via intercom, asking me to move my arms, legs and head. I mutely comply with each of his requests. It's like I've been abducted by aliens.

"Essentially, what we do is see what you're doing while you're sleeping and, in some cases, what you're not doing." George Bellamy, the clinic's manager, told me this just before Don started wiring me up. Like Don, Bellamy is built like a bouncer. He's carrying a super-size mug of coffee, which might explain why he, like the other SleepCor professionals I've met, speaks in complete, ultra-articulate paragraphs.

According to Bellamy, about 80 percent of the patients at SleepCor have sleep apnea or related symptoms. They also see quite a few people with limb movement disorders - a tendency to twitch or jerk in bed to the point where sleep is broken - as well as insomnia.

"A lot of people have very poor sleep hygiene in this country," Bellamy says, referring to bedtime activities like watching TV, eating and working. He reiterates what Spencer told me, that when it comes to sack time, sleep and sex - that's it.

Sleep and sex. These words form a kind of mantra for me as I lie in my darkened room, listening to the faint hiss of circulating air. Neither seems likely in this setting. Indeed, the clinical weirdness of this place only serves to underline how anxious and even desperate it can feel to go without decent sleep. Why else would anyone submit to this? Bellamy, of course, tells me that while it's not unusual for first-timers like myself to get a touch of what he calls "white coat fever" when they come here, others say they sleep better here than anywhere else they know.

Eventually, I feel like I'm floating. I know I"m dropping off because I lose all sense of time. The only real problem I have is that whenever I move my right arm a red light, like an unidentified flying object, crosses the horizon of my sleep and rouses me. It's that damn plastic clip on the end of my finger.

Wake-up call

A few weeks later, I talk to Bellamy on the phone and he gives me my test results. It turns out that by their measurement I only slept 53 percent of the time I was at SleepCor - not really as high a percentage as they'd like in a test like this.

I also manifested sleep apnea; I was apparently roused from slumber 40 times in roughly six hours. George asks if I've ever slept on my side. I tell him that's the way I usually sleep, but I found it almost impossible at the clinic because every time I tried, the electrodes on my chest pinched. My heart rate and oxygen saturation level were fine, he tells me, adding that I did some twitching and kicking, which awakened me twice.

I don't bring up being awakened by Don, who crept in at one point to readjust the sensors in my nostrils. Ah, the interests of science. Bellamy suggests that if I want to follow up on the sleep apnea finding, I should make an appointment for another test and a meeting with Spencer. I thank him and tell him I"ll take a pass for now. I'm sleeping OK. In the meantime, I've ruled out watching TV and eating in bed. It's sleep and sex for me.

Useful web sites  National Sleep Foundation Restless Leg Syndrome Foundation, Inc. American Sleep Disorders Association American Sleep Apnea Association SleepCor


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