How to get your ZZZZ's

Sleep Therapy

by Dennis Meredith
A Duke sleep scientist helps our bleary-eyed correspondent reform his snoozing techniques and get his quota. That makes one insomniac down, 40 million to go.
It's not t he electrodes glued fast to my scalp that keep me awake, even though the wires stick out like a Rastafarian alien's electric fright wig. And it's not the other wires snaking down to electrodes taped to my face and legs. Or the Velcro collar that gathers t he whole caboodle into a sheaf that runs to the humming tape recorder wrapped in a towel under my pillow. Or the plastic gadget strapped under my nose to measure my breathing.

Nope, it's my damnable insomnia. Although the electroencephalograph (EEG) gear makes me feel a bit trussed up, after I manage to arrange it, I'm pretty comfortable lying there in the dark listening to the quiet breathing of my sleeping, long-suffering wif e (LSW). It's actually kind of reassuring knowing that the little box harvesting my brain waves could help me climb out of the nocturnal pit of sleeplessness.

For years, I've been too much a creature of the night. Fatigued at nine p.m., I'd drag off to bed early, only to pop awake hours later for an all-night round of yo-yoing in and out of shallow slumber. Sometimes for hours I'd haunt the darkened house alone like some doomed wraith. I'd watch infomercials on TV, write, or stare out a window, hoping that something amazing would happen out there in the silent gloom. Maybe I'd get to sleep, maybe I wouldn't, but I'd almost always feel the lack during the day. I n the afternoon, I'd be enveloped by a gray fatigue, almost palpable in its texture. I'd either be forced to nap or to spend the rest of the day fighting to stay productive. Coffee was out; my middle-aged digestive tract rebels against the stuff. And anyw ay, coffee seemed somehow a cheat. I sensed something was wrong with my sleep habits that chemicals wouldn't fix.

At first I figured that my sleeplessness must be just another sign of aging, as is my thunderous snoring that my LSW has patiently endured for years. However, she is wise to me. She Who Sleeps Through the Night informed me I have a sleep disorder.

A new dawning came in the form of a newspaper ad for a sleep disorder research project at Duke. The ad, seeking people with insomnia between the ages of forty and eighty, brought me into the hands of psychologist Jack Edinger at Duke Medical Center's Slee p Disorders Clinic. I found that the clinic, staffed by neurologists, psychiatrists, and psychologist Edinger, treats all manner of sleep problems, both organic and psychological. The clinic's physicians help apnea sufferers, whose airways sag closed in d eep sleep, obstructing breathing and creating fragmented sleep and daytime fatigue. They help sufferers from narcolepsy, a frightening disease of the brain's sleep center, which causes patients to drop uncontrollably into deep sleep throughout the day. An d they also help sleepwalkers, sleeptalkers, people dependent on sleeping pills, depressed patients, and sufferers from anxiety. All these people's medical problems have unraveled the fragile web of sleep, leaving them vulnerable not only to fatigue, but also to serious medical problems.

As the clinic's psychologist, Edinger concentrates on behavioral treatment of insomniacs, defined as "somebody who has difficulty initiating or maintaining nighttime sleep or who has chronically poor sleep quality, with associated daytime symptoms." For E dinger, insomnia is in the heavy-lidded eye of the beholder. If you don't think you're an insomniac, you're not, he says. "For example, somebody who's a short sleeper, maybe five hours a night, and has no daytime complaints, isn't an insomniac. But the pe rson who sleeps eight hours a night and needs ten could have insomnia." Insomniacs are often "sleep hygiene abusers," says Edinger. "They're people who want to live like the gods, but sleep like us mortals. They don't understand that there are only so man y things you can fit in a day, and if you burn the candle at both ends, it is often going to invade your sleep process."

I'm a sleep hygiene abuser, he tells me. I've fallen into a common sleep-habit trap. Sometime in the past, I began suffering poor sleep during some period of stress. To compensate, I adopted the "logical" ploy of going to bed earlier and napping during th e day. But mine was false logic, because the result was fragmented, non-re-storative sleep. Abusers like me differ markedly from apnea sufferers. Such people, says Edinger, experience especially frustrating sleep problems. "They may be in bed eight hours a night, several nights in a row, and still wake up unrefreshed and have difficulty staying awake in the daytime. They're often deeply puzzled as to why."

The study I joined is one of several comparing behavior therapies for insomnia. My hot-wired night that began the twelve weeks of the study aimed to record my sleep patterns and make sure that I didn't have apnea or nocturnal leg-twitches--another neurolo gical problem that disturbs sleep. I also kept detailed sleep logs showing bedtimes, wake-up times, and periods of awakenings.

In my study, Edinger and research psychologist Bill Wohlgemuth are testing techniques of relaxing the body to induce sleep, as well as methods of changing sleep habits to improve sleep hygiene. In one effort to change my sleep habits, my therapist, psycho logist Ruth Quillian, first added up from my sleep log the total sleep contained in my sleep fragments--about six-and-a-half hours. Then she gave me a sleep schedule adjusted to squish my fragmented sleep into one midnight-to-6:30 a.m. chunk. Over a perio d of weeks, she would allow me fifteen minutes more per week, until my new sleep habits had been established. She also asked me to adhere to Edinger's Rules of Good Sleep Hygiene, which really make eminent sense for everybody seeking a good night's sleep: Wake up at a standard time; use the bed only for sleeping (and sex)--no reading or television watching; never spend long periods awake in bed, but get up and go to another room until sleepy again; avoid worrying, thinking, and planning in bed; avoid dayt ime napping; and go to bed when sleepy, but not before.

All in all, it was a tough regimen, leading me to dub, jokingly, the caring, professional Dr. Ruth, the "sleep Nazi." Since Edinger's research study is still ongoing, I can't be more specific about the treatment or its results, but such studies will certa inly help sleep researchers pinpoint the best techniques to help insomniacs like me get their quota of Z's. Edinger emphasizes, though, that therapies should recognize the highly personal nature of sleep habits. "I believe in the old adage, if it ain't br oke, don't fix it," he says. "If somebody has been Sunday-napping or reading in bed for years and they don't have an insomnia complaint, I'm not going to tell them to stop. On the other hand, if they do have a complaint, then we need to restructure things , because obviously what they're doing isn't working."

Besides his sleep hygiene rules to help bring on the Sandman, Edinger offers other good advice. He advises a relaxing buffer time--watching TV or reading--between the last heavy mental activity and bedtime. "I see this one guy from Research Triangle Park who pounds away on a computer right up until bedtime and expects to shut it off and go right to bed. That doesn't work." He advises against worrying too much about age-related sleep changes. "Sure, as we get older, we tend to have lighter and more broken sleep. And that contributes to the risk of sleep disturbance. But it's not equivalent to sleep disturbance."

And Edinger strongly cautions against depending on sleeping pills. "You have to treat the underlying cause of sleep problems, and not the symptom that is insomnia," he says. "If you had a fever and went to the doctor, you wouldn't walk away with fever pil ls. You'd get your problem diagnosed and would be pre- scribed a treatment that would affect the underlying disorder. Unfortunately, too many primary-care physicians seeing a patient with a sleep complaint just give them a sleeping pill."

According to Edinger, there's really no such thing as a true "sleeping" pill. "The majority of sleeping pills now on the market produce a drugged sleep that's not normal." Also, he says, sleeping pills prove a poor crutch for insomniacs. "Many folks get v ery dependent on the medicine for sleep, they get tolerant to them, and they have withdrawal reactions to some of them. They sleep more poorly when they try to stop them abruptly and they lose their sense of self-efficacy as sleepers. They insist, 'I can' t sleep without my pills.' They get themselves into this round of worrying about their health, their ability to perform on the job, about getting fired, and they're strongly motivated to stay on the medicine."

Edinger also advises against using the latest "wonder drug," melatonin, a natural body chem-ical associated with the sleep-wake cycle. "It's not a magical panacea," he says. "For one thing, we still don't understand its effects. And for another, when you buy a drug that's not regulated by the Food and Drug Administration, you're not sure what you're getting." He recalls a previous health disaster when the natural amino acid tryptophan was touted as a sleep aid. The substance was thought to help in-crease a brain chemical related to sleep. While pure tryptophan is relatively benign, a contaminated tryptophan shipment reached the shelves of health food stores, causing many consumers to suffer a condition known as eosinophilia, with symptoms of autoimmune di seases and rheumatoid arthritis.

The only nightcap for sleep, Edinger says, is one worn on the head. "Sure, alcohol will put you to sleep, but it's not very good sleep. Alcohol's a depressant from which you get a rebound that causes you to have broken sleep later." In fact, he says, slee p problems are a major block to quitting drinking. "When alcoholics abstain, they have sleep disturbances, which makes them more likely to relapse."

The most fundamental problem in treating sleep disorders is that scientists' knowledge of sleep is but a small splash of light in a vast realm of darkness. "You take two steps in any direction and you go beyond the frontier of what we know about sleep," s ays Edinger. Although scientists have general theories about sleep, they don't really understand why we sleep, what happens to the brain when we sleep, how to create true sleeping drugs or to engineer the best insomnia treatment. Edinger and his colleague s have mounted studies to shed light on some of those issues. The study in which I participated is a three-year effort funded by the National Institute of Mental Health to compare behavioral treatments for insomnia.

How normals and insomniacs react to taking EEG data in home and in laboratory environments is another Edinger interest. "Most of the research on insomnia has been done in sleep laboratories," he says. "However, a laborator y is a very novel setting that itself affects sleep, depending on the type of individual you're studying. Normals who sleep well at home often sleep worse in the lab. And if you take insomniacs out of the home, where they struggle to sleep every night, an d put them in the novel setting of the laboratory, suddenly many of them will sleep better, at least ini-tially. The effect of all this is to level any differences between normals and insomniacs."

Edinger is comparing insomniacs' nighttime sleep with daytime functioning. Eventually, he hopes to mount more studies of how drugs might fit into behavioral therapy in treating sleep disorders. "One problem with behavioral treatments is that it takes a wh ile for them to work. Maybe there's a way of using standard sleeping medication to jumpstart behavioral treatment, although it would be very tricky."

Despite progress in understanding and treating sleep disorders, Edinger remains pessimistic that our culture will ever value sleep highly enough. "So many forces in our society run counter to good sleep habits--our twenty-four-hour work and play schedules , our emphasis on high achievement, on high productivity, on going the extra mile." As it happens, he notes wryly, even the sleep researchers don't follow their own prescriptions. "At conventions of the sleep societies, about everything we do there is cou nter to what we teach. The convention schedule is so jam-packed and it goes from dawn to dark!"

As for me, I'm now a reformed sleep hygiene abuser. Of course, I backslide now and then into an afternoon snooze. And I sometimes toss and turn a bit. But my newly learned sleep habits have given me confidence that I can find my way to dreamland. I've dis covered, much to my surprise, that I'm not slave to my sleep, but its master.

Some Eye-Openers about Sleep

Copyright 1996 Duke University. All rights reserved.
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