Deep sleep


Sleeping lessons from recovered insomniacs Deep Sleep at the Mayo Clinic

Judy's journey to the Mayo Clinic was nowhere near as stylish as the one made by the emir of Kuwait. The emir--or maybe it was the crown price, the local gossips buzzed--arrived in a luxurious jet plane that looked decidedly out of place on the little runway in the midst of rural Minnesota. Judy(*) arrived in a humble Toyota Corolla. She and her husband rose bleary-eyed in the predawn hours to drive three hours from Iowa, through mile after mile of sullen beige countryside. Judy went without breakfast. She wasn't sure what medical tests she might need when she finally reached her destination: the world-famous Mayo Clinic, where Middle Eastern dignitaries and midwestern music teachers alike come to seek treatment for what ails them. This morning Judy meets with sleep specialist Peter Hauri. This afternoon she sees a psychiatrist. Tonight she may be one of those slumbering--or trying, at least, to slumber--upstairs in a sleep lab, with electrodes stuck onto her body.

Judy has insomnia. She's had insomnia since 1995, and has consulted her family doctor, a psychiatrist, and two psychologists; gotten advice from many a well-meaning friend and relation; swallowed melatonin pills from her local health food store and several brands of sleeping pills from her GP; and tried snacks at bedtime, relaxation therapy, antidepressants. She's tried anything she can try, in fact. And now she's traveled almost 200 miles to see if Hauri, renowned insomnia expert, can help her get some rest.

Insomnia isn't cancer. Insomnia isn't AIDS. Breathlessly confiding, "I didn't sleep a wink last night!" won't elicit buckets of sympathy from anyone. But experts take the problem seriously. Sleep, after all, is vital: Prevent a rat from sleeping and it dies. Human insomniacs are two and a half times more likely to have accidents than are other drivers. They're less likely to advance in their careers--and no wonder, since sleep loss takes a toll on concentration, analytical thinking, and creativity. Insomnia may even weaken the immune system and increase the risk of major depression.

And yet, as Judy's experience shows, a solution can be elusive. General practitioners and other nonspecialists tend to be poorly educated about the causes of insomnia and its nondrug treatments. Fortunately, says Hauri, a few visits with an insomnia expert can greatly help. Indeed, one of his studies showed that a single appointment, with phone follow-ups, eased sleeplessness for 75 percent of the patients. These visits are fairly free of fuss--unlikely to involve slumbering in a spaghetti-like tangle of electrical wires. And they don't have to involve a trip to the Mayo Clinic; most major cities have a sleep center accredited by the American Sleep Disorders Association.

What a world it would be if everyone got a good night's sleep, muses Hauri: happier, friendlier, safer. Judy, though, isn't looking for Utopia. She'd settle for a little peace of mind. "I'm crabby and depressed," she says. "I'm sluggish and tired, and so anxious about my sleep. Insomnia can just take over your life."

SITTING IN HAURI'S of office as the consultation begins, Judy is clearly keyed up about her problem, though even with her sleep deficit she looks younger than her 35 years. Her earrings, little treble clefs, hint at her love of music: She's a piano teacher by profession. She's also a superbusy mother of three. Her husband, Doug,* sandy haired and youthful looking too, sits quietly while Judy tells her tale, gently nudged along by Hauri, a middle-aged bespectacled man with a comforting bedside manner.

Hauri has been treating insomnia for decades. He opened one of the first sleep disorders centers in the United States and later helped found the American Sleep Disorders Association. His self-help book on sleep problems was a best-seller in 1990. His mother had trouble sleeping. Hauri did too, once upon a time.

That's partly why insomnia interests him. He also enjoys playing detective, and even before Judy arrived, he'd begun gathering clues. He had her fill out a weeklong sleep log--a detailed account of her bedtimes and wakenings, naps, and other bits and pieces of her life such as mealtimes, exercise, and medication. He gave her a questionnaire about her attitudes toward sleep and a psychiatric evaluation known as the Minnesota Multiphasic Personality Inventory, a booklet-size test filled with true/false statements such as "I like poetry" and "I loved my father." And he has a sheaf of notes from her doctor and counselors.

Hauri needs a lot of clues because insomnia isn't a condition; it's a symptom. People caught in its grip are a kaleidoscopic mix. Some have anxiety or depression. Some have biological rhythms gone awry. Some have an undiagnosed medical condition.

Judy has just had a thorough physical exam, so Hauri can rule out illness such as diabetes, arthritis, or an infection. But there are other medical possibilities. Does she, Hauri asks, have weird, nasty, creepy-crawly feelings in her legs when she's trying to drop off? "Does she kick a lot at night?" he asks Doug.

If Judy's husband had said, "Yeah, she kicks up a storm," Judy might have found herself in the sleep lab that night, with wires on her head, torso, and legs. Instead, from the long list of possible causes of insomnia, Hauri crosses off "periodic limb movement," in which people are repeatedly woken by their flailing legs. Off the list, too, goes a related condition called restless legs syndrome in which legs feel so antsy the would-be sleeper can't get comfortable.

And Judy might have ended up in the sleep lab if Doug had said, "Doctor, her snoring's driving me nuts!" That would suggest sleep apnea--that Judy's upper airways are closing off during sleep, starving her of oxygen and rousing her as many as 100 times each hour.

Judy doesn't snore, though, so Hauri moves on. How long does she take to fall asleep? When does she awake? Does she ever doze off in the early evening, say in front of the TV?

Hauri is exploring the possibility that Judy's daily rhythms run too fast or too slow. We all have clocks ticking away inside of us, whose cogs and springs are biological, not mechanical; these clocks govern a host of internal rhythms. "About 5 percent of insomniacs sleep the right amount but at the wrong time," says Hauri. "They'll fall asleep at four A.M., then sleep till noon, or nod off at seven at night and be up at three."

But Judy has trouble sleeping at both ends of the night, to say nothing of the middle. She's just a normal sleeper gone wrong. "I had no problem sleeping as a child," she says. "I slept well in high school and college. I used to stay in bed longer than Doug would."

This is quite encouraging. Some people have trouble sleeping all of their lives, from the get-go. "Just as some individuals are smarter than others, some are better sleepers than others," Hauri says. Innately poor sleepers are harder to help. But as Hauri talks with Judy, it becomes clear that her insomnia was created by circumstance.

Which circumstance? Take your pick.

Circumstance number one was being pregnant with her third child while her first and second clamored for her attention. That's when insomnia first paid Judy a visit. It settled in as the pressures piled up.

The baby, a little boy, developed asthma at age one--severe asthma that led to several spells in the hospital and waves of panic through the night for Judy. Then pneumonia hospitalized him again, this time for a week. It happened to be the same week in which Judy was preparing for a piano recital. As if that wasn't enough, one of her fingers suddenly went numb. "Nobody was telling me what I had," she says. "So I got it into my head that it was something really serious, like multiple sclerosis."

Judy's work, at least, was going well. Too well. She had more pupils than she could handle. Then her older son lost a large patch of hair from the top of his head. "If she hadn't developed insomnia with all that going on, I think we would have to conclude that she was crazy," comments Hauri.

But the crises passed. Judy's little boy came out of the hospital. His asthma was stabilized. His brother's hair grew back. Judy's numb finger turned out to be just a pinched nerve, and she cut down on her workload by gently saying good-bye to her more stress-inducing students. Did the insomnia go away? No, it did not.

Meanwhile Judy had been getting lots of input. Her family doctor prescribed sleeping pills. Counselor number one pronounced her clinically depressed; counselor number two said she wasn't. In between she saw a psychiatrist, who put her on antidepressants and told her to expect three years of treatment. "So much advice," mutters Hauri.

These days Judy takes a sleeping pill before she goes to bed and another if she awakens in the night. Hauri isn't happy about this. "In the beginning the drugs work quite well," he says. "But you build up a tolerance and have to up the dose." In large amounts, sleeping pills can have side effects such as memory impairment and elevated blood pressure. Even at low doses, the sedation can seep into the next day, making accidents more likely.

As the two-hour interview winds to a close, Hauri begins to offer his own advice. He wants to get Judy off sleeping pills: She's relying on them too heavily, and studies show that behavioral changes produce longer-lasting solutions. Of all the reasons for insomnia, he says, anxiety and depression loom largest; psychological causes account for maybe half of the cases that end up at sleep clinics. Hauri isn't just talking about full-blown clinical disorders but also fretfulness in response to life's stresses. Judy's ordeals more than qualify. Indeed, this afternoon a Mayo psychiatrist sees enough residual strain in Judy to suggest a brief period on antianxiety medication.

But there's something else going on here, Hauri tells her. Many of Judy's pressures have eased, yet the insomnia continues. "We see this a lot," says Hauri. "People develop a fear that, my God, if they're not asleep in ten minutes, they'll be awake all night. The worry itself creates insomnia."

Hauri once made a bet with 20 cocky undergraduates who swore they could sleep anywhere, anyhow, as soon as their heads touched the pillow. "I told them, `I'm going to give you a nice bed in my lab, and if you can fall asleep in five minutes I'll give you $100,"' he says. "Only one of them could do it. They were all too focused on getting to sleep."

Even with their egos slightly bruised, those undergrads probably slept just fine once they got back to their cozy dorm rooms. But Judy's habit of insomnia is ingrained. Unlearning it will take work.

First, says Hauri, she has to teach her body to think of the bedroom as the place where sleep occurs. University of Arizona sleep researcher Richard Bootzin has developed a stringent set of rules to accomplish this. No going to bed until you're sleepy, number one. Number two, do nothing in bed except sleep--no reading, no TV, nada. (Sex is permitted, though. "We don't tell people to have sex on the kitchen table. Americans prefer not to do things like that," Bootzin says.) If sleep doesn't come within 15 minutes, get up and do something relaxing. Lie down again only when sleepy. Then it's out of bed at a regular time each morning, however little sleep you've had. And absolutely no napping!

Hauri isn't such a stickler. Researchers don't know which changes will help which insomniacs, he says, so patients need to experiment. Most shouldn't nap during the day, for instance, but Hauri has found that a short siesta helps some insomniacs sleep better at night. (He advises Judy not to nap.) And he frequently suggests that patients read or watch videos in bed--even that they fight sleep. "It often seems that the harder they try to stay awake, the more likely sleep is to overpower them," he says.

No television, though. TV will tell you the time, and knowing how long you've been lying awake isn't helpful. Hide the clock. And no obsessing over events of the day; set aside time outside the bedroom for that.

Hauri has a few more tips for Judy. She and Doug should schedule regular kid-free time together, be it only a humble meal chez McDonald's. She should exercise in the late afternoon, not the evening. Exercise is temporarily stimulating but makes sleep easier five to six hours later, when body temperature drops extra-low as a result. And she should cut her time in bed. Researcher Arthur Spielman of City College in New York has shown that sleep restriction helps force insomniacs into better sleeping habits.

Finally Judy and Doug head off to find lunch. "She's had quite a time," says Hauri once she's gone. "Still, I feel sure that she'll be able to look back on this episode as just that--an episode."

A few months later it looks that way. Judy's off the sleeping pills, but she's getting a blissful eight hours of sleep just about every night. She'll keep taking her antianxiety medicine for a few more months. After that, she says, she'll rely on the behavior changes she's made.

"Insomnia was consuming me," she says. "I would look at other people and think, What is wrong with me? Look at all those people who can go home now and sleep, while I can't. Now I sleep through the whole night. It's such a relief. I feel normal again. "

The Problem Sleeper's Checklist
Whether it's simple angst or a profound depression, psychological upset is the leading cause of insomnia. Another biggie is fretting about sleep, which nearly every insomniac has learned to do. But insomnia isn't all in the mind, say experts. Here are some of the questions they ask when a good night's sleep seems out of reach.

Insomnia can result from many physical complaints: the pain of arthritis, say, or the metabolic speedup of a hyperactive thyroid. A condition called sleep apnea, too, can cause nighttime awakenings: Poor muscle tension allows the throat to collapse during sleep, interfering with breathing. If you've had trouble sleeping most nights for three to six months, your first order of business should be getting to your doctor for a checkup. However, it may take a sleep specialist to identify exotic conditions known as restless legs syndrome and periodic limb movement. Their names say it all: Legs feel creepy-crawly, keeping you awake, or jerk around, waking you up. Too much caffeine or too little exercise can lead to these disorders, as can poor circulation. They can be treated with a drug called Sinemet.

Some people seem to be naturally poor sleepers, apparently because their bodies are hyperaroused. (They burn 9 percent more calories than the rest of us, for instance.) If you've always struggled to slumber, it's critical for you to make your life sleep-friendly. Restrict caffeine, keep a regular sleep schedule, exercise in the afternoon, and use relaxation techniques such as stretching and meditation.

"Doctor, I can't sleep," you say, but in the sleep lab your brain waves look like those of any other sleeper. If you take a sleeping pill, though, you wake up feeling rested--suggesting there really is an underlying problem. Unfortunately, scientists don't know what it is. Sleep state misperception, as this condition is called, is very rare; doctors suggest the behavioral changes recommended for more common forms of insomnia. Another sleep-quality complaint, called nonrestorative sleep, causes shallow sleep by night, sore muscles and sleepiness by day. The reason? When sufferers should be sleeping deeply, their brains put out alpha waves, normally seen when people are awake. Regular exercise dampens the muscle pain, while an antidepressant called Elavil restores normal brain waves during sleep.

We all have biological clocks that keep us on a close to 24-hour cycle. Close is good enough, because sunlight synchronizes us with the world. But people can nudge their clocks out of phase if they stay up late and rise late. Adolescents tend to have slow clocks, which explains why teens are night owls and morning slugabeds. Older people find their clocks speeding up; they may nod off at nine in front of the TV, then wake at four in the morning. You can reset your clock with a specially designed light box or a low-tech outdoor stroll. Can't get to sleep? Dose yourself with light for an hour or two in the morning. Wake too soon? A walk before dark may help.

Rosie Mestel

For a list of accredited sleep clinics, write to the American Sleep Disorders Association at 1610 14th St., Suite 300, Rochester, MN 55901.

Remedies for the Middle of the Night
The most common prescriptions for insomnia read like the house rules of a Trappist monastery. Bedtimes and wake-up times are strictly enforced. Caffeine, alcohol, and nicotine are off limits. Meditation is encouraged; napping is a sacrilege. It's a regimen that sleep specialists hold up as the best long-term weapon against sleepless nights. Still, there are times when a body simply wants to take something--something that puts out the lights.

Many herbs are reputed to act as sedatives, from humble chamomile to exotic passionflower. But the most impressive results come from studies of valerian extract. This herb has been prized as a gentle tranquilizer for thousands of years in Europe and is still widely used in France, Switzerland, and Germany. (German health authorities officially recognize valerian as a natural sedative.) In a recent study of 128 people, Swiss researchers found that the extract helped troubled sleepers drop off faster and stay asleep longer. Valerian is available in capsules and tinctures; it can be brewed into tea, but many would-be users are put off by its unpleasant taste.

"As long as they're taken appropriately, prescription sleeping pills have an important place," says psychiatrist Frank Zorick, who researches and treats sleep problems at the Medical College of Ohio in Toledo. "Often all a person needs is a couple weeks of the medication to get them back into a sleep routine. It can nip the problem in the bud." Benzodiazepines are the most frequently prescribed. They can be habit forming if taken daily for months, but used intermittently they're safe, inducing a continuous though not deep sleep. Long-acting versions such as Dalmane are best for people who feel anxious during the day. Short-acting pills like Ambien are better for those who are tired by day and wide awake at night.

Over-the-counter products such as Unisom, Sominex, and Nytol offer a low-cost accessible alternative. They contain antihistamines and create the same heavy-headed drowsiness many cold medicines do. If you take a large dose, sleepiness and even disorientation can last well into the next day. But a moderate dose may be useful if you have occasional sleep-onset insomnia--that is, trouble falling asleep.

Naturally produced by the body, this hormone keeps internal clocks in sync with the cycles of day and night. A number of studies have shown that melatonin pills can reliably treat jet lag. There's been less research on it as a sleep aid, but in a well-publicized 1994 trial it helped people fall asleep more quickly than a placebo. Many studies have found short-term use to be safe, but researchers say the effects of prolonged use aren't known. Melatonin is sold in health food stores and drugstores.

The strongest medicine of all may be another kind of discipline: exercise. Accumulating evidence suggests an afternoon work-out improves sleep quantity and quality. In one recent trial at Stanford University people with moderate insomnia fell asleep twice as fast and slept, an extra hour once they began going for brisk walks. No side effects, no worries about overdoes--and no one has to enter a monastery.

Benedict Carey



By Rosie Mestel

Rosie Mestel is a contributing editor.

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