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To Sleep
They save me,
or passed day will shine
Upon my pillow
breeding many woes
Save me from my curious conscience,
that still hoards
Its strength for darkness,
burrowing like a mole;
Turn the key deftly in the oiled wards,
And seal the hushed casket of my soul.-Keats
Pining for sleep introduces a new torture for
its victim as the nights suddenly grow thick and dreary. Effectively
deteriorating rational thought, chronic insomnia leeches the reason
from reality. Festering inside the victim's guts, an ache grows
steadily worse as the minutes tiptoe by the clock. A sense of
hopelessness blooms maroon and black.
No one knows the diseased effects of sleep deprivation like Isabel Conners*. Her nights draw longer than any typical sleeper could imagine. Dry, wasted hours spent longing for sleep wait for her at the end of every day. Even a fantastic day seems clouded by the prospect of another sleepless night. Behind every thought lurks the knowledge that she will not sleep that night.
"How hard will tomorrow be, if I don't sleep tonight?" she wonders.
At first, Isabel didn't know that she had become an insomniac. Isabel's son Ryan had just been born to her and her husband Leo, and with a new baby in the house, no one sleeps very much. A typical schedule goes to hell when a baby joins the family, so the couple didn't notice the change immediately.
Every morning, about 3 a.m., Isabel's son Ryan awoke for a diaper change and a early feeding. Although Isabel often had trouble falling back to sleep after getting up with the baby, she never suspected a problem. Only when Ryan reached 10 months old did Isabel realize the situation. At the usual time, Isabel rose from her sleep intending to feed Ryan, but she found the baby to be steadily sleeping. Long after Ryan began sleeping through entire nights, Isabel stirred as if awakened by her son's cries.
Once Isabel's sleep cycle became disrupted, her every attempt to sleep through the night failed. Three years and three months after her son's birth, Isabel still faces insomnia every night.
Denial came first. Although her sleepless nights grew more frequent, Isabel ignored the heart of the problem and forced herself to get into bed. Some nights she would watch old movies until dawn, but mostly, she waited under the covers in distress.
"I laid there for hours and hours," she said.
On the rare occasions that Isabel did fall asleep, the slightest disturbance shattered her chance for rest. A jarring motion or a small cough from Leo could wake Isabel with no chance of returning to her dreams.
"Don't snore, sneeze or cough," she would tell him, half-joking.
Night after night of draining frustration made her days sluggish while her temper grew shorter. After a while Isabel began hating herself for what she had become.
"[In the daytime] I couldn't do anything but lay in the floor and watch Ryan play," Isabel said. "I became a big slug. I just laid there and couldn't even turn my head."
Isabel's lethargy opposed her usual confidence as a hard worker. In control of her life, Isabel had always gone after problems aggressively, searching for a solution. She did everything in her power to solve the problem, and results came fairly easily. Insomnia stopped Isabel in her tracks because it paid no attention to her hard work.
Irritable and angry about her inability to
fall asleep, Isabel stared at the ceiling above her bed, struggling
to relax and fall asleep. Peaceful sleep
never came. Similar to a Chinese finger trap, as more force is
applied to try to fall asleep, insomnia grips more fiercely.
"Sleep was all I could think of," she said.
When she grew tired of fighting the night, Isabel dozed in broken fragments. As the hours drug on, Isabel reluctantly rose and paced about the house.
"You look out the window into the pitch black and think, 'I know they are all asleep.' You get angry because you can't sleep. It just isn't fair. Then you see the lights come on and people come out to get their papers," Isabel recalled.
Finally, her frustration reached a limit. After four months of wretched sleep, Isabel called for help, frantic to find a cure.
"I had these horrible, dark, black circles under my eyes. I would stare in the mirror think, that is not me. I didn't like who I was. I wanted a magic cure."
"I thought it would fix itself," she explained. "In my mind I thought, 'how hard can this be? Sleep is natural.' So, it took me a while to go see Dr. Brown."
Nestled into a corner of the Washington Regional Hospital basement, the green double doors of the Neurological and Sleep Disorder Center wait patiently for people like Isabel to reach out for help.
A collection of assorted miniature figures and Winnie-the-Pooh static window pieces greets patients as they enter the small office. Dr. Melinda Trimble, the center's head polysomnographic technician, offers a friendly smile to ragged, sleep deprived patients. Recognizing the nervous look of a new patient in her office, Trimble began the visit by handing Isabel a book of questions to fill out.
"Fill this out, and you'll see the doctor, soon," Trimble says. Ranging from simple name-and-address questions to complex personal perception questions, the form inquired about any physical or psychological torment that could be causing the insomnia.
"The questionnaire was long and somewhat intimidating. It asked all of these detailed questions about my childhood. Dr. Brown knows all about me now," Isabel said, laughing.
Dr. David Brown, a nationally certified sleep specialist, uses the questionnaire to begin ciphering through possible causes for the disruption of sleep. Both Trimble and Brown work with patients continuously in the nationally-accredited sleep center to help solve the sleeplessness.
Defined by the American Sleep Disorders Association insomnia comes in three general packages. Although every patient's body makes his or her own sleep cycle, three forms of insomnia encompass most cases, and the questionnaire helps to give clues about the patients specific case of insomnia.
Transient insomnia, the mildest form of sleeplessness, does not generally cause any long-term harm as it only generates a few nights of interrupted sleep. Temporary, this version of insomnia often occurs as a result of excitement or stress. A fight with a spouse can interrupt a few evenings of rest, and folks might toss and turn before giving a presentation at work. Usually, these bouts with insomnia fade.
Slightly more distressful loss of sleep occurs with short-term insomnia. Two or three weeks of interrupted sleep caused by a stressful situation such as the death of a family member or starting a new job also generally fades when the victim becomes accustomed to the new situation. Over-the-counter pills often help patients get past the insomnia by alleviating the anxiety of falling asleep.
Sharply contrasting the other two forms of insomnia, and as the most severe sufferers of insomnia can explain, chronic insomnia amounts to no less than wakeful torture. All or most nights pass offering little or no sleep to the victims.
According to the disorder association, more than 35 million Americans complain of chronic insomnia with all or most nights riddled with poor sleep, further stating that sleep is an active state, essential for mental and physical restoration.
Almost everyone in the world faces some sleepless nights, and stress as simple as moving into a new apartment or as complex as the loss of a family member can cause struggle with falling asleep. Even Brown confesses to facing a few frustrating nights of insomnia.
"All of us, at one point in time, are liable to have some difficulties with our sleep," Brown said in his low, even voice. "When it happens to me, I ask myself about the daytime problem that is keeping me up at night," he said, noting that almost all of his patients have an underlying issue that causes the insomnia. According to the ASDA, trouble falling asleep or staying asleep, insomnia, plagues one in three American adults.
Many treatments, with various backgrounds, have been used to treat sleeplessness. At www.well.com/user/mick/insomnia, many methods of falling asleep are listed. Some, such as taking a warm bath, drinking warm milk, getting some exercise during the day and avoiding naps have been traditional treatments for a long time. Other treatments on the site tend to be a little more out of the ordinary, such as rubbing the tummy clockwise with the circles getting smaller and then counter-clockwise with the circles getting bigger. Wiggling toes to release tension is another suggestion for insomniacs.
During his occasional nights of wakefulness, Brown tries to relax and fall asleep naturally.
"Any time you're trying to force yourself to go to sleep, you're essentially arousing yourself, and you become more alert," Brown explained. "Tummy rubbing and the others mostly help the person to relax and avoid forcing the sleep."
When the Isabel finally finished the mass of questions on the form, she and Leo joined Brown for an initial sleep consultation.
The doctors requested Leo's presence during the consultation because bed partners often have a clearer understanding of the victim's sleeping problems than the victim herself. When the patient's sleep is disturbed, the patient might not reach full consciousness, but the loud snoring associated with sleep apnea, which actually blocks oxygen from reaching the brain, or the jerking motion of periodic leg movements often disturbs the bed partner rather than the patient.
Isabel said she was grateful Leo joined her for the initial consultation.
"I'm very lucky that he's such an understanding husband," she said. During the process of sorting through Isabel's insomnia, Leo tried to help Isabel whenever possible by watching Ryan or just offering moral support. Eventually, Isabel and Leo faced the fact that they would have to sleep in separate beds. Isabel's tossing and turning disturbed Leo, and any noise from him woke her. Although the couple has made various attempts to sleep in the same bed, they seem to accommodate one another in separate rooms.
The problem, Isabel said, also put a strain on their love life for a while. With chronic insomnia draining all of the patient's energy, nothing but sleep is left on the person's mind. However, smiling bashfully, Isabel said, "We've got that worked out now. I'm just glad he was so understanding."
Aside from the obvious symptoms of wakefulness, Brown looked for evidence of a physical ailment in Isabel.
"Insomnia is often a symptom of a deeper
problem, medical or psychological," Trimble said. According
to the Association of Sleep Disorders Centers, about 50 percent
of ch
ronic insomnia complaints
stem from physical ailments such as breathing problems or involuntary
muscle activity, and a sleep study performed in the sleep center
offers a great amount of information about the patient's sleep.
Until recently, the expense of sleep study kept many people from investigating their insomnia, but as more people realize the importance of restful sleep, more funding becomes available to programs like the sleep center. Most insurances and Medicaid cover sleep study because the effects of fatigue can be dangerous.
According to Jim Hall, chair of the National Transportation and Safety Board, the Exxon-Valdez oil spill remains one of the most detrimental mistakes made by a victim of sleep deprivation. On March 2, 1989, the third mate on the Exxon-Valdez became too sleepy to operate the vessel. As a result, more than 258,000 barrels of oil spilled into the ocean, destroying wildlife and the surrounding environment and accruing more than $2.3 billion in clean-up costs.
"As fatigue increases, performance becomes more variable, making performance less reliable," Hall said, in a recent speech. "Speed of physical reaction time and speed of thought processes are slowed. There is a tendency to make mental errors and flawed judgments. False responding, or responding when a stimulus is not present, also increases. Memory errors are more likely to occur. Finally, vigilance decreases, and motivation is reduced."
Recognized as an ounce of prevention, sleep studies have begun to flourish in the last 12 years, beginning with the founding of the ASDA, designed to increase awareness of sleep disorders.
Sleep studies examine the patients body during sleep. Measuring brain waves, muscle, eye and leg movements, breathing through the mouth and nose, snoring, and heart rate, the study outlines every physical attribute of the patient's sleep.
"It's a way of monitoring the brain waves so we can score the sleep and see how many arousals they have. It is a way of monitoring oxygen, heart, breathing efforts, and extra movements, if they have any," Brown said, adding that sleep can score from 1 to 10 depending on the readings from their polysomnogram.
Electrodes, microphones and a video camera in the center's bedroom supply the technicians in a nearby control room with the readings from all of the monitors during the study. Although the sleep study should help the patient in the long run, sleeping with electrodes and straps protruding from even the softest covers can seem awkward.
"We try to make it as much like a hotel room as possible so it won't be intimidating like a hospital room," Trimble said.
A clean floral spread covered the large double bed in the center of the room. A small nightstand and several overstuffed comfy chairs completed country-style bed-and-breakfast feel of the room. Easy pinks and soft greens subdued the room, effectively masking its purpose.
While technicians expect a certain level of situational sleep problems during the sleep study, (no one is accustomed to sleeping with wires poking out in all directions) most studies manage to split the night between studying the patient and diagnosing the patient.
Patients settle into sleep with the monitors for the first half of the night, and if the problem presents itself, the technicians fit the patient with a treatment for the rest of the night. If the patient's sleep disorder goes undiagnosed until the end of the study, patients must return for a second night of sleep study.
Sleep apnea often presents itself early in the night, and a Continuous Positive Airway Pressure machine offers treatment for the patients to try during the second half of the night.
Sleep apnea, obstruction of the airway, contributes to many complaints of daily fatigue. With sleep apnea, the patient falls asleep, and the trachea closes, sometimes for as long as three or four minutes. During the night, a victim of sleep apnea may actually stop breathing 300 to 400 times a night. Each time, smothered, the brain awakens the sleeper to start breathing again. Often loud snoring alerts the victim's bed partner of sleep apnea.
"Quick snorting sounds are the brain startling to start up the breathing," Dr. Trimble said.
Levels of sleep include drowsiness, light sleep, deep sleep, and dream sleep, but sleep apnea patients often have trouble going through a full cycle because they keep waking.
Those diagnosed with sleep apnea have few choices for treatment. Experimental surgery offers an option, but there is no guarantee of success. Many sleep disorders, sleep apnea among them, remain clouded because of a lack of funding for sleep study.
"We can tell that [sleep apnea] happens, and we can fix it, but the why is still a gray area," Trimble said.
Currently, CPAP stands alone as the best possible treatment for apnea victims.
CPAP delivers a stream of air to open the passageway to the lungs, but patients must learn to sleep with a mask their faces that blow air down into their noses. Patients must also train themselves to breathe in and out of their noses rather than their mouths.
"Sleeping with a mask disturbs people at first, but it makes a big deal to apnea victims who don't get air otherwise," Trimble said.
Although the CPAP device makes an immediate difference for apnea patients, Trimble said that most patients do not use the machine as faithfully as they should.
CPAP's main success can be seen by contrasting the oxygen levels of apnea patients before CPAP and after.
"If we sat here and held our breath until we passed out, our oxygen levels might only drop to 94," Trimble explained. "Normal breathing stays between about 100 and 90. When an apnea patient sleeps, and their throat closes, they can sometimes dip down into the 50s."
Periodic leg movements also cause many people to lose sleep. Muscle contractions, brief, but repeated about every 30 seconds or so, can arouse the sleeper from a deep restful sleep. Hundreds of leg jerks a night disrupt the sleep cycle, preventing the person from relaxing. As a person grows older, the severity and frequency of the periodic limb movements rises. Restless legs, as the doctors call it, can be treated with sleeping pills, evening exercise and stretching or a warm bath.
Heartburn, arthritis and headaches can also disrupt sleep.
"We don't know why we need to sleep.... Something, we don't know what, is restored or recharged with sleep," Brown said.
After checking for evidence of physically disrupted sleep, Brown suggested that Isabel's loss of sleep stemmed from a psychological obstacle.
Psychological factors claim about half of all chronic insomnia complaints, and doctors in the sleep center have become accustomed to insomniac patients who have not yet dealt with the underlying issue of their insomnia.
Just as an insomnia complaint can mask a more serious physical problem, sleeplessness can also be a symptom of a deeper psychological issue.
"Approximately half of the chronic insomnia [cases] have a mood or anxiety disorder," Brown said. "They obsess over loss of sleep, but may not sleep as badly as they think." Brown also said that in extreme cases, some people sleep but are not aware of it.
"Some strongly misperceive their sleep," Brown said.
Brown hypothesizes that those patients who claim to have not slept a single minute in two years might monitor their sleep differently than most other people.
"Maybe they feel
like they don't sleep because they monitor their surroundings
more vividly than the rest of us. They remember everything, even
the most meaningless noise. Most people discard the memory of
a car passing on the road outside of the house, but these folks
might take note of each noise and remember it. When they wake
up in the morning, they think they were awake all night,"
Brown said.
"Some people who sleep the full eight hours may still have an insomnia complaint. Someone else may only sleep five hours, but if they don't feel tired or somehow unrestored, they have no complaint," he continued.
Taking a step back to get an objective, clear look at the situation often helps to find the solution, so Brown first gave Isabel a sleep diary to fill.
"Using a sleep diary helps to get rid of preconceptions of sleep," Trimble said. "You can plainly see the problem areas and assess sleep habits."
A simple journal of nighttime habits can sometimes bring the problem into focus.
Noting what time a person gets into bed, gets out of bed and wakes in the night can be helpful to pinpoint a problem. Many troubled nights stem from poor sleep hygiene, the consideration a person takes toward preparing for a night's rest.
Teaching proper sleep hygiene and counseling make up most treatments for those people facing psychologically-based insomnia.
Part of good sleep hygiene, as defined by pamphlets available through the sleep center, includes following a list of activities people should not do in bed. The "Not for Cot" list includes watching television, eating meals, doing homework or reading, making phone calls, arguing or working a crossword.
When people do lots of activities in bed, they begin to associate the bed with a place to do work or worry.
Instead, only getting into bed for two reasons helps to encourage the brain to associate the bed with sleep.
"My bedroom is for sleep and sex," Isabel said, smiling as she followed Brown's advice.
By teaching effective sleep hygiene and helping people understand their problem, "We try to make the patient responsible for their sleep," Brown said.
Further tips for effective sleep hygiene include avoiding late-night exercise, caffeine within four hours of bedtime, smoking cigarettes, and drinking alcohol within six hours of going to sleep. A "nightcap" might help the patient fall asleep quickly, but he is more likely to wake during the night.
Bright glowing clocks should also be removed from the sleeping area as they encourage insomniacs to contemplate the time they have not spent sleeping.
When patients cannot sleep, they should allow fifteen minutes to fall asleep, and if they stay awake, they should get out of bed immediately.
"Try not to be frustrated with the bed," Brown said. "They should get up and do something relatively boring."
Most doctors concur that improving sleep habits are the only way to make a permanent change for the better.
"Insomniacs take longer to treat," Trimble said, noting that a simple physical problem usually has a direct treatment available, while psychological issues often require more time to solve.
Seeking treatment as soon as the problem persists heightens the patients opportunity to stop the cycle.
"You need to nip it in the bud, so to speak," Brown said. Once the insomnia gets going too long, people forget the original problem. Insomnia tends to cause pre-sleep frustration by building on itself. Anxiety grows if the patient anticipates not being able to sleep.
Victims of insomnia should visit a doctor or sleep specialists if their insomnia perseveres for more than one month.
Usually, patients suffering from psychologically based insomnia end up being referred to a local counselor to try to help the patient deal with the underlying problems.
In several studies reported in the Journal of the American Medical Association, only insomniacs who try to change their bedtime behavior ever see any long-term benefits. Based on a series of sleep experiments, the study showed that although the behavior-therapy group members had to change their lifestyles, the overall effect of the treatment lasted. However, the group in the study that took a pill to sleep only achieved temporary satisfaction.
Customary with most insomniac cases, Brown tried to counsel Isabel about her sleep hygiene. The simple guidelines, if followed faithfully, can make a difference with troubled sleepers over a period of time.
Isabel chose to try sleeping pills first.
"Going to bed used to be my enemy, and I was not winning," she said. From there, Isabel began a vicious cycle of dependence.
At first, the medication offered Isabel heaven. She slept hard and long without any disruption, but her mornings were groggy and irritable. Sometimes, Isabel truly shook off the restraints of sleep only after two hours of being awake. A zombie to wake up, she again grew irritated with her sleep.
"I got hooked," she explained. "If I forgot my pill when we went out of town, I completely freaked out. I just could not sleep without them."
Initially reluctant to take the drugs, Isabel's independent tendencies shone through, and she didn't want to be addicted to the medication.
"I only took half of a pill when I could get away with it," she said.
Only a few weeks passed before Isabel's miracle cure began to fail. As an insomniac, Isabel's nights averaged five hours, but with the medication even those hours became broken.
Addicted to the drugs, Isabel didn't know how to sleep anymore. It had been two years since she took her first pill, and she was running out of hope.
"I am totally convinced that you don't cure anyone of insomnia with medication," Dr. Brown said adamantly, adding that he only prescribes sleeping pills as a temporary solution.
After intensifying the dosage and strength of her medication, Isabel finally picked up her true salvation from insomnia.
During one of her follow-up visits, Dr. Brown suggested Isabel read Dr. Greg Jacobs' book, Say Goodnight to Insomnia. A last chance to make the change she needed, Isabel read the book with initial skepticism, but her mind changed with her results.
"I swear by that book. It is the only thing that helped me get of the drugs, " Isabel said, her face lighting up.
Jacobs' book approaches the insomnia patient with the assumption that they are depending on drugs to fall asleep. Addressing the patient in an easy tone of conversation, Jacobs explains the physiology of insomnia and the courage it takes to master it. Words of encouragement seep through the pages, and the energy of compassion surges full in the book.
Stories of survivors pepper the chapters, and a sense of independence grows strong. By chapter three, Jacobs addresses the change necessary to stop using the sleeping pills.
Gradually cutting back on the doses of sleeping medication begins the process of learning to fall asleep naturally. A potentially painful process, stopping the cycle of pills often causes symptoms of withdrawal for the patients.
As patients learn to fall asleep naturally, Jacobs supports the lasting effects of natural sleep by teaching the patients good sleep hygiene.
Jacobs explained that insomniacs should use their bed area for sleep and sex only, leaving all of the work and worries for the rest of the house. Other techniques such as setting a regular waking time also help to establish rules for insomniacs to control sleeplessness.
Jacobs' book brought hope back into Isabel's nights. The situation became clear to Isabel, and she came through as a stronger person.
"It was all a mental thing for me," Isabel said. "You have to train yourself."
On nights when Isabel faces a bout of sleeplessness, which is still several times a week, she knows just what to do.
First, she ignores everything interesting.
Avoiding the television because she really gets into the late-night movies, Isabel nestles into a spot on the couch. Dressed in her most comfortable green nightshirt, Isabel reads the most boring magazine she can come up with, Leo's latest issue of Car and Driver.
Because Isabel harbors no interest in cars or their inner working parts, the magazine almost always puts her to sleep.
"They talk about the stupidest stuff!" she laughs.
Fortunately, Isabel and Leo developed a sense of humor about her sleeping troubles, but she can remember when she would burst into tears over it.
Now Isabel faces the night confidently, accepting her plight as a way of life.
"I can go to sleep," she said with affirmation. "I have made progress."
Isabel said she knows she will never be cured of her insomnia. She will probably always be a light sleeper, but comparing the experience with alcoholism, she explains that she will always be an insomniac. However, she can fight it as much as possible, day by day.
Insomnia still effects Isabel's life, mainly by keeping her memory short.
"I can't remember anything. I have to write it down," she said. Isabel keeps her keys by the backdoor next to the phone, and she has found that sticking notes to herself in the same place creates a greater chance of remembering the notes.
"You do what you have to do," she said, shrugging her shoulders, but Isabel still holds the hope that she might someday sleep free of her insomnia.
"I want to sleep a coma sleep for a week. I want the sleep that makes you stretch when you wake," she said.
*All subjects names have been changed to protect privacy.