Getting the Z’s You Want
Sleep-sense in the 21st Century
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Having experienced years of problems getting to and remaining asleep, and like all practising psychologists seeing many people who similarly suffer, I have long felt a need to try and resolve “the sleep problem”. Indeed, sleep is almost the new sex—a highly valued experience that seems to be increasingly hard to obtain in a world that is spinning so fast it appears to be at risk of flying apart. While people generally are able to get the Z’s they want, we still need education about what does and does not work, both to improve sleep quality and instil sleep-sense.
Sleep plays a vital role in emotional well-being. When we don’t get enough sleep, or experience poor-quality sleep, we are less able to cope with most of life’s challenges. Conversely, getting a sound night’s sleep can bolster our ability to cope. Our physical health is also greatly impacted by our ability (or otherwise) to get good-quality sleep. One of the functions of sleep, for example, is to recharge our immune system, making us less prone to a broad range of illnesses. Studies have shown that people with routinely poor sleep are also more prone to developing chronic pain following an injury (and the vast majority of people with chronic pain experience poor sleep).
Other problems associated with lack of sleep include an increased likelihood of having a road accident while sleep-deprived, with the level of risk at times being worse than drunk-driving. Lack of sleep affects both mental processes and fine motor skills, slowing down reaction times and the ability to quickly make sense of risky situations. Being overly tired also impairs a person’s normal sense of danger, and can result in actions that would not ordinarily be taken. A tired brain has to work harder to make sense of experiences because it is not working efficiently; the sleep-deprived brain is busy sending energy to the prefrontal cortex to try and overcome the effects of fatigue as a compensatory strategy. When we are overly tired, we tend to lose the ability to focus on one item amongst a whole field of stimuli, which can create problems with work as well as driving. Sleep deprivation also affects memory, compromising both our short- and long-term memories. Dream, or rapid eye movement (REM) sleep, plays a large role in committing experiences from short-term to long-term memory in a process referred to as memory consolidation. Sleep deprivation makes it difficult to plan activities or know when to start or stop particular actions. As a result, we tend to fall back on habitual ways of responding to situations, which is fine so long as the habits are constructive ones, but is not so great if they aren’t. At its most extreme, sleep deprivation can result in mania-type symptoms, including those commonly associated with psychosis, such as paranoia, hallucinations, extreme energy levels and aggression. Sustained sleep deprivation has been associated with damage to brain cells. Clearly, sleep matters.
Objecting to the term “sleep hygiene”, I prefer the term “sleep-sense”. The notion of hygiene has a questionable place in the discussion of sleep, as it gives a misleading impression of sleep problems being medical problems with hygienic (sterile) solutions. Sometimes sleep problems do indeed have medical causes, and sufferers need to consult with a suitably qualified health professional to either eliminate or treat such possibilities, especially if they have worrying or puzzling symptoms. But I suggest this with a degree of caution if there is no clear medical problem, due to the risk of being told to take a pill for an intermediate time, or forever. There are very real problems associated with the prescription of sleeping tablets and benzodiazepines (minor tranquilisers), both short and long term, which will be discussed in a later section.
Rather than being about hygiene, sleep is more often to do with “sense”, and we do need to be thinking clearly and sensibly about the issues and factors involved. Some of the sleep-sense program discussed in my book (Alexander, 2017) will appear to be just common sense, while other information and proposed strategies are likely to be novel to the general population as the book introduces sufferers to what science and research say about obtaining sound sleep.
Surfing Brain Waves for Sleep
An essential place to start is the basic rest activity cycle, or BRAC, which can perhaps be more accurately thought of as the brain rest and activity cycle. The BRAC is a human biological cycle of approximately 90 minutes (ranging from 80–120 minutes) that is characterised by different levels of brain excitement and relaxation. The cycle is controlled by the human biological clock and occurs in order to allow the brain to take a regular rest. All brain activity utilises sodium and potassium ions for electrical signals between neurons. After a sustained time of high levels of brain activity, these ions become diminished. For the purpose of restoration, the brain goes into slow brain wave states, resulting in day-dreaminess, tiredness and more proneness to sleep.
Being a cycle, the BRAC repeats itself every 80–120 minutes. If feeling alert and focused, it is likely that the person’s brain is in the first 80–100 minutes of the cycle, characterised by a fast brain wave state. If finding it harder to focus, there is a good chance that the person is in the second half of the BRAC, with brain waves slowing down. During the last twenty minutes of the BRAC, people tend to feel day-dreamy and tired. This can be problematic at work, but it is highly conducive to sleep. During this stage of sleepiness, in which the brain is restoring sodium and potassium ion levels, and once the twenty minutes of rest is complete, the brain will move back toward a faster brain wave state and alertness.
When a person is asleep, the BRAC can be seen cycling between lighter and deeper sleep. Where the diagram points to the resting phases (the time when people are more likely to fall asleep) as being the low trough of a wave, it is referring to a low level of brain wave activity. This trough in the cycle will be experienced as a wave of tiredness that washes over the person, making it hard for them to stay awake unless they are involved in an engaging activity.
The relevance of the BRAC for going to sleep is apparent. People are much more likely to sleep if the timing of their attempt to sleep coincides with the rest phase of the BRAC. If the person is trying to force sleep during the activity phase (because sleep at this time fits their plans, if not their brains), they are not likely to succeed; everything in their brain is working against their best efforts, and frustration will ensue. This understanding of sleep coming to us in waves is totally opposite to the notion of trying to make oneself sleep. Like digestion and circulation, sleep is a function of the organism that no conscious effort can force. In fact, any effort to force sleep will most likely interfere with the natural ability to be taken by the next wave of sleepiness. The best we can do is to foster the conditions that will allow sleep to occur.
People can make themselves entirely anxious about sleep so that they end up trying too hard to make it happen. Waves of sleepiness can carry the person along if they have not weighed themselves down with excessive anxiety about getting to sleep. There are many other factors that can interfere with catching the next wave as well, but what people do to themselves in generating sleep anxiety is a primary issue. As a recreational surfer, I regularly encounter skinny young guys getting all the waves; middle-aged people such as myself, being heavier than our younger counterparts, generally have to work a lot harder to catch waves. Young surfers seem to require minimal exertion, one or two paddles, to be taken along by the next wave. So, just as being physically light is an advantage to catching waves in the surf, being psychologically “light” is conducive to catching BRAC waves for sleep.
When experiencing sleep problems over a sustained period of time, a normal response is to become anxious about the whole proposition of sleep. As with any other form of anxiety, sleep anxiety involves a heightened state of arousal with associated limbic area activity, none of which is conducive to sleep. A person’s regular sleep-time rituals can begin to elicit distress and fears of yet another night of torment. In addition, a “master-identity” as a poor sleeper emerges over time, further entrenching the expectation of poor sleep, and the associated anxiety becomes more extreme.
Substances and Sleep
In desperation, and being unaware of other options, sufferers of poor sleep will often resort to substances to aid their efforts. While alcohol and cannabis in sufficient doses can be sedating enough to induce sleep, they are often associated with rebound effects whereby the person is likely to wake up in a highly alert state once the substances have been metabolized and the sedating effects have worn off. When the brain’s normal level of arousal has been suppressed by substances, it is able to alter levels of neurotransmitters to counteract the sedation. The person is then likely to wake up in the very early hours of the morning with such a high level of brain arousal that no further sleep can occur.
A further problem is the impact that psychoactive substances can have on REM sleep. Only two standard drinks of alcohol are required to suppress normal levels of this essential stage of sleep. While harder to quantify due to inconsistent potency, cannabis can have the same impact. Being REM-deprived is common among people who drink regularly (having two or more standard drinks a day), and this reality is similarly compounded by those who regularly consume cannabis on a nightly basis. Contrary to claims that cannabis assists with sleep, research recently conducted by the University of Boston concluded that daily cannabis users scored higher on the insomnia severity index than non-users (Conroy, Kurth, Strong, Brower, & Stein, 2016).
Many others seek assistance from their physicians and are prescribed antidepressants, minor tranquilisers and/or sleeping tablets. While these may increase the amount of hours asleep, each of these classes of drugs has the ability to inhibit REM sleep. For example, SSRI antidepressants can suppress up to 30% of REM sleep (and may also result in too much arousal for sleep), while tricyclic antidepressants can suppress up to 50% of REM sleep and MAO (monoamine oxidase) inhibitors can suppress up to 100% of REM sleep. As dreams appear to be our species’ nightly psychotherapy session, enabling memory consolidation and other psychological “digestive” processes to occur, any inhibition of REM sleep is likely to result in poorer psychological well-being and functioning. The same problem is evident with both minor tranquilisers and sleeping tablets. Consequently, between alcohol, cannabis and prescribed pharmaceutical drugs, it is reasonable to suggest that our culture is to a great extent REM-deprived. The Western world suffers from not enough dreaming. This is problematic when one considers the research evidence testifying to the adverse cognitive and emotional effects of not enough REM sleep.
Further problems are also evident with the use of sleeping tablets and minor tranquilisers. For example, researchers at the University of New South Wales, Australia, collected data from unexpected and violent deaths that occurred in that state between 2001 and 2011 (Corderoy, 2012). They found that zolpidem (marketed as Stilnox in Australia and Ambien in America) contributed to the deaths in around one third of all cases. The study leader, Professor Shane Darke, suggested that zolpidem be considered an unsafe drug to take, and that it should be investigated as a possible factor in all cases of unexpected or violent deaths (Corderoy, 2012). Bizarre and confusional behaviour, sleep-walking, actions with no conscious awareness or memory, violence and suicide have all been associated with sleeping tablets.
In addition to these dangers, research from San Diego, using a sample of over 10,000 subjects matched with more than 20,000 controls not using prescriptions drugs, found the rate of mortality amongst consumers of sleeping tablets and minor tranquilisers was nearly five times higher (Kripke, Langer, & Kline, 2012). The rates of mortality were dose dependent, the risk increasing with increased use of the drugs, and these rates held when other health issues were statistically controlled for. It has been rightly pointed out that correlation is not causation; nevertheless, room for concern is present. The authors noted that the findings were robust among 12 distinct classes of comorbidity, indicating that hazards associated with hypnotic drugs were not attributable to pre-existing disease. Despite these risks, most sufferers of sleep problems presenting to either GPs or psychiatrists for help come away with a script for one or more of these drugs. The British Medical Journal Open article that reported the above research concluded that physicians need to explore non-pharmaceutical options with their patients (Kripke, Langer, & Kline, 2012).
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This has been an excerpt from Getting the Z’s You Want: Sleep-sense in the 21st Century by James Alexander. To download the full article, and more excellent material for the psychotherapist, please subscribe to our monthly magazine.