Insomnia might feel like a punishment from the gods, but it is generally thought to be a mind-body problem. While your body would like to sleep, your mind is much more interested in listing every thing you need to do tomorrow. But there’s a difference between a bad night’s sleep and a night of insomnia.
There is no negotiating with insomnia — you are at the mercy of your brain’s whims, like a pregnant vegetarian who finds herself eating slices of bologna slathered in jam. Thus the thrashing in bed (which makes us so popular with loved ones) begins: “I want to be on my left side. Wait, that is not quite right. Put your right arm up a bit. Now, uh, bend your left knee and put your left hand under your pillow. No, bend your knee more. Go to your right side now. You know what? Changed my mind. What I really want is to lie on the bathroom tile floor.” And when you have insomnia, you get up, grab your pillow, and head off to the bathroom because this is the tenth night in a row, and you know that without at least four hours of sleep you’ll break down crying in public again, and maybe, on the tiles, sleep will finally come.
The market is flooded with sleep remedies, but for the most part they target short-term, occasional sleep problems: sleeping pills you are not supposed to take consistently, relaxation tapes, and “just get out of bed and do something else.” But chronic insomnia is more insidious, more painful, and much more damaging than troubled sleep. For some people, the very mechanism that brings on sleep just seems to be broken, and finding an uninterrupted, solid eight hours is maybe a once-a-month occurrence.
For an affliction that 30 percent of Americans claim as their own, not much is known about insomnia. It’s still listed in the DSM-IV as something that is “conditioned” — as in, the person suffering from insomnia has brought this on herself through poor “sleep hygiene” — rather than a physical problem. Daniel Buysse of the University of Pittsburgh School of Medicine’s Psychiatry Department lays it out for Gayle Greene in her book Insomniac: “We do not know the real causes of insomnia, nor do we know whether any treatments, including behavioral and psychological treatments, actually treat these causes.” And Gary Richardson and Thomas Roth from the Sleep Disorders Research Center tell us, “We do not know…the nature of the basic neural mechanisms underlying primary insomnia (meaning insomnia that is not the byproduct of another ailment). Nor do we know the identity of specific neurotransmitters that might be involved, or even whether specific neurotransmitter systems are involved. The genetics of the disorder are also not known.”
Sleep research is still new, and little is known about what sleep does, why creatures do it, or the basic purpose of dreaming. Scientists only discovered REM in 1953. We also don’t know why people’s sleep patterns fluctuate greatly: Some only need three hours of sleep; some need nine. Some people cannot get to sleep before 3 a.m.; others are hardwired to be morning people. At its basic definition, insomnia is an inability to get enough restorative sleep, but the whys seem to vary from person to person.
There is a lot we don’t know, and at the moment few people seem to be looking. While in 2005 the pharmaceutical company Sanofi-Aventis spent $123 million advertising Ambien, their blockbuster sleep aide, the National Institute of Health spent only $20 million on insomnia research that same year. We are aware of some correlations, but no one can tell what is cause and what is effect. Are insomniacs anxious because they are not getting enough restorative sleep, or are they not getting restorative sleep because they’re anxious?
What we do know is what happens to a person when they can’t sleep. In extreme cases, like with fatal familial insomnia, a genetic disorder that comes on in middle age, a total lack of sleep can kill someone in about a year. But for those who are merely not getting as much sleep as they need, doctors find decreased levels of growth hormone and increased levels of cortisol. After a week of sleep deprivation, a previously healthy man or woman can become insulin resistant. Their memory, ability for creative problem solving, motivation to complete tasks, and learning potential all suffer. Long-term insomnia puts you at a greater risk for osteoporosis, heart disease, weight gain, and diabetes. Knowing all of this, by the way, does nothing to help soothe you when you wake up at 3 a.m. again.
That same list of health problems comes with a diet based around fast food, though. What the insomniac list is missing is the existential dread. The ailment causes actual suffering, and is linked to alcoholism and suicide. Jacqueline, profiled in Insomniac, tells Greene, “If I get three hours, I celebrate, it means I have a good day…If I have two nights of no sleep in a row, everything hurts, the brain burns, the head aches, I have burning inside the joints, feet that become frozen. If I go a week like this — well, you know, you get suicidal.”
Gayle Greene tries to collect in Insomnia all of the information she can about research and treatment, as well as anecdotes and personal histories of those suffering. Some of it is fascinating, like the discovery of “pseudo insomnia” — a state wherein patients report not sleeping while their EEGs register sleep patterns. In the morning, patients at the sleep clinics would grumble about a poor night’s sleep, and the researchers would dismiss them as being neurotic because their EEGs said they were actually asleep. But pseudo-insomniacs suffer from the same debilitating physical problems as subjective insomniacs — attention deficit, elevated metabolism, grogginess, and anxiety.
In a normal sleep cycle, the sleeper goes from beta (random, fast brain waves of wakefulness) to alpha (calm wakefulness) to theta (sleep) and delta (slow wave sleep, or deep sleep). When we slip from alpha to theta, it’s as if a switch is flipped. One instant there is awareness of the outside world, and then there is not. And with normal sleep, all ability to form memories at this point stops. But with insomniacs, the mental activity — and the ability to remember that activity — does not cease in the same way. Insomniacs remember more of their awakenings in the middle of the night, and are so aware of the outside world that they would swear they were awake while their brain waves report sleep.
Despite the compelling subject matter, however, Insomniac is painful to read. Greene constantly repeats herself; cannot seem to make her statements in clear, concise ways; and cannot remove herself from the story for more than a few pages at a time. There is so little collected elsewhere on the subject, however, that someone desperate to know what goes on in those wee hours may have to plow through Insomniac despite its considerable shortcomings.
Not that there is any hope in these pages. People can rearrange their entire lives and still be unable to sleep. A “San Francisco insomniac” wrote Greene and told her:
I quit my job, told my boss I could not sleep and it could be due to my work. I began to change my entire life for the sake of sleep. I work as a photographer now, no longer spending hours sitting, or in front of a computer… I eat well, I exercise daily, but I don’t work out close to bedtime. I don’t take drugs. I try to keep a schedule. I get into bed by ten and get up by seven. In actuality, I get in bed, and after my girlfriend falls asleep, usually in less than 30 seconds, I lie in bed until the sun comes up. I’m aware of all that happens in between.
The list of potential remedies is a useless gathering of lifestyle habits, herbs, drugs, alternative medicines, and sensory deprivation methods that have maybe helped a few people on occasion. It may help to cut out all sugar from your diet, or to restrict protein to certain hours of the day. On the other hand, that might have no impact whatsoever. You can take Ambien, which does nothing to help bring on the deepest parts of sleep, and may lead you to unconsciously go for a drive, eat a stick of butter, or rape your wife. There’s cognitive behavior therapy, which was designed from the assumption that insomnia is the result of poor sleep habits. When your sleep mechanism is broken, however, you might as well use ancient Roman remedies, like “anointing the soles of the feet with the fat of a dormouse,” or “drinking a potion made from the gall of a castrated boar.”
For now we insomniacs will take what we can get, self-medicating or slowly coming to terms with the fact that while everyone else is sleeping, we’re rummaging through the refrigerator, watching Encino Man on cable, or feng shui-ing our bedrooms. Sleep is still a mysterious, uncharted territory, and a place where some of us are strangely not granted access. • 10 September 2008