“You wake up at Seatac. You wake up at O’Hare, Dallas-Fort Worth, BWI. Pacific, mountain, Central. Lose an hour, gain an hour. This is your life, and it’s ending one minute at a time. You wake up at Air Harbor International. If you wake up at a different time, in a different place, could you wake up as a different person?
When you have insomnia, you’re never really asleep, and you’re never really awake.”
-Lou, narrator in the 1999 film, Fight Club.
Insomnia does make for a catalyst in a movie/novel plot. Al Pacino plays a detective on a serial killer’s trail in the movie Insomnia, adapted from a Stephen King novel by the same name. This is the part of Alaska where the sun never sets. Drained by the cerebral case and disoriented by the perennial sunlight, the detective develops Insomnia making the plot even more thrilling.
But there is nothing pulp fiction about it when it happens to you or a family member. As mentioned in the previous feature, insomnia is what we tend to group anything related with sleep under. But there are varieties of sleeping disorders and many often appear along with other health issues. Hence, it is important to know a little about the more common conditions. Also, some of the conditions are downright entertaining to discuss!
Insomnia may be defined as complaints of disturbed sleep in the presence of adequate opportunity and circumstance for sleep. For diagnosis, one or more of the following features must be observed:
Since different Physicians may consider different criteria for diagnosis on a case by case basis, there is no monolithic definition of the condition.
As most disorders, insomnia can be both chronic and acute. Acute; off course, is what you and me can experience on a given day or a few days if an all-important interview is coming up or the next morning is of the Monday variety. Such one-off bouts may be responsible for you reading features such as this one! Chronic insomnia, like any other disorder, is one that lasts for more than 6 months. However, in this case, difficulty sleeping due to any of the above mentioned characters for a period of one month may be enough to be considered as a chronic case. Insomnia can thus last for relatively short periods of time in some patients while it may haunt others for decades. It can also relapse after a lull.
Approximately 1 in 8 or 11.76% or 32 million people in U.S.A. are estimated to be suffering from Insomnia. The total with undiagnosed cases, i.e. incidence would be higher. This figure is expected to be around 10% in India too. The results of epidemiological studies vary according to how stringent a definition of insomnia is being considered.
It has been long debated weather prevalence is higher among older people. Earnest Hemingway said we sleep lesser and lesser as we age because you know you don’t have a lot of time! However, some studies suggest that the elderly are unable to maintain sleep for a long time due to declining health and institutionalization but make up for it by daytime naps which may not be noticed. There have been studies attempting to link up insomnia with everything from divorce and separation to poverty and lack of education but results remain inconclusive. Genetic etiology is also strongly hinted. So Physicians may enquire about family history while diagnosing.
Prevalence among women is much higher, especially after menopause.
Co-morbidity and Confusion:
As already noted in the previous feature, insomnia can lead to cardiovascular, gastrointestinal and other disorders. It may also be an outcome of such disorders, i.e. co-morbidity is high. Co-morbidity with depression is a dangerous cocktail. Mood disturbances and cognitive disturbances in concentration and memory are often cited. In fact, insomnia is a symptom of depression and may be linked to depression more often than any other ailment. Drugs prescribed are also more or less similar, at least in primary stages. We shall take a look at treatment a little later. It is not always straightforward to determine which one is the cause and which is the effect. Development of standardized and conclusive diagnostic methods is very important.
Diagnosis is based primarily on examination of signs and symptoms. Apart from a clinical interview of the patient, information from family members and care-givers may be equally important, if not more so. This is because patient’s recall of sleeping patterns is not reliable. Patient’s history and family background are to be considered. In some cases, more in-depth clinical investigation is required to assess the presence of co-morbid syndromes.
No standard diagnostic test has yet been developed and universally accepted and therein lies the issue. It is also possible that because of the dynamic nature of the condition, a standardized test may never be possible. One tool is multichannel polysomnography. In this elaborate experiment, the patient is made to lie down in a controlled setting. Numerous channels are attached to monitor patients’ brain activity and other vital stats. A pattern of the patient’s sleep and wakeful states is arrived at for diagnosis. However, the highly controlled environment makes it difficult to re-produce normal conditions. Also, patients have been found to report disturbed sleep even when graphs suggest otherwise, probably due to anxiety.
Following are some common sleeping disorders:
Sleep Apnea is when breathing gets paused during sleep for varying lengths of time. A majority of cases are due to obstruction to respiratory passage, i.e. snoring. Smoking, drinking and obesity are believed to be triggers. The patient is almost never aware of it during sleep or when he wakes up. He may become conditioned to the symptoms of day-time drowsiness and fatigue and may never take medical advice. It is thus noticed more often by family and caregivers. It can seriously impair the sleep quality of the bed partner. Such people will tell you that snorers always fall asleep first!
But medical help should be sought as this seemingly benign condition can even lead to vascular complications as the oxygen levels in the blood go down due to periods of paused breathing. Snoring can cause headaches, difficulty in concentration, fatigue and reduced work performance. Polysomnography is most widely used in the diagnosis of this disorder. Non-surgical treatment in the form of a C-PAP (continuous positive airway pressure) machine is becoming popular. It includes a pump with a mouthpiece which creates continuous positive pressure in the air way. So once you get used to sleeping with something resembling an oxygen mask on your face every night, life will have reached a newer plain of normality!
However, it is important to note that people may snore without having apnea. Also, the loudness of the snoring is not necessarily indicative of severity of condition. Sleep apnea is associated with stroke and heart failure with long periods of obstructed breathing. So the handful of thousand rupees you may have to spend on the diagnosis may be well worth it.
Circadian Rhythm Disorders:
Circadian rhythms are natural clocks keyed in every organism typically in response to environmental stimuli such as position of the sun and changing seasons. This is why bears hibernate and humans generally sleep at night. But imagine if bears had to do something unnatural like travel across time zones and work rotating shifts. They would end up suffering from circadian rhythm disorders. Disorientation is a major manifestation along with difficulty falling asleep. Behavioral therapy is needed along with arranging an appropriate sleep environment. This may even include so-called light therapy: alternately using bright and dim lights as cues to sleep at desired timings.
Restless Leg Syndrome:
Restless Leg Syndrome (RLS), as the name suggests involves restlessness which is to a great extent uncontrollable. The movement is in response to sensations described variously from tingling to burning. It most commonly affects the legs but can affect other parts of the body too. However, movement provides only temporary relief.
RLS is idiopathic though genetic links are suspected. It is associated with certain medical conditions such as iron deficiency, varicose veins, autoimmune disorders etc. Certain drugs such as anti-psychotics and antihistamines are known to trigger the condition. Prolonged periods of inactivity worsen the situation. Hence, RLS can most be pronounced at night, disturbing sleeping patterns of not only the affected person but people around.
A narcoleptic person suffers from excessive day time sleepiness to the extent that he or she may fall asleep at random. You definitely wouldn’t want your driver to suffer from this. Although disturbed sleeping patterns maybe observed, a person may be narcoleptic even after getting adequate sleep. Genetic origins are suspected. It is often mistaken for insomnia or other sleeping disorders.
Explicit symptoms are cataplexy (sudden muscular weakness or numbness), sleep paralysis*, hallucinations and **automatic behavior. To think that people pay big bugs for hallucinogenic drugs, so much so that narcolepsy may be mistaken for drug abuse is pretty amazing.
*Sleep Paralysis is when the Central Nervous System (CNS) creates muscle atonia so that dangerous movements are not acted out during sleep. If this state is experienced while going to sleep or just waking up, the person’s senses are awake but he can’t move his body for a few seconds to a few minutes. This can be a very frightening experience. In Rapid Eye Movement disorder, the opposite is observed. So if you notice anyone practicing backstrokes while sleeping, you know what they are dreaming about and what disorder they may be suffering from.
**Automatic behavior is when a narcoleptic person falls asleep in the middle of an activity like talking. He may go on talking and not remember it when he wakes up! It is easy to see why sleeping disorders have inspired many in popular culture.
Is one of the better known sleeping disorders having featured in everything from Macbeth (One of William Shakespeare’s plays) to Bhoolbhulaiya (Bollywood Movie) to real-life murder cases! One may carry out a range of normal activities while sleep walking from dancing to driving a car making it perfect for movie and novel plots. These actions are not acted out of dreams as the person is not completely unconscious and won’t have strong memories of his actions. Accused have been acquitted of murder on grounds of their having been sleepwalking. But don’t be getting any ideas!
Good ideas would be sleeping on the floor, locking doors and windows, locking away weapons (intended and otherwise) and keeping alarms.
Also documented are sleep-eating and sleep-sex but we’ll let you google those.
Sleep medicine is a growing market by itself let alone the abuse of anti-depressants and anti-histamines. Sleep centers are flourishing in the U.S. The American Academy of Sleep Medicine is already being cited as being lobbied by Big Pharma. That is sure sign of market potential. Sleep medicine is a full-blown post-doctoral specialization. The most common drugs prescribed are sedatives and anti-depressants. Anti-psychotics may also be prescribed in some cases. But these can at best provide symptomatic relief. Long term usage poses serious risks of side effects. This is a problem if the condition is chronic. Behavioral therapy may be administered simultaneously if the case requires so. Many people have erroneous and anxiety producing notions about sleep. These are tackled in therapy along with relaxation techniques and maintaining a conducive sleep environment and routine at home. It is evident that the effects of such therapy last far longer than those produced by medication. Maintaining sleep diaries may also help come to terms with the nature and gravity of the condition.
Lack of education is the biggest issue. It leads to ignorance of conditions, even uninformed reporting, wrong diagnosis and drug abuse. Anti-histamines and cough syrups are still the top sellers in the Indian Pharmaceutical market when dry and wet cough are certainly not our biggest public health issues, And alcohol off course; is the cure for all evils. In addition, sleeping pill overdose is too common a tool in run-of-the mill movies and soaps. As if people weren’t getting enough dangerous ideas already!
What would be clear by now if you were hooked enough or sufficiently sleep deprived to read through the end of this feature is the pervasion of sleep related conditions and how they are bound to affect us at some stage to varying degrees. The chronic nature of the disease means it wont hurt you enough in the now and here for you to do something about it. It will simply irk you on the sidelines as you prepare for the impossible deadline whilst cursing habit forming substances. And lest I be the hypocritical preacher, I have consciously not stayed up late working on this feature. It may have taken longer but it has fermented better and if I continue this pattern of working, I may have fewer grey hair later.
-Punit G. Pania