To Sleep, Perchance to Dream

When I was working as a program manager of an adolescent psychiatric treatment unit in the 1990s, I encouraged the staff to change the time we required the kids to be in bed each night.  Lights out was 9:30 p.m.  Based on the circadian rhythms of most teenagers, I recommended 10 pm or better yet 10:30 pm.  You would have thought I was asking the staff to jump off a bridge.  We finally agreed to 10 pm with later hours on weekends, but this was also based on the behavioral rewards system we used.  The more “points” you earned, the later you could stay up.  So, if you didn’t earn enough points you had to still be in bed by 9:30.  The 10 pm bedtime was only for the most compliant kids.  Unfortunately, being compliant is not the easiest things for teenagers with mental health issues.

My recommendation about later bedtimes came from research indicating the onset of sleep arrives ever later for children as they get older.  By the time they are teenagers, they naturally fall asleep between 11 pm and 11:30 pm and wake up between 8 am and 9 am.  That’s why it is such a struggle for parents to rouse their teens to get ready for school and also why so many teens are not mentally alert in their morning classes.  And notice that not only are their natural sleep times different from most adults, but they also require more sleep; about nine hours versus the recommended 71/2 to 8 hours of sleep for adults.

Years later I had changed jobs within the organization and the treatment units were now being managed by the unit psychiatrists.  They were revising the rules for the treatment programs and when I saw they were still advocating the same bedtimes I sent the psychiatrists a memo recommending later sleep times with reference material about sleep studies with adolescents.  Nonetheless, like the direct care staff years earlier, they were resistant to the suggested changes; they actually wanted to go back to the 9:30 pm bedtime!  It took some work to get them to at least keep it to 10 pm.

Adolescents are not the only ones who have different sleep cycles than most adults.  As any new parent will tell you, infants actually have to be trained to the “normal” nighttime routine of sleep.  It’s actually not until they are two to three months old that they “sleep like a baby.” 

My interest in sleep has increased as I’ve aged; I’m in my early 70s, and no longer sleep as deeply or for as long as when I was younger.[1]  For me, getting up three times a night to take a pee is a good night.  At least once a week I’m up five to six times.  The frustrating thing is that each time I have a full bladder.  During the day, I can go four to five hours without having to urinate, but at night, two and half to three hours is about as long as I can last.  One reason for this is that as age we do not enter deep sleep cycles for as long as we did when we were younger, thus our brains are more sensitive to the signals our bladders are sending. 

When I was in my 40s and 50s it wasn’t uncommon for me to have a dream where I was someplace and needed to find a bathroom.  I would search all over, but couldn’t find one and then if I did, the urinals and toilets were broken, or they were in a place where I would have to urinate in public.  It was my brain’s way of trying to rouse me from a deep sleep.  Now, I don’t typically have those dreams, I just wake up and go to the bathroom.  Unless you’re a senior this may sound odd, but if you are a senior you know exactly what I mean.

Even though we spend a third of our lives in the unconscious to semiconscious state we call sleep, research into the biology and psychology of sleep did not begin in earnest until the 1950s and the real breakthroughs didn’t begin until the 1980s when sleep researchers developed devices to externally monitor sleep, such as measuring an individual’s brain waves while slumbering.  For example, they found that our circadian rhythm corresponds to body temperature: as the day wears on our body temperature decreases, preparing us for sleep.  And during the night, body temperature continues to decline, by several degrees, to its lowest point around 3 am.  After that, body temperature starts to increase in preparation to waking.

When I first started to notice that I was waking more often I purchased a bottle of melatonin.  Melatonin is a naturally occurring chemical in our brains which helps signal when it is time to fall asleep.  It is secreted by the pineal gland which is attuned to the levels of daylight; the less light the more melatonin that is secreted.  I thought the medication might help me sleep, but I don’t like taking medications, so it sat on a shelf in my medicine cabinet for about a year before I threw it away.  Just as well, because while melatonin can help the body to recognize when it is time to sleep based on the amount of sunlight (which is why it helps travelers who cross time zones), it has little if any impact on the quality of sleep or how long you will remain asleep.  Once it has done its job making you sleepy, other chemicals in the brain take over to regulate the “normal” sleep cycles between deep sleep and lighter sleep.

Normal sleep is composed of five, roughly ninety minute cycles of NREM and REM sleep.  NREM or nonrapid eye movement sleep is when our brains go into a very deep sleep, with little dreaming as measured by brain waves.  During each successive ninety minute cycle, the duration of NREM sleep decreases, while the time in REM sleep increases.  That’s why we are more likely to remember a dream if we wake up in the early morning hours (between 4 am and 7 am) then if we wake up around 2 am.

Normal however, is not entirely normal.  As noted, the amount of time we sleep and the amount of time we spend in NREM and REM sleep depends on a number of factors, such as age, genetics, to some extent gender, as well as external factors such as weight and amount of exercise we’ve had during the day.  For example, people who are overweight tend to suffer from sleep apnea which results in chronic disruption of what should be normal sleep cycles.

In addition to feeling sleepy or groggy if we don’t obtain quality sleep, a lack of sleep (sleep deprivation) can take both a physical and mental toll on our bodies.  Studies show that students who stay up late to cram for exams don’t perform as well as those who get a good night’s rest.  Studies also demonstrate that when confronted with a problem to solve, participants who “sleep on it” can solve it more quickly than subjects who were deprived of sleep.  And a lack of quality sleep among seniors appears to contribute to the development of age related dementias.

The thing that caught my attention in relation to this blog, i.e. the impact of sleep and sleep disorders on universal health care, was the cost associated with treating sleep problems.  About one in four Americans acknowledge sleep problems significant enough to seek out some assistance with falling and staying asleep, from purchasing restful music to help fall asleep to taking prescription medications.  Taken together, sleep aids including sleeping pills are a $28 to $30 billion dollar a year business in the U.S.[2] with sales of sleeping pills accounting for about $1.5 billion of those revenues. 

Interestingly, as a result of sleep research, there are many things we can do to improve sleep without costly sleep aids, particularly medications.  Over the past two decades researchers have found that exercise, relaxation, and therapy are just as effective in treating depression as taking an antidepressant medication and likewise, these three activities are effective in addressing sleep problems.  For example, exercise helps maintain healthy metabolism and weight, therefore reducing the incidence of sleep apnea. 

The Dalai Lama once said, “Sleep is the best meditation”, however, it also turns out that meditation makes for a good night’s rest.  Relaxation techniques, such as yoga, transcendental meditation, and mindful mediation, can help reduce stress and anxiety, which influences both the ability to fall asleep as well as being able to stay asleep, such as when you wake up in the middle of the night, ruminate on issues, and have difficulty falling back to sleep.  Finally, some interventions such as cognitive behavior therapy, can help you become aware of things that interfere with sleep and can help you identify and practice behaviors to address those issues.

For my part, I have been trying to identify things that cause me to awaken more often.  For example, in Charles Dickens’ A Christmas Carol, Scrooge says to Marley’s Ghost, “You may be an undigested bit of beef, a blot of mustard, a crumb of cheese, a fragment of underdone potato.”  Even one hundred and fifty years ago people recognized that how they metabolized food can influence how well they slept; in this case Scrooge rationalizes that he is experiencing a dream or hallucination brought on by his evening’s meal.  Similarly, I’ve come to recognize that caffeine is a big no-no for me.  Caffeine is not only a stimulant, it can also increase urgency and frequency of urination.  While I enjoy a nice cup of hot chocolate on a cold winter’s evening, I also know that I’ll pay for it later with multiple trips to the bathroom throughout the night.      

I’ve also discovered through my reading, that a short nap in the middle of the day – even just 10 to 15 minutes – can improve my physical and mental wellbeing, without infringing on my ability to fall and stay asleep at night.  And I’ve learned that seniors typically experience shorter NREM cycles.  It’s an aspect of aging that I can’t change, but I can continue to try to identify things, such as certain foods, that might cause me to wake up more often.  And I can make sure that the bedroom is very dark and cool, two environmental factors that appear to improve the quality of sleep.

Although we spend a third of lives asleep, sleep research is still in its infancy.  With the help of new technologies, such as imaging devices we are just now beginning to understand how the brain works, including its biochemical and bioelectrical mechanisms.  For example, we now know that the brain never rests.  Even when we are in deep sleep our brains are active, just at tasks it might not do when we are awake.

If you are like millions of Americans who have trouble falling or staying asleep the good news is that there is a lot of helpful information on the internet.  For example, if you have a serious problem such as sleep apnea, you can find enough information to determine if you should see a doctor and seek treatment.  As adults, we may never be able to go back to the time we slept like a baby, but we should be able to improve the quality of our sleep and ultimately our total health.

[1] The two primary sources for this article are:

Randall, David K. (2012).  Dreamland. Adventures in the Strange Science of Sleep. W.W. Norton & Co., N.Y.

Walker, Matthew (2017). Why We Sleep. Unlocking the Power of Sleep and Dreams. Scribner. N.Y.


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