Guy Leschner is the chief physician of the American Department of Sleep, who has worked for many well-known medical institutions such as Imperial College for more than two decades, accumulating a wealth of rich and thought-provoking cases in the treatment of insomnia. According to his analysis, there are many reasons why people are difficult to break the insomnia dilemma, and one of the most important points is that an unhealthy conditioned reflex is established between us and the sleeping space, and breaking the conditioned reflex is almost equivalent to making an attempt to violate the instinct. However, once we have adopted scientific means, we can establish a healthy conditioned reflex. The following is an excerpt from "The Brain Won't Sleep Well" with the permission of the publisher, with deletions and changes, and the subtitle is added by the editor.
The Brain Doesn't Sleep Well: The Wonderful Tale of the Sleep Doctor, by Guy Leschner, Version: Republic | Taiwan Straits Publishing House 2021.7
Annoying insomnia:
The new "epidemic of the times"?
Regardless of how sleep deprivation is currently defined, it has been used as a means of interrogation or torture for thousands of years. The earliest official accounts of it appeared in the late 15th century as a Catholic Inquisition, and it has been used for centuries to come, from witch hunts in Scotland in the 16th century to interrogation camps set up by the Soviet KGB, and to this day it undoubtedly exists in dark corners around the world.
It is true that sleep deprivation does not leave scars on the body, but it can not only cause psychological scars and mental pain, but can also be highly dangerous. Although no one has studied long-term systematic sleep deprivation with appropriate scientific methods in humans, in animals, studies have shown that it can be fatal. Dogs who are forced to stay awake will die after 4-17 days. Similarly, rats die after 11-32 days of waking.
The first time she walked into my office, Claire was already sick, though it didn't look like it. On the surface, she was neatly dressed, in her early 50s, slim and quite pretty. She looks like many successful and wealthy women, striding down the streets near London Bridge and a few more steps to the City. But for the past five years, she has been exhausted by insomnia.
Her sleep began to worsen near menopause, but in her mind, the direct cause of insomnia was clear: "After 15 years of caring for my children at home, I decided to return to work. Part of the reason for my insomnia is that at the age of 50, I was desperate to prove myself in the workplace. I'm actually paid very little, but I have a lot of responsibility. I have a mission to prove that I am worthy of the job and that I am a valuable person. ”
Work at work seemed to push her to the brink of collapse. "Now I can't sleep anymore. I know it sounds ridiculous, but I really feel like for about a year and I'm getting so little deep sleep that I can't live a normal life. I asked her about her sleep patterns during that time, and she said, "I'll still go to bed and lie down, but as soon as I walk up the stairs, I start to panic." I know what's going to come up. Then my heart began to beat faster. It wasn't panic attacks yet, but I could feel the adrenaline flowing throughout my body. ”
Insomniacs wake up in the middle of the night and see the whole world asleep, and this loneliness is really incomparable. Claire wrote a sleep diary, she wrote: "The other family members are asleep, and I have only despair, because I have tried many methods, but every night I still go down here [the living room]. It felt so lonely, as if there was no end in sight. ”
But in fact, she is not alone, absolutely not, because insomnia is more common than imagined. If you're like Claire, who finds it difficult to fall asleep, who wakes up easily after falling asleep, or who wakes up feeling badly asleep, you're part of this huge group. Insomnia is one of the most common sleep disorders, with far more patients than others. About 1/3 of adults reported poor sleep; 1/10 of long-term insomnia, which in turn causes a persistently low sleep experience, but also causes various consequences during the day, such as tiredness, irritability, difficulty concentrating, lack of motivation and so on. But insomnia is not only a medical condition, it is also a symptom, which may reflect a medical problem such as hyperthyroidism, or it may be a consequence of taking medication. Insomnia can be a manifestation of a variety of mental disorders, such as anxiety, depression, or bipolar disorder. In fact, half of insomnia sufferers have been diagnosed with mental illness (although this also means that the other half are not). Even if there are no other underlying problems behind it, "insomnia" itself as a medical disorder is a "pocket" term. It contains different types, and strangely enough, not every insomniac lacks sleep.
For some people, their experience of poor sleep is not supported by evidence. I rarely take insomnia patients into the sleep lab. If you don't sleep well at home, it's definitely harder to fall asleep after sticking electrodes on your body, lying in an unfamiliar bed, and knowing that your every move is being recorded and analyzed. However, if I need to understand the cause of my patients' insomnia, or suspect that they have other sleep disorders, I will let them stay in the hospital overnight.
One of the things that's very common: When I see patients after sleep monitoring and ask them how they're sleeping, they say, "I slept very bad that night." But when we look at the monitoring results, we see that the sleep quality is good: at least seven hours, with a lot of deep sleep in between—although the patient in front of us insists that he has only slept for one or two hours. This type of insomnia is known as "sleep-state perception disorder" (SSM) or "paradoxical insomnia," and it may explain why there is a huge overlap between sleep monitoring in people with insomnia and those who sleep normally. People who say this, they experience sleep differently than ordinary people. Maybe their sleep quality is really bad, but this can't be measured by the standard sleep monitoring technique Polysomnography (PSG). Or the reason may simply be that people often wake up briefly during normal sleep, but the brain fills in these waking moments as part of sleep; But patients with these types of insomnia treat these moments as waking, rather than deep sleep as shown by sleep monitoring.
There is also a category of insomniacs whose sleep may be fragmented and interrupted several times a night, but their total sleep is still at normal levels. Even for those with shorter total sleep durations, the amount of deep sleep may be normal, and deep sleep is the most important stage of sleep for physical and mental recovery.
Last Night's 1001st Sheep: A Little Book for the Insomniac, by Marina Benjamin, Version: Spring Tide | CITIC Publishing Group
But for people with severe insomnia like Claire, there is clear evidence that their sleep duration is indeed very short, sometimes only a few hours a night. In these people who sleep very shortly, we also clearly see the physiological indicator of stress, the so-called "hyper-arousal.". Nerve throbbing, rapid heartbeat, a state of full alertness, feelings of agitation or vigilance are all characteristics of hyper-arousal. When a person is stressed, a variety of neurotransmitters and hormones act. A state of stress or anxiety can trigger multiple systems in the body, causing elevated levels of cortisol, epinephrine, and norepinephrine. Studying these systems in insomniacs, mainly those who slept for shorter periods of time, we found an increase in the breakdown of these hormones in their urine. Such insomniacs also show other characteristics of the "hyper-arousal state": an accelerated heartbeat at night, an increase in oxygen consumption (indicating an increased metabolic rate), and enlarged pupils, which in turn is responsible for regulating the fear-fight-flight response. Importantly, these changes are not seen in "sleep-well-sleep" insomniacs.
Is insomnia and lack of sleep the same thing?
Insomnia is often confused with lack of sleep. The health risks of not getting enough sleep, or not getting enough sleep, have been well documented: there can be countless conditions such as death, weight gain, high blood pressure, and diabetes. Therefore, insomniacs naturally worry about these problems: decades of poor sleep quality must have the same damage to health? However, sleep deprivation and insomnia are quite different. If you study sleep-deprived people in a sleep lab, you'll find that they fall asleep quickly, but when they wake up, they perform poorly on alertness tests. In stark contrast, insomniacs who sleep shorter take a long time to fall asleep, but they also wake up alertly.
In addition, there is an extremely important difference between shorter sleep times and normal sleep duration, and these two types of insomnia. Both types of insomnia are associated with brain hyperactivity. Using imaging techniques to monitor brain waves, we will find that both types of insomniacs have increased brain activity during sleep, which may explain why people with sleep state perception disorder or insomniacs who sleep normally treat sleep as if they were awake, or listless after sleep. However, only these patients with short sleep periods will show a state of high full body activity, which is reflected in chemical and physiological indicators such as heart rate. Although the impact of brain activity on both types of insomnia greatly reduces the subjective experience of sleep, many of the health problems associated with insomnia seem to be limited to those who sleep for a shorter period of time and whose physiological over-arousal affects not only the brain but also the whole body. The researchers looked at the cognitive performance of those who claimed to have insomnia and found no significant differences between them and normal sleepers. However, if the insomniacs who sleep normally (even if the quality is poor and intermittent) are further distinguished among insomniacs and those who have been objectively measured for a shorter period of time, it will be found that those with significant cognitive problems are insomniacs with short sleep durations. In contrast, people who did not have insomnia problems but were sleep deprived did not show hormone and neurotransmitter activity and cardiovascular indicators related to excessive arousal, nor did they show the same degree of cognitive problems.
Similarly, the risk analysis of diseases such as hypertension and diabetes in insomnia patients will also find that those with insomnia who have been properly measured for a shorter sleep time have a higher risk of developing these diseases, while those who sleep at least 6 hours at least have a corresponding risk of not increasing at all. Studies have even shown that insomniacs with short sleep periods have a slightly higher mortality rate than the average person, but the reasons for this result seem to be different from sleep deprivation. We know that sleep and weight gain are related, so is it possible that insomniacs with a very short sleep time will also gain weight and become more susceptible to diabetes, high blood pressure and various related diseases? No, people with long-term insomnia who sleep shorter don't seem to gain weight more easily than people who sleep normally. In fact, compared with normal people, they are less likely to be obese. The chemical and physiological effects of possible over-arousal are the direct cause of higher mortality.
Cortisol is a natural steroid that has been linked to rising blood pressure and increased diabetes. Some patients suffer from autoimmune nervous system diseases, and we often see them taking steroids to suppress their immune systems. Steroids increase the activity of the sympathetic nervous system, and the secretion of related chemicals such as epinephrine increases, which directly affects their hearts and blood vessels, causing blood pressure to fall normally during the night.
In short, the above physiological effects of insomnia with severely shortened sleep time should be to indicate the relevant physiological changes in people's hormones and cardiovascular status, and it seems that they should also be responsible for some health risks carried by insomnia. For those insomniacs who sleep for a reasonable amount of time, although there is evidence that their brain activity is abnormal, from the perspective of the body, they are more similar to people who sleep normally.
So what provokes a state of hyper-arousal in people with severe insomnia that causes them to sleep very little? Is it the short sleep of these insomniacs that causes over-arousal, or is the over-arousal state causing insomnia? The answer is not entirely clear. But in both groups of people with sleep disturbances (i.e., subjectively believing that sleep is poor but the total length of sleep is normal) and no insomnia problems but lack of sleep, these chemicals and nervous system activity levels are low, which clearly indicates that the over-arousal state itself triggers these serious types of insomnia.
There is no doubt that there are genetic factors in this. Insomnia is often prevalent in the family. Twin studies have shown that 57% of insomnia can be explained by genes. A recent study confirmed 7 genes associated with insomnia, so it's entirely possible that this hyper-arousal state may also be genetically predisposed. When people are under pressure, change jobs, have bad feelings, and have family members die, they often have a period of insomnia and excessive arousal. And if you happen to have those genes and happen to be experiencing these stressors, you may be at higher risk of entering a state of mental and physical overexcitedness that persists after the stressors are gone. Driven by this state of hyper-alertness or arousal, your insomnia may turn chronic.
24/7: Late Capitalism and the End of Sleep, by Jonathan Clary, Edition: Nanjing University Press, Sanhui Books, May 2021
This is obviously also mixed with psychological factors. As mentioned earlier, about half of patients with chronic insomnia have mental disorders behind them, especially anxiety, and over-arousal is a significant manifestation of anxiety. Therefore, anxiety itself can cause insomnia. And what about those who don't have anxiety problems, the other half who don't have any mental disorders?
Many of the patients I receive at the clinic do not have panic attacks and do not worry during the day. But many people recount the same experience: they say they feel good during the day, but as soon as they go to bed at night, they start to worry, especially about the process of falling asleep. They are anxious that they will not be able to fall asleep and will turn over all night. They live in fear of the long night ahead. When their heads are stained with pillows, instead of associating the comfortable bed with the joy of a happy sleep, they see the bedroom as a place of torture, a torture device. They often say it over and over again:
"I was tired when I first went to bed, but as soon as the lights were turned off, my mind was racing and my consciousness was clear." It was at this moment that they became overly aroused, their brains were "extremely excited", and their drowsiness was instantly out of reach. Just as Sisyphus immediately pushed the stone to the top of the mountain, only to slip off his hands and roll all the way back to the foot of the mountain, sleep became something that these patients could not hope for: they were about to fall asleep, but their drowsiness was suddenly taken away. The longer this state persists, the worse the relationship between the corresponding population and sleep.
But there is another aspect to this state of mental and physical lifting of stress responses: it makes people feel bad. In addition to not sleeping well, insomniacs may feel that they are on the verge of death, and if you do not clearly realize that anxiety is a major cause of insomnia, your insomnia may become heavier, because you will start to worry about whether you have a serious illness. For example, Claire said, "I've Googled insomnia and thought I must have some syndrome." I asked her if she was worried about a particular syndrome, but I had heard many patients say this and already had the answer in mind, and sure enough, she said, "Fatal familial insomnia (FFI)." I was convinced I had less than six months to live. ”
FFI is a prion disease associated with C-Jacques disease, known as "mad cow disease". This insomnia, caused by genetic errors and passed down from generation to generation, is a neurologic disorder that progresses ferociously, and all patients die after an average of 18 months. Patients present with progressively worsening insomnia. With the progression of the disease, the patient's autonomic nervous system will change, blood pressure can not be maintained, there are obvious up and down fluctuations; It also sweats and becomes constipated. What follows is delirium, accompanied by hallucinations and behavioral changes. In the advanced stages of the disease, the patient will constantly hover at the boundary between wakefulness and sleep. However, the disease is very rare, with only 40 known families worldwide. Perhaps because its symptoms correspond to the high levels of anxiety in some insomniacs, occasionally someone quickly gives themselves the diagnosis and believes they have other symptoms of the disease.
Insomnia and psychological problems
The relationship between insomnia and psychological or mental problems is complex. As mentioned earlier, the state of hyper-arousal that is common in severe insomnia may be behind some form of anxiety. Insomniacs who sleep too short often have specific psychological characteristics, such as low mood, exhaustion, and anxiety about health. People with sleep-state perception disorder overlap to some extent with severe insomnia, and they are depressed and anxious, but they often spend their time on the tip of the horn, thinking about their state over and over again, and will also have uncontrollable thoughts. Because of the nuances of these mental states, coupled with physiological disorders related to hormones and cardiovascular indicators, some researchers have proposed that these two types of insomnia are fundamentally different. Insomnia patients with normal sleep times, known as SSM people, do not over-arouse physical manifestations, so they rarely have long-term consequences and seem to respond better to treatment. Short-term sleepers who are physiologically over-aroused, i.e., people with amplified chemical and physiological systems responsible for regulating the fear-fight-flight response, have different psychological characteristics, have a higher risk of insomnia-related health problems, and are often more difficult to treat.
In short, mental problems can definitely cause insomnia. Insomnia occurs in 90% of patients with clinical depression. When I was still a student in medical school, I learned that waking up in the early hours of the morning is an important sign of depression, but other types of insomnia, such as difficulty falling asleep and easy to wake up after falling asleep, are also common phenomena. Patients with schizophrenia often have severe insomnia, and before the psychosis gradually occurs, the person will often have signs of increasing difficulty falling asleep. But the relationship between sleep and mental disorders is not one-way. Insomnia is also a risk factor for triggering mental disorders and may make mental disorders more difficult to treat. Even if all other factors are excluded, insomnia alone significantly increases the risk of subsequent depression, especially in patients with short-term insomnia. For people who already have depression, insomnia marks an increase in suicidal ideation and an increased risk of recurrence of depression. Depressed people who also have insomnia problems will become more complex and refractory.
Many questions remain unanswered. The field of science is still in infancy, and neither the intricate relationship between sleep and mental health nor the principles behind it are fully understood. Insomnia and mental disorders both alter the circuitry and biochemical responses in the brain, so it's not surprising that changes in sleep and mental health can have collateral consequences for each other. Both are both chickens and eggs. But it's also possible that insomnia and mental problems are caused by common genetic factors, and if so, research in the field adds a layer of complexity. Whatever the nature of the relationship, it emphasizes the need for psychiatrists and sleep doctors to think holistically, not just focus on the problems they are most familiar with, and not just wear colored glasses for their profession when treating patients.
Historically, strategies to treat insomnia have focused on medications. After the benzodiazepines were introduced in the early 1960s, they quickly became the mainstay of insomnia and anxiety, and sales soared. The drugs were so popular that the Rolling Stones, who were not opposed to recreational chemicals, wrote a song called "Mother's Little Helper" to celebrate Tranquility. Over the past few decades, however, the dangers of benzodiazepines and related drugs (such as zolpidem and zopiclone) have also emerged: they increase the risk of morning sedation, traffic accidents, and fractures of the buttocks after falls, can trigger sleepwalking and other non-REM sleep abnormalities, and importantly, withdrawal reactions and dependence: to achieve the same sleep effect, patients need to increase the dose of the drug.
As a result, people are already abandoning these drugs in favor of other preparations such as melatonin, antihistamines, and antidepressants with sedative effects. These agents have their own problems, with different side effects and reduced efficacy, but it is helpful to use them correctly.
More worryingly, there is growing evidence that hypnotherps, especially benzodiazepines and related drugs, increase the risk of subsequent dementia. But like a lot of sleep-related issues, it's also a complex area. For example, the lymphoid system, a network of tubes in the brain, is also responsible for removing waste products like the lymphatic system elsewhere in the body. In deep sleep, these tubes open up to 60 percent, transporting potentially toxic substances out of the brain, such as amyloid, a β associated with the mechanisms behind Alzheimer's disease. Deep sleep promotes cleansing of the brain, and if you are sleep deprived of sleep due to insomnia or other reasons, this cleansing process of the brain will be affected. Lack of sleep precipitates more β-amyloid protein in the fluid in these tubes, which means that the cleansing effect of this protein and other toxins is reduced, and they enter less of the cerebrospinal fluid (the fluid that envelops the brain and spinal cord). Therefore, sleep deprivation and insomnia with shorter sleep durations are likely to increase the risk of Alzheimer's disease itself, not necessarily related to drugs.
Stills from the movie Fragments of Memory
But there is one possible explanation. Many degenerative problems in the brain can lead to subtle changes years or even decades before the onset of obvious symptoms. Think of John's act of acting out dreams, which is often a precursor to Parkinson's disease years before the onset of Parkinson's disease; Think again about the relationship between anxiety and this disease. In Alzheimer's disease patients, biochemical pathways in the brain may have changed long before memory declines, leading to poor sleep or anxiety. Perhaps insomnia is not the cause of Alzheimer's disease, but rather a manifestation of the early stages of the disease.
Try to treat insomnia
The relationship between low-quality sleep and Alzheimer's disease hasn't been fully unraveled yet, but whatever its nature, concerns about this relationship, along with other side effects of drug treatment, have dramatically changed the way we treat insomnia. Specifically, there has been a drastic shift towards non-pharmacological treatments. One of the most widely studied and used is called cognitive behavioral therapy for insomnia (CBTi). This treatment uses behavioral techniques to vigorously reprogram the brains of insomnia patients.
In the 1890s, the Russian scientist Ivan Pavlov began experimenting with dogs. He noticed that every time he walked into the room, several of his dogs began to drool in anticipation of food. He realized that although the secretion of saliva from food was an innate reaction, associating him with food must have been acquired. Then he began to train the dogs to associate the sound of a bell with the presence of food, and soon the dogs began to secrete saliva as soon as they heard the bell ringing. This phenomenon is called "conditioning" and is a learned response. In some ways, humans are no different from Pavlov's dogs and are subject to conditioned reflexes. For example, think back to a certain diet that made you sick, and now you may feel sick just by seeing it, and you can't even mention it. And conditioning has an effect on sleep.
Without sleep disturbances, you'll associate the bedroom with drowsiness, with the comfort of covering the duvet, the feeling of the pillow in your head, and the wave of relaxation when you fall asleep. The conditioned reflexes of insomniacs are very different. For them, the bedroom is a place of stress and anxiety, linked to the fear of the long night ahead. The bed itself becomes the cause of mental or physical hyper-arousal, making sleep more difficult. As Claire said, "It [my bed] is now a place of misery, a torture chamber."
At its core, CBTi is to break this negative conditioning of the patient's bed and rebuild a positive connection. Its trick is to reinvent the bed as a shelter, not a execution chamber. There are several ways to do this. The first is to use a strict system to prevent yourself from lying awake in bed for a long time at night, forcing yourself to leave the bedroom after a few minutes of tossing and turning, and avoiding using the bedroom for other purposes outside of sleep. The second is to take advantage of sleep deprivation. This sounds counterintuitive at first glance: after all, insomniacs are most afraid of lack of sleep. But to compensate for the poor sleep, many insomniacs will lie in bed for a long time. The result is to prolong the time they lie in bed without falling asleep, thereby reinforcing negative conditioning. Therefore, limiting the time in bed to about 5 hours a day in a two-week period can build a driving force for sleep in the brain. Just as Claire would fall asleep at three or four in the morning, eventually, sleep deprivation would overwhelm the over-arousal state and then fall asleep. This is a critical step to rebuild the connection between bed and sleep.
The most extreme example of sleep deprivation as a treatment for insomnia is in Australia, where an experimental technique called "intensive sleep retraining" has been developed. The researchers asked patients to stay in bed for no more than 5 hours the night before and then invited them to the sleep lab. At 10:30 p.m. that night, treatment began. For the next 24 hours, the patient was allowed to go to bed every 30 minutes with electrodes attached to the scalp. If they haven't fallen asleep after 20 minutes of going to bed, they have to get up. But if they fall asleep and are confirmed by brain waves, they will also be woken up after 3 minutes of continuous sleep. By the end of this 24-hour period, the patient had 48 opportunities to fall asleep. Theoretically, by the end of treatment, they were severely sleep deprived and would fall asleep as soon as they had the chance. There is also a new connection between bed and sleep. The technique sounds like it came directly from Guantanamo Prison, but the results of the trial are encouraging. This sudden treatment quickly reconstructs the conditioned reflex to going to bed and quickly improves the patient's sleep.
CBTi uses a similar principle, but the method is not so cruel, and also combines other techniques to relax people, inhibit excessive arousal, and teach patients good sleep hygiene (referring to the way of behavior about sleep), such as avoiding bright lights and caffeine, leaving enough time for relaxation, and so on. CBTi works equally well. The patient's sleep improved in a short period of time, as effective as or even more than hypnotics, and studies have shown that this effect can be maintained for up to three years.
Ivan Petrovich Pavlov was a Soviet physiologist, psychologist, physician, founder of the theory of higher neural activity, and the founder of the physiology of higher neural activity. The constructor of the conditioned reflex theory, and one of the most influential figures on the development of psychology outside the traditional field of psychology, has won the Nobel Prize in Physiology.
Therefore, cbti is now generally recommended as a first-line insomnia therapy, sometimes combined with drugs in the short or medium term. CBTi can also be used for gradual withdrawal from long-term use of sleeping pills.
When discussing treatment options for her long-term insomnia with Claire, we were the first to decide to take this option and avoid further medication. Her effect is remarkable. A few weeks after starting CBTi, we met again. She confessed: "At first I was skeptical because I had tried so many methods to no avail. I was obsessed with medication and didn't believe anyone could help me. Now she has met with a sleep therapist twice and is strictly following the plan of the CBTi project. She is now bedridden for no more than 7 hours a day.
I had to count minutes every day to hold out until 11 o'clock because I couldn't get stuck and it was too hard not to lie down. I'll just wait, wait. I have time to relax. I spend an hour soaking in the bathtub and lighting candles. Every morning as soon as the alarm goes off at 6 o'clock, I have to get up immediately. Then I went straight downstairs and sat down, feeling a little sorry for myself. I strictly adhered to this routine every day for three weeks. And then I'm getting better and better. I couldn't believe it was true. I was able to fall asleep. The [sleep-controlling] switch seems to be back!
The situation was simply unbelievable. The sleep therapist and I were cautious and didn't want to be overly optimistic. But Claire felt like she had been reborn, she said: "I can't remember how long I haven't felt so personal, so energetic, so focused." I'm very excited about my life right now. "Despite my reservations, Claire underwent another three months of rigorous CBTi treatment, during which her insomnia was always under control. As sleep improved, so did her restless legs syndrome.
Ask any insomniac what sleep means to him, and you'll immediately understand the importance of sleep. Sleep affects every aspect of our waking life: mood, energy levels, cognition, memory, immune system, metabolism, appetite, anxiety levels, and more. Sleep also affects our relationships with everyone around us, and even with ourselves. As Claire says, "Sleep changes everything, and without it, no one can live a normal life." You can try it a little bit, and then the whole person will strike. I felt like my body and brain were on strike for those years. After I recovered from sleep, I was all at work again. ”
The original author | [English] Guy Leschner
Excerpt from | Liu Yaguang
Editor| Zhang Ting
Introduction Proofreading | Liu Baoqing