SLEEP AND SLEEP DISORDERS

- Dr Adelbert Scholtz

Counselling psychologist

1.     The function of sleep

1.1   The phenomenon of sleep

The most important activity every human being undertakes every day is actually to become inactive – that is when he is asleep. Adults are supposed to sleep more or less eight hours per night and that means that they use one third of their lives to sleep. No other activity takes so much time – except perhaps for work, that is, if the person works seven days per week for eight hours or more per day, something that seldom happens.

Since ample amounts of sleep and the correct type of sleep is necessary for one’s physical health – and also his spiritual health! – it is important that you be informed about this aspect of human existence, since a sleep deficit or the occurrence of sleep disorders in your own life may lead to an inability to enjoy life.

The popular viewpoint through the ages has always been that sleep only has one function, namely to afford an opportunity for a person to rest so that he may continue with his life and work the next day with renewed vigour. Research during the previous number of decades has shown that it is not so simple. It is clear that sleep is a complex process with different phases or stages and that it is essential for continued existence and good health.

1.2 Types of sleep

REM-sleep

Eugene Aserinsky found in 1953 that sleep has various stages. He started off by examining the brain waves of sleeping people in his sleeping laboratory and he observed that people asleep were moving their closed eyes rapidly during certain periods and that one of them even had started crying. When he woke people during these stages they told him that they were busy dreaming at that stage. He called this stage of sleep REM-sleep (REM is the abbreviation for "Rapid Eye Movement"). Since that time, this aspect of sleep has been intensively studied. All the secrets regarding REM-sleep have not yet been unraveled, but investigators have, nevertheless, discovered quite a lot about it.

It was found that the first episode of REM-sleep starts between 70 and 90 minutes after the person fell asleep. After that, another two to four episodes follow. Although the sleeping person is unconscious, his brain is very active – even more than during a waking state, and brain activities exhibit many similarities with a waking state. Although blood pressure rises and breathing accelerates, the body is effectively paralyzed.

This type of sleep is apparently necessary for the processing of emotions and memories. It appears as if the brain is busy transferring memories regarding new experiences and newly acquired skills from the short-term memory to the long-term memory. In the process, memories seem to be rearranged and new associations with old memories are being formed. People who have been prevented from having REM-sleep during experiments could not recall skills that they have acquired the previous day. In contrast, verbal memories are being stored and rearranged during other phases of sleep. This is due to the fact that certain types of protein are only produced during sleep, which proteins are necessary for storing memories in the brain.

The rearrangement of memories during sleep is seemingly due to the fact that irrelevant and even unpleasant memories are being “erased” and dumped into oblivion. It is important to get enough REM-sleep in order to be rested and relaxed the next day. REM-sleep occupies about 20 – 25% of an adult’s sleeping time, although it becomes less in the elderly. In contrast, about 80% of a newly-born baby’s sleep consists of REM-sleep and elder children spend about 50% of their sleeping time on REM-sleep.

It appears that new connections between neurons are being formed during REM-sleep and that certain circuits connected to certain activities are strengthened.

Because REM-sleep is strongly connected to the learning process it is understandable that children, who are still discovering the world and who have to learn many more new things that adults, need more REM-sleep. Therefore, it does seem as if this type of sleep is necessary to enable cognitive activities, such a speech, memory and creative thinking. It is, though, still a mystery why people have to be unconscious and why these activities cannot take place during a waking state. Perhaps these brain activities occur more easily when one is unconscious and cannot pay attention to the external world.

Many people have had the experience that when they encounter a problem and they “sleep on” the problem, they may have found a solution the next day. This depends probably on the fact that the brain stays busy during the night and especially during REM-sleep when memories of the past few days are being processed and rearranged.

Deep sleep

Another important type of sleep, apart from REM-sleep, is deep sleep. Somebody who has a sleep deficit and gets the opportunity of catching up on lost sleep usually goes into deep sleep.

If somebody awakens often during the night - for instance, to care for and feed a baby - a deficit of especially deep sleep is being experienced. People who work shifts and, therefore, have irregular sleeping times usually have a deficiency of deep sleep. The continuous abuse of substances such as alcohol and nicotine may inhibit deep sleep, while somebody who falls asleep because of intoxication is rather in a stupor than really sleeping.

1.3 Stages of sleep

The arrival of sleeping time People have an inborn clock that regulates the cycle of sleep and waking. This clock is light-sensitive and when it becomes dark it conveys the message that bed-time has arrived. In addition to that, the chemical substance adenosine is released during the day as our bodies use up energy. The more adenosine accumulates in the brain, the more the message is received that one needs sleep.

A typical night's sleep goes through the following stages:

Drowsiness

This stage only takes 5 - 10 minutes. The eyes move slowly under the eyelids, the muscles relax and the person can easily awake again.

Light sleep

During this stage eye movements cease, brain waves become slower, the heart rate decelerates and the body temperature drops. Adults spend almost one half of their sleeping time on this phase.

Deep sleep

The sleeping person cannot be easily awakened during deep sleep and if he is woken he may be disoriented. The blood supply to the brain degreases. During this phase somnambulism and enuresis in children occur.

REM-sleep

During this phase, which occurs between 70 - 90 minutes after the person has fallen asleep, dreams are being experienced and the eyes move rapidly to-and-fro. This is being followed by between two and four additional episodes of REM-sleep. During these phases memories and feelings are being processed. Breathing is shallow, irregular and rapid, the heart beat accelerates, blood pressure rises and so-called "wet dreams" may occur. After the episode of REM-sleep has passed the cycle again starts at the first phase. A full cycle takes between 90 and 110 minutes.

1.4 The benefit of sleep

According to researchers, sleep is beneficial or necessary for the following reasons:

• During sleep the immune system becomes more active to fight off possible infections and energy is being canalised from the muscles to the immune system. Experiments have demonstrated that sleep is vital for the continued existence of a living organism. Rats and other experimental animals who, for instance, have been prevented from having REM-sleep, died five weeks later on average, while animals who got no sleep at all, died on average three weeks later - amongst others, because their immune systems collapsed.
• During REM-sleep the receptors for neurotransmitters on the dendrites of neurons get the opportunity to recover in order to be able to tackle another day's brain activities with renewed vigour - perception, thought, speech, actions etcetera. New connections between neurons are also being created. Without sufficient REM-sleep a person speedily acquires all sorts of behavioral problems and health problems due to the malfunctioning of these receptors.
• During deep sleep growth hormones and other hormones are being released and that is necessary for growth in children and the repairs of damage to muscles on account of use during the day. The synthesis of proteins for this purpose is being accelerated during deep sleep. This synthesis of proteins is supposedly also connected with the recovery processes occurring in the brain during sleep.
• During deep sleep the parts of the brain responsible for the control of emotions, decision making and social interaction are largely inactive - probably with the goal of repairing damaged neurons in these parts in order to enable the emotional and social functioning of people to continue effectively during the day.
• It is also possible that the brain practices certain necessary connections between neurons and circuits in the brain, which may otherwise become redundant due to a lack of use.
• Sleep also seems to be necessary to detoxify the brain. During waking hours many destructive molecules, known as free radicals, are being produced by the body as noxious by-products. The brain cells are especially sensitive to the damage caused by free radicals and it appears that the brain repairs this damage during sleep.

It is often thought that people who are anesthethesized or are in a coma are also asleep. This is not correct. They cannot be woken from these states and they show little, if any, brain activity - in contrast with people who are really sleeping.

2. Dreams

2.1 The phenomenon of dreams

Explanations of dreams

A dream may be described as a series of images, sounds and emotions that are being experienced during sleep, accompanied by rapid eye movements in the sleeping person. Dreams usually take between 5 and 40 minutes.

In the Bible, we read of various dreams: Jacob's dream (Gen 28:12), Joseph's dreams (Gen 37: 5 - 11), the dreams of the baker, the butler and the Pharaoh's dreams, which were interpreted by Joseph (Gen 40 en 41), king Nebuchadnezzar's dream, which was explained by Daniel (Dan 2), the dreams of Joseph, Mary's husband (Matt 1: 20, 2: 13 and 19) and the dream of Pilate's wife (Matt 27: 19). All these dreams were seen as predictions of the future and revelations from God.

Israel and the early Christians were not the only people who saw dreams in this light. Almost all the known religions see dreams as divine revelations or communications from the spirit world or from the deceased. Meanings for these dreams were sought and these were often utilised in the healing of the sick.

There are today still people who regard dreams as containing special symbols, messages and meanings. Many books have been written on the purported symbolism of dream images and the explanation thereof. These efforts to interpret dreams run counter to each other on important points and are, therefore, not very trustworthy.

Current researchers are not yet totally sure how the phenomenon of dreams have to be explained. There are, nevertheless, various views regarding the explanation for the functions of dreams:

• Certain scientists believe that dreams are the efforts of the brain to make sense of the chaotic signals and images that circulate through the brain during REM-sleep.
• The emotions that are being experienced mostly during dreams are fear and anxiety; dreams are perhaps a method to process these negative feelings and to lessen stress levels.
• During the night the sleeping person receives various stimuli from his environment, especially sounds. Dreams may be an endeavour to make sense of these stimuli. Certain stimuli, such a baby crying or an alarm clock going off will actually awaken the sleeping person.
• The brain probably utilises dreams and REM-sleep to sift through memories and to erase irrelevant memories. New associations between memories and ideas are tested and in this manner creative impulses and solutions to problems may appear.
• Dreams help people to phantasize about matters, which they would allow into their consciousness during a waking state - including phantasies about sex.

Interesting facts regarding dreams

Researchers have, in addition, unearthed the following facts regarding dreams:

• It sometimes happens that dreams are repeated.
• Previously people dreamt mainly in black-and-white; under the influence of colour television and colour movies most people nowadays dream in full colour.
• People with a lack of vitamin B-complex in their bodies forget their dreams more easily than people who ingest sufficient quantities of these vitamins.
• Nightmares are dreams with a strong unpleasant emotional content - mainly anxiety and fear. The content of the dream mainly deals with some or other danger, pain, bad experience or death. Nightmares often occur where a patient is feverish, if the face of the sleeping person is pressed into his pillow and he runs the risk of suffocating or if the person had a meal shortly before bed-time and that accelerated his metabolism. It may also be that the person experienced some or other traumatic event and that is re-experienced continuously during nightmares - which condition may be diagnosed as post-traumatic stress disorder (cf chapter 15). A nightmare can be so severe and cause so much distress to the sleeping person that any further sleep becomes impossible.
• Nightmares occur more frequently in children over the age of five and adolescents than in adults or toddlers. A correlation has been found between the number of nightmares a younger person experiences and the level of anxiety that he experiences during the waking state.

3. Insomnia and sleep deficit

3.1 The phenomenon of insomnia and sleep privation

Sleep privation

There are various indications that people in industrialised communities get more that 20% less sleep than their grandparents in agrarian communities a century ago. Where people slept on average nine hours per night at the start of the previous century, city dwellers nowadays sleep less than seven hours per night.

The cause for this phenomenon is probably the fact that there is much more pressure on working people than in the past. Employers expect maximum productivity and their workforce and employees often have to work overtime. Many workers live far from their workplace and much time is spent on the way in trains, taxis and motor cars. Apart from that, workers mostly have domestic duties and obligations towards their communities, which occupy more of their time. The result is that too little time remains for sleep and many people develop a sleep deficit.

Insomnia

Insomnia is a sleeping disorder that is characterised by an inability to fall asleep or to sleep long enough, in spite of ample sleeping time. In most cases, insomnia is a symptom of another condition or malady.

One can distinguish three types of insomnia:

• Temporary insomnia - this persists only for a few days or weeks and disappears when the cause does not exist any more.
• Acute insomnia - this is the inability to sleep well for a period up to six months.
• Chronic insomnia - this condition can persist for years; it may be caused by another condition or it may be seen as an independent sleeping disorder.

Prevalence

Investigations have brought to light that more or less 40% of adult women and 30% of adult men suffer or have suffered from some or other form of insomnia or are experiencing a sleep deficit. These numbers are probably applicable to most industrialised communities.

3.2 The causes of insomnia

As has been mentioned above, insomnia is mostly a symptom of another condition or malady. The following causes of insomnia may be mentioned:

• The use of various drugs or stimulants, including certain types of medication, herbs, amphetamines and caffeine, which may interfere with the normal sleeping patterns;
• Withdrawal symptoms - if somebody is being weaned from a drug the withdrawal symptoms usually cause insomnia;
• Psychological disorders, such as depression, bi-polar disorder, an obsessive-compulsive disorder or schizophrenia;
• Existential problems and work-related problems, which are accompanied by unpleasant emotions, such as fear, uncertainty, stress and anxiety (cf Gen 31: 40 and Est 6: 1);
• A mourning process;
• An excess of nightmares, which cause so much distress that any further sleep is impossible (cf Dan 2: 1) - especially in cases of post-traumatic stress disorder;
• A malfunctioning biological clock;
• Changes to the rhythm of life connected with shift work or air travel over time zones, which confuse the biological clock of the person;
• A life style characterised by bad sleeping discipline, which causes an irregular sleeping routine and which may also confuse a person's biological clock; bad sleeping discipline also occurs where people struggle till late at night with work or other problems, which prevent them from shutting down when they get into bed;
• Certain neurological disorders, such as brain injuries;
• Diseases, which cause high fever, physical discomfort or pain;
• Back ache, neck ache and other types of chronic pain;
• Bladder problems, which cause the person to visit the bathroom repeatedly during the night;
• Hormonal imbalance during menopause or before menstruation in women; and
• Unfavourable sleeping circumstances - too much noise in the environment, for instance

3.3 The consequences of a lack of sleep

Problems with physical health

Insomnia, or a lack of sleep, which is being caused by an overburdened daily programme may cause all sorts of unpleasant and unwanted consequences for the physical health of the person in question:

• It has been found that a lack of sleep causes obesity. The reason for that is that the hormones that regulate the appetite of a person are being released during sleep; if he gets too little sleep his appetite is increased and the he eats too much.
• A chronic lack of sleep causes a decrease in the mass of the brain - which may be connected to the fact that the person does not get enough opportunity to grow new neurons in die place of damaged neurons.
• Many accidents are being caused by drivers of vehicles or operators of heavy machinery who do not have the necessary co-ordination, reaction speed or discriminatory powers, or who fell asleep due to a lack of sleep.
• Acute insomnia, which causes people to sleep less than four hours per night, increases those peoples' chances of an early death. This is due to the fact that the human immune system is more active during sleep than during the waking state and that somebody who sleeps too little will have a defective immune system, which will cause him to get ill so much easier.
• A chronic lack of sleep increases the chances of developing diabetes or heart problems.
• People who use sleeping pills in an endeavour to cure insomnia have a greater chance of an early death than people who do not use them.
• A lack of sleep increases the effect of alcohol and other drugs and lessens self-control, co-ordination and the ability of people to complete tasks effectively.
• It is a well-known method of torture to deprive people of sleep because of the physical and mental harm and pain caused by it.

Problems with mental health

People who get too little sleep may expect to experience the following problems regarding their mental health:

• Children who sleep too little often demonstrate behavioral problems, permanent sleeping disorders and other disorders during later life. This may be due to the fact that the brains of these children are smaller than those of children who have normal sleeping habits.
• A lack of sleep decreases the ability to concentrate, the ability to remember, discernment, logical thinking processes and co-ordination and influences a person's mental state and energy levels negatively. This is due to the fact that one needs REM-sleep to consolidate memories in die brain and that damaged neurons have to be repaired or replaced during sleep.
• People who have a chronic lack of sleep may hallucinate or become mentally unstable - which is also due to the fact that the brain needs enough sleep for repairs and the excretion of free radicals and other toxic substances.

Signs of a lack of sleep

If one or ore of the following signs are present it may be a sign that the person gets too little sleep:

• If somebody falls asleep almost immediately after he has laid down his head on his pillow;
• If somebody struggles to wake up properly in the morning;
• If he needs an alarm clock every day to awaken him;
• A lack of concentration power, clumsiness, an inability to think logically and an inability to take rational decisions;
• Irritability; and
• An inability to stay awake during the day.

People often ask how much sleep do they need. There is no single answer that applies to all since the needs of people differ. If somebody does not get out of bed each morning refreshed and full of energy - and he is not otherwise indisposed -it is a sign that he needs more sleep.

Young babies generally need to sleep 16 hours or more each day. Toddlers need to sleep 12 - 14 hours per night and teenagers should preferably sleep nine hours per night. Adults get along with eight hours on average per night.

Misconceptions

The following misconceptions regarding sleep are often encountered:

• There is a widespread idea that elder adults need less sleep than younger people. The correct state of affairs is, though, that elderly people suffer more from insomnia than younger people due to health problems and that they simply have to get along with less sleep - which may rather aggravate their health problems.
• One cannot stay awake indefinitely by using stimulants, such as strong coffee. Sooner or later the need for sleep will simply become too strong and the person will fall asleep, even if he drank so much coffee.
• There are those who think that it is not possible to catch up on lost sleep. This is not true. If somebody slept too little for a few nights it is necessary for him to plan his programme in such a manner that he can catch up on that sleep until he has wiped out his sleep deficit.
• It does not help to cram the night before an examination because one needs sufficient sleep to store the material that has been learnt, in the long-term memory.

Treatment

Since insomnia is a condition that causes so many problems it should not be accepted as a state of affairs about which nothing can be done. The following can be done:

• Identify the cause of the insomnia - a list of possible causes has been given above. If the cause is some or other ailment or psychological disorder, or if it is due to the abuse of some or other drug, it is obvious to address this state of affairs with suitable treatment. Apart from that, the patient has to be taught healthy and appropriate sleeping habits.
• If the person uses sleeping pills to fight his insomnia he has to be weaned from these. The use of sleeping pills has only value as an emergency measure and only for a short period of time because people can become dependent upon them, because the body gets used to them with the result that the doses have to be increased and because it does not address the underlying problem. If somebody ceases the use of sleeping pills his insomnia will inevitably recur, but then the underlying cause thereof has as a matter of fact to be dealt with.
• If somebody has accumulated a large sleeping deficit the administering of melatonin an hour before bed-time may be considered in order to restore the sleeping rhythm. Melatonin is the hormone that is being secreted by the pituitary gland when it becomes dark and which causes one to become drowsy. This is, therefore, not a substance to which one may become addicted since it is produced by the body itself. Usage of it during a lengthy period of time has, though, to be discouraged, because it may cause the pituitary gland to become lazy to produce enough melatonin on its own.
• The amino acids 5-HTP or L-Tryptophan, which are essential for the production of serotonin, are often successfully utilised in the treatment of insomnia because these substances also tend to make people drowsy. For this reason, it has to be taken at
• The application of behaviour therapy and/or clinical hypnosis are effective to help people to develop a healthy sleeping rhythm and to overcome underlying psychological problems.

4. Sleeping disorders

There is a long list of other sleeping disorders - apart from insomnia - of which people may suffer. Only the following conditions receive attention here: sleeping apnea, bruxism, restless leg syndrome, somnambulism and narcolepsy.

4.1 The most common sleeping disorders

Sleeping apnea

Sleeping apnea is a chronic ailment, which causes the sleeping person to stop breathing for periods of 10 seconds or longer and which may occur frequently during the night. Although the sleeping person may perhaps not be aware of the cessation of breathing it, nevertheless, interrupts the normal sleeping pattern and that has the effect that the person does not derive the value from his sleep he ought to get. Other sufferers from this condition awake often, due to a lack of breath. The result is that the person stays drowsy during the day and may fall asleep on inappropriate times.

The following causes have been identified for this condition:

• Overweight and an excess of tissue in the throat, which block the breathing canals;
• Tissue that becomes relaxed due to age and blocks the breathing canals; and
• The brain that "forgets" to keep the breathing reflex going.

The following symptoms usually accompany this disorder:

• Loud snoring noises and gasping for breath during sleep;
• Excessive sleepiness during the day;
• Forgetfulness, concentration problems and learning problems;
• Headaches, especially in the morning: and
• Irritation and/or depression.

Bruxism

Somebody with this disorder gnashes and bites on his teeth during sleep. This may cause broken teeth. The reason seems to be excessive stress and other unresolved negative emotions and conflict that surface during sleep.

Somnambulism

Somnambulists are mostly children, although adolescents and adults may also suffer from this disorder. The nocturnal walks take place during the phase of deep sleep and have no connection with dreams. The person usually has no recollection of the episode afterwards. It may, at times, give rise to accidents if the person falls or hurts himself in other ways.

Restless leg syndrome

It is mostly elder people who suffer from this disorder. The person often experiences unpleasant twinkling or itching sensations in the legs and an urge to move or kick the legs continuously. This may cause insomnia at night. In some cases this is connected to other conditions, such as diabetes or anemia.

Narcolepsy

Narcolepsy is a neurological disorder, which may cause the person to fall asleep without warning - often in inappropriate or even dangerous situations. It is obvious that a serious accident can occur if a person who is sitting behind the steering wheel of a vehicle or is operating heavy machines suddenly falls asleep. These sleeping episodes take anything between a few seconds and half-an-hour, even if the person has had ample sleep the previous night. This disorder usually starts during adolescence and the tendency thereto is seemingly inherited, although neurological conditions, such a head injuries, may also contribute to it.

4.2 Guidelines for good sleeping habits

The following guidelines or tips may help to prevent or overcome sleeping disorders:

Keep a strict routine

Go to bed every night at the same time and get up every morning at the same time. Keep this routine up also over weekends and during holidays in order not to confuse the biological clock.

Exercise

It helps to get exercise daily for 20 - 30 minutes in order to relax the muscles. Avoid exercise shortly before bed time because that keeps one awake.

Avoid caffeine, nicotine and alcohol

Caffeine, contained in coffee, tea and chocolate, is a stimulant and keeps one awake. Smokers often sleep lightly and withdrawal symptoms through the night may wake them up. Alcohol interferes with REM-sleep and deep sleep and keeps people in the lighter phases of sleep - which prevents them from getting the full benefit of their sleep.

Somebody who falls asleep due to an abundance of ingested alcohol does not really sleep - he is rather unconscious and cannot easily be awaken from this condition. During his unconscious condition he does not get enough REM-sleep and deep sleep.

Relax before bed-time

A warm bath, a few pages in a magazine or story book or soothing music shortly before bed-time may help one to relax and to facilitate falling asleep.

Keep work and sleep apart

It is a mistake to use the bedroom also as a working space since the association between the bedroom and work may keep one awake. A bedroom ought to be used only for three activities: sleep, getting dressed and making love.

Get into the sunshine

The human biological clock operates better if one is exposed to sunlight during the day - especially early in the morning.

Do not roll around in bed

If you do not fall asleep within 15 minutes it does not help to roll around in bed in an endeavour to fall asleep. Fruitless efforts to fall asleep only cause frustration and tension and that makes sleep impossible. Rather, get out of bed and go and watch TV, read a book or listen to soothing music until drowsiness returns.

Control the room temperature

People sleep more difficult in extreme temperatures. If in any way possible, see to it that the room is not too cold or too warm. Make sure that there is ample ventilation and fresh air since a stuffy room may interfere with good sleep.