Sleeplessness assessing sleep need in society today

SLEEPLESSNESS
ASSESSING SLEEP NEED IN SOCIETY TODAY

Jim Horne


Sleeplessness



Jim Horne

Sleeplessness
Assessing Sleep Need in Society Today


Jim Horne
Loughborough University
Leicestershire, UK

ISBN 978-3-319-30571-4 (hard cover)
ISBN 978-3-319-32791-4 (soft cover)
DOI 10.1007/978-3-319-30572-1

ISBN 978-3-319-30572-1

(eBook)

Library of Congress Control Number: 2016940600
© The Editor(s) (if applicable) and The Author(s) 2016
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To My Family



Preface

Apparently, many of us in today’s society are, unknowingly, suffering from
chronic sleep loss, known as ‘sleep debt’—search the term on the internet
and there are millions of hits. This ‘societal insomnia’ is largely attributed to the pressures of modern waking life, and seems to be yet another
cause of obesity, cardiovascular disease and other disorders. Besides, such
claims further add to the worries of those actually suffering with insomnia, striving even for 6 hours’ sleep, only to hear that 7–8 hours is the
ideal goal. Yet, human nature being what it is, little has actually changed
since Victorian times, when ‘sleeplessness’ was a common topic of medical debate, and it is here where we begin, with some remarkable insights
from physicians of that era, that ought still to give us pause for thought,

and underlies the theme of this book.
A diagnosis of ‘insomnia’, and indeed the term itself, is largely a
twentieth century convention, mostly heralded by the discovery of new
hypnotic medicines, allowing the condition to become more ‘medicalised’
rather than a more benign ‘fact of life’, as it was then seen to be. By continuing to take this more ‘matter of fact’ approach to today’s sleep debt,
Sleeplessness looks more closely and dispassionately at insomnia itself, its
various phenomena, and the ‘overwakefulness’ that pervades it, which
is more likely to be remedied, not by sleeping tablets alone, but by the
therapies of wakefulness rather than those of sleep.
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Preface

Moving on to the wider issues of ‘societal insomnia’, Sleeplessness argues
that sleep debt is overstated, as the great majority of us have sufficient
sleep, especially as our 7-hour average sleep has changed little over the
last century. Thus claims that we ‘need 8 hours’ are doubtful, as most of
us happily sleep less than this amount and, apart from the natural differences between people in the duration of their sleep, judging it merely by
its length overlooks the importance of its quality, and another underlying
theme for Sleeplessness.
Hour by hour, a night’s sleep is not equivalent in terms of its recuperation. As one might expect, sleep at its beginning, reflected by the
EEG as ‘slow wave sleep’ (SWS—‘deep sleep’), is more beneficial than
sleep towards its end, when Rapid Eye Movement sleep (REM) is at its
most prolific, with its accompanying dreaming at its most intense. Whilst
SWS seems to be critical for the brain’s (cortical) recovery following the
demands of prior wakefulness, REM is much like wakefulness and mostly
seems to prepare us for the ensuing wakefulness, more so with ‘emotional

preparedness’, maybe even linked to food choice and its desirability.
More to the point, REM towards the end of sleep seems to be interchangeable with wakefulness depending on whether waking needs are
greater or lesser, when REM can act as a time-filler to extend sleep when
the pressure for wakefulness is low, or taken simply from pleasure. Such a
flexibility in sleep duration, especially with REM, and without necessarily affecting sleepiness nor a need for extra ‘recovery sleep’, is not achieved
‘overnight’ but can require longer-term adaptation. For example, before
the advent of the electric light and with the seasonal changes in daylight
and food availability, waking pressures on sleep duration would naturally
alter, as can still be seen in today’s non-industrial societies. Interestingly,
REM has brain mechanisms in common with feeding behaviour, with
REM also able to suppress feelings of hunger appearing towards the end
of our nocturnal sleep which usually develops into a fast.
All our biological needs are flexible, harmlessly able to be reduced
somewhat, or taken to excess, as with our ability to eat and drink beyond
the feelings of hunger and thirst, depending on tempting opportunities from the sight and smell of attractive food, or the social drinking of
coffee, tea and beer for example.


Preface

ix

A critical examination of the links between short sleep and mortality,
obesity, diabetes and heart disease, shows these to be modest at best, only
really seen in those sleeping fewer than five hours a night, where many,
here, are indeed chronically sleep deprived, but who comprise only a
small minority of the population. Whether this inadequate sleep is an
actual cause rather than a correlate of obesity, for example, is a matter
for much debate, despite statistically significant findings which, in real
terms, are often too small to be of real clinical significance. This issue,

that both types of ‘significance’ are synonymous, is misleading and can be
seen with other aspects of sleep and, again, all too easily leading to other
potentially worrying distortions of actual risks. For example, weight gains
attributed to sleep debt, even for 5-hour sleepers, typically average less
than 2  kilograms a year, contrasting with those hundreds of hours of
apparently annually accumulated ‘lost’ sleep. Besides, few obese adults
are such short sleepers, and neither by extending their sleep, nor by using
sleeping tablets, is any such weight gain likely to be prevented, particularly when compared with the far more rapid effectiveness of diet and
exercise.
The extent to which today’s children and adolescents suffer from
sleep debt is another focus for Sleeplessness comprising similar issues and
controversies. Again, the historical evidence is revealing when compared
with the extensive recent findings and, once more, it is plus ça change …
particularly when considering obesity and the extent of the claims that
this is also linked to their short sleep.
More light, especially daylight, is shed on the body (circadian) clock,
both in its role as the terminator of sleep, and on the recent, popular
concept of ‘social jet lag’ which, in many respects, is akin to sleep debt.
Yet again, these factors also reflect the ability of our sleep to adapt (within
limits) to essential waking needs, in a ‘give and take’ manner. However,
as shift work and actual jet lag do present difficulties, these topics have an
airing that includes practical advice.
Inasmuch as we can sleep to excess, then it is argued, here, that the
sleepiness preceding this ‘extra’ sleep is not indicative of sleep need, but
is incidental or ’situational’, overcome without the need for sleep, but by
more worthwhile waking activities. This is comparable with our ‘appetite’ for food, as in that tempting second helping, rather than hunger as


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Preface

in a need to eat. However, this ‘appetitive’ sleepiness, unnoticeable in
everyday activities can be eked out by boredom or maybe created by it,
but is not indicative of sleep debt. Nevertheless, sleepiness attracts much
research effort, utilising tedious tests so sensitive to sleepiness; even a
sleepiness not normally evident. The extent to which we are aware of
our own sleepiness, without necessitating these tests, has medico-legal
ramifications, even though it is argued, here, that this awareness is probably as good as these tests.
‘Tiredness’ is not synonymous with sleepiness, and although those
with insomnia often attribute their tiredness to a lack of sleep, this is
more of a feeling of weariness with a loss of interest in the world at large,
which is distinct from sleepiness and a propensity to fall asleep. Such
tiredness is not necessarily ‘cured’ by more sleep but, rather, by creating
a better wakefulness. At the other extreme is the profound and perpetual
sleepiness due to severe sleep disturbance seen with, for example, obstructive sleep apnoea syndrome, often unrecognised by sufferers, believing
that they sleep well, but who remain perplexed as to why they are indeed
so sleepy during the day.
Sleepiness is such a distinct aspect of sleep that it attracts considerable
research attention, to the extent that other potentially important aspects
of sleep are so easily overlooked. That is, sleep is not only for relieving
sleepiness, inasmuch as eating food is not simply for relieving hunger, as
the different nutrient contents of food have more subtle roles, as do the
components of sleep, typically reflected by the EEG in the form of SWS
and REM for example.
These less obvious roles of sleep takes Sleeplessness to the brain’s cortex,
especially its frontal region, comprising a third of our cortex, at its most
highly developed in humans, and largely the seat of our uniquely human
and subtle behaviours, collectively called ‘executive functions’, including
those ‘conscious decisions’ of whether or not we decide to go to sleep.

Until only a few decades ago this relatively huge brain region was thought
to be ‘surplus to requirements’, mostly because there were no appropriate measures of such behaviours, all too easily missed under clinical
and laboratory settings utilising relatively simple tests of brain function
(an account of this historical oversight is given in the Appendix).


Preface

xi

Today’s research shows that even a single night of total sleep loss, as
happens with long night shifts, causes temporary impairment to these
executive functions, quickly reversed with recovery sleep. Such effects only
really appear under real-world settings when we are confronted by unexpected, changing and challenging situations with competing distractions,
requiring one to ‘think out of the box’, beyond routine responses; even
when dealing with protracted, difficult overnight negotiations involving
‘hidden agendas’, and nuances in the behaviour of others. While caffeine
and other ‘psychostimulants’ help overcome ‘ordinary sleepiness’, they
have little benefit for these executive impairments.
SWS is also important for the ageing cortex in maintaining ‘use it or
lose it’, in helping to create new connections during sleep that can help
offset ageing effects. Although physical activity itself is thought to promote more of this cortical rewiring, there is more to this topic than at first
seems, as the real benefit of such activity, especially for the frontal region,
is not so much the exercise itself, but the extent to which it brings a
variety of novel and interesting sensory and cognitive encounters with
one’s surroundings and people, to elicit new thoughts, emotions and
experiences that need to be assimilated and remembered, leading to more
SWS and its rewiring benefits. Whereas sitting reading or watching TV
are too passive and less effective, all one really needs to ‘exercise the cortex’
are a comfortable pair of walking shoes, curiosity and a desire to explore.

So, here are some of the many topics to be covered in Sleeplessness in
its critical appraisal of how much sleep we really need and what it is for,
together with more reassuring perspectives on the beliefs concerning our
apparent lack of sleep. Together, these might also provide further insights
into insomnia, both for the individual and for that ‘societal insomnia’,
otherwise seen as sleep debt.



Contents

1

Insomnia
1.1 Sleeplessness: Lessons from History
1.2 Insomnia: ‘Medicalising’ Sleeplessness?
1.3 Today
1.4 Severity
1.5 Contradictions
1.6 Ambiguities
1.7 ‘Inverted U’
1.8 Lack of Sleep?
1.9 Sleeping Tablets
1.10 Cognitive Behaviour Therapy for Insomnia (CBT-i)
1.11 Sleep Hygiene
1.12 Overwakefulness?
1.13 Tiredness
1.14 Fatigue
1.15 Causing Serious Illnesses?
1.16 Summing Up

References

1
1
5
8
9
11
12
15
16
17
23
25
27
28
31
31
32
33

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2

Contents

Sleep Debt: ‘Societal Insomnia’?
2.1 Yesterday and Today
2.2 Time in Bed and Daytime Naps
2.3 Non-industrial Societies and Seasonal
Flexibility of Sleep
2.4 Needing Versus Desiring More Sleep
2.5 Gender
2.6 For Better or For Worse?
References

37
37
42

3

Short Sleep, Mortality and Illness
3.1 Overstated
3.2 Clinically Significant?
3.3 Rounding Up and Down
3.4 Mortality
3.5 Cardiovascular Disease (CVD)
3.6 Breast Cancer
3.7 Immunity
3.8 Wear and Tear
3.9 William Gale
References

51
51

52
54
55
58
60
61
62
64
66

4

Obesity
4.1 Lean Times
4.2 Body Mass Index (BMI)
4.3 Population Studies
4.4 Metabolic Syndrome and Type 2 Diabetes
4.5 Overview: Unlikely Bedfellows?
References

69
69
72
73
77
78
80

5

Childhood and Adolescence
5.1 Kids: Too Little Sleep?
5.2 Growth
5.3 Obesity

83
83
89
90

42
44
46
47
48


Contents

5.4 Of Greater Concern
5.5 Late Nights
References

xv

93
94
96

6

When Is Enough, Enough?
6.1 Priorities
6.2 The End of Sleep
6.3 ‘Oversleep’
6.4 ‘Social Jet Lag’
6.5 More or Less
6.6 Napping and Siestas
6.7 Summing Up
6.8 Sleepless in New Jersey
References

99
99
101
103
105
107
110
113
114
116

7

Illumination
7.1 Enlightenment
7.2 Curtains
7.3 Larks and Owls
7.4 Jet Lag

7.5 Shift Work
References

119
119
121
122
124
125
127

8

Sleepiness
8.1 Implications
8.2 Falling Asleep Versus Staying Awake
8.3 Monotony
8.4 Subjective Sleepiness
8.5 Mind over Matter
8.6 Twice as Sleepy or Half Alert?
8.7 Road Safety
8.8 Circumspection
References

129
129
130
133
135
136

138
140
142
142


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9

Contents

Extreme Sleepiness
9.1 Badly Disrupted Sleep
9.2 Excessive Daytime Sleepiness (EDS)
9.3 Obstructive Sleep Apnoea (OSA)
9.4 Kicks and Restless Legs
9.5 Narcolepsy
References

145
145
146
147
150
151
151

10 Brainwork
10.1 Cortical Readiness

10.2 Being Human
10.3 Brain Imaging
10.4 Glia: Silent Witnesses
10.5 ‘Hidden Attractor’
10.6 Stage 2 Sleep
10.7 Memory
10.8 Lost Sleep
References

153
153
155
156
157
158
160
161
163
164

11 Prolonged Wakefulness
11.1 Night Work
11.2 ‘Distractability’
11.3 Negotiations
11.4 Countermeasures
11.5 Inertia
11.6 Summing Up
References

165

165
167
169
169
170
172
173

12 Use It or Lose It
12.1 Enrichment
12.2 Exercise Is Not Enough
12.3 Boosting SWS
12.4 ‘Fresh Air’
References

175
175
176
177
179
180


Contents

xvii

13 REM Sleep: Food for Thought?
13.1 Phenomena
13.2 REM Wakefulness

13.3 Appetite for REM
13.4 Summary
References

183
183
186
189
191
193

14 Overview

195

Appendix: Frontal Assault
Early Traumas
The Next 100 Years
Lost Souls
References

199
199
202
203
204

Index

205

List of Figures and Tables

Figures
Fig. 1.1

Optimum performance differs between easy
and difficult tasks according to arousal level
Fig. 2.1 Sleep durations in 2000 UK adults—adapted from
Groeger et al. (2004)
Fig. 2.2 Sleep durations in 110,000 US adults—adapted from
Krueger & Freedman (2009)
Fig. 6.1 Hypnogram showing the distribution of sleep stages
over a typical night—note the 90-minute cycling and
predominance of SWS at the beginning and REM
at the end of sleep, respectively
Fig. 6.2 The interaction of sleep pressure (‘Process S’) with
the circadian rhythm (‘Process C’), as in the ‘two process
model’. Upper figure—for a normal night. Lower
figure—on a recovery night following a night of sleep loss.
Note how the morning circadian rise acts as a sleep
terminator—see text for details
Fig. 7.1 Typical circadian differences in alertness for ‘definite’ morning
and evening types
Fig. 10.1 Cortical lobes seen from the brain’s left side. Note the large
frontal lobe with its orbitofrontal region below

15

40
41

100

102
123
154

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List of Figures and Tables

Fig. 10.2 Upper—Stage 2 sleep showing spindle and K Complex.
Lower—1 Hz delta waves as seen in SWS. Note the
similarity between these waves and the K Complex.
See text for details

158

Table
Table 5.1 Historical comparisons of children’s sleep from three
studies and countries, Bernhard (Germany, 1907)
Ravenhill (UK, 1908) and Terman and Hocking
(USA, 1913)

88

1
Insomnia

1.1

Sleeplessness: Lessons from History

Literature owes much to Charles Dickens’ poor sleep when, on occasions,
he would get out of bed and tramp the nighttime streets of London,
encountering the people and places that gave him so many inspirations
for his novels and for his conceptions of the tortured minds of many of
his characters. His remarkable accounts of these wanderings and wonderings, which he called his ‘houselessness’, are described in his little known
book of ‘Night Walks’, which might be seen as a positive side to insomnia
and how he turned this affliction very much to his advantage. After walking for many miles, he would return home at sunrise, to his northwards
pointing bed, to sleep exactly in the middle, placing his arms out and
checking that his hands were equidistant from the bed’s edge. At other
times, when he could not sleep, he would stand at his bedside until feeling chilly, shake up and cool his pillows and bedclothes, then get back
into bed. In fact, unlike the rest of his methods this latter technique is
based on sound science as the body indeed needs to cool in order to
ensure more rapid sleep onset.

© The Editor(s) (if applicable) and The Author(s) 2016
J. Horne, Sleeplessness, DOI 10.1007/978-3-319-30572-1_1

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Sleeplessness

Nevertheless, his was a magnetic personality in more ways than one as,
away from home, he would realign the bed to the north, which is why he
always carried a compass—to foster his creativity as he also had to be facing north before he would put pen to paper. He believed in mesmerism
(also called ‘animal magnetism’), thought to be linked to real magnetism,
as Mesmer, himself, would use pieces of magnetic iron ore (‘lodestone’) as
part of his mesmeric treatments, even for curing insomnia. But this was
too much for Dickens, who dismissed such use of magnets as ‘unnatural’.
Nevertheless, lodestones embedded in pillows were a very popular cureall amongst the Victorians. But we shouldn’t mock, as even in the 1960s,
a ‘magnetic field deficiency syndrome’, with symptoms including insomnia, was a common diagnosis in Japan, and even today, magnetic pillows
and mattresses continue to be advertised to alleviate insomnia.
However, Dickens, who died in 1870, couldn’t really be called an
‘insomniac’ as the term was seldom used at the time. Yes, he suffered
from insomnia, but then it was called ‘sleeplessness’, and another 30 or
so years elapsed before ‘insomnia’ became the word of choice, coinciding
with the development of new medicines and changes to medical practice
(more about this, later).
Until then, the obvious remedies for sleeplessness were either alcohol (gin for the poor and whisky or brandy for the wealthier), or the
readily accessible and cheaper ‘fix’ of opium in one form or another,
with the most popular being laudanum, a tincture of alcohol and morphine. Being unrestricted, it could be bought almost anywhere. In fact,
so popular was opium, that the British had largely gone to war with
China, in the ‘opium wars’, to maintain the lucrative supplies. Byron,
Shelley, de Quincey, Coleridge, Poe and even William Wilberforce were
‘opium-eaters’, using the drug not just as a sleeping aid, but also for
pleasure or out of addiction. Meanwhile, cannabis, also easily available,
was regarded to be more dangerous than laudanum, until it became
known that Queen Victoria had been prescribed it by her personal physician, Dr JR Reynolds, to ‘assist sleep during menstrual cramps’. Some
years later, in 1890, he reflected in an article for the Lancet, that cannabis was ‘one of the most valuable medicines we possess for treating

insomnia’.


1 Insomnia

3

For those after a milder treatment for their sleeplessness, there was the
herb valerian, named after the sleepless Roman emperor Publius Licinius
Valerianus, who advocated its use throughout his empire. Although,
pharmacologically, it had only a modest soporific effect, it benefited from
having such an influential user and patron, and became the medicine of
choice for the sleepless Romans, especially when coupled with the power
of such a celebrity endorsement. Human nature being what it is, such
placebo effects remain with us, more than ever with today’s ‘over-thecounter’ remedies, including modern prescription medicines that are
truly hypnotic, but also have additional placebo effects.
But to return to the Dickensian era, where there was good insight into
insomnia, albeit quaintly amusing and still relevant today, lamentations
about sleeplessness abounded in the then medical literature. For example,
an editorial in the BMJ of 29 September 1894 (p. 279) bemoaned, “The
subject of sleeplessness is once more under public discussion. The hurry and
excitement of modern life is held to be responsible for much of the insomnia
of which we hear; and most of the articles and letters are full of good advice
to live more quietly and of platitudes concerning the harmfulness of rush and
worry. The pity of it is that so many people are unable to follow this good
advice and are obliged to lead a life of anxiety and high tension”.
The editorial went on to review various attested treatments, pointing
out that different remedies suit different people, to the extent that one
apparently effective remedy can be the exact opposite of another. For
example: hot baths versus cold baths, hot drinks versus cold drinks, long

walks (in bare feet) versus sitting whilst attempting ‘steady but monotonous counting’ or ‘the more difficult feat of thinking about nothing’. The
article concluded with what must be the most extraordinary account of a
cure, originally taken from the Glasgow Herald:
Soap your head with the ordinary yellow soap; rub it into the roots of the hair
until your head is just lather all over, tie it up in a napkin, go to bed, and wash
it out in the morning. Do this for a fortnight. Take no tea after 6 pm. I did this,
and have never been troubled with sleeplessness since. I have lost sleep on an
occasion since, but one or two nights of the soap cure put it right. I have conversed with medical men, but I have no explanation from any of them. All that
I am careful about is that it cured me.


4

Sleeplessness

The editorial wisely ends with the comment that “we cannot help
thinking that some of our sleepless readers would prefer the disease to the cure.
But if any should like to try it, may we advise that they should first, at any
rate, follow that part of the advice which relates to the tea, and leave the soap
part as a last resource”.
The interesting word, here, was ‘disease’ , as this was still a time when
‘the mind’ was somewhat of a little understood, embarrassing enigma,
largely ignored by physicians and well before the era of Freud and his
contemporaries. None of the numerous remedies for sleeplessness
involved anything along the lines of what one might call psychological
therapy, even though stress and a troubled mind were well known to be
the common basis, as reflected over 30 years earlier, in another insightful
BMJ editorial (9 November 1861, p. 489), entitled ‘On Sleeplessness’, by
Dr James Russell:
In treating these cases [of sleeplessness], the key to success lies in the management

of the patient’s mind, and unless we recognise the large share which is taken by
mental disorder in producing and perpetuating the various and puzzling symptoms which present themselves, we shall not only fail in our object, but shall be
in danger of actually aggravating the malady. Much may be done by soporifics
and tonics; but our chief attention must be directed to regulating and strengthening the mind, otherwise our medicines will only serve to fix the patient’s
attention more closely upon the symptoms, and induce reliance upon external
measures rather than upon self discipline. The treatment required is suggested
by the nature of the malady. We find self-control diminished, the will inert, the
emotions dominant, the thoughts of the sufferers occupied entirely about themselves, and the idea of disease the one subject engrossing their attention; we find
every sensation registered, every fresh complaint welcomed and symptoms which
at first seem to belong to organic disease are discovered, by further experience of
the case, to have their origin in nothing but exaggerated sensitiveness or disordered fancy … The task of ministering to such a condition is no light one; and
it is hard to say whether the discipline is more severe to the patient or to the
attendant …

This was also the era when fortitude and a ‘stiff upper lip’ were expected
of patients, and when the prevailing medical opinion was that emotions
caused bodily changes, particularly within the cardiovascular system,