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By Gayle Greene
UNIVERSITY OF CALIFORNIA PRESSCopyright © 2008 The Regents of the University of California
All rights reserved.
The cure for insomnia? Get plenty of sleep. W. C. Fields
The first thing to go is your sense of humor. Then goes the desire to do the things you used to do, then the desire to do anything at all. Parts of your body ache that you don't even know the names of, and your eyes forget how to focus. Words you once knew aren't there anymore, and there's less and less to say. People you once cared about fall by the way and you let them go, too.
Insomnia is a problem most insomniacs don't want to talk about. In fact, it's a problem many of us don't know how to talk about. "Oh, you know, a bad night," I say to a colleague's "What's wrong?" on one of my walking-into-walls days. "Why, Gayle, what do you have to lose sleep about? You've got no problems," says my colleague, eyebrows raised. If I'd been up with a bad tooth or a sick child, that's something he would understand. If I just plain can't sleep, that's weird. Anyhow, chronic insomnia is not just "a bad night." Chronic (i.e., lasting, constant, continuous) insomnia is a bad night that goes on and on.
Look on the Web, read what insomniacs say on Sleepnet.com and Talkaboutsleep.com, and you'll find stories of lives wrecked by this affliction, marriages ruined, educations abandoned, jobs lost, careers destroyed. I can't work, I can't date, I can't connect with anyone anymore. I had to drop out of school. I used to be a lawyer; now I'm the walking dead. I was a teacher once; there's no way I could face a classroom now. It's like being punished for something, only I don't know what I did. Does anybody have any advice? Please, please, can somebody tell me what to do? (Here—and throughout the book—I've italicized the words of insomniacs. Since most of the names I'd attach to insomniacs' quotes would be pseudonyms, I've left names off, except where speakers have told me they're willing to be identified.)
We reach for metaphors, analogies, figures of speech to say what "it's like." It's like someone opened a tap at the bottom of your body and just tapped out all the blood, and it's just gone, there's nothing left. It's like some vital juice is drained away and what's left is bone on bone. It's like I'm wasting away, slipping away, losin' it. It's like I'm being sucked dry, eaten away, stolen away, swallowed up, coming unglued—these are the terms I hear. It's a beast that can pounce on you without warning or cause. It chews you up and spits you out.
When you have insomnia, you're never really asleep, and you're never really awake, says a character in the film Fight Club. It's a claustrophobia of crawling through a tunnel of unbroken, undifferentiated time, a nighttime landscape that's neither sleep nor dream, says an insomniac I interviewed. Says Romanian writer E. M. Cioran,
Normally someone who goes to bed and sleeps all night almost begins a new life the next day.... He has a present, a future, and so on. But for someone who doesn't sleep, from the time of going to bed at night to waking up in the morning, it's all continuous, there's no interruption ... no suppression of consciousness.... So, instead of starting a new life, at 8 in the morning you're like you were at 8 the evening before. The nightmare continues ... and in the morning that new life doesn't exist....
When that's stretched out for months and years ... you do not see what future to look toward, because you don't have any future.
He adds, "And it requires an extraordinary will to not succumb."
"Succumb to what?" asks his interviewer.
"To the temptation of suicide. In my opinion, almost all suicides, about 90%, say, are due to insomnia. I can't prove that, but I'm convinced." Studies corroborate Cioran's suspicion, suggesting that insomnia may well be a risk factor for suicide. It is certainly a risk factor for alcoholism.
Insomnia has been with us as long as we've had language. Ancient Egyptian hieroglyphs record a lament for "three living hells," one of which is "to be in bed and sleep not." The sorrows of Job, in the book of Genesis, include the lament "When shall I arise, and the night be gone? I am full of tossings to and fro unto the dawning of the day." In the Latin epic Silvae, a first-century-a.d. insomniac prays to Somnus, the Roman god of sleep, the "gentlest of the gods": "By what crime or error of mine have I deserved that I alone lack thy bounty?" References abound, in the literary texts, diaries, letters, and legal documents of Europe and America of two hundred to five hundred years ago, to "restless" sleep, troubled sleep, broken sleep. The Pharaohs' tombs held urns of sleep-inducing herbs to guard against sleepless nights in the life to come. Remedies are described in ancient Greece and Rome, in medieval and Renaissance Europe and England. They include anointing the soles of the feet with the fat of a dormouse, brushing the teeth with the earwax of a dog, anointing the temples with a mixture of camphor and woman's milk, drinking a potion made from the gall of a castrated boar, and drinking hemlock—which may have induced a longer sleep than intended.
Insomnia may come with the territory of being human, but it has, for a variety of reasons, become the plague of modern times. Surveys indicate that about a third of the American population suffers with it enough to complain about it, and that as many as 10 to 15 percent have it chronically. Incidence is this high in other industrialized countries, the United Kingdom, Europe, Japan. Among the poor, the female, and the elderly, the incidence is much higher—in people over sixty-five, estimates are as high as 60 percent. Since there are no outward and apparent signs for what we have, no wounds, scars, crutches, casts, wheelchairs, this is an invisible epidemic. Insomnia is not seen, and it's certainly not heard, since insomniacs are not speaking out. Sleep researchers estimate that seven out of ten people with sleep problems never even discuss the problem with a professional. "Insomniacs are seen as neurotics who should have more will power," says Stanford researcher Richard Coleman. "Knowing that they'll be granted little sympathy if they mention some of their miserable daytime symptoms ... or ask for sick leave, insomniacs tend to keep their sleep complaints to themselves.... They prefer medication and go on secretly living with insomnia."
Mostly I have been reluctant to complain about insomnia to doctors, an insomniac wrote me. I'm becoming aware of how much I have internalized the stigma associated with it, the assumption that it's something I'm doing wrong, some emotional problem or bad sleep habits. From a U.K. insomniac, I hear, Most people don't want to talk about it because of the way we are regarded, I think. Some tell me, You're the first person I've talked to about this. I never talk about it to anyone. Some don't want to talk about it at all: you'll just see how neurotic I am. Several say that it's an issue too private or painful to go into, or that talking about it might make it worse: I find myself reluctant to talk about it, for fear of invoking it. From more than one I hear: I'm not an insomniac, I just can't sleep.
I understand, nobody wants to wear a badge that says neurotic. And yet, by not owning up to it, not naming it, we leave it, well, unnamed—unrecognized, undiagnosed, underresearched, underground, "the great underground ailment of modern society." Insomnia is, as one insomniac called it, the world's best-kept secret. It's like a dirty little secret we sweep under the carpet, hoping it'll go away.
But for the chronic insomniac, it doesn't go away.
* * *
When it began for me, I can't remember. The truth is, I remember very little of my childhood. What I do remember is the following scene, played at various times throughout my youth, most vividly in my early adolescence: "But I can't sleep!" I'd protest as my parents tried to wrestle me into bed at what they called a decent hour, meaning any time before 1 a.m.
"Nonsense," said my father, "of course you can. Everyone knows how to sleep. Why, even animals know how to sleep. Just close your eyes, relax, and you'll get sleepy. It's the most natural thing in the world, sleep." My father was a normal sleeper, and to the normal sleeper, sleep is "the most natural thing in the world."
"But Daddy, I can't! I don't know how!"
"Well, you get all wound up. Now if you'd only listen to your mother and go to bed earlier ..." He knew it was something I was bringing on myself, some obstinacy of mine that I could change, if only I would do something different, be something different—if only I would change my attitude, change my ways.
My father was a doctor, an old-style family practitioner who carried a black bag and delivered babies at home, one of a heroic, vanished breed. But that didn't mean he knew a thing about sleep. Sleep had no part in the medical school curriculum at Yale in the 1930s when he was there. Sleep has little part in medical curricula today, when doctors get an average of one to two hours' instruction in sleep and sleep disorders. The advice he gave me is a version of the advice I've been hearing ever since: you're stressed out, you're anxious, you're depressed, you have bad habits. These are the things insomniacs are still told. There may be—there often is—truth to such explanations, but they may also be ways of passing the buck back to the sufferer, a thing doctors have been known to do when confronted with problems they don't well understand.
We also hear a lot of cheer-up-it's-not-so-bad advice:
"Don't worry about it—you probably just worry too much."
"You probably just need more exercise—try yogi" (that's not a typo). I do yoga stretches. I swim three times a week and walk on the days I don't swim.
"As you get older, you need less sleep." A myth that's been called into question by recent research: we may get less sleep as we age, but it's not clear that we need less sleep.
"You probably sleep more than you think you do—people often do." I run this one by my partner, Bob. "No-o-o-o, I don't think so," he says. Too many of my sleepless nights have become his.
Psychophysiological insomnia is the diagnosis given to garden-variety insomniacs like myself, people who have no egregious psychological or medical problems. It's a sort of catchall term for insomnia that cannot otherwise be explained. The psycho suggests that the mind (or psyche) is involved; the physiological suggests that the body's there, too, except that nobody—neither the doctors nor the writers of the self-help books that crowd the bookstore shelves nor the researchers themselves—seems much interested in the body's part. No doctor I ever saw showed the slightest curiosity about the cocktail of hormones, estrogen, progesterone, thyroid, that I ingest daily, though any of these might affect sleep. The psycho explanation is so much easier. When 501 physicians were interviewed about how they treated insomnia, "they revealed that they asked an average of 2.5 questions and their questions were most likely to be about psychological problems." Fewer than a quarter "even asked about patients' evening coffee intake."
"Uh, Psychiatry handles that," said my primary caretaker at my HMO when I asked him for a sleep med. I made an appointment with "Psychiatry" (which took six weeks) and talked to a nice man who made sure I wasn't suicidal, referred me to an "antianxiety workbook," and offered me an antidepressant, though I told him that antidepressants make me, well, depressed. "Sure, that's how it works," says a psychotherapist friend, Ilene, who works with patients referred to her by the HMOs. "The hardcore insomniacs get shunted to us. As though we know how to deal with it!" "The patient with a chronic complaint of insomnia (even though it may have a purely physical etiology) will usually be referred to the psychiatrist," concludes a 1980 survey. Maybe this is why so few insomniacs take their problem to a doctor.
"Sleep in a dark, quiet room," "Make sure you have a comfortable mattress"—these are things I get told. All very true, but what kind of an idiot would I have to be to have lived this long with this problem and not know this? "Go to bed earlier," "Go to bed every night at the same time and get up at the same time," "When you can't sleep, get out of bed and do something else," "Never use the bed to read or work." All very well, but nothing I didn't hear from my father those many years ago—except now there are new names: sleep hygiene (a term that makes me feel like I'm not only a bad sleeper, but a dirty sleeper) and sleep restriction therapy (restrict time in bed to the hours you sleep consecutively) and stimulus control therapy (learn to associate the bed only with sleep) and cognitive restructuring (change your way of thinking about the problem) and cognitive behavioral therapy to deal with maladaptive thought patterns. A real mouthful, that, but what it all comes down to is—change your attitude, change your ways.
Friends and family weigh in with further advice. "Oh, I had insomnia once. I just got up and did something else. I told myself, 'Just cut this out,' and after a week or so, I was fine. If I don't worry about it, it goes away." Everybody's had a bad night now and then, so everybody's an expert, right?
"You're probably not 'getting enough.'" Sex, he meant. But for some reason, most of the things that put other people out perk me right up: sex, hot baths, whiskey, meditation, eating carbohydrates at night, eating protein at night, eating nothing at all.
Or, "A little warm milk—puts you right out."
Or, "A shot of whiskey does the trick."
"A hot bath ..."
"A big plate of pasta ..."
"Have you tried melatonin?" Yes, I have tried melatonin. I've tried (nearly) everything anyone has ever told me worked for them, and it's taken me some strange ways: lathering myself in sesame oil, brewing a Chinese herbal tea so foul that my dog fled the kitchen when it steeped, concocting a magnesium supplement that hissed and spat like something out of Harry Potter. I've driven across two counties to a guru who claimed to have the secret of sleep. I've tried valerian, kava kava, chamomile, skullcap, passionflower, homeopathic concoctions, l-tryptophan, 5-HTP, GABA, melatonin, Elavil, Zoloft, trazodone, tricyclics, and pills whose names I never knew. I took the talking cure with a psychiatrist and a psychologist, and though the psychologist helped me sort things out, she hadn't a clue why I sleep so badly or what I should do about it. I've tried most of the benzodiazepines—Librium, Valium, Xanax, Dalmane, Klonopin, Restoril, Halcion, and more Ativan than I care to remember or probably can remember, since this drug erodes memory. I've taken the nonbenzodiazepines Ambien and Sonata and, in the bad old days, I dipped into Nembutal, Seconal, and Miltown, as well as over-the-counter products like Sominex, Nytol, Sleep-Eze, and others whose names I've repressed. I've tried acupuncture, biofeedback, meditation, hypnosis, self-hypnosis, relaxation tapes, ayurvedic medicine, adrenal support supplements, blackstrap molasses, wheat germ, bananas by the bunch, licorice root, SAM-e, St. John's wort, yoga positions, and at one point, I was swimming three to four miles a day. I've worn a magnet necklace. And yes, I have tried regularizing and restricting my sleep, cutting out all caffeine and alcohol, doing all those "sleep hygienic" things we're told to do. I thought I'd tried everything there was to try, but when I started talking to insomniacs, I realized I'd missed a few: I have not consulted a psychic, hung in a flotation tank, done cranial electrical stimulation, or slept with a cathode ion collector dish by the bed. I have not tried chelation treatment (getting the lead out), colostrom (don't ask), sleeping with my head pointed north or west, or ordeal therapy, unless you call vacuuming the house at 4 a.m., which I used to do, "ordeal therapy."
"If there's any illness for which people offer many remedies," says a character in Anton Chekhov's The Cherry Orchard, "you may be sure that particular illness is incurable."
Excerpted from Insomniac by Gayle Greene. Copyright © 2008 The Regents of the University of California. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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Table of ContentsAcknowledgments
3. Blame the Victim
4. Sleepless in Seattle: The Conferences
5. The Brain of an Insomniac
6. Sleep, Stress, and Stages of Life
7. Rock, Hard Place: The Drugs
8. Change Your Attitude, Change Your Ways: Behavioral Modification
9. Asleep at the Switch: The Clinics
11. Bedding Down with the Beast
12. Making Change
What People are Saying About This
"Greene's book is the best available on the subject."New England Journal of Medicine
"Insomniac is far too interesting to lull you into dreamland."O: the Oprah Magazine
"A harrowing memoir."Wall Street Journal
"Provides . . . insights that many sleep researchers and doctors have lost track of. . . . Among the best books of its kind."Nature
"Greene imparts a feeling of solidarity to fellow sufferers."Library Journal