Sleep Disorders

Sleeping sickness

By Sarah Boyd, The Dominion Post

There's a growing industry devoted to keeping us awake and then helping us sleep. Sarah Boyd and Anneli Knight report.

You can survive 42 days without food before you die. But without sleep you will perish in 10. Along the way you'll become prone to infections, your personality will change dramatically and stress hormones will accelerate. Hair falls out and weight loss continues no matter how much food you put in your mouth. Eventually, your heart just fades away.

Palmerston North woman Amanda Harvey, 38, reckons few people understand the seriousness of lack of sleep. When she tells people about her long-term insomnia, the common reaction is "That's great -- you must get so much done."

"It's not a good thing. It's had a really bad effect on my enjoyment of my family and on everything."

A survey by Massey University's sleep wake research centre showed most New Zealanders get about 7.4 hours sleep a night, much less than the nightly nine hours recorded 100 years ago. A conference dubbed Sleepless in Sydney last week brought together experts from both sides of the Tasman to discuss all aspects of what is considered a growing modern-day problem.

"You need a certain volume of sleep to survive," says Matthew Naughton, a doctor at the Alfred Hospital Sleep Clinic in Melbourne. "We've had patients who think they can do without sleep. They just take more Coca-Cola. But it doesn't work like that."

Society is adapting to a longer day -- and reinforcing it, says Dr Naughton. "There is a 24/7 society and increased demands on time -- computers, Internet banking, 24-hour supermarkets and all-night convenience stores. We travel more so we have more jetlag, and we expect production companies -- transport, shipping, health care -- to work 24 hours," he says. "And while the demands on people's time are increasing, there are more things to distract us to keep us awake for a longer period of time. We are also working longer hours -- there's been an increase in overtime and shiftwork."

Meanwhile, he says, our health is suffering.

"We're eating more and doing less exercise -- we're becoming fatter," says Dr Naughton. "The number of people with obesity has doubled over 10 years. And the implication of less exercise and increased body weight is that disorders associated with sleep have skyrocketed."

This is not bad news for everyone, however. A diverse sleep industry -- for both keeping us awake and getting us to sleep again -- is growing around the longer day. Take the energy drinks market. Different brands of caffeine-rich drinks have proliferated in the past five years and in Australia the market is now worth A$32 million. A 2002 study by Consumer magazine in New Zealand showed that some drinks contain more caffeine than a cup of plunger coffee.

Various supplements, such as guarana, claim to increase vitality and counter sleepiness, and then there are more powerful drugs. In the United States, a drug called Provigil is reported to be the new "24-hour wonder drug", used by students, partygoers and workers such as long-distance truck drivers to stay awake. It has also reportedly been purchased in large quantities by the US and British military. In Britain it's recently been approved for treatment of sleep problems linked to shiftwork.

Here, it's known as Modavigil and available only from specialists to alleviate daytime tiredness in people suffering the rare sleep disorder narcolepsy, though the company which distributes it, CSL NZ Ltd, plans to look at the data behind the British decision and may apply for extended use.

Perhaps the biggest business lies in methods to help us get some shut-eye. The sleep disorder treatment industry is among the fastest growing in the world. Insomnia can be treated, with varying degrees of expense, with therapy, medication and stress management skills. The sleep wake centre recommends people go to bed only when they're sleepy, establish relaxing rituals, exercise regularly and avoid alcohol, cigarettes and coffee immediately before bed.

Auckland occupational therapist Fiona Johnston, who specialises in treating insomnia and sleep problems caused by shiftwork, says she's encountered people who have become addicted to sleeping pills in their desperation to sleep.

Shiftworkers are often keen to take melatonin, an over-the-counter supplement, to help them adjust their sleep cycles. But, she says, it is better for people to keep their body clock set on day and to simply keep working into the night if they have to. Under OSH guidelines, they shouldn't be doing more than four nights in a row.

"Melatonin could be useful if you're going to a different country and you have to perform on arrival. But as a lifestyle thing, it's not."

She finds that people who are naturally morning people -- larks -- can usually not cope with shiftwork for long, anyway. She advises people to concentrate on what she calls sleep hygiene -- the rituals and behaviour around sleep -- and to look at deeper causes for sleeplessness, such as stress.

Mrs Harvey did try sleeping pills when her insomnia worsened earlier this year, but she found they made her drowsy instead of helping her sleep, and she felt heavy-headed in the morning. She considered consulting a sleep hypnotist, but balked at the $100 per session price tag.

Instead, she now goes through a relaxation routine consisting of a bath and warm drink. She tries to read for half an hour in bed and have the light out by 11pm. She wears earplugs and the cat that used to wake her in the night has been banished.

Most useful was the advice of a friend to repeat a mantra about how she was going to sleep as soon as her head touched the pillow, and that she was going to sleep for eight hours. "It's worked really well. If I feel my mind wandering to other things, I'll say it over again."

Ms Johnston says the symptoms of fatigue are a bit like being drunk: "And you don't turn up to work drunk. You're actually legally required to sleep. Fatigue is written into the law as a hazard that has to be managed. You manage it by sleeping well."

Chit Shu Chan, medical director at Sydney's Sleep and Chest Disorder Centre, says the 24-hour society is causing sleep debt and an acceleration in sleep disorders.

"Inadequate sleep causes an increase or surge in stress hormones and when that happens it causes various changes -- blood pressure increases, heart rate increases, cholesterol triglycerides increase, insulin levels increase and we develop a hormonal imbalance at the same time."

Such changes have far-reaching effects, including reduced cognitive function, short-term memory and concentration span, and the lower levels of hormones released during sleep can lead to obesity.

Babyboomers have brought sleepiness to the attention of medical practitioners, Dr Naughton says. "They're not prepared to accept it -- they are going to complain and they are going to look for answers."

People are pushing their bodies past natural sleep cues and this contributes to sleep disorders, says Peter Birrell, a sleep research expert at the University of New South Wales' school of psychology.

"People have an ordinary drowsiness that is the preamble to going to sleep. By associating preparations for bed not with calm and tranquillity, but with anxiety, ruminations about unsolvable worries, arguments between partners or spouses -- all of these things tend to produce a counter-conditioning to the sleep ritual."

The amount of light in the home also keeps people up longer. "We get external cues from televisions, home computers and from bright domestic lights -- 40 to 50 years ago domestic lights were not as bright."

Once this natural drowsiness passes, it is more difficult to get to sleep because there is a renewed arousal and alertness in the brain. "People are putting off the onset of sleep till 11, 11.30, 12 and they get up at about the same time, so the actual sleep period of time is reduced. By the weekend, people have sleep debt."

While a sleep debt can be paid back in the short term, continuous under-sleeping can lead to chronic partial sleep deprivation, Dr Birrell says. This leads to emotional instability and could explain the dramatic incidence of road rage, supermarket rage and domestic rage, he says.

As well as an increased susceptibility to stress, there is a serious health risk. "There is a very dangerous immune system depression that occurs with chronic sleep deprivation. It is an insidious pattern and it accumulates if you don't get compensatory sleep. You're more likely to come down with whatever is going around from trivial minor viral infections to major problems."

The immune system's capacity to kill off inchoate cancer cells may be compromised, but there is no evidence to link the increase in sleep deprivation with an increased incidence of cancer. "Who knows? There is not enough research," Dr Birrell says.

Adds Dr Chan: "We are still scratching the surface in sleep research."