Insomniacs: Are We Dreaming About Sleeplessness?

Rapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

In the past few years, though, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Insomnia sufferers may be remembering dreams of sleeplessness rather than lying awake for hoursRapid eye movement sleep (REM sleep) is when most dreams occur. Episodes of REM sleep also help defuse negative emotions and improve the learning of motor skills.

Until recently, insomnia wasn’t thought to be a problem of REM sleep. Insomnia, the thinking went, was caused mainly by phenomena occurring—or failing to occur—during quiet, or non-REM, sleep: insufficient deep sleep, for example, or wake-like activity occurring in other stages of non-REM sleep, resulting in insufficient or poor sleep.

But in the past few years, REM sleep has become a suspect in the quest to identify what causes people to wake up frequently in the middle of the night and too early in the morning. (This type of insomnia is called sleep maintenance insomnia). Here’s more about this intriguing proposition.

Do Insomniacs Really Underestimate Sleep Time?

It’s said that insomniacs tend to underestimate the amount of sleep they get. Polysomnography (PSG), the test conducted in the sleep lab, often shows that insomnia sufferers are sleeping more than they think.

Investigators now agree that PSG, as conducted and scored in standard fashion, is too crude a measure to capture what’s going on in disturbed sleep. Finer measures are needed. One such measure involves counting the number of arousals and micro-arousals—brief awakenings—during sleep.

In a seminal study published in 2008, a team of German scientists used PSG, sleep time estimates of study participants, and micro-arousal analysis to ascertain what the differences were between insomniacs and good sleepers. The results showed that compared with good sleepers, insomniacs

  • Got less non-REM and REM sleep overall
  • Experienced more micro-arousals during both non-REM and REM sleep, but the number of micro-arousals during REM sleep was more pronounced: about 2 to 3 times larger than the number experienced by good sleepers. Further, the more REM sleep insomniacs got, the greater was the mismatch between their sleep time as recorded by PSG and the sleep time reported by the insomniacs themselves.

These results suggest that (1) it may be disturbances that occur during REM sleep, more so than during non-REM sleep, that account for the discrepancy between PSG-measured sleep and insomniacs’ perception of their sleep, and (2) disturbed REM sleep may be the main problem for people with sleep maintenance insomnia.

How Disturbed REM Sleep Might Develop

Not much brain activity occurs during non-REM sleep. But REM sleep is marked by a mix of arousal in some parts of the brain and quiescence in other parts. The same group of scientists in a 2012 paper describe REM sleep as “a highly aroused ‘paradoxical’ sleep state requiring a delicate balance of arousing and de-arousing brain activity.” This brain activity involves many different groups of neurons. The over- or underexpression of any of these groups might disturb that “delicate balance,” causing fragmented REM sleep.

This idea fits in with the dominant explanation for chronic insomnia: it’s a manifestation of hyperarousal, which may come about in part due to stress. Stressful life experiences often cause sleep loss. If the poor sleep continues, then sleeplessness and worry about the daytime consequences themselves become stressors and insomnia becomes a chronic affair. The chronic stress accompanying chronic insomnia also leads to changes in the brain. These changes could cause REM sleep fragmentation and disrupted or poor sleep.

Remembering Dreams of Sleeplessness

The idea of REM sleep fragmentation as a driver of sleep maintenance insomnia also fits with the continuity hypothesis of dreaming, which posits that the content of dreams comes from everyday concerns. Not much research exists on the content of insomniacs’ dreams. What is known is summarized in a paper published in Sleep Medicine Reviews:

  • Compared with normal sleepers, insomniacs tended to experience themselves more negatively in their dreams
  • Problems that occurred in dreams were related to current real-life concerns
  • Health problems also appeared more frequently in insomniacs’ dreams.

People with chronic insomnia are prone to worry about sleep loss and its consequences, and these concerns might well dominate the content of our dreams. And if we’re experiencing lots of micro-arousals as we’re dreaming, the content of those dreams would be more accessible to conscious recall. Instead of actually lying awake for hours at night, sleep maintenance insomniacs might be awakening briefly but often to dreams of sleeplessness, making it feel like we’re sleeping less than we are.

Precisely how REM sleep becomes fragmented remains to be seen. But the finding that REM sleep is significantly unstable in sleep maintenance insomniacs is a step in the right direction.

Does the idea of REM sleep instability as a driver of sleep maintenance insomnia seem plausible to you?

Sleep Studies: Do You Really Need One?

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

Sleep studies are useful when insomnia is complicated by another disorderWhen I ask people with persistent insomnia if they’ve had a sleep study, the common responses I get are these:

  • “I had one and all I learned from it was that I don’t have sleep apnea.”
  • “I want one, but my doctor won’t write the prescription.”

If you haven’t had a sleep study, you may wonder if spending the night at a sleep clinic might help the doctor understand your problem and how to fix it. Polysomnography, or PSG, is the test conducted at the clinic. New guidelines from the American Board of Internal Medicine (ABIM) clarify when PSG is useful in cases of chronic insomnia and when it isn’t. Here’s a summary and explanation of the guidelines.

When a Sleep Study Is in Order

PSG is good at detecting sleep apnea, sleep-related movement disorders, and violent or harmful behavior that might be occurring at night. If a doctor suspects that your insomnia is associated with any of these disorders, you’ll likely be going in for a sleep study.

Occasionally a person with insomnia reports such an unusual assortment of symptoms that, even after taking an extensive patient history, the doctor can’t figure out what’s going on. Here, too, PSG may help. The doctor may also prescribe a sleep study if you’ve undergone treatment for insomnia (with or without drugs) but your sleep has failed to improve.

When Sleep Studies Won’t Help

But neither the ABIM nor the American Academy of Sleep Medicine recommends sleep studies for other insomnia patients. Here are some of the reasons.

1.  PSG cannot do much except confirm the symptoms you report to the doctor during a clinical interview.

  • Let’s say you wake up several times at night and have trouble falling back to sleep. PSG may confirm that you experience these wake-ups but will not shed light on why.
  • Or maybe your problem is that it usually takes you a long time to fall asleep. Upwards of $2,000 is a lot to spend on a procedure that merely corroborates what you already know.

2.  PSG does a poor job of discriminating between normal sleepers and people with insomnia. In fact, up to 50 percent of the time, the brain activity of insomniacs looks identical to that of normal sleepers.

3.  In some insomniacs, there is abnormal brain activity occurring at night—activity typically associated with being awake. But standard PSG will not show evidence of this wake-like activity. As a measure of what’s going on in the brain at night, PSG is not finely tuned.

4.  Finally and importantly, in most cases of persistent insomnia, PSG will not suggest a course of treatment that differs from treatment that would be prescribed based on a thorough clinical interview.

  • If your complaint is that you’re a light sleeper and wake up frequently at night, the doctor will probably prescribe cognitive-behavioral therapy for insomnia (CBT-I) or some other behavioral treatment before considering medication. PSG might corroborate your symptoms but would not alter the diagnosis or the treatment.
  • Or let’s say your main complaint is that your thoughts keep you too wound up at night to fall asleep easily. The doctor isn’t going to need for you to undergo a sleep study in order to diagnose and treat the problem.

The Bottom Line

Sleep studies are an indispensable tool for people suspected of having sleep apnea and many other sleep disorders. But as conducted now, they’re of no help to insomnia sufferers unless your insomnia is related to another health problem.

If you’ve had a sleep study, what did you learn from it?

 

How Much Sleep Is Enough?

Getting 8 hours’ sleep a night is as healthful as eating 9 servings of fruit and vegetables and getting daily exercise—or so we’re told. In truth there’s no way to determine how much sleep any one of us really needs.

But the 8-hour recommendation is based on something, which is why we hear it so much. For those concerned about getting too little sleep, here are 3 ways to find out how much you’re actually getting.

Regarding sleep need, sleep quality may matter more than sleep durationGetting 8 hours’ sleep a night is as healthful as eating 9 servings of fruit and vegetables and getting daily exercise—or so we’re told. In truth there’s no way to determine how much sleep any one of us really needs.

But the 8-hour recommendation is based on something, which is why we hear it so much. Recent studies show “a strong association between nightly sleep duration and mortality risk,” Michael Grandner and colleagues say in a paper on sleep duration and health. Overall, people who report sleeping 7-8 hours a night live longer than people who report sleeping 9-10 hours and those who report sleeping 6 hours or less.

The same is true of the relationship between sleep duration and cardiovascular disease (and related conditions such as hypertension and diabetes). Short and long sleepers tend to be more vulnerable to these ailments than people who sleep 7-8 hours a night. Of interest to those of us with insomnia, short sleepers (who sleep 6 hours a night or less) with poor quality sleep have a much higher risk of developing cardiovascular disease.

Counting the Hours

If you’re concerned you’re not sleeping enough, consider the possibility that you may be sleeping more than you think. About 5 percent of insomniacs have “paradoxical insomnia.” Usually pretty energetic during the day, they feel like they sleep just a few hours a night. Yet polysomnography (PSG)—the test performed in a sleep lab—shows 7 or 8 hours of sleep-like activity going on in most of the brain. (I’ll explain this phenomenon in another blog.)

Many of us perceive the lightest sleep stage as waking. Up to 50 percent of the time, the brainwave patterns of insomniacs who undergo sleep studies look exactly the same as those of normal sleepers. So our perception of sleep does not always jibe with sleep as measured by PSG. And the while PSG cannot assess sleep quality, its assessment of sleep duration is important. People whose polysomnograms show they get considerably less than 7-8 hours’ sleep a night are the ones most vulnerable to cardiovascular disease and early death.

Objective Sleep Measures

Here are 3 ways to find out how much you sleep.

  • A sleep study. There are lots of downsides to going this route. It requires a doctor’s prescription, costs a lot, and is just a one-shot deal. Insomniacs’ sleep tends to vary a lot from night to night, and a sleep study is not going to provide information about your sleep duration over time, which is really what you want.
  • Actigraphy. This involves wearing a wristwatch-type device to bed for several nights. The actigraph assesses your sleep-wake patterns based on bodily movement. It’s fairly reliable most of the time. It also requires a doctor’s prescription.
  • Sleep-monitoring devices available without prescription. I’ve written about the Beddit, and a Google search will acquaint you with several others. These devices are relatively inexpensive, but none of them have been tested on insomniacs. They may not be sensitive enough to assess the nuances of insomniac sleep. (Coincidentally, just a few days after this blog post went out, Dr. Christopher Winter, who tested several sleep tracking devices on himself, posted a review of his findings in Huffington Post. It’s definitely worth reading if you’re considering buying one for yourself.)

Me personally? I know I’m a short sleeper but I’m not so concerned with racking up the hours. Health and longevity depend on several factors. Regarding sleep, I’m convinced that quality, and not quantity, matters more.

If you’ve undergone a sleep study or tried monitoring your sleep in some other way, what did you find out? Were you sleeping more—or less—than you thought?