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Nine, ten, never sleep again

Boing Boing’s David Pescovitz comments on an Ananova story about a man who has puzzled medical experts by being unable to sleep for the past twenty years. There are a series of follow-up posts listing novels about insomniac characters (many of whom seem to be private eyes). I would love to see some more detailed medical investigation of real-world insomniacs. Although the ultimate necessity of spending an average of a third of our lifespan asleep remains a mystery, we are garnering knowledge about the variety of necessary functions it serves, both in terms of cognitive housekeeping and tissue repair and restoration of physiological equilibrium. How does this guy function, on both interpersonal, psychological, and physiological levels?

I’m not sure, in any case, about the veracity of the Ananova story, given that there’s a machismo about not sleeping (perhaps because sleeplessness turns us into the worst caricature of macho??) and I often run into people who boast that they need less sleep than the rest of us. There is something culturally consonant about sleep deprivation, too, as society is more and more frenetic and productivity-driven. Performance in many fields (especially medicine; more about that below) seems to be measured at least partly by how long and how far and how fast one can go on. People in general sleep less than they used to, and we are intrigued by ‘alertness agents’ like modafinil (about the value of and concerns about which I have written here), which appear to treat fatigue and compensate for sleep deprivation with fewer consequences than stimulants of the amphetamine family.

//www.zyworld.com/vampirelore/Mara1med.jpg' cannot be displayed]There is also a separate but related allure of the wee small hours per se. I guess it is true of many children who are curious about what mysterious and magical things might happen after they are asleep, as I was. There was always a frisson, when I went to the zoo or the natural history museum, at seeing the somehow more eerie nocturnal creatures. And, in the 1931 film, one of my childhood favorites, Dracula’s ecstatic celebration of “the children of the night” as the air was suffused with the distant howls of wolves always sent a delicious chill up my spine. I began trying to stay up late as soon as I could tell time. I would sneak my transistor radio — if any of you know what those were — into bed and put it under my pillow (it was especially exciting when I finally got an earphone for it) and try to stay awake to break the magical barrier of midnight; it was a long time before I succeeded. Since then, I have always been a night owl, as you can tell from the timestamps on many of my posts here at FmH. I have never gotten over the romance of the middle of the night, both the stillness and aloneness, the cold hard clarity of a world reduced by starlight and moonlight to nocturnal hues, and the seedy quality of the covert activities that transpire, in reality or imagination, in the dark, beyond the ring of illumination thrown by our streetlights. Many of the insomniac characters in literature seem to enjoy walking deserted city streets in the middle of the night, and so too did I. There is an element of transgressing boundaries, the thrill of doing something forbidden, in being up when no one else is, when no one is supposed to be. One of the subliminal attractions of being sleeepless may also be that one challenges the Big Sleep, pushing to transgress the ultimate boundary at the end of life. It is a medical truism, by the way, that Death comes for people disproportionately in the wee hours. Perhaps I have always wanted to be staring her in the eye when she arrives. Sensuality, too, if of course intimately associated with the nocturnal.

“I’ll sleep when I’m dead,” Warren Zevon and others have said. One can cheat death too by packing more into life, I have thought, by spending more of one’s living hours as waking hours. For most of my life, I felt that I did not have the time to waste on sleeping, and (here comes that macho boast?) felt that I could get away for many days running with shorting myself on sleep if there was something compelling to read, write or watch instead. There is a sort of machismo associated with being able to function while sleep-deprived during medical training, when the sleep deprivation is, of course, outrageous and, I am convinced, gratuitous. Training directors, or caricatures of them, supposedly reason that decision-making skills are shaped, and character built, by sleep deprivation, and that “if it was good enough for me when I trained, it’s good enough for the new generation of whiners.” When there is an egregious medical error, like that which caused the celebrated death of Libby Zion in New York some years ago, there is anguished handwringing about the liability and morbidity caused by our proclivity for sleep-depriving medical house officers making life-or-death decisions, but it never seems to change anything. The real incentive the system has to make residents do round-the-clock shifts, of course, is not a training need at all; it is the easiest way to use the indentured servitude of medical residency to meet the manpower needs of a modern healthcare facility.

My acceptance of sleep deprivation during my medical school years had an added momentum, though. When I went through medical school, I was hellbent on not ‘becoming’ a doctor, in the sense of that being all there was to my identity forever after. It needed to be just one of the things I did in my life, not my defining attribute. That created an added impetus to stay up late to do other things after keeping up with the literature in my field, writing consultation reports, etc. And after my wife and I started a family, I also took to my parenting responsibilities by carving out the wee small hours for my other pursuits after a full day of being present and active as a father as well as a doctor.

There is an intimate relationship between sleep disruption and depression, as we know in psychiatric practice. Depressions come in sleepless and hypersomnic varieties. Part of the difference is surely biological, but people are also built differently in terms of their characteristic coping strategies. Some people are escapists, and may sleep more in an effort to avoid distress. (They also seem to be the ones, in my experience, who can can entertain thoughts of suicide for the purposes of relief or escapism, among the various purposes that suicide can serve in my patients’ psyches.) But, even for people who try to use sleep as an escape mechanism, I have long suspected that sleep can promote depression, and there is a body of literature supporting me, even speculating that some sort of depressogenic neurochemical is produced during sleep. Depressed patients often feel most depressed upon awakening and their mood improves as the day proceeds (so-called “diurnal mood variation”). If they take a daytime nap, they often face another period of renewed depression after they get up from the nap. Even if it is not biological, you can imagine how difficult it is to face depressing realities immediately upon awakening from a period of blissful ignorance. The possibility that sleep promotes depression has led to speculation that some people may be sleep-depriving themselves as a sort of inadvertent self-medication for depressive tendencies. In other words, is the sleeplessness of some depressions a consequence of, or an attempt at compensation for, the depressed mood? Noting that I tend to push my bedtime further when my mood is bluer, I have wondered as well. It may also be that those are the times it is more urgent to do more for myself.

It took me literally several decades to realize that burning the candle at both ends was making me far more impatient and irritable than I needed or wanted to be, and that sleep-depriving myself was not a free lunch. This dawned on me at approximately the same time as, studying the physiological necessity of sleep and the psychiatric consequences of sleep disruption, I began to take note of medical research showing that sleep deprivation shortened organisms’ lifespans. So, ironically, cheating death by shoe-horning more wakefulness into a fixed lifetime turns out not to be as simple as I had assumed. Of course, it is also well-known that sleep deprivation reduces cognitive efficiency in certain empirically measurable respects. So even if one is up more, one may end up paying for that quantity of waking hours with quality. Moreover, I realized, sleep deprivation is cumulative; the commonsense notion that you can pay back your deficit by ‘sleeping in’ the next weekend doesn’t work. If you are supposed to sleep eight hours a night, let’s say, you can’t go three nights in a row with four hours a night and then erase the damage with a twenty-hour night’s sleep.

One of the other skills I developed as a medical resident on call was the ability to rapidly return to sleep after I had dealt with a challenge in the middle of the night. It was never as extreme for me as for some of my colleagues, however, who could seemingly conduct their on-call duties without waking up fully at all. One of my friends, a surgical resident, eventually learned that she was managing many of her patients’ problems — always clinically appropriately, to hear her tell it — over the phone in the middle of the night without remembering what she had done when her surgical team did morning rounds on the patients the next day. She finally arranged for the hospital operator who paged her to listen in on the calls and take notes about what orders she issued. She would swing by the switchboard in the morning, before rounds, and use the notes as a cribsheet when reporting on the care she had given the night before. (I don’t know if this was a liability or an adaptive strategy to her work as a surgeon; she has since gone into a different field of medicine. Dream on…)

So now I want to sleep more. Now that I realize it is not necessarily desireable to short myself so much on sleep, when I am awakened in the middle of the night by my beeper going off from the hospital, I want to get back to sleep again as soon as I have dealt with the call. But, in middle age, I am finding, ironically, that I can no longer get back to sleep rapidly. If I am awakened, I am typically going to be up for at least a couple of hours. Of course, I could do something boring and soporific with the time, to hasten my return to sleep, but it still sticks in my craw to waste wakefulness. So some of the middle-of-the-night FmH entries you will see these days are, in a sense, under duress. Enjoy them anyway; I do. I still do some of my clearest thinking in the holy stillness, or at least so I imagine.