A Thousand and One Sleepless Nights

The New York Times, February 25, 2010
By Patricia Morrisroe

In Ernest Hemingway’s short story “Now I Lay Me,” Nick Adams, the writer’s alter ego, stays up at night listening to the silk worms feeding on mulberry leaves outside his army tent in Italy. During World War I, Hemingway had himself developed insomnia so severe that he was afraid to go to bed with the lights out. And he struggled with sleeplessness the whole rest of his life, although this issue was often hard to separate from his other ailments — including severe depression, chronic alcoholism and diabetes. “I myself did not want to sleep,” he writes, “because I had been living for a long time with the knowledge that if I ever shut my eyes in the dark and let myself go, my soul would go out of my body.”

Sleep and death have long been intertwined, with the ancient Greeks creating a colorful genealogy to explain it. Nyx, the goddess of the night, gave birth to twin boys: Hypnos (sleep) and Thanatos (death). Hypnos fathered Morpheus, the god of dreams, who lived surrounded by opium poppies, the giver of dreams. While there would be no Morpheus without Hypnos, the Greeks weren’t very interested in sleep per se, but in its magical offspring: dreams. They made pilgrimages to special “dream temples,” where, after offering sacrifices and bathing in sacred waters, a healing deity would appear to them in sleep, curing whatever troubled them. The Chinese believed in two different souls — p’o and hun — that represented the physical and spiritual worlds. The hun, which could separate from the body during sleep, often visited the land of the dead, where it brought back news of deceased ancestors. According to Robert L. Van de Castle, in his book “Our Dreaming Mind,” if the soul failed to return to the body before the dreamer woke up, “dreadful consequences would follow.”

At the turn of the 19th century, insomnia was depicted as a horrible torture that often led to suicide. An 1888 article in The Washington Post explained that “it is a well known fact that loss of sleep, carried to [sic] far, will produce insanity.” It was believed that something called the “nerve fluid” was produced at night, and if one didn’t get a sufficient quantity of it, the nerves would become “abnormally sensitive and irritable — almost as if they were bare” — and the victim would go crazy.

Though we’ve come a long way in our understanding of sleep, if you asked an insomnia sufferer today to describe her symptoms, she might provide a similar account. According to the National Center for Sleep Disorders Research, 30 to 40 percent of American adults experience intermittent bouts of insomnia over the course of a year. Ten to 15 percent report chronic symptoms. That’s a lot of irritable nerves.

But when someone says “I don’t sleep,” what exactly do they mean? If they have fatal familial insomnia, they are describing a situation that ultimately leads to death. There is no cure. F.F.I. is caused by an accumulation within the thalamus — the part of the brain that controls sleep regulation — of abnormal proteins called “prions.” The disease usually begins between the ages of 40 and 60, and its first symptom is progressive insomnia. Eventually the person falls into a coma, dying from the consequences of sleep deprivation.

Since F.F.I. is extremely rare, most people who complain that they can’t sleep usually mean that they do indeed sleep, but not long or deep enough. Perhaps a job loss or divorce is to blame, and in such cases, the insomnia usually resolves itself with time. When the insomnia is a symptom of underlying depression, a combination of therapy and anti-depressants can work. Does the patient snore? That could be a sign of sleep apnea, which can be helped with a breathing device or dental appliance.

Insomnia is a unique disorder in that the patient is also the chief diagnostician. The American Academy of Sleep Medicine, which sets the clinical standards for the field, recommends overnight studies for all people with sleep complaints. But what’s the point of watching someone not sleep? And if you’re told you have insomnia, which you knew anyway, what can be done about it? Often sleep doctors will prescribe cognitive behavioral therapy, which involves a set of “sleep-hygiene” rules, like avoiding stimulants and alcohol, regularizing bedtime and wake-up time, and using the bed only for sleep and sex.

While in theory “sleep hygiene” makes sense, in today’s culture, which affords no time for relaxation, it’s hard to put into practice. We’re on the computer at all hours and then we snuggle with our Blackberries. Our kids are even more hyperactive, texting way past their bedtimes, although today even the concept of “bedtime” sounds quaint. To compensate for being so tired in the mornings, they eat caffeinated foods, gulp energy drinks, and pop Adderall and Ritalin. In recent years, the “wake-promoter” Provigil has gained ground with college students as a “smart drug.” A 2005 national study, led by a University of Michigan research team, found that 7 percent of college students have used prescription stimulants for non-medical purposes over their lifetimes and 4 percent have used them in the past year. In a sample of middle- and high school students, the illicit use of stimulant medication was 4.5 percent. As the anthropologist Matthew Wolf-Meyer notes, “If a society can’t rest, how can it sleep?”

To combat what he calls our “culture of exhaustion,” Americans spend nearly $24 billion a year on sleep-related goods and services, buying $5000 mattresses, 600-thread count sheets and high-end sound machines that simulate the surf or chirping birds. By 2012, the market for insomnia drugs is expected to grow 78 percent, to nearly $3.9 billion. But with sleeping pills what are we really getting? They only provide an additional 11.4 minutes of sleep over placebo pills, and they interfere with memory formation, with the result that people sometimes forget how badly they actually slept. Some sleep doctors say, “What’s wrong with that? If people perceive their sleep is better, they’ll feel better.” But that strikes me as “Alice in Wonderland” logic: “I wonder if I’ve been changed in the night? Let me think. Was I the same when I got up this morning? I almost think I can remember feeling a little different. But if I’m not the same, the next question is, ‘Who in the world am I?’”

I can’t think of anyone more dissimilar to the hard-boiled Hemingway than Michael Jackson, yet he too suffered from chronic insomnia. One can only imagine the pressure Jackson was under rehearsing for a grueling world tour with the sadly prophetic title, “This Is It.” Over the years sleeping pills and other tranquilizers had lost their effectiveness to the point that he demanded that his doctor administer the powerful anesthetic propofol, which was later ruled a major factor in his death. Jackson referred to it as his “milk.” There’s something terribly sad about someone wanting to sleep so badly that he’d opt for a hospital anesthetic, rather than the old-fashioned sedative: a cup of warm milk.

But perhaps we’re way beyond such homespun remedies. We live in stressful times. Some would say that’s nothing new. People have been searching for ways to induce what Shakespeare called “the honey-heavy dew of slumber” for as long as they’ve been able to harvest medicinal plants. A reference to opium poppy was found on Sumerian clay tablets dating back to 3,000 B.C. We know little about the way prehistoric man slept — there are no sleep “bones” for us to analyze — but as they huddled together in caves, they probably worried that giant bears would eat them. Now we lie down on $22,000 hand-groomed horsehair mattresses and worry that underwear bombers will blow up our planes. So tonight many of us will be wide awake listening to the silk worms on our high-priced sound machines, afraid that our souls will leave us, afraid that we have no souls, afraid that with each passing day, this is it.