For some, lucid dreaming is a curiosity, or even a spiritual experience. It has frequently been dismissed as a figment of the imagination. It does have clear neurobiological markers, however. Lucid dreaming has been reported as arising after strokes in the thalamus, deep in the centre of the brain, but it can also be detected objectively, not just through people describing it. Monitoring the brainwaves of lucid dreamers using EEG as they move from non-lucid to lucid REM sleep shows changes in the frontal regions. Moreover, in a quite remarkable study, researchers have been able to definitively prove lucid dreaming. Taking six regular lucid dreamers into a scanner, the researchers asked the subjects to signal the onset of lucid dreaming. Remember that we are paralysed in REM sleep, with the only muscles not affected being the muscles that move the eyes, and those that allow us to breathe. As the subjects entered into lucid sleep, they signalled this in the only way they could, by moving their eyes in a pre-agreed combination. Left-right-left-right. The subjects used this signal not only to indicate the onset of lucid dreaming, but were asked to dream of clenching one hand for ten seconds, signal again before dreaming of clenching the other hand, and to continue doing this for as long as they could. Clearly, they could not really clench their hands, which were paralysed like the rest of them. Two of the subjects managed to complete the task. And in one, the results were staggering. The subject who lucid-dreamt of clenching his fist showed increased activity in the sensorimotor cortex on one side, which switched over to the other side when he also dreamt of switching sides. The activity in the sensorimotor cortex was similar to that seen when performing the task in wake, with real movements of the hand, thus clearly demonstrating that lucid dreaming is a very real phenomenon, with features of wakefulness while clearly in dreaming sleep.
Like many sleep phenomena, lucid dreaming represents another of these dual brain states. It appears to be an overlap between wakefulness and REM sleep, in the same way that sleepwalking does between wakefulness and deep sleep. When put in these terms, it is perhaps not surprising that people with narcolepsy report lucid dreaming much more frequently than those without the condition. If Christian often spends time hovering between wake and REM, which is what the hypnagogic hallucinations, sleep paralysis and vivid dreaming represent, then the fact that he lucid-dreams is almost to be expected. In fact, up to 80 per cent of people with narcolepsy report lucid dreaming.
The real significance of lucid dreaming, however, is that it provides a playground for dream researchers to understand the significance of dreams. If you can consciously influence your dreams, then this provides a natural experiment, to see how the content of your dreams relates to your daytime life. Consider a new skill, like learning to play the piano. As a lucid dreamer, if you push your dreams towards playing the piano, perhaps this might mean you learn it more quickly. Or the artist lucid dreamer, whose creativity and talents are boosted by lucid dreams of painting. The possibilities are endless.
* * *
Treating Christian’s narcolepsy has been problematic. For him, the biggest issue is not the cataplexy but the excessive daytime sleepiness. Even small doses of stimulants have given him side effects. He hates the sensation of taking these medications, and says they make him feel ‘chemical’. ‘I’ve taken recreational drugs in my lifetime, so I understand the sort of feeling. And I get that from it [the stimulants].’ He feels a little high, but the doses that we have been able to give him without accentuating this sensation are insufficient to properly keep him awake. He often feels ‘wired’, but not enough to stave off sleep. So, while he will occasionally use these medicines, he is reluctant to take them on a regular basis. And he is equally reluctant to use stronger, different types of medications, like the sodium oxybate that has made such a difference to Phil. ‘Well, at the moment I’m able to manage my life. I’m lucky in this country, that I cannot work but still obviously receive some benefits. And in some other countries, you wouldn’t even have any sort of treatment. But during the days, I can go to sleep – and generally I do two or three times a day.’
The daytime naps are a common way to treat narcolepsy, even alongside treatment with medications. Many of my patients with narcolepsy have planned naps – predetermined times at school or at work when they retire to a quiet room, or sometimes even a storage cupboard or toilet cubicle, and nap for ten to twenty minutes. One of the hallmarks of narcolepsy is the refreshing nature of these brief sleeps, recharging the batteries and allowing people to feel awake for the next few hours. He continues, ‘I’m able to manage my life, housework, shopping, chores that people consider to be normal living – I’m able to manage that because I haven’t got the pressures of a job. So, basically, I receive my current prescription, but I’m not filling myself up with it every day. I take it in the mornings if there’s something important going on, something that I really need to be conscious for.’
Christian also voices a sentiment that I occasionally do hear from some of my other patients with narcolepsy: there are some aspects of the condition that he rather likes. ‘If you’ve seen the film Inception with Leonardo DiCaprio, that will give you a very good example of what my dreams are like.’ On another occasion he tells me, using another film metaphor: ‘It’s like the Matrix exists, well within the confines of my own mind. Of a night-time I will just live another life.’ I ask him if, in his dreams of the Matrix, he is Keanu Reeves or Laurence Fishburne. He chuckles: ‘No, I’m just me. I’m the hero of the story that’s being told. And I do kind of enjoy that.’
For Christian, I suspect the enjoyment he gets from leading multiple lives at night to some extent makes up for the limitations that his narcolepsy places upon him in his waking life. I tell him that I have one other patient who tells me that he feels that the dreams caused by his narcolepsy have some spiritual significance, that he communicates with the world on a different plane of existence. ‘Yeah, I do feel kind of special, if that makes sense. And because I’ve got such a suspicion of certain areas of science and government, I do read stuff. I don’t necessarily believe it, but I do take concepts on board of telepathy and stuff like that. And in my mind, if it is a real thing, I am going to be quite a good candidate to be able to do that. I do feel that I’m trying to communicate with people in my sleep, you know?’
I am not sure how much Christian really believes of this, but he clearly spends a lot of time trying to interpret his experiences, and make sense of them. What is clear is that there are some benefits to this personal nocturnal world. ‘I see things that no one has ever seen, and no one’s ever likely to see. Even though they’re not real, I’ve still experienced them and seen them. The average Joe is never going to experience that because the average Joe doesn’t remember. They might remember one or two dreams in a lifetime, you know?’
As for why we dream, when I look back through this chapter, I see lots of questions, but few definitive answers. REM sleep and dreaming probably have multiple purposes, and these are probably different at various stages of life. But, for the moment, the answer is still, ‘I don’t know.’
14
LOSING SLEEP
In 2005, the New Yorker magazine published an exposé on the regime of enemy combatants imprisoned in Guantanamo Bay (or ‘Gitmo’). It detailed the techniques used by medical and scientific personnel ‘intended to exploit the physical and mental vulnerability of detainees’. The practices to which the prisoners were exposed were based upon a Pentagon-funded programme called SERE – ‘Survival, Evasion, Resistance and Escape’ – developed originally by the US Air Force to help pilots shot down in the Korean War to cope with extreme abuse if captured.
At the core of these techniques applied in Gitmo was sleep deprivation and disruption of sleep patterns. The author of the piece writes, ‘Sleep deprivation was such a common technique . . . that the interrogators called the process of moving detainees every hour or two from one cell to another “the frequent flier program”.’ The aim of this practice was to psychologically stress detainees to such an
extent that they would lose the ability to ‘self-regulate’, or, as the article described it, ‘the ability to moderate or control his own behaviour’. This loss of self-control would facilitate interrogation, softening the prisoners up and making them more likely to reveal important morsels of intelligence.
The argument as to whether systematic sleep deprivation in this context represents a legal and ethically valid form of interrogation or frank torture rages. It leaves no wounds or scars, and causes no pain. The United Nations, in its Convention Against Torture, defines torture as
any act by which severe pain or suffering, whether physical or mental . . . intentionally inflicted on a person for such purposes as obtaining from him . . . information or a confession . . . when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity. It does not include pain or suffering arising only from, inherent in, or incidental to, lawful sanctions.
It is this last phrase, ‘lawful sanctions’, that is vague, open to interpretation, and debated. Sleep deprivation would certainly qualify as an act to cause suffering.
Regardless of how sleep deprivation is currently defined, it has been utilised in the arsenal of interrogation or torture techniques for centuries. First properly documented in the late fifteenth century as being used in the Catholic Inquisition, it has been relied upon through the ages, from the witch-hunters of sixteenth-century Scotland to the interrogation camps of the KGB, and no doubt still in various dark corners of the world to this day.
And although it is true that sleep deprivation leaves no physical traces, not only can it leave psychological scars and mental pain, it is also potentially highly dangerous. While in humans systematic sleep deprivation for long periods has never been properly scientifically explored, in animals it has proven fatal. Dogs kept awake will invariably die after 4–17 days. Similarly, rats die after 11–32 days awake.
Imagine for one moment that you were subject to this torment. You crave nothing more than a few snatched minutes of sleep; you cannot think clearly, your vision is blurred, your limbs ache with fatigue. It is not a Catholic Inquisitor or a Guantanamo guard shaking you awake at the first sign of dropping off, however. It is yourself, your own brain: you are your own torturer. And that is insomnia.
* * *
When Claire first walks into my consulting room, she is in trouble. She does not look it, though. At first sight, she is immaculately dressed, in her early fifties, slim, and really rather beautiful. She appears just like many successful, wealthy women striding through the streets around London Bridge, a stone’s throw from the City of London. However, for the past five years, she has been plagued by debilitating insomnia.
Her sleep initially worsened as she approached the menopause, but the precipitating cause of her insomnia in her own mind is clear. ‘I was going back to work after fifteen years at home with the children,’ she tells me. ‘It was partly me being fifty and wanting to prove myself so badly in the workplace. I actually had a really low-paid job, although it was very high responsibility. I was on a mission to prove myself and show that I was worth it and of value.’
It sounds as though she put herself under enormous stress in an effort to impress, which was compounded by her battling for a pay rise. ‘In the lead-up to the menopause I was struggling with sleep, but I would just say [to myself], “I have trouble sleeping. I wake up in the night. I’m just not a great sleeper.” But I could still function during the day.’
The situation at work seemed to have tipped her over the edge, however. ‘I stopped sleeping. I know that it sounds mad, but I really think for a year or so I got so little proper deep sleep that I stopped functioning.’ I ask her more about her sleep patterns at that time. ‘I would go to bed. But literally as I was walking upstairs I would be starting to get panicky. I just knew what was coming. And then my heart would start beating fast. Not a full-blown panic attack, but I could feel the adrenaline going through my body.’
The anxiety about the process of getting into bed would become a self-fulfilling prophecy; the fear of how difficult it would be to go to sleep added fuel to the fire of insomnia. Claire continues: ‘So I’d lie there for a couple of hours and then I just knew that it wasn’t going to happen. So I’d get up and go downstairs and make myself a cup of herbal tea, walk round the kitchen, keeping the lights quite low. And then I’d go back and try again.’ But the distress of sleep always being out of reach took its toll, both physically and emotionally.
‘I’d start to get quite upset. Sometimes I’d wake up my husband, crying and semi-hysterical – I hate to admit that. He would be very sweet and he’d try to calm me down. He used to say all the right things, he really did. And then towards the early hours I’d probably get some kind of very light, dreamlike sleep, but I’d wake up feeling wrecked.’
And so began the downward spiral into oblivion. Her lack of sleep made it even more of a struggle to perform to her own expectations at work, raising her anxiety levels further and making sleep even more elusive. ‘And then I had a breakdown,’ she says.
* * *
There is nothing quite like the loneliness of the insomniac, awake in the middle of the night while the rest of the world sleeps. Claire has kept a sleep diary, in which she writes: ‘Everyone else in the house is asleep and I’m just despairing really because I’ve tried so many things, and every night I just find myself back down here [in the living room]. It just feels really lonely, like this is never going to end.’
But she is not alone. In fact, far from it, for insomnia is unbelievably common. If, like Claire, you have found yourself unable to drift off to sleep, with difficulty staying asleep, or waking up feeling that you have slept very poorly, you are in a very large club. Insomnia is by a significant margin the commonest condition affecting sleep. Roughly a third of adults will report features of poor sleep, and about one in ten adults will have chronic insomnia, resulting in an ongoing poor experience of sleep, coupled with daytime consequences such as fatigue, irritability, difficulty concentrating and lack of motivation. But insomnia is not just a medical condition, it is also a symptom – of medical problems like an overactive thyroid gland, or as a result of medications. Insomnia can be a feature of psychiatric disorders like anxiety, depression or bipolar disorder. In fact, 50 per cent of people with insomnia have a psychiatric diagnosis (although that also means 50 per cent do not). Even insomnia as a medical disorder, in the absence of any other underlying problem, is an umbrella term. There are different types of insomnia, and although it sounds strange, not everyone with insomnia is deprived of sleep.
For some people, their experience of poor sleep is not borne out by the evidence. It is rare that I bring patients with insomnia into the sleep laboratory. Someone who does not sleep very well at home will definitely struggle to sleep covered in electrodes, in a strange bed, knowing that their every move is being recorded and analysed. Occasionally, however, when there are questions as to the cause of their insomnia, or I am wondering about another type of sleep disorder, I will admit patients for a night.
It is incredibly common, when we meet after the sleep study, and I ask how they slept, to hear: ‘I slept terribly that night.’ But when we look at the sleep study, it shows a very decent night’s sleep – seven or more hours, with lots of deep sleep – despite the person in front of me being adamant that they only slept for an hour or two. This type of insomnia is termed ‘sleep state misperception’ or ‘paradoxical insomnia’, and is likely to explain why there is a huge overlap between the sleep studies of patients with insomnia and normal sleepers. Something about the way the person experiences sleep is different. Perhaps it is the quality of sleep, something we cannot gauge with our standard technique of measuring sleep, the polysomnogram. Or maybe it is as simple as the brain filling in time between the brief awakenings that are a feature of normal sleep, perceived as wakefulness by someone predisposed to this form of insomnia, rathe
r than the deep sleep seen on the sleep study.
For others with insomnia, their sleep may be broken, disrupted several times per night, but their total sleep is a normal amount. Even those with a reduced total sleep duration may actually have normal amounts of deep sleep, that stage of sleep most important to physical restoration and refreshment.
For the hardcore insomniac, like Claire, however, there is clear evidence of very curtailed sleep, sometimes only a few snatched hours every night. And it is in those people with a short sleep duration that we see clear biological markers of stress, what is termed ‘hyperarousal’. That jangling of the nerves, the racing heart, being on full alert, the feeling of being excited or vigilant – all of these are features of hyperarousal. When under stress, a number of neurotransmitters and hormones come into play. The state of being stressed or anxious leads to the boosting of a number of systems in the body, resulting in higher levels of cortisol, adrenaline and noradrenaline. When these systems are studied in patients with insomnia, crucially with a short sleep duration, we see increased levels of the breakdown products of these hormones in the urine. This category of insomniacs also demonstrates other features of this ‘hyperarousal state’ – increased nocturnal heart rate, increased oxygen consumption (implying a higher metabolic rate) and increased pupil size, once again a measure of the heightened activity of the sympathetic nervous system, which mediates the ‘fright-fight-flight’ response. Importantly, these changes are not seen in people with insomnia who are actually getting a reasonable amount of sleep.
The Nocturnal Brain Page 27