by Sandi Mann
Spotlight: Sleeping like a baby
While newborn babies can sleep for up to 17 hours each day (though, sadly for their parents, often in short bursts of a couple of hours at a time), their sleep cycles (see next section) are far shorter than those of adults. Babies also spend more time than adults in rapid eye movement (REM) sleep (which means they dream a lot more than adults). Because this is a lighter state of sleep, newborns are much more likely to wake up in response to noises, changes in temperature and movement. When they are dreaming, newborns can make quite a few little noises and their eyes, facial muscles, arms and legs will move a lot – this can even wake them up, which is why swaddling is thought to help babies sleep. Dreaming allows vital brain development to continue even when the baby is asleep.
Newborns also do not seem to develop effective circadian rhythms until they are around six weeks old, or later (which is why they make no distinction between day and night).
Towards the end of the night, the body starts to secrete cortisol in preparation for the anticipated stress of the day, in what is known as the cortisol awakening response.
Stages of sleep
Adult humans sleep in periods of approximately 90 minutes in four to five cycles per night of REM and non-REM (NREM). During the NREM stage, body temperature, heart rate, breathing rate and energy use all decrease, while brain waves get slower and bigger. The American Academy of Sleep Medicine (AASM) divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-wave sleep. The whole cycle normally proceeds in the order: N1 → N2 → N3 → N2 → REM. Each stage may have a distinct physiological function. There is a greater amount of deep sleep (stage N3) earlier in the night, while the proportion of REM sleep increases in the two cycles just before natural awakening.
• NREM (N1): this is the stage of sleep that usually occurs between sleep and wakefulness. Sudden twitches and jerks may be associated with the onset of sleep during N1. During non-REM1, the organism loses some muscle tone and most conscious awareness of the external environment. This stage typically lasts only around five to ten minutes and a person awakened from this stage might feel that they have not actually been asleep.
• NREM (N2): in this stage, sleepers become gradually harder to awaken. During this stage, muscular activity as measured by EMG decreases, and conscious awareness of the external environment disappears. This stages lasts about 20 minutes.
• NREM (N3): this stage is called slow-wave sleep (SWS) or deep sleep. The sleeper is less responsive to the environment; many environmental stimuli no longer produce any reactions. Slow-wave sleep is thought to be the most restful form of sleep, the phase which most relieves subjective feelings of sleepiness and restores the body. Bed-wetting and sleepwalking are most likely to occur at the end of this stage of sleep.
• REM: Entering rapid eye movement (REM) sleep, where most muscles are paralysed and heart rate, breathing and body temperature become unregulated, the sleeper may experience vivid dreams. REM sleep is activated by acetylcholine secretion and is inhibited by serotonin-secreting neurons. An adult reaches REM approximately every 90 minutes, and remains in REM sleep for longer during the latter half of sleep.
Dreams
Dreams are successions of images, pictures, scenes, ideas, feelings, motions and sensations that occur usually involuntarily in the mind during certain stages of sleep (mainly during REM sleep when brain activity is high). The length of a dream can vary; it may last for a few seconds or up to 20–30 minutes. Most dreams are instantly forgotten, although we are more likely to remember the dream if we wake during the REM phase.
There are various theories that attempt to account for why we have dreams:
• The Psychoanalytic Theory of Dreams: according to Freud in his well-known 1900 book The Interpretation of Dreams, our dreams represent the unconscious desires, wishes and thoughts that we normally suppress. They are thus an outlet for our real feelings.
Spotlight: The most common dreams
Being chased
Water
Vehicles
People
School/classroom
Paralysis
Death
Flying
Falling
• The Nudity Activation-Synthesis Model: this theory, proposed by J. Allan Hobson and Robert McClarley in 1977, suggests that areas in the limbic system of the brain that are involved in emotions and memories (such as the amygdala and hippocampus) are activated during REM sleep. The brain attempts to find meaning in these signals, which results in dreaming.
• Information-processing theories: some theorists believe that dreaming facilitates the information-processing that is thought to be a function of sleep. Some dream experts suggest that dreaming is simply a by-product or even an active part of this information-processing. This is why we often solve problems during our sleep – our minds are freed from the logical constraints of wakeful thoughts. Some believe that dreams allow us to mentally prepare for change or rehearse for new events that might happen in our lives. This is why we often dream about events that are going to happen to us in the future.
Spotlight: The benefits of dreaming
Various well-known figures have attributed success to dreams. The Golfer Jack Nicklaus once related how he was trying to figure out how to improve his swing. He noticed that in his dreams he had no problem and that his hands were positioned differently in the dream than in real life; he adopted this new grip and saw dramatic improvements in his game. Paul McCartney allegedly heard the tune of ‘Yesterday’ in a dream, while Stephen King claims to have dreamed the idea for his best-selling book Misery.
Sleep disorders
Sleep is such a vital part of our life that, when things go wrong in that department, it can cause a lot of stress. Most people at some point in their lives will have some difficulties with sleep, the most common of which are to do with problems getting or staying asleep; according to the NHS, a third of people in the UK will experience this. Insomnia can be short term (up to three weeks) or long term (above three to four weeks) and can lead to memory problems, depression, irritability and an increased risk of heart disease and driving-related accidents.
Spotlight: The effects of sleep deprivation
In rats, total sleep deprivation is lethal after two to three weeks; they lose weight despite increasing food intake, and progressively fail to regulate their body temperature. They also develop infections, suggesting an impairment of the immune system. In humans, lack of sleep leads to impaired memory and reduced cognitive abilities, mood swings and even hallucinations. The longest documented period of voluntary sleeplessness is 264 hours (approximately 11 days).
The DSM-5 criteria for insomnia include the following:
• Difficulty getting to sleep
• Difficulty staying sleep, characterized by frequent awakenings or problems returning to sleep after awakenings
• Early-morning awakening with inability to return to sleep.
In addition, to be classed as insomnia, the sleep disturbance should also cause clinically significant distress or impairment in social, occupational, educational, academic, behavioural or other important areas of functioning; it should occur at least three nights per week; it should persist for at least three months, and it precludes those times when there is not the opportunity to sleep (e.g. with a newborn baby in the house) or when drugs or medication are involved.
Causes of insomnia are varied but the most common reasons for people seeking psychological help are often centred around anxiety. Sleep is a deep state of relaxation, so it is difficult to fall asleep if you are not relaxed. Individuals may experience anxiety-provoking events that stop them relaxing, but often anxiety about not sleeping contributes to the condition, too. The other important condition for sleep is that the individual must be tired! This might sound odd, but people with sleep difficulties often doze during the day and may thus not be tired enough at night. Dozing during the day can affect circadian rhythms
(see below), which can make it harder to fall asleep at night.
Treatment for insomnia can be pharmaceutical, with benzodiazepines such as temazepam and diazepam (best only for the short term as the benefits wear off as tolerance builds up) or by using psychological techniques such as relaxation therapy, sleep hygiene methods (e.g. ensuring that a bedroom is quiet and dark, that no caffeine is consumed during the evening, that there is no daytime dozing, etc.) and paradoxical intention. Paradoxical intention is a cognitive reframing technique where the insomniac, instead of attempting to fall asleep at night, makes every effort to stay awake (i.e. essentially stops trying to fall asleep). This can be effective because it relieves the ‘performance anxiety’ that arises from the perceived need or requirement to fall asleep.
Spotlight: Alcohol and sleep
Alcohol is often used as a form of self-treatment of insomnia to induce sleep. However, using alcohol in the long term to induce sleep can actually be a cause of insomnia as it is associated with a decrease in NREM stage 3 and 4 sleep as well as the suppression of REM sleep.
Hypnosis
Hypnosis, while appearing to hold quite magical powers, is merely a state of deep relaxation. It involves an altered state of consciousness during which the client is focusing their attention totally on the therapist and is thus receptive to receiving suggestions and instructions from them. During a hypnotic state, the person is so relaxed that their subconscious processes can be accessed. Hypnosis is normally preceded by a ‘hypnotic induction’ technique, traditionally viewed as a means of putting the subject into a ‘hypnotic trance’.
The origins of hypnosis go back many millennia; indeed, many ancient cultures and civilizations knew of hypnosis and used it as a therapeutic device. Although there was some documented use of hypnosis by the druids in ancient Britain and Gaul, the development and introduction of hypnosis to the modern world is attributable to Islamic scientists of the Middle Ages.
From the fifteenth and sixteenth centuries onwards physicians from many nations further developed and refined the concept of hypnosis and its uses. Even though this knowledge spread throughout the European continent and to the British Isles, it remained mostly confined to a small group (scientists, physicians and universities) and never quite reached the attention of the masses. However, in the eighteenth century the Austrian physician Frantz Anton Mesmer (1734–1815) used magnets and metal frames to perform ‘passes’ over the patient to remove ‘blockages’ (i.e. the causes of diseases) and to induce a trance-like state.
‘The real origin and essence of the hypnotic condition, is the induction of a habit of abstraction or mental concentration, in which, as in reverie or spontaneous abstraction, the powers of the mind are so much engrossed with a single idea or train of thought, as, for the nonce, to render the individual unconscious of, or indifferently conscious to, all other ideas, impressions, or trains of thought.’
J. Braid, Hypnotic Therapeutics: Illustrated by Cases: with an Appendix on Table-moving and Spirit-rapping (Edinburgh: Murray & Gibb, 1843)
It is from this that the verb ‘mesmerize’, which means to hold someone’s attention to the exclusion of anything else so as to create a trance state, originates. After Mesmer’s death in 1815 one of his disciples, Amand-Marie-Jacques de Chastenet, Marquis de Puységur (1751–1825), carried on his work and took it one step further. He discovered that the spoken word and direct commands induced trance easily and noticeably faster than ‘mesmeric passes’ and that a person could be operated upon without pain and anaesthesia when in a trance. This technique was used for many following decades by surgeons in France; Dr Récamier performed the first recorded operation without anaesthesia in 1821.
Soon after, chloroform was discovered and mesmerism dropped out of favour as an anaesthetic; it was much faster to inject a patient than induce a state of trance!
In 1841 the Scottish optometrist James Braid (1795–1860) discovered by accident that a person fixating an object could easily reach a trance state without the help of the mesmeric passes advocated by Dr Mesmer. He named his discovery ‘hypnotism’ based on the Greek word hypnos, which means ‘sleep’; it was a total misnomer as hypnosis is not sleep; yet the name remained and mesmerism became hypnotism.
Hypnosis was officially approved as a tool in medicine by the British Medical Association in 1955 and three years later the American Medical Association recognized the therapeutic use of hypnosis.
Case study: Joe Thompson
A 12-year-old schoolboy from Weston-super-Mare, in Somerset, Joe Thompson, was so afraid of flying that he was stranded in the United Arab Emirates for 18 months. He was only able to return home thanks to hypnotherapy.
Joe had travelled to Abu Dhabi with his family in 2009 after his father began work as a manager at a private hospital. In 2012 the family planned to return home, but Joe developed such a fear of flying that their plans were scuppered. Not only did he develop this debilitating fear of flying but he was also afraid of any form of long-haul transport, which meant he was trapped in the UAE. After four separate attempts were made to get Joe to board a plane, the rest of his family returned to Somerset, leaving Joe with his father abroad. His parents spent about £40,000 trying to cure Joe’s fear and on cancelled air fares and accommodation in the UAE, but his distress was so severe that he was simply unable to board the planes; he was so terrified as he approached the departure gate he would slump to the floor sobbing with stomach cramps.
Joe was finally able to return to the UK after undergoing three months of hypnosis therapy (in combination with CBT – see Chapter 16) from the therapist Russell Hemmings.
Circadian desynchronization and shift work
As we become an increasingly 24/7 society, more and more of us work some kind of shift pattern. It is thought that 4 million people in the UK – 17 per cent of employees – work shifts. What used to be the domain of medical personnel has now become endemic to many other professions such as retail workers, care workers and even call-centre employees. Yet rotating shifts are known to cause mental and physical health problems stemming mainly from working in opposition to the body’s normal circadian rhythms, especially the sleep–wake cycle. Documented problems of shift work include the following:
• Incidence of peptic ulcer disease in shift workers eight times higher than that of the rest of the population
• Increased risk of obesity
• Increased risk of cardiovascular mortality
• Other physical problems including chronic fatigue, excessive sleepiness and difficulty sleeping
• Increased divorce rate
• Higher rates of substance abuse and depression.
There are other phenomena associated with shift work:
• Shift workers are much more likely to view their jobs as extremely stressful.
• Accidents are known to increase as a result of working shifts. Many major disasters attributed to human error (the Exxon Valdez oil spill, Three Mile Island, the Bhopal chemical plant explosion, Chernobyl) occurred on the night shift.
• Shift workers are more likely than non-shift workers to have a life-limiting longstanding illness; they are also more likely to have more than one longstanding illness.
• Men and women doing shift work are more likely than non-shift workers to have diabetes (possibly due to the disruption in insulin production).
• Cigarette smoking prevalence is higher among shift workers than non-shift workers.
• Fruit and vegetable consumption is lower among shift workers than non-shift workers.
‘The main physiological consequence of such shift schedules is disruption of circadian rhythm which can have a deleterious effect on performance, sleep patterns, accident rates, mental health, and cardiovascular mortality.’
J. M. Harrington, ‘Health Effects of Shift Work and Extended Hours of Work’, Occupational and Environmental Medicine 58 (2001): 68–72
Much of these effects are thought to be due to the disruption in circadian rhyt
hms that happens when we don’t get chance to sleep at regular times. The term ‘circadian’ originates from the Latin words circa (about) and dia (day) and refers to the physical, mental and behavioural changes that follow a roughly 24-hour cycle. Sometimes these are referred to as our ‘biological clocks’ and they regulate sleep–wake cycles, hormone release, body temperature, heart rate, digestion and other important bodily functions. Circadian rhythms are vital to the sleep–wake cycle.
The key area of the brain that controls the sleep–wake cycle is the suprachiasmatic nucleus (SCN) in the hypothalamus, which contains thousands of nerve cells. This region controls the production of melatonin, the hormone that makes us sleepy. When there is less light, the SCN tells the brain to make more melatonin. Overnight, melatonin levels remain high. They drop at daybreak and remain low during the day. During the day, other chemicals (neurotransmitters) – such as noradrenaline and acetylcholine – increase in the body and keep us alert. Thus, shift workers will find it hard not to feel sleepy and less alert at night. However, the SCN is also influenced by other factors – such as our place in the circadian cycle. This explains why jetlag occurs; even if it is dark, if our internal body clock says it is daytime, it is hard to sleep.