Wegner demonstrated how the mind’s ironic sense of control played out in the real world of sleep. He sent 110 undergraduates home with a Walkman, a cassette, and instructions to listen to the tape as soon as they got into bed and turned the lights off. Each student was a normal sleeper, without any history of insomnia or another chronic sleep disorder. As they lay in bed, half of the test subjects heard this message: “Good evening . . . As you listen to the music that follows, you should try to fall asleep as quickly as possible. Your task is to put yourself to sleep in record time. Please concentrate on going to sleep quickly.” The other group, meanwhile, heard essentially the opposite. “Your task is to fall asleep whenever you would like.”
The design of the experiment included a second tier of anxiety. Ninety minutes of music followed the instructions. Half of the subjects who had been told to fall asleep as soon as possible heard the blaring of a loud marching band. Wegner chose this music to give subjects an additional mental hurdle to pass. Not only had they been given a deadline, but also they now had to question whether it would ever be possible to meet it in the first place. The other half of the subjects in the study heard what the experiment described as “new age music . . . containing restful outdoor sounds such as birds, crickets, and a stream bubbling in the background.” An equal number of subjects who had been told to fall asleep whenever they wished heard either the marching band or the crickets as well.
As predicted, subjects who had been told to fall asleep quickly took longer to do so. Their minds were so focused on falling asleep in record time that they found themselves consciously checking on their progress, unable to let their thoughts drift off and guide them to dreamland. And not surprisingly, those who were trying to fall asleep urgently while listening to the taxing music of the marching band fared the worst by far.
But here was where the study defied expectations. The misfortune of the fall-asleep-as-quick-as-you-can group wasn’t just limited to time spent listening to the marching band music. Throughout the night, these subjects woke up more often, and had a harder time getting back to sleep, than any other group, even after their headphones went silent. The next day, they reported feeling less rested than their peers. The stress of trying to fall asleep while the music was playing had lingered well into the early morning. Just like Bunce in the military training film, they wanted to sleep so badly in those first minutes in bed that they couldn’t calm their minds down throughout the night. Wegner had set in motion the cycle of insomnia.
Treating insomnia isn’t easy. Part of the reason is the fact that science, as a whole, has a fuzzy definition of what constitutes the disorder. One night of bad sleep because of a blaring car alarm or an upcoming stressful day at work doesn’t classify as insomnia. Instead, it is generally thought of as a string of otherwise peaceful nights during which a patient can’t fall asleep when he or she wants to. The National Institutes of Health identifies the condition as “difficulty getting or staying asleep, or having non-refreshing sleep for at least one month.” The classic form of short-term insomnia has no known cause yet is widespread. About one in ten people in the United States suffer from it during their lifetime.
There is no medical test that proves whether someone is suffering from a temporary bout of sleepless nights or a more serious disorder. Some patients go to sleep labs and undergo tests to rule out conditions such as sleep apnea, but knowing what they don’t have offers little help in treating what they do. Instead, doctors rely on self-reports from patients, which can be maddeningly vague, a result of the difficulty that we have with accurately noting how many hours we truly spent sleeping on any given night. Patients who have spent a night in a sleep lab, for instance, often complain that it took them more than an hour to fall asleep when a chart of their brain waves shows they were asleep within ten minutes. Problems of self-reporting aren’t limited to judging how long it took to get to sleep. Some patients wake up in labs claiming that they didn’t sleep at all during the night, despite hours of video and brain wave evidence to the contrary.
It is a part of the paradox that sleep presents to a conscious mind. We can’t easily judge the time that we are asleep because that time feels like an absence, a break from the demands of thought and awareness. The times that we do remember are those that we wish we couldn’t: staring at the clock in the middle of the night, turning the pillow over desperately hoping that the other side is cooler, kicking the covers off or pulling them up close. Those experiences, even if they last only three minutes, often become exaggerated in our minds and overshadow the hours that we spent sleeping peacefully, simply because we remember them.
When insomnia starts to interfere with the routines of normal life, many people decide to turn to pharmaceuticals. Medicines that help someone fall asleep, stay asleep, or be comfortable in between accounted for $30 billion in annual sales by 2010 in the United States alone, which is a little more than what people around the world spend each year going to the movies. Sleeping pills are responsible for the majority of those profits. It is a remarkable turnaround, considering that it wasn’t that long ago that public distrust of sleeping pills led Coronet magazine, a spin-off Esquire published until the mid-1960s, to call them “the doorway to doom.”
In 1903, a physician named Joseph von Mering and a chemist named Emil Fischer developed the first modern medication that promised a safe way to induce sleep. Von Mering had made a name for himself fifteen years earlier when he discovered that the pancreas was responsible for the production of insulin, an important leap forward in the treatment of diabetes. To determine exactly what the pancreas did, von Mering decided to open up his dog, cut out the organ, and see what happened. The dog survived the surgery and undertook a revenge that was all too short-lived. Though house-trained, the dog began to urinate in von Mering’s lab. This happened so often that von Mering decided to have the urine tested. He found that it had high levels of sugar, one of the telltale signs of diabetes.
In an early attempt at branding, von Mering and Fischer called the sleeping pill they developed Veronal, hoping that the name would play off the image of the city of Verona as a place of peace and quiet. The new drug belonged to a class of medications known as barbiturates, which, when taken in low doses, often make a patient feel intoxicated. While the pills did allow some patients to at least temporarily reach what Veronal advertisements described as “natural sleep,” they came with some serious side effects. Chief among them was that the body easily developed a tolerance for the drug, making a patient require progressively larger doses for it to work.
This wouldn’t have been so bad had the recommended dosage of the pills not been so close to a fatal one, especially when mixed with a little alcohol. For the next sixty years, sleeping pills were blamed for countless accidental overdoses when patients took an extra pill or two in a half-asleep daze. Brian Epstein, the manager of the Beatles, died in his London home after taking a lethal dose of barbiturate pills. The death was officially ruled an accident. Their availability and potency also made barbiturate sleeping pills a factor in a number of well-publicized suicides. Actor Grant Withers, who appeared in a string of John Wayne films, turned to sleeping pills when he took his own life in 1959. A bottle of barbiturate sleeping pills was found next to the body of Marilyn Monroe three years later. The popularity of the drugs plummeted after the deaths in Hollywood, as both doctors and patients were spooked to realize that the pills in their bathrooms were capable of killing so easily.
A family of sedatives called benzodiazepines became popular in the 1970s because they were thought to be safer than their predecessors. This type of drug, which includes variants such as Valium (diazepam) and Rohypnol (flunitrazepam), work by binding to the receptors in the brain that arouse a person out of sleep, essentially making it harder for him or her to wake up. While these pills were an improvement over barbiturates because they drastically lowered the chance of an overdose, the high they gave some patients made them more likely to be abused. That wasn’t all. In
the late 1980s, patients started to show signs of memory loss after taking a benzodiazepine known as Halcion (triazolam).
The worst of the conditions linked to Halcion was something called traveler’s amnesia, which often took place during international travel. Typical patients who experienced traveler’s amnesia would take a dose of Halcion while on a red-eye flight, to ease the adjustment to the time difference. When they woke up at their destination, however, their memory would be blank. Patients lost track of who they were, where they had landed, and why they were there. Others would wake up in their hotel rooms and realize that they had no memory of their plane landing, of walking through customs, or of riding in the cab that picked them up from the airport. The United Kingdom banned the drug in the early 1990s, while several other countries severely restricted its availability (it is still legal in the United States).
The sleeping pill market changed in 1993 when a French company now known as Sanofi introduced a new drug called Ambien, also known by its generic name zolpidem. Ambien worked in essentially the same way as the benzodiazepines, though with far fewer side effects. It appeared safe enough, in fact, that many doctors broke their long-standing refusal to prescribe a medication for run-of-the-mill insomnia. Ambien quickly dominated the sleeping pill market and rang up more than a billion dollars in sales a year. At one time, Ambien accounted for eight out of every ten sleeping aids prescribed in the United States, a near monopoly enjoyed by few other drugs in history.
It wasn’t until 2005 that its first real competitor emerged. That was when a small biotech company in Marlborough, Massachusetts, called Sepracor introduced Lunesta, also known as eszopiclone. Though in the same class of drugs as Ambien, Lunesta had two advantages over it. One was the fact that the FDA approved it for long-term use, which meant that patients weren’t advised to forgo taking the drug every couple of days like they were with Ambien. The second was a branding campaign that featured a little green moth that floated onto the faces of happy, smiling actors pretending to be asleep in the company’s commercials. “The word ‘nest’ is hidden in Lunesta so people think of their nests when they sleep,” one brand consultant said while praising its launch. Sepracor made sure that everyone saw its moth by spending $230 million on advertising the year Lunesta was introduced, making it the most-promoted drug of the year.
All told, sleeping pills accounted for more than $1 billion in advertising between 2005 and 2006. The sheer number of commercials may have caused as much insomnia as the drugs treated. Just like in Wegner’s instructions to his test subjects to fall asleep as quickly as they can, constant reminders and advertisements about obtaining good sleep would be enough to push anyone into the cycle of insomnia, beset by worries over whether his or her sleep measured up to what the commercials offered. In one year, the total number of sleeping pill prescriptions written in the United States jumped from 28 million to 43 million. Every week, 120,000 new patients asked their doctors for a sleeping pill, a growth rate that rivaled the spread of Facebook. After it brought in almost $100 million in sales in its first quarter on the market, Wall Street analysts declared that Lunesta could do for the insomnia market what Prozac did for depression. Brandweek awarded Sepracor its Marketer of the Year Award and proclaimed that, thanks to the company, “insomnia is sexy again”—though, to be fair, it was never technically sexy in the first place. By 2010, about one in every four adults in the United States had a prescription sleeping pill in their medicine cabinets.
But here’s the twist. A number of studies have shown that drugs like Ambien and Lunesta offer no significant improvement in the quality of sleep that a person gets. They give only a tiny bit more in the quantity department, too. In one study financed by the National Institutes of Health, patients taking popular prescription sleeping pills fell asleep just twelve minutes faster than those given a sugar pill, and slept for a grand total of only eleven minutes longer throughout the night.
If popular sleeping pills don’t offer a major boost in sleep time or quality, then why do so many people take them? Part of the answer is the well-known placebo effect. Taking any pill, even one filled with sugar, can give some measure of comfort. But sleeping pills do something more than that. Drugs like Ambien have the curious effect of causing what is known as anterograde amnesia. In other words, ingesting the drug essentially makes it temporarily harder for the brain to form new short-term memories. This explains why those who take a pill may toss and turn in the middle of the night but say the next day that they slept soundly. Their brains simply weren’t recording all those fleeting minutes of wakefulness, allowing them to face each morning with a clean slate, unaware of anything that happened over the last six or seven hours. Some sleep doctors argue that this isn’t such a bad thing. “If you forget how long you lay in bed tossing and turning, in some ways that’s just as good as sleeping,” one physician who worked with pharmaceutical companies told the New York Times, voicing what is a widely held opinion among the sleep doctors and physicians that I spoke with.
Serious problems can arise when people taking a drug like Ambien don’t actually stay in bed. Some have complained of waking up the next day and finding things like candy wrappers in their beds, lit stoves in their kitchens, and bite marks on the pizzas in their freezers. Others have discovered broken wrists that came from falling while sleepwalking, or picked up their cell phones and seen a list of calls that they have no memory of making. Ambien was part of a kinky footnote in the Tiger Woods saga. One of his mistresses said that the pair would take the drug before sex because it would lower their inhibitions. Visitors to Sleepnet, an Internet forum, have noted their own troubles with sleeping pills. “Many people have tried to convince me that Ambien is a good drug. Maybe it works for some people, but I have to tell you it has been one big nightmare for me and my family,” one person wrote. “I have done the most dangerous and humiliating things after taking the drug. To provide some examples, I have called people, who I never would have called and said things that I would never have said, leading to very uncomfortable relationships and explanations of why I called. I have had sexual encounters that I barely remember. I have left my apartment in pajama-like attire to go shopping in the middle of the night. Once I wrote all over the walls of my apartment with nail polish. That was a nightmare.” Not long after a member of the Kennedy family blamed a car accident on the effects of Ambien, the Food and Drug Administration issued new rules that require pharmacists to explain the risk that taking certain sleeping pills could lead to things like sleep eating, sleepwalking, or sleep driving.
Those warnings have done little to tamper with the popularity of sleeping pills, especially since the most popular one is cheaper than ever. Ambien went off patent a few months before the FDA issued its new requirements. While the total number of dollars spent on sleeping pills fell by more than $1 billion a year because of the availability of cheaper generic versions, the number of patients filling a prescription for them remained steady. Many people who take sleeping pills find that their sleep quality reverts to its previous, poor state the night they decide to go without medication, a vicious cycle that increases their dependency on a drug approved only for short-term use. Facing a night of sleep without backup produces the same form of stress that originally caused the insomnia cycle to begin.
Yet there is a way to treat insomnia without setting patients up for a letdown as soon as the prescription runs out. Charles Morin is a professor of psychology at Université Laval in Quebec. For more than ten years, he has studied whether modifying behavior can be as effective at treating insomnia as taking medication. His research focuses on a type of counseling called cognitive behavioral therapy, a treatment that psychologists often use when working with patients suffering from depression, anxiety disorders, or phobias. The therapy has two parts. Patients are taught to identify and challenge worrisome thoughts when they come up. At the same time, they are asked to record all of their daily actions so that they can visualize the outcome of their choices.
When used as a treatment for insomnia, this form of therapy often focuses on helping patients let go of their fear that getting inadequate sleep will make them useless the next day. It works to counter another irony of insomnia: Morin found that people who can’t sleep often expect more out of it than people who can. Patients with insomnia tend to think that one night of poor sleep leads to immediate health problems or has an outsized impact on their mood the next day, a mental pressure cooker that leaves them fretting that every second they are awake in the middle of the night is another grain of salt in the wound. In the inverted logic of the condition, sleep is extremely important to someone with insomnia. Therefore, the person with insomnia can’t get sleep.
In a study in 1999, Morin recruited seventy-eight test subjects who were over the age of fifty-five and had dealt with chronic insomnia for at least fifteen years. He separated his subjects into four groups. One group was given a sleeping pill called Restoril (temazepan), a benzodiazepine sedative often prescribed for short-term insomnia. Another group was treated with cognitive behavioral therapy techniques that focused on improving their expectations and habits when it came to sleep. The members of this group were prompted to keep a sleep diary and meet with a counselor to talk about their patterns, as well as carry out other actions. The third group was given a placebo, and the fourth was treated with a combination of Restoril and the therapy techniques.
The experiment lasted for eight weeks. Morin then interviewed all of the subjects about their new sleeping habits and the quality of their sleep each night. Patients who had taken the sleeping pill reported the most dramatic improvements in the first days of the study, sleeping through the night without spending any of the lonely hours awake they had come to expect. Subjects who were treated with the cognitive behavioral therapy began to report similar results in sleep quality a few days later. Over the short term, sleeping pills had a slight edge in sanding down the rough edges of insomnia.
Dreamland: Adventures in the Strange Science of Sleep Page 19