The One whose mercy flows freely to the undeserving is not a machine. He is not a mechanical Grace Dispenser. He is a Person. His smile is not an all-approving grin. He has moral sensitivities. We please Him, and we displease Him, moment by moment. Within the gospel framework of His grace, inside the relationship of His fatherly acceptance, He is fully capable of confronting us. Not rejecting us, not casting us off, but correcting us. Because He’s a good Father. I’ll take it further. The One who is for us (Romans 8:31) can also bluntly say, “I have something against you” (Revelation 2:4, 14, 20). The One who will never leave us nor forsake us (Hebrews 13:5) is also quite capable of saying to us, “We need to have a serious talk. It’s time for you to make some changes. If you will listen and follow, I will continue to use you. If you turn away, I will set you aside”... If your theology includes the message of justification by faith alone, I hope you will never back off from that. I hope you will keep that message central. But I also hope your theology includes another message – the grace of obedience fully pleasing to the Father.
Ray Ortlund

Making It Through The Night I

Making It Through The Night I

ON MAKING IT THROUGH THE NIGHT

Sleeplessness was in the news when news was no more than gossip. Today is no different, except that nowadays drugs are often used to induce sleep. This database examines the safety of some of those drugs as well as coping with the problem without chemicals.

Insomnia is the triumph of mind over mattress, as one joke has it. But for many people insomnia is no laughing matter.

Americans spend approximately $25 million a year on over- the-counter (OTC) sleep aids, and additional millions are spent by the approximately 8.5 million Americans who take prescription sleeping pills. In 1977, about two million of these insomniacs took prescription sleep medications every night for two consecutive months or longer.

But the recent recall of OTC sleep aids containing methapyrilene and a previous FDA warning about the efficacy of OTC sleep aids, coupled with an Institute of Medicine report on prescription sedatives and hypnotics, has brought into question the wisdom of indiscriminate and widespread use of both OTC and prescription sleep medications.

In 1975, FDA’s expert panel on sleep aids, daytime sedatives, and stimulants cautioned those with chronic sleep problems to seek medical help. It warned against using sleep aids containing bromides and scopolamine compounds, and found “irrational” the use of passion flower extract and vitamin B1 (thiamine hydrochloride) in sleep aids. Although most sleep aids containing these ingredients were reformulated after the panel’s report, some remain on the market.

More recently, OTC sleep aids containing the antihistamine methapyrilene, a carcinogen, were recalled down to the retail level in June (see FDA CONSUMER, July- August 1979). Manufacturers again reformulated their products, mostly with a chemically similar antihistamine, pyrilamine, which has not yet been tested for carcinogenicity. This action leaves thousands of users of OTC sleep aids wondering if they should continue to take these drugs, see their doctor for a prescription medication, or possibly look for other ways to relieve insomnia.

Adding to the insomniac’s quandary is the recent study on sedative-hypnotic drugs issued by the National Academy of Science’s Institute of Medicine (IOM). IOM conducted the study at the request of the White House Office of Drug Policy and the National Institute on Drug Abuse. Of significance to insomniacs seeking prescription drugs was the IOM report’s advice to physicians to restrict use of sedative-hypnotic drugs to short-term treatment of insomnia. IOM found little evidence that sedative hypnotics in general continue to be effective when used nightly over long periods. Indeed, sleep laboratory research on sleeping pills shows that practically all lose their sleep promoting effectiveness after 3 to 14 days of continuous use.

In addition to the time limitations on effectiveness, studies show that many of the prescription drugs interfere with various stages of sleep. The barbiturates suppress REM (Rapid Eye Movement) sleep during which persons dream.

In the last several years, this knowledge, together with the association of barbiturates and drug abuse, has been responsible for a shift away from prescribing barbiturates in favor of the benzodiazepines, most notably Dalmane. However, there is now evidence that the benzodiazepines suppress sleep stages 3 and 4.

To better understand the significance of such suppression, we can look at an explanation of the various stages of sleep.

In their book, INSOMNIA (Doubleday, N.Y., 1969), Gay Gaer Luce and Julius Segal describe what happens when a person falls asleep. At the threshold of sleep, body temperature goes down and what are known as “alpha rhythm” brain waves occur. At this point, after the alpha state is reached, many people experience a sudden jerking awake. This is technically known as the “Myoclonic Jerk” and signals neural changes resulting from a sudden burst of activity in the brain. Typically, the sleeper jerks half awake, then quickly enters stage 1 of sleep. Muscles relax and the pulse slows. Sleepers awakened at this point often feel that they have not been asleep.

If unawakened, the sleeper now enters stage 2. At this time if an EEG (electroencephalograph) were being made the tracings would show a burst of activity as the brain waves grow larger. The sleeper’s eyes roll from side to side. If the eyes open, they do not see. At this point, although asleep about 10 minutes, a person if awakened might wonder if he or she had been sleeping or might believe no sleep had occurred.

After about 30 minutes of sleep, stage 3 is reached. Brain waves are large and slow, rather like mountains. Muscles are relaxed and breathing even.

The sleeper then enters stage 4, or “delta” sleep. This is the deepest sleep of all and lasts longer in the first part of the night than toward morning. Initially, after about 20 minutes of delta sleep, the sleeper ascends near waking again, but does not awaken. Instead, the sleeper goes into REM sleep, so named for the rapid eye movements which occur during this phase. The sleeper dreams during 85 percent of REM. The heartbeats are irregular and blood pressure fluctuates; the brain waves resemble those of a waking person. The first REM period lasts about 10 minutes, and then the cycle begins again with the sleeper entering sleep stage 2. This cycle repeats itself about once every 90 minutes. Toward morning there is less delta sleep and more REM.

The orders of the sleep cycle and each of its stages seem to be biologically essential. Studies of people deprived of REM show that they become hostile, irritable, and anxious. Those deprived of delta sleep seem to become depressed and apathetic. Both the REM- and the delta-deprived make up the missed stages as soon as possible when allowed to return to normal sleep.

Given this knowledge, it is understandable that medical authorities are questioning the use, especially over extended periods, of sleeping pills that may suppress these important phases of sleep.

What, then do you do if you don’t want to take pills but you can’t get a good night’s sleep? Just such a question was recently addressed in the JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (JAMA, Nov. 17, 1978, Vol. 240, No. 21). In an article entitled “What to Use Instead of Sleeping Pills,” Thomas J. Coates, Ph.D., and Carl E. Thoresen, Ph.D., point out that the insomniac should be given a thorough physical examination to make sure that the insomnia is not related to liver, kidney, or heart disease, a metabolism problem, or some other physical ailment. With these problems ruled out, the authors then suggest that physicians advise insomniac patients to look to their eating, drinking, exercise, and relaxation habits to see if these might be preventing good sleep.

In another article along the same lines in Harvard University’s MEDICAL FORUM (Vol. IV Nov. 7, May 1979), Dr. Quentin R. Regestein, director of the Sleep Clinic at Peter Bent Brigham Hospital, Boston, observes that most insomnia cases are related to lifestyle problems such as irregular times of going to bed and arising, night work, daytime naps, completely sedentary daytime routine, overuse of caffeine or other stimulants, and chronic abuse of tranquilizers, sleeping pills, or alcohol.

Luce and Segal point out that there are a number of types of insomnia and a variety of reasons a person may be having sleeping problems.

A major problem for many is not inability to sleep but fear they will not sleep. The Greeks had a word for it: agrypniaphobia, fear of not being able to sleep. Then there are people who dwell on their sleeplessness, constantly pointing to it as the insurmountable problem in their lives, as a way of avoiding confrontation with more threatening problems.

Others believe mistakenly that they have insomnia. These persons may actually be getting adequate sleep for their needs, but because they have not had a full 8 hours of sleep, believe they have a problem. In fact, 8 hours may be too much sleep for some people and not enough for others. There is no statistical evidence that everyone needs 8 hours of sleep at night. Average amounts of habitual sleep can vary from 5 to 10 hours a night. There are even a few persons who habitually get as little as 2 or 3 hours sleep a night and awake feeling refreshed.

There is a type of insomnia in which persons believe they have not been asleep when they actually were. This occurs, Luce and Segal theorize, because periods of light sleeping and wakefulness are often fused and the insomniac believes he or she has not slept at all. In addition, some persons have more difficulty judging time at night than in daytime and therefore are likely to overestimate wakeful hours.

Another type of insomnia occurs when something upsetting or exciting happens in a person’s life. This type disappears by itself when the crisis is over.

Then there is pathological insomnia which may be a sign of emotional illness. For example, early morning awakening is often a sign of depression.

If an insomniac’s problem does not seem to fall into any of these areas, then he or she should look to environment and habits.

Irregular times of going to bed and awaking may make sleeping more difficult because the body gets used to sleep at certain times. There is the lark and owl syndrome–the larks being those who are at their best when they go to sleep and arise early, and the owls those who excel when they go to bed and get up at later hours. This variation is apparently linked to individual biological rhythms and possibly heredity, and can vary greatly from one individual to another. Therefore, insomniacs might do well to experiment with different times of going to sleep and arising, to see if they can get a better synchronization with their natural body rhythms.

Another factor that can affect sleep is age. People require less sleep as they grow older, and this becomes increasingly evident after age 55.

There is sexism in tossing and turning. Several studies indicate that women have more trouble with insomnia than men. The question arises whether this is because, as with other physical or psychological complaints, women tend to seek help more often than men or whether there is an actual biological difference. It is known that women can be more easily roused from sleep than men and that, at an earlier age, they start requiring less sleep than men. In addition, there may be a hormonal factor, the sleepiness of early pregnancy due to progesterone release and the insomnia of premenstrual tension being two examples.

Besides these factors, there are environmental variables, such as diet and exercise, which are more amenable to change.

Interestingly, that old folk remedy for sleeplessness, a glass of warm milk, had some scientific basis. In a study, one of the amino acids found in milk was given in large doses to volunteers and was found to have a sedative effect. In another experiment, when persons were deprived of two other amino acids that occur in high protein foods, there was a drop in the amount of REM sleep. Therefore, a good rule of thumb might be to have a high protein dinner and a glass of milk before bedtime.

On the other hand, insomniacs would be wise to avoid beverages containing caffeine, such as coffee, tea, and colas, because they act as stimulants in most people. Smokers should note that nicotine is also a stimulant and that many ex-smokers have reported improved sleep after quitting.

Alcohol, in that old standby the nightcap, may not always work to induce sleep because it, too, can be a stimulant. In addition, some alcoholics report that their problem began with bedtime drinking. There also is evidence showing that at some dosage levels alcohol reduces REM sleep.

Exercise–the right kind at the right time–can be a sleep aid. Exercise during the daytime, especially if followed on a routine basis, has a beneficial effect on sleep. However, exercise at night may make sleeping a bit more difficult, especially if you are not used to it. Similarly, mental stimulation before bedtime can make it harder to fall asleep.

Controlling the environment factors will often alleviate or eliminate sleep problems. Those for whom this approach is insufficient may want to try some of the alternatives to medication alluded to in the JAMA and MEDICAL FORUM databases and also discussed by Luce and Segal.

One solution is referral by a physician to a sleep clinic. Some sleep clinics are set up as part of hospitals. Others are connected with privately owned sleep labs and are thus more research oriented. Some sleep clinics accept people on an in-patient basis only; others accept both in-patient and out-patients. The program in most sleep clinics includes a thorough physical exam and psychological testing preceding several nights of EEG studies during which the insomniac is monitored to determine what abnormalities exist in his sleep pattern. A list of sleep clinics is available from Peter Bent Brigham Hospital Sleep Clinic, 721 Huntington Avenue, Boston, Mass. 02115, or Dr. William Dement, Association of Sleep Disorders Centers, Stanford University School of Medicine, Stanford, Calif. 94305.

Biofeedback, which came into wide use in the late 1960’s as a way of reducing tension, has also been used to relieve insomnia. Although medical experts differ on the extent of its success for various problems, laboratory tests have shown that people can learn to control, at least partially, body functions–such as blood pressure and heart rate–that are not usually subject to conscious control.

In BIOFEEDBACK: TURNING ON THE POWER OF YOUR MIND LIPPINCOTT, PHILA., 1972), Marvin Karlin and Lewis M. Andrews describe a biofeedback training program for insomniacs. In this program, people overcome sleep difficulties by first learning to relax their forehead muscle through feedback from an EMG (electromyograph) that emits a rising tone when the forehead muscle contracts and a falling tone when it relaxes.

After learning to control the forehead muscle, the subjects then learn, through similar EEG feedback, how to produce the alpha brain waves that precede sleep.

Although some insomniacs have found relief through biofeedback techniques, their acceptance is by no means universal, and some experts, such as Beata Jencks, Ph.D., in YOUR BODY: BIOFEEDBACK AT ITS BEST (Nelson Hall, 1977), suggests that the body itself, through exercises and relaxation techniques, can be taught to act as its own biofeedback mechanism.

A number of relaxation techniques have been successful in helping people attain more beneficial sleep. Simply tensing and relaxing each muscle in the body can make a person more receptive to sleep. Similar methods are included in programs of Hatha Yoga and some forms of meditation.

Hypnosis, in the hands of a qualified professional who gives a posthypnotic suggestion that the subject will sleep and feel rested, can also be a solution to insomnia. Another, similar method, is self-hypnosis. With both these methods, however, one should be certain that there is not a deep psychological problem underlying the insomnia–a problem that may resurface in another perhaps more destructive manner. For those whose insomnia is rooted in emotional problems, psychotherapy may be the best answer.

Whether or not one of these alternatives appeals to you, one thing seems certain: there is a growing body of medical opinion, including the IOM report and the FDA panel recommendations, which sees sleeping pills as, at best, a temporary solution to insomnia. The informed consumer, with expert medical advice, will explore the alternatives to drugs to find an effective, safe, long lasting solution to sleep difficulties.