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Jun. 14th, 2008 02:10 am![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
chhotiiArgh, I'm awake! Yes, it really is 2:10 am! What is worse is that I'm awake AND sick, making it hard to get up and do anything useful with the found time.
But rather than whine about it any more, I'm going to make a stab at writing a somewhat-relevant book review.
I recently finished my first reading of an excellent new book: Insomniac, by Gayle Greene. If you are at all interested in brain science (and/or psychology), or have insomnia, or know anyone who has insomnia, or just like reading long-ish books, put this on your short list! Dr. Greene tackles the subject of chronic insomnia from the refreshing viewpoint of a non-scientist (she's an Engiish lit professor) and a long-term insomniac, and argues convincingly that sleep science-- while it has made great strides in the past 50-some years-- has so far totally failed to understand or help chronic insomniacs.
Note, I'm not a chronic insomniac. I am the total opposite: not the perfect sleeper, but the OCCASIONAL insomniac. Like tonight, for instance. My hypothalamus is trying to tell me something: either that I need to cut back on caffeine (the trouble with yummy iced coffee is that slurped up through a straw, you wind up consuming more coffee); or that I shouldn't drag home mental baggage from the office, chiding myself that I should be thinking through software architecture after Sophia goes to bed, when, really, I'm barely alert enough to watch the baseball game at that time; or maybe even that the ice cream before bed was a bad idea, and late snacks should be restricted. Or maybe I've been over-doing the antihistamines (pollen has been hellish) and zonking out too much and I've accumulated a negative sleep debt. Probably all four. Anyway, I'll mend my ways, be more mindful about Sleep Hygiene, and go back to sleeping fine. Or not; I can keep doing everything wrong, and eventually sleep debt will catch up with me, and I'll sleep. Just, perhaps, not the most conveniently timed sleep.
This is how it works for most people, but not the chronic insomniacs Greene is talking about. Many chronic insomniacs can devote their lives to following the Sleep Hygiene rules perfectly, and still not sleep well, night after night. Chronic insomniacs don't get much sympathy when they talk to occasional insomniacs. Occasional insomniacs say inane things like "oh, I have a bad night sometimes too, I just get up and write down all my worries so I can put them out of my mind" or "have you tried warm milk?" Because, hey, that worked for them. Guess what-- Duh! People who have had insomnia have tried the counting and the warm milk and the hot baths and the frakin' herbal frakin' tea and they still don't sleep. This is big news to the Occasional Insomniacs; we think we're the experts in sleeping well because we can fix our own sleep problems, and thus think the chronic insomniacs should just be doing what we are doing. Note well the condescending tone of a typical web page on Sleep Hygiene.
It occurred to me as I was reading Greene's rant on this subject that it's very similar to the reason fat people get little sympathy. Enough people have had the experience of suddenly telling themselves "hey, I'm too fat", resolving to make some simple lifestyle change (such as eliminating soda or walking on lunchbreak), and losing an easy 5 pounds. Most of these people then believe that fat should not be a problem, and will tell you what you should do to fix it, because hey, it worked for them! Silly, isn't it? We should see that everyone has a different body, a different metabolism, and a different situation. But look how well diet books, all claiming to contain The Answer, sell.
Really our collective understanding of the problem of obesity is much more advanced and nuanced than the problem of insomnia. (And yet still fat people take abuse; look at that WisCon flap...) I think a lot of people realize that some people are sensitive to sugar, and thus might lose weight on a carbohydrate-restricted diet, whereas people who aren't should perhaps pay more attention to fat. OTOH, Sleep Hygiene rules are written as though set in stone, invariant for everyone; we should recognize that different things work for different people. For example, some people should avoid TV before bed, whereas it might actually be helpful for others.
The most brilliant books are the ones that make clear what you should have already realized. It should have been stunningly obvious that chronic insomnia has a neurobiological basis. (As opposed to temporary insomnia, brought on by example by berating yourself about your lousy software architecture right before bed, which rightly could be considered a psychological problem.) Things I already knew:
* Freud had everyone convinced for a while that all diseases are caused by neurosis. Freud was generally wrong about just about everything. Science has been discovering physiological bases of illnesses that used to be treated by Freudian analysis one by one: schizophrenia, irritable bowel syndrome, narcolepsy, RLS, OCD, etc., etc., etc. About time the pendulum swung the other way, and medicine stopped assuming that it's all in the patient's head whenever a disease can't be linked back to a scan or a test result.
* The neurobiological systems regulating sleep, and the genetics underlying them, a very complex. Complex systems fail in complex ways. Wasn't I just reading a paper about mice with a mutant form of HOMER1a sleeping less than wild-type mice? Why aren't researchers looking for polymorphisms in HOMER1, HOMER1a, Zif68, CLOCK, PER, etc., etc., etc., in people who can't sleep enough or can't sleep at the normal time?
* The field of sleep medicine is completely obsesses with apnea, because that's where the money is. Thus, not much attention to hard problems such as insomnia.
* Then again, there is money in insomnia: the pharmas must rake it in selling benzos and other GABA agonists. These drugs suck. (Sorry if I'm dissing your favorite drug.) It's speculated that they induce something more like anesthesia than natural sleep, and patients show a lot of daytime impairment. And then there's the habituation that seems to come with any GABA agonist, so there must be some really tight feedback loop regulating the expression of GABA receptors based on GABA activity. But, Big Biz Pharma is content to keep selling the same-old same-old, as long as it's making money, even if it sucks.
* The old-fashioned R&K sleep scoring rules are full of shit. Insomniacs are generally considered crazy, because if you wire up someone with insomnia with EEG leads, you will see stage 3 sleep waves, whereas the patient will claim that they were awake, or maybe in stage 1 at the most. This is called "sleep state misperception". I don't believe that these people are all crazy. I believe that the human brain is large and complex, and sometimes different parts of the brain are not in sync with each other. Clearly the part of the brain that generates delta waves can be more asleep than the part of the brain governing memory and awareness; and in insomniacs, the delta wave generator can be more asleep than whatever part of the brain "knits the raveled sleeve of care" (or however Shakespeare put it). (I wouldn't hypothesize that memory and awareness suppression are always correlated to the refreshing quality of sleep. If you think you're awake for hours and hours but feel well in the morning, you're just a "short sleeper". Insomnia is defined as feeling like crap during the day.)
BTW, you might think, based on my claim that nearly everything is neurobiological not psychological, that I'm one of these people who think talk therapy has been made obsolete by medication. Not at all; I really think it's unfortunate that medication has edged out talk therapy so much. Psychoactive drugs are problematic and far from perfect. Even if medication is available, most patients need help, guidance, and support.
Pardon the possible incoherence, it is the nadir of my day. Really, you don't have to work in sleep research to enjoy this book-- the author is an Shakespearian scholar.
But rather than whine about it any more, I'm going to make a stab at writing a somewhat-relevant book review.
I recently finished my first reading of an excellent new book: Insomniac, by Gayle Greene. If you are at all interested in brain science (and/or psychology), or have insomnia, or know anyone who has insomnia, or just like reading long-ish books, put this on your short list! Dr. Greene tackles the subject of chronic insomnia from the refreshing viewpoint of a non-scientist (she's an Engiish lit professor) and a long-term insomniac, and argues convincingly that sleep science-- while it has made great strides in the past 50-some years-- has so far totally failed to understand or help chronic insomniacs.
Note, I'm not a chronic insomniac. I am the total opposite: not the perfect sleeper, but the OCCASIONAL insomniac. Like tonight, for instance. My hypothalamus is trying to tell me something: either that I need to cut back on caffeine (the trouble with yummy iced coffee is that slurped up through a straw, you wind up consuming more coffee); or that I shouldn't drag home mental baggage from the office, chiding myself that I should be thinking through software architecture after Sophia goes to bed, when, really, I'm barely alert enough to watch the baseball game at that time; or maybe even that the ice cream before bed was a bad idea, and late snacks should be restricted. Or maybe I've been over-doing the antihistamines (pollen has been hellish) and zonking out too much and I've accumulated a negative sleep debt. Probably all four. Anyway, I'll mend my ways, be more mindful about Sleep Hygiene, and go back to sleeping fine. Or not; I can keep doing everything wrong, and eventually sleep debt will catch up with me, and I'll sleep. Just, perhaps, not the most conveniently timed sleep.
This is how it works for most people, but not the chronic insomniacs Greene is talking about. Many chronic insomniacs can devote their lives to following the Sleep Hygiene rules perfectly, and still not sleep well, night after night. Chronic insomniacs don't get much sympathy when they talk to occasional insomniacs. Occasional insomniacs say inane things like "oh, I have a bad night sometimes too, I just get up and write down all my worries so I can put them out of my mind" or "have you tried warm milk?" Because, hey, that worked for them. Guess what-- Duh! People who have had insomnia have tried the counting and the warm milk and the hot baths and the frakin' herbal frakin' tea and they still don't sleep. This is big news to the Occasional Insomniacs; we think we're the experts in sleeping well because we can fix our own sleep problems, and thus think the chronic insomniacs should just be doing what we are doing. Note well the condescending tone of a typical web page on Sleep Hygiene.
It occurred to me as I was reading Greene's rant on this subject that it's very similar to the reason fat people get little sympathy. Enough people have had the experience of suddenly telling themselves "hey, I'm too fat", resolving to make some simple lifestyle change (such as eliminating soda or walking on lunchbreak), and losing an easy 5 pounds. Most of these people then believe that fat should not be a problem, and will tell you what you should do to fix it, because hey, it worked for them! Silly, isn't it? We should see that everyone has a different body, a different metabolism, and a different situation. But look how well diet books, all claiming to contain The Answer, sell.
Really our collective understanding of the problem of obesity is much more advanced and nuanced than the problem of insomnia. (And yet still fat people take abuse; look at that WisCon flap...) I think a lot of people realize that some people are sensitive to sugar, and thus might lose weight on a carbohydrate-restricted diet, whereas people who aren't should perhaps pay more attention to fat. OTOH, Sleep Hygiene rules are written as though set in stone, invariant for everyone; we should recognize that different things work for different people. For example, some people should avoid TV before bed, whereas it might actually be helpful for others.
The most brilliant books are the ones that make clear what you should have already realized. It should have been stunningly obvious that chronic insomnia has a neurobiological basis. (As opposed to temporary insomnia, brought on by example by berating yourself about your lousy software architecture right before bed, which rightly could be considered a psychological problem.) Things I already knew:
* Freud had everyone convinced for a while that all diseases are caused by neurosis. Freud was generally wrong about just about everything. Science has been discovering physiological bases of illnesses that used to be treated by Freudian analysis one by one: schizophrenia, irritable bowel syndrome, narcolepsy, RLS, OCD, etc., etc., etc. About time the pendulum swung the other way, and medicine stopped assuming that it's all in the patient's head whenever a disease can't be linked back to a scan or a test result.
* The neurobiological systems regulating sleep, and the genetics underlying them, a very complex. Complex systems fail in complex ways. Wasn't I just reading a paper about mice with a mutant form of HOMER1a sleeping less than wild-type mice? Why aren't researchers looking for polymorphisms in HOMER1, HOMER1a, Zif68, CLOCK, PER, etc., etc., etc., in people who can't sleep enough or can't sleep at the normal time?
* The field of sleep medicine is completely obsesses with apnea, because that's where the money is. Thus, not much attention to hard problems such as insomnia.
* Then again, there is money in insomnia: the pharmas must rake it in selling benzos and other GABA agonists. These drugs suck. (Sorry if I'm dissing your favorite drug.) It's speculated that they induce something more like anesthesia than natural sleep, and patients show a lot of daytime impairment. And then there's the habituation that seems to come with any GABA agonist, so there must be some really tight feedback loop regulating the expression of GABA receptors based on GABA activity. But, Big Biz Pharma is content to keep selling the same-old same-old, as long as it's making money, even if it sucks.
* The old-fashioned R&K sleep scoring rules are full of shit. Insomniacs are generally considered crazy, because if you wire up someone with insomnia with EEG leads, you will see stage 3 sleep waves, whereas the patient will claim that they were awake, or maybe in stage 1 at the most. This is called "sleep state misperception". I don't believe that these people are all crazy. I believe that the human brain is large and complex, and sometimes different parts of the brain are not in sync with each other. Clearly the part of the brain that generates delta waves can be more asleep than the part of the brain governing memory and awareness; and in insomniacs, the delta wave generator can be more asleep than whatever part of the brain "knits the raveled sleeve of care" (or however Shakespeare put it). (I wouldn't hypothesize that memory and awareness suppression are always correlated to the refreshing quality of sleep. If you think you're awake for hours and hours but feel well in the morning, you're just a "short sleeper". Insomnia is defined as feeling like crap during the day.)
BTW, you might think, based on my claim that nearly everything is neurobiological not psychological, that I'm one of these people who think talk therapy has been made obsolete by medication. Not at all; I really think it's unfortunate that medication has edged out talk therapy so much. Psychoactive drugs are problematic and far from perfect. Even if medication is available, most patients need help, guidance, and support.
Pardon the possible incoherence, it is the nadir of my day. Really, you don't have to work in sleep research to enjoy this book-- the author is an Shakespearian scholar.
