Broken Sleep May Be Natural Sleep
Broken Sleep May Be Natural Sleep
Once again your patient, an accountant and tax specialist, is complaining about his sleep. More nights than not he awakens at about 2 am. An hour goes by, sometimes 2, before he returns to sleep. You've prescribed 4 different hypnotics. Each gave the same unsatisfactory result. For 2 weeks, your patient got the 8 hours of uninterrupted sleep he—and you—seek, but then the old pattern returned. Following your instructions, he avoids caffeine, doesn't exercise after 6 pm, and confines his activities in bed to sleep, but to no avail. You refer him to a sleep laboratory, and the results there are entirely consistent with what he's been telling you. In the sleep lab he falls asleep at 11 pm, awakens at 2:30 am, returns to sleep at 4 am, and awakens for good at 7:30 am. He does not have sleep apnea, restless legs syndrome, or depression.
Your patient seems more concerned as the years go on. You've suggested to him that when he wakes up, he should get out of bed and read until he gets sleepy. But he spends his awake time worrying about why he can't sleep and how his interrupted sleep will affect his work. The length of his time awake appears to be increasing. He insists that his daytime concentration isn't as good as it once was.
At a drug company-sponsored dinner, between the veal marsala and chocolate mousse, you learn that interrupted sleep is among the most common sleep problems and that a new hypnotic promises to be better than previous ones at providing "continuous sleep-consolidated sleep," as the speaker calls it. To her credit, the drug company-sponsored speaker does not shy away from the fact that the new hypnotic works by enhancing γ-aminobutyric acid transmission, just like the older ones.
Do you subject your patient to yet another drug trial, this time with a more expensive, albeit not very different, agent? Given your patient's misery about his sleep problem and the fact that you've exhausted the available options, such a course is not unreasonable. Yet a recent discovery, not from a drug company laboratory or a university research program but from a historian, suggests that there may be another, very different, way to relieve your patient's problem.
Sleep in times past
In the course of gathering information for his book about night in preindustrial times (At Day's Close: Night in Times Past), A. Roger Ekirch, professor of history at Virginia Polytechnic Institute, uncovered the fact that before artificial illumination was widely used, people typically slept in 2 bouts, which they called first sleep and second sleep.1 In those times, sleep was more closely tied to sunset and sunrise than it is now. Within an hour or so after sunset, people retired to bed, slept for about 4 hours, and then woke up. They remained awake for a couple of hours and then returned to sleep at about 2 am for another 4 hours or so.
Written records from before the first century onward indicate that the period between first and second sleep afforded a chance for quiet contemplation, but people also got out of bed during this interval and did household chores or visited with family and friends. Although diaries, court documents, and literature of the time indicate that this sleep pattern was widely known and acknowledged, until Ekirch's work this bit of history had been lost to the current era. This pattern of sleep is no longer the norm in developed countries, where artificial light extends the day, but anthropologists have observed a similar pattern of segmented sleep in some contemporary African tribes.1 Ekirch notes that the Tiv people of central Nigeria even use the same terms—first sleep and second sleep—used by the Europeans of times past.
Thanks for this article. I have had a segmented sleep pattern all my life and have never thought of it as a problem unless in times of trouble when I rather be asleep than be awake in the middle of the night worring!
Thanks for this article. I feel a whole lot better. I have been suffering from broken sleep for the last 2 and half months every since winter started and the skies became darker. Anxiety about the broken sleep (I kept getting up at 4 am) caused me to keep awake for the rest of the night. I took melatonin once and what's interesting is that I still woke up at 4am to use the restroom and then fell back asleep after 20 minutes. Sometimes I sleep straight through but only for 6 hrs. Yesterday I had the broken sleep again. I feel okay. The most I stay awake is 1 hr and back to sleep at 5am, sometimes half an hr. Wow I am glad I read this. Next time it happens I will use it to meditate spirtually and practice yoga breathing. :)
Evolutionary trends are fascinating. Reframing nighttime arousal into a historic perspective may provide cognitive relief but we live differently. Not only artificial light but the need for nighttime arousal for a short period may have been helpful when large nocturnal animals were probing for breakfast.
Total sleep time was likely greater historically as well.
Lack of sleep consolidation runs closely in with mood and stress dysfunction and is grossly undertreeated.
Let's not run too hard on the normal variant hypothesis. There can be few problems worse than daytime hypoarousal and nighttime hyperarousal. It is almost always closely linked with distress.
In the above mentioned patient, resetting the pattern to hit wakefulness to alter the signal to noise ratio during the day may be helpful. A very low dose ssri and clonazepam for maintenance, Ambien for oset and 300 mg neuron tin would probably do the trick. 25-50 mg quetipene in addition can help.
The afternoon siesta is likely an adaptation to heat, and climate, early onset of activity with sunrise will get people to sleep early.
This will not change my practice but will alter my counseling. Good review, thank you.
Thanks for this article. I have had a segmented sleep pattern all my life and have never thought of it as a problem unless in times of trouble when I rather be asleep than be awake in the middle of the night worring!
What is also missing from this conversation is the effect created when seratonin levels fall with advancing age. While the melatonin/circadian connection is now popular, the seratonin/sleep-duration connection is less so. It becomes a chicken & egg question. Is the old guy cranky because he is sleep-deprived, or is he cranky because of reduced seratonin levels, also resulting in sleeplessness and symptomatic depression?
Evolutionary trends are fascinating. Reframing nighttime arousal into a historic perspective may provide cognitive relief but we live differently. Not only artificial light but the need for nighttime arousal for a short period may have been helpful when large nocturnal animals were probing for breakfast.
Total sleep time was likely greater historically as well.
Lack of sleep consolidation runs closely in with mood and stress dysfunction and is grossly undertreeated.
Let's not run too hard on the normal variant hypothesis. There can be few problems worse than daytime hypoarousal and nighttime hyperarousal. It is almost always closely linked with distress.
In the above mentioned patient, resetting the pattern to hit wakefulness to alter the signal to noise ratio during the day may be helpful. A very low dose ssri and clonazepam for maintenance, Ambien for oset and 300 mg neuron tin would probably do the trick. 25-50 mg quetipene in addition can help.
The afternoon siesta is likely an adaptation to heat, and climate, early onset of activity with sunrise will get people to sleep early.
This will not change my practice but will alter my counseling. Good review, thank you.
What is also missing from this conversation is the effect created when seratonin levels fall with advancing age. While the melatonin/circadian connection is now popular, the seratonin/sleep-duration connection is less so. It becomes a chicken & egg question. Is the old guy cranky because he is sleep-deprived, or is he cranky because of reduced seratonin levels, also resulting in sleeplessness and symptomatic depression?
Thanks for this article. I feel a whole lot better. I have been suffering from broken sleep for the last 2 and half months every since winter started and the skies became darker. Anxiety about the broken sleep (I kept getting up at 4 am) caused me to keep awake for the rest of the night. I took melatonin once and what's interesting is that I still woke up at 4am to use the restroom and then fell back asleep after 20 minutes. Sometimes I sleep straight through but only for 6 hrs. Yesterday I had the broken sleep again. I feel okay. The most I stay awake is 1 hr and back to sleep at 5am, sometimes half an hr. Wow I am glad I read this. Next time it happens I will use it to meditate spirtually and practice yoga breathing. :)