Dreamland: Adventures in the Strange Science of Sleep (19 page)

But the positioning of the tongue in the
Homo sapiens
mouth complicates the acts of eating, drinking, and breathing. Food could literally go down the wrong pipe, a biological problem unique to modern humans. Darwin noted “the strange fact that every particle of food and drink we swallow has to pass over the orifice of the trachea with some risk of falling into the lungs.” The longer tissues of the soft palate at the back of the throat made it possible for the airway to become blocked after a routine exhalation, which could start the cycle of sleep apnea. In the mid-1990s, researchers in Japan found that slight changes in the size and position of the pharynx at the back of the throat drastically increased the likelihood that someone would develop a breathing disorder during sleep. The shape of a person’s neck and jaw can also be a factor. A large neck, tongue, or tonsils, or a narrow airway often signal that a person will develop sleep apnea because of the increased chance that breathing will become blocked during the night.

And yet the physicians who first recognized sleep apnea were half right when they assumed that the disorder was a side effect of obesity. Sleep apnea is a flaw that is part of the blueprint of the human body, and excess fat often teases it out. The chances of developing sleep apnea go up with weight because the tissues in the throat become enlarged, making it more likely that they will obstruct the airway during sleep. For some patients, losing weight alone can solve the problem. Other changes in behavior—like drinking less alcohol, cutting back on smoking, sleeping on one’s side instead of on the back, or doing exercises or playing musical instruments that build up the muscles in the throat—can also help.

Breathing masks like ResMed’s are the most common medical treatment for sleep apnea, but they aren’t for everyone. Some patients never get used to the awkward sensation of sleeping with a mask on their face, or never become comfortable with breathing in the cold air that is continuously pumped into their mouth throughout the night. In the long term, patients with mild sleep apnea wear the masks between 40 and 80 percent of the time, according to various studies. There is also a social stigma that complicates treatment. Some patients with sleep apnea decide not to use a CPAP machine because they are worried that it will make them less attractive to the person they are sharing a bed with. In an online support group for patients with sleep apnea, a man wrote that he was “feeling like I am going to be Darth Vader if I have to wear one.” A woman wrote that her husband “fought it, cried, said he is defective, said he would prefer to put a gun to his head then wear one of those things.” Another wrote that “I’ve yelled that I feel like a freak to my husband way too many times this fall.”

Dental devices are typically the next choice. These aren’t as effective as CPAP machines for severe sleep apnea, but they may be easier for some patients to use, especially those who have to travel frequently. One of the most popular looks like a sports mouthguard. It forces the lower jaw forward and slightly down to keep the airway open. Another device holds the tongue in place to prevent it from getting in the way. Surgery is the last option. One procedure, called a uvulopalatopharyngoplasty, consists of removing excess soft tissue from the back of the throat. Its long-term success rate is only about 50 percent, and it can lead to side effects such as difficulties swallowing, an impaired sense of smell, and infection. It is also extremely painful. Few medications have been shown to help sleep apnea, and may in fact make the problem worse. Sleeping pills and tranquilizers, for instance, can make the soft tissues in the throat sag and obstruct the airway more than they would otherwise.

I made my way to Peter Farrell’s office in the ResMed building. He sat behind his desk, oval glasses perched on his nose, and stared at me with the intensity of a boxer. He had made a fortune from his work with Sullivan. Still, he thought that sleep apnea remained poorly understood and underrecognized in the United States. “We are still in the early phases of a monster area,” he told me, in a thick Australian accent. “This is arguably the biggest health problem in the country and we think that three in ten adults have it. There isn’t anything remotely close to that. We have so much runway ahead of us that it’s like we haven’t even started.”

Much of ResMed’s growth had come since 2000. That year, four separate studies found conclusive evidence that sleep apnea was associated with increased rates of hypertension. Left untreated, patients with sleep apnea are at a greater risk of developing kidney disease or vision problems, or having a heart attack or stroke. Those studies helped convince government insurance programs such as Medicare, Medicaid, and the British National Health Service to pay for a portion of the cost of each device, which can be several-thousand dollars if a patient were to buy it out of pocket. Sleep labs across the country now conduct overnight tests in which patients who are suspected to have sleep apnea are hooked up to equipment that monitors their hearts, breathing patterns, and brain activity, as well as the number of times they wake up throughout the night and how often they move their limbs.

As scientists began to understand sleep apnea in more depth, they started to see it as the foundation for serious illnesses affecting the mind. In one study, researchers at UCLA conducted brain scans of patients with long histories of sleep apnea and compared them with the scans of control subjects who had normal sleep patterns. The investigations focused their inquiry on the mammillary bodies, two structures on the underside of the brain so named because they resemble small breasts. Mammillary bodies are thought to be an important part of the memory and have long been associated with cases of amnesia. This memory center of the brain was 20 percent smaller in patients with sleep apnea. Had a doctor looked at a patient’s brain scan alone, it would have suggested severe cognitive impairment: a similar shrinkage in the size of the mammillary bodies is found in patients with Alzheimer’s disease or those who experienced memory loss as a result of alcoholism. It was the first indication that sleep apnea leaves a permanent scar beyond the daily difficulties of focus and attention that come with sleepiness. “The reduced size of the mammillary bodies suggests that they suffered a harmful event resulting in sizable cell loss,” noted Ronald Harper, professor of neurobiology at the David Geffen School of Medicine at UCLA and the lead investigator for the study. “The fact that patients’ memory problems continue despite treatment for their sleep disorder implies a long-lasting brain injury.”

A study published in the
Journal of the American Medical Association
supported this conclusion. Kristine Yaffe, a professor of psychiatry at the University of California, San Francisco, led a study that recruited nearly three hundred elderly women who were mentally and physically fit. The average age of the subjects in the study was eighty-two. Each woman spent a night in a sleep lab, and Yaffe found that about one in every three met the standard for sleep apnea. Yaffe reexamined each woman five years later. The effects of age on the mind seemed to depend on the quality of sleep. Nearly half of the women with sleep apnea showed signs of mild cognitive impairment or dementia, compared with only a third of the women who slept normally. After controlling for factors such as age, race, and the use of medicines, Yaffe found that the women with sleep apnea were 85 percent more likely to show the first signs of memory loss. The frequent interruptions in sleep, and the reduced oxygen in the brain, may reduce the brain’s ability to form and protect long-term memories.

Sleep apnea’s effects on the brain can also have devastating consequences on the highway. By any measure, commercial truckers have a difficult job. Confined to one position and forced to maintain attention for a long time while racing to meet constant deadlines, many truckers wear the signs of stress on their bodies. Stefanos N. Kales, an assistant professor at Harvard Medical School and the Harvard School of Public Health, began tracking the outcome of a truck driver’s lifestyle, including poor nutrition, little exercise, and less sleep. Obesity was widespread and contributed to a much higher rate of sleep-disorder breathing than what is found in the general population. Previous studies suggested that about one out of every three big-rig truckers had moderate to severe sleep apnea, a rate indicating that thousands of drivers were straining to stay awake on the road. By Kales’s estimates, a driver with sleep apnea was seven times more likely to get in an accident. More disturbingly, Kales found that one out of every five accidents involving a commercial truck was caused by its driver falling asleep at the wheel.

Drivers are rarely willing to admit that they have sleep apnea, much less seek treatment, because doing so could increase their chances of losing their commercial licenses and livelihoods. Kales led a study in which his team observed nearly five hundred truckers from fifty different companies over a period of fifteen months. Screening questionnaires flagged about one in every six drivers as showing signs of probable sleep apnea. Of these, only twenty drivers agreed to spend a night in a sleep lab. All were shown to have the disorder. And yet only one driver out of the group began treatment, using a CPAP device regularly. “Screenings of truck drivers will be ineffective unless they are federally mandated or required by employers,” Kales and his team members noted.

The Government Accountability Office, the nonpartisan research arm of the federal government, found that the process of certifying commercial drivers routinely overlooks serious health concerns that could impact a driver’s ability. Its report identified more than half a million truckers nationwide who had a commercial driver’s license at the same time that they were eligible to receive full disability benefits from the federal government. Sleep apnea was common and untreated, and it had fatal consequences. In July of 2000, the driver of a big rig rammed a Tennessee Highway Patrol car that was protecting a highway work zone. The patrol car exploded upon impact, taking the life of a state trooper. The driver of the big rig had been diagnosed with sleep apnea, but he wasn’t treating his disorder. Nor was it his first accident. Three years earlier, he had struck a patrol car in Utah. Five years later, another trucker with a severe form of sleep apnea collided with a sports utility vehicle in Kansas. Its passengers, a mother and her ten-month-old baby, were killed. Like in Tennessee, the driver of the big rig had been diagnosed with sleep apnea. But in order to get his medical clearance, he went to a doctor who had never treated him before and did not disclose his illness. The driver was later found guilty of two counts of vehicular manslaughter. One federal proposal would require sleep apnea screenings for drivers whose body mass index exceeds 30, the baseline number for obesity. Truckers have been vocal in their opposition. “There is no direct relationship between a person’s body weight and his ability to drive an 18-wheel truck,” said a spokesperson for an organization that represented about 160,000 commercial truckers. “Show me where that’s a better predictor than a person’s driving record.”

Sleep apnea and weight are not problems limited to the United States, a fact that hasn’t been lost on companies like ResMed. Kieran Gallahue, CEO of the company at the time of my visit in 2010, came to ResMed after holding a series of positions at Procter & Gamble and General Electric. In his new role, he retained the no-nonsense air of a rising executive at a blue-chip company. He brought me into his office. With the flick of a switch behind his desk, a white board rose up from a bookshelf next to him. He began diagramming the company’s long-term strategy, sprinkling in phrases like “We are going through our organizational adolescence” that would have made his professors at the Harvard Business School proud. Gallahue argued that ResMed’s breathing machines have the ability to prevent serious illness, and in the process drive down the costs of health care. “We’re a solution to the cost containment problem,” he said.

At the same time, however, the company was counting on worldwide obesity rates to continue to rise. The spread of Western fast-food companies like McDonald’s, Kentucky Fried Chicken, and Pizza Hut to emerging countries such as China and India may be the greatest growth engine for ResMed. Simply put, more fat in the bodies of the world’s population equals a larger number of sleep apnea cases, creating a larger customer base for ResMed’s products. “Genetically you’re still engineered for a low-calorie, low-fat diet,” Gallahue told me. “That’s what your body has been optimized for over centuries. Boom, you introduce burgers, and your body is not going to handle it. One of the outcomes is going to be a skyrocketing in the prevalence of sleep disordered breathing.”

Everywhere I turned in ResMed’s headquarters were signs of a company trying to stay ahead of itself. Gallahue’s office overlooked what appeared to be a lush private park for ResMed’s employees. A group of workers was eating lunch at one of many clusters of benches spread over a space larger than a football field, lined with a jogging trail and decorative footlights. Metal sculptures glimmered in the sun. I asked Gallahue if setting up the outdoor area was meant to help the employees’ quality of life and morale. He paused for a second as he considered my question and then laughed. “Actually, that’s land that we plan to build a second building on,” he told me. “The park is only temporary.”

11

Counting Sheep

A
1945 U.S. Navy training film begins by showing a room full of sailors watching a cartoon. The men literally hoot and holler as Donald Duck tries, and repeatedly fails, to fall asleep. First, Donald misjudges the location of his pillow and slams his head down onto a metal bed frame. Next, his alarm clock begins ticking so loudly that it shakes the nightstand. Donald becomes enraged and smashes the clock into the wall. Finally, just when it seems like everything is calm and he lays his head back on the pillow, his Murphy bed snaps shut with him inside it. A sailor named Lucky laughs so hard at Donald’s misfortune that he has to dab his eyes with a handkerchief.

But Bunce, a curly-haired sailor sitting next to Lucky, watches the film with sullen, unblinking eyes. While the men around him laugh and joke with each other, he broods, finding no humor in Donald’s losing battle to get to sleep. The cartoon ends, and Lucky and Bunce turn to leave. Lucky asks Bunce why he wasn’t enjoying the film along with the rest of the group. “What’s so funny?” Bunce snaps back at him. “You’re one of those slap-happy guys that sleeps like a babe.”

We soon learn that Bunce suffers from insomnia, and he doesn’t find it a laughing matter. Lucky decides that he can cure his buddy’s sleep problem before the night is over. As the men brush their teeth, he tells Bunce to stop worrying about a girl who hasn’t written him for three weeks. Standing in the shower, he reminds Bunce that everyone gets sleepless sometimes. No one in their unit slept while they were preparing for the attack on Saipan, for instance. And as they head to bed, Lucky tells Bunce that he should tell him if anything is on his mind.

None of it works. As Lucky sleeps with a smile on his face, Bunce lies in bed, staring at his wristwatch as the seconds tick by. The camera zooms in on his pouting face, and we hear a voice-over of Bunce’s increasingly frantic internal monologue. “Go to sleep. Go to sleep! Why can’t I get some sleep? Night after night. I can’t take it. I’d rather be dead. Probably will die. Nobody, nobody can last without sleep night after night. Night after night after night.”

That’s when the voice of a friendly off-screen doctor chimes in. “Oh no,” he says, with a slight down-home twang and laugh. “We know how you feel. But in all of medical history, nobody has ever died from lack of sleep.”

The reminder that insomnia isn’t fatal is a small comfort to someone experiencing it. Every night, about two of every five adults in the United States have problems falling and staying asleep that aren’t related to a persistent sleep disorder. As they lay in bed, many are caught in the classic paradox of insomnia: wanting sleep so badly that they can’t get it. “The condition of sleep is profoundly contradictory,” noted Emily Martin, a professor at New York University who has studied insomnia. “It is a precious good . . . but it is a good like none other, because to obtain it one must seemingly give up the imperative to have it.” The psychologist Viktor Frankl noted in 1965 that “sleep [is like] a dove which has landed near one’s hand and stays there as long as one does not pay any attention to it; if one attempts to grab it, it quickly flies away.”

For doctors, insomnia presents a bit of the chicken or the egg problem. Is the sleeplessness a result of another condition, such as depression, or is the insomnia the root of the other problem? One report by the National Institutes of Mental Health found that depression rates were forty times higher for patients with insomnia than those without sleep problems. Mental health experts increasingly view depression or anxiety as an effect, rather than a cause, of insomnia. Taking care of insomnia may therefore calm other aspects of a patient’s life.

And yet insomnia is a unique and difficult condition to treat because it is self-inflicted. The cause is often the brain’s refusal to give up its unequaled ability to think about itself, a meta-phenomenon that Harvard professor Daniel M. Wegner has called “the ironic process of mental control.” To illustrate this concept, imagine someone telling you that you will be judged on how quickly you can relax. Your initial reaction most likely is to tighten up. After he posed that challenge to research subjects, Wegner found that the average person becomes anxious as his or her mind constantly monitors its progress toward its goal, caught up in the second-by-second process of self-assessment. In the same way, sleep becomes more elusive as a person’s sleep needs become more urgent. This problem compounds itself each night, leading to a state of chronic insomnia.

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).