Counting Sheep

31 October 2010 - 11:07 By Claire Keeton
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Stress, pain, living conditions and psychological problems can all stop you getting to sleep. Claire Keeton reports



THE silence, white sheets and curtains covering non-existent windows at the three sleep rooms at Wits University send out subliminal messages that it's time to slumber.

But the volunteers who enter the sleep laboratory are more likely to be counting sheep because they mostly have sleeping disorders, an increasingly common problem in South Africa. An estimated 30% of the population have sleeping problems and the way people tackle them usually make them worse.

That bogeyman insomnia - "psychological-physiological insomnia", to be precise - causes problems for many people. The chairman of the SA Society of Sleep, DrKevin Rosman, says that this type of insomnia is the most common in his practice. And it is often caused by "obstructive sleep apnoea" - a sleeping disorder that disrupts breathing and may be a warning sign of heart disease.

Like other sleep clinics, Vincent Pallotti Hospital's sleep lab in Cape Town has equipment to do full sleep studies. Electrodes are attached to the head and the body, along with a nasal canister, respiratory belt and oxygen-monitoring device. (Surely anyone who can sleep with all this doesn't need to be there.) The results show how much time a patient spends in each state of sleep:

  • Rapid eye movement (REM) sleep during which time you dream; and
  • Non-REM sleep, which has four stages.

Wits physiologist Stella Iacovides, who manages the Wits sleep lab, says that primary insomnia (sleeplessness that cannot be attributed to a medical, psychological or environmental cause) is rare - unlike psycho-physiological or secondary insomnia.

"The vast majority of people have secondary insomnia from stress, pain, post-traumatic stress, psychological reasons and living conditions like cold and noise," she says.

Rosman says that usually some stress or life event, like a death of a loved one, sets this off.

"Then the person does what is logical but not correct. For example, he goes to bed earlier, stays too long in bed or watches TV in bed, and establishes bad sleeping habits.

"This perpetuates the problem and it gets worse and worse. Then he gets sleeping pills, which were never designed for continuous use, and gets habituated to them so that they stop working, and he takes more and more. It's a vicious cycle."

Chronic insomnia leads to fatigue and distress during the day says the manager of the Cape Sleep Clinic, Dr Brian Govender.

"It's all about switching off the brain at night. People who are highly stressed, for example, running their own business, [struggle] to switch off."

He says the younger generation are also prone to "bad sleep hygiene" or habits, such as keeping on their cellphones during the night.

The fix for sound sleep is to establish good sleeping habits so that getting into bed equals sleep.

Rosman says: "You have to condition your reflex so that getting into bed is the final reflex to sleep. You must have an appropriate and regular time," he says.

"What you do in bed is only two things, and one of those is sleeping. Bed is not for TV and not for reading, unless a few pages help you to relax.

"The brain does not just get switched on and off. In the morning it takes about an hour to boot up fully, and you need a minimum of an hour at the end of the day to wind down."

To sleep well the specialists recommend:

  • A bedtime routine, for instance, taking out the dog or having a bath;
  • Going to bed at the right time to get about seven-and-a-half to eight hours of sleep;
  • A cool, quiet room, since no music induces sleep, even calming music;
  • No exercise before bedtime; and
  • No caffeine and avoiding alcohol or eating big meals immediately before bedtime.

It could be your heart keeping you awake

Sleep specialists are seeing more and more cases of obstructive sleep apnoea with the rise of obesity in South Africa. Johannesburg cardiologist Dr Jeff King says: "Obstructive sleep apnoea is the most under-recognised problem, and is significantly associated with cardiac complications.

"It affects about four percent of the normal population," he says. "But 25% to 30% of my patients are affected since I have a cardiac practice."

People with OSA stop breathing because of an obstruction in their upper airways, usually from neck fat and floppy muscles, and this interrupted breathing decreases the oxygen in the blood.

Gounder says: "They stop breathing, on average for two minutes. This can happen several hundred times a night."

These disturbances can be repeated all night, accompanied by snoring and choking, and leave sufferers with headaches and daytime sleepiness.

Sleep Studiezzzzzzzz

The relationships between sleep and pain, spinal-cord injuries, HIV and restless-legs syndrome are being investigated by the Wits Dial-a-Bed Sleep Laboratory in the physiology department.

Wits physiologist Stella Iacovides says: "A lot of people with chronic pain have disturbed sleep and this affects how they perceive pain. If we can treat the sleeping problems, the pain may not feel worse the next day."

Her research with women who have severe menstrual pain and sleeping problems confirms recent findings that pain left untreated can make those suffering it "more sensitive to all pain stimuli". Once their pain was treated, their sleep returned to normal.

  • Sleeping tablets prescribed appropriately by doctors are safe and not chemically addictive, but they can become psychologically habit-forming, specialists at the Montefiore Medical Center Sleep Disorders Center in the United States warn. Before resorting to the "Z-drugs", the cause of the insomnia must be diagnosed, since lifestyle changes, behavioural cognitive therapy or antidepressants may be more appropriate.

"We usually use both behavioural and medication therapy, either alone or together, to get the best response. The aim is to have the patient come off the sleep medication completely when the insomnia resolves," say Dr Michael Thorpy and Dr Shelby Freedman Harris.

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