I Was Awake All Night. So How Did This Drool Get On My Shirt?
A sleep doctor explains our misperceptions about our own sleep.
Excerpted from The Sleep Solution: Why Your Sleep is Broken and How to Fix It by W. Chris Winter, MD.
One of the first patients I evaluated in my private practice came with the urgent complaint that she had not slept for the last six months. When this highly anxious woman said she had not slept, she didn’t mean she hadn’t slept much; she meant at all, and she was scary serious.
The Sleep Solution: Why Your Sleep is Broken and How to Fix It
You know now that this is impossible, but she did not. To begin working on a patient’s sleep problem, the patient and I need to arrive at an understanding that everyone sleeps some. Sure, humans have the ability to pull the occasional all-nighter and some highly motivated individuals have been able to push the limits of sleep deprivation in highly artificial circumstances. But other than that, we all sleep. I sleep and this problematic woman sitting in my office, staring at me and waiting for me to hand her the magic sleeping pills, sleeps too.
“Well, if I sleep, how come I see the clock change all night long? I watch TV all night long or sometimes I get up to iron.”
“Well,” I replied, “you probably do wake up and see the clock and notice things on TV, but you are squeezing some light sleep in there.”
“How do you know what I’m doing? You don’t sleep with me.”
Indeed I do not. Things were heading down a dark road. Confronting people about their sleep when they think they are not sleeping is occasionally unpleasant.
Quick story. Once, I and my wife, Ames, went to see The Usual Suspects. The Atlanta theater was practically empty when we sat down. The film started out with a dark scene of shady characters running around and shooting one another on a boat docked in a harbor. Before the scene was over, Ames was out cold (for good reason: she was a schoolteacher at the time—the hardest job in the world). About an hour later, she was awakened by a loud noise; I’m going to guess more gunshots. She immediately said, “This movie is too dark and slow.” In her mind, she had closed her eyes for just a second, almost as if she traveled through time an hour or so. She complained the rest of the time about the fact that the movie did not make any sense, yet she’d missed a critical hour of the story without realizing it. Weeks later I overheard her telling someone how bad the movie was. It annoyed me because I loved that movie. But she had no conception of how her sleep had altered her experience of seeing the film. She’d missed it, and in her mind, it didn’t happen. She couldn’t recognize her misperceptions.
And neither could my patient. She similarly could not recognize that she could look at the clock and notice the time, then fall asleep. When she wakes up and looks at the clock again, she assumes it’s just the first time she’s looked again. She doesn’t recognize she has been asleep in between looking. In some cases, patients can even dream about looking at the clock and other mundane things that happen at night, yet not be able to distinguish their dream activities from reality.
Going back to my patient… because we couldn’t arrive at an agreement that she slept even a little bit, we scheduled her for an overnight sleep study as a way to measure and record her sleep in a more scientific way. With the sleep study, we would, among other things, be able to pinpoint exactly how much she slept by analyzing her brain and neurological activity during the night. When I read her sleep study, I saw that not only had she slept but she slept like a drunk fraternity brother.
When I saw her again to review the results of her study, her first words to me as I walked into the exam room were “Told you so.”
“Told me what?” I asked.
“Told you that I don’t sleep. How can anybody sleep with all those wires glued to your head and people watching you? I’ve still got glue in my hair.”
“You not only slept but you slept a lot.” At this point I produced a summary of her night’s sleep, which came to six hours and forty-seven minutes, and in anticipation of her skepticism, I produced a video of her sleep. When I showed her the results of her study, she stood up with hellfire in her eyes. At this point she turned to her demure husband and griped, as if I were suddenly not in the room, “We’re leaving. I told you he was too young to be a doctor,” and she stomped out of the office.
What this woman experienced goes by many names, the most current of which is paradoxical insomnia. Paradoxical insomnia is the phenomenon in which an individual thinks she is either not sleeping or is sleeping a very reduced amount compared to her actual sleep, which often is fairly normal. In the past, it was referred to as sleep state misperception. Before that, it was called twilight sleep.
When you think about sleep, particularly your own, you absolutely must forget everything you know or think you know about sleep in general and your own sleep. We are constantly being bombarded with misinformation about sleep that does more harm than good. For example, many people who feel like they don’t sleep at all at night actually sleep a perfectly normal amount. Conversely, many individuals who feel they sleep great at night, but are tired during the day, are not in fact sleeping great… I am one of those people. Just ask my frazzled wife after she removes her earplugs.
One of my favorite questions to ask a patient is what his snoring sounds like at night. The fact that many of them attempt to answer the question illustrates the central problem of acquiring information about an individual’s sleep: He can’t tell you about it because he is asleep. Funny how this doesn’t stop my patients from providing long and detailed explanations about how they sleep, their sleeping behaviors, and the neurochemistry behind their sleep. I once had a patient who prefaced her sleep complaint by telling me in a very matter-of-fact tone that her pineal gland had “disintegrated.” As a reminder, the pineal gland is a small structure in the brain that produces melatonin (that sleep-promoting chemical, remember) in response to light. The woman had no evidence that this had occurred, no MRI pictures of her brain, no history of traumatic injury… nothing. It just made sense to her over time that her sleep complaints fit best with that explanation, so she adopted it. In the end, there was really nothing wrong with her at all besides some minor difficulties initiating sleep that she had escalated in her mind to catastrophic proportions.
When people think about sleep, there is a certain degree of artistic freedom that seems to be allowed. I’ve yet to meet an individual with a broken leg who would explain the event by saying that the metabolic processes involved with calcium regulation had gone awry and this led to the fracture. Most people simply say they fell and heard a pop. Although in many ways sleep is not much more complex than that, we make it out to be.
The point of this exercise is simple: The reality of the time we sleep is often quite different from the perception of how long we have slept. Many of us tend to radically underestimate this time. It is common for individuals who are a bit anxious and who sleep lightly to experience this type of sleep. The important take-home message is that if you are reading this book and feel like you are not sleeping, you are not alone. In fact, you are so not alone that a sleep doctor devoted a whole chapter to this one phenomenon. It is also important to understand that even though these individuals are sleeping, that lack of sleep perception is not normal. I repeat: Not feeling like you sleep, even though you do, is not normal!
Beyond being abnormal, paradoxical insomnia can be a real soul-crusher. People like to sleep, and they get very disturbed when their sleep is not happening properly. While paradoxical insomnia is usually a primary condition, there have been cases of obstructive sleep apnea that presented like paradoxical insomnia, as noted in a 2010 study. There have been reported cases of individuals being so distraught and helpless because of their perceived lack of sleep that practitioners have resorted to electroconvulsive therapy to help patients “feel” their sleep.
When it comes to sleep, everyone is entitled to feel that he slept. In other words, it is not my intention to simply prove to you that you are sleeping when you don’t feel like you are and then leave you feeling that way forever. No way! Everyone is entitled to feel that wonderful amnesia that sleep brings. You hop in bed, kissy-kissy good night if there is someone else in bed with you, set your alarm, and turn out the light. What follows should feel like you hopped in a time machine that transports you to the sound of an alarm clock waking you for the day. That is the goal, and we can achieve it.
For many, simply relaxing and understanding that they really are not in danger of not sleeping cures their sleep woes. For others, it’s tougher. Just use this chapter to help understand and describe your problem on a deeper level and realize that you might be getting more sleep than you realize.
In 2015, M. R. Ghadami published a study looking at the sleep of thirty-two veterans with documented PTSD and sleep-related difficulties. The individuals in this hyperaroused group reported an average of four hours and twelve minutes of sleep but actually averaged seven hours and six minutes of sleep. They estimated their sleep efficiency to be 59.3 percent (meaning that of the time they were in bed, almost 60 percent was spent in sleep), when in reality, their measured sleep efficiency was 81.2 percent. In addition, the test subjects estimated it took them an average of about seventy-six minutes to fall asleep when in reality, it took only about twenty minutes.
This study illustrates why as many as 80 percent of patients with PTSD suffer from paradoxical insomnia, and just how much of a role hyperarousal plays in our ability to perceive sleep. In fact, for many people who struggle with their sleep, you can almost think of their nightly angst as a mini-PTSD episode!
So if you’re that woman who said I was too young to be a doctor: I’m older now and getting gray hair. While I still stand behind what I said about the fact that you sleep, I would still love to be able to finish what we started and help you feel sleep more than you do right now.
Excerpted from The Sleep Solution: Why Your Sleep is Broken and How to Fix It by W. Chris Winter, MD, published by Berkley, an imprint of Penguin Random House LLC. Copyright © 2017 by CNSM Consulting LLC.
W. Chris Winter, M.D. is author of The Sleep Solution: Why Your Sleep is Broken and How to Fix It (Berkley, 2017). He’s a neurologist and sleep specialist based in Charlottesville, Virginia.