Information

Putting the Fear of Sleeplessness to Rest

Putting the Fear of Sleeplessness to Rest

Fear can be a powerful disincentive to change. It was one of several factors that kept me from undergoing cognitive-behavioral therapy for insomnia (CBT-I) for over a decade.

Not that I wasn’t eager to trade in my bad nights for better nights. I’d struggled with bouts of sleeplessness since my teens. Stress at work or anticipation of a challenging day ahead could keep me wound up until 2 or 3 in the morning, and occasionally all night. A few bad nights could usher in a cycle of insomnia lasting three or four weeks.

But knowing in advance what CBT-I would entail — restricting my sleep every night — was a deal-breaker for me. Subject myself to a series of short nights that were sure to make my daytime symptoms worse? Prolong my exhaustion, my bad mood, and my trouble thinking, on the slim chance that sleep restriction would turn my problem around?

The prospect was not just distasteful. It was also scary. What if during my sleep period the Sandman never showed up? The fear of it tied my stomach in knots. While CBT-I might help others, it was not for me.

But I laid my apprehensions aside and decided to try it as part of my research for a book about insomnia. CBT-I was every bit as difficult as I’d anticipated. Restricting my time in bed turned me into a zombie the first few days. I shuffled along with mush for brains, forgetting where I put my keys and barely able to compose a paragraph. Which made me cross: why such punishment to achieve something that should be effortless?

But it was at night when the sleep issue came to a head, forcing me to confront my fear of sleeplessness face to face. How else to explain the freak show those early nights of treatment became? No matter that I had to march myself around the house to stay awake until 12:30, my designated bedtime. As I was heading to the bedroom, fear ambushed me in the doorway. I panicked at the thought of not sleeping and how rotten I’d feel the next day. I was much too aroused to fall asleep.

Treatment protocol required that I avoid the bedroom until I felt sleepy, so I turned away and sat down to read until I felt myself drifting off again. But when I went to the bedroom to lie down, fear seized me again, and then a third time, and a fourth. I got up, I lay down. Lay down, got up. How long would the torture last?

I battled my fears for three nights and slogged through three miserable days. If I hadn’t been determined to see the thing through for the sake of my research, I might easily have given up. But at 12:30 on the fourth night I collapsed and slept until the alarm woke me at 5:15. I’d been shot cleanly through the goalposts without a moment’s wakefulness.

That was the beginning of the end of my protracted bouts of insomnia. I still had miles to go: adding time in bed as sleep became more solid, tweaking bed and wake times, modifying my bedtime routine. But staying the course with CBT-I eventually led to sounder, more regular sleep. It didn’t “cure” my insomnia; I’m still susceptible to stress-related sleep disturbance. But now it takes a bigger challenge to throw my sleep off course, and when it goes off course I can right the ship in days rather than weeks.

CBT-I was also an exposure therapy for me, routing my fear of sleeplessness. Before treatment, the mere sight of the sun setting or the thought of a bad night ahead could make my stomach clench.

But no longer. By forcing me to confront my fear while priming me to sleep by means of sleep restriction, it effectively extinguished that fear. As the days went by, I found myself sleepier and sleepier at bedtime and often fell asleep within minutes of lying down. I was less fatigued and my thoughts were clearer during the day. As bedtime approached, I began to expect that I would sleep. Eventually my fear of sleeplessness all but faded away: a great boon after having lived with the fear for so many years.

But CBT-I as I experienced it was not a gentle or systematic desensitization. It was scary to contemplate and scarier still to follow through with. During an interview in September 2011, I told sleep investigator Michael Perlis that it was like staring at a big spider in front of my nose.

Perlis, associate professor of psychology and director of the Behavioral Sleep Medicine Program at the University of Pennsylvania, acknowledged my point. “I never said that sleep restriction was kind and gentle, and you’re right to say that it’s not systematic. There are other forms of therapy that are implosive,” he said, “where they throw you in a bin with snakes” in an attempt to change a response or behavior very quickly. The mechanism that enables CBT-I to work as effectively as it does — a dose of sleep restriction sufficient to enable the rapid and overwhelming buildup of sleep drive — would be lost if therapy were administered in attenuated doses. An already disagreeable treatment would only be further drawn out.

But as Perlis and I were discussing why the response rate to CBT-I is only 70 to 80 percent*, I returned to the scare factor. Not everyone with chronic insomnia develops fear of sleeplessness. I wondered aloud if the insomniacs who do — whose fear would tend to manifest as trouble getting to sleep at the beginning of the night, or “sleep onset insomnia” — might be more likely than others to drop out of therapy.

CBT-I works equally well for all three subtypes of insomnia patients, Perlis replied: people with sleep-onset insomnia, people prone to middle-of-the-night awakenings, and those who awaken too early. But if a study were done to ascertain who across the subtypes tended to suffer the most during treatment and drop out, Perlis thought I might be right. “It’s all the onset folks, because [with sleep restriction] you’ve just done the meanest thing you can do.” Not only have you set them up to experience sleep deprivation; you’ve also forced them to face down a monster in their bed.

My fear of sleeplessness is water over the dam. But the thought of having to face it was part of what kept me from trying CBT-I many years before I did, and I regret it. Those years would no doubt have been better without the tormenting bouts of insomnia I experienced so often and at such great length.

My concern is now for others like me, who, struggling with fear of sleeplessness, shy away from CBT-I or get overwhelmed early in treatment and drop out. As the sleep community looks for ways to deliver therapy to more patients, addressing the anxieties of this group of insomniacs early on might make a difference. Talking about fear of sleeplessness when presenting CBT-I as an option, or at the start of sleep restriction, might encourage more sleep onset insomniacs to try it and stick with it long enough to reap the benefits.

Reference

Morin, C.M., et al. (1999). Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22(8), 1134-1156.


5 Psychological Strategies to Get You Up in the Morning

Getting up early in the morning can be a real challenge for our us. Whether it be because of another depressing working day ahead of us or because we have not slept enough hours, the alarm clock suddenly becomes our worst enemy. However, this is not so difficult if it’s important for us to get up in a leisurely way and gain an upper hand on the clock or, simply, not to fall back to sleep again.

Today we will talk about 5 psychological strategies that will help us to get up early. The truth is that they work, although many may consider them to be “laughable”, either because they seem funny to us or because we have seen them done in a movie. The truth is that they are key to achieving that goal that many people find so difficult.

Adopting healthy sleep habits will allow you to rest better, to be more productive throughout your day.


The monster mind

The monster rises… it’s there, right there in front of you! Or is it?
A range of cognitive and perceptual factors are hard at work, causing you to see monsters, ghosts and ghouls where none truly exist. And the familiar can become weird too, with even natural creatures observed taking on odd shapes, gigantic proportions, or with their features altered, just scaring the wits out of you!
Something imagined or real may kick-start your perception of monsters. Yet, surprisingly, it’s all the result of a normal process essential to the operation of your brain, how it handles the stimulation it needs, while also providing the capacity to keep you safe and away from danger.

Love them or hate them, monsters keep coming back to frighten us. We tell each other stories, share them online, watch scary movies and TV programmes. Monsters loom large in our consciousness and literally too when you consider the recent Godzilla movie. At 150 metres this latest incarnation of the prehistoric sea monster was approximately 40 per cent the height of New York’s Empire State Building. The creature started out much smaller, at around 50 metres in 1954 (see tinyurl.com/pr368qb). That’s a threefold increase in 60 years. For evolution to accomplish the same thing would take millennia.

For a psychologist it’s fascinating to consider explanations for the popularity and increasing scale of such beasts. Largely these centre on an existential event that might well affect all of us in some terrible way. We’re potentially under threat these days – or so we’re told – to a far greater extent than ever before, whether it’s from global warming, solar flares, nuclear devastation caused by a rogue regime, or any other large-scale catastrophe. Could it be that the bigger the threat, the bigger the monsters we create?

There’s clearly historical precedent that some form of cognitive externalisation of this type is the case – from the monstrous Grendel of the ancient Beowulf epic to the terrifying creatures depicted in our modern-day fantasies (Asma, 2009), or the enormous shape-changing metallic aliens of the successful Transformers movie franchise. Big, scary, and often even extremely ugly, it’s possible we may use the monster in all its forms as a means to crystallise our fears. But there’s more to it. Research during the last few years, and particularly from the fields of perception and anomalistic and developmental psychology, suggests that we actually seem to be wired to see monsters.

Monsters on the brain
One of the most bizarre demonstrations of our brain’s disposition to see fiendish creatures was discovered by researchers at the University of Queensland. They found that pairs of faces flashed at around four to five a second caused the observer to see the faces morph into grotesque images. If a person has a large forehead it becomes even larger, a small chin gets smaller, noses that are slightly bent become even more bent and crooked, the faces all becoming caricatures of themselves. It is known as the flashed face effect (Tangen et al., 2011), and it’s quite astounding when you see it. The latest offering of this illusion on the web (tinyurl.com/ohpx9al) has celebrities turning into extremely ugly monsters before your very eyes!

Our visual system, it appears, tries to encode one face relative to the other. But trying to do two at the same time creates interference when the brain comes to sort out the incoming sensory data into a coherent picture, and in this way exaggerating the features.

Characteristics of the eye like the scotoma or ‘blindspot’ only add to strange perceptions, making you believe – like the ghoul from The Legend of Sleepy Hollow – heads have gone missing from torsos (see it for yourself at tinyurl.com/mf48bq). Yet it is faces that have a particular resonance for our brains. So much so, in fact, that we are prone to see faces when no such face is actually there. This tendency, known as pareidolia, encompasses any false perception of an image due to having a heightened sensitivity to perceiving patterns in otherwise random sensory information. It is core to our make-up and believed necessary for our survival (see Sagan, 1965), and for this reason it is designed to activate on very little data.

But though the human brain may use a simple face-patterning method as a warning device – the amygdala responding more readily to faces with emotionally charged characteristics (Morris et al., 2001) – there’s also a lot of more complex interaction in the cognitive processing of the incoming information (Palermo & Rhodes, 2006). Furthermore, if the image you see suggests a face yet is not quite right, distorted, it jars your sense of what a face should be, tripping a whole range of associations from memory. Aliens, skulls, evil-looking ghouls, all have been observed by people on a variety of surfaces and substances, including the gigantic face on Mars (tinyurl.com/kaxbxdg), a demon behind the sofa (tinyurl.com/7yxxtng), even a haunted scrotum (tinyurl.com/nq3vl2k):

A 45-year-old man was referred for investigation for an undescended right testis by computer tomography … the right testis was not identified but the left side of the scrotum seemed to be occupied by a screaming ghost-like apparition. By chance the distribution of normal anatomical structures within the left side of the scrotum had combined to produce this image. What of the undescended right testis? None was found. If you were a right testis, would you want to share the scrotum with that? (Harding, 1996)

What the patient made of it all isn’t reported but clearly Dr Harding saw the humour in this very strange scan.

Another primary aspect of visual processing is, of course, size perception. But this too can suffer from inaccuracy. Imagine you’re in a boat. You might think a creature you see is further away than it actually is. Research bears out this strange inability of people to judge where a creature actually is, even when looking straight at it. Contrary to expectation, the reported distance in the majority of sightings of apparently unknown, large, marine animals or ‘sea monsters’, by witnesses in a boat or in the water, were at a close range of less than 200 metres (Paxton, 2009).

Because an animal is in reality closer, there should be more chance of identifying its features correctly. But this isn’t necessarily the case. Size perception of spiders by arachnophobics, for example, shows that fear plays an important role, where the greater the fear the bigger the spider (Vasey et al., 2012)! An early study puts a rather nice spin on this, demonstrating that children’s drawings of witches were larger after Halloween compared to before (Craddick, 1963). Granted, this may have more to do with excitement than fear. Alternatively, there may be some other factor that blocks the person’s ability to analyse size and what they’re seeing as familiar from facts held in memory. This might be due to, say, standing on a hill (Stefanucci et al., 2005), whether they’re able to determine the contour or edge of what they’re observing (Cavanagh, 1991), or their brain’s ‘Gestalt’ tendency to fill in gaps, to make a perception whole.Perceptual issues like these could explain many sightings of the Loch Ness monster, where really all that’s being seen may be formations of logs or swimming otters.

Size perception, however, is not only about perceptual and cognitive error, or indeed fear. Godzilla may look very much like a giant dinosaur – as intended by its creator Ishiro Honda (Smith, 2002) – but it has another important characteristic. As a huge beast tossing immense skyscrapers of steel and concrete aside as if they were made of cardboard, Godzilla creates awe in the viewer. In an experiment to study awe, subjects were asked to stare at a seven-metre-high Tyrannosaurus rex dinosaur skeleton for one minute. A second group were asked to stare at an empty hall. Those who stared at the dinosaur were more likely than the other group to see themselves as connected to something beyond their immediate concerns, to something bigger than themselves (Shiota et al., 2007). And when people feel part of a greater whole that changes how they interact with the world and the people around them, as well as altering the values they hold.

Studies like this begin to shed light on why our minds are geared to see monsters in the way they do. And why, for example, these great creatures are such a recurring theme of children’s toys, as well as why a similar kind of overwhelming feeling of awe is promoted when we look at the Grand Canyon or down on our Earth from space, as astronauts report experiencing (Suedfeld et al., 2010) Something changes in our perspective it’s meant to. The brain wants sensory stimulation, new thoughts to exercise it – even from TV and movies – but with an inherent richness of overwhelmingly strong content, this is like having a banquet as opposed to a meal.

Perception though consists of both external sensory input, bottom-up, and also internal cognition and memory acting on it, top-down. And just as vision largely shuts off during saccadic movements so you’re not aware of the blur (see the stopped clock illusion), the visual cortex enhances its top-down tendency by disengaging during insightful thought. Gamma wave production – reflecting increased attention to problem solving – is immediately preceded by the firing of alpha waves, suggestive of a waking restful state (Kounios & Beeman, 2009). This ‘brain blink’ is necessary so that the brain is able to draw as much as it can from around its extensive neural networks without being distracted, making new associations and novel linkages, so promoting the chances of innovative thought to deal with new problems.

Your brain is designed to be inward-looking in this way. Seeing the occasional monster is perhaps the price you pay for your ability to have insight and be creative.

Help, the monster’s got me!
And it is quite a price. This top-down, inward-looking tendency of the brain results in stimulation being generated internally from its imaginative content, and evoked through several powerful though very strange perceptual means.

Sleep paralysis (see tinyurl.com/luxy8gq) is an experience causing some of the most startling monster hallucinations. And many of them – including devils, succubae, witches, vaporous dark intruders and little green men – have found expression in folklore as well as modern fantasies. It occurs essentially because part of you wakes up and part doesn’t. You continue to be in a state of REM-induced sleep paralysis, and an element of your dream state remains present as you regain consciousness. Research bears this out, with alpha waves suggesting a wakefulness state combined with the experience of the normal paralysis that sleep brings to the body (Takeuchi et al., 1992). And in those reporting visual hallucinations, their alpha waves during sleep paralysis were interrupted by beta waves, suggesting that something had caught their attention. In this inward-looking state, the brain is likely to be creating some powerfully scary images as its focus.

Staring too can be associated with some very odd effects. The Bloody Mary illusion is quite well-known amongst teenagers, who often dare one another to go through the ritual in a darkened room that makes her appear from a mirror (spin around while saying her name three times, then stare at the mirror). Yet it’s your brain that’s the cause, and you’re not seeing malevolent spirits. In an experiment to test this, participants were asked to do nothing more than look closely in a mirror for 10 minutes in a dimly lit room and describe what they saw (Caputo, 2010). None of the subjects were given any hint or information about what they might experience. Two thirds of the participants reported seeing huge deformations of their own face. Nearly half described seeing ‘fantastical’ or ‘monstrous’ beings! A few reported seeing faces of parents, ancestors, and strangers, including women and children. Every one of them saw someone or something in the mirror other than themselves! Many of them also reported feeling that the other someone was watching them, with several becoming extremely scared as they believed the face in the mirror was angry at them too.

Without some level of eye movement you stop perceiving external images. Even tiny movements of the eyes have benefits in this context, helping to provide ongoing stimulation to the brain’s visual centre and stopping you going blind (Pritchard, 1961 Hafed & Clark. 2002). Micro-movements, microsaccades, are occurring all the time, producing a kind of baseline stimulation for your eyes. Intense staring overrides this when your eyes can’t provide the stimulation, your brain tries to compensate and makes some up.

Lack of external stimulation is a key extraneous factor that helps create the hallucinatory monster. For example, the sensed presence is a dissociative effect that can occur when people are isolated – such as walking through the Arctic alone or in hostage situations. Often it is innocuous – the presence of another person, though not real, providing a supporting role in their survival (Geiger, 2009) – but at other times, much like the intruder of sleep paralysis, horrific presences can be seen (Siegel, 1984). In many of these instances, however, there is violence occurring, which is a possible contributory factor in what creatures are observed.

A similar effect is caused when external stimulation ceases through vision loss due to illness. In an extreme form of Charles Bonnet syndrome monsters are seen that are reminiscent of our most enduring horror fantasies. Sufferers are not delusional, yet may describe snakes coming up from the ground or floating, disembodied heads that wriggle into their field of vision at random times. These often have wide, unblinking eyes, prominent teeth, and features like those of a hideous stone gargoyle (see tinyurl.com/kjcuafw).

When the neurological wiring goes wrong, one rare condition, often associated with schizophrenia, stands out. In paraprosopia the person sees facial transformations (see Kemp & Young, 2003). And like Bruce Banner turning into the Hulk, Dr Jekyll becoming Mr Hyde and not a few actors changing into werewolves, the paraprosopic sees a complex bit-by-bit transformation of a face they’re looking at.

Monsters in the cupboard
It is the normal childhood brain that underpins much of the process of monster perception. Our imaginative prowess begins its expansion in childhood, of course, but the brain is developing in other cognitive ways too, giving rise to a number of nightmarish effects that children experience (while often giving parents sleepless nights as well).

Several developmental theories bear this out, including the change from concrete to abstract thinking (Piaget, 1970), fantasy versus reality appreciation (Sharon & Woolley, 2004), verbatim versus gist understanding underlying how memories are recalled or creating ‘pseudo-memories’ (Brainerd & Rayna, 1998), and reality–pretence distinctions (Bourchier & Davis, 2002). Yet what is apparent from the research is that the cognitive processes involved are not clear-cut, nor does it appear to be a simple matter of giving children the time to develop new abilities. Indeed, young children appear to have many capabilities and understand a considerable amount about what’s real and what isn’t. Rather than being about acquiring new abilities, many of the cognitive structures that develop to support monster perception, it seems, are already in place.

And it’s not just these structures. When three-year olds are shown a series of pictures, all of caterpillars except one which is of a snake, the time they take to identify the snake is faster than if the pictures are largely of snakes and they are asked to identify the single caterpillar (LoBue & DeLoache, 2008). Similar experiments additionally show that identification times are faster when snakes are depicted ready to attack as opposed to being depicted at rest (Masataka et al., 2010) and that the fear response for snakes and spiders compared to, say, mushrooms, extends into adulthood (Ohman et al., 2001). What this points to is a neurocognitive template, but rather than a range of animals loaded into that template the suggestion is that the human brain is wired to see features – for example, long teeth or fangs, claws and squirminess. It is in fact the case that people can be taught to associate an electric shock and the fear it promotes equally with pictures of snakes and spiders or pictures of flowers and mushrooms – but the effect lasts much longer with the snakes and spiders (Masataka et al., 2010 Ohman & Mineka, 2001). In evolutionary terms we therefore have the ability built-in to identify a whole range of dangers in our surroundings, and apply them to novel situations too. But just as these features are characteristic of snakes and other wild beasts, they are also characteristic of monsters.

You may be bleary-eyed from pacifying your child in the middle of the night and checking under the bed and in cupboards for the umpteenth time for hiding trolls and goblins, but between evolving cognitive processes and templates there’s clearly a lot interacting in children’s brains. Any night terrors are likely to be a way for the immature mind to come to terms with, and integrate, this external and internal experience.

Conclusion
Those memories created as a child stay with us into later life, informing our perceptions about scary creatures. And wired in the way you are there’s a great deal of psychology involved in the perception of monsters – something often forgotten when hunters or TV shows go searching for Bigfoot and Nessie. So spare a thought for your brain next time you see a monster!

Jonathan Myers
is a psychologist specialising in behavioural finance [email protected]


Monsters In The Dark: Understanding Teraphobia

As a small child, were you ever terrified at the thought of a monster lurking in your closet or underneath your bed? Did you ever see a monster on TV that gave you nightmares or caused you to have difficulty falling asleep? If so, you were probably like a lot of other children your age who feared the same thing. However, this fear can sometimes persist well into our adult years and still make us feel afraid of what might be lurking in the dark. This is known as teraphobia.

What Is Teraphobia?

Teraphobia is defined, simply, as the fear of monsters. It can extend to a fear of the dark, spurred by a fear of what may be in the dark. It's pretty common among preschoolers and elementary-aged children and typically fades away as the years go on, although this isn't always the case. Many teens and adults can also fall victim to this kind of phobia, so don't feel as though you're the odd one out. It's a very intense fear and can cause a host of issues for the individual, their family, and friends. It can even become so overwhelming that it prevents them from basic functioning.

Now, it's worth noting that feeling slightly afraid or disturbed at the thought of a frightening creature doesn't mean that you're completely teraphobic. In fact, fear is a completely rational human response to actual danger, and as children helps program and prepare us for the possible dangers in the world so that we don&rsquot just go running into every situation without thought. The deciding factor is whether or not you believe that these perceived monsters are real and pose a threat to you. So, how can you recognize symptoms of teraphobia?

Signs Of Teraphobia In Children

Most often, children will be quick to let a parent or adult know when they are afraid of something. It will appear in questions like, "Will you check under the bed?" or "Can you check the closet?" This is most often where their fear resides. What is hidden in the darkness could be something malicious to them, when in reality it's likely something completely harmless like a blanket or a coat.

Less obvious signs of teraphobia may appear in the form of insomnia, lack of appetite, and refusal to go outside in the dark. While it's encouraged for kids to remain indoors at night for safety reasons, it can make going to the movies or attending dinner in the evening a bit of a chore. A sunny day outside can help with this temporarily until the fear subsides.

Usually, the object of fear is relatively non-specific. It takes the form of a generic monster that your child might formulate in their head. It might be inspired by environmental factors like an aggressive classmate, a robber from the news, a recently-watched scary movie, or a combination of things that they saw while out in the real world. An oddly-shaped tree in a nearby park that resembles a scary face could also inspire such a monster to come to life in their mind.

Another way this fear develops is through story-telling. Small children are susceptible to frightening stories told by their peers and adults. Books like Goosebumps or Scary Stories to Tell in the Dark are intentionally designed to allow the reader to imagine frightening creatures on their own. This can sometimes cause severe enough reactions in children to spur the development of teraphobia and the need for treatment to assuage their fears.

Teraphobia In Adults

Teraphobia isn't just limited to children it can affect many adults of all ages. The above symptoms can become a daily nightmare, making it difficult to get through a night without a source of light. These fears are either held onto from childhood or can develop from watching horror movies and reading horror books. If the fear persists enough, you should consider seeking out possible solutions that can help you escape from it. It's important to tackle these issues before they become a sleep disorder. Untreated teraphobia can have detrimental effects on your health that could last for years if not given proper attention. While it might seem embarrassing at first, you'll find that there are other adults out there who struggle with similar fears and there&rsquos no need to feel embarrassed or alone!

Effects Of Teraphobia

The effects of teraphobia will become apparent in the way that you, your child, or teen function. A lack of sleep will have one of the biggest effects on kids. Losing sleep will cause them to become extremely tired and fatigued, making daily tasks like basic motor functions and focusing on schoolwork incredibly difficult. Sometimes the child may suffer from nightmares in which their imagined monster will visit and terrify them. This only increases their fear as well as it keeps them from getting enough rest. In more extreme cases, children may even develop insomnia, which is why seeking treatment as soon as possible is crucial.

Parents of children with teraphobia might also find themselves losing sleep. If you're not at your best, it can prove difficult to handle everything that comes with being a parent. Driving, cooking, discipline, playing with your children, and going to work will feel like overwhelming chores. You might become anxious about whether your child is healthy while other irritable symptoms can occur, such as headaches and feelings of panic.

In addition to losing sleep, a loss of appetite is also associated with this phobia. You might notice your child eating less than usual, not enjoying their favorite snacks, or even refusing food altogether because of a bellyache likely spurred by anxiety. More severe effects can be headaches, physical pains (like the aforementioned stomachache), and edginess in everyday situations. Anxiety causes them to become jumpy in common environments, especially if there are loud noises. Places like fast-food restaurants or playgrounds that have lots of children can make them a bit uneasy.

Your Reaction Means Everything

Your children look to you for everything &ndash basic care, comfort, and emotional support during times of stress. It's important to remember the following when your child approaches you with a fear of monsters:

  • Do not make light of the situation or use their fear against them for discipline purposes. To do so would cause feelings of shame and even guilt in young children who will carry it well into their adult life. Validate their concerns and comfort them while gently reminding them that monsters are not real.
  • Show them that there is nothing to fear. Go into their room and shine a light into the dark corners. If possible, put a night light in an outlet or glowing stars on the ceiling. When there is a light to chase away the darkness, it can ease them into a better sleep schedule and help eventually get rid of their fear.
  • Ever heard of &ldquomonster spray&rdquo? Pediatricians and child psychologists have gotten into the habit of handing this to children when they bring up the fear of monsters during check-up visits. The bottle contains water and is labeled as &ldquomonster spray" to help kids combat their fear. Allowing them to use it before bedtime in dark corners or around the room can allow them to rest without fear.
  • Take them to a specialist. Sometimes, teraphobia will require intervention by a therapist. If it is rooted in real-life situations &ndash like bullying, for instance &ndash therapy can help the child gain valuable coping mechanisms.
  • If it's a friend, validate their fears while reminding them that their imagination is creative. Don't tell them they are too old to have these fears. Encouraging them to seek help will put them on the road to recovery instead of increasing their anxiety and paranoia.

Other Treatment Options For Teraphobia

If home treatment isn't going well and the fear persists without signs of letting up, it might be time to take your child or teen to a therapist. A licensed specialist can help them come to terms with their fear as well as accept it as part of their imagination. They will be encouraged to draw, write, or even act out their fear to help showcase and understand where the fear is rooted.

If the fear has a religious basis &ndash such as the devil, demons, or other supernatural forces &ndash it might be helpful to see a therapist who practices or studies the same religion. A combination of spiritual efforts can help them feel comforted and more at ease in addition to getting over the fear. A phobia that persists well past traditional behavioral therapy might require medication. Using anti-anxiety medication can help your child or teen function better daily. Sleep medication may also be prescribed, though typically this is employed after other therapies have been attempted. Getting to the root of the fear is the top priority.

Alternative Solutions

If you or your child aren't ready to seek out therapy, that's okay. There are several alternative solutions for you to consider trying out.

Go Behind the Scenes

You don't have to stop watching your favorite horror movies or shows on TV. Instead, head online and look up some behind-the-scenes content of whatever it is you last watched. Understanding the process of what went into the production of the film will help your mind better distinguish reality from fiction. It can also be helpful during a particularly frightening scene to remember that there&rsquos an entire camera and sound crew there, and imagine them around the actors.

Night Lights

Night lights are a go-to favorite for parents of children who are afraid of the dark. These dim and subtle devices can easily be plugged into any outlet and blast away the dark of night while not being so bright as to disturb sleep.

Monsters aren't always terrifying on the contrary, they can be quite humorous and entertaining. Movies like Monsters, Inc. and Hotel Transylvania portray scary-looking creatures as fun, family-friendly characters that people of all ages can enjoy watching. Watching these and seeing monsters portrayed in a fun light can help alleviate some fear.

You don't have to continue living in fear and anxiety of monsters &ndash no matter which treatment option that you choose to pursue, BetterHelp has your back. Online therapy has been found to be just as effective as in-person therapy for treating anxiety conditions in adults as well as children and teens. In fact, 94% of BetterHelp users prefer it to face-to-face therapy, and 98% of clients have made significant progress in their emotional health journeys.

We offer discreet online counseling so that a licensed counselor is available to you from the comfort and privacy of your own home (or wherever you have an internet connection). If you don&rsquot have a reliable internet connection, our therapists are also available via phone calls and texting &ndash whatever works best for you! No matter how severe your phobia is, we'll match you with someone who cares using a personalized questionnaire to determine what you&rsquore looking for, your particular needs, the type of counseling you&rsquod prefer, and so on. Read some reviews of BetterHelp counselors below from people seeking help with overcoming various fears.

Counselor Reviews

"Kelly is fantastic! She really gets me and I feel like I can tell her anything. She is helping me work through a lot of my greatest anxieties and fears that were holding me back before."

"Debbie is thoughtful, patient, and understanding. She's able to navigate some of my fears, pains, and anxieties and give me useful feedback for how to better myself."

There's no need to feel embarrassed or ashamed of your teraphobia. However, a truly fulfilling life in which fears don't hold you back is possible &ndash all you need are the right tools. Take the first step today.


Dismantle the Time Bomb

So, what can you do? The cure is twofold. First, you need to train yourself to let go of your obsession with not having enough minutes or days. You can do this by dropping &ldquocatastrophic&rdquo thoughts, like I never have enough time to X, or I don&rsquot have time to do Y, which create a sense of terror in the body, Chapman says. Replace them with realistic, upbeat affirmations that you can whip out when your brain gets overwhelmed, such as I have time for only one thing, but I&rsquoll do it well.

Then realize that watching the hours go by isn&rsquot as detrimental as it seems. Start by letting go of the idea of wasted time: &ldquoAttach a purpose to every activity you are doing, even if it feels like &lsquonothing,&rsquo &rdquo says Dr. Lickerman. If you&rsquore spending Friday night Net­flixing in bed, you&rsquore resetting your brain after a crazy week, which will help you own your Monday. Standing in line at the grocery store? You&rsquore thinking ahead about a week of dinners with your partner, or calling your mom for a catchup. Once you reframe your perspective, make a note of even the tiniest takeaways every night (like in a gratitude journal, if you want).

&ldquoRarely do you go through a 24-hour period when you don&rsquot move the needle in some way,&rdquo says Dr. Lickerman. On one day, that might be crushing your workout on another, it&rsquos just putting away the clean laundry. Every win counts. Another fun mental exercise? &ldquoBully time,&rdquo as Chapman describes it. &ldquoBe late to an event when you won&rsquot get fired for it and see how not-scary the consequences can be,&rdquo he says. Confronting your fear helps you feel in control of it.

That&rsquos exactly what I did for my last date: I cut my two-hour prep allotment down to 30 minutes, which made me get ready in 20 (shorter period = faster decision-making). And guess what? I was seven minutes late but totally calm. And it was the best time I&rsquove ever had.

This article originally appeared in the September 2019 issue of Women's Health.


Confessions of a Recovering Insomniac

One woman recounts her (successful) struggle to get a decent night’s rest.

Joan Didion wrote in The White Album, “We tell ourselves stories in order to live.” As she suggested, we search for the hidden kernel of meaning in the shifting phantasmagoria that is our life so we can make sense of what is so often senseless—random gunfire that takes the life of an innocent child, an earthquake that kills thousands, a medical diagnosis that rocks us to our core.

But sometimes our stories become fixed, frozen, unchanging—even when change is both possible and desirable—especially the stories we tell ourselves about ourselves.

Here’s a story that until very recently I told myself about the insomnia that has plagued me for 30 years: “My body doesn’t know how to sleep. There’s obviously something very wrong with me. The only way I can fall asleep is to take a pill, and sometimes the only way to stay asleep is to take another pill. I hate how groggy the pills make me, but I am helpless and powerless to stop taking them. If I try, I’ll never sleep. I’ll be a complete wreck and fall apart and not be able to live up to my responsibilities. Sooner or later the lack of sleep will make me sick and die.”

This was the story I told myself night after night under cover of darkness, believing it to be the absolute, immutable truth, not a made-up tale spinning in my mind. In the morning I’d tell myself another story, depending on how many hours of sleep I’d had, usually ranging from three or four on a bad night to sixish on a good one. Soon after I awoke, I’d feel the rumblings of anxiety about the night ahead. I’d try to calculate: How many Xanax—an anti-anxiety benzodiazepine, my drug of choice—would I need? One? One and a half? Or could I get by with just a half? The panic would build throughout the day and peak as bedtime neared.

Like many stories of sleeplessness, mine began with a single incident. Though in childhood I’d had some anxiety about falling asleep, as an adult I was a pretty solid snoozer. That is, until I was 35 and a neurologist prescribed Inderal, a beta blocker, to treat my persistent migraines. The trouble was, beta blockers also lower heart rate and blood pressure—and my baseline for both was already low. Before long my usual vitality plummeted and I felt so weak and drained of energy that, without consciously deciding to, I began to keep myself awake at night, terrified that if I allowed myself to descend into sleep, I’d never wake up. That became an increasingly vicious cycle: sleep deprivation, exhaustion, insomnia, followed by even greater exhaustion—and mounting terror. I felt on the verge of collapse. But instead of grasping the whole picture, my internist prescribed sleeping pills. It wasn’t until I was rushed to the coronary care unit of my local hospital with a dangerously low heart rate that the problem got sorted out and I was taken off Inderal. But by then my story about not being able to sleep without pharmaceuticals had crystallized.

Still, I worried constantly about the long-term effects of the drugs on my mind and body, and took frequent stabs at rewriting my story. I’d try the latest, supposedly less harmful, wonder drug. When that didn’t work, the natural supplement and herbal sleep aid industry made a pile off of

me. I meditated, aerobicized, did tai chi, qigong, and yoga, consulted acupuncturists, shrinks, energy healers, and Reiki masters. There were even periods—weeks or even months at a time—when, miraculously, I slept unaided. But then I’d have a pressing deadline, an overseas trip, a big meeting and the story would return full-blown. Within a night or two, I was again the victim of my own dark and doom-filled narrative, abetted by my doctors. The prevailing wisdom was that it was better to take a pill and get some sleep than to spend the night tossing and turning. One physician even told me not to worry, I could take a little Xanax every night for the rest of my life, no harm in it.

According to the American Academy of Sleep Medicine, as many as 30-35% of adults complain of insomnia. The percentages spike to 40-60% in people over 60. Women are twice as likely as men to have trouble falling or staying asleep—the two sides of the insomnia coin. The disorder is diagnosed when: patients get less than 6.5 hours of sleep it takes 30 minutes or more to fall asleep, and symptoms persist for at least one month after six months the diagnosis is classified as chronic insomnia.

The Centers for Disease Control has labeled insufficient sleep a “public health epidemic,” and estimates that 50-70 million adults in the US suffer from a sleep or wakefulness disorder. Only a third of Americans (and almost no one I know personally) get the standard recommended eight hours of sleep a night. In a report issued in 2014, the CDC warned that people who get too little sleep are at risk for increased mortality, as well as chronic diseases such as cancer, diabetes, hypertension, heart disease, obesity, and depression. Sleep deprivation is also strongly linked to impaired immune function.

It’s no wonder. In 2013, researchers at UC Berkeley found that sleep deprivation fires up the brain’s amygdala and insular cortex, regions associated with emotional processing. The resulting pattern mimics the abnormal neural activity seen in anxiety disorders. “These findings help us realize that those people who are anxious by nature [hello!] are the same people who will suffer the greatest harm from sleep deprivation,” said Matthew Walker, a professor of psychology and neuroscience at UC Berkeley and senior author of the paper, which was published in the Journal of Neuroscience.

Another 2013 study, published by the CDC’s National Center for Health Statistics, revealed that nearly nine million US adults take prescription sleep aids, called hypnotics—a number that is on the rise—with women leading the pack. And emergency room visits due to bad reactions to the drugs—especially zolpidem, the active ingredient in Ambien—are also on a steep uptick, having nearly doubled between 2005 and 2010.

The day I returned home in the fall of 2014 after a trip to Italy, I found this email message from a close friend in my inbox: “You have to STOP taking Xanax NOW. ”

My friend’s concern was prompted by a new study reported by French and Canadian researchers showing that benzodiazepine use is linked to higher rates of Alzheimer’s disease, and that the correlation increases with greater exposure to the drugs.

“The more the cumulative days of use, the higher the risk of later being diagnosed with dementia,” Antoine Pariente, a pharmacoepidemiologist at the University of Bordeaux and a coauthor of the study, told The New York Times. The researchers found that older adults who took daily doses for 91-180 days had an increased risk of 32% those who popped benzos daily for more than 180 days had an increased risk of 84%. It didn’t seem to matter whether the number of days patients consumed the drugs took place over six months or five years.

“One physician even told me not to worry, I could take a little Xanax every night for the rest of my life, no harm in it. I wanted to believe him.”

These researchers were talking days, not years, and I’d been taking the stuff for the better part of 30 years—that’s 10,000 days, give or take. I completely freaked out.

What’s more, the risks are just as great for the newer generation of Z-drugs (zolpidem, eszopiclone, zaleplon—i.e., Ambien, Lunesta, and Sonata), as for older benzos like Halcion, Dalmane, and Restoril—and Xanax. In fact, researchers at three universities, including Harvard Medical School, have shown that about half the effectiveness of the Z-drugs is due to a placebo response, making their clinical use highly questionable.

And, I learned from watching UC Berkeley’s Matt Walker in a YouTube video called “The Mysteries of Sleep,” the sort of shuteye you get from taking hypnotics is really sedation, not true sleep—and lacks the essential benefits to the body and brain that occur during natural sleep cycles.

Obviously, I needed a new story—fast. But I knew it wouldn’t be easy.

“Often, when people try to go off these meds, they worry that their bodies won’t be able to sleep on their own and they won’t get as much rest as they need,” said James Lettenberger, a Washington, DC psychopharmacologist whom I consulted when I lived there. “It can definitely be done, but to be successful people need both a strong desire to stop taking the medication, and the belief that they can,” he told me over the phone.

I had the desire, but would I be able to change my belief system—my story—something I’d been unable to accomplish in the past?

Sick joke: Which is worse, the dementia you get from taking sleeping pills or the dementia you get from sleep deprivation?

At the same time I got wind of the bad news about sleeping pills and decided to taper off the Xanax, I came down with a nasty cold, which turned out to be a stroke of luck. I felt so rotten that all I wanted to do was sleep. And I did—soon, without pharmaceutical help.

I’m cured! I thought to myself. Free at last! The cold went away and still, I slept—about six, sometimes seven, hours. Oh, I’d wake up in the middle of the night, but more often than not I’d drift back. The ease with which this took place seemed like a blessing bestowed by a beneficent universe—especially the falling asleep part, my greatest challenge. A new story was emerging—a fragile chrysalis.

It didn’t occur to me that my turnaround had anything to do with the fact that it was taking place during the holidays. I had no deadlines and few obligations. Then January rolled around and with it, a pressing deadline. The old story came rushing back and took possession of my mind and body like some kind of spooky apparition. Each night became a battle royal between my desire to sleep unaided and the fear that I couldn’t, and the weeks of grace came to seem more like a blip than the start of a new story. Feeling defeated and defective, I reached for my stash of Xanax.

Though I was still determined to sleep drug-free, I cut myself some slack. Clearly, healing my sleep disorder was going to be a process, not a quick fix. And I needed help. I talked to an holistic doctor and an acupuncturist, who each suggested herbal remedies, while my more mainstream internist recommended trazodone, a tetracyclic antidepressant that has some side effects, but doesn’t seem to rot your brain like hypnotics do. These things helped some, as did my morning meditation and a soothing bedtime visualization recording made for me by a psychotherapist. Still, I continued to resort to hypnotics off and on, especially when I felt stressed.

It was obvious I needed more help.

For the past several years, the gold standard, non-pharmaceutical treatment for insomnia has been Cognitive Behavioral Therapy for Insomnia—or CBTI, which in numerous studies has been shown to be more effective than sleeping pills. In fact, CBTI is now recommended as the number one treatment for chronic insomnia by the National Institutes of Health.

The program is based on a simple concept: Insomnia is caused by learned thoughts and behaviors that can be unlearned or changed. In other words, it deals directly with the story.

So why did it take me so long to check it out? Delusion, perhaps. Another story I told myself, about how I should be able to conquer my insomnia on my own.

Although there are sleep clinics that offer CBTI in the San Francisco Bay Area where I live, I decided to try an online program that’s available to anyone, anywhere. For $44.85, I signed up at cbtiforinsomnia.com and got the five-week program, plus a few extras, including evaluation of my weekly sleep diary by Dr. Gregg Jacobs, an insomnia specialist at the University of Massachussetts Memorial Medical Center.

The basic drill, week by week, is this: 1) education about the stages and functions of sleep 2) sleep scheduling and stimulus control (i.e., don’t spend too much time in bed awake, and only sleep or have sex there) 3) cognitive restructuring and medication reduction techniques (!) 4) daytime relaxation techniques and stress-reducing attitudes and beliefs 5) bedtime relaxation techniques and lifestyle practices for improving sleep.

Photograph by Nicky Willcock/Millennium Images, UK

In case I thought I was special, I learned that the themes in my personal narrative were among the 10 most common negative thoughts about sleep, and were addressed head-on. For example, a corrective to I will never fall asleep is My brain wants to obtain my core sleep (5.5 hours—and I most likely will). An antidote to the I will not be able to function tomorrow belief is Sleep loss does not always have a significant impact on my functioning.

All first-rate stuff. I began relying less on the pills and sleeping more or less the way I imagined normal people do. In fact, I thought I was doing brilliantly until I got this email from Dr. Jacobs after submitting my sleep diary. “Your time allotted for sleep (lights out to arising time) was 8.5 hours on many nights. Because you averaged 6.5 hours of sleep, your time allotted for sleep goal should not be more than 7.5 hours from lights out to arising time. Therefore, you need to reduce time allotted for sleep by 1 hour on many nights. This is the most crucial goal for improving your sleep and you did not meet this goal for the past two weeks of this five-week program. If you do not meet this goal this week, you are unlikely to experience significant improvement in your sleep from this program.”

Really? So I read in bed more than half an hour on several nights and lingered a bit in the mornings is this a crime? Did Dr. J. (or his canned bot) have to be such a scold? Couldn’t he at least comment on how well I was doing, how much less medication I was taking—also noted in my diary? The program was certainly valuable in helping me to reframe my story, but I could have done with a bit more friendly reinforcement.

A newer approach that shows great promise, but is still in the developmental stages, is Mindfulness-Based Therapy for Insomnia—or MBTI. Although both mindfulness meditation and Mindfulness-Based Stress Reduction (MBSR) have been shown to improve sleep quality in adults, MBTI integrates specific behavioral strategies from CBTI with mindfulness meditation practice.

“Insomnia is a disorder of cognitive and physiological hyperarousal, which mindfulness addresses but CBTI doesn’t deal with directly,” said Jason Ong, a psychologist at Rush University Medical Center. This inspired him to combine the strengths of each approach into one program. What’s more, he told me over the phone, MBSR lacks targeted cognitive and sleep hygiene techniques that are key to CBTI. Ergo, Ong recently conducted a randomized controlled trial comparing MBTI to MBSR in patients struggling with chronic insomnia, and found that MBTI showed significantly greater—and longer lasting—benefits in reducing insomnia.

A lot of acronyms, I know. But in a funny way, by practicing mindfulness meditation daily (well, almost) in tandem with CBTI, I have (loosely) been practicing my own version of MBTI.

“Letting go into sleep is no longer the dark herald of death, imprinted in me so many years ago.”

And, yes, I sleep. Drug-free now for months, I sleep. Not always as many hours as I’d like, sometimes fitfully, yet I sleep. On nights when I’m having trouble, my little herbal cocktail—melatonin and the L’s, tryptophan and glycine—help. On other nights I need to talk myself down, like a parent to an anxious child, placing my hand over my heart and reminding myself that my body does indeed know how to sleep. And when I have a really lousy night, I don’t panic the way I used to. For the most part, sleep has become what it’s designed to be—rest and recuperation for body and brain—and I would add, spirit. Letting go into sleep is no longer (in my most fearful imaginings) the dark herald of death, imprinted in me so many years ago.

The expectation that I will sleep has made all the difference. So has realizing that, like many people who struggle with insomnia, I had swallowed some pretty basic myths. For starters, the notion that we need eight hours of shuteye every night: Recent studies involving over a million people found that those who sleep seven hours live longer than people who sleep eight or more. Even more surprising, sleeping five hours a night is associated with longer life expectancy than sleeping nine hours. And seven (some studies suggest that the range is between 6.5 and 7.5) hours per night appears to be the sweet spot. The same number holds true for preserving memory. A landmark study of 15,000 female nurses conducted at Brigham and Women’s Hospital in Massachussetts found that women who slept an average of seven hours each night had significantly stronger cognitive skills later in life than those who slept less than five hours or more than nine.

Perhaps the most liberating of the debunked myths is the discovery that the belief we hold so dear—namely, that we should sleep undisturbed in eight-hour chunks—is a relatively recent development in human evolution. In 2001 Roger Ekirch, a history professor at Virginia Tech, published a paper revealing a wealth of historical evidence showing that for millenia—until there was artificial light—humans slept in two segments, usually referred to as the first and second sleep. The time between the two chunks was often devoted to prayer, meditation, quiet reflection—and it was also notably the hour when many babies were conceived. Ekirch’s hypothesis, based on 16 years of research, was backed by an experiment conducted by psychiatrist Thomas Wehr, a prominent scientist at the National Institute of Mental Health. In Wehr’s study, subjects were plunged into darkness 14 hours a day for one month. After adapting to the new schedule, they typically slept for four hours, then awoke for one or two hours before falling into a second fourish-hour snooze.

In his new book on the subject, Waking Up to the Dark, author Clark Strand writes: “Recently, as a result of Wehr’s study and others like it, some sleep specialists have reported that the best treatment for the Hour of the Wolf [Strand’s term for middle-of-the-night agita] is to tell patients that nightly waking is natural and, consequently, that they shouldn’t struggle against it. A doctor told me that once he explained this to them, many of his patients simply went to bed earlier each night and never asked him for sleep medications again.”

A glowing new spin on a damaging old story.

Just like the bright new spin on my own story, which continues to unfold.

Sleep Reminders

Here are a few mindfulness principles that you can explore, and recall, if you need help getting to sleep or falling back asleep. These tips are compiled by Jason Ong, Ph.D., a psychologist at Rush University Medical Center who works with Mindfulness-Based Therapy for Insomnia.

Beginner’s mind
Remember: Each night is a new night. Be open and try something different! What you have been doing to this point is probably not working well.

Non-striving
Sleep is a process that cannot be forced but instead, should be allowed to unfold. Putting more effort into sleeping longer or better is counterproductive.

Letting go
Attachment to sleep or your ideal sleep needs usually leads to worry about the consequences of sleeplessness. This is counterproductive and inconsistent with the natural process of letting go of the day to allow sleep to come.

Non-judging
It is easy to automatically judge the state of being awake as negative and aversive, especially if you do not sleep well for several nights. However, this negative energy can interfere with the process of sleep. One’s relationship to sleep can be a fruitful subject of meditation.

Acceptance
Recognizing and accepting your current state is an important first step in choosing how to respond. If you can accept that you are not in a state of sleepiness and sleep is not likely to come soon, why not get out of bed? Many people who have trouble sleeping avoid getting out of bed. Unfortunately, spending long periods of time awake in bed might condition you to being awake in bed.

Trust
Trust your sleep system and let it work for you! Trust that your mind and body can self regulate and self correct for sleep loss. Knowing that short consolidated sleep often feels more satisfying than longer fragmented sleep can help you develop trust in your sleep system. Also, sleep debt can promote good sleep as long as it is not associated with increased effort to sleep.

Patience
Be patient! It’s unlikely that both the quality and quantity of your sleep will be optimal right away.


What Is Insomnia?

Insomnia simply means difficulty falling asleep or staying asleep. While we all have occasional nights when we don’t get restful sleep, insomnia is a sleep problem that is more ongoing. And I believe it’s only becoming more common as we continue to surround ourselves with increasing demands and technology. It is slowly becoming an epidemic in our society.

Let’s start to tackle this growing problem by reviewing the causes of sleeplessness—the different types of insomnia.

Types of insomnia: [1]

Short-term insomnia: As the name implies, this is a brief form of insomnia. It occurs in about 15 percent to 20 percent of people and lasts for up to about three months.

Chronic insomnia: About 10 percent of people have this longer-lasting form of insomnia. Sleeplessness usually about three times a week and the condition lasts for at least three months.

Benzodiazepines (such as Xanax or Valium) or certain non-benzodiazepine are commonly prescribed as sleep aids. Benzodiazepines are sedatives that were originally intended for short-term use only. Long-term use of these drugs can result in serious side effects and even cause rebound insomnia and withdrawal symptoms once you stop taking them.

Non-benzodiazepine drugs such as zolpidem (brand name Ambien) and other similar drugs have been known to cause serious side effects as well, including dangerous episodes of sleepwalking (for example, driving a car while “technically” asleep). These incidents have occurred because these drugs don’t induce normal sleep patterns.

In fact, my patients have shared some unbelievable stories about getting up in the middle of the night after taking Ambien and cleaning the house, driving to the store, or making meals on the stove—and they do not recall any of it in the morning. That means that they were not in a restorative sleep state after taking this medication. Instead, they were essentially “awake” and behaving as such. Scary, right?

Now, I understand that you are likely at a point of desperation after periods of minimal sleep, but try to take a step back and consider your holistic health picture before picking up these prescriptions. There are numerous studies on the higher mortality rate associated with these medications, so they should be approached with caution.

How Does Sleep Work?

Sleep is just as important and vital to survival as food and water. While its “biological purpose” isn’t yet fully understood, we do know that sleep is critical for virtually every system in your body. Your brain and nervous system, heart, lungs, and immune system all rely on getting enough quality sleep to function properly.

Without adequate sleep, the risk of disease increases, particularly for chronic conditions like high blood pressure, depression, diabetes, and obesity.

Sleep is actually part of your parasympathetic nervous system, which is essentially when your body is calm and performing daily functions such as digestion, toxin removal, and cellular repair. In this day and age of technology and cell phone attachment, we are continually stimulating our sympathetic nervous system, the “fight-or-flight” mode where the body ceases regular function and reacts to stimulation. As a result, we are adapting to this stimulation and spending less time in a calm state.

So, what does this do? It results in poor digestion, anxiety, fear, anger, sense of urgency, and, of course, poor quality of sleep. By using the medications mentioned above to force sleep, you are not addressing the issue in your nervous system. I relate this to my “bear scenario.” In my opinion, taking prescription sleep aids is like being forced to sleep while your mind is still racing, worried about the bear. This means the sleep is non-restorative and you become dependent on the mediation to knock you out. The problem is that when you remove the medication, the underlying sympathetic nervous system will kick back in, resulting in more stimulation (or rebound insomnia).

The Stages of Sleep

Sleep occurs in stages. These stages fall under two types of sleep: rapid eye movement (REM) and non-REM. Non-REM occurs in three stages. The body repairs itself and strengthens the immune system during REM sleep.

As you age you spend less time in REM sleep. While people under 30 years old get about two hours of deep sleep per night, those over 65 only get about 30 minutes.

REM occurs in the last stage. The percentage of this type of sleep is highest during infancy and childhood and declines as we age. [2]

Here are brief descriptions of the sleep stages: [3]

  1. Stage 1. This is a light non-REM stage of sleep that only lasts a few minutes. It occurs as you begin to fall asleep. As your brain waves begin to slow down as they transition from wakefulness to sleep, your heart rate and breathing also slow and your muscles relax.
  2. Stage 2. During the second non-REM stage, your heartbeat and breathing slow and your muscles continue to relax as your body temperature drops. Your eye movements stop during this stage and your brain activity slows down yet has short periods of electrical activity. You spend more time in this stage than the others.
  3. Stage 3. The third non-REM sleep stage is critical because this is the period of deep sleep that allows you to feel rested when you wake up. At this stage, you are fully relaxed and your heartbeat and breathing are at their lowest levels.
  4. REM sleep. This occurs after about 90 minutes of sleep and it is the stage when you dream the most. Your arms and legs are temporarily paralyzed to stop you from acting out your dreams. This stage is called REM because your eyes move quickly under your closed eyelids. Your breathing gets faster and may become irregular. Your blood pressure and your heart rate increase, similar to levels when you are awake.

Key Neurotransmitters for a Good Night’s Sleep

Several neurotransmitters or hormones are important to ensure that your body gets the rest it needs. Here are four of the key hormones you need to get a good night’s sleep:

GABA (gamma-aminobutyric acid)

GABA calms the body and it’s crucial for sleep. Lower levels of GABA have been linked to major depressive and anxiety disorders. Some medications that are often prescribed for sleep, such as benzodiazepines like Xanax and non-benzodiazepines such as sedatives like zolpidem (brand name Ambien), affect GABA. Chronic use of these medications lower our ability to make more GABA on our own, which will absolutely worsen not only insomnia but other health conditions as well.

Serotonin

The amino acid tryptophan is converted into serotonin, along with the help of some key vitamins and minerals. Although often associated with depression, serotonin also helps to regulate sleep as it goes on to make melatonin. Low levels of serotonin can cause difficulty in sleeping.

Cortisol

Cortisol is a hormone that is released to divert the body into a sympathetic “fight-or-flight” state. It’s also critical in our sleep/wake cycles. If you are surrounding yourself with constant stimuli, the cortisol rhythm will change course, resulting in higher-than-normal levels in the evening hours. This will commonly impact your ability to fall asleep. It can also jolt you awake in the middle of the night (often between 1 and 3 a.m.), and make you unable to fall back asleep easily.

Melatonin

Your body needs to produce enough serotonin to in turn make melatonin. If your body has enough serotonin to make melatonin, levels of cortisol are reduced and you will sleep. Without enough serotonin and melatonin, your cortisol level will be impacted and it will be difficult to sleep. Conversely, having higher cortisol levels will impact melatonin production. Many people take melatonin to help them sleep, and often it will work for a while. However, if you do not address the underlying cause of why the melatonin was low, it will eventually lose its effectiveness.

Certain vitamins and minerals are necessary to produce the neurotransmitters you need to sleep. These include vitamins C, B6, B5, and the minerals zinc and magnesium. Deficiencies in these vitamins and minerals can impact your sleep. In my experience, I have found numerous cases of poor sleep linked to low levels of iron. We also need proper gut bacterial flora to balance and maintain these neurotransmitters. Proper nutrition, good elimination, and gut microflora are a critical component to sleep.


Is our fear of insomnia what’s actually keeping us up at night?

getty Images/Getty Images

THERE’S A CONTRADICTION BEHIND Jean O’Connor’s restless nights: She stays awake fearing what a lack of sleep will do to her in the morning. A speech pathologist in southern Connecticut, O’Connor says she’d never had trouble sleeping until a dozen years ago, when her two teenage daughters started staying out late. O’Connor worried until they came home, then more worries followed her to bed — about whether she’d remembered to pay the mortgage, whether she’d be too tired to work, whether she’d even have enough energy to go grocery shopping. Again and again, O’Connor would count how many hours’ sleep she’d get if she dozed off right now, then panicked once the count fell below six.

Two years of Tylenol PMs left O’Connor feeling groggy, so her general practitioner prescribed 1 milligram of Lunesta, a sleep aid that, when you add in its generic version eszopiclone, was prescribed almost 3 million times in 2014, according to the health care consulting firm IMS Health. Lunesta wasn’t perfect , but the good nights far outnumbered the bad.

When we spoke in July, however, the 59-year-old O’Connor hadn’t had a good night’s sleep in weeks. The Saturday of Memorial Day weekend, her pharmacy told her she was out of Lunesta refills, and she didn’t sleep until after reaching her doctor on Tuesday. Several days later, she underwent a previously scheduled knee operation and abstained from Lunesta while on pain medication — as a result, she slept only two hours a night for a month. She and her doctor once tried substituting trazodone, an antidepressant prescribed off-label to treat insomnia, but the relief faded. Now she takes trazodone on top of a Lunesta dosage that’s increased to 3 milligrams, the maximum allowable. Today, she says, she feels lucky if she gets five hours’ sleep.

O’Connor’s profile fits under a familiar headline: We’re in the midst of a sleep deprivation epidemic. The Centers for Disease Control and Prevention (CDC), which calls insufficient sleep “a public health problem,” published a study in February showing that roughly 1 in 3 American adults regularly slept less than the recommended seven hours a night. Every year, some 40 million Americans experience insomnia, according to the National Sleep Foundation, and O’Connor is one of 9 million Americans who use prescription sleep medication.

But to another faction of sleep researchers, the overstating of the sleep-deprived-society narrative is one of the main things keeping us up at night. They say we’re not truly sleeping less than recent generations — that sleeping nine hours is actually worse for you than sleeping seven, and that inflating the amount of rest we “need” sends anxiety-driven insomnia sufferers down a worrisome path, to the benefit of pharmaceutical companies.

Whether sleeplessness is an epidemic or an exaggeration, O’Connor says she doesn’t hear many of her peers bragging about getting by on diminished rest. “I don’t meet a lot of people who say, ‘I only need four hours of sleep.’ It’s more like, ‘I only got four hours of sleep, and I’m miserable.’ ”

SUITE 4 IS ONE OF SEVEN ROOMS used for inpatient studies by the Division of Sleep and Circadian Disorders at Brigham and Women’s Hospital. It looks like where the world’s least imaginative decorator rests his head: empty walls, no windows, a desk, a bed, all stark white, as if someone has stretched a blank canvas over everything. But Dr. Elizabeth Klerman — an associate professor of medicine and neurology at Harvard Medical School, director of the analytic and modeling unit at the Brigham, and my guide — says at the pace of an auctioneer that the suite is part of the best sleep research lab in the world.

Until the mid-20th century, scientists considered studying sleep a waste of time. But in the last 30 years the science of slumber has exploded, connecting dots between sleep and mental health, memory processing, hormonal function, and more. In another suite, Klerman and her colleagues are gauging various effects of specialized colored lights in a NASA-backed study. Lights like these, designed by a large group of researchers that included members of the Brigham staff, will soon be rocketed to the International Space Station.

White lights blanket the ceiling of Suite 4. “Why don’t you take us down to four lux, please?” Klerman calls to a tech — “lux” is a measure of brightness — and the suite goes yoga-room dim. But when she calls for 2,500 lux, I momentarily think I’m beaming up to the mother ship. (“I didn’t even ask him to take us to 10,000 lux,” Klerman says.) In the context of a sleep study, these changes in artificial light affect subjects’ circadian rhythms, the 24-hour-ish sleep-wake cycles believed to control broad aspects of human biology. For instance, light — especially the wavelengths of blue light that beam to your eyes from laptops, iPhone screens, and other electronic devices — suppresses melatonin, the hormone that induces sleep.

For more than a century, artificial light has also had an enormous cultural effect on the third of our lives spent unconscious. After Thomas Edison — who once wrote that sleep was a “loss of time, vitality and opportunities,” yet also had napping cots in his office — invented the first practical electric light bulb in 1879, the world opened up to after-dark leisure and round-the-clock factory shifts. According to Roger Ekirch, a history professor at Virginia Tech and author of At Day’s Close: Night in Times Past , it also helped fundamentally remake our sleep habits. Humans previously slumbered in two nocturnal blocks, separated by an hour or so of wakefulness, Ekirch says, and sleeping in one consolidated stretch was a compromise for working life during and after the Industrial Revolution. When we wake up in the night and can’t fall back asleep, he says, it might be a vestige of “this long-dominant pattern of sleep which has never entirely left us.”

According to a Gallup Poll, the average American adult sleeps 6.8 hours per night — more than an hour less than they reported sleeping in 1942, and less than the seven- to nine-hour recommendations for adults aged 18 to 64 set by the National Sleep Foundation. Ekirch says we’re probably not sleeping worse than ever — think of 16th-century Europe: all those drafty homes, all that disease, all those bedbugs — but he agrees that sleep deprivation is a modern epidemic, one largely of our own making. “Too many of us make the conscious decision to try to stretch another hour of wakefulness out of the night and think we can get away with it, myself included,” he says. “I’m on my second cup of coffee as we speak.”

Caffeine consumption is one symptom of our bleary-eyed society: Energy drinks alone have grown into a roughly $10 billion industry. So are $3,000-plus Tempur-Pedic mattresses the midnight-oil-lit corners of office buildings where all-nighters remain proof of dedication the fact that we have a neologism for the same person closing up shop at night and unlocking doors in the morning (“clopening”) and the fact that our Republican presidential nominee boasts of sleeping four hours or less per night. (That would put Donald Trump in rare company: Short-sleepers, who function fine with fewer than six hours’ rest, represent as little as 1 percent of the population.) Even if you — like me — aren’t one of the estimated 50 to 70 million Americans with a sleep or wakefulness disorder like insomnia or sleep apnea, you know what it feels like to force your eyelids open when you want nothing more than a pillow.

“There are many people in our society who, even if they want to get better sleep, are trapped in their situation by things outside of their control,” says Dr. Charles Czeisler, chief of the Brigham’s sleep lab, after he heard my 4-month-old son wailing midway through our phone interview. Besides wide-awake infants, those constraints include shift work Czeisler says that jobs starting before dawn are among the fastest-growing employment sectors. Then there’s the litany of social gatherings, concerts, sports, and TV. “If you have to get up early, all these late-night activities are going to take a toll,” he says.

Without enough sleep, pretty quickly we’ll notice we have trouble learning and remembering. Our motor skills deteriorate. We’re more vulnerable to illness. We become moody and prone to emotional outbursts. It’s not just all-nighters, either: Sleeping six hours a night for 12 days is roughly equivalent to staying awake for a whole day and night. When it comes to your performance, if you’ve been awake for 24 hours, you might as well have a 0.10 percent blood alcohol level, which is above the legal limit. (Klerman says sleep researchers are exploring chemical biomarkers of sleep deficiency that could lead to “the equivalent of a breathalyzer for when you’re sleepy.”) But the cure for short-term sleep deprivation is usually simple: Go to bed.

Turning too little sleep into a habit, however, might come with a cost. Long-term sleep restriction contributes to heart disease, depression, diabetes, hypertension, and other chronic illnesses. The World Health Organization called night-shift work a probable carcinogen, and other research suggests links between too little sleep and Alzheimer’s disease. The costs can be literal, too: A 2011 study by a Harvard Medical School researcher and other experts estimated that an insomnia-addled US workforce costs $63.2 billion in lost productivity every year. And there are lives at stake: In a 2014 study, the AAA Foundation for Traffic Safety found that 1 in 5 fatal car accidents involved a drowsy driver. After a Green Line train crashed into another in 2008, the National Transportation Safety Board said the operator who died in the accident briefly nodded off in an episode of so-called “micro-sleep.”

Whether from fear or from enlightenment, segments of society have stopped looking at sleep as a slacker’s favorite pastime. Companies from Nike to Ben & Jerry’s to the Huffington Post — whose cofounder, Arianna Huffington, authored The Sleep Revolution , a best-selling plea for the world to get some rest — have employee nap rooms. As part of Aetna’s wellness program, the Connecticut-based insurance company pays employees up to $300 per year for logging seven hours of sleep on multiple nights. And for jet-lagged pro sports teams, gaming players’ sleep has become a secret weapon. Ahead of the 2013 Red Sox season, Czeisler helped players tweak their sleep habits—his suggestions included building a nap room at Fenway. The season ended with Boston clinching its third World Series in a decade and, for his efforts, the team gave Czeisler a championship ring and a spot in the victory parade.

“If someone asks me, ‘Am I sleeping too much?’ ” Czeisler says, “my answer to them is usually a categorical no.”

Dr. Charles Czeisler, chief of the Division of Sleep and Circadian Medicine at Brigham and Women’s Hospital, in the sleep lab. Aram Boghosian for The Boston Globe

OVER THE PHONE, Gregg Jacobs spends 55 breathless minutes spelling out what he says labeling sleep deprivation an epidemic has done for his insomnia patients: It’s made them sleep worse, and it’s put some of them in danger. Spending endless hours in bed tossing and turning further fragments their sleep. (One hypothesis suggests that waking up repeatedly might be worse than sleeping fewer total hours.) Some admit to taking Ambien mixed with alcohol, opioids, or benzodiazepines. Jacobs — an insomnia expert at UMass Memorial Medical Center and an assistant professor of psychiatry at UMass Medical School — says they’re all chasing the misguided idea that the best thing they can do is get as much sleep as possible.

With the exception of fatal familial insomnia, a disease so rare it’s only believed to affect about 100 people on earth, experts agree that lack of sleep doesn’t directly lead to death. “Insomnia patients have been led to believe that they have to be sleeping eight hours a night, and if they don’t, they’re going to die sooner,” Jacobs says. “They’re willing to go to significant, scary extremes in order to alleviate that anxiety and to satisfy the belief that ‘the more sleep I get, the better.’ ”

But at a sleep symposium in June, Jacobs was heartened to hear that more sleep might not actually be better for us and that reports of the demise of our slumber have been greatly exaggerated. The encouraging message from a quartet of sleep researchers was delivered at a meeting of the American Academy of Sleep Medicine and the Sleep Research Society in Denver.

Nick Glozier, a professor of psychological medicine at Australia’s University of Sydney and one of the symposium’s speakers, offers a few explanations for the persistence of the notion that sleep deprivation is an epidemic. It starts with us: Virtually every person sleeps incrementally fewer hours with age, which we falsely assume means our contemporaries get less shut-eye than our forebears. Instead of endorsing those Gallup Poll results that have us sleeping an hour less than previous generations, Glozier points to a Sleep Medicine Reviews analysis that found no evidence of healthy sleepers slumbering more in 1960 than in 2013. And last fall in Current Biology, a high-profile study of the sleep habits of modern hunter-gatherers — societies ostensibly isolated from artificial light and other sleep-inhibiting stressors — showed an average sleep time of 6.4 hours a night without adverse impacts.

Glozier also points to evidence of publication bias in academia. For example, a 2011 review published in the journal SLEEP suggested academics were far more likely to cite colleagues’ studies that showed a decline in sleep duration rather than research that showed an increase or stasis. There are other sources giving momentum to sleep-deprived narratives: researchers who nod along as they secure grant money and keep their field in the public eye manufacturers of medicine and sleep trackers who see economic opportunity beneath widespread apprehension and media looking for big-problem-big-solution headlines. “No one in the health media ever writes ‘Things are actually OK, and they’re not getting worse,’ ” Glozier says.

By vilifying reduced sleep (and neglecting the role of bad diets and sedentary lifestyles), we make an illogical leap, Glozier says: If less sleep is bad, then we should get as much sleep as possible. In a statement published in the Journal of Clinical Sleep Medicine last year, researchers from the American Academy of Sleep Medicine and the Sleep Research Society recommended that adults should sleep seven hours or more per night, with no hard upper limit.

“That’s terrible advice,” says Jerome Siegel, a professor of psychiatry at the University of California Los Angeles, who led the Current Biology study and organized the symposium. (To be fair, the Journal of Clinical Sleep Medicine statement acknowledged that for healthy adults, “it is uncertain whether sleeping more than 9 hours per night is associated with health risk.”)

Siegel emphasizes that he doesn’t advocate reducing sleep for better health. Instead, he’s incredulous that open-ended recommendations don’t have controlled, longitudinal studies to back up claims that sleeping beyond seven hours makes us healthier. In fact, there’s some evidence of the opposite. A 2016 study in the online journal Scientific Reports showed a correlation between ever-increasing risks of mortality the longer the subjects slept past seven hours and markedly less risk with subjects who slept less than seven. Sleeping just seven hours corresponded with the lowest risk of all. (The Brigham’s Charles Czeisler notes that links between prolonged sleep and mortality could indicate a prevalence of preexisting illnesses for which studies don’t account. In Brigham studies, he says, “we haven’t seen healthy people who [regularly] sleep 11 hours.”)

There’s another hidden hazard to more-sleep-is-always-better recommendations, Siegel says. “When you tell people to increase their sleep, you make them anxious about sleep.” That leads to healthy, seven-hour-a-night sleepers visiting their doctors, and their physicians perhaps allaying their concerns with a solution from a medicine bottle. “The obvious result is they’re going to get sleeping pills.”

PHYSICIANS WROTE MORE THAN 55 MILLION prescriptions for Lunesta, Ambien, and other sedative-hypnotic sleep aids in 2014, according to IMS Health. But pill-enabled sleep gains can be modest. An FDA-reviewed Lunesta trial showed that subjects fell asleep only 15 minutes faster and slept 37 minutes longer (for a total 6 hours, 22 minutes) than the control group. While it’s unclear whether sedative-hypnotics reproduce the physiology of natural sleep, users have reported side effects like sleepwalking, sleep-driving, hallucinations, even outbursts of physical violence. (Jean O’Connor, the speech pathologist from Connecticut, says she tried Ambien and that she’ll never use it again after “getting up and doing things I wasn’t aware of.”)

Sleeping pill use itself could be deadly under certain circumstances, though the limited research on that issue is far from settled. A 2012 study led by Daniel Kripke, an emeritus professor of University of California San Diego and a longtime critic of prescription sleep drugs, correlated prescription sleeping pill users with a more than fourfold increase in mortality compared to nonusers (the findings have been criticized). “Saying that everyone should sleep more — to the extent that they’re encouraging people to take sleeping pills — they are literally causing people to die earlier,” says UCLA’s Jerome Siegel.

And to Siegel and UMass Memorial’s Gregg Jacobs, the influence of Big Pharma creates the potential for conflicts of interest that pervade sleep science. The National Sleep Foundation (NSF) has accepted funding from pharmaceutical companies, for example, and the disclosure section of the “7 hours or more” statement in the Journal of Clinical Sleep Medicine includes names like Merck and Purdue Pharmaceuticals. “When you’re dependent in part on drug companies’ funding, the studies you conduct and the things you talk about in media interviews to some extent have to be supportive of the mission of drug companies,” Jacobs says. “And their mission is more sleep.” (The NSF, which also receives grants from nonprofit foundations and federal sources, says it maintains editorial independence by not agreeing to any restrictions on grants from health care companies and other corporations.)

Jacobs himself advocates for cognitive behavioral therapy for insomnia (CBT-I), a psychology-based treatment often covered by insurance that involves setting healthy habits, such as regular bedtimes and regular exercise, and fostering attitudes that reduce anxiety and encourage rest without medication. All told, Jacobs says he has taught CBT-I principles to tens of thousands of people — he also sells versions of the program online — and points to multiple controlled trials that indicate 70 to 80 percent of patients have improved their sleep while reducing or eliminating sleeping pill use.

For the insomnia sufferers he hasn’t reached, fixing sleep problems starts with tweaking those open-ended recommendations. “We need to stop telling people ‘The more sleep the better,’ ” Jacobs says. “Instead, we should tell them that there seems to be an optimal amount of sleep. It’s around seven hours a night.”

BACK AT THE BRIGHAM’S SLEEP LAB, Elizabeth Klerman and I leave the blinding-white interior of Suite 4 and talk about the gray in the wider world of sleep science. That sleep deprivation increases reaction time or that we become dangerous behind the wheel after an all-nighter — those are basically settled issues. But how much sleep is enough remains an open question. Hypothetically — Klerman emphasizes that these numbers are imaginary, not factual — a person might need eight hours of sleep to feel rested and alert, but less for proper immune or metabolic function. “We don’t know how much sleep you ‘need,’ ” she says, miming air quotes.

Part of that ambiguity comes from the shortcomings of sleep studies. Self-reported data — the backbone of large-scale epidemiological studies — are especially fraught, considering the hazy nature of sleeping itself. “Rumble strips would not exist if people knew when they were awake versus when they were asleep, right?” Klerman says.

Fitbits and other consumer-grade sleep trackers don’t offer much more clarity: By mistaking motionlessness for slumber, they can overestimate sleep duration by as much as an hour. Simply asking how tired someone feels is problematic, because if they’re sleep-deprived, they lack the perspective for an accurate answer.

While big conclusions from big studies should be taken with a grain of salt, Klerman says the same applies to her team’s small-population studies at the Brigham. “If I’m only doing a study with 10 or 15 people, how generalizable is that?” Ideally, sleep duration policy recommendations would be informed by a symbiosis of epidemiology and physiology. If a large study finds a link between sleep duration and lifetime risk of diabetes, a lab like the Brigham’s could design thoughtful, controlled experiments to explore that connection.

To be clear, Klerman believes sleep deprivation is indeed a public health problem. She also cautions against long-term sleeping pill use and accepts that framing sleep loss as an epidemic could cause patients with anxiety-based insomnia to suffer (and says they should seek professional help). “That doesn’t mean that sleep deprivation is not a public health problem for many, many more people for whom [anxiety-based insomnia] is not the issue,” she says. Klerman recalls a woman approaching her to ask if it was OK that she fell asleep behind the wheel at red lights. Klerman’s response: No, it’s not OK, and you’re a danger to yourself and everyone around you.

After leaving the Brigham, I eat a late lunch and drive from Boston back home to Connecticut in rush hour. By the time the road opens on I-395, my eyelids are heavy. I pull into a gas station and buy a 16-ounce can with enough caffeine in it to keep me moving. I’ll sleep when I can. I’m just not sure for how long.


Terror in the night

Sleep paralysis can be a terrifying experience that is surprisingly common. It can involve the inability to move, auditory and visual hallucinations, a strong sense of presence, difficulty breathing, sensations of movement, and intense emotion. The causes and interpretations of sleep paralysis are described in this article, as well as some practical suggestions for coping with it.

My eyes are open and usually I get the sense that something in the room is happening, so it’s more like apprehension. It’s a sort of belief that something’s going to go off and then a shape gathers, a sort of black, small black cloud gathers and it’s the devil… a monster. And it comes onto me and I can feel its weight and basically the belief is that it’s holding me and that it’s going to drag me down into an abyss… I can feel sensations on my body, it’s multi-sensory. I can sort of smell it too. I feel sensations in my body like in a lift, I feel like I’m going down… I can’t move, certainly. Well, I try but it never works. Usually all I can do is make a kind of hum in my throat and try to make a feedback cycle, make that louder, as it gets louder the more awake I get, the more I can do until I can eventually perhaps shout. And that wakes me up, properly wakes me up.

Amazingly, experiences similar to the one above, which was related to us by a fellow academic, are very common. The experience is called sleep paralysis and it is classified as an REM-related parasomnia.

What is sleep paralysis?
Sleep paralysis is a period of transient, consciously experienced paralysis either when going to sleep or waking up. During an episode the individual is fully conscious, able to open their eyes but aware that it is not possible to move limbs, head or trunk. There may be also be the perception of respiratory difficulties and, understandably, acute anxiety (Dahlitz & Parkes, 1993).

In addition, the individual might experience hallucinations. In a sample of 254 college students who had experienced sleep paralysis at least once (Cheyne et al., 1999), 75 per cent had concurrently experienced body paralysis and hallucinations. Commonly experienced hallucinations include:

- Proprioceptive hallucinations: sensations of floating, flying, out-of-body experiences feelings of being lifted up, of spinning and turning and sensations similar to those felt when going up or down in a lift.

- Tactile hallucinations: sensations of pressure touching or pulling on the chest, limbs or head pressure on the bed feeling the bedclothes moving and feelings of tingling, vibrating, shaking, pain, smothering or choking.

- Auditory hallucinations: hearing footsteps, knocking, shuffling, breathing, talking, indecipherable whispering, mechanical sounds
(e.g. humming) and other noises.

- Visual hallucinations: seeing wisp of cloud or smoke-like substances or areas of intense darkness seeing a human, animal or monster and possibly interacting with them.

- Olfactory or gustatory hallucinations.

Attacks often involve feelings of intense fear, terror, bliss, joy, anger, and feelings of dying or imminent death. False awakenings are also commonly reported. The individual believes that they have awoken and that the episode is over, only to discover that they are still in fact asleep.

Sleep paralysis usually occurs when the individual is lying on a bed – it is unlikely to occur if in an uncomfortable sleeping position such as sitting upright (Hishikawa, 1976). It is more likely to occur when the individual is lying supine facing upwards than in any other sleeping position (Cheyne, 2002). An episode can last between a few seconds and 10 minutes and can end either spontaneously or because of an intense effort to break the paralysis by the person experiencing it, or by the touch or voice of another person (Goode, 1962).

Who gets sleep paralysis?
Although estimates vary, it appears that up to 50 per cent of the population will experience sleep paralysis in one form or another at least once in their lifetime, and some people experience it far more often than that. Although sleep paralysis can be a symptom of narcolepsy, it is also common amongst non-narcoleptics. Narcolepsy, which is a sleep disorder that affects approximately 0.02–0.05 per cent of the population (Lavie et al., 2002), consists of four major symptoms:

- sleep attacks: overwhelming episodes of drowsiness or sleep

- cataplexy: sudden loss of muscle tone usually triggered by a strong emotion

- sleep paralysis: consciously experienced paralysis whilst falling asleep or waking up

- vivid hypnagogic hallucinations: hallucinations at sleep onset.

Most narcoleptics do not have the full tetrad of symptoms, but approximately 17–40 per cent experience sleep paralysis (American Sleep Disorders Association, 1997) and 20–40 per cent experience vivid hypnagogic hallucinations (Broughton, 1990). Many of these people with narcolepsy who experience sleep paralysis will do so several times a month, and some of them will experience it every time they fall asleep – and this may be several times a day (Hishikawa, 1976).

Surveys from around the world indicate that between 20 per cent and 60 per cent of the non-narcoleptic population experience sleep paralysis at least once in their lives (French & Santomauro, 2007). When people experience sleep paralysis without other symptoms of narcolepsy it is sometimes referred to as isolated sleep paralysis (ISP). Many people experience ISP just once in their lives but between 3 per cent and 6 per cent of the population will experience ISP more often than that. These people can experience it severely (episodes occurring at least once a week) and chronically (for six months or longer: American Sleep Disorders Association, 1997). The term sleep paralysis is used in this article to include attacks in both people with narcolepsy and ISP.

It should be noted that although sleep paralysis is itself quite harmless, there are other sleep-related experiences that can be mistaken for sleep paralysis but may actually require medical treatment. Such experiences could be epileptic in nature in young people (e.g. partial seizures) or cardio-respiratory in origin in older people.

What causes sleep paralysis?
In the words of one sufferer:Definitely stress. Sometimes it happens when I’m not stressed but maybe tired, maybe I’ve stayed up a bit too late. Another kind of stress, a sort of physical stress on my body… It’s a sort of feedback cycle, so it’s happened and then you get a bit stressed and then it seems to happen more and then you’re going to bed thinking ‘I hope this doesn’t happen’ which is immediately fear, isn’t it?… So you’ve already primed yourself for some kind of anxiety, fear response, and made it more likely to happen.

Sleep paralysis can be considered to be an intrusion of rapid eye movement (REM) sleep characteristics into wakefulness. That is, the muscles of the body are deeply relaxed (they cannot be moved) and the dreamlike element of any associated hallucinations may result from the brain activity – dreaming – that is typical of this sleep period (Dement & Kleitman, 1957). Putting it simply, wakefulness has occurred but the body and part of the brain is still in REM sleep.

Usually, REM sleep is experienced after an hour or more of sleep, yet many people experience sleep paralysis at sleep onset. This is because people who experience sleep paralysis often have sleep-onset REM periods (SOREMPs), which have been found to be associated with sleep paralysis. People with narcolepsy who experience the symptoms of sleep paralysis, cataplexy or hypnagogic hallucinations often have SOREMPs and people who have narcolepsy without these symptoms do not experience SOREMPs (Hishikawa & Kaneko, 1965). When members of the former group were woken up from various stages of sleep, it was discovered that sleep paralysis was regularly reported when the person was woken up from a SOREMP and not reported if the person was woken up from non-REM sleep, nor if they were woken up from REM sleep that occurred after a period of non-REM sleep (Hishikawa et al., 1963).

Polysomnagraph recordings confirm that in laboratory studies narcoleptics experienced sleep paralysis exclusively during SOREMPs (Hishikawa & Kaneko, 1965 Hishikawa et al., 1978).

SOREMPs are also found in people without narcolepsy. They usually occur after disruption of the sleep–wake cycle or after interruption of sleep (Takeuchi et al., 1992). It is possible to induce a SOREMP by waking the person up at a particular point in the sleep cycle (Miyasita et al., 1989). Researchers in Japan elicited SOREMPs in participants using a sleep interruption method, and 9.4 per cent of induced SOREMPs elicited an episode of sleep paralysis (Takeuchi et al., 1992).

This research strongly suggests that sleep paralysis is related to REM sleep, and in particular REM sleep that occurs at sleep onset. Shiftwork, jetlag, irregular sleep habits, overtiredness and sleep deprivation are all considered to be predisposing factors to sleep paralysis (American Sleep Disorders Association, 1997) this may be because such events disrupt the sleep–wake cycle, which can then cause SOREMPs. Of course, episodes of sleep paralysis occurring as people emerge from sleep cannot be explained in terms of SOREMPs, but it seems reasonable to argue that such episodes may well involve a similar state of consciousness, mixing aspects of both normal wakeful consciousness and REM consciousness. Needless to say, for practical reasons such episodes are inherently more difficult to study in psychophysiological terms as there is currently no known way to induce their occurrence.

How is sleep paralysis interpreted?
First of all I dream that I have awoken, although, usually, not always, I am not conscious of that fact until after the experience. I believe that I am awake and lying in bed. I cannot move because there is a huge weight lying on top of me which I fear is some kind of monster (I’m always lying on my front with the monster on my back). Sometimes I can hear a kind of unearthly growling coming from the monster. At this point I panic, but to no avail. I can’t move! I panic more and apply all my strength to rising. I try to scream for help, usually this is impossible as my voice is paralyzed as well. Sometimes I can manage to scream, but with great difficulty (clearly it’s inaudible as it never disturbs anyone). Eventually I awake, but remain feeling very frightened, sometimes to the extent that I cannot return to sleep for the rest of the night.

The experiential elements of sleep paralysis have been reported from many countries and cultures around the world but it is known by many different names and interpreted in many different ways. For example, in Newfoundland sleep paralysis is called the ‘Old Hag’. This is described as suddenly being awake but paralysed, usually just after having fallen asleep, and often feeling a weight on the chest and sometimes seeing a grotesque human or animal astride the chest (Ness, 1978). Newfoundlanders think it might be caused by either working too hard, the blood stagnating when they lie on their back, or hostile feelings from another person.

In Hong Kong a condition that seems identical to sleep paralysis is termed ‘ghost oppression’ (Wing et al., 1994). Chinese people have often thought that ‘the soul of a person is vulnerable to the influence of spirits during sleep’ (Wing et al., 1994, p.609) and, in a dream classification book written around 403–221bc, there are six types of dreams described. Wing and colleagues suggest that e-meng, dreams of surprise, are actually sleep paralysis and are distinct from ju-meng, fearful dreams.

Amongst the Inuit of Canada sleep paralysis is interpreted as attacks from ‘shaman or malevolent spirits’ (Law & Kirmayer, 2005). In Japan sleep paralysis is called kanashibari and is related to the magic of one of the Buddhist gods, Fudoh-Myohoh. Historically, it was believed that monks could use this magic to paralyse people in their sleep more recently it is often believed that evil spirits cause the phenomenon (Fukuda et al., 1987). In St Lucia, sleep paralysis is termed kokma and is alleged to be caused by the spirits of unbaptised babies who haunt the area (Ness, 1978). In Korea, it is termed ha-wi-nulita which can be translated as being squeezed by scissors (Dahlitz & Parkes, 1993). Many other cultures have their own interpretation of sleep paralysis and often the cause is attributed to some supernatural force.

Throughout Europe, from the 1500s until the 1700s, sleep paralysis experiences were often considered to be the work of witches who were accused of using their witchcraft to terrorise sleepers who had offended them in some way. Such episodes were sometimes termed as being ‘witch-ridden’. In 1747, a woman testified at a witch trial that she found her husband in bed ‘lying there stiff, barely drawing breath’, and when he woke up he said, ‘My Lord Jesus help me! Oh! Fiery witches took me to Máramaros and they put six hundredweight of salt on me’ (Davies, 2003, p.186). This sounds like an episode of sleep paralysis involving visual hallucinations (fiery witches), tactile hallucinations of pressure on the body (the six hundredweight of salt) and proprioceptive hallucinations of floating and flying (when the witches took him to Máramaros). Another common interpretation of sleep paralysis episodes in the Middle Ages was that they were attacks by sex-crazed demons, known as a succubus when in female form or an incubus when in male form. The word incubus is sometimes translated as ‘one who crushes’ and the lay term ‘incubus attack’ is still occasionally used to describe an episode of sleep paralysis.

Even in modern Western societies, individuals who suffer attacks of sleep paralysis may often be tempted to explain their experience in terms of a nocturnal attack by spirits or demons, simply because that provides a preferable explanation of their disturbing experience compared with the most obvious alternative – that is, that they are ‘going crazy’. There is no doubt at all that a sizeable proportion of ghost stories have their origin in episodes of sleep paralysis (see, for example, Huston, 1992).

Another recent interpretation of such episodes in Europe and the US is the belief that the individual has been abducted by aliens. It is claimed by many so-called ufologists that the memory of the actual abduction may be erased by the aliens but a memory of the sensations of paralysis and the hallucinations before and after the event retained (French, 2001, 2003 Holden & French, 2002). Although this seems a highly fanciful interpretation of a sleep paralysis experience, if one does not know that it is a commonly experienced sleep disorder then one would be strongly motivated to look for some explanation for it. If the belief system of the individual includes belief in alien abductions, then one can understand how such a conclusion might be drawn. McNally and Clancy (2005) compared individuals who believed they had been abducted by aliens with those who had not and found that the alien abduction participants had higher rates of sleep paralysis. Similarly, French et al. (2008) found higher self-reported incidence of sleep paralysis in people claiming alien contact than in a matched control group.

Treating sleep paralysis
For people with a diagnosis of narcolepsy, sodium oxybate is the preferred treatment, although this treatment appears to have little direct effect on rates of sleep paralysis (Xyrem International Study Group, 2005). For people who regularly experience ISP it might be possible to reduce the occurrence of episodes by avoiding events that can cause SOREMPs. Having a regular sleep schedule that includes going to bed and getting up at the same time, and minimising sleep interruptions during the night is recommended. In reality, such steps might be impossible due to shift-work, travelling commitments, socialising or taking care of a baby. Psychotherapy can often help with more severe cases, which are often aggravated by stress.

It is may also be helpful to offer a method of ‘breaking’ the episode of sleep paralysis once it has started. Anecdotally, many sufferers find that moving a small muscle, such as the eyes, fingers or toes, can allow them to snap out of the paralysis. Others report that getting the attention of their bed-partner, for example by making a noise in their throat, so that he or she can touch them can also break the paralysis. However, for some, making any sound is impossible.

Once an episode has stopped it is advisable to get up and move around in order to become fully awake, otherwise there is the possibility of falling back to sleep and returning to a state of sleep paralysis. It is not unusual for sufferers to report several such episodes in a single night.

Other research participants have learned to not feel fearful of the experience and have even come to enjoy them. Often the mere fact of learning that such experiences, although terrifying, are actually quite harmless is enough to bring enormous relief to sufferers and to allow them to at least consider this option. For example, consider this account from a former sufferer from sleep apnea whose sleep paralysis episodes ceased when a continuous positive airway pressure (CPAP) machine was used to treat the disorder:

For me, sleep paralysis mostly makes me feel like I’m floating and leaving my body. Usually I levitate just above my body. But sometimes I’ll get across the room. I feel heavy and move in slow motion. I cannot talk or scream. I feel like someone is pushing down on top of me. I am not afraid though. In fact, I relish these moments and find them exhilarating. I no longer have sleep paralysis, however. I was diagnosed with sleep apnea. With a CPAP machine to help me breathe better, the sleep paralysis has stopped. Too bad for me!

A need for awareness
Sleep paralysis is a fascinating phenomenon. Although we are gradually coming to understand the nature of such attacks, we still have a great deal to learn not only about the underlying neuropsychological causes but also about the complex ways in which the same core experience can be interpreted in different ways according to prevailing cultural beliefs. Most urgently, there is a need for greater awareness of the nature of the sleep paralysis amongst the general public and, particularly, amongst health professionals in order to minimise the anxiety and distress that often result from such attacks.

Box: Sleep paralysis – an account
‘I’m lying on my back with my eyes closed and I feel a crushing weight on my chest. I’ve felt this before, so I’m not scared. I open my eyes just a little bit and I see this two-dimensional grey humanoid on top of me with three-dimensional dirty grey hair hanging in my face. He is clutching my chest and dragging me down the bed into a wooden box that looks like a casket at the foot of my bed. I know that if he drags me into the box that I will die. I turn my head sideways and look into the mirror that faces my bed and watch myself being pulled down the bed towards the box. I am absolutely terrified by this point and I finally wake up, when I am transported back to the top of my bed with my head looking up at the ceiling.’

Julia Santomauro is in the Anomalistic Psychology Research Unit, Goldsmiths, University of [email protected]

Christopher C. French is in the Anomalistic Psychology Research Unit, Goldsmiths, University of London
[email protected]


How to Sleep With Anxiety

Sleep problems are extremely common for those struggling with anxiety. Ideally, you'll need to focus on reducing your anxiety and stress in general so that you're less consumed by the negative thoughts and experiences, and can drift off to sleep more easily.

There are tips and strategies you can use to get more rest with anxiety. Consider the following:

  • Journal Writing One successful tool is journal writing. People may see journal writing as important for kids, but writing your thoughts in a journal has an effect on your ability to sleep as well. Your brain is a fascinating thing, and when your mind knows that you have written a persistent thought down (one that keeps you awake), it will feel better about letting the thought go, knowing that it's in a permanent place. Any time you have a thought that won't leave your mind, try writing it in a journal.
  • Melatonin Supplement Melatonin is a chemical in your brain that aids in falling and staying asleep. Some find that taking an over the counter melatonin supplement can be helpful in getting a better night’s rest. You should be sure to consult with a physician before taking melatonin and for correct dosage instructions, particularly if you are taking other medications.
  • Daily Jogging or Exercise At least 3 to 4 hours before you go to sleep (and possibly as early as the morning), try to get out for a long jog. Jogging is actually a natural anxiety reduction strategy, and one that releases endorphins that calm the mind and body. But beyond that, jogging tires the muscles, so when you go to bed they will be much less tense. If jogging is not something you are interested in, try another form of exercise which increases heart rate and exerts a good amount of physical energy, as it will have the same effects as jogging.
  • Essential Oils Some people have found that diffusing essential oils in an essential oil diffuser by their bed at night aids in better sleep. Lavender, cedarwood, vetiver, and chamomile are a few that have been found to relax the body, making it easier to fall asleep.
  • Drink a cup of tea It sounds simple but slowly drinking a cup of non-caffeinated tea such as chamomile or valerian tea can help to relax both your mind and body. There are also “sleep” or “nighttime” blends that are available.

Mental distractions can also be beneficial, especially for heavy sleepers. Some people find that turning on radios, podcasts, or television sets, and putting the volume as low as possible so that you can barely make out the words can be helpful. Your mind tries to listen to the distraction, causing it to stop focusing on the stressful thoughts, and ultimately you're able to fall asleep.

This solution does not work for everyone, however.

Another important thing that you can do is to create a bedtime routine. It can be difficult to go through your daily activities and then get into bed and just turn everything “off”. By giving yourself an hour before you want to fall asleep to go through the same motions every night you train your brain and your body to prepare for sleep. This in turn can make it easier to both fall, and stay asleep.

Unfortunately, these tips are likely not enough. You still need to stop experiencing anxiety so that sleep comes much more naturally.