Everybody sleeps. It’s true of humans and essentially all living creatures. Sleep is an extended period of downtime, and it’s anything but a waste of time.
“Very simply, the reason that sleep is so important is it allows our body and our brain to basically recuperate, restore from the day’s functions,” says Stephanie Stahl, MD’10, director of the multidisciplinary Sleep Medicine Fellowship Program in the IU School of Medicine. “And there’s a lot of data that not getting enough sleep is associated with so many different health issues.”
There’s also plenty of data showing that vast numbers of people aren’t getting enough good sleep. Research suggests that anywhere from 50 to 70 million Americans have some sort of ongoing sleep disorder—about a third of all adults are snorers and roughly three-quarters of Americans either have a sleep issue or live with someone who does.
“Probably the biggest causes of sleep problems are insomnia, sleep apnea, and insufficient opportunity to sleep,” says Spencer Dawson, clinical assistant professor in IU’s Department of Psychological and Brain Sciences. He trains students in cognitive behavioral therapy techniques and is a member of the Board of Behavioral Sleep Medicine, which certifies clinical specialists in treating sleep issues through a behavioral-health lens.
The link between sleep and broader aspects of health can be a bit of a chicken-and-egg scenario—sleep of insufficient quality can lead to a host of health problems, but at the same time, there are medical and mental health issues that can result in poor sleep. Many people know they have sleep problems, while others may be unaware that a seemingly unrelated health issue is tied to how their body is functioning between bedtime and morning.
So, it’s well worth paying attention to sleep because other parts of your life may depend on taking sleep seriously. And IU is busily training clinicians—and employing seasoned experts such as Stahl and Dawson—who would love nothing more than to lull people to sleep so they can wake up to a better day.
The Importance of Good Sleep
When it comes to sleep, both quantity and quality are vital considerations.
“One of the things that’s really important is sleep duration,” Stahl says. “There are different needs in kids and infants, but once you hit age 18 it doesn’t change much. The recommendation for ages 18 through 64 is seven to nine hours of sleep. And 65 and older, seven to eight hours of sleep.”
Call it a minimum of seven hours a night. What happens if you don’t get that consistently?
“There’s a 30 percent higher risk of dementia with getting less than seven hours of sleep on a regular basis—and increased risk of heart attacks, strokes, cancer, poor metabolism, and weight gain. So, [there are] a lot of things we can blame to some degree on insufficient sleep,” she says.
That’s the quantity aspect. The quality consideration relates to the different kinds of sleep and the normal cycles of sleep patterns.
“There’s a very particular way that we normally cycle through different stages of sleep,” Stahl explains, “including important stages of slow-wave sleep—our deepest most restful stage of sleep—and REM [rapid eye movement] sleep— the vivid dream state of sleep. Anything that causes disruptions of our normal sleep architecture can also add to the risk of other health issues and poor quality of life.”
Stahl says REM sleep comprises up to about a quarter of the night, split into three to five episodes. Meanwhile, there are three stages of non-REM sleep. The first is a brief, light sleep right as a person is first drifting off, while half the night is typically spent in the second stage of moderately deep sleep. The third stage is the deepest, the highly important and restorative slow-wave sleep, which makes up about 15 percent of the night.
Regarding slow-wave sleep, she adds: “It’s thought that that [might be when] our brain clears out toxins that build up over the course of the day or over our lifetimes, such as those that build up in Alzheimer’s disease.”
Sweet dreams are, apparently, a lot rarer than many people realize. Insomnia is a major focus of Dawson’s clinical and academic work. Simply put, insomnia refers to a person having trouble falling asleep, staying asleep, or getting back to sleep, either in the middle of the night or later, when morning is approaching but it’s not quite time to get up, he explains.
It’s not uncommon for a person to have trouble sleeping from time to time. Insomnia turns from annoyance to disorder when it becomes more frequent and starts to impact the rest of one’s life. “[It becomes an issue when] it’s causing you distress, it’s worrying you, it’s causing problems at home, at work, socially, difficulties with concentration, attention, memory, irritability, moodiness, fatigue, not having much energy,” Dawson says.
Insomnia often can be linked to behavioral health concerns, such as depression and anxiety. Those concerns may be chronic, or they may be tied to specific life circumstances such as unusual stresses. That’s why cognitive behavioral therapy, or CBT, can be a highly effective treatment—it’s intended to help patients deal with those underlying mental health concerns.
One of the side benefits of therapy sessions includes educating people about sleep: sleep cycles; the “sleep drive” that builds during the day to help people fall asleep; the circadian rhythm, which helps keep the body on a daily schedule; and other important aspects of sleep. A better understanding, combined with the insights of a sleep specialist, can help a patient create strategies and stick with effective sleep practices and schedules.
Dawson points to the “three P’s” that can lead to insomnia. The first P is for predisposition, like genetic factors or temperament that make a person more likely to develop insomnia.
The second P stands for a precipitating factor or series of factors, such as stressful life events. “It can be a good stress, it can be a bad stress,” he continues. “It can be the birth of a child, death of a loved one, loss of a job, starting a new job, moving across country, end of a relationship. It can be starting school, or graduating and all your friends move away.”
It’s not surprising, he says, that any of these things might get in the way of sleep. “It activates our arousal system, our fight-or-flight system; one of its functions is to keep us awake when there is danger.”
But stressors or precipitating factors usually don’t last forever. They pass and people often move past the stress—and yet they may continue to have trouble sleeping.
That’s where the third P comes in: perpetuating factors. Many people might experience stress-related sleep issues, and those sleep issues end up creating their own stress, he says. Worry too much about whether you’ll get back to sleep and the terrible things that’ll happen if you don’t, and that worry can become a self-fulfilling prophecy.
Battling Sleep Apnea
Sleep apnea, meanwhile, refers to repeatedly interrupted breathing while sleeping, and is a prominent focus of Stahl’s work. Sleep apnea can happen many times a night—even hundreds of times—and can wreak havoc with sleep patterns. The most common condition is obstructive sleep apnea, during which throat muscles relax and narrow, blocking airflow to the lungs.
If you think that sounds potentially serious—interrupted breathing—you’re right. It’s largely undiagnosed or under-diagnosed, Stahl says, and frequent snoring is just the beginning of the problems.
“It causes a lot of awakenings throughout the night, disruptions into our normal sleep architecture, and drops in our oxygen levels. And that leads to a lot of the same things that an insufficient sleep can.”
Technology often provides the most effective treatment for obstructive sleep apnea, particularly CPAP (continuous positive airway pressure) devices. A CPAP device sends a constant flow of air pressure through a mask, which keeps airways open and unobstructed. Stahl has seen the technology work miracles for sleep apnea patients.
She has also seen many frustrated patients who have found their CPAP devices, particularly the mask, to be uncomfortable. She recalls one patient who was diagnosed with sleep apnea, but he couldn’t stand his CPAP machine, so he quit using it despite his sleep disturbances and the snoring that kept his wife awake.
Then his cardiologist told him that because of high blood pressure he should get his sleep apnea treated. With a heightened sense of urgency, he connected with Stahl, who explained that there are different CPAP variations and improved technologies.
She says it’s well worth persisting even after an unsatisfying CPAP experience, and that’s what she told the patient. By turning to different CPAP technology, Stahl says, “he did feel better, his blood pressure did improve, and his wife wasn’t bugging him anymore about snoring and waking her up all throughout the night.”
Evaluating Your SleepGiven the statistics, there’s a high likelihood that anyone reading this article has a sleep problem or is in the same household with a problem sleeper. How does one know whether to consult a sleep expert?
“If you snore loudly or frequently, that’s a really strong indicator that you have sleep apnea and should be evaluated, without question,” Stahl says. “If you’re having a lot of awakenings throughout the night, that may be an indicator that you have a sleep issue such as sleep apnea.”
On the other hand, Stahl says, it’s completely normal to have very brief awakenings throughout the night, sometimes as many as 10 times in an hour.
If you’re not getting back to sleep easily, or you have lots of trouble when first going to bed, that could be an indicator of insomnia, she says, which is also worth consulting an expert about. “Especially if it’s significant— really reducing your total sleep time or affecting your daytime functioning,” she says.
Indeed, people who are excessively sleepy during the day may be having troubles at night, whether they’re nodding off while reading or watching TV or—more dangerously—driving a car. “It’s important to note there are a lot of other things, too, that can cause sleepiness including a lot of medications and other medical problems, and so that one’s not always as clear cut,” Stahl says.
Many people will try to address sleeping disorders on their own, something both Stahl and Dawson warn may not turn out well.
“People will try a lot of different things over the counter: Benadryl, melatonin, valerian, CBD, cannabis, alcohol,” Dawson says. “None of those are recommended by the American Academy of Sleep Medicine as treatments for insomnia.”
Indeed, in some cases they can make matters worse.
Many troubled sleepers wait for years, even decades before they seek help, Dawson adds.
“It’s really not unusual for folks, by the time they see me, to have had sleep problems for 10, 20, 30 years and have tried every medication available, but to no avail. I recommend people don’t wait that long to get help with a problem like insomnia.”
Depending on the symptoms and concerns, a sleep study may be required for a full diagnosis. It may take place in a sleep lab, where a patient’s slumber is carefully monitored to track breathing patterns, eye movement, brain activity, heart rhythm, and body movements. Increasingly, home sleep studies are an option, though they don’t track as many metrics. If a home study suggests that sleep apnea is an issue, it might be necessary to follow up with a more detailed study in a sleep lab.
If sleep apnea is the determination, CPAP therapy may be in order. But some patients with a milder case may be able to achieve improvement by losing weight, quitting smoking, abstaining from alcohol, or trying different sleep positions.
For insomnia, cognitive behavioral therapy can be of great value, especially in helping patients work through the stressors that may have precipitated the insomnia or the factors that are perpetuating it, Dawson says.
Another prime behavioral intervention is known as sleep restriction therapy. It involves carefully monitoring sleep issues, then adjusting bedtimes to help build up the “sleep drive.” The goal is to ensure that when a person heads to bed, the body is really ready to sleep, and the individual doesn’t spend frustrating hours trying to doze off. “The idea here is to get good quality sleep and then slowly expand it,” he says.
The IU Connection to Sleep
Back in her medical school days, Stahl was training as a neurologist, and “in neurology a lot of people don’t get better,” she says. Then she took a sleep-medicine elective and was thrilled to learn that “people get better if you can fix their sleep. They feel great, they think you’re the best person in the world, and they’re appreciative, and you feel like you’ve made a big contribution to their health.”
Now, Stahl helps others pursue satisfying careers in sleep medicine by leading IU’s Sleep Medicine Fellowship program. “We get a good mix of fellows [from many medical disciplines]. In that one-year program, we go through how to review and interpret sleep studies and other diagnostic testing.”
Dawson, too, has steered his career into the world of sleep after an academic experience piqued his interest.
“After college, I worked at a sleep research laboratory at the University of Michigan for about four years, running overnight studies, doing day-shift work, and doing studies on folks with psychiatric disorders,” he recalls.
His research interests spread to non-medication cognitive behavioral therapy for treating insomnia. He eventually moved to Bloomington, established a practice, and became increasingly involved at IU, where he’s now an assistant clinical professor, in addition to running a private practice.
“My main responsibility here—as part of our doctoral program in clinical psychology—is to run our CBT research and training clinic. I train our students to do cognitive behavioral therapy.”
Helping people sleep better is incredibly rewarding work, Stahl says.
“That’s the whole reason I went into sleep medicine to begin with—so many people were coming back and feeling better. And they were happy,” she says. “It wasn’t that I had to throw a bunch of medications at them to get them to feel good. In fact, a lot of times we’re trying to get people on medications. So, I tell people all the time, ‘I don’t know why everybody doesn’t want to go into sleep medicine because it is a really gratifying specialty.’”
This article was published in the Fall 2023 issue of the IU Alumni Magazine. View current and past issues of the IUAM.
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