Sleep

Hail,
Been thinking about a lot of things, sleep and religion and parrots and Tycho Brahe and so on, and I might try to write this down.

There has been a bit of a hiatus in the blogging, by the way, a combination of a number of things - Sarah, packing up stuff into boxes, doing some writing, the approach of Autumn - but in a week or so I start psychiatry training, and posting should improve from then. Reflecting and thinking and writing is encouraged in psychiatry, although posting your patient's sufferings to the world as entertainment is possibly less so. Unfortunately, until then (early Feb) it's probably going to be pretty slim pickings.

First off - go and have a look at this. Shout it from the rooftops, preach it from the pulpit, print it up and put it on a bloody great tee-shirt. Whoever the author is, s/he shouldn't have typed this blog entry, s/he should have carved it on stone tablets for all eternity, because it is truly bloody glorious. Seriously. Print it out and stick it up somewhere.

But anyway. Sarah's on opiate patches at the moment, and I think we've got the right dose. Things are better than they were before, the pain is better, and there isn't so much of the early morning nausea* and vomiting that she was getting, but she says the patches make her sweat, and they affect her appetite, and, most distressing for her, they cause strange dreams.

Not strange dreams in the exciting way. These strange dreams are not ornate oneiric visions in the Edgar Allen Poe sense of the word, or Jungian strange dreams redolent with symbolism and secret meaning, they are dreams that are strange because they are so... unstrange. They are utterly mundane, confusing and occasionally embarrassing dreams that very closely resemble "real life".

Dreams where she wakes up and brushes her teeth and checks her email and then she really wakes up and has to brush her teeth and check her email again.

Wild voyages through the subconcious where she has a cup of tea, vivid multicoloured phantasies wherein she chats with her mum, delirious surrealist reveries involving paying the electricity bill. A few nights ago she either couldn't sleep and spent the night tossing and turning until just before dawn, or she slept like a log but had a dream where she couldn't sleep and spent the night tossing and turning until just before dawn.

She says it's not that whole spacey "One night the great sage Chuang Tzu dreamed he was a butterfly" stuff, either. It's more "One night the great sage Chuang Tzu dreamed he had returned the DVDS so he drove off without them and then a week later he got a hostile phone call from the DVD people and the great sage Chuang Tzu said 'What the hell's wrong with you people, I gave them back Tuesday' but it turns out he hadn't, it was just a dream" kind of thing.

Anyhow.

Speaking of sleep, an interesting article in the New York Times suggesting that what we call normal sleep - like normal eating or normal childhood - is actually a recent and historically abnormal phenomenon. Pre-Industrially it may have been that we slept in two shifts, each of a few hours - a first sleep and a second sleep. Between these two sleeps was a period of remarkable alertness and productivity, reading or talking or tending the animals at two or three in the morning. Priests could pray, adulterers could meet at windows, slaves could whisper together.

Or that's what the author reckons. If that's true, you could argue that what we today call insomnia is normal, is something that used to pass unremarked. I have no idea if this is true or not, and it's of only theoretical interest to the person who wakes tired and red-eyed, but it's an oddly intriguing idea.

I like the idea of that interregnum, that time away from the heat and the light and the eyes of priests and neighbours, purposive and vigorous instead of lying in the dark and staring at the ceiling. I know there is some intimate connection between light and mood - I know that light can be used to treat some severe forms of depression - the most famous is Seasonal Affective Disorder, or SAD. I also know that several of our guests, when we lived in the hills away from the city, so dark you could see nine of the Pleiades, could not sleep in our house - it was too dark, too quiet.

I suppose another reason that my thoughts are inclining this was is that the "sleep medication" zolpidem (sold over here and in the UK as Stilnox, in the US as Ambien) may be reclassified over here as a schedule 8 drug - subject to the same legal restrictions as morphine and methadone. I don't know about this. Zolpidem certainly doesn't help sleep in the way it is used by most people I know, but the more I find out about sleep and mood and cognition, the more complicated it is and the more questions I have.

I have some of the answers in a book on my desk. I have downloaded all four hundred pages of the ICSD DCM, the International Classification of Sleep Disorders Diagnostic and Coding Manual. This is to sleep what the DSM IV is to madness - or rather, what it is to sanity. It classifies sleep disorders, first into dyssomnias, parasomnias, those with medical, mental and other causes, and finally "proposed" (sleep disorders that are on the waiting list), and then fuirther, into hundreds of separate sleep pathologies. As far as I can see, they are listed in order of intrinsic horribleness.

For example: the dyssomnias include relatively common entities like narcolepsy and obstructive sleep apnoea, and the common-sense (stimulant dependent sleep disorder - if you take a lot of speed you don't sleep). It also contains the more unusual: altitude insomnia and food allergy insomnia.

The parasomnias mention impaired sleep-related penile erections and the alarming but hopefully not fatal "sleep related sinus arrest" - you go to sleep and your heart stops - presumably it starts again.

Amongst the "medical and mental" group are (unsurprisingly) African trypanosomiasis (the original sleeping sickness), but also the disorders of sleep that occur as the architecture of the personality is eroded - the insomnias of the various dementias, the slow derangement of Parkinsons Disease. You read about these conditions with a deep sense of - I don't know what, a yearning to offer some comfort to these people, a wish you could just do something. In fatal familial insomnia the part of the brain that permits sleep is scarred and stutters and fails. The ability to sleep is lost, these people can no more sleep than you or I can clench an amputated hand. The time between the last moment of sleep and eventual death is measured in months.

Anyhow. On that happy note I have to start seeing patients, almost all of whom feel and believe that they cannot sleep, haven't not been tired for decades. This means that parrots (and it's a damn interesting parrot) and religion and Tycho Brahe will have to wait until the next post.

Speak soon. Thanks for listening,
John


*No.