Sleep is a complicated physiological process. it is regulated by two brain processes. One is the restorative process when sleep occurs naturally in response to how long we are awake: the longer we are awake, the stronger is the drive to sleep. The second process controls the timing of sleep and wakefulness during the day-night cycle. Timing is regulated by the circadian biological clock that is located in our brain. This part of the brain, the SCN or suprachiasmatic nucleus, is influenced by light so that we naturally tend to get sleepy at night when it is dark and are active during the day when it is light.

Sleep is observed in all mammals, all birds, and many reptiles, amphibians and fish. Regular sleep is essential for survival. Sleep duration is affected by circadian rhythm which is regulated by a gene named DEC2. Some people have a mutation of this gene: they sleep two hours less than normal. Sleep is considered to be adequate when there is no daytime sleepiness or dysfunction.

I begin my day with a 67 year old female patient who I have known for five years. She complains that she cannot sleep. Although I have given her Ambien in the past, recently she has had cognitive difficulties with the Ambien, so I did not want to prescribe that. Tension ensued. As a physician, I am well acquainted with the pressure to prescribe. I feel the conflict of wanting to make my patient feel better in the short run, but at the same time, I need to do what is good in the long run. I tell her about sleep hygiene. I remind her that we could try other kinds of medications. I remind her that the more active she is during the day, the better she will sleep at night. After an hour, she leaves threatening to never return. She is angry with me that I will not give her Ambien.

I end my day with a new patient, a nine year old female, accompanied by her mother, both of whom become tearful because sleep is so difficult for this young client. Again, I review sleep hygiene. We discuss medications to help her sleep, but I remind them that things may get worse before they get better. This comment, as I later learned from the mother, was "incredibly destructive" . The little girl felt more hopeless. Upon further review of the situation, I come to understand that although the night time is not smooth in that there are awakenings quickly followed by going back to sleep, she is sleeping roughly nine hours a night. The deeper issue is that this little girl has many worries during the day. I conclude that she is tired because her anxiety exhausts her. As such, I want to change the focus away from the "sleep issue" and reframe it as an anxiety issue. This family is not happy. They want me to guarantee that a particular medication will solve her sleep problem. I cannot do that. They leave thinking about how they want to proceed.

Although the importance of a good night's sleep is clear, in these two clinical situations, sleep has become a stand-in for inner peace. Both of these clients are looking to feel comfortable internally. However, it is hard to articulate the internal discomfort, and it is easier to focus on sleep since that is a measurable experience. I return to the messiness of my field. Words are sometimes hard to use. Medications can be useful, but they can also be harmful. My new patients and my long term patients get frustrated with me. I want them to be happy. I want them to feel better, but at the same time, I need to think about the long term. I need to think about solving the big picture problem as well as the small picture problem.

Sleep is a naturally recurring state of relatively suspended sensory and motor activity. To some, it is a symbol of peace. To others, it is an escape from life. On this particular day, these two clients understood sleep to be the essence of mental health. My efforts to encourage both of them to work on their mental health so that the body will return to its genetically pre-programmed urge to sleep was met with hostility and disappointment. Subsequently, my sleep was disrupted. I wondered how to communicate in a way that was not so far from their expectations. My challenge remains.

About the Author

Shirah Vollmer, MD

Shirah Vollmer, MD, is an Associate Clinical Professor of Family Medicine and Psychiatry at the David Geffen School of Medicine at UCLA.

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