Hennepin County's sleep-disorder clinic is world-renowned, in part because staff separates stigma from sleeplessness
Imagine a hellish symphony of 32 kindergarteners rubbing smooth and serrated sticks together in their first music class. Yet viewed on grainy, black-and-white video, this is the work of just one set of jaws; molars on molars, grinding with more power during sleep than their middle-aged owner could ever muster while awake.
The horror-movie sound nearly eclipses something more extraordinary: this sleeping woman is eating popcorn. She unzips a Ziploc bag of popcorn on her bed, grabs a fistful, throws it towards her mouth (most of it makes it in) then carefully reseals the bag and returns it to its spot.
She's a sleep-eater. And on any given night, one of the six to eight patients being monitored in Hennepin County Medical Center's Minnesota Regional Sleep Disorders Center is likely eating, or doing something even more interesting in their sleep.
If the bag weren't on the woman's bed, she'd probably rip the electrodes from her head, jump the bedrail and hunt for food (or anything that can pass for it) even where she is being diagnosed. According to Dr. Mark Mahowald, the clinic's director, not even combination locks on cabinet doors deter sleep-eaters. "They just unlock them," he said with a shrug.
Mahowald is used to (as he puts it) such "strange but beautiful" stories.
The soft-spoken, bespectacled physician is, in his quiet way, a sleep revolutionary who has helped strip the stigma from sleep problems.
Twenty-five years ago, Mahowald said, he was taught that unusual sleep patterns indicated deeper psychological problems. He taught this to students until the '80s, when he and his University of Minnesota research partner, Carlos Schenck, decided to test 100 people with major sleeping disorders for evidence of psychological problems.
They found the overwhelming majority to be in good mental health, and their stirring findings helped spur a sort of sleep-disorder transformation.
Many doctors now understand that sleep disorders are primarily biological. Researchers have found that people inherit predispositions towards the disorders, just as they do for some physical and mental illnesses.
Mahowald explains there are basically three stages of human existence: wakefulness, REM sleep (when you dream the most and your brain is very active, more so than when you're awake) and non-REM sleep. Until recently, scientists believed these states to be walled off and distinct. What Mahowald and other sleep researchers have found, though, is that these states can, and do, overlap. And it is in these overlapping states, he said, "where things get interesting."
At the eighth-floor clinic, infrared video cameras capture clinic patients' bizarre, unconscious moves -- pounding, running, thrashing -- and sounds: screaming, muttering, groaning, lip-smacking. A web of wires and electrodes, primarily attached to heads and jawlines, reveal brainwaves.
By correlating the video's dramatic episodes with the jagged peaks and plummets in the EKGs, Mahowald and the other doctors, nurses and students diagnose and treat their patients. The documentaries of the nexus of sleep and wakefulness contribute to Hennepin County's renowned research in the emerging sleep studies field. (The 914 S. 8th St. clinic -- part of the Minneapolis Medical Research Foundation and the University of Minnesota -- is also celebrated for training hundreds of doctors who staff sleep clinics worldwide.)
Patients most commonly have sleep disorders such as insomnia, sleep apnea and night terrors. Overnight observations are reserved for the more unusual and extreme cases.
Many patients have what Mahowald refers to as "sleepwalking disorders" -- involuntary movements during non-REM sleep. While eating or running in bed -- or outside but unconscious -- can seem unusual and dramatic, the doctor estimates that 5-10 percent of adults (that would be about 1,750 to 3,500 of you reading this paper), suffer from some kind of sleepwalking disorder. Another one in every 200 adults lives with a secondary parasomnia called REM Behavior Disorder or RBD, Mahowald said.
About four years ago, retired high school biology teacher Noel Faber, now 57, realized he had a sleeping problem, "in reference to some of the kinds of movements I was having that would wake me up, and things of this sort," he said.
Such "movements" included a sort of full-body convulsion -- a lateral jumping in bed. Then, he said, he would act out his dreams, kicking, thrashing and worse.
"A couple times I actually threw myself out of bed," Faber said -- and he doesn't mean rolling off. "In my mind, at least, I was in danger and someone was after me. And in the process of trying to get away I basically [stood up on and then] dove out of bed onto the floor."
After a few bumps and bruises, he decided to do a little research online. While Web sites were no substitute for doctors, he said they did reinforce the idea that he had a legitimate, even a fairly common, medical concern. This, he said, made it much easier for him to come into Hennepin County's sleep clinic.
Faber described his sleepover at the center as "an unusual but not unpleasant" experience. "It takes about 30-45 minutes to hook up all the electrodes," he said, adding that it was a little strange to try to sleep in a bed with metal rails on it, knowing cameras are recording your every move. "But eventually I settled in for one of the best night's sleep I'd ever had."
Researchers got what they needed -- Faber's EKG revealed a dual diagnosis. The lateral jumping was a severe version of a common sleep phenomenon, myoclonic contractions. As people finally begin to drift off, many are jarred awake as they "step off a curb" and their foot jerks and they feel like they're stumbling or falling. Multiply that by 10 for Faber's case.
As for his thrashing, the EKG revealed that Faber's brain "forgets" to throw his body's switch into paralysis mode during deep REM sleep, when most dreaming occurs. Don't flip that switch, and a person will physically act out their dreams.
Faber said he has been sleeping fine ever since he left the clinic. They diagnosed him the morning he woke up and he received a prescription for an effective tranquilizer that, he said, does the job -- and keeps him from waking his wife Ronni, an elementary school teacher.
Faber is quick to mention that others' untreated disorders were much worse than his own. Some wake up with broken bones or lacerations from walking through windows, or to find that they have unwittingly beaten their wife, mistaking her for an intruder. "Some people have gone to the extreme of having someone strap them in at night," he said.
Such home remedies testify to the strength of the stigma attached to sleeping disorders. People often don't go in for treatment, Faber said, because they are afraid the doctor will either tell them not to worry about it or, on the other end, that they need to see a psychiatrist.
"There's things going on in the brain and in the nervous system [with sleeping disorders]," Faber explained, "but that in and of itself does not mean that a person has a mental disorder."
General practitioners -- the doctors people first approach when they have a problem -- do not always know much about research that has largely happened in the past two decades. The idea that sleepwalking indicates a mental disorder remains in some medical textbooks, Mahowald said. "Once something gets in the literature, it's like a bad smell -- it's really hard to get out."
Researchers have found that individual human sleep constitutions are distributed in a bell curve. On one end there are people who can fall asleep anywhere and, it seems, at any time. On the other are the fragile sleepers, the ones awakened by barking dogs a block away and whose circadian rhythms are most easily knocked off course.
While Mahowald emphasizes sleeping disorders' biological roots, he does not deny that psychology and society play significant roles.
"People get 20 percent less sleep now than our ancestors did a hundred years ago," Mahowald said. "In our society, sleep deprivation is a badge of honor . . . And rather than saying, 'OK, I want to do this new thing, so I'm going to drop this old one,' people just cut back on their sleep. But it's a biological imperative, not a negotiable commodity."
Societies such as ours, where sleepiness is perceived as slothful, are bound to see a jump in sleep disorders, Mahowald said. Sleep deprivation, along with stress and alcohol consumption, can trigger an inherited disorder. And while it's impossible to know for certain, there is a general consensus that sleeping disorders are on the rise.
Individual psychology can also play a major role treating disorders, or making them worse. Mahowald said he spends much of his time simply reassuring people that they're normal, and that this alone can be enough to solve their sleep problems -- they don't need to stay in the labs or take medication.
He said one common male sleepwalking habit is to wake up with a full bladder and, being just half-awake, walk into and pee in a closet. When some men are told that it's basically a common and certainly not life-threatening unconscious habit, this can decrease their stress enough to prevent further occurrence.
"Learned insomnia" is also fairly common, he said. In short, a person wakes up in the middle of a night for a legitimate reason -- a loud noise, a cramp, a cat jumping on the bed, etc. -- that they may or may not recall. They then try to force themselves back to sleep (which is pretty much impossible, Mahowald said) and end up making an unconscious association between bed and frustration. Thus, the next night, they wake up without the legitimate reason, stress about it and the cycle repeats.
Mahowald's clinic primarily treats "learned insomniacs" with behavioral techniques -- keeping a sleep diary and following certain rules, such as don't do anything productive at 3 a.m. -- prevent positive reinforcement. They also say don't stay in bed when you're unable to sleep. Mahowald said such techniques and/or medications can successfully treat about 99 percent of all sleeping disorder cases.
He adds that clinic staffers do occasionally find that patients suffer from a psychological problem: nocturnal dissociative disorders. People in dissociative states basically act out physical, verbal or emotional abuse in a state that appears similar to but isn't the same as sleeping.
Despite the success rate, sleep experts estimate that only one in five people with sleep disorders ever comes in for treatment. Mahowald suspects that there are many more people in the metro area who should, but most likely won't come into the clinic. He said most people, at the least, are sleep-deprived.
How many people sleep normally? "I don't know," Mahowald said with a laugh, "they don't come in here."
How does he sleep? "Like a log. I practice what I teach."
Sleep tips: you snooze, you win
- People can't sleep longer than they need to. So if you or your kids sleep late on the weekend, don't worry about it. Teens, on average, need more sleep, approximately nine hours per night.
- Lying in bed awake for more than 15 minutes leads to sleeplessness. Get out of bed and do something without any positive reinforcement, like watching infomercials on late-night TV, and return when sleepy.
- Some medications produce sleeplessness or insomnia, including antidepressants such as Prozac. Ask for an alternative.
- People only need to make up one-third of the sleep they lose. For example, if you need eight but get just six hours sleep three days in a row, you're down six hours. Sleep an extra two one night, and you're fine.
- Individuals' sleep requirements vary, but you know you're sleep-deprived if you nod off during a boring meeting or lecture, long car rides, etc. Boredom doesn't make you drowsy; sleep deprivation does.
- Alcohol and caffeine hurt sleep (alcohol has a sort of wake-up backlash after the slow-down phase), but sugar usually doesn't.
Source: Minnesota Regional Sleep Disorders Clinic
Sleeping disorders A to Zzzz
There are over 80 official sleeping disorders, here are a few of the most prevalent.
- Excessive Daytime Sleepiness (EDS) features excessive drowsiness during the day and an overwhelming urge to fall asleep, even after getting enough nighttime sleep.
- Narcolepsy features sudden, uncontrollable episodes of sleep at inappropriate times, such as while having dinner, driving, etc. It can also manifest as an inability to talk or move when falling asleep or waking up.
- Sleep Apnea is a potentially life-threatening breathing disorder that affects 6 million adult Americans. It features interruptions of airflow caused by brief closings of relaxed throat muscles.
- Periodic Leg Movements in Sleep (PLMS) consists of body movements the sleeper is unaware of. People with PLMS often complain of insomnia and frequent awakenings from unrefreshing sleep.
- Restless Legs Syndrome (RLS) is marked by uncomfortable leg sensations -- burning, tingling, a "creepy-crawly" feeling -- that occur continually while the body is at rest.
- Circadian Rhythm Disruption More than 25 million Americans have nontraditional work schedules. No matter how long they work a "graveyard shift," however, they may never adjust to sleeping during the day. These struggles are biologically based, such schedules conflict with most people's biological clocks. This can result in impaired job performance and increased accidents, as well as memory, stomach and weight problems for workers.
Source: National Sleep Foundation
If you think you have a sleeping disorder, call the Minnesota Regional Sleep Disorders Center, 873-6201, to schedule a clinic appointment.
Stirring sleep facts
- Researchers estimate the direct cost of sleep deprivation and disorders to be $15.9 billion. Although it is still being researched, it is widely accepted that sleep-deprived people think and move more slowly. They also make more mistakes, have lower job productivity and can cause accidents, leading to an additional $150 billion in indirect costs.
- Approximately 100,000 police-reported crashes annually involve drowsiness/fatigue as a principal causal factor. Including at least 1,500 fatalities and 71,000 injuries.
- Research points to links between sleep deprivation and depression in teens and between untreated insomnia and depression in adults.
- Some studies indicate a link between certain sleeping disorders and Parkinson's Disease and heart problems.
- Most disorders involving the acting out of violent dreams occur with men over 50.
- Some suicides may be related to sleep disorders. For example, a train hits someone who runs in their sleep, or someone fleeing dream-time monsters jumps from a high-up window.
Sources: National Sleep Foundation, U.S. National Highway Traffic Safety Administration, Minnesota Regional Sleep Disorders Center