Chasing the dream of a good night's sleep
A full night's sleep seemed like pure fantasy to Erin Anderssen, until a quest to solve her chronic fatigue led to a failed bake-off, midnight pep talks and a sleepover under the watchful eye of a clinician wielding electrodes
On a single bed in a spartan, narrow room at the sleep clinic of the Royal Ottawa Hospital, a technician is carefully gluing the last set of electrodes to my face. It is around 10 p.m. on a Monday in November, and I am already in pyjamas, as per instructions, prepared to spend the night. Five other patients are being wired up in their own rooms. The entire process takes about an hour, and Mike Godbout, a soft-spoken psychology grad who has been watching people sleep at the clinic since 2003, makes sure I stay seated – a nervous patient once fainted on him.
People come to the Royal, the main mental-health hospital in the capital, for all kinds of sleep disorders. This includes sleepwalkers and sleep eaters, patients who consume muffins unconsciously in the middle of the night, with only the crumbs as evidence in the morning. Others have REM sleep behaviour disorder, which causes them to act out their dreams. (After one male patient leapt up in his sleep, punched a wall with his fist and broke his hand, clinic staff moved the beds.) But it's snoring that often brings people here, particularly men whose partners can no longer handle the jet engines revving on and off from the pillow beside them.
I am here to investigate why, for all my hours in bed, I still wake up tired. Not long ago, I was a night owl by choice, and sleep was mine to control. But recently it's become work, a test I keep failing. I am hardly alone: According to a 2016 survey conducted by Angus Reid at the behest of the Dairy Farmers of Canada (to "encourage healthy living," the group said), 67 per cent of Canadians said they wish they could sleep better, and 45 per cent said they woke groggy most mornings after a restless night.
Lousy sleepers have their own stories. In my case, I can fall asleep easily, but regularly wake up in the middle of the night, tossing and turning with worry for an hour or more, then rising in the morning foggy-brained and stressed about not having slept well.
As one expert explained, this is partly due to environment and biology: fortysomething, caffeine-addled working parents with snoring partners lose sleep like socks in the laundry. But while wearing mismatched socks won't kill you, chronically poor sleep can make you sick. Research suggests it increases the risk of dementia, cancer and heart disease. It's linked to anxiety, depression and weight gain. (It also gives you wrinkles.) The point is, there's no shortage of science to distress the sleepless. Thus incentivized, I set out to find a good night's rest. And what I learned, during months of investigation, is that when it came to sleep, I'd been telling myself the wrong bedtime story.
The blue numbers on the oven read 3:22 a.m., and I am standing in my kitchen, watching the timer tick down the 20 minutes that it takes to bake banana-chocolate muffins, trying to remember if I added the required cup of sugar to the bowl. It's early on in my own ad-hoc sleep study, and I am testing out one of my first lessons gleaned from Google: If you can't sleep, don't stay in bed stewing about it. Anxiety about not sleeping tends to make insomnia worse, and experts suggest that a good way to cut the worry loop is to distract the brain with another activity. A sleep app on my phone suggests knitting, decluttering or menu-planning. But I read somewhere about an insomniac who got out of bed and baked, which sounded more appealing than cleaning out a drawer, and more productive than my typical early-morning habits of watching old Saturday Night Live skits on YouTube and looking up the whereabouts of celebrities – where are you now, Nathan Fillion? – while tucked under the covers to hide the blue light of my smartphone. (WiFi: the serial sleep killer.)
I am not much for baking even when the sun is shining, but there is something meditative about doing it in the middle of the night, without any distractions. The oven is warm, and sleep beckons. It's working! But then the flaw in the plan is revealed: I would like to go to bed, but the darn muffins aren't finished. By the time their tops are browned, my eldest has woken up for rowing practice, and the newspaper has arrived. Going back to bed, on this October morning, seems pointless. Baking as a sleep exercise was a bust. It cost me four hours. "I thought it was a dumb idea," my husband tells me when he rises, annoyingly chipper. "But the boys and I really wanted muffins."
Exploring a more mindful path to better sleep, late last fall I visit Mary Ann Juurlink, a yoga instructor in Chelsea, Que., who runs sleep sessions for her clients. She has them keep a detailed sleep diary, including what they ate each day to monitor how their sleep is affected, teaches them a series of stretches focused especially on the neck and shoulders, and proposes relaxing bedtime habits, including avoiding stress-inducing news or televisions shows. (Some of this she learned from her 92-year-old mother, who sleeps blissfully, swears by cherry juice – a traditional sleep remedy – and a strict bedtime schedule.)
Sitting by the fireplace in her yoga studio, picture windows offering a view of snow-tipped trees, Juurlink tells me that when she can't sleep, she sometimes comes down here and stands on her head for 10 minutes. "Then I go back to bed and sleep like a baby." There's no way I am doing a handstand – even for 10 seconds. Instead, she prescribes slow meditative walking, with my eyes closed and the lights off, beside the bed. (I try this for several nights: As it turns out, concentrating on not stubbing your toe on the bedroom bookshelf does focus your thoughts.) All these steps, she tells me, "are very helpful." But if poor sleepers could follow only one piece of advice, she says, it's to stop being so hard on themselves. "If you dump it all you go right to the best result, which is: I am fine. I didn't sleep a lot last night. I will sleep more tonight."
Juurlink isn't a psychologist, but exploring sleep has led her naturally to some of the key lessons of cognitive behavioural therapy (CBT), one of the most scientifically studied and effective therapies when it comes to treating insomnia.
If sleep was an exam, apparently I'd fail. According to the survey I completed online, my score is 3.8 out of 10, or POOR, as I am informed in big block letters. I've decided to experiment with online CBT – downloading a couple of apps, signing up for an online therapy program, picking up a sleep workbook at Chapters. Quantifying and documenting is a big part of it, so that people can get a true picture of their sleep and recognize patterns to help them improve. There is no shortage of options to try – desperate insomniacs are lucrative consumers – and some will cost you hundreds of dollars.
But all the CBT-based programs are designed around a central idea: that by teaching someone the science of sleep, by analyzing how much and how well they sleep, they can improve their mindset about sleep and make constructive changes that can cure insomnia. This includes calculating sleep efficiency – how long you spend in bed versus how long you are actually asleep. (A typical recommendation for insomniacs, who tend to be highly inefficient sleepers, is to avoid napping and to stay awake until they are sleepy, to build up their "sleep bank.") CBT also requires keeping a sleep diary to track changes and set a schedule, especially for waking up.
Aside from documenting, CBT also targets self-talk, teaching new middle-of-the night mantras to soothe the worrying mind. For example: "I am awake alone at 3 a.m., but that's not the end of the world." Education is meant to be reassuring, particularly about the fact that people almost always underestimate their sleep; they get much more than they think. (The sleep clinic at the Royal sees this all the time.)
I choose an online program that costs around $60 – a five-week course designed by Dr. Gregg Jacobs, a sleep expert and assistant professor of psychiatry at the University of Massachusetts Medical School, that includes lesson plans and an individual response to sleep diaries.
My sleep diary reveals that I was getting about seven hours a night, even with wake-ups – within the normal adult range. "Use this as a positive sleep thought," I was advised by Jacobs via e-mail. "Keep in mind that you are likely obtaining more sleep than you think." Sleeping too long, I am informed in an early lesson, can also be hazardous to your health, a point reinforced by the citation of a massive longitudinal study from Norway that found that adults who slept longer than nine hours a night, on average, died younger than those who slept six hours. For the wonky insomniac, the program offers access to pages of sleep research.
The CBT made one important difference: When I woke at night, I practised telling myself not to worry about it, eventually falling asleep more often without getting up. I was also told to go to sleep no earlier than 11 and wake up at 6:30. But staying up until 11 was difficult, and I still felt sleepy during the day. If I was getting enough sleep on paper, why was I still so tired? One recommendation that came back: "Consider an evaluation at a sleep clinic."
By the time Mike Godbout left my temporary sleeping quarters at the Ottawa clinic, he'd attached 17 electrodes on to my legs, face, the top of my head, under my chin. The sensors measured leg and eye movement, recorded brain waves and assessed muscle tone. This last helped to assess if my throat constricts at night, cutting off oxygen to the blood, a serious condition called sleep apnea, where people briefly stop breathing while they sleep, and of which loud snoring is a primary symptom. To track oxygen, Godbout slid a sensor onto my index finger. Finally, he handed me a two-pronged "nasal pressure transducer" to plug into my nose. A camera recorded my sleep position. A microphone captured any snoring. Godbout leaves me alone, with a couple of magazines on the bedside table. A minute later, I hear his voice, robotic through a speaker, bidding me good night.
"This is a picture of your sleep," says Dr. Elliott Lee, a psychiatrist and sleep specialist at the Royal, when we meet to discuss the results in his office the following day. He shows me a couple of graphs with jagged lines that tracked transitions through the various stages of sleep and monitored what happened to my breathing at the same time. Apparently I slept really well at the clinic, better than most patients. My oxygen levels also remained above 90 per cent; in severe cases of sleep apnea, oxygen levels in the blood can fall precipitously, and over time this can spike the risk for heart attacks, among other health problems. Overall, my sleep complaints are pretty average. "So that's all good," he says, "however.…"
What he did find was moderate evidence of something called upper airway resistance syndrome, a more mild form of sleep apnea, in which breathing becomes shallow enough to interrupt sleep very briefly, but not enough to lower the oxygen in the blood. This sounds harmless enough, until Lee offers this description: "It's as if someone is putting their hand around your neck, compressing just enough to wake you up and then letting it go," he explained. "Most people don't remember these episodes happening." Being choked multiple times a night sounds like a problem you should get fixed. It also happens more often in the REM sleep stage, which might explain, he says, why I wake up at night.
So what are my options? This is where it gets complicated, explains Lee, who is clearly fond of metaphors: Solving sleep issues, he says, is like taking your broken car to the mechanic. Maybe she fixes the engine, and it still won't start. She replaces the piston, and it works. That might lead you to think the pistons were the problem, when, in fact, the engine also needed fixing. In my case, Lee says, managing worry might help. Melatonin might be useful. Certainly, giving up my late-afternoon Starbucks lattes is necessary. (As well as cutting back on that evening glass of wine.) An electric fan to drown out a snoring husband is worth trying. But ultimately, Lee says, if you compare your sleep to a house, you first need a strong foundation. "When it comes to sleep," he tells me, "the foundation is breathing."
To help breathing during sleep, today's gold standard is what's called CPAP, the continuous positive airway pressure machine that pumps air into your nose through the night, automatically adjusting the pressure as needed. This is certainly a better option than a tracheostomy or jaw surgery – older treatments for sleep apnea – so, in December, I find myself sitting in a recliner in the office of Claire Laferrière, at Inspiration Medic, an Ottawa respiratory-care clinic, while she straps various masks to my face.
Laferrière explains that she used to see only overweight men in her waiting room, but now she treats teenage girls and athletes. Today, only 40 per cent of people diagnosed with sleep apnea are obese. What's more, she says, while being overweight puts you at a higher risk, sleep apnea itself can cause weight gain. Cut off from oxygen, your brain panics and releases sugar into your blood, but then you fall asleep too quickly to produce the insulin needed to process it. If that happens throughout the night, it's similar to eating chocolate bars in your sleep.
Some of her clients return after one night of using the machine and are transformed. She's worked with teenage girls suffering from depression who started on the CPAP and saw their symptoms resolve. Since my case is more mild, she says, it may not be so dramatic. Time will tell. She sends me off with a free trial of a beige and pink machine with a long tube and a shallow double-pronged plug that sits just inside my nostrils. If I choose to buy it, between OHIP and private insurance the machine will likely cost under a couple of hundred dollars. It's a good deal, but Laferrière can see I am resistant. Maybe I could just try yoga? Or lose 10 pounds. "It's okay," she says. She's seen my kind before. Often, she says, they bring the machine back. A few years later, she sees their names again on her appointment list.
For days, I leave the machine in its bag, thinking it over. I finally try it one night for four hours and get tangled up in the long tube. But then, over Christmas break, when I should be rested, I fall asleep in the movie theatre during the latest Harry Potter spinoff, just as the fantastic beasts are getting interesting. (Falling asleep when you don't want to is a worrisome sign; it's also why the risk of car accidents is higher among people with untreated sleep apnea.) So I decide to commit. On my third night, I sleep with the CPAP for eight hours, and when I wake up, I feel better. My family tells me I look like a patron from the Mos Eisley Cantina in Star Wars with the plugs squished up against my nose. But I am sticking with it, waiting to see how it turns out.
Update: For writer Erin Anderssen, finding a good night's sleep is still a work in progress. She is trying to stick to a schedule; thus, fewer smacks on the snooze button. She can now turn in bed without getting twisted up in the sleep-machine tube. She is waking up less often at night but falls asleep more quickly. And she considers it a successful sign that she hasn't recently been tempted to power nap in the washroom stall at work. Meanwhile, her husband, an impressive snorer, has been referred for his own sleep-clinic sleepover.