Understanding sleep afresh
By Deepshikha Punj | Published: 28th July 2013 12:00 AM |
Did you know that a lover’s spat and sleep have an inversely proportional relationship? According to a research released earlier this month by UC Berkeley, sleepless nights can worsen couple fights. Psychologists Amie Gordon and Serena Chen found that people are much more likely to lash out at their romantic partners over relationship conflicts after a bad night’s sleep. UC Berkeley professor Chen, says, “For the first time, to our knowledge, we can see the process of how the nature, degree, and resolution of conflict are negatively impacted by poor sleep.”
So if you were wondering why you are in a constant struggle in your relationship, look closely, you may be ignoring a banal routine that most of us typically don’t give much thought to: sleep.
In a recent study conducted by AC Nielsen and Philips, involving 5,600 respondents across 25 cities in India; 93 per cent Indians were sleep deprived and surprisingly only two per cent went to discuss their lack of sleep with a physician while 15 per cent face difficulty in concentration due to sleep deprivation and 62 per cent displayed a high risk of Obstructive Sleep Apnea.
This situation has also given rise to a marginally large ‘sleep industry’ in the country. Corporate estimates put the market for sleep products in India at around Rs 16,000 crore, where nearly 70 million Indians are affected by sleep disorders.
An often less understood phenomena, sleep is intertwined closely with human behaviour; and only recently has research thrown open the doors to decode its labyrinth. Dr Deepak Raheja, Psychiatrist and Psychotherapist, Director, the Hope Foundation and Head Psychiatry and Psychotherapy, Paras Hospitals, Delhi says, “Studies indicate that sleep has an impact on a large array of physiological and psychological processes. It plays a crucial role in all our physiological systems, enhancing the growth and repair of our immune, nervous, muscular, cardiovascular, endocrine and skeletal systems. It is the body’s antidote to the damage done to our bodies during the course of the day, replenishing our immune system, eliminating harmful free radicals, and warding off heart disease and mood problems.”
Raheja adds that interestingly sleep is involved in memory processing. “This includes the consolidation of learning, mental relaxation and the regulation of important hormones,” he says.
However, the study of sleep is incomplete without identifying its disorders; and one of the most common which Indians suffer is insomnia and the lack of sufficient sleep. Raheja says, “Several studies have discovered that lack of sleep influences different parts of the brain such as the amygdala which decodes our emotions, the medial frontal cortex which regulates our emotional responses. A causal relationship between impaired sleep and psychiatric symptomatology has been observed.”
He also observed that sleep deprived individuals exhibit mood disturbances, difficulty concentrating, difficulty making rational decisions and sound judgements, impulsive behaviour, persecutory ideation, hallucinatory experiences. All of which may also be observed in a psychotic episode.
However, Dr Mohankumar Thekkinkattil, Senior Consultant Pulmonologist at Sri Ramakrishna Hospital in Coimbatore has a different opinion. He says, “Although there has been ample study done on sleep, its disturbance can occur and produce behavioral changes and it should be taken as such. Do not club sleep disorders and psychosis together.”
In a study conducted by AIIMS in 2009—which was done on 380 road traffic accident (RTA) victims who had suffered minor injuries—it was observed that a significant number of commercial drivers involved in road accidents had abnormal sleep patterns. According to the study, 60 per cent of those who got injured in such accidents had not slept properly a night before the accident and 15 per cent had abnormal sleeping habits.
Raheja says, “Sleep disturbance is often an early symptom of an impending mental illness. Psychiatry and psychology have defined distinct class of sleep and arousal disorders such as insomnia; hypersomnia or excessive amount sleep; narcolepsy or excessive day time sleepiness; obstructive sleep apnea syndrome; nightmares; circadian rhythm sleep disorders such as jet lag or shift work (night shift); or somnambulism.”
Pandi-Perumal Seithikurippu Ratnas, Independent Researcher, President and Chief Executive Officer, Canada, Medicine and Sleep Medicine, in his long-standing career has written several papers, books and journals on the subject. Ratnas along with Rocco R Ruoti, Milton Kramer edited a book called Sleep and Psychosomatic Medicine. The writers focused on the emerging challenges in the fields of both sleep and psychosomatic medicine. “Psychosomatic illness can generally be considered as physical illnesses that are believed to be psychologically based; hence they are often referred to as “psycho physiological” disorders,” the book says.
Experts believe that in order to completely understand the phenomenon of sleep, one must understand the problems that one may face due to lack or too much of it.
The hygiene of the night
According to a recent study conducted by AC Nielsen and Philips, involving 5,600 respondents across 25 cities in India; 93 per cent Indians were sleep deprived and surprisingly only two per cent went to discuss their lack of sleep with a physician. The study which included people between the age group of 35 and 65 years also observed that only 87 per cent agreed that lack of sleep affects their health.
Bidur Dhaul, Senior Director, Home Health Care, Philips Healthcare India says, “We observed that the top four sleep disorders that Indians suffer from include insomnia—trouble falling asleep or staying asleep, restless legs syndrome—strong urge to move your legs while sleeping, narcolepsy—this disorder causes extreme weakness and bouts of falling asleep during the day and sleep apnea—pauses in breathing or shallow breathing while sleeping.”
The report also highlights the result of these disorders. “We found that 72 per cent wake up one to three times every night, 58 per cent feel their work suffers due to lack of sleep, 38 per cent have seen a colleague falling asleep at work, 15 per cent wake up over stress at work, 11 per cent take leave from work due to lack of sleep, 15 per cent face difficulty in concentration due to sleep deprivation and 62 per cent displayed a high risk of Obstructive Sleep Apnea,” says Dhaul. Clearly indicating that in India, sleep disorders represent a significant yet overlooked health problem; and is evident from the fact that by 2010 end there were only 170 sleep labs in India.
“There are about a 100 sleep disorders which humans suffer from and yes, these are in fact the top four including inappropriate sleeping hygiene,” says Dr Preeti Devnani, the Clinical Director of Sleep Disorder Clinic in Mumbai and a consultant physician at the Jaslok Hospital and Research Centre, Mumbai, Department of Neurology and Clinical Neurophysiology and Sleep Medicine. Recent studies have also shown that one in five adults shows signs of chronic sleep deprivation, and a shortage of sleep has been linked to health problems as different as diabetes and Alzheimer’s disease. Recent studies have found some interesting connections between illness and what is happening in our brains as we snooze. Devnani, however, says that these disorders are also a result of undiagnosed medical conditions, some merely relying on myths.
Fact from fiction
Sleep may be a subject of global medical discussion; myths associated with it are what refrain people from participating in sleep studies that better understand the subject. Dhaul says a perfect example of this can be found in India. “In India, many people say “Oh look, he is snoring, must be sound asleep,” on the contrary, that person may actually be suffering from a sleep disorder and needs to undergo proper diagnosis,” he says.
Top ten popular ‘beliefs’ which refrain people from even knowing the nature of sleep disorder they may have include believing that sleeping eight hours for ‘complete rest,’ or more sleep is better, you can make up for lost sleep by sleeping in on the weekends, if you cannot sleep rest in bed, or watching TV is a good way to relax before bed, snoring is harmless, alcohol helps to sleep better, an afternoon coffee won’t affect your sleep, bedroom should be warm and cozy, taking a nap will mess with your sleep at night, exercising at night will keep you awake or that it’s OK for your pet to share your bed. Surprisingly, they are all untrue.
Busting the myths, Devnani says, “Television in the bedroom is bad sleep hygiene, it interferes with sleep and stimulating frequency of not only TV but all electronic media such as computers, iPads, Blackberry and so on. They all emit light and this light has an adverse effect on the rhodopsin pigment that in turn stimulates the suprachiasmatic nucleus. Afternoon coffee if taken too late can have an adverse effect on your health as it increases awakening so you don’t want to have caffeinated drinks late evening.”
She says that other common myths include cozying up the bedroom. “The bedroom should not be too warm and cozy. In fact it should have a cooler environment. And what is advocated is a warm bath a little before sleep which increases the body temperature and that temperature starts reducing as you sleep in a cooler environment and induces sleep.” A nap late in the afternoon also impedes the ability to sleep at night. “Because you’re body is already getting some rest and so you have a reduction in your homeostatic drive. So you want to nap, it is short and is finished by 4 in the afternoon, not later than that,” she says. The other myths on the list include prevention of Rapid Eye Movement sleep in the human as by severe insomnia may be a factor in the precipitation of acute psychosis. As well as persons experiencing sleep insufficiency are also more likely to suffer from chronic diseases such as hypertension, diabetes, depression, and obesity, as well as from cancer, increased mortality, and reduced quality of life and productivity.
Dr Samir Parikh, Director, Mental Health and Behavioral Science, Fortis Healthcare, Delhi, says, “First up sleep deprivation can have various impacts including psychosis, this is mostly a research finding and thus the REM. Some of the other common myths are that sleep tablets are harmful, or occasional self-medication of sleeping tablets is okay, or dream content is important and weekend sleep can compensate for weekdays sleep.” Parikh adds an interesting observation. “Nightmares can be associated with panic attacks in sleep and irregular sleep, and they may need treatment,” he says.
If these are all myths then does ‘too much sleep’ exist? Devnani explains, “There is a u-shaped curve, which is explained in the studies done on the cardio vascular risk factor of sleep. If you sleep for less than four hours and more than 10 hours, both have adverse effect on your life including cardio vascular parameters and mortality, so both are harmful.”
Interestingly, sleep, too much or lack of it, has led to the formation of a huge ‘sleep industry’ which thrives on a combination of comfort and medical repercussions.
The Market Science
Industry estimates put the market for sleep products in India at around `16,000 crore, where nearly 70 million Indians are affected by sleep disorders. ITC recently undertook a survey on the industry and revealed that almost 70 per cent of business travellers found it difficult to sleep in the unfamiliar surroundings of a hotel room. Nakul Anand, ITC’s business chief and executive director says, “In a different city and a different environment from morning until night, they basically need the hotel just to catch up on their sleep. You can offer the finest services and the greatest cuisines housed in the most stunning architecture, but if you haven’t slept well, the purpose of your visit is completely defeated. In fact, many hotels have spoken about the bed that they’ve introduced.” ITC has also introduced a ‘sleep menu’, which includes a choice of pillow sizes and density, a range of calming aromatherapy essential oil sprays, in-room foot massages and even a ‘dream-kerchief’ - a handkerchief doused in aromatherapy oils.
They also have a specially designed WelcomSlumber kit that the customer will find in ITC hotels. “This is the result of extensive research wherein apart from an eye mask and ear plugs we provide our guests with a selection of aroma-therapy products,” says Anand. ITC has also started a sleep index for its hotels where it tracks reasons why a guest has not slept well. Anand adds, “We are working on a chocolate now, which induces sleep with carefully paired natural ingredients that are known to have a soothing effect on the system, gently.”
T Sudhakar Pai, Managing Director, Kurlon says, “To put things in perspective, we usually spend about 7-8 hours (1/3rd of our day) sleeping on the mattress. When we sleep, our spinal discs rehydrate, recuperate from the strain of the day and regain their elasticity. That’s why it is so important to get a full night’s sleep.” He says that mattress industry has also grown exponentially in our country.
Interestingly, companies such as Philips and GE are also expanding their in-home sleeping aid devices business, while demand for anti-snoring devices and sleep products too is growing, they say.
Dhaul says, “Our study revealed some startling facts about the nature in which sleep is treated in our country and a combination of comfort and medical repercussions has helped us design several instruments which aid quality sleep.”
According to a recent study by BBC Research, globally, the market for sleep aids is estimated to be more than $33 billion by 2014. Philips alone has set up 200 sleep labs in hospitals and clinics across the country. “We are trying to help doctors accurately diagnose sleep disorders. The company says its in-home sleeping aid devices are growing at a double-digit rate,” says Dhaul. Among its high range of products, Philips has designed some interesting sleeping-aid products including the RUSleeping RTS which is an in-home objective screening device that provides continuous apneic event scoring, or improved humidification Dry Box.
While the Philips range of in-home sleeping aids is sold in anything between Rs 25,000 and Rs 60,000, GE India has priced its products between Rs 30,000 and Rs 4 lakh.
Additionally, several drinks have been introduced to induce sleep. For instance, the Himalaya Drug Company has rolled out a sleep tea which acts as a relaxant and mild sedative. A statement by the company says that its other two sleep-support products—Ashvagandha and Tagara—too are growing at 42 per cent and 15 per cent, respectively.
Technology has also helped the ‘sleep industry’ grow. While few of the top selling applications for Apple’s iOS includes ‘Sleep Pillow Sounds’, which generates background noise that helps fall asleep; for Android, their ‘SleepStats’ app is quite popular and tracks the users sleep pattern.
Clearly, sleep is no mean task, from creating specialized laboratories to specialist doctors, and a whole new industry, this mysterious phenomenon will soon no longer be mysterious.
THE BIG PROBLEM
AAC Nielsen-Philips research found that around 62 per cent Indians suffer from Sleep Apnea. This disorder is characterised by pauses in breathing or instances of shallow or infrequent breathing during sleep. Each pause in breathing is called an apnea and can last from at least 10 seconds to minutes, and specialists say may occur five to 30 times or more an hour.
Similarly, each abnormally shallow breathing event is called a hypopnea. Sleep apnea is often diagnosed with an overnight sleep test called a polysomnogram, or “sleep study”.
Dr Mohankumar Thekkinkattil explains, “Sleep apnea is a cessation of breath for 10 seconds or more. So there will be desideration and this will produce various changes in the body. There is a cure by putting the patient on Continuous Positive Pressure devices called CPAP. Sleep apnea, bruxism, sleep walking, insomnia, nocturia, erectile dysfunction, behavioral changes occur due to shifts in metabolism and sympathetic activity in the night.”
He adds that there are three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (which is a combination of central and obstructive) constituting 0.4 per cent, 84 per cent and 15 per cent of cases respectively. “In a person suffering from CSA, breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to airflow despite respiratory effort, and snoring is common,” he says. Some experts also suggest that there are 120 million adults with OSA in India.
However, simple observations can help identify and diagnose the problem better. Generally, symptoms of OSA begin insidiously and are often present for years before the patient is referred for evaluation. If a person is found snoring, usually loud, or has insomnia; restless sleep, frequent arousals and tossing or turning during the night, he or she may be showing nocturnal symptoms of OSA. The daytime symptoms include non-restorative sleep, morning headache, dry or sore throat and excessive daytime sleepiness.