In this article we will be looking at the causes of sleep disturbance and the best way of coping with four sleep troubles that we encounter frequently in the course of our work: bed-wetting rhythmic movements, such as scratching and body-rocking’ the night wanderings of the elderly; and sleeping too much
Causes of sleep disturbance
If you have trouble getting to sleep, this last condition, no doubt sounds like a blessed state rather than something to worry about; but, as we shall be showing, it can prove to be quite a handicap.
1. Bed-wetting (enuresis)
Most small infants wet their beds until they are three years old, many up to the age of five, and some when they are seven they are and older. Each child is different in its rate of development of night-time bladder control.
Parents are human and it is not surprising that they may their irritation on finding their five-year-olds bed wet yet again in the morning.
But getting angry will only aggravate the situation by making the child feel guilty-unjustifiably-and thus possible prolonging the bed-wetting.
How it is that the sensations of full bladder control. In any case, with time, the bed-wetting will cease, except in very unusual cases. Sometimes a child has been dry and starts wetting the bed again after an emotional crisis, such as the arrival of a new brother or sister, or a few days in hospital away from home.
Again, parental patience and tolerance should be the order of the day.
A very few children have something wrong with their bladders or reflexes, so it is worth consulting a doctor if your child continues bed-wetting until school is started.
Generally, though, there is no known cause, and occasionally bed-wetting may persist into the teens or early twenties before it finally stops its own accord.
If tolerance, patience, and understanding seem, in time, not to be helping the problem, then with your child’s willing co-operation as an important factor, your doctor may suggest trying one of the following forms of treatment.
Various drugs have been tried in the past in an attempt to prevent bed-wetting. It used to be thought that perhaps children’s sleep was kept light by drugs like dexamphetamine (Dexedrine), and then the bed-wetting might cease.
These drugs, however, are no longer in fashion.
Some of the drugs given to treat adults when they are ill with depression, like imipramine (Tofranil) and amitriptyline (Elavil or Tryptozol) have a number of side-effects, including interfering with the normal nervous reflexes that are required to begin urination.
Older men can suddenly find themselves completely unable to pass urine when they have started on these drugs, and even women, for whom the act is usually simpler, may sometimes experience difficulty in getting going.
This action of these antidepressant drugs has been applied to the treatment of bed-wetting, and it does seem that, on average, they do offer some benefits.
However, drugs are dangerous in overdose. The safest and most useful method of treatment is the so-called ‘buzzer and pad’ system.
The ‘buzzer and pad’ system
Wetting the bed really does occur during sleep. It is not that the child lies there awake, and just empties his bladder in order to be mischievous.
Bed-wetting is one of those episodic disorders that occur most often in the early night, and almost always at the end of a period of deep slow-wave sleep.
Sleep is a time when learning does not readily occur; although the mental activity of sleep may be vivid, it is largely unremembered in the morning.
The ‘buzzer and pad’ system that can be prescribed by your family doctor has to contend with this that it is difficult to learn while asleep.
The idea behind the treatment is that as soon as possible after the sheets become wet the child should awake. In order to achieve this a special pair of pads with metallic contacts, separated by a dry sheet, are placed beneath the sheet on which the child lies.
A small difference of electrical potential is applied to the two pads so that when the sheet between them becomes wet, an electric current can pass which riggers off a loud buzzer. Thus, when the bed is wet, the buzzer goes off, and the child wakes up.
In the language of the Great Russian scientist, Pavlov, the loud noise is the unconditioned stimulus and the awakening is the unconditioned response.
Shortly preceding the loud noise, however, there must have been internal signals from the distended bladder to the nervous system, which were unsuccessful in causing awakening.
These signals that always precede the unconditioned stimulus. With repeated experience, over and over again, learning should take place (with luck), so that, when there is a strong conditioned stimulus of nervous messages from the tightly distended bladder, these alone should cause awakening, which could now be called a conditioned response.
Hey, presto! The full bladder in the night now causes awakening without the intervening wetting of the bed.
Complicated as this method sounds, it does work, though not quite always. The commonest reason for failure is probably the parents’ lack of understanding of exactly what they have to do.
If the child is woken up after wetting the bed they should get out and go to the lavatory to get rid of the urine that remains in his bladder, and a new, dry sheet should be placed between the pads.
Another reason for failure is that the child simply sleeps through the noise of the buzzer, while all the rest of the household are awakened.
A good technician can fix up an alternative device, by which a harmless electric shock can be delivered to the child’s leg, in place of the buzzer.
Even so, there are a few young people, who, despite repeated experiences over many months of being woken up after the bed is wet, fail consistently to awaken before it is wet.
For them, learning during sleep has not occurred. It is not their fault, it is just bad luck. There is another approach that can still be tried, and that is to find out when the bed-wetting characteristically occurs.
It may, for example, nearly always take place about two hours after going to bed. If so, it can be arranged for the electric stimulus to wake up the sleeper after about an hour and three quarters, so that he can go and empty the bladder, and thereby avoid wetting the bed.
Finally, it is worth repeating that no treatment for bed-wetting can work without the willing co-operation of your child.
2. Rhythmic movements in the night
While we are asleep, we lose many of our waking capabilities; but rhythmic movements are well within our compass and among these are scratching, tooth-grinding, and what is known as head-banging or body-rocking.
In children and adults who are prone to make these rhythmic movements, they can occur at any time of night, though least often in deep slow-wave sleep.
We have studied the sleep of many people with itchy skin conditions such as eczema and tried a number of drugs to relieve the itching but without a great deal of success.
Drugs that are specifically supposed to reduce itching seems to be no more effective than can be accounted for by the fact they make sleep rather heavier.
Mostly, the scratching occurs when sleep is fairly light, and the scratching is certainly one of the reasons why some skin troubles are perpetuated and made worse, since scratched skin has to heal, and healing skin is often itchy. It is a various circle.
Keeping your nails short and scrupulously clean is obviously a sensible idea if you discover that you must have been scratching while asleep but the solving of this problem is really a matter for your family doctor, and if he or she thinks it necessary, for a skin specialist also.
Tooth-grinding or bruxism as it is termed is quite common, particularly among children. The tooth grinder performs munching movements for perhaps ten seconds at a time that recur frequently during the night.
In adults, the movements are sometimes brought on by drugs, but generally are the persistence of a childhood habit that has not been lost. It causes concern to dentists who find the teeth more worn away than would be expected, and it can be disconcerting for a bed partner at least at first. It does not signify any serious trouble and certainly requires no treatment.
Headbanging and body rocking
Rhythmic head banging and body rocking like sleepwalking are more dramatic than significant. Rhythmic activity is relaxing and comforting; mother rocks the baby, granny is it’s in her rocking chair and gum chewing remains popular.
Infants whether they are infant monkeys’ chimpanzees or humans will often squat on their haunches and rock their bodies to and fro when they are frightened and lonely.
Others suck their thumbs. So one child when put to bed will suck his thumb and another will rock to and fro. The rocking may be a side to side movement of the had, perhaps with humming, or it may involve getting on to hands and knees and banging the head on the pillows.
It is commonest at around eighteen months to two years of age after which time it usually diminishes in frequency eventually to disappear with the passing of years.
A few children come to do it not only when they are first put to be but actually during their sleep. They may do it recurrently during the middle of the night so that the whole cot shakes violently.
This is alarming to the parents, but in our experience and to the best of our knowledge, no one-child or adult-has come to any harm in this way.
Rarely, these movements persist into adult life, and there is nothing more remarkable than to see a large man asleep, but hurling himself with extraordinary vigor from side to side, perhaps 100 times a minute and for as long as a minute, repeating the performance several times before the night is out.
Like sleep-walking, body-rocking at night does not signify and any serious psychological abnormality, although episodes of body-rocking do occur more frequently at times when daytime anxiety is higher.
It may be that the rocking is some kind of long-established during dreaming. Whatever the cause, once again, the passage of time usually sees the habit disappear.
3. Night wanderings of the elderly
We all grow old, but we grow old at different rates. Some people retain complete lucidity of mind when they are ninety, while others are less favored and their minds show the changes in old age when they are only seventy.
When the aging process in the brain is very rapidly or far advanced, the brain’s powers of organizing information and of forming new memories, so that tomorrow the events of today stances sleep is greatly fragmented.
There is relatively little paradoxical sleep, there is no deep orthodox sleep, and the night may be punctuated by clambering out of bed and wandering around the house or down the street in a confused state of wakefulness, with diminished awareness of surroundings and even lack of recognition of familiar faces. This kind of nocturnal wandering is common among the very elderly.
Getting lost can be bad enough by day, but things are much worse by night, without the stabilizing influences of ordinary daytime routines and of well-lit rooms.
And to compound, the difficulties, our biological clock, which helps us to bed efficient by the day, make all of us less mentally efficient in the middle of the night.
When this loss of efficiency comes on top of the impairments of old age, fairly severe mental confusion is especially likely during the night.
If one of your family is prone to such episodes, then it is certainly worth taking the simple precautions we described causes and solution of sleep-walkers and sleep talking, and maybe even following the example we mentioned of the lawyer who used to hide his door key to prevent his sleep-walking taking him too far afield.
The nocturnal confusion and wanderings often come during the course of a mild chest or kidney infection and tend to arise more easily in unfamiliar surroundings, so that they often accompany a stay in the hospital.
Here, at least, the elderly are in the hands accompany a stay in hospital. Here, at least, the elderly are in the hands of staff trained to cope with just this sort of event.
Great caution has to be exercised in the use of drugs to help sleep for these older people, indeed many of the conventional sleeping pills, such as the barbiturates, only make matters worse. It requires guidance from an experienced medical adviser.
4. Sleeping too much
Complaints about sleeping too much are less common than complaints of sleeping too little, and, to be precise, what is generally complained of is sleeping at inappropriate times.
Some are perfectly happy and healthy with only three hours of sleep a night, most of us like seven or eight hours, and there are others who need ten or twelve.
Given the chance, there are a few people who will sleep for twenty-two hours in the twenty-four, though it is not something they can keep up day after day.
If it is your natural pattern to have longer-than-average sleep you will probably find you have difficulty in getting up in the morning and take more sleep by the day by having naps.
Those who have particular difficulty in waking up properly in the morning may suffer from what is termed ‘sleep-drunkenness’. It is possible that they really need longer sleep, but it is more likely that their biological clock runs in such a way that full awakening is delayed.
They tend to be confused and irritable when first awakened, and are often late for work. An afternoon or evening shift job may be the answer.
Sleeping too much is not always a matter of spending long hours in bed. There are three little-known conditions in which the sufferers fall asleep involuntarily during the day.
They are idiopathic narcolepsy, hypersomnia, and sleep apnoea. We have already dealt with causes and possible solutions to sleep apnoea since it is also a cause of insomnia at night.
This is a condition that affects around one person in a thousand, that is to say, some 50,000 in Britain alone. It can be a real nuisance for the sufferer, embarrassing, annoying, and can have consequences that certainly need to be more widely understood.
Sufferers fall asleep once, twice or three times a day, for periods of about the minutes, at times then they don’t want to.
Usually, after a year or two of this, they also become subject to what are strengths for a period of a few seconds, affecting the whole or part of the body, and are triggered off by sudden emotion.
In one person, it is momentary anger that is responsible; in another, fear; in another, laughter; in yet another, triumph. The sleep attacks and the catalectic attacks can come on at any age, though they usually do so in the earlier decades of life. In a few people, they seem to go away in old age.
When most of us fall asleep, we go into orthodox sleep and never immediately into paradoxical sleep, but the person with idiopathic narcolepsy quite often goes directly from wakefulness into paradoxical sleep.
The catalectic attack is in fact a half-hearted entry into paradoxical sleep, with the paralysis of the muscles, but only for a few seconds.
A common experience of the same phenomenon is sleep paralysis. Any of us can have a bad dream and, waking from paradoxical sleep, momentarily find ourselves paralyzed.
The narcoleptic is particularly liable to be aware of episodes of sleep paralysis, not just at night, but at any time when he takes asleep.
Owing to their association with paradoxical sleep, vivid dreams-sometimes taking the form of nightmares-are particularly often remembered on waking from these involuntary daytime naps.
While many of us may on occasion fall asleep when we are bored on a bus or train, the narcoleptic falls asleep far more often in these situations so that he misses his stop engaged in the work of a repetitive nature, he wakens to find that he has failed to attend to his duties for some minutes.
The secretary wakes to find herself slumped across her typewriter, and discovers that she has typed nonsense for the last few lines before dropping off.
Walking along the street, the young man becomes sleepier and sleepier, sees double, and is taken for drunk by passers-by.
On another occasion, he is playing table tennis and is about to make a triumphant smash when the muscles of his body suddenly go limp. The young mother has to sit down before her friends tell a joke in case she laughs and drops the baby.
It is of course dangerous to drive or operate heavy machinery if you are a narcoleptic; hardly surprisingly people with the condition have a high rate of accidents, often through running into the back of other vehicles.
Narcolepsy can strike at awkward times. A girlfriend taken out to the cinema will not think it complimentary when her young man quickly falls asleep beside her.
The wife who has patiently prepared a good meal feels no encouragement if her husband then falls asleep in the middle of eating it. Among the most important thing, you can do as a sufferer is to try to help those close to you, and people at work to understand that falling asleep is not a sign of sloth or lack of interest in their company, but is as much a disability as a peptic ulcer.
The cataplectic attacks are usually much less of a nuisance than the sleep episodes, though it is the sleep episodes that are the more difficult to treat.
There are modern drugs, particularly one of the antidepressants called clomipramine (Anafranil) that very effectively get rid of the cataplectic attack while leaving the sleep trouble much the same.
There are other drugs that will reduce the frequency of sleep attacks and doctors vary in their attitudes to their use. We think it more important that you should avoid drugs and try to regulate the pattern of life so that the sleep attacks cause the least disturbance.
If a deliberate nap is taken at the morning coffee break, for example, and another opportunity to lie down is taken in the lunch hour, and yet another at the afternoon tea break, then the involuntary naps are less likely to arise at awkward times.
Hypersomnia affects the same number of people as idiopathic narcolepsy around one person in a thousand. Hypersomnia differs from narcoleptics in that they do not have the hallmark of going direct into paradoxical sleep, and when they do fall asleep it is more often for half an hour to an hour at a stretch, perhaps three or four times per week.
Again, their disability makes it dangerous for them to drive. Occasionally the time of onset can be traced back to an infectious illness or a head injury, but generally, there is no identifiable cause.
What can be done?
Although there is no specific treatment for the condition, there are certain common-sense measures that can be taken.
Obesity should be reduced, the weight is brought down, if possible, to slightly under the ideal weight for height caffeine in pill form or from coffee may be used to help sustain alertness on important occasions; and once again it is most important that the family and colleagues at work should understand that the falling asleep does not represent laziness, unsociableness or lack of appreciation of their company.
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