In a series of rooms in a bunker-like facility at the University of British Columbia, pajama-clad people lie in beds with wires and electrodes affixed to their heads and bodies. As these patients, all of whom are here because they have chronic sleep problems, drift into dreamland, the electrodes record data on brainwave activity, blood oxygen levels, heart rate, leg movement, eye movement and muscle tension. This information is relayed to technicians in a nearby control room, who track the incoming data on their computers and observe the patients on video cameras. The mass of information that can be collected in one eight-hour session is vast. Once analyzed, it will be used to determine a diagnosis and treatment.
Twenty years ago, sleep clinics were a rarity. Today, they are a growth industry, with some 3,000 in North America alone. In Canada, many clinics are attached to Canadian universities, like this one in Vancouver – the Leon Judah Blackmore Centre for Sleep Disorders – which sees about 40 patients a day from across B.C., the Yukon and parts of Alberta.
Sleep disorder clinics have become necessary because so many people are not getting adequate amounts of sleep. According to the U.S. National Sleep Foundation, an estimated 80 million North Americans now suffer from some type of sleep disorder. In Canada, researchers at Université Laval found that 30 to 40 percent of adults suffer from some degree of sleep loss in any given year, with about 10 to 15 percent categorized as chronic or severe.
Sleep science is a relatively new discipline, and it’s advancing fast due to the influence of modern technologies such as magnetic resonance imaging that allows front-row access to the brain. As Stuart Fogel, a neuroscientist and assistant professor of psychology at the University of Ottawa, notes, “the blending of neuroimaging with computers is a very powerful combination. It’s allowed us to dig deeper and actually observe the processes that unfold during sleep.” Although not all the questions about sleep and its functions have been answered, what has been learned has confirmed the important role of sleep in our waking lives.
Sleep more, live longer?
Sleep scientist Matthew Walker, a professor of neuroscience and psychology at the University of California, Berkeley, and author of the bestselling book Why We Sleep: Unlocking the Power of Sleep and Dreams, has some sobering observations on the pernicious effects of sleep deprivation. According to Dr. Walker, more than 20 large-scale epidemiological studies all report the same correlation: the shorter your sleep, the shorter your life span. Research has also linked lack of sleep to high blood pressure, heart disease, diabetes, obesity, Alzheimer’s disease and depression.
“The message we’re trying to convey to the public is that sleep is not a luxury. It’s essential to our physical and mental well-being,” says Julie Carrier, a psychology professor at Université de Montréal and researcher at the Centre for Advanced Research in Sleep Medicine at the Hôpital du Sacré-Coeur de Montréal. Dr. Carrier is also network director of the Canadian Sleep and Circadian Network. Established in 2015, it’s an association of 60 researchers from 19 Canadian universities whose ultimate objective is to improve the outcomes of patients with sleep disorders. The network received a grant of $4 million over five years in 2015 from the Canadian Institutes of Health Research to help fund its activities. “It’s the first time we have put our efforts into combining data from all the different sleep labs in Canada,” says Dr. Carrier.
Unfortunately, clinical discoveries about the dangers of insufficient sleep have not made major inroads into the public mind. Dr. Carrier says the idea that sleep should be ranked with diet and exercise in the gospel of good health has yet to find widespread acceptance among her students. “Many of my students have the attitude that sleep is not productive. Some even brag that they don’t get much sleep. It’s crazy. It’s like boasting that I’m eating at McDonald’s every day,” she says.
The attitude that sleep is a nuisance is not new. Inventor Thomas Edison discounted the value of sleep, calling it a wasteful activity (“a heritage from our cave days”) and insisted that he needed only four hours a night. Fittingly, Edison’s invention of the incandescent light bulb in 1879 meant that sundown no longer effectively meant the end of our working, or waking, hours.
In a sense, Edison was a forerunner of today’s tech entrepreneurs, whose inventions have made everyone accessible at any time and given new impetus to the term “24-7.” Digital technology has become a prime factor in sleep theft, especially among the young. Robert Comey, a clinical instructor of psychiatry at UBC and sleep technician at the Blackmore Centre, has noticed an increase in the number of university students who come to the clinic seeking help. Dr. Comey attributes the rise in sleeplessness to a combination of academic and economic stress, social anxiety, and the insidious influence of smartphones and computers.
As Dr. Comey notes, “Interacting on social media before bed is a bad idea because it stimulates the brain.” As well, he points out that the blue light emitted by computers and smartphones can fool the body’s inner clock and cause it to delay its release of the hormone melatonin, which prepares our bodies for sleep.
A 2015 Swiss study from the University of Basel, published in the Journal of Youth and Adolescence, reported that teenagers’ nightly smartphone use is linked to an increased risk of sleep problems and depression.
The researchers found that only 17 percent of smartphone owners turned their devices off, or put them on silent mode, when they went to bed. Similarly, in a study of Canadian students aged 11 to 20 published this January in the journal Acta Paediatrica, researchers at U of Ottawa found that the more these students used social media, the less sleep they got.
The body clock
Many sleep problems stem directly from a disruption in people’s internal or circadian clock, or a mismatch between this internal mechanism and the external environment. Our circadian rhythms are set by the superchiasmatic nucleus, a pinhead-sized structure located in the centre of the brain that regulates our blood pressure, body temperature and sleep hormones during the day to control alertness and drowsiness.
Young people often confuse their circadian clocks on weekends by staying up late on Friday and Saturday nights and then sleeping in. They fall prey to what is known as “social jet lag,” says James MacFarlane, an assistant professor of psychiatry at the University of Toronto and a fellow of the American Academy of Sleep Medicine. The result is a groggy mind on Monday morning. “For someone living in Vancouver, it’s the same effect as flying to Hawaii for the weekend,” explains Dr. MacFarlane. “Full recovery may not occur until Wednesday, which leaves only two days before the cycle begins again.”
The most common form of circadian rhythm sleep disorder is insomnia, which is characterized by a difficulty falling or staying asleep, or by awakening too early. Typically, insomniacs suffer from low energy, difficulty concentrating, mood disturbances and decreased performance in work or school.
But while insomnia may be common, sufferers do not always get the best treatment. Sleeping pills are often prescribed, but these are only effective in the short term and can become addictive. According to many experts, including Charles Morin, a professor of psychology and director of the Sleep Research Center at Université Laval, the most effective treatment is cognitive behavioural therapy, or CBT. Merging elements of talk therapy and behavioural modification, CBT has been used to treat mood disorders for decades, but it was only recently accepted as a valid treatment for insomnia. CBT aims to change actions or thoughts that hamper your ability to sleep, and to help you make lifestyle changes and learn effective sleep routines.
“Ideally, I’d like to see every single sleep clinic have an insomnia program, which is far from being the case currently,” says Dr. Morin, who is also the president of the World Sleep Society, an organization representing 28 of 53 sleep societies from 64 countries whose goal is to advance sleep health worldwide. Unfortunately, Dr. Morin notes, there are few physicians qualified to provide CBT in Canada; and, it is not normally covered by public health plans, making the treatment, which usually consists of six to eight visits with a psychologist,
Until very recently, no Canadian schools offered courses in CBT so physicians had to attend American universities to get the training. The availability remains limited and sleep as a subject is still often overlooked in medical education. As Dr. Carrier notes, there are 13 full-time researchers, all professors at U de Montréal, at the sleep medicine research centre where she works, “and yet it is only in the last four or five years that the medical curriculum [at the university] included three hours of training in sleep disorders.”
Dr. Comey in Vancouver agrees that access to treatment is a concern. “The waitlist at our clinic for a patient that isn’t deemed urgent or semi-urgent is roughly six months to see one of our respiratory doctors, while the wait to see a psychiatrist for insomnia and most other sleep disorders is one to two years. We’re trying to improve on this by adding group therapy sessions for insomnia. The major issue is that we don’t have enough doctors. We’re trying hard to find people, but very few are trained to do this type of work in Canada.”
While medical options are less than ideal for insomnia, considerable clinical effort is being put into understanding the physiology of sleep in the hopes of not only finding cures or better forms of treatment for sleeping disorders, but also for neurodegenerative diseases such as Alzheimer’s, Parkinson’s and Huntington’s.
What happens when we sleep
Scientists have come to realize that a variety of important activities occur inside the human body when we sleep: muscles and cells recuperate, mood and appetite are regulated, and a form of biological cleansing takes place in the brain. During the day, our activity creates a build-up of debris in the cerebral cortex, including toxins such as beta-amyloid, a protein associated with Alzheimer’s. When we fall asleep, channels in our brain expand to allow fluid to flow in and flush out the debris.
Sleep is also now recognized as a time of learning. “Sleep seems to be actively engaged in the formation of memory,” says U of Ottawa’s Dr. Fogel. Using neuroimaging technology, Dr. Fogel’s research team has discovered that brainwave bursts called “spindles” that flash repeatedly during non-REM sleep reinforce the memory of tasks that we have just learned. “These memory traces are quite fragile. They need to go through a consolidation process to be more easily recalled,” explains Dr. Fogel.
The process, which some scientists have likened to a form of cellular chanting, enhances procedural memory – the ability to recall how to play a song on a piano or to reproduce a dance routine. “When we go to practice later, we’re better at the task that we just learned,” he says. “But if we don’t get sufficient sleep, the spindle activity is dramatically reduced and memories become fragmented.”
Meanwhile, researchers at Western University’s Brain and Mind Institute launched in June 2017 what is reportedly the world’s largest sleep and cognition study. Conducted entirely on the internet, the testing will involve potentially 100,000 participants from around the world. Study participants are being asked to track their sleep over a three-day period, while taking a set of tests of brain function. Neuroscientist Adrian Owen, who heads the project and holds the Canada Excellence Research Chair in Cognitive Neuroscience and Imaging at Western, says: “The internet has provided us with this unprecedented opportunity to involve the public in scientific research that can draw out a gold mine of sleep and brain data that we’ve never before had access to.”
Another puzzle that sleep scientists are attempting to solve concerns the mysterious realm of REM sleep. This is a sleep phase in which our heart rate and breathing quickens and we produce brainwaves similar to when we are awake, and in which we dream vividly, and yet the body’s muscles are paralyzed. Investigators at Montreal’s Centre for Advanced Research in Sleep Medicine believe this paralysis may be a built-in measure to protect us from damage that could occur if we were to physically act out our dreams.
Other insights into REM sleep may come from Japan, where scientists at a neuroscience laboratory in Kyoto report that they have been able to use MRI scans to reveal the images that people were seeing as they slipped into an early stage of sleep, with 60 percent accuracy. Having made this first step toward realizing the sci-fi concept of a dream-recording device, they now propose to look at deeper sleep, where the most vivid dreams are thought to occur, and determine if brain scans can help reveal the emotions, colours and actions that people experience as they slumber.
For Canadian researchers like Dr. Morin, who has seen the science of sleep evolve in a just a few decades from a time when scientists blithely assumed that sleep was a passive state and the brain simply switched off at night like a desk lamp, to a subject of intense professional inquiry, there is a sense of gratification. But, even so, he contends that sleep science is still in its infancy. “Even with all the new discoveries, there are still many unsolved mysteries about sleep,” says Dr. Morin. “That’s what makes this such an exciting field of study.”