In his sleep clinic, consultant neurologist Guy Leschziner observes our weird night-time behaviour. He diagnoses dangerous sleep disorders that could kill us — and encounters the odd faker
Gerry Gajadharsingh writes:
“As I often say to patients, when we go to sleep our subconscious comes out to play (or for some patients to torment them). The article correctly flags up that for many people sleep is mis-sold as “peaceful slumber”. The concerning thing is that sleep is meant to be restorative, helping the body and mind repair from the challenges of the day.
There are millions of people in the UK who “survive” on poor quality and reduced quantity of sleep having an adverse effect on their health.
Like many of our behavioural patterns, we can learn good ones but we can also learn bad ones. Elevated levels of “stress” can often be implicated in poor sleep, this might be situational, i.e. once the situation passes our sleep return to normal. But it can often become chronic and habitual and before we know it, it has become our new pattern. We can of course learn how to restore a better pattern, but this is sometimes hard work and like with many health challenges paying attention to various factors may be necessary to break the bad habit.
Learning relaxed breathing behaviour, adopting good “sleep hygiene”, not using IT devices in bed, minimising stimulants during the day and evening, lavender mist on your pillow and making love with your partner are just a few of the things that put our minds in a more relaxed state before we go to sleep. This may help us to get to sleep quicker and give us better quality sleep. Sometimes prescription medication may be needed to help a particularly bad sleep pattern but can be problems with continued use. Maybe we need a natural sleep tonic to help the process? Let’s see if I can develop one!”
It is one of the great delusions of humankind: that our sleep is peaceful. “Me?” we say the next morning when told about crazy mumblings, choking snores and unstoppable donkey kicks. We can’t accept our monstrousness. That, somehow, was not us; we were not there. If I’m ever accused of nocturnal antisocial behaviour I flat-out deny it.
I couldn’t to Guy Leschziner. He would have me wired up in his sleep clinic, finding the truth. As an NHS consultant neurologist, the head of one of the largest sleep clinics in Europe and one of Britain’s most eminent sleep experts, his message is that sleep is mis-sold as “peaceful slumber”. For too many of us sleep is violent, brutish and short, and our rampant undiagnosed sleep disorders may be killing us.
The woman who mounts the bed and urinates on the mattress next to her sleeping partner? She’s not the only one. The man who performs sleep sex? A gift to stand-up comedy, but as a piece of “lying-down” outrageousness not rare. Sleep apnoea that affects one in ten men and risks the health of their hearts and brains, but is barely diagnosed or treated. Restless legs, derided as a ridiculous made-up complaint, even by doctors, that seriously affects one in twenty of us and puts our mental health at risk.
Sleep, the chance to walk, eat and talk. Even before we get started on the growing insomnia problem, for millions of us in Britain sleep is exhausting. And for millions of our partners — sleep clinics specialise in “long-suffering” partners — it is too. In his new book of case studies, The Nocturnal Brain, Leschziner quotes Socrates: “In all of us . . . there is a lawless wild beast nature, which peers out in sleep.”
I meet Leschziner for breakfast at a café before he heads to his sleep clinic at Guy’s Hospital in London. He has a groomed American handsomeness that you don’t expect in harried British doctors; his manner is kind. The thing that keeps him up worrying is his patients, which feels nicely ironic. He looks well rested today, which I take as a backhanded insult; before he gave an interview to BBC Radio 4’s Today programme, “I didn’t sleep at all”.
At 15 he had a life-changing run-in with the work of Oliver Sacks, the British neurologist and author. His book is a tribute to Sacks’s famous The Man Who Mistook His Wife for a Hat; each chapter is a case study of a real patient, mostly using their real names. The patients were keen to participate — their lives have been dogged by people and doctors not taking sleep seriously enough and they have been mocked or ignored. “Value sleep,” he says simply when I ask what our nation could do to improve our nights.
He treats sleep and its absence, as well as truth and untruth. This cannot be decided by the sleep-tracker app on your Fitbit or smartwatch; people pushing their sleep trackers under his nose is the bane of his life. He is, to put it mildly, “cynical” about the trackers. Obsessively metering your sleep begets its own sleep problems, plus the devices are inaccurate. “If sleep trackers actually tracked sleep, that would be a huge leap forward,” he says.
Instead it is the sleep clinic that creates shocks. After a night in the clinic insomniacs are asked to estimate how much they slept; for a significant proportion the answer is “not at all” or “an hour or two”, despite data from the electrodes recording a satisfying seven hours. “They’re really shocked,” Leschziner says. For some reason this group overestimate the brief spots of wakefulness in every normal night’s sleep. What proportion of chronic insomniacs this applies to “we don’t know”?
Yet before we go any farther, I have to raise the case of the man “who developed profound and untreatable sleepiness shortly after the birth of his child”. He confined himself to bed, dozing, while his partner became a single parent, managing childcare and a job. Five years and many neurologists later the case came to Leschziner. The clinic showed that during the long periods he called sleep, he was actually awake. Leschziner suspected that the problem was psychological; he booked the man a stay in a neuropsychiatric unit. Three days before he was due to be admitted his partner reported a miraculous recovery. “It’s amazing,” she said. “He is wide awake and engaging in family life.” He knew his fakery was going to be found out.
His partner was incredibly supportive, I say. “She was a saint.” Still, I think this sounds like some kind of parable. “It is unfortunate it was a man who was pretending. I think it was quite an illustration.” Well, it could have been the other way around. “I think it was always more likely to be the man.”
There is another of Leschziner’s patients who was sleep-talking. About one in fifty adults will “act out” in deep sleep, talking, walking or eating. “It’s not rare,” Leschziner says. “Every time I go to a party, I always have people say, ‘I do that.’ ” Yet this man had sought help because his girlfriend told him that he was spewing violent threats, about abusing children, animals and the dead.
In an erudite, mild-mannered pensioner it was disturbing — was it a brain tumour or dementia? After one nap he was woken
by his girlfriend screaming at him for the things he said. Later, he listened to the covert voice-activated recorder he had set up in the room. All was silence, until his girlfriend woke him up. It was a chilling moment. “My jaw dropped,” Leschziner says. The couple soon parted.
Other patients have to put their car keys in a safe or lock the kitchen door — one of his sleep-eaters wakes up with coffee grounds in his mouth. One man, who is anonymised because he is a renowned professional still working in his eighties, would beat up his frail wife, kicking and thumping her. She would survive the night but be covered in bruises and scratches. After he grabbed her arm so violently that his nails drew blood they moved, to his great guilt and sadness, into separate bedrooms. Emotional parts of the brain are on fire in sleep.
One study found that one in ten people had sexual activity in sleep. In the clinic they see patients perform sexual acts while the electrodes show them to be deeply asleep. They must be mortified, I say. Leschziner shrugs. “You can see from electrodes attached to their scalp they are in deep sleep. It is clear sexsomnia is a real entity. A lot of the behaviours we exhibit in sleep are primitive: eating, terror, aggression. It’s not surprising that sex might be one of those manifestations.”
People do not come forward for their sexsomnia. In ten years only forty cases have sought help from the clinic. However, when Leschziner publicised the phenomenon in a news story he was inundated with queries from male and female sufferers. “If you ask people whether they’ve ever done anything sexual in their sleep, it’s very common. If it occurs with your regular long-term partner, maybe it’s
a bit of an annoyance, but not something to go to the doctor about.”
Yet it became crucial for one of his patients, who was imprisoned for the rape of his girlfriend, which the man later believed to be due to sexsomnia. The condition is starting to be used as a legal defence. “It’s right to be sceptical,” Leschziner says. The lines between “too drunk”, “trying it on”, sexual assault and sexsomnia are not easy to draw or prove.
The big three reasons to enter a sleep clinic are, in order, insomnia, sleep apnoea and restless legs. Insomnia, Leschziner says, “is the one I dread”. One in three of us will have bouts of extended bad sleep, but one in ten will have insomnia for three months or more. In simple cases he recommends a cognitive behavioural therapy in which the patient practises falling asleep by, counterintuitively, restricting it, in some cases being deliberately woken every three minutes. Your brain has a method for coping with sleep deprivation: sections of it take it in turns to have micronaps, which you experience as that exhausted “zoning out”.
Sleep apnoea — heavy snoring that restricts breathing — is a real danger. It’s hugely underdiagnosed, despite it leading to possibly irreversible brain and heart damage, as well as raising the risk of diabetes. Leschziner argues that we need a revolution in the way we think of heavy snoring. It’s an illness to be sorted urgently, not a joke that requires ear plugs. You or someone close to you are one of the one in ten men who have it. “There are probably hundreds of thousands of people out there who have sleep apnoea and don’t know,” he says.
The treatment is an air-pressure mask — as sleep doctors say, “if in doubt, pressurise the snout”. One of Leschziner’s patients, a female medic whose snoring was waking her
86 times a night, was “shocked at how serious it was and the damage I had done not having it treated”. They are not yet sure if treating the apnoea brings down the risk of dementia and heart disease or if people leave it too late. If they can prove that treating apnoea reverses chronic disease, “it’s a very potent argument for making sure everyone is screened”, Leschziner says.
Regarding restless legs, we all get this a bit, but it is a bedtime torture for one in twenty adults. Yet few take it seriously, even doctors — “Part of the problem is it has a silly name.”
The syndrome is proven beyond doubt in studies on biochemical changes in the spinal cord, yet, when Leschziner wrote about it in The BMJ, many in the medical profession reacted with scorn. “I get ridiculous emails from random doctors saying this is a made-up condition, they just need to walk a bit.”
Ignorance is the issue in so many ways. For instance, his book talks about how we dream in REM and non-REM sleep. I tell him I had it drummed into me at school that it is only REM sleep that is dream sleep. “It’s drummed into you at medical school as well,” he says. “I think most doctors would say the same as you.”
REM dreams are different; they have the complicated Hollywood-blockbuster plots; they have narrative. Non-REM dreams are more art house: strong emotions, not much going on. Like terror at the face of your headmaster, that sort of thing.
“If you think,” Leschziner says as he gets up, “we enter an alternate reality every night, it’s very strange.”