April 23 1990



April 23 1990

Jordan Goldman says that since he gave up trying to live normally, his health has improved. The 18-year-old Toronto-area youth adds that he is sleeping so well that he no longer becomes dizzy and falls down from exhaustion a dozen times a day. He is also more at peace with himself. But his search for relief lasted five years. During that time, his distraught parents took him to about two dozen doctors in Canada and the United States, trying to find out why he constantly suffered from debilitating, disorienting fatigue. Then, four years ago, a Toronto specialist found the answer: the teenager had delayed sleep-phase syndrome, a condition in which the body’s internal biological clock is so out of order that nighttime sleep is either elusive or impossible. In Goldman’s case, it is impossible; he has abandoned his punishing pursuit of a full-time high-school education and sleeps during the day. The syndrome that affects him is one of 60 different sleep disorders that significantly afflict as many as 2.5 million Canadians and pose what some experts are beginning to describe as a serious national health problem.

There is increasing evidence of the problem. About a dozen sleep-disorder clinics in hospitals and university medical research centres in Canada are besieged by thousands of people complaining of disorders ranging from insomnia to excessive sleepiness. At some clinics, waiting lists of those seeking diagnosis are six months long. The distress of those who are sleep-deprived is compounded by the fact that diagnosis is covered by government health insurance plans in only three provinces: British Columbia, Ontario and Quebec.

Undefined: Dr. Harvey Moldofsky, 55-year-old chief of psychiatry and head of the sleep-disorders clinic at Toronto Western Hospital, says that sleep disturbances are a largely undefined menace that haunts airline pilots, motorists, and shift workers in factories, nuclear power plants, hospitals and police departments. Added Moldofsky, whose clinic treated 900 people last year and currently has a waiting list of 650: “It is a serious national health problem that is not being recognized.”

The quest for answers began shortly after the discovery in 1953 by two University of Chicago researchers that rapid eye movement (REM) and distinctive brainwave patterns signalled the onset of dreaming (pages 41 and 44). That finding, showing that sleep was a far more complex state than had previously been realized, confronted scientists in Canada, the United States and elsewhere with two basic issues: What is sleep and why does it occur? Science has yet to produce all of the answers, but the quest has identified scores of sleep disorders and what happens to people who have them.

Fatigue: For the Goldman family of Stacey Crescent in Toronto’s north suburb of Thornhill, the problem involved a long and nightmarish search for the reason why Jordan could not wake up in the morning or fall asleep at night and was collapsing from fatigue so often. Said Carol Goldman, his 42-year-old mother: “One sleep specialist in Toronto saw us for 10 minutes and said we were overly concerned parents, that we should get him up at 7 a.m. to jog. Since that was about the time Jordie was going to bed, if we had taken him jogging we would have had to pull him on a rope.”

She said that, when her son was 11, another doctor told her and her husband, Melvyn, 44, an electronics importer, to give him sleeping pills to “knock him right out.” A third doctor said that their son was probably faking because the symptoms were so unusual. A fourth said that Jordan should simply try harder to get to sleep. A fifth recommended that they force their son to stay in bed for 10 hours a night. Says Carol Goldman: “That was when I got hysterical.”

The family finally met Moldofsky, who said that Jordan was falling down simply because he was exhausted. He administered several tests. One showed that the boy’s waking-sleeping body temperature cycle was the reverse of a normal one, and then he diagnosed delayed sleep-phase syndrome. The challenge, said Moldofsky, is to get Jordan to “synchronize with the clock. There is a centre in the brain that is responsible for the body’s round-the-clock rhythm, and his may be for some reason not working right.” For five years, Moldofsky has been conducting nighttime experiments with special lights in an attempt to shift the young man’s unconscious perceptions of day and night. Meanwhile, he sleeps from about 6 a.m. to 2 p.m., studies Canadian history at Bayview High School two nights a week and works other evenings at a sporting goods store. Said Goldman: “I used to worry about my situation a lot, but not so much now. As I’ve gotten older, it has become a little easier to manage and deal with.”

Personality: Many sleep disorders are less troubling than Goldman’s, and range from sleeping too little to sleeping too much. Moldofsky says that there are several varieties of insomnia caused by psychological or personality problems, drugs, alcohol or caffeine. There are also various disorders related to sleeping too much and to a disrupted sleep-wake schedule, and dozens of disorders reflected in poor-quality sleep. Those include falling asleep late and waking up late, going to sleep early and waking up early, sleepwalking, bed-wetting, dream-anxiety attacks, teeth grinding, angina (characterized by severe chest pains) and other symptoms of heart disease, asthma and headaches. As well, researchers are studying so-called night terror, whose victims sometimes wake up screaming, and sleep apnea, which causes the throat to close off, sometimes resulting in choking.

The consequences of sleep disorders are almost as numerous. Some people are irritable and cannot concentrate. Some become confused, disoriented and forgetful. Others sink into depression or complain of such physical problems as aches and pains, excessive, prolonged fatigue, even complete exhaustion. Said Moldofsky, who has been studying sleep disorders for 20 years: “It’s a major under-serviced health challenge, because sleep is widely regarded by governments and a lot of physicians as a matter of personal responsibility.”

Lifestyle: The success of treatment varies widely from one condition to another. Doctors can treat some cases of sleep-loss merely by changing a lifestyle—persuading a patient to drink less coffee, go to bed earlier or stop taking pills that often ultimately interfere with sleep rather than promote it. Surgery can correct the dangerous sleep apnea by widening the throat airway, or a masklike device can pump air into the sufferer’s nose and mouth while he sleeps. There are drugs to prevent the symptoms of narcolepsy, the sudden, uncontrollable sleep attacks that can strike victims while driving a car—or even during sex. Shift work, which Moldofsky says “presents serious problems of major dimensions,” has been rescheduled by several corporations, among them Du Pont Inc. and Alcan Aluminium Ltd. Instead of alternating day, evening and overnight shifts weekly, employees switch every three weeks on a schedule that rotates clockwise, more in line with the body’s internal rhythm. The result has been a 20-per-cent increase in productivity.

Telltale: But experts in the field say that millions of North Americans either fail to recognize that they have a problem or are afflicted by conditions that specialists are still unable to treat. At Dalhousie University in Halifax, psychology professor Benjamin Rusak and Harold Robertson, professor of pharmacology, are attempting to find out if telltale chemicals are manufactured in a part of the brain called the suprachiasmatic nucleus. A characteristic of the nucleus is that it is stimulated by light at predictable times of the day and it produces feelings of fatigue or wakefulness. Meanwhile, at the University of Toronto, biologist Martin Ralph transplanted suprachiasmatic nucleus tissue from hamsters with a normal 24-hour sleep-wake cycle into the brains of mutant hamsters with 20-hour cycles. The mutants moved to a 24-hour rhythm. Then, when he put mutant tissue into normal hamsters, they behaved like mutants. At Trent University in Peterborough, Ont., psychologist Carlyle Smith says that depriving people of REM sleep at critical periods for several days can lead to the “relatively permanent” loss of recently acquired information.

Still, sleep may be more complicated than anyone yet realizes. Dr. Roger Broughton, professor of psychology at the University of Ottawa, originally discovered that “the brain’s internal wiring” makes it want to sleep twice a day, not just once. People kept in windowless rooms, where they are not allowed to keep track of time, says Broughton, “will have two major sleep periods, one at night and one in the afternoon.”

Impossible: Calculating nap time is simple: it is about 12 hours after the midpoint of the previous night’s sleep. Said Broughton, whose Ottawa General Hospital sleep clinic is the oldest in Canada and treats about 800 patients a year: “It is not essential that everybody nap, but if one does not get enough sleep at night, it is important to know that there are times during the day when the brain will nap easily and other times when it is almost impossible—even when people are quite sleepy.” However, said Broughton, among people who do not get enough regular sleep the normal urge to nap can become irresistible and assume the proportions of a sleep disorder.

One of the most disturbing sleep disorders, rare in adults, is sleepwalking, which generally occurs only at night. Last month, the Ontario Court of Appeal reserved judgment on an application by the Crown for a new trial for 29-year-old Kenneth Parks of Pickering, Ont., who was acquitted in May, 1988, of murdering his mother-in-law because he said that he did it in his sleep. The prosecution contends that trial judge David Watt erred when he told the jury that sleepwalking was not a disease of the mind. It was believed to be the first time in Canada that a person was found not guilty of a killing committed while sleepwalking.

Sleepwalking: Dr. Rosalind Cartwright, director of the sleep-disorders service at Chicago’s Rush-Presbyterian-St. Luke’s Medical Center, says that sleepwalking could have been involved in a widely publicized October, 1980, Illinois case as well. One night in the west-Chicago suburb of Oak Park, theology student Steven Linscott, now 35, reported that he had had a two-part dream about murder. In the first part, a woman opened her front door to a man, apparently a salesman, whose friendly appearance turned evil as soon as she let him in. He was holding something behind his back, Linscott said later. At that point, he said, he awoke greatly disturbed and left his sleeping wife to wander around their apartment, trying to ease his agitation.

When he went back to bed, the dream resumed with the man beating the kneeling and bloodied woman to death. The next day, a policeman canvassing neighborhood residents called at the Linscotts’ home, and Linscott said that he had noticed nothing unusual the night before. But afterward, he said later, he remembered the dream and went to the police, who were investigating the killing of a woman on the same street. Linscott’s dream story included details that had not been made public. He was charged and convicted of murder, served seven years and now is free pending his appeal.

Incidents: Similar incidents have for years confronted scientists who still have not discovered the mechanisms of many sleep disorders or, indeed, of sleep itself. Dr. J. Allan Hobson, a Harvard Medical School psychiatrist, says that various chemicals stimulate brain function. He added that one explanation is that “you sleep in order to rest these chemical systems.” He added: “When you’re out fighting the weather, these systems are massively energized. They may be intuitively vulnerable to fatigue, so it makes sense to turn them off from time to time to give them a chance to refresh themselves.”

Dr. Barbara Jones, a Philadelphia-born professor of neurology at McGill University’s Montreal Neurological Institute, said that the basic cycles responsible for sleeping and waking are “still fundamental mysteries.” Added Jones: “What we have done up to now, in many ways, is just to describe the phenomenon.” For his part, psychologist John Antrobus of City College of New York said: “We don’t in fact know what sleep is for; we don’t know its real function. We do know that if you go without it, you disintegrate in many ways: you don’t function well, you lose the ability to pay attention, to have any kind of effective short-term memory.”

In the Toronto suburb of Thornhill, Jordan Goldman is well acquainted with the effects of losing sleep. “I have a lot of trouble concentrating, remembering things,” he said. “Maybe I won’t remember where I left my keys. I’ve put them away safely but I won’t remember that. Right now, almost my whole life is at night. It’s like you have a separate existence from everybody else.” For Goldman and thousands of other Canadians, life has become a time of waiting for science to discover a way to achieve what they want most: a simple, good night’s sleep.