I am taking the lovely Lesley Poma-Steven's advice. Last night, as we scrambled into "Its Complicated," my stylish friend, interior designer to the capricious fashion world ( you can hire her at www.pomasteven.com) blurted out a brilliant idea.
"Qanta, you have to write about the decade in sleep!"
It got me thinking later, unfortunately for me, right at my usual time of sleep onset. Lesley had hit upon something. As a nation, I couldn't help agreeing with Lesley, we had been on a roller coaster when it comes to how we now sleep and what a ride we have been on.
At the close of this year, whether we surmise the impact of the decade on American politics, global warming, the international geopolitik, futures with no future and securities now made insecure, or perhaps special milestones in our own personal lives, there is a lot to ponder. Just please don't ponder at bedtime.
A decade bookended by unspeakable terror and unmitigated financial implosion, the 2000s were to be a decade of sleeplessness. Amid all the myriad carnage this period would bring, a silent but very serious casualty en route has been that elusive luxury which even big bucks can't buy: a good night's sleep.
9/11 saw the unprecedented loss of three thousand American souls. They left in their wake grieving families and a bowed nation. Even now, almost a decade later, I continue to see patients in my office who are experiencing severe sleep disruptions as a result of the heinous act of an unimaginable crime. It's taken them some of them close to ten years to identify 9/11 as the precipitating culprit.
One patient, a retired elevator mechanic came to see me for insomnia. He described troubling and repetitive dreams which were intrusive.
"I was on the 100th floor that day, doc. I'll never forget it. I started seeing burning insulation floating down from the ceiling, like snowflakes, except it was ash. The building was on fire." Through tearful stoicism, he went on to describe how every snowfall triggers a flashback even years later and how he dreams of ashen snowscapes. Such is his PTSD.
Another patient had been a police sergeant on duty, a first responder to Ground Zero. Formerly an athlete and a New York City marathoner, the 2000s had yielded a 100lb weight gain and an uneasy companion of pervasive anhedonia. He had abandoned physical activity for reasons he couldn't articulate. Now he sought he out help with troublesome snoring. In the course of our conversation, we discovered more than the possibility of obstructive sleep apnea syndrome. Instead, after a few careful questions, he described his eighteen-month assignment in a post 9-11 makeshift morgue where he cataloged the fragmented remains of lost lives. Shortly after this grim task, he was assigned first responder to a major plane crash in the Tri-State area. He had carefully filed away all his thoughts and feelings until one day, on vacation, he found himself stepping out of a pool with a damp wallet in his swimming trunks. Back in his hotel room, he laid out the soggy contents, peeling apart wet greenbacks to dry them on a dresser. His tears brimmed to the surface, surprising the patient, as he relived the distant events in my office, catapulting him to the moment he retrieved a body awash in the flotsam of the jet wreckage years earlier. He told me what he remembered so vividly: sifting through the seawater soaked wallet in search of an identity.
There are countless New Yorkers I term 'walking wounded,' nursing unidentified, unknown injuries deep in their core. Much of this angst manifests as non-refreshing sleep, a reliance on sleep aids, difficulty staying asleep or falling asleep or early morning awakenings. Unquestionably, the 'Complicated Decade' was rough on a good night's sleep. As the decade rolled on, we found it wasn't going to improve anytime soon.
Some of my patients were soldiers returning from Afghanistan, or parents who had both children in Iraq, even one grandfather who had insomnia worrying about his son and daughter-in-law who chose to simultaneously serve their nation while he cared for his grandchildren, unsure if their parents would ever return. I met a Veteran of the Korean War, a crumbling man in his late eighties recovering from respiratory failure in a VA hospital in the South. He held us captive; spellbound to his wheezy rage at the disservice he believed his military brethren were exposed to by the Bush Administration. As we stood in our white-coated ranks, we listened, humbled, somehow shamed. The decade was indiscriminate: suffering has been universal; experience, no attenuator.
The first inkling of a housing crisis arrived in the form of a ten am appointment one day, long before Subprime had gone Prime Time. A patient of mine in Charleston had sought a consult for trouble sleeping. I had seen her a few weeks earlier when she had been doing much better and as we talked I discovered her sleeping environment had changed. In a few short weeks, her mortgage payment had gone from a manageable to $700 a month to a stratospheric $3000, promptly putting her out of house and home. Losing her home, she sought shelter with a kindly friend who could ill afford the space or meet her needs. She was now sleeping in a borrowed recliner not her bed. Yes, patients do tell us these sorts of things, and unfortunately, many times, no amount of medicine or training can solve these challenges.
Another patient, an 11-year old boy, came to be evaluated for sleep disordered breathing. At 265lbs, his family was unable to afford a bed to support his weight and with a head hung low, in a barely audible voice, he described his bedroom: a place on the floor of the trailer his family called home. 'This is America?' I thought to myself. For most, Michael Moore's movie Sicko is no more than acerbic theatrics or entertaining diversion. For those of us treating Americans, its closer to the truth than you might imagine.
At the other extreme, in the early 2000s the New York Times published an article about luxury home building, detailing the rising trend of double master bedroom suites for 'his and her's' sleep disorders. Understanding the need for many couples to maintain diametrically separate schedules, the suites were designed complete with fifties style conversation rooms for the scheduled marital rendezvous' such a power couple would likely require. Even home builders recognized America was becoming deeply sleep disordered, though it didn't prevent them from fueling bad sleep environments with state of the art flat screens and surround sound stereo systems, both very destructive to sleep.
In later months, luxury home builders themselves, in gorgeous places like Kiawah, SC, began experiencing new insomnia, no longer helped by their current treatment strategies. They watched as their formerly indestructible, bloated businesses went rapidly belly up. Suddenly, construction of new homes over $7million went into suspended animation and then, shortly thereafter, interminable hibernation. As one patient phrased it, "the Bear Stearns bucks just vaporized".
This decade also ushered in the age of the iPhone, the explosion of BlackBerry use and the arrival of social networking phenomena. Suddenly we were Facebooking, Tweeting and Tumblring. Patients are actually managing virtual chicken coops on Farmville when they cannot sleep in the middle of the night! It's not unreasonable to say Americans either need bioprosthetic LCD screens surgically implanted or surgically removed, depending on which way one chooses to look at the pervasive problem of 'screen dependency'.
Sleepless stockbroker patients routinely check the NASDAQ and the Dow Jones on scrolling BlackBerry tickers. A quick glance at the glowing screen and their sleeplessness is either stoked or soothed. An unassuming hedge fund manager explained the spike of insomnia he experienced one recent 'Black' September which became clear only during an interview with me several months later. He admitted it had been extremely stressful to compulsively unwind billions of other people's money as Bear Stearns turned terminal and to rapidly succeed in offloading these unwieldy dollars without attracting the attention of a market made coltish at the scent of the imminent bloodbath which would be Lehman's extinction.
These are more than cautionary tales, or after-dinner anecdotes. This year's National Sleep Foundation survey -- The 2009 Sleep in America Poll -- found that one in three Americans was experiencing sleep loss directly as a result of the September 2008 Crash. Americans were found to be worried by economic loss of material values, the prospect of losing homes, the possibility of job loss and ultimately the fear of losing health insurance. Americans feared these specters more than the regional conflicts in Iraq or Afghanistan and much more than the (to them) remote, ethereal Global War on Terror. These findings were published in March 2009. Since then I ask each of my patients how he or she believes the economy is contributing to their sleep loss. I am always amazed at how diverse the impacts have been. My patients span the entire economic spectrum that encompasses modern America. No one has been unscathed.
Through it all Americans have stuck to what they know best: major league sports and Prime Time TV. An elegant sixty something year old patient of mine struggled with his insomnia, dutifully following all my instructions for sometime. One visit, late in the autumn, he reported his insomnia had suddenly resolved. I was perplexed. What a doctor likes less than not knowing what is wrong with her patient is not knowing why things got better. Drawing a blank, I asked my patient his interpretation.
"Well Dr. Ahmed, everything got better for me on October 10th". I stared at him dumbly. The date held no meaning for me. Patiently he explained this was the end of the Major League Baseball Season. I still failed to see the connection.
"My son is a relief pitcher, out West, for the Major League," I waited in polite silence, wondering if his child was some form of batsman. The patient went on, oblivious to my confusion, "Well, when he plays, its on West Coast time. So, I wake up to check the score. If he has done well, I am too excited to sleep. If he hasn't, I am too depressed to sleep," As the season had ended, so too had the need for relief pitching, it appeared. The father was now able to sleep uninterrupted and without 'performance-anxiety- by-proxy' intruding on a good night's rest. We even noticed his blood pressure had improved as a consequence of resolved sleep deprivation. We were both amazed as we connected the dots: he, cultural ones for me; me, physiologic ones for him.
And Prime Time TV, let us remember, is not without its own detrimental impacts. Americans have struck a dubious bargain, trading sleep for late night Leno and Letterman. The focus of a future column, American appetites for television and movie watching have only increased in this beleaguered economy. The box is proving more of a draw to audiences than usual; doubtless much to the relief of insomniac big-ticket studio bosses. More than 99 channels per capita available 24/7 makes for a lot of late night light exposure. Coupled with Millenials now habituated to handheld screen exposure through iPod video players, social jet lag is here to stay. All this light exposure after sunset switches the brain's intrinsic hormone of darkness, melatonin (the natural trigger to sleep onset) firmly off. TV-dependent Americans therefore take longer to fall asleep.
Prime Time pundits themselves have a good degree of sleep loss. David Letterman was forced to give up prime Rapid Eye Movement Sleep time to meet a fellow CBS employee weaving a web of extortion over an indiscretion. Americans glued to the box were indeed dismayed, but in the wake of Tiger's antics, Letterman is placed duly into two-dimensional perspective. Tiger must surely be experiencing some monumental insomnia of his own as he is rocked to sleep in the floating cabin of his unfortunately named vessel Privacy. Some of us, like his erstwhile sponsor Accenture, are even losing sleep wondering what Tiger will do next.
To more serious causes for sleep loss, thinking of this decade defined for many of us by American combat operations, I cannot help but be reminded of Jenny Holzer's powerful exhibition, "PROTECT, PROTECT" here in New York City at the Whitney Museum. Among many, many installations that precipitated my own insomnia that weekend, I was struck by one display detailing the use of sleep deprivation as an instrument of torture by a government I hold to high standards of justice and humanity. Deeply troubling to see this is what we had come to.
Looking back, I learned much this decade. I learned about the optimism of love and the clarity of death. I lived in the Middle East and there learned of the West. I lived in the American South and there finally learned of the nation I had long ago chosen to love. I have in these years, learned of the power in exercising my own voice, literally and figuratively. But one of my most precious discoveries was to follow. This decade, I finally learned I practice not in the sterile vacuum of an amputated office but as part of a vibrant, multifaceted and very dynamic cultural matrix. Sports. War. Catastrophe. Hope. Each impacts my patients and their distresses, such that their narrative unfolds as a component of their surroundings and not a disembodied figment of an anonymous medical record.
If I can share a beautiful phrase from Hank, the last friend this decade would gift me, my experiences with those generous enough to become my patients in this decade have helped me understand this relationship to the vast American ether in which we all strive to make our fragile, moon-splintered lives across this nation.
Yes, it's complicated but simply stated, this decade has fragmented many lives, dimensions, and beliefs and in doing so, very much fragmented our sleep. Americans, like America, need rest and rejuvenation.
My vote is in: let's all sleep on it.
Follow Qanta Ahmed, MD on Twitter: www.twitter.com/MissDiagnosis
Pythia Peay: Reflections on the Soul, Shadow and the American Psyche
Rubin Naiman, Ph.D.: We Don't Get Sleep Because We Don't 'Get' Sleep
My mom and I have talked about this and she is finding comfort in a few minutes of daily, spiritual
meditation that has her centering on positive mindful thoughts// rather than the external contexts and variety of stresses in the outer world.
(I was looking forward to catching up on sleep over the winter break, but I've found myself on the same sleep schedule, reluctant to miss a moment of vacation before I return to school.)