On the Use of Medication in Sleep and Psychotherapy

There is a recent piece in the NY TIMES (“Pills’ Risk Complicate Long Wait For Sleep,” March 13, 2012, Science section) that states that those taking sleep medication on a regular basis are nearly five times as likely as non-users to die over a period of two and a half years. Now why is that? Before I answer, let me say that in my life and in my practice I find that at least half the people I come into contact with have trouble falling asleep or sleeping more than an hour or two without waking up. So many of us cannot sleep, and sadly that includes doctors and surgeons who really need their sleep, not to mention airline pilots. The article states that there were 60 million prescriptions for sleeping pills last year in America.

Of course, those who need sleeping pills are already in trouble, usually suffering from anxiety disorders and/or deep depression. And these people may already be on daytime pills for a variety of psychiatric disorders. So why no sleep? I think that lifetime sleep patterns are established in the womb and at birth and just after. A carrying mother who is highly anxious or depressed may interrupt the fetal sleep patterns. It dislocates how we sleep thereafter in the same way that trauma while we are being carried produces lifetime patterns of behavior or symptoms such as headaches. It is also the time when our hormone, neurotransmitter, and neuromodulator output all begins, so that traumas during this period can change the setpoints of so many neurochemicals that affect sleep. Just not enough serotonin can do it, as well as alterations in dopamine. The system may be imprinted with too high a level of vigilance hormones that work against sleep. Or there may be compromised gating functions that prevent us from blocking low-level imprints.

But let us not concentrate only on sleep because any serious anxiety imprint that the carrying mother suffers means the baby suffers too. And that means overloading the gating system early on. The result is that when we try to cede high-level cortical alerting functions in order to reach down deeper in sleep levels, the pain is there waiting and prevents any rest. This is usually the result of serious neglect and trauma while we are living in the womb. And so because the gating system is weak we cannot block enough of the pain in order to get some rest. And we take pills in order to quiet the onrush of pain. And those pills work on pain centers; some work directly on the vigilance centers of the brain stem such as the locus coeruleus. They do what they are supposed to do: quiet the agitation.

The faulty gating system already means serious pain when the gating system was being organized, sometime around the midpoint of pregnancy. An anxious or depressed mother can overtax the baby in the womb; too much input from the mother, so much so that the inchoate gating system becomes defective. And later in life when we try to sleep our minds are racing, racing because the first line is in a hyper state. Why hyper? Because there is danger from the imprinted deep first-line feelings, and so the system must stay alert against the feelings. So long as that imprint of a turbulent agitation remains in place sleep will always be a problem. That imprint has no doubt already lowered the effectiveness of the gating system, making sleep problems unavoidable. So of course we take pills to try to make the physiologic function be normal; those pills are an attempt to normalize the system, to establish a brain system that can shut down when necessary. So they are life-saving and life-threatening. In the daytime we see this in the anxious patient who is go-go-go all of the time, unable to sit still and relax. Sleep problems are only an extension of the daytime behavior. It is still the same person, night and day. He may also exhibit impulsive behavior during the day, as an expression of impaired gating. It isn’t that we have sleep problems at night but are perfect during the day. It is the same system misbehaving at night: on the go when one shouldn’t be, night and day. Same imprints driving it all.

Taking sleep pills is, of course, life-endangering. But here is what an expert, the president of the American Academy of Sleep Medicine, says: “If someone comes to me on a sleeping pill, usually my tactic is to try to take them off it.” Without looking into its biological necessity? Maybe one needs it to equalize the psychic economy. It is clearly what the system needs to go on functioning. Today the experts believe that it is safer to take non-benzodiazepine sedatives than benzodiazepines or barbiturates. Not sure. Maybe, although it is still suppressing the pain, just by a different method. How about discussing the pain, what it is and how to get rid of it? Why is it always a given that we must suppress? Why don’t we express? Assuming we know what we are dealing with, that is. Ah, that is the problem—not enough knowledge about what is behind sleeplessness. It is, after all, a big leap from womb-life to not being able to sleep last night. I could never have figured it out without observing patients who have sleep problems relive first-line feelings and begin to sleep peacefully at last. We see the great inner agitation during the primal, and then see the drops in blood pressure and heart rate and later, reports of sound sleep. One piece of advice: when there is that stab of some feeling upon arising in the morning, instead of running from it, lie back and let it sweep over you. It often helps, and you will eventually understand why that problem is there in the first place.