Mr Sandman ... bring me a dream
16 Mar 2012
PSYCHOLOGIST Michelle Baker still remembers her first patient, a woman with a sleeping problem. “Weeks later I felt like I had done her a disservice because I didn’t know enough,” admits Baker ruefully. “I wish I had known then what I know now.”
The problem wasn’t that Baker was underqualified — as a neurophysiologist with a Master’s degree in clinical technology, she’d been working in the field of sleep disorders for years. She started the first sleep laboratory in Durban in the mid-eighties, and as an executive member of the Sleep Society of SA gave talks to medical specialists and health-care practitioners. She also lectured and trained students at Nelson Mandela School of Medicine.
But the landscape of sleep disorders (SD) is vast and, at the time Baker was working in the sleep lab, still largely uncharted. The importance of sleep, a naturally occurring state found in all mammals, birds, and some reptiles, amphibians and fish, is often greatly underrated — until it is absent. Considered crucial for the growth and rejuvenation of the immune, nervous, skeletal and muscular systems, sleep deprivation can compromise a range of bodily functions, including memory, wound healing and the functioning of the immune system.
Research in the area only started internationally in the sixties and in the late seventies here in South Africa. Baker’s work in the lab was mostly with people suffering from sleep apnoea, a chronic disorder the lab focused on because of its prevalence and its dramatic impact on physiology. But through this work she became aware of the magnitude of other SDs and eventually followed her interest into another field that dealt with them — psychology.
“I began studying through Unisa and eventually left the sleep lab in 2004. I had become fascinated by how huge SDs were. The more I started to understand [about them] the more I realised that there was a lack of interest in the medical field.”
According to Baker, insomnia — the inability to fall asleep and stay that way — is often not what meets the eye because many SDs — such as restless leg syndrome — are primary conditions impacting on the ability to sleep.
Her new interest became shifting behaviour. “I wanted to work as a clinician in sleep disorders, not prescribing, but working in collaboration with doctors and other health-care practitioners.”
Since qualifying, she’s been building a practice in general psychology in Kloof specialising in SDs for the past five years.
“I now have quite a bit of knowledge in SDs. I assess and refer. I may refer someone to a sleep lab for a polysomnography . This can pick up if there really is a sleep problem. Some people suffer from Sleep State Perception Disorder where they actually sleep better than they think they do. A sleep lab can tell us how they sleep.”
Diagnosing what is causing the lack of sleep in a patient is crucial. “Behaviour modification works in certain things, but in some instances insomnia is secondary to another condition,” says Baker. “Sleep disorders are not always just about behaviour. Psychologists and psychiatrists are very focused on sleep and appetite — what are called vegetative states — because they are significant. They are part of the process of trying to understand a person’s metabolic processes, which are linked to circadian rhythms. It’s like an onion and you have to peel away the layers.”
Where there is no underlying SD causing the insomnia, other factors are examined, like family history, lifestyle or personal problems. Frequently, a precipitating event can result in behaviour that affects sleep. Long after the event, the behaviour persists maintaining insomnia.
The World Association of Sleep Medicine says that up to 45% of the world’s population suffers from sleep problems and SA is no different. Baker believes the problem is worse than it used to be, for myriad reasons, including hypervigilance about safety, busy lives and people juggling multiple roles.
People either work very hard, or, if unemployed, may spend the day sleeping because they’re bored, and end up with fragmented sleep.
Baker says a growing problem is for teens to suffer from a form of pseudo- insomnia called Phase Advance Syndrome, because they’re on their phones late at night when they’re supposed to be asleep and then have to get up early for school. On holiday they tend to go to bed after midnight and sleep late into the next day, creating a shift in their sleep pattern.
Treatment for sleep disorders varies according to the disorder.
Is Baker a good sleeper? She replies with feeling: “My sleep was great until I hit menopause, now it really sucks! But I’ve learnt a lot about sleep from my own problems. I know when I won’t sleep. I use my own techniques to get to sleep and I’m excited to say that they actually work.”
She says that menopause causes sleeping problems for many women and advises a change of diet and exercise as a first resort, often working with a dietician and advising that patients exercise. “Also check sleep hygiene. Is your room dark, is the TV on, does your partner snore? Sometimes you need to see your GP or a specialist like a gynae or an endocrinologist for blood tests.
“HRT can make a big difference. There’s lots of doom and gloom about HRT which is misdirected. It can have a protective effect.”
She talks about “spousal arousal syndrome”, where one’s partner’s restlessness disturbs your sleep. Many sleep problems are the result of fragmented sleep caused by a baby, partner, or caring for a sick relative.
“People underestimate the impact sleep fragmentation has on them,” she says. “It affects, mood, concentration, memory and productivity.”
Some restlessness, however, is normal. “Sleep is not a deathlike state. It’s like a symphony with different phases. It’s normal to have up to 12 arousals a night.”
Dreams have been an area of where Baker has learnt a lot since becoming a psychologist. “Dreams are very powerful. To me the patient is always about who they are when they’re awake and when they’re asleep.
“I don’t interpret the dreams. I empower the patient to work out what the symbols in their dreams mean. I work with [the theories of] Carl Jung.
“The patient and I try to understand the unconscious and what stuff is affecting them. By looking at dreams you understand the metamorphic process and often dreams change as therapy progresses.”
Her own growth continues and Baker has just registered for a PhD. “I’ve been on such a massive learning curve,” she says. “ I learn something new with every case. People don’t get it, how complex sleep is.”
This is changing. She says momentum is gathering and GPs are becoming more aware about SD. More doctors in her area are referring people to her instead of just continuing to prescribe sleeping pills.
It seems it’s not all darkness in the Land of Nod, after all.
• Michelle Baker has the Behavioural Sleep Medicine portfolio of the newly formed South African Society for Sleep Medicine (SASSM – www.sassm.co.za). The society is actively engaged in standards of practice and education and training in SDs.