Psychology for Writers: Insomnia

I'm planning to write some posts on sleep deprivation in general and what that might look like, but for today, I thought I'd focus on insomnia, as I see it come up a lot in books and it's not always accurately portrayed.

The word insomnia itself simply means lack of sleep, so in that sense, many characters in books might experience insomnia - being unable to sleep well due to anxiety or excitement, for instance. But the diagnosis of insomnia refers to habitual sleeplessness, with diagnostic criteria usually specifying that the patient should have had difficulty sleeping for at least a month before it can be considered insomnia, and that it should be interfering with the person's ability to function normally (that is, if the person doesn't get much sleep but feels fine, they don't have insomnia - they might just need less sleep than the average person).

There are three ways insomnia can manifest, and patients may have one, two, or all three:

1. Difficulty initiating asleep - It's considered "normal" to fall asleep within about 15 minutes of getting into bed. For people with insomnia, it can take many minutes or even hours to fall asleep.
2. Difficulty maintaining sleep - Waking up multiple times in the night and/or waking up early (e.g., before the alarm) and being unable to go back to sleep.
3. Restless or nonrestorative sleep - Feeling tired, even after getting sleep, likely because the person was unable to go through full sleep cycles and get sufficient amount of sleep in each stage.

When I read books in which characters have insomnia, usually it manifests as #1. But a person might be able to fall asleep normally, but not be able to maintain it, waking up multiple times in the middle of the night and/or being unable to get back to sleep. Books also may portray someone with insomnia as unable to sleep at all, which is highly unlikely. A person with insomnia may be able to sleep for small spans of time, perhaps only making it into the lightest stages of sleep (the stages close to wakefulness). And someone who is severely sleep deprived is likely to fall asleep for short spans of time without meaning to - these are known as microsleeps, where the person may nod off for just a few seconds.

A person may be unaware that they fell asleep, but one tell is that they may have sudden dream-like images - this may happen, especially in a person with insomnia, for a couple of reasons:

1) The lightest stage of sleep is very similar to the stage of sleep in which we dream. In fact, if you look at brain activity of a person in the lightest stage of sleep and in dreaming sleep (REM or rapid eye movement), they'll look surprisingly similar. (Fun fact, they'll also look surprisingly similar to brain activity of a person who is awake.)

2) People with insomnia likely have a deficit of REM sleep. When a person has a deficit of REM sleep, an interesting thing happens that doesn't happen for other sleep deficits: they'll go into REM sleep more quickly and spend more time there. This phenomenon is known as "REM rebound." A person with insomnia may nod off and immediately have dream-like imagery and experiences. This, in fact, is a great explanation for people who report hearing voices, as well as for supernatural experiences; it's no coincidence that people are more likely to report seeing ghosts at night. Auditory and visual hallucinations are very similar to dreams, and are likely the result of the same processes that give us dreams.

The big question, of course, is what causes insomnia. One cause is that a person may be predisposed (genetically) to poor sleep. For instance, I recently did 23andme, and one of the things they look at in their health analysis is whether a person has genetic indicators of being restless during sleep. It makes sense, then, that some people simply don't sleep as well as others for no reason beyond what's written in their genetic code.

Of course, a person may also be genetically predisposed to other conditions that impact sleep, such as depression and anxiety. Insomnia caused by one of these conditions usually occurs because a person is unable to "turn off his/her brain" to fall asleep; instead, they may lay awake worrying or ruminating. But the direction of causality could be flipped, with insomnia causing depression. Sleep is one of the times your body replenishes important neurotransmitters. If your body isn't able to carry out those processes normally done during sleep/rest, they'll experience deficits that could manifest in a variety of conditions.

Among women, hormones can exacerbate insomnia. Many women report having insomnia during their period. (It's likely that hormones affect men's sleep as well, but unlike women, fluctuations in men's hormones are less predictable.) This is more likely to occur among women who have insomnia the rest of the time; it may simply be more severe at certain times in a woman's cycle.

Insomnia is also a symptom of post-concussive syndrome; that is, a person who had a concussion may end up experiencing insomnia. For some, this is short-term until their brain heals. For others, this is a long-term/permanent condition as a result of a head injury. (There are other symptoms of post-concussive syndrome the person may have, such as depression and tinnitus - ringing in the ears.)

Lastly, insomnia may be behavioral. Lack of good sleep hygiene could lead to insomnia. And people who have programmed themselves to be awake at night or to wake up easily at night (e.g., they care for a relative with a chronic illness and have to be awakened multiple times at night) may also end up developing insomnia as a result. However, people who have been diagnosed with insomnia and are working to deal with it tend to have the best sleep hygiene: they avoid things like reading or watching TV in bed, and often won't even have these distractions in their bedroom; they have a standard bedtime routine; and they tend to very thoughtful about what they consume, especially caffeine, close to bedtime. So if you're writing a character who has insomnia, this is one characteristic you could give them: an almost obsessive attention to sleep hygiene.

People with insomnia are also more likely to experience an unbelievably terrifying sleep disturbance: sleep paralysis. I could write a whole post (or two!) about sleep paralysis, which also explains many supernatural experiences. In the meantime, there's a documentary about it available on Netflix. I see insomnia used all the time in books; I rarely see related sleep disturbances like sleep paralysis. So if you're writing a character with insomnia, you might consider adding something like sleep paralysis in as well.

Other quirks of people with insomnia:

• They may find it difficult to sleep when they're supposed to and difficult not to sleep when they aren't supposed to, such as during the day, while watching TV, etc. 
• They tend to be better at remembering their dreams, because they often wake up after a dream, and have some time to think about/process it. 
• They may find it difficult to differentiate dream from reality, not necessarily in the moment, but after the fact. That is, they may remember something later on and be unable to tell if that actually happened or they only dreamed about it.
• They may be hesitant to tell others they have insomnia because people (usually normal sleepers, who may have a bout of insomnia every so often) will respond with remedies they use when they're unable to sleep. As a person with insomnia since I was about 8 years old - which at its worst, results in me getting only 1-2 hours of sleep a night, and typically, results in me getting 5-6 hours of sleep - I have tried just about everything, and have heard it all, from the mundane to the bizarre to the borderline inappropriate (my favorite, and you're welcome to use it in a book: a Starbucks barista who told me I needed "nature's sleeping pill, which is more of an action," followed by a gesture to make it very clear he was talking about sex). 

Sleep well, writers! And if you don't, use it for story inspiration. 

My YouTube Rabbit Hole

I woke up super-early this morning, and unable to get back to sleep, I decided to get up and do some writing on my laptop.

Yeah, about that... I'm pretty sure my Macbook Air is dead. I tried to do some trouble-shooting, but no luck. Since it was still crazy early, I decided to deal with it later when people who can help are actually awake, and instead fell down a YouTube rabbit hole on my phone. Here's what I watched.

Jenna Marbles giving 30 life lessons she learned over her 30 years of life - everything from moving to new places whenever you can ("sometimes you just need to be in a place where you don't know anyone and you have to go figure your life out") to always do what's right unless it doesn't feel right ("karma is real, but it's not always your job to make sure it gets served"):

John Oliver on Trump's sarcastic (but not really, but maybe) comment on Obama as the founder of Isis. Yes, John, Trump is indeed a "tremendous floater":

This amazing footage being streamed live from the International Space Station:

And finally, this, because reasons:

Alexander Hamilton, Sleep, and Memory Consolidation

I'm currently reading Alexander Hamilton by Ron Chernow - the book on which the Broadway musical, Hamilton, is based.

I'm currently about 250 pages in, so it doesn't look like I'll finish before the end of my vacation, but I've made a good dent. In the current section, which is about Hamilton's writing habits, particularly with regard to the Federalist Papers, I found this description of Hamilton's approach to writing from William Sullivan's Public Men of the Revolution:

One who knew his habits of study said of him that when he had a serious object to accomplish, his practice was to reflect on it previously. And when he had gone through this labor, he retired to sleep, without regard to the hour of the night, and having slept six or seven hours, he rose and having taken strong coffee, seated himself at his table, where he would remain six, seven, or eight hours. And the product of his rapid pen required little correction for the press.

What Hamilton was doing - and I'm certainly not downplaying his genius, or his Mozart-like ability to write without the need for revision - was taking advantage of the memory consolidation function of sleep. That is, during sleep, your brain builds neural connections and essentially transfers events and what you learned that day into long term memory. This is why one of the effects of sleep deprivation is memory issues. So Hamilton did the thinking (and some research) needed to gather his thoughts, then slept to allow them to coalesce and organize. Then he would wake up and write it all down. In fact, I just received a link to yet another study demonstrating the memory consolidation effects of sleep.

Of course, what Hamilton did was even more extraordinary when you consider that it was not yet known that sleep could do this - at least, not from scientific study. Psychology wasn't even considered a field yet; that would happen in 1870s Germany. That Hamilton fellow was pretty smart.

Trivial Only Post: Journal Entry From the Past

I was cleaning today and discovered an old journal from 10 years ago.  I came across this entry, dated June 17, 2005.  Based on the time period, I was probably in one of my worst bouts with insomnia of my life, so I blame the goofiness of this entry on severe sleep deprivation.  Here it is, in its unedited glory:

I'm sitting in my apartment playing Space Invaders and I started to wonder: Just who are these invaders from space?  Why do they attack us?  Are they after our natural resources?

And another thing, why do we just sit back and wait for them to come to us?  Why don't we go find their planet, go down there, and invade them?  I mean, they can't be far away.  With how slow they move, they have to be close by or it would take them a hundred years to get to us.  And by then, what's the point?

And hey, what's with the single tank waiting?  Give me 10 tanks with some more of those fort/armor things, and I'll wipe out their entire species.  It only takes one shot to take them down, and I, apparently, have been gifted with extra lives.  Like a cat.  A cat soldier.  So, I'm good.

On Sleep Disturbance, Color Perception, and the Loneliness of Perception

I just watched a wonderful video that discussed something I've wondered about before: is my perception of color the same as yours?  As I suspected, the video stated that this is something we will never truly know.  Specifically, it is part of the "explanatory gap" - the failure of language and human understanding to adequately communicate to another human what their own perceptions feel like or, in the case of color, look like.

We learn color through exposure.  No one is able to explain to us in words what "yellow" is; instead, they have to show us.  This school bus is yellow.  This pencil is yellow.  Over time, we learn how to identify yellow on our own, based on what we have been shown, as well as our ability to generalize learned information to other things.  We also learn to discriminate - to learn definitions in such a way that we can say, "This thing is yellow.  This thing, on the other hand, is orange."  We can never describe in words how we know this thing is a different color than another, except to say that it looks different.  These abilities are one of the reasons that, even a human of low intelligence is smarter than a computer when it comes to detecting context and experiencing things through perception, rather than hard numbers.

Which leads me to another story.  When I was 8 years old, I began my lifetime struggle with insomnia.  At best, I can get 7 or 8 hours a night - if I go to bed really early, and intend on staying in bed for far more than those 7 or 8 hours to make up for the latency in falling asleep and all those times I wake up in the middle of the night.  At worst, I get 2 to 4 hours a night.  These are the nights I dread.  It doesn't matter how tired I am.  It doesn't matter if I can barely keep my eyes open during the day.  I may still find myself exhausted and in bed, but unable to sleep.

It's a difficult thing for people without sleep disturbance to understand.  How can one be sleepy, but unable to sleep?  In fact, it isn't just their inability to feel my feels - I didn't even know that what I was experiencing was abnormal for a very long time.

Our only experience that we can truly know is our own.  As the video I linked above says, we are alone in our perception of the world.  We can use language and examples to describe our perception to others, but we can never truly know if they feel what we feel.  So for the longest time, I thought my sleep was perfectly normal, because I only had my own experience to draw upon.  I thought everyone took 30-60 minutes to fall asleep.  And I thought everyone woke up multiple times in the middle of the night.

I remember one time in high school, when I was sick, that I actually slept the whole night through without waking up.  I mentioned this to a friend the next day, expecting that they would say, "Yeah, you must have been really sick to be able to sleep that much."  Instead, I got, "What do you mean you wake up multiple times at night?"  Of course I do.  Doesn't everyone?  I was surprised to learn that, no, my sleep was different from others.

Still, I didn't think much of it, until I got to graduate school.  As a psychology student, I was taught again and again that the primary determinant of whether any disorder is problematic (and in need of treatment) was if it interfered with one's life.  When the stress of grad school caught up with me to the point that I was getting only a couple hours a night, I knew I had a problem.  And when I began forgetting things - important things, like class assignments and assistantship duties - I knew I needed to get help.

I was 23 or 24, and for the first time in my life, was finally diagnosed with insomnia.  Something I'd already spent 15 or 16 years of my life battling.

There is a clear stigma around mental illness - perhaps less so with regard to sleep disturbance, but the end result is the same.  People don't talk about it.  And given that our only experience of the world is our own, we may not know how it feels to be other people because we can't experience it.  Unlike color perception, however, we can use language to describe the experience of feelings: sadness, fatigue, anxiety, euphoria.

But we don't know what others are feeling - truly feeling - unless they tell us.  We may not realize that others feel sad for no other reason than they are and that things feel hopeless.  We may not realize that others feel anxious about different events.  We may not realize that others sometimes want to stop living in this world for any number of reasons - or no reason at all.

With the recent news of Robin Williams's suicide, the world is talking.  They're talking about depression.  Suicide.  They're expressing disbelief, or understanding, or fear that it may happen to someone they love.  Remember, no one knows what it feels like to be you, unless you tell them.  Here's to keeping the conversation going.  You never know what sharing that side of yourself to others may do.  It just might save someone's life.

Deeply yours,
~Sara

Willpower, Self-Regulation, and One NYU Professor's War on "Fatties"

You've locked yourself in your apartment, finally beginning to tackle the thing grad students dread, the stuff of nightmares, the fodder for PhD comics, the event grad schools create support groups about: your dissertation. But, gosh, that leftover piece of chocolate cake looks so tasty. Well, it will only take a minute to eat. At least, that's how I eat chocolate cake.

Okay, now that that's gone, time to get back to this dissertation thingy. Oh, but I have chips. And cheese. Nachos? Brilliant.

What was I doing? Oh yeah, dissertation. Oh, but I'm still hungry. Better get some food. Can't work hungry. Before you know it, the dissertation is but a foggy memory in your food binge coma.

Sound ridiculous? Not to this NYU professor:

You know, this tweet seemed fishy, until he hash-tagged it truth. Now it's indisputable.

I know what you're thinking. "Really, this guy has a PhD in psychology?" Unfortunately, perhaps he slept through the lesson on self-regulation. Self-regulation, or what some people might refer to as "willpower", is a cognitively demanding task, involving multiple processes, including self-monitoring (what am I doing?), social comparisons (what would I like to be doing or what should I be doing), and thought suppression (am I thinking about the thing I shouldn't be thinking about?). These processes require a great deal of our working memory, basically short term memory, which years of psychological research shows is a limited resource. Ever hear the expression "5 plus or minus 2"? That is the number of digits you can keep in your working memory at a time. That comes from a psychologist also, unfortunately, named Miller (George A. Miller, in fact), who hopefully would have been a bit more thoughtful in what he tweeted.

Some research does show that ability to self-regulate in childhood (usually measured by ability to forgo a small reward  - often sweets - for a larger reward later - often more sweets) has a significant correlation with ability to self-regulate later (frequently measured by achievements and completion of higher education, like a graduate degree). It's possible, then, that Miller did pay attention to this lesson, but got the wrong message. This research does not support (or even say) that children who like to eat a lot are unlikely to obtain higher degrees. The studies are simply operationalizing their concepts using things kids can understand; children, regardless of their weight status, in general like treats, and even the children who were able to forgo the treat now for a bigger treat later still ate the treat. And ate more as a result of their self-regulation. Kids who were able to "self-regulate" because they didn't actually like the treat offered were probably not included in the study results, because what they were doing was not truly self-regulation.

Additionally, the ability to self-regulate is a general trait. It's not situation-specific. So people who are shown to be good at self-regulation in one situation are likely good at self-regulating in another situation. BUT, not if those situations occur at the same time; because it's a general trait, and a limited resource, exercising strong self-regulation in one situation can actually lessen your ability to self-regulate in another. So people who practice what Miller refers to as "willpower" in completing their dissertation might actually find it difficult to self-regulate in another situation, such as healthy eating.

And grad students eating unhealthily? Yeah, that never happens. </sarcasm>

Further, grad students have another thing that could stand in the way of maintaining a healthy weight. Sleep deprivation has been shown to have a strong effect. I heard one doctor say, "Trying to diet while sleep deprived is like trying to ski uphill." Sleep deprivation has a lot of negative effects on your brain, including monitoring of hunger and satiation (feeling full). When you're sleep deprived, you feel hungry much more because your brain is telling you you're hungry, even if physiologically, you have ingested enough. So those good grad students who work long hours, late into the night, to finish their dissertation might find themselves reaching for the Cheetos a bit more often than those able to get a healthy amount of sleep. Of course, eventually, sleep deprivation does begin to attack your cognitive skills, but that's another post for another day.

So what am I trying to say? What many have said in the backlash against Miller's tweet: that weight status has no bearing on ability to complete a graduate degree. While also giving a healthy dose of psychological knowledge. Because regardless of what I may think when I look at my waistline, I have my brain and all the psychology info acquired through years of education.

Oh yeah, and my PhD. While eating all the carbs I want. Take that, Miller! Now where's that chocolate cake?

~Thoughtfully (and carb-iliciously) yours,

Sara

Forgiveness and the 10-Year Anniversary of 9/11

Today, we remember the 10th anniversary of the attacks of September 11th. In church today, the message was one of forgiveness. There are many religious and spiritual arguments for the importance of forgiveness that I won't go into. Psychologists also have explored this concept, and have discovered how forgiveness (and its converse, unforgiveness) influences an individual's mental and physical health.

Forgiveness is defined in many ways, but all of these definitions add up to one thing: forgiveness is something a wronged person offers to the one (or ones) who perpetrated the wrongdoing. It is generally viewed as a process that the forgiver works toward through many emotions and behaviors. Forgiveness is also often viewed as a personality trait; some people are simply more forgiving than others.

A lot of evidence suggests that being in a state of unforgiveness is damaging to both your mental and physical health (read one of many reviews here). Conversely, forgiveness is associated with better mental and physical health. Forgiveness is something you do, in part for the other person, but also for yourself. Refusing to forgive and continuing to hold a grudge is, for lack of a better word, toxic to your well-being.

This is because, in refusing to forgive, we often dwell on the wrongdoing. Psychologists refer to this constant dwelling on the negative as "rumination", and refer to rumination about perceived wrongdoing as "vengeful rumination". Research on rumination in general finds negative effects. Rumination is negatively correlated with sleep quality (abstract), as well as alcohol misuse, disordered eating, and self-harm (full paper). It makes focusing attention and problem solving difficult, because ruminators tend to be less confident in their problem solving abilities (full paper), and also because rumination uses working memory that could be devoted to the problem (full paper). Ruminators generate more biased interpretations of negative events, are more pessimistic about the future, and are poorer at solving interpersonal problems, as well (full paper).

Rumination is also associated with poor physical health. High ruminators show physiological stress markers, such as increased salivary cortisol (full paper here and abstract here) and immune system activity (full paper). People who ruminate also take longer for their heart rate and blood pressure to return to normal after being made to feel angry, which can put them at risk for organ damage over time (full paper).

Forgiveness is not "letting someone off the hook". It is not the same as condoning or absolving someone of wrong-doing. The old adage of "forgive and forget" doesn't necessarily lead to better outcomes, mainly because of the forgetting part. It is good to forgive, but not necessarily good to forget. Forgetting means failing to learn a lesson - a lesson that may be very important for you later on. This leaves the "forgiver" in a rather difficult position; one in which he or she must remember the wrongdoing without holding a grudge.

How, then, do you forgive? And how do you think about the act in such a way, that you can find forgiveness without simply ruminating on the event? Rumination has one key component - it is dwelling on the negative without trying to find a solution for the negative. You're stuck in the mud and simply spinning your wheels without really getting anywhere. Reflection, on the other hand, involves thinking through an event and trying to find closure. Reflective thought leads to a change in the thinker.

The review I linked to above (linked again here) discussed some of the reflection “forgivers” engage in. One cognitive process is empathy, in which the forgiver puts him- or herself in the other’s shoes, and attempts to experience the same emotional state. Not only do “trait forgivers” experience more empathy, but people who are randomly assigned to engage in empathy are also able to experience forgiveness. This provides some evidence that anyone, even people who are not naturally empathetic, can use this experience to forgive.

Forgivers are more generous in their appraisals of the one(s) to be forgiven, seeing them as more likable or having more likable traits. They are also better at understanding another person’s explanation for the behavior. In essence, they try to see the situation from the other person’s point-of-view. You don’t have to accept another person’s explanation, but rather, try to understand where they’re coming from. At the very least, this understanding can aid in finding a solution or determining a path to reconciliation. People often have a very self-centered view of the world in that they have difficulty recognizing that other people do not see things in the same way or have the same knowledge (a good blog post for another day).

Of course, one thing that may make forgiveness such a difficult process in the case of 9/11 is the severity of the wrong as well as the fact that the group responsible has such different worldviews. In a previous blog entry, I talked about stereotypes and ingroup/outgroup, all of which is definitely relevant here. Our tendency to dehumanize the outgroup makes forgiveness complicated, because forgiveness is a between-human experience. Forgiveness in this case is not impossible, but would have to involve an even greater degree of understanding and attempts to characterize the other group’s point-of-view.

Forgiveness is a process. Even 10 years later, the emotions are still very raw, but we can still continue moving forward.

Thoughtfully yours,
Sara