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STORY BY PETER MEREDITH PHOTOGRAPHY BY NICK CUBBIN

We spend one-third of our lives asleep, but we still don’t know why. New research is shining light on one of science’s enduring questions. >

Dr Helen Wright, a sleep scientist at Flinders University, Adelaide, tests prototype light-emitting spectacles she helped develop to correct out-of-sync body clocks. The spectacles, named ‘Retimers’, can be used to treat certain kinds of insomnia and jet lag.

SLEEPTHE MYSTERY OF

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FOR FIVE YEARS, insomnia gnawed away at Kim Budimir’s life. Locked into a vicious cycle of fractured nights and exhausted days, the 36-year-old Adelaide resident would doze off in front of the TV in the evening and then,

having crawled into bed, sleep until 2 or 3am. “I wouldn’t be able to go back to sleep after that, so I’d get up and watch television,” Kim says. “By the time I needed to get ready for work, at about 6.30am, I was tired and ready to sleep. But that was impossible; I just had to push through it.”

At her desk after fewer than six hours of straight sleep, her brain fogged by fatigue and her stress levels amplified by anxi-ety over her chronic sleep deficit, Kim had to focus hard on avoiding mistakes in her demanding job at the office of the Premier of South Australia. She’d schedule challenging tasks in the morning and more mundane ones in the afternoon.

“After 2pm I was a basket case,” she says. “I had no social life...no desire to do anything but come home and sleep.”

By late 2011 Kim had had enough. With a referral from her GP, she contacted the Adelaide Institute for Sleep Health, based at the Repatriation General Hospital, and turned up for her first appointment early this year.

KIM IS AMONG the 1.5 million Australians who’ve been tormented by one of 70 or so recognised sleep disorders. Whatever their form, these disorders have the same

single outcome: sleep deprivation.

Insomnia made Kim Budimir’s (top) life a misery before she sought help. Sleep disorder studies, such as the one that student Jun Hao Hong (above), 18, is taking part in here at Flinders University’s Sleep Research Laboratory, are helping scientists understand and treat these debilitating conditions.

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Nick Cubbin has a special interest in portrait photography and telling people’s stories. This is his first feature for AG. Peter Meredith is a former associate editor of AG. At different times in his life he’s also been a drummer, a hang-glider pilot, a sailor and a hole-driller in a plastic lampshade factory.

More than 20 years of pioneering research into sleep, circadian rhythms and insomnia treatment – particularly bright-light therapy – lies behind the LED spectacles that Professor Leon Lack, of Flinders University’s School of Psychology, developed with Dr Helen Wright. A sleeker model of the spectacles will soon be made available to the public. One day each week Leon treats sleep disorder sufferers at the Adelaide Institute for Sleep Health. Among his patients was Kim Budimir, whose insomnia he cured with the additional help of bright light at home.

THE PROFESSOR LEON LACK

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Sleep is a period of deep rest when humans and many animals are unaware of what’s happening around them. At various points during this state, voluntary muscles are paralysed, breathing and heartbeat slow down – and at times speed up – body tem-perature falls, and some parts of the brain become less active and others supercharged. Most living creatures need this downtime every day. If they don’t get it, they experience mental and physical disturbances. But sleep is easily disrupted. We wake instantly at a loud noise, a flash of light or if shaken.

Two primary mechanisms power the sleep–wake cycle. One is ‘sleep pressure’, the simple need for slumber. The longer we’re awake, the greater the pressure.

The other mechanism is the biological clock: the brain’s pacemaker. This remarkable machine resides in two pinhead-sized clumps of nerve cells known collectively as the suprachiasmatic nucleus (SCN). Sitting directly above the optic nerves, the SCN monitors the amount of light entering the eyes. Once it has this information, it resets the clock every day, establishing the body’s circadian rhythm.

One of the crucial connections the SCN has in the brain is with the pineal gland, a pea-sized organ that releases melatonin, the sleep hormone (dubbed the hormone of darkness), as day-light fades. The SCN ensures melatonin levels rise during the night and fall towards dawn. It’s one of the major drivers of the sleep–wake cycle. If all is well with the system, this cycle is finely coordinated with the planet’s day–night timetable.

NOBODY REALLY KNOWS why we sleep, although theories include: sleep revitalises the brain and nervous system, builds protein and restores the brain’s control over

muscles and other body systems. Dreaming may help consolidate memory and aid mental activities such as learning and reasoning. “There is good evidence that sleep acts like a glue

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that holds memories together – that it’s important for memory consolidation, and the flip side, forgetting,” says Associate Professor Kurt Lushington, director of the Centre for Sleep Research at the University of South Australia. “You need to wipe some stuff out and reinforce other stuff.” Sleep also improves daytime concentration and alertness, he says. “When someone’s alert they can think sideways, react differently, creatively, and process multiple things at a time, while their thinking and emotions are well coordinated and interacting.”

How much sleep needed varies from person to person and depends on many factors, including genetics. We sleep less as we age: four-year-olds require 10–14 hours, but most adults only 7–9 hours. Some adults seem naturally able to function

Electrodes connected to a sleep study device monitor the brainwaves, heartbeat, breathing, eye movement and muscle activity in Lucy Im as she dozes during a study at Flinders University’s Sleep Research Laboratory, Adelaide.

THE SLEEP–WAKE CYCLESleeping and waking are controlled by our body clock, which synchronises itself with the day–night rhythm. The body clock is housed in a nerve-cell cluster called the suprachias-matic nucleus (SCN), part of the hypothalamus. Its position just above the optic nerves allows it to monitor the amount of light entering the eyes. In bright light the SCN uses its multiple connec-tions to keep the brain alert. At night, it spurs the pineal gland to secrete melatonin, a hormone that promotes sleepiness.

It has just gone midnight and registered nurse Susan Gutterez completes a ward round and checks patients’ records in the cardiology wing of the Sydney Adventist Hospital. Susan is on duty from 10pm to 8am.

Night work throws the body clock out of sync with natural biological rhythms, resulting in shallow, disrupted sleep during the day. In extreme cases, a major side effect is severe sleep deprivation leading to fatigue at work, with the increased risk of errors. However, many shiftworkers tolerate the costs of their unnatural routine in return for benefits such as more time off, better pay, increased job satisfaction and a quiet working environment. Most become skilled at managing the risks of their chosen lifestyle.

NIGHT OWLS THE SHIFTWORKER

Optical nerve

Suprachiasmatic nucleus (SCN)

Pineal gland

Melatonin

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Dental sleep medicine is a growing field in which dentists treat sleep-related breathing disorders, such as snoring and obstructive sleep apnoea (OSA), with oral appliances. Dr Graham Hawkins, who runs a dental practice in Penrith, Sydney, says dentists are on the frontline in the battle against sleep disorders because they are often the first to spot the signs. These markers are often con-spicuous as soon as a patient opens their mouth. Some 20 per cent of Graham’s patients have OSA (see ‘The big four’, opposite).

THE DENTIST DR GRAHAM HAWKINS

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well on less than seven. Other people need more than nine. People who sleep for eight hours a night in their 30s might need an hour less in their 60s.

If we don’t get enough, we struggle to concentrate, especially on dull, repetitive tasks. We react more slowly and we make mistakes, though we do better on more stimulating tasks. We’re also easily distracted, moody, irritable and even irrational. Worse, we may be so fatigued during the day that we doze off, maybe while doing something like driving. Extreme sleep deprivation is so unpleasant, it’s used as a form of torture.

Professor Drew Dawson, director of the Appleton Institute for Behavioural Science (an Adelaide-based campus of Central Queensland University), has long had an interest in the impacts Continued on page 91

of shiftwork on sleep. In 1997 he published a paper that likened the effects of fatigue to those of alcohol intoxication, expressing hours awake in terms of blood-alcohol concentration. Drew says a person who’s been awake for 24 hours continuously has a blood-alcohol equivalent of up to 0.1. “So somebody driving home after their first night shift is as impaired as if they’ve had twice the legal limit of alcohol,” he says.

WE THINK OF A normal night’s sleep as a single eight-hour stretch. Scientists call this monophasic sleep. But this hasn’t always been the norm.

In pre-industrial Europe, going back to Roman and ancient Greek times, biphasic sleep was common.

SLEEP DISORDERS: THE BIG FOUR

1 Obstructive sleep apnoea

(OSA) is potentially life-threatening. It occurs when a sleeper’s airway collapses, partly or fully, so that breath-ing stops, in some cases for a minute or more. This may happen hundreds of times a night without the sleeper realising. Snoring can be a

symptom.

Dentist Graham Hawkins (above) uses a pharyngometer on OSA patient Greg Cant to check his airway. Greg’s treatment includes a Continuous Positive Airway Pressure mask (below) and an oral appliance (left) to help prevent airway collapse.

AIRWAY BLOCKED

2 Insomnia sufferers either have difficulty falling

asleep or they wake during the night and can’t get back to sleep. Common causes of insomnia are stress, illness, pain, medication, post- traumatic stress disorder, circadian rhythm problems (including jet lag) and other sleep disorders.

3 Restless leg syndrome causes unpleasant creep-

ing sensations in the legs while a person is sitting or lying awake in bed. The only way to alleviate these is to move the legs, usually by walking. This is different from periodic limb movements, which are regular muscle jerks that wake the sleeper.

4 Narcolepsy is an uncom-mon condition of daytime

sleepiness that may prompt a person to doze off in the mid-dle of an activity. Narcoleptics may also have cataplexy, a sudden muscle weakness triggered by emotions such as anger, surprise or joy, causing the person to collapse, for instance when laughing.

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Movies and games keep 15-year-old Loc of Clovelly, Sydney, awake late into the night. But even without the laptop-generated stimulation, he’d be struggling to get to sleep at a civilised hour. The massive neural and hormonal changes happening in his

adolescent body would have already wreaked havoc on his body clock, leading to late nights and long lie-ins in the morning. They are a natural part of growing up, but 21st-century technology makes things worse. Result: more schoolkids falling asleep in class.

NIGHT OWLS THE TEENAGER

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People slept in two spells, separated around midnight by 1–2 hours of chatting, snacking, housework or sex. A few people still sleep like this.

Premodern peoples such as ancient hunter-gatherer societ-ies – and similar groups surviving today – had even less-structured sleep habits, termed polyphasic sleep. They may have slept in groups, with individuals of different ages waking at different times through the night, ensuring that there was always someone alert to danger. They also took naps during the day, a bit like today’s so-called siesta cultures, in which people sleep for 5–6 hours at night and nap for 1–2 hours after lunch.

In the late 1800s, artificial light doomed both biphasic and polyphasic sleep. People carried on their daytime activities late into the night – and even right through it. Sleep was taken in a single, mostly uninterrupted stint and became compressed. As a result, many sleep experts believe we’re probably getting 1.5 hours less sleep than people did 100 years ago.

L IFESTYLE-BASED sleep problems are just a few of the sleep disorders that bedevil our society. These disorders range from snoring and mild insomnia, sleep apnoea and narco-

lepsy, to restless leg syndrome and chronic insomnia. A 2012 report says that, combined, these disorders bleed the Australian economy of $36.4 billion annually. Although not all stem from circadian rhythm disturbances, they spawn the single overarch-ing monster: sleep deprivation.

In a study published in April this year by the Appleton Institute, almost 40 per cent of people quizzed said they had fallen asleep at work or during meetings. Thirty per cent had called in sick because of sleep-related issues. Sleep disorders are behind 9 per cent of work-related injuries, 8.3 per cent of depression and 7.6 per cent of non-work related road accidents. Some 90 per cent of Australians experience a sleep disorder at some point in their lives.

The big daddy of them all is obstructive sleep apnoea (see page 86), which accounts for about half of all sleep disorders and has the biggest economic impact. Insomnia comes second, at about 30 per cent. Insomnia takes several forms. Mostly it’s transient, but when it persists, its impact on the sufferer’s life can be pervasive and distressing.

Professor Leon Lack, of Flinders University, Adelaide, is a sleep expert renowned internationally for his pioneering work on insomnia. He and co-researcher Dr Helen Wright have been studying the human circadian rhythm for more than 20 years. “The main theme of our research is the involvement of circadian rhythms in insomnia, in people whose rhythms are delayed and who have trouble falling asleep and are waking late, and people whose rhythms are advanced and are falling asleep and waking too early and aren’t getting enough sleep,” Leon says. Worry usually worsens the distress, creating a nasty feedback loop.

Penelope’s dream. A lithograph by John Flaxman illustrates a version of Homer’s Stories published in 1878.

Insomnia takes several forms... Its impact on the sufferer’s life can be pervasive and distressing.

Dreams place us in fantasy worlds where scenes are vivid, emotions are intense and events are linked more by association than logic. Some dreams reflect real experiences, mixing illusion with memory. They’ve been called divine revelations, prophesies, communications from departed souls and expressions of repressed sexual desires.

Eighty per cent of dreams occur during REM sleep. On average, we spend two hours a night dreaming. We often don’t recall what we dreamt.

Through modern scanning technology, many sleep researchers are coming to see dreaming as simply the product of biological activity as chemi-cals fire up different parts of the brain. It’s believed that while we’re dreaming, the parts of the brain involved with logic, critical thinking, and awareness of time and place become inactive, while those sup-porting instinct, emotion and vision are hyperactive. That’s why our dreams are emotionally and visually lurid, but bewilderingly illogical.

One theory holds that dreams help consolidate long-term memory, a process that includes dump-ing redundant material. Another says dreams allow us to mentally rehearse activities vital to our survival, such as feeling fear and fleeing danger. But since most dreaming takes place during REM sleep, it may be REM sleep and not dreaming that performs these functions.

THE MEANINGS OF OUR DREAMS

The lights very rarely go out in today’s electrified world, such as this office block in central Sydney. Before electricity, the sleep patterns of our ancestors were aligned with the planet’s day–night cycle. People were active when it was light and slept

when it got dark. Now we’re active at night too, working or playing. This can lead to sleep deprivation and a condition dubbed ‘social jet lag’, in which bodies and minds are turbocharged at night but fatigued during the day, the reverse of our natural state.

NIGHT OWLS THE OFFICE WORKER

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Although intense interior light may be enough to shift the rhythm in milder cases, more powerful light sources could be needed in others. Initially, the researchers used light boxes as a source, but they were cumbersome and patients didn’t enjoy sitting in front of them for long. Then, in 1997, Leon had a brainwave. Opening his garden shed one day, he saw that his daughter had left the lights of her bicycle on. “The LEDs were still flashing after three days. I realised immediately they were a very efficient source of very bright light. It occurred to me that they might enable you to put the light source close to the eyes to be effective for light therapy, but with much less electrical power needed compared with the conventional light boxes.”

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You don’t sleep. You worry about not sleeping. Your worry keeps you awake more. “The anxiety night after night is prob-ably the biggest issue,” Leon says.

Some people’s body clocks run either abnormally fast or slow. In less extreme forms, this mistiming turns some people either into owls (late-nighters) or larks (early risers). It doesn’t take much to push the body clock just a little further either way and turn owls and larks into insomniacs. Sometimes the trigger is stress, caused by an event such as a marriage break-up (as was the case with Kim Budimir) or a death in the family. With luck the stress passes and the insomnia wanes. But sometimes the insomnia becomes entrenched.

Teenagers are notorious sufferers of phase-delayed insomnia. Mostly this is triggered by the momentous changes taking place in their brains and bodies during adolescence, but it’s exacer-bated by poor sleep habits like watching TV or using laptops, tablets and mobile phones in bed late into the night.

Leon and Helen have pioneered treatments for circadian rhythm mistiming using bright light. They’ve found that light at the right intensity and colour (blue, green or blue-green are best) administered at strategic points in the rhythm can suppress melatonin production and push the rhythm in one direction or another. Bright light in the early part of the night delays the rhythm, so that a person wants to go to sleep later, while bright light in the early morning advances it, so that the sleeper wakes earlier.

While taking part in a sleep study in Flinders University’s Sleep Research Laboratory, Lucy Im (above) wears red-tinted glasses that filter out brain-arousing blue light during a bathroom break. Honours student Philippa Turvey (top) checks a printout from an actigraphy monitor, a device that records body movement, worn by one of the subjects in the study.

So was born the concept of light-emitting spectacles that insomniacs (and even people suffering from jet lag) could wear for their treatment with minimal inconvenience. Helen worked on prototypes for her PhD and now the latest design, Retimer, with LEDs and rechargeable batteries in the frame, is about to come on to the market.

Both Leon and Helen take time out from their research to treat patients at a couple of sleep clinics, Leon at the Adelaide Institute for Sleep Health. And it was here that he and Kim Budimir met in January this year.

FROM THE START Kim was sceptical. “I’d tried everything and nothing had worked,” she says. “When Professor Lack told me we were going to sit and talk and then make some

minor adjustments to my day, I couldn’t see how this was going to help.” First Leon asked Kim to go to bed later. “He wanted me to stay up till 10.30. For someone who was in bed by nine and awake at three or four, that hurt. I almost cried!”

Kim realised the aim was to begin the gradual process of pushing her circadian rhythm back to its normal timeslot.

NIGHT-TIME ROLLER-COASTER

Sleep is a nightly roller-coaster ride during which we plunge repeatedly from peaks of light sleep into troughs of deep sleep and up again. Cycles are repeated up to five times a night and can be separated by brief awakenings. Disruptions of light sleep are a normal part of the sleep period; our ancestors experienced biphasic and polyphasic sleep patterns, where they slept in several blocks, separated by various activities.

You don’t sleep. You worry about not sleeping. Your worry keeps you awake more.

Stage 1: We enter a light sleep marked by a brainwave pattern lacking the high-frequency Alpha waves of wakefulness. We can wake easily and, if roused, may feel we haven’t slept at all. This stage lasts five minutes or more. Stage 2: We are now truly asleep and on our

way to deep slumber. Brainwaves are slower but they occasionally show bursts of hyperactivity known as ‘sleep spindles’ or ‘K-complexes’. This lasts 20–60 minutes.

Stages 3 and 4: The brainwaves of these stages are similar. They are big and slow and called Delta waves. They are created by neurons in a resting pattern and are firing simultaneously. Often called slow-wave or Delta-wave sleep, this is deep sleep.

REM sleep: About 60–90 minutes after falling asleep we enter dream sleep, a stage marked by rapid eye movement (REM) and brainwaves like those of wakefulness. Some 90–100 minutes after the start of the cycle we begin a new one.

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“That lasted 2–4 weeks. Then he added that nugget: ‘Let’s turn on every light in every room you’re in.’’’

Accustomed to unwinding in soft, cosy light in the evenings, Kim now had to do everything under a harsh glare. It was a shock to her system – but it worked spectacularly. Within weeks she was falling asleep at about 11pm and waking at 6am, getting about seven hours sleep a night. She had the last of six consul-tations with Leon in May.

“These past few months have brought a huge change to how I feel,” she says. “I feel good in the morning and during the day, just naturally tired from my work and not exhausted by fatigue from lack of sleep.

“I’m amazed that a couple of quite simple tweaks to behav-iour have resulted in completely shifting my sleep pattern and making it more normal.” AG

One-quarter of all Australians regularly have their sleep disrupted by snorers. A snorer is five times more likely to have a marriage breakdown than a non-snorer.

2 More than 5 million prescriptions are issued annually for sleeping pills under the Pharmaceuti-cal Benefits Scheme, 9 per cent more than in 2001.

3 In a typical classroom, 25–30 per cent of kids have a sleep disorder.

4 People who typically sleep fewer than six hours or more than nine hours a night have an increased risk of dying earlier, though the causes are still unclear.

5 People with moderate obstructive sleep apnoea (OSA) have double the risk of dying from cancer compared with people without the condition. OSA has been linked to conditions such as obe-sity, diabetes, high blood pressure, heart attacks, strokes and depression.

SLEEPY FACTS

The Transport Workers Union says many truckies – such as Josh Mieglich (above) – work long hours, often driving throughout the night. Night drivers are advised to get a decent amount of sleep during the day, take frequent breaks, keep the cabin cool and play the radio to keep their minds active.

AUSTRALIAN GEOGRAPHIC and Peter Meredith would like to thank Sarah Blunden, Mary Carskadon, Drew Dawson, Sally Ferguson and Brooke Michell, as well as everybody else mentioned in the story.

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