Once upon a time, before we had children, I used to work as a Catholic priest. On one occasion, I fell asleep during one of my own sermons, an accomplishment which is easier than it sounds.
I said Mass on Sunday evenings in a parish full of wonderful young families. I thought I was doing everyone a favour by keeping the sermon short, a discipline I achieved by sticking to topics I knew something about. Generally my wisdom had petered out by the end of the third minute. One day, after the service, a mother of three young boys took me to task for my brevity. She wasn’t concerned that she was missing out on the secret of God; with three kids she knew much more about that than I did.
The woman’s problem with me was practical. She put good money on the plate and wanted better value. Mass was her only chance on the weekend to have a rest and by late Sunday afternoon she was totally exhausted and facing the weekly prospect of getting the lunches cut, the boys to school and herself to work the following morning. The sermon was her only chance for a bit of a nap. Would I mind stretching it out a bit longer? She’d be grateful if I could. She needed the rest. I said I would do what I could.
I knew I was improving when I nodded off during the sermon myself. This may be divulging a trade secret, but once a sermon gets beyond a couple of minutes, it reaches a delicate point at which the preacher has no idea what he or she is going to say next. In the Jesuit tradition of which I was a part, this point normally came closer to the start of the sermon than the end. The custom was to keep the sermon ticking over until something popped into your head, a practice known as relying on the spirit, a risky way of going about things, especially when the most likely thing to pop into your head was either what you’d already said or what you’d soon wish you’d never said. Another strategy when stuck for an idea was to pause briefly and invite the congregation in a reassuring tone to think about, reflect on or, if you were particularly desperate, to meditate on what you had just been saying. This bought a bit of time to come up with something else. It was on one such occasion that, with my hands joined devoutly on the lectern, my head started to nod. My eyes closed. My breathing slowed and deepened. It was only when I bumped into the microphone that I woke myself up and noticed that the congregation was giggling. I remember thinking that I must have said something funny and wondered what it was.
This wasn’t the first time that I had amused a congregation when I thought I was being serious. Soon after I was ordained, I was asked to preside at a service on Good Friday, the day Christians ponder the death of Jesus on the cross, hardly the happiest moment in human history. I wanted to make the point that the message of Jesus was hard to reduce to a few choice slogans. Unfortunately, what I said was that Jesus was a hard man to nail down.
At least now I had a bit more experience under my belt: it appeared that I could give a sermon in my sleep.
The incident was part of a bigger picture. I wasn’t just falling asleep during my own sermons; I was falling asleep anywhere and everywhere. I would go to bed early, get up as late as possible and yet by ten o’clock in the morning there was nothing I wanted more than to go back to bed. After lunch, I’d crawl under my desk at work and grab some shut-eye. It was getting harder and harder to stay awake. At the same time, my snoring was getting worse and worse. I could make a monastery sound like a factory.
I underwent my first sleep study in January 1997 at the age of thirty-five. The cheerful technicians stuck a suite of electrodes to my scalp, chest and legs and put a band around my chest to measure my breathing. They also put a microphone somewhere to record my snoring; this, I presumed, was how they made sound effects for disaster movies. The electrodes were all connected to a machine called an electroencephalograph (EEG) which traces brainwaves, drawing a picture of what the brain is doing during sleep; this computer was kept outside in a command booth. Then, trussed up like a chook at Christmas, I was asked to get as good a night’s sleep as possible. I knew at once that this was a ridiculous request. I wasn’t going to sleep a wink. Nobody had advised me to bring my teddy bear.
When I got the results, I discovered it had taken me nine minutes to fall asleep, an interval known as sleep latency. Even in the comfort of your own bed, if you fall asleep in less than ten minutes it’s an indication of sleep deprivation.
There were more results as well. The morning following the test the technicians came in with big smiles and said that they had big news to tell me.
‘Oh,’ I asked warily. ‘What’s that?’
‘We can’t tell you.’
‘How come?’
‘You have to see the doctor in a couple of weeks.’
‘The suspense will kill me.’
It wasn’t suspense that was going to kill me. It was sleep, or at least what was happening in my sleep. When I turned up for my appointment with the doctor early on the day after a public holiday, his waiting room was packed, suggesting I was not the only person in the world with problems. Meeting the doctor, John, was one of those experiences – a bit like what I imagine it is to discover that your partner has been having an affair for years – when you realise that you have known very little about a major part of your own life. John produced an impressive little pile of print outs, technically known as a polysomnograph, which were generated during my night in the sleep lab. He started circling parts of them with a magnificent black Mont Blanc fountain pen which I began to eye off.
‘How do you think you slept in the lab?’ he asked.
‘All things considered, not too bad,’ I replied.
‘Were you aware of waking in the night?’
‘No, I reckon I slept right through.’
‘Undisturbed?’
‘Totally undisturbed.’
He was writing all this down with his Mont Blanc. He then put the lid on the pen with a small flourish, indicating it was time for him to stop listening and start speaking.
‘Actually,’ he said. ‘You woke up 287 times.’
I found this hard to believe. Perhaps he’d mixed up my results with those of a young mother somewhere. The Mont Blanc reappeared and circled the key statistic, to impress upon me that 287 was a very big number and not to be joked about. I noticed the pen had a broad nib, the type that requires skill to wield without making a mess, altogether a very nice writing instrument. I wished we could talk about that.
‘You slept for a total of five hours and forty-nine minutes. This means you were waking up on average forty-nine times an hour or, in other words, almost every minute.’
‘What about the snoring?’
‘This is related to the waking. I’ll explain how that works in a minute. We were recording you at well over 80 decibels, which is the same as traffic noise or shouting. Normal conversation is 60 decibels; hearing damage starts at 90 decibels. You weren’t far short of that. It was quite a racket, I believe.’
‘Wow.’
‘Yes, wow indeed.’
He picked up the pen but then put it straight down; he knew he had my attention now.
There were some important things I needed to understand. The 287 interruptions to my sleep were called apnoeas, a word of Greek origin which means the cessation of breathing, and I had a condition called Obstructive Sleep Apnoea which, in those days, was not well known. That situation has changed dramatically in recent years: the ailment has reached epidemic proportions in well-fed countries. Sleep apnoea is a condition which more commonly afflicts men although their partners also suffer: its proper treatment has been known to feature in the pre-nuptial agreements of women who don’t want to spend their marriages feeling like they’re sleeping on a runway. It does affect women themselves as well although it is one of the few maladies for which men are more likely to go looking for help, usually with considerable urging from home. Dr Christopher Worsnop, a sleep physician, explains that the classic interview with a couple goes like this:
‘Do you snore?’
Man: ‘She says that I do.’
Man: ‘She says that she doesn’t.’
Being overweight is a significant risk factor. As a luggage handler once said, I had a bad case.
Sleep apnoea is in large measure the result of a design fault in the upper airway. The human throat is a floppy tube, something that distinguishes us because all other species have rigid throats, a situation which is thought to have come about because of the human need to speak. While you are asleep, your tongue and soft palate, which is the fleshy part at the top rear of your mouth, relax and your throat collapses. Your uvula, the bit that hangs over your tongue like a stalactite and becomes visible when you gargle, also flops in the way, as do your tonsils. As a result of so much slack behaviour behind your teeth, the passage of air to your lungs may be blocked, especially if you’ve had a bit of alcohol or if your throat is narrow. Why might your throat be narrow? Perhaps you’re a bit chubby: the body stores fat in visible places and also invisible ones such as the walls of the throat. On the other hand, it might just be a matter of luck. People with jutting jaws are more likely to have open throats and hence be less susceptible to snoring and sleep apnoea. Chris Worsnop points out that superheroes such as Superman and Batman are often drawn with strong jutting jaws, a feature which, since the time we lived in caves, has been seen as attractive to women. The reason women may be attracted to jutting jaws may have nothing to do with jutting biceps or jutting anything else; it simply makes it less likely they will have to put up with snoring.
If your throat falls in on itself or becomes obstructed, the level of oxygen in your blood decreases and the amount of poisonous CO2 rises. If something didn’t happen at this stage, you’d suffocate. But luckily the increase of CO2, decrease of O2 and the work of various receptors in the throat, lungs and chest all send a message to the brain that it needs to wake up and the brain obliges. The brain does a lot of things for you without even letting you know. It’s good like that. The loud spluttering, strangling, gargling noise that passes as snoring is actually your attempt to push the palate and tonsils out of the way, open the throat and clear the airway. The noise sounds desperate and it is. You are struggling for life and you don’t even know. Untreated sleep apnoea is a killer; the main way it kills people is when they fall asleep driving. If you don’t actually choke, it may put pressure on the cardiovascular system. Even if you avoid these pitfalls, you wake up exhausted, as someone who has been disturbed 287 times in a night has every right to be.
‘Would this be happening every night?’
John picked up the pen and held it between his two forefingers like the rod of judgement.
‘Yes. Every single night of your life. You’re lucky we found out. It was five minutes to midnight for you.’
‘Don’t worry,’ he said. ‘I love the old Cold-War language.’
Had I been talking with John twenty years earlier, his options would have been limited. I could have tried sleeping on my stomach, an old-fashioned idea which can make a difference because it allows the soft tissue in the upper airway to fall forward and make less of a nuisance of itself. The advice given to snoring blokes in a bygone age, to put a tennis ball in a sock and pin the sock to the back of their pyjama top, is not just an old wives’ tale. Another idea is to put on a bra backwards and put tennis balls in the cups, a form of evening wear which can be confusing to a partner in the middle of the night.
Upping the ante, he could have suggested a tracheostomy, an operation which puts a little hole in your throat below the site of the blockage. This hole is then left open at night, like a window, to let some air in, but it is not a sightly addition to the physiognomy as it makes a person look a bit like a bassoon. The air bypasses the collapsible throat but in so doing also bypasses the vocal cords, so you can only speak during the day by inserting a plug into the hole. A further and yet more drastic option may have been an uvulopalatopharyngoplasty, a word which required nothing less than the services of a Mont Blanc fountain pen to get itself onto a piece of scrap paper so I could contemplate it with all its vowels.
‘Don’t worry,’ said John. ‘It is normally just called a UPPP.’
A UPPP involves the removal of the tonsils as well as a serious trim of the soft palate, the uvula and the pharyngeal arches, whatever they are. John wasn’t recommending this form of major surgery. It tended to be very painful and was by no means guaranteed of success. Like a vasectomy, it isn’t a procedure you can do yourself.
But luckily there was something which had become available of more recent times. It was called CPAP (meaning Continuous Positive Air Pressure) and was the brainchild of a professor in Sydney called Colin Sullivan, of whom John spoke with awe. Sullivan had come up with a clever solution to a problem that had baffled the boffins for ages. While others were dabbling in such elaborate ideas as injecting silicon into the soft palate to stiffen it up so it maintained its condition during sleep, Sullivan realised that the upper airway was a bit like a door which kept banging shut in the night. It just needed somebody willing to stand with their foot in the door. Or maybe a breeze that would stop the door closing. That was it! Sullivan realised that what was required was a machine which would use simple air pressure to splint open the airway; the machine would fit into a mask and the mask would sit over the nose of the patient. It was a simple but ingenius mechanical solution to a problem for which others had sought surgical, pharmacological and even psychological solutions. Colin Sullivan’s bright idea has saved tens of thousands of lives.
I returned to the sleep laboratory to experiment with CPAP and the results were remarkable. Over several appointments I got to know John and enjoy his whimsy. A snazzy new computer appeared on his desk and he now used the Mont Blanc to point to things on the screen. He explained to me that sleep has distinct stages, each stage marked by a certain type of brain activity; the function or purpose of each stage has long been the subject of argument and conjecture. These stages rotate through the night in cycles of approximately ninety minutes; five cycles is a good night’s sleep for most people. The fifth stage, which begins an hour or more into a night’s sleep, is in a class of its own and is so unique and mysterious that it is often known as Paradoxical Sleep, meaning it is a time when the body looks asleep and the brain looks awake. It is called REM sleep. We’ll be hearing more about it later in the small hours. REM sleep is so different that the other four stages are known as Non-REM or NREM sleep. Stages three and four have a particular importance and are known as Slow Wave Sleep. Many sleep researchers do not divide the states of human being into sleeping and waking. They divide them into three separate categories: waking, NREM sleep and REM sleep.
Like many people with sleep apnoea, I was missing out on stages three and four sleep, the time in which growth hormone is released, a substance that uses small doses to achieve a long list of useful results. I was more than just tired. I was sick.
‘You also have periodic leg movements.’ He Montblanced this new problem onto page two of the polysomnograph. ‘This means your legs are moving all night long, kicking. You spend the night walking without going anywhere.’
‘Why?’
‘Well, it’s one of a number of sleep disorders in which people do rhythmic things during the night. Bruxism is another one. Teethgrinding, in other words. Bruxism is most common in children and more common in adult women than adult men. We think these sorts of disorders may be some kind of release mechanism.’
‘I probably need the exercise.’
‘You’re lucky you’re a priest. At least nobody else is going to get kicked in the night.’
He produced a cheap ballpoint which he kept for writing on a prescription pad where carbon copies were required and wrote a prescription for a drug called pergolide, usually given to people with Parkinson’s Disease to control their shaking. Pergolide was to become embroiled in controversy a few years later and was withdrawn from the market, angrily pursued by a group of people who blamed it for causing compulsive behaviour such as gambling. It was also held responsible for heart valve problems in people with Parkinson’s. John didn’t know that at the time. He just thought it might cause nausea, like motion sickness, a strange side effect for something that prevented motion.
‘There’s more to sleep than meets the eye,’ I said. ‘I never realised.’
‘Most of it happens in the dark, so it doesn’t meet the eye, which is why it’s been one of the last frontiers of medical research.’
Over time, John elaborated. He told me that many people think sleep is a passive state.
‘It’s not like that at all. I think of it as the night shift coming in. The plant doesn’t close down. There are all sorts of active processes going on that need to happen overnight.’
‘So why do we sleep anyway?’
John looked around. I think he was trying to find his pen. He drew a deep breath.
‘Well,’ he said. ‘It’s not like there’s one explanation. It depends who you ask.’
If you ask a neurophysiologist, sleep is when a lot of neuro-chemicals get replenished; in other words, it is when the brain eats. If you ask a physician, sleep has a metabolic function; it’s when a lot of tissue repair takes place. If you ask a psychiatrist, it’s all about memory consolidation and the reprocessing of information, and dreams have a role in this. If you ask a developmental physiologist, sleep may be a remnant of our fetal existence and could be a hangover of circuit testing in the fetus, where dreams and dreamlike activity are important for helping a brain discover what it can do and teaching it how to do its job. Most fetal sleep is REM sleep, the type where the brain is really pumping. The percentage of REM sleep diminishes over a lifetime. If you ask an adolescent pediatrician, you will discover that in the months before puberty the pituitary gland is working double time during sleep to get the process started.
I interrupted him.
‘What about you? What do you think it’s for?’
‘I think it performs all these functions.’
‘Really.’
‘And more besides.’
The long and short of it is that no one fully understands why we sleep but everyone agrees that sleep is both vital and universal. Fish, amphibians and reptiles don’t have REM sleep. Birds and mammals do. So it could be that REM sleep is a sign of having got further up the evolutionary ladder. Nevertheless, it appears that even insects have inactive and active periods, much like a sleep–wake cycle, although lab technicians have found it difficult to get those electrodes onto the brains of bees.
John wrote down the name of a chemist who sold the kind of CPAP machine I required, as well as the pressure at which the machine would need to be set. I didn’t notice what pen he used. I was too busy looking at where I had to go next.