Moon shadows and haunted nights

Ruth M. Powell

When we were in our first year of medical school, my friend Jean rented a room from a woman who was 100 years old. The woman lived in the first floor flat of her grand old house in the South End of Halifax and didn’t want a full-time caregiver or companion, just someone young and vibrant coming and going, who could keep an eye out for her. She was becoming physically frail, but remained mentally very bright, with a keen and active mind.

Often, after studying late at the library, Jean would come home in the wee hours to find the old lady awake, studying her bible in French. She would inquire about Jean’s day, and Jean would crawl under the covers for a chat, a special time for both of them. Jean would tell her about medical school, and the old lady would talk about her long life and all that she’d experienced over the years. She told Jean that as you get older you sleep differently, more “snatches of naps” rather than longer sleeps. It didn’t bother her; she understood that this was the way of things.

moon shadows
sleep dancing just
out of reach

Jean was never much of a sleeper herself. I remember a long weekend that we both had off and decided on the spur of the moment to take a train to Quebec city. After a long day of traveling and exploring, I fell into my bunk at the youth hostel exhausted and was asleep in minutes. The next day Jean told me that she hadn’t been able to fall asleep, so got up and spent a couple hours enjoying some Québécois music at a nearby cafe. She explained that she really only needs 4 or 5 hours of sleep a night and embraces the extra hours fully. So many times over the years I’ve envied her those extra hours. It seems that she’s experienced and accomplished twice as much as I have. She calls those hours “delicious”—when the rest of the world is sleeping and she has the house to herself to work on projects and be alone. She does wonder if there will be a tradeoff in later life. Will she develop burnout? Is she at increased risk of dementia? So far she shows no signs of either.

stolen hours
a new doll’s dress
by morning

Unlike Jean, I always needed my 8 hours of sleep, and I was thankful to be a good sleeper. It was lovely to sleep through anything and wake refreshed. Not so good for being on call. But my sleep is far from uneventful. There are vivid, often horrifying dreams with graphic images, so different from my daytime life. Episodes of sleep paralysis. Waking up feeling overwhelming sadness, intense anger, or sweet joy—not remembering the dream or any reason why I should feel this way. And later, when my sleep patterns started changing, there were nights where I’d wake up in a sweat every hour, recalling every mistake I’ve made in my medical practice. Or suddenly knowing the diagnosis that had been eluding me. I remember once a radiology colleague called me early in the morning and said, “Ruth, I woke up at 3:00 AM and realized that your patient might have a brain tumour. I read her CT as normal, but I don’t think it is. She needs an MRI.” He was right, and she was able to have her tumour resected while it was very small. As for the dreams, I’ve learned to interpret them somewhat, or at least reflect on them and allow them to inform me of things my subconscious already knows. The conscious mind can be a slow learner.

sleepless cricket
recounting all my
guilty deeds

waking in tears
you tell me the truth
in my dream

Knowing how some people suffer with insomnia, I feel gratitude for sleep—dreams and all. One of my sisters has had insomnia since birth. Another stopped sleeping when her first child was born and again at menopause. We all have patients and colleagues with similar experiences. These aren’t the ones who only need 4 hours of sleep a night, feel well, and function at a high level. They suffer during the sleepless hours, dreading the day to come, when they struggle along in a foggy state. Bosses and children don’t care; their demands don’t change. Often there is an element of anxiety and hyperalertness. The insomnia affects all aspects of their lives: work, home, relationships, recreation.

sleepless
flitting around the lamp
my gray thoughts

When it comes to this kind of insomnia, we have such poor offerings. Over the decades we’ve learned that many drugs touted as panaceas for the sleepless are habit forming or have unwanted side effects such as weight gain, daytime somnolence, memory loss, and more. Sleep hygiene and exercise help, but they’re no cure. Sleep clinics are useful for diagnosing those with treatable problems such as sleep apnea or restless leg syndrome, and for learning about how much and how well people are actually sleeping. For the remainder of patients we need to show empathy, have a good discussion about what they can do to improve their likelihood of sleep, be honest about what medications can and cannot do, and diagnose and treat underlying anxiety if they are open to that. We should decide which drugs we are not comfortable prescribing; and with the remaining options we have to offer, discuss with patients what side effects they might be willing to tolerate, as there will always be a trade-off. Letting patients know that sleep patterns change through the life cycle can be helpful. Many people think they are abnormal if they don’t sleep straight through 8 hours at the age of 60, and some simple reassurance is all that’s needed. Dream analysis is not in fashion these days, and in our culture we tend to brush dreams off and ignore them, probably to our detriment. Not that everyone needs to see an analyst, but as a culture we could learn to pay more attention, listen to our dreams.

It has been said that we need a neurologist, a psychoanalyst, and a poet to understand sleep and dreams.¹ We could probably add a physiologist, a geneticist, and a few others. Family physicians are often the listeners, the empathizers, the ones who work with people to find solutions.

Sleeplessness, the dream world, a “shadowland” that exists only at night: these have been written about by poets, playwrights, and songwriters for centuries. Night and day, shadows and light, dreams and our waking lives, conscious and subconscious, the dualities that make up our selves and our lives. Sleep can free us from our daytime cares, allow healing, give our unconscious minds time to synthesize our daily observations and experiences into understanding and perhaps wisdom. So lovely it is to wake up refreshed, with a better outlook or some new understanding.