These days you can’t turn on a television without encountering an advertisement for some pharmaceutical sleep aid, and sleep centers have sprung up all over the country. Yet for experts like Dr. Mark Mahowald, that explosion of treatment options—and the ceaseless wave of sleep-deprived patients seeking them—is both a blessing and a curse. That’s because the sheer range of sleep-related afflictions often still baffles even the most experienced specialists.
Mahowald is the director and cofounder of the Minnesota Regional Sleep Disorders Center at Hennepin County Medical Center, and for more than thirty years he has been at the forefront of a burgeoning industry.
Back in the ’70s, when Mahowald and fellow neurologist Milton Ettinger launched the MRSDC, sleep science was still a little-understood and largely neglected field. At the time only two facilities in the country—New York’s Montefiore Hospital and Stanford University in California—were seriously addressing the subject. Faced with a growing number of local complaints, Mahowald and Ettinger began conducting studies at HCMC using polysomnographic gear that Mahowald built in his living room.
Today Mahowald is widely recognized for the MRSDC’s pioneering research and treatment in the area of REM sleep behavior disorder, an often dangerous parasomnia in which individuals act out all manner of dreams and nightmares, with often violent results—they drive, for instance, or choke their spouses, or commit sexual assaults. Mahowald and his MRSDC colleague, Dr. Carlos Schenck, recently published an article in a medical journal on one particular (and peculiar) class of these behaviors, dubbed “sexsomnia.” That’s part of the reason why the Associated Professional Sleep Societies, which attracted more than five thousand attendees to its annual confab at the Minneapolis Convention Center in June, asked Mahowald to deliver the keynote address. There, Mahowald and Schenck also received the American Academy of Sleep Medicine’s William C. Dement Award.
Are we experiencing an epidemic of sleeplessness?
Well, certainly far too many people are sleep deprived today, but a lot of the things we see in the lab are really nothing new. I don’t think most of these sleep disorders are more prevalent now, just that there was such complete ignorance in the past. We frankly didn’t have any idea what we were in for.
So what do you know now that you didn’t know thirty years ago?
At that time there was very little awareness or understanding of apnea or narcolepsy—we’ve learned that apnea is actually as common as diabetes or asthma—and we hadn’t even come close to identifying the broad spectrum of parasomnias [sleepwalking, sleeptalking, teeth grinding, REM sleep behavior disorder, etc.]. Even something like Restless Leg Syndrome was barely talked about in those days, and now we know that it affects something like ten percent of the population. Essentially it’s a whole new field today. An extraordinary number of treatments have been discovered, most of which have proved remarkably effective.
Are we primarily talking about pharmaceuticals?
Drugs, yes, but also things you can address with simple behavioral modification. And CPAP [continuous positive airway pressure] machines to treat apnea. I mean, this is a serious disease that wreaks havoc on people’s lives, and all you have to do is pump air into the nose and it’s gone. Fifteen thousand people have come through our labs who are now wearing CPAP masks at night and getting restful sleep.
We heard recently of some guy who allegedly stabbed his wife to death in his sleep. As someone who has extensively studied the forensic ramifications of parasomnias, do you really believe that a person can commit a crime while asleep—and retain no memory of having done so?
I do. And although it’s very difficult to prove, the defense has held up in a number of court cases.
Have you witnessed these sorts of violent parasomnias in the laboratory?
Unfortunately, they show up very infrequently in the laboratory.
Then how do you prove that someone was sleeping when they committed a crime?
You don’t. You can’t. The forensics are very difficult, but there are ways to evaluate these cases. You have to take a very careful and thorough look at a person’s medical history and determine whether there’s any background of violent or seriously disordered sleep. But there is, of course, no way to tell after the fact what exactly was happening at the time these things occurred, and we obviously have to be careful that we don’t get some character scheming to get a diagnosis of a dangerous parasomnia so they can go home and kill their spouse.
It seems like sleep science is a pretty contentious and increasingly competitive field. You’ve got so many types of doctors—psychiatrists, neurologists, pulmonary physicians—treating patients with sleep disorders. How can people be sure they’re getting the best treatment for their particular problem?
The increased awareness of sleep disorders and the societal costs of sleep deprivation are a good thing, but the business of sleep medicine—and I emphasize the business part—poses concerns. At HCMC we were interested in studying sleep from a medical and scientific standpoint. We didn’t think there was going to be much money in any of this. Now people are realizing that there is. I divide the field into givers and takers. The givers are giving back to the field through research and education; the takers are making money but not giving anything back. To the best of my knowledge we’re still the only sleep lab in town doing any research, not to mention education. A large percentage of medical schools still don’t address the issue of sleep.
What bothers you about this apparent divide?
Again, it comes back to the money, and the conflicts of interest that introduces. Obviously drug advertising is out of control; you’ve got physicians doing consulting work for pharmaceutical companies and serving on speakers bureaus that essentially promote these drugs. Stuff is being overprescribed. And a lot of these other centers generate revenue by dispensing CPAP machines—which we don’t do—so people who’ve got barely more apnea than a cadaver get sent home with a CPAP.
Do you think there’s still a lingering belief in the medical community that many sleep disorders—insomnia, primarily—are rooted in psychological causes?
That’s been a big change. Once we were all taught that most disordered sleep had a psychological component, or was an indicator of psychological problems. I think there’s pretty universal agreement now that the majority of these disorders are entirely unrelated to psychological disease. If anything, untreated insomnia is a risk factor for the development of depression and anxiety. It’s difficult when someone’s sitting in your office to know what came first.
Is there a sense that sleep deprivation is sort of a societal canary in the coal mine?
It extracts a huge toll, on the highways, in the classroom and workplace. People endure voluntary sleep deprivation for social and economic reasons, and we’ve come to view that willingness to sacrifice sleep as a sort of badge of honor, an indicator of dedication and hard work. Few people brag about how much sleep they get, and all these places are now open twenty-four hours for no real reason. I know that I would not want my car fixed by someone at three o’clock in the morning. I always tell people that if they have to use an alarm clock to wake up in the morning, they’re sleep deprived.
