The Train of the "hypo-sleep" syndrome

The "train of the hypo-sleep syndrome" is the illustration that summarizes, in our opinion, the main evolving stages of tiredness.

This natural evolution depends on the conjunction of three factors : the basis level, the resistance abilities and the intensity of the traumatic event of life (like the ditch that protects people from normal waves, but can overflow in case of a tsunami).

In other words, nobody is inexhaustible but the intensity of the reaction is not always correlated to the intensity of the agression.

• The genetic ground sets a true congenital "somnological fragility or solidity" (the family nature of migraine or lumbago is well-documented).
• The psychological ground sets the personal ability of resistance (of "deafness") to tiredness. This factor may be modified by the influence of psycho-active drugs (pharmaceutical or not).
• The nature of the events of life sets the importance of their impact on sleep. We say that they are more, or less, "somnotoxic".

- Some clinical forms sometimes remain discrete (paucisymptomatic) with a couple of spontaneouly evolving aches;

- Some of them will become chronic (migraine, lumbago, constipation ...);

- Others will evolve more or less quickly towards their aggravation and a handicap (implying long interruptions of work).

- Tiredness and discouragement are such that “psychological” symptoms like insomnia and depression eventually appear in the end of the course. [1]

In our opinion, this figure summarizes all the questions of millions sick people and thousands doctors who can only notice the failure of current medicine..

• The False true-sick people or "misunderstood sick people", try in vain to find a sense to symptoms that "don’t fit well" and to find a treatment that would finally "work" (without involving adverse effects ...).
• The True false-sick people or "imaginary sick", try, in vain, to be recognized like the other really sick people.

The couple doctor-patient avoids to go frankly into the subject.

• One, because he/she fears the sedative treatment that will make him/her "more tired" and induce an addiction ("I don’t want to be drugged").
• The other, because these notions of "hypo-sleep" are not (yet?) familiar to him/her. Sleep remains the poor relative of the medical education (a teaching emptiness that contrasts with the selling power of the pharmaceutical companies who sell the sleeping pills ).

In the beginning

Often, right from childhood, the first functional disorders... stomach upset, abdominal migraine, growing cramps, colics, recurrent throat infections, can be identified as infantile fibromyalgia.

In the adult, it sometimes simply becomes visible with the regular intake of medications (tonics, "light" sedatives, paracetamol, laxatives...)

A sudden weight gain can, in itself, witness for a starting fatigue syndrome, showing the narrow links between sleep and food balance (under the action of a common hormone called orexin or hypocretin)

In the course of evolution

• The risk of the (medical) complications and the (often astronomical) cost [2]) of this medical course depend on the patient’s trust (credulity?) and on the type of incriminated pathological mechanism.

  The interview of the patients often reveals a heavy past of medical explorations, treatments or operations with no conclusive result.

  Fortunately, there seems to be more and more caution towards surgical indications in functional disorders :

  - less "just in case" surgery of the appendix;

  - less surgery for lumbago "because the medical treatment has failed".

  - less removals of the gall-bladder for "upset stomach" on gallstones. And so on...

  The therapeutic results of these surgical interventions, often much more practiced in the past, have regularly revealed unefficient and, sometimes, catastrophic.

• Psychotherapy can sometimes be of great help at the stages of the illness when the sick person becomes conscious of his/her exhaustion.

  It can be deplored that notions of sleep hygiene are not more mentioned in that context. It is too often only a matter of support and the prescription habits are such that it is exceptional, at that stage, not to resort to benzodiazepines which, in reality, accelerate the "hypo-sleep" process.

• The resort to "alternative medicines" is also an unavoidable step on the sick person’s path because it is tempting to invent one’s own answers rather than to sink into despair.

  The sales figures of the tonics’ market exceed, by far, that of the by the Public Welfare System paid back medication.

  In the context of functional disorders, it is, at best, a prejudicial loss of time - at worst, an open door to sectarian excesses.

  Besides, some references to sleep are made from the angle of "common sense" but they are limited to the spreading of accepted ideas which often prove to be counterproductive (go to bed early, relax, empty one’s mind...).

In the end of the evolution only

Two symptoms come forward to give the diagnosis a new turn : insomnia and depressive traits.

• Insomnia.

  The "sleep disorders" are mentioned in the descriptions of functional pathologies but they only become important in the end of the evolution.

  Moreover, we think that the sensation of tiredness is one of the engines of insomnia (which summarizes in wanting to sleep).

  Although they are present from the very beginning, the protagonists of the couple doctor-patient avoid to go frankly into the subject :

  - One, because he/she fears the pill that will make him/her "more tired" and induce a dependency ("No, Doctor, I don’t want to be drugged")

  - The other, because these "hypo-sleep" notions are not familiar to him/her, will often have no other choice than to prescribe a sedative.

  • 
    In fact, the subject has already been for a long time trying to extend his/her sleeptime in order to get some rest. He/she willingly describes him/herselp as a "marmot", always sleeping, but, in reality, this search for sleep insidiously results in more and more early or nocturnal arousals.
  • 
    In fact, the doctor has already been for a long time (more or less consciously) trying to offer sedatives (benzodiazepines +++). There are benzodiazepines, often a bit "concealed", in the composition of many treatments with a "symptomatic purpose".

    On the short term, most of the functional disorders (related to tiredness) respond very well to a sedative treatment but this approach is to be banned because it pushes the subject into a true vicious circle.

    - The induced tolerance and addiction phenomena are real and lead to an increase of the doses and of the undesirable side effects (memory, falls).

    - The excessive daytime sleepiness induced by the treatment leads the subject to extend even more his/her sleeptime, which will lead to insomnia.

    • rheumatological problems (lumbago, stiff neck, tendinitis)
    • neurological problems (migraine, neuralgia, dizzy spells, tinnitus, dyskinesia ...)
    • digestive problems (colics, gastritis ...)
    • cardiac problems (palpitations, pains...)
    • circulatory problems (heavy legs, sweating, low blood pressure ...)
    • etc ...

  Finally, at the stage where insomnia starts to show, the doctor will thus hope to "kill two birds with one stone".

  As we now know, this analysis (which we consider obsolete) of the situation contributes to worsen the subject’s tiredness. All in all, that tiredness will take the appearance of a depression and the exhausted subject will agree with his doctor to envisage the intake of an antidepressant treatment, sometimes presented like a "pill of happiness".
• Depression.

  There is a well established dogma, in psychiatry courses, that says that "a morning insomnia is a sign of depression".

  That old notion, that doesn’t take the sleep medicine’s progress into account, is totally called into question by modern psychiatrists.

  It is now thought that that type of insomnia is, on the contrary, an element of defence meant to increase the psychological resistance of the subject in a situation of stress, just like fever is a way to increase the immune defences.

  The organism would react with insomnia in order to increase the point of arousal and performance of the subject.

  In practice, some psychiatric units complete the treatment of depression with carrying out sleep deprivations (a sleepless night in three with light and sport stimulation).

  Under this modern lighting, it is easy to understand that the intake of a sleeping pill (or a tranquilizer) can exert an extremely aggravating effect in a subject who is starting an authentic depression...

  NB: tears and "depressive speech" are very frequent in the end of the evolution because the subject is truly exhausted (very close to the "stage of emergency stop"(cf.). These depressive traits give cause to a large overestimation of the diagnosis of depressions. Yet, suicidal attempts are exceptional in this context.

  In our experience, the sick persons who really think of "letting go" are very rare. Quite the opposite, the doctor’s mentioning of a possible "masked depression" type etiology is often badly perceived by the subject who feels "neither crazy nor sad".

  But, even so, one has to be careful, the possibility of a true depression must not be neglected. Bad self-esteem, constant sadness and the loss of the hope to recover are signs that urgently justify a specialist’s opinion, and probably an antidepressant treatment for a duration of several months at least.

  It is, besides, admitted that 15 to 30% of chronic fatigue patients present real depressive periods in the course of the evolution of their illness. It is the same percentage as for the other chronic and incurable diseases (diabetes, multiple sclerosis or Parkinson’s disease, for example.)

Sleep remains the big absent in the doctor-patient relationship !

• And yet, if one takes the time to search for it, the complaint of "tiredness" is the common denominator to all functional symptoms...
• And yet, the link from cause to effect between that tiredness and the efficiency of sleep is well demonstrated in sleep labs and with night workers...
• And yet, the common sense shows, through a multitude of set phrases, that people take as an alarm sign each of these symptoms ...
• And yet, it is easy to make the diagnosis (after a minimum check-up) with a simple and well carried out somnological interview (now, when it all looks, regarding sleep, as though a patient consulting about obesity ... was asked about his/her appetite in the start of a meal).
• And yet, the treatment is easy to carry out under the condition that the instructions for the use of the "somnications" which are sport, light, pleasure and the nap are well known. Prescribe rest to a tired subject is not efficient...
• And yet, probably huge health savings could be made, that way...

One day, maybe...

Sleep will be part of the patients’ and their doctors’ preoccupations when sleep medicine courses will teach the future doctors to interview the sick persons better.

More widely, beyond the sleep troubles themselves, the concept of "somnicology" could contribute to better understand tiredness problems.

A better understanding of the "hypo-sleep syndrome" would allow, in our opinion, to take better care of the functional disorders that charaterize it.