PSYCHOLOGICAL CAUSES OF INSOMNIA

By far the most frequent source of insomnia is some form of mental or emotional disquiet. Since one primary biological reason for sleep is to provide the brain with a chance to rest, it is perhaps not surprising that one consequence of a troubled mind should be troubled sleep.

I must hasten to point out that in using such terms as "mental disquiet" or "psychological disturbance" I am not suggesting, by any stretch of the imagination, that people with insomnia are thereby crazy, or that their sleep troubles are "all in their minds." Quite the contrary. Insomnia is a very real, and very widely experienced, phenomenon. Insomniacs really do sleep less than other people, as measured not just by their own perceptions but clinically and scientifically in sleep laboratories. Nor do victims of insomnia have unrealistic expectations or beliefs about what constitutes a good night's sleep; studies have shown that insomniacs desire only the same amount of sleep as other people.

While it is true that insomnia is a feature of a number of severe mental disorders, including clinical depression, it may also appear when a psychologically healthy person's life is unusually stressful or tension-filled. Often people with sleep disorders have endured troubling situations over which they had no control—an unhappy home life during childhood, for example/ And the increasing pressure and pace of today's society adds to everyone's mental load. The primary purpose of labeling insomnia as largely psychiatric in origin is not to suggest that the disorder is illusory or that its victims are mentally disturbed but to call attention to the types of therapy that have the greatest chance of succeeding.

With that in mind, then, let me proceed to describe some of the behavioral patterns and mental attitudes that are frequently associated with insomnia. Perhaps you will recognize one or more of these traits in yourself or in a loved one who suffers from sleepless nights. If so, you will be better able to focus on the cause of the problem—the first step toward resolving it.

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ALCOHOL AND THE BODY: BREAKDOWN AND REMOVAL

The removal of alcohol from the body begins as soon as the alcohol is absorbed by the bloodstream. Small amounts leave un-metabolized through sweat, urine, or the breath. The proportion of alcohol in exhaled air has a constant and predictable relationship to the blood alcohol concentration. This is the basis for the use of breathalyzers. At most, elimination by these routes accounts for only 5% of the alcohol consumed. The rest has to be changed chemically, metabolized.

The first step in the metabolism of alcohol is its change to acetaldehyde. A liver enzyme, alcohol dehydrogenase (ADH), accomplishes this. The acetaldehyde that is formed is then acted on by another liver enzyme, acetaldehyde hydrogenase. Then, very rapidly the acetaldehyde is metabolized into acetic acid. The acetic acid then leaves the liver and is dispersed throughout the body, where it is oxidized in cells and tissues to carbon dioxide and water. In summary, the chain of events is as follows:

alcohol – acetaldehyde – acetic acid – carbon dioxide - water

As you can see, the liver occupies the key position in this process. Almost any cell or organ can break down the acetic acid, but only the liver can handle the first steps. The rate is set by the availability of a key substance (NAD+), which is essential for the enzyme ADH to act. Generally the rate at which food is metabolized depends on the energy requirements of the body. Experience will confirm this, especially for anyone who has taken a stab at dieting. Chopping wood burns up more calories than watching the tube. Too much food, and a storehouse of fat begins to accumulate around the middle. By balancing calories taken in our meals with exercise, we can avoid accumulating a fat roll. Again, as a food, alcohol is unique. It is metabolized at a constant rate. The liver does not have a "piece-rate" work-set when it comes to alcohol. The presence of large amounts does not prompt the liver to work faster. Despite alcohol's seeming potential as a fine source of calories, increased exercise (and hence raising the body's need for calories) does not increase the speed of metabolism. This is probably not news to anyone who has tried to sober up a drunk. It is simply a matter of time. Exercise may only mean you have a wide-awake drunk, rather than a sleeping one, to contend with. But he's still drunk. The rate at which alcohol is metabolized by the liver may vary a little between people. It will also increase somewhat after an extended drinking career. Yet the average rate is around 0.5 ounce of pure alcohol per hour. That is roughly equivalent to one mixed drink of 86-proof whiskey or one 12-ounce can of beer. The unmetabolized alcohol remains circulating in the bloodstream, "waiting in line." The presence of alcohol in the blood, and hence the brain, is responsible for its intoxicating effects.

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