"Tossing and turning in the wee hours of a winter morning, I arise from bed only to return soon thereafter," wrote Liu Yung during the Southern Song dynasty. "When the quest for sleep is fruitless, a night seems like a year." Sleeplessness, it turns out, isn't a condition peculiar to modern times after all. The ancients had their bouts with it too. Nevertheless, as lifestyles have changed, the problems caused by insomnia seem to be growing only more severe.

According to the World Health Organization, more than half of all traffic fatalities worldwide stem from fatigue, either because drivers suffer from insomnia or have gotten too little sleep for some other reason.

More alarming, there are rumors that both the Challenger space shuttle disaster and the accident at the Three Mile Island nuclear plant were caused in part by workers who got sloppy because they hadn't slept enough.

Although there are no statistics for Taiwan, Chen Ning-hung, director of the sleep impediment center at Chang-Gung Memorial Hospital, points to statistics released by the American government last year. In the United States car accidents due to insomnia cause losses or damages totalling US$12 billion a year. Insomnia is second only to alcohol in the number of traffic fatalities it causes. While there are no similar statistics for Taiwan, anecdotal evidence suggests that many traffic accidents are sleep-deprivation related.

Whether or not one can fall asleep is tied closely to the surrounding environment and atmosphere. The market is full of products purporting to help busy and anxious modern people fall asleep.

Seeking the elixir of sleep

How much sleep do people really need? And how little do you have to sleep to be considered an insomniac?

According to the Directorate-General of Accounting, Budget and Statistics, the average person in Taiwan sleeps 8.3 hours a day and 9.1 hours on holidays. These figures seem ample, but Li Yu-chou, a psychiatry professor at National Taiwan University, notes, "Sleeping long doesn't equate with sleeping well."

The need for sleep varies considerably, both from person to person and from one stage of life to another-from an average of 16 hours a day as a baby, to six hours a night in old age.

According to epidemiological research, about one-third of all people suffer from sleeping disorders, some fleeting and some chronic. Generally speaking, jet lag, changes in environment, stress and so forth can cause temporary insomnia. If the condition doesn't last for more than a month, then it isn't too serious. It is more worrisome, however, when sleeping problems persist for over a month with no sign of improvement. This is "chronic insomnia," and it may strike three or four times a week.

"Eating, drinking, defecating, urinating and sleeping" make up the traditional Chinese quintet of basic bodily functions. Among these, sleep is the hardest for people to exercise control over.

Depending upon the underlying cause, insomnia is regarded as either "primary" or "secondary." Li explains that primary insomnia, whose occurrence is linked to heredity and body type, is regarded as an illness in its own right. Starting in childhood, some people just have problems sleeping. But most insomnia is secondary insomnia, which is a symptom of other underlying causes. Internal medical problems, physical or mental illnesses, and nervous disorders can all cause insomnia.

Doctor Su Tung-ping conducted a study at Taipei's Veterans General Hospital of more than 100 cases of insomnia. He discovered that one-third were primary insomnia, one-third were secondary, and one-third were a mix of primary and secondary insomnia. "Insomnia is not simply a matter of not being able to sleep well," remarks Su. "It develops as it goes along. If you don't deal with it early on, it will only get worse and worse."

In the "sleep lab" an assortment of devices hooked up to patients with sleeping disorders can determine whether they suffer from sleep apnea, a condition in which air flow temporarily ceases.

All but me asleep

Scientists have done much to unveil the mysteries of sleep, but there are still limits to what they know.

Fifty years ago, scientists discovered that people experience two different types of sleep: REM (rapid eye movement) sleep, during which the eye moves quickly right and left; and a deeper kind of non-REM sleep, during which the eye doesn't move. The former is associated with dreaming and thought to be important for learning, and the latter is connected with physical recovery-the proverbial recharging of one's batteries. A sleeper will regularly shift back and forth between these two forms of sleep, with four to five cycles during an average night.

According to research by American scientists, insufficient sleep over long periods impairs mental and physical skills, causing people to become slow to react and forgetful.

Li Yu-chou points out, "When people sleep, their brains and bodies enter a state of high metabolic activity during which there is protein synthesis, cell division, and hormone creation. All are important for supporting immune functions and keeping healthy." What is more, for those who suffer from chronic hepatitis or epilepsy, insufficient sleep is likely to trigger a turn for the worse in the state of the disease.

What sort of people are apt to suffer from insomnia? Li Yu-chou explains that the elderly, as well as those who suffer from chronic diseases, nervous system disorders, and mental illness, are at high risk. In particular, those who are over 65 are five or six times more likely to suffer from insomnia than the young.

Nevertheless, sleeplessness is not the exclusive province of the old. A study by National Taiwan University Hospital has discovered that sleeping disorders are also common among Taiwan's teenagers and children. One out of four tosses and turns in bed at least twice a week. Surveys show that schoolwork and the pressures of preparing for the joint entrance exams for high school and college are chief culprits in childhood insomnia. Urban households where some members habitually stay up late also contribute to the problem.

"Insomnia causes a lot of suffering!" say psychiatrists. But most people may wonder what the fuss is all about.

Li, a doctor at NTU Hospital, opened a special clinic for insomniacs ten years ago. He has heard all manner of complaint about sleeplessness. The comment that left the deepest impression was this: "It's been so long since I've had the sweet taste of a good night's sleep!"

Whether or not one can fall asleep is tied closely to the surrounding environment and atmosphere. The market is full of products purporting to help busy and anxious modern people fall asleep.

Don't hold your breath

While there are many more insomniacs, who want sleep but can't find it, others suffer from conditions while sleeping. Among these, Li says that he sees most often narcoleptics (who can fall suddenly asleep at any moment) and patients who sufferer from sleep apnea, which means that their air flow temporarily gets blocked as they sleep. The latter snore at night and then lack energy during the day, whereas the former can be wide awake and then suddenly fall into REM and experience hallucinations. In the past narcoleptics were mistakenly regarded as suffering from mental illnesses or as being feeble minded.

Narcolepsy is rare, but many people snore. An American study revealed that among those aged 20-60, 9% of men and 4% of women snore. And among those who do, one quarter suffer from apnea. If the same proportions hold for Taiwan, then it could have a snoring population of 400,000 to 1 million, and 200,000 people who suffer from apnea.

"Many of these patients seek treatment because the noise of their snoring or the pain in their chests is frequently waking them up," says Chen Ning-hung. Cheng points out that snoring is the result of a soft jaw or excessive looseness of the uvula system, so that when patients lie down their breathing channels are narrowed. Those who are at higher risk for snoring include men; people who are overweight; people with thick necks, large tonsils, and deformities of the jaw or the cartilage separating the nasal passages; as well as those who suffer from endocrinal disorders or who consume alcohol, depressants, or sleeping pills.

If someone is simply snoring, then the worst they are doing is disturbing a bedroom's peace. But if their condition leads to a cessation of airflow, then their life is at risk. Long-term oxygen deprivation can lead to high blood pressure, heart failure, angina, coronary thrombosis, stroke and other illnesses.

Those who snore are three times as likely to have high blood pressure, and five times as likely to have a heart attack. Foreign research has also shown that people who snore are three to five times more likely to have strokes. And those with apnea are three times more likely to die suddenly in their sleep.

If you want to know if you suffer from sleep apnea, the best way is to sign up for medical observation. A doctor can arrange for you to spend a night in a "sleep lab," where various items will be monitored. They will check to see if your breathing ever stops, take measurements to see if you suffer from oxygen deprivation, make electrocardiograms, check the air flow through the nasal and oral cavities, record the number of times you snore, and so forth. Through such observations, they can determine whether or not you suffer from apnea.

Chen Ning-hung points out that if there is no apnea, and the snoring isn't causing any difficulties in the patient's life, then many people elect just to let it go. But if it is apnea or other conditions that cause real problems, then the first course of action is to try to eliminate the underlying conditions responsible for the snoring. Those who are fat are told to lose weight, and other patients may be advised to curb their consumption of alcohol or sedatives, or to adopt certain sleeping positions.

Then doctors may suggest patients use a "continuous positive airway pressure device" when they sleep, or wear a retainer to keep their tongue and chin in place. These will keep the breathing channels clear, and improve the apnea. But all these strategies treat only the symptoms and not the underlying causes.

If you want to get to the root of the problem, you can select carbon dioxide lasers or procedures that can cut away parts of a soft jaw or hanging uvula to correct their shapes. According to American statistics, 50-60% of patients who have such operations find that their situations improve.

Yet insomnia is still the most common sleeping disorder. Doctors encourage people to treat it as early as possible. In which case, what does Western or Chinese medicine have that can help people to fall asleep?

Although people spend a third of their lives asleep, science still has only limited understanding about the mechanics of sleep, dreams, and why some people are insomniacs.

Sleepless summer nights

In the era before sleeping pills, the ancients became experts at keeping the body, heart and spirit in balance. In "Formula for Sleep" by the Song dynasty writer Tsai Chi-tung: "Sleep on your side with body bent; when you wake, stand and stretch; and keep regular hours. First put your mind at rest, and then close your eyes." In "A Thousand Gold Piece Prescription" the Tang dynasty writer Sun Szu-miao reveals his method for getting to sleep: "Get half drunk from wine and lie alone in a warm bed with a soft pillow. If you can calm the mind, sleep will naturally follow." One can see that having a calm mind was given paramount importance time and again for conquering sleeplessness.

Tsao Yung-chang, a modern-day doctor of Chinese medicine at Taipei Municipal Chung Hsin Hospital, says that in Chinese medicine the acupuncture point regarded as being tied to sleep is the heart. "Most asthenia syndromes [chronic diseases marked by deficiency of vital energy and lowering of resistance] are caused by a deficiency of yin in the blood or a lack of conditioning of the heart. If a physically strong patient is suffering from shizheng disorders [such as high fever, constipation, or stasis of the blood], it is because the 'fires' of the heart are too high." As a result, traditional Chinese treatments for insomnia call for medicine that releases these "inner fires" and calms the heart.

Peace of mind is hard to obtain these days. Psychiatrist Wang Hao-wei points out that people must lose control in order to achieve sleep, but many people find it difficult to relax. When their bodies and minds bear accumulated stress over long periods of time, they naturally find it difficult to get to sleep.

Hsu Tzu-you, who has helped terminal cancer patients employing Chinese and Western folk medicine, has in recent years been a forceful proponent of preventative medicine. He states that the human body is a thing of marvel and mystery, explaining how the sympathetic nerve and the parasympathetic nerve help each other obtain balance. But now that people live very sedentary lives, they are constantly exercising their brains but little else. This just increases stress. The sympathetic nerve is overtaxed, whereas the parasympathetic nerve atrophies. As a result, many people find it impossible to relax. He suggests that insomniacs try some light stretching exercises to relax before they go to bed. He especially recommends bending the arms back to stretch the chest muscles, and lying on a wine bottle like a pillow for 15 minutes. This is extremely effective, and there are no bad side effects.

Of course, the quickest and most effective method for combating insomnia is taking sleeping pills. But these can lead to other problems, such as drug dependency or negative reactions of the body. Most people choose not to take pills for sleep.

Li Yu-chou points out that there has been great progress in developing sleeping pills since the 1970s, when diazepam (marketed under Valium and other brand names) and other benzodiazepine drugs became all the rage. Diazepam is extremely safe, but it can easily lead to addiction. The new generation of benzodiazepine sleeping pills-including Halcion and Ativan-have proven to be even safer, with much lower rates of addiction.

"Today physiological dependence on sleeping pills isn't a big problem," says Li. "Instead, it is psychological dependence and excessive fear that have become the biggest points of concern for patients and doctors." Li says that if drugs are combined with therapy to recognize behavioral aspects of the problem, then most people can gradually reduce their intake of drugs, with some coming off them entirely.

Whether or not one can fall asleep is tied closely to the surrounding environment and atmosphere. The market is full of products purporting to help busy and anxious modern people fall asleep.

Sleep isn't just a dream

So-called "behavior recognition" therapy focuses on insomnia after it becomes chronic. Psychological and behavioral factors can exacerbate the insomnia, and these require behavioral adjustments. Li gives this example: Being scared of sleeplessness only makes it harder to fall asleep, as does working hard at trying to fall asleep. Likewise, naps taken during the day to make up for the lack of sleep the night before only make it harder to fall asleep at night once again. To beat these problems one needs behavior therapy and counseling. Li is adamant that behavior recognition therapy must be done in conjunction with psychological counseling. It requires at least five or six sessions, though going at least ten times is ideal. And with the present-day shortage of psychiatric personnel in Taiwan, this isn't easy to accomplish.

Furthermore, one can also use phototherapy to correct maladjusted biological rhythms that can lead to sleeplessness. Su Tung-ping explains how patients undergoing phototherapy are exposed to light of 10,000 lux (20 times the typical intensity of light indoors). When the eyes are exposed to this much light, it triggers the body's production of melatonin, which eases the way to sleep. Nonetheless, phototherapy is a gradual, long-term form of treatment that requires at least a week or two to adjust the body's circadian rhythms.

By using a double-pronged approach of getting a doctor's diagnosis and treatment and matching it with changes in behavior, it should no longer be an insurmountable task to say goodbye to those nights of counting sheep. But what is appropriate behavior? Why not consult these lines that Li Yi-ta, the head of psychiatry at Chiayi's St. Martin Hospital, wrote about high-quality sleep: "Sleep at regular times and regular amounts; don't go to bed unless you want to sleep; drink alcohol and coffee in moderation; don't nap at lunch; exercise and leisure can play a part; keep things peaceful after dark; bathe before going to bed; eat appropriately at all three meals and nighttime snack; relax your muscles and meditate; and sleep in the most comfortable place: bed." By so doing, sleeping well night after night needn't be an impossible dream.

Give it a try! Here's wishing you a night of peaceful sleep, with one good dream upon another.

Whether or not one can fall asleep is tied closely to the surrounding environment and atmosphere. The market is full of products purporting to help busy and anxious modern people fall asleep.

Some insomniacs who don't want to take sleeping pills turn to traditional Chinese medicine. One such treatment involves stimulating one of the ear's acupuncture points. One needs merely to rub the right place ten or twenty times in order to calm down and get to sleep.