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CHAPTER OUTLINE
4.1 What Is Consciousness?
4.2 Sleep and Why We Sleep
4.3 Stages of Sleep
4.4 Sleep Problems and Disorders
4.5 Substance Use and Abuse
4.6 Other States of Consciousness
INTRODUCTION Our lives involve regular, dramatic changes in the degree to which we are aware of our surroundings and our internal states. While awake, we feel alert and aware of the many important things going on around us. Our experiences change dramatically while we are in deep sleep and once again when we are dreaming. Some people also experience altered states of consciousness through meditation, hypnosis, or alcohol and other drugs.
This chapter will discuss states of consciousness with a particular emphasis on sleep. The different stages of sleep will be identified, and sleep disorders will be described. The chapter will close with discussions of altered states of consciousness produced by psychoactive drugs, hypnosis, and meditation.
4.1 What is Consciousness?
LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Understand what is meant by consciousness
• Explain how circadian rhythms are involved in regulating the sleep-wake cycle, and how circadian cycles can be disrupted
• Discuss the concept of sleep debt
We experience different states of consciousness and different levels of awareness on a regular basis. We might even describe consciousness as a continuum that ranges from full awareness to a deep sleep. Sleep is a state marked by relatively low levels of physical activity and reduced sensory awareness that is distinct from periods of rest that occur during wakefulness. Wakefulness is characterized by high levels of sensory awareness, thought, and behavior. Beyond being awake or asleep, there are many other states of consciousness people experience. These include daydreaming, intoxication, and unconsciousness due to anesthesia. We might also experience unconscious states of being via drug-induced anesthesia for medical purposes. Often, we are not completely aware of our surroundings, even when we are fully awake. For instance, have you ever daydreamed while driving home from work or school without really thinking about the drive itself? You were capable of engaging in the all of the complex tasks involved with operating a motor vehicle even though you were not aware of doing so. Many of these processes, like much of psychological behavior, are rooted in our biology.
Biological Rhythms
Biological rhythms are internal rhythms of biological activity. A woman’s menstrual cycle is an example of a biological rhythm—a recurring, cyclical pattern of bodily changes. One complete menstrual cycle takes about 28 days—a lunar month—but many biological cycles are much shorter. For example, body temperature fluctuates cyclically over a 24-hour period (Figure 4.2). Alertness is associated with higher body temperatures, and sleepiness with lower body temperatures.
If we have biological rhythms, then is there some sort of biological clock? In the brain, the hypothalamus, which lies above the pituitary gland, is a main center of homeostasis. Homeostasis is the tendency to maintain a balance, or optimal level, within a biological system.
The brain’s clock mechanism is located in an area of the hypothalamus known as the suprachiasmatic nucleus (SCN). The axons of light-sensitive neurons in the retina provide information to the SCN based on the amount of light present, allowing this internal clock to be synchronized with the outside world (Klein, Moore, & Reppert, 1991; Welsh, Takahashi, & Kay, 2010) (Figure 4.3).
Generally, and for most people, our circadian cycles are aligned with the outside world. For example, most people sleep during the night and are awake during the day. One important regulator of sleep-wake cycles is the hormone melatonin. The pineal gland, an endocrine structure located inside the brain that releases melatonin, is thought to be involved in the regulation of various biological rhythms and of the immune system during sleep (Hardeland, Pandi-Perumal, & Cardinali, 2006). Melatonin release is stimulated by darkness and inhibited by light.
There are individual differences in regard to our sleep-wake cycle. For instance, some people would say they are morning people, while others would consider themselves to be night owls. These individual differences in circadian patterns of activity are known as a person’s chronotype, and research demonstrates that morning larks and night owls differ with regard to sleep regulation (Taillard, Philip, Coste, Sagaspe, & Bioulac, 2003). Sleep regulation refers to the brain’s control of switching between sleep and wakefulness as well as coordinating this cycle with the outside world.
Disruptions of Normal Sleep
Whether lark, owl, or somewhere in between, there are situations in which a person’s circadian clock gets out of synchrony with the external environment. One way that this happens involves traveling across multiple time zones. When we do this, we often experience jet lag. Jet lag is a collection of symptoms that results from the mismatch between our internal circadian cycles and our environment. These symptoms include fatigue, sluggishness, irritability, and insomnia (i.e., a consistent difficulty in falling or staying asleep for at least three nights a week over a month’s time) (Roth, 2007).
Individuals who do rotating shift work are also likely to experience disruptions in circadian cycles. Rotating shift work refers to a work schedule that changes from early to late on a daily or weekly basis. For example, a person may work from 7:00 a.m. to 3:00 p.m. on Monday, 3:00 a.m. to 11:00 a.m. on Tuesday, and 11:00 a.m. to 7:00 p.m. on Wednesday. In such instances, the individual’s schedule changes so frequently that it becomes difficult for a normal circadian rhythm to be maintained. This often results in sleeping problems, and it can lead to signs of depression and anxiety. These kinds of schedules are common for individuals working in health care professions and service industries, and they are associated with persistent feelings of exhaustion and agitation that can make someone more prone to making mistakes on the job (Gold et al., 1992; Presser, 1995).
Rotating shift work has pervasive effects on the lives and experiences of individuals engaged in that kind of work, which is clearly illustrated in stories reported in a qualitative study that researched the experiences of middle-aged nurses who worked rotating shifts (West, Boughton & Byrnes, 2009). Several of the nurses interviewed commented that their work schedules affected their relationships with their family. One of the nurses said,
If you’ve had a partner who does work regular job 9 to 5 office hours . . . the ability to spend time, good time with them when you’re not feeling absolutely exhausted . . . that would be one of the problems that I’ve encountered. (West et al., 2009, p. 114)
While disruptions in circadian rhythms can have negative consequences, there are things we can do to help us realign our biological clocks with the external environment. Some of these approaches, such as using a bright light as shown in Figure 4.4, have been shown to alleviate some of the problems experienced by individuals suffering from jet lag or from the consequences of rotating shift work. Because the biological clock is driven by light, exposure to bright light during working shifts and dark exposure when not working can help combat insomnia and symptoms of anxiety and depression (Huang, Tsai, Chen, & Hsu, 2013).
Insufficient Sleep
When people have difficulty getting sleep due to their work or the demands of day-to-day life, they accumulate a sleep debt. A person with a sleep debt does not get sufficient sleep on a chronic basis. The consequences of sleep debt include decreased levels of alertness and mental efficiency. Interestingly, since the advent of electric light, the amount of sleep that people get has declined. While we certainly welcome the convenience of having the darkness lit up, we also suffer the consequences of reduced amounts of sleep because we are more active during the nighttime hours than our ancestors were. As a result, many of us sleep less than 7–8 hours a night and accrue a sleep debt. While there is tremendous variation in any given individual’s sleep needs, the National Sleep Foundation (n.d.) cites research to estimate that newborns require the most sleep (between 12 and 18 hours a night) and that this amount declines to just 7–9 hours by the time we are adults.
If you lie down to take a nap and fall asleep very easily, chances are you may have sleep debt. Given that college students are notorious for suffering from significant sleep debt (Hicks, Fernandez, & Pelligrini, 2001; Hicks, Johnson, & Pelligrini, 1992; Miller, Shattuck, & Matsangas, 2010), chances are you and your classmates deal with sleep debt-related issues on a regular basis. In 2015, the National Sleep Foundation updated their sleep duration hours, to better accommodate individual differences. Table 4.1 shows the new recommendations, which describe sleep durations that are “recommended”, “may be appropriate”, and “not recommended”.
Sleep Needs at Different Ages
| Age | Recommended | May be appropriate | Not recommended |
|---|---|---|---|
| 0–3 months | 14–17 hours | 11–13 hours 18–19 hours |
Fewer than 11 hours More than 19 hours |
| 4–11 months | 12–15 hours | 10–11 hours 16–18 hours |
Fewer than 10 hours More than 18 hours |
| 1–2 years | 11–14 hours | 9–10 hours 15–16 hours |
Fewer than 9 hours More than 16 hours |
| 3–5 years | 10–13 hours | 8–9 hours 14 hours |
Fewer than 8 hours More than 14 hours |
| 6–13 years | 9–11 hours | 7–8 hours 12 hours |
Fewer than 7 hours More than 12 hours |
| 14–17 years | 8–10 hours | 7 hours 11 hours |
Fewer than 7 hours More than 11 hours |
| 18–25 years | 7–9 hours | 6 hours 10–11 hours |
Fewer than 6 hours More than 11 hours |
| 26–64 years | 7–9 hours | 6 hours 10 hours |
Fewer than 6 hours More than 10 hours |
| ≥65 years | 7–8 hours | 5–6 hours 9 hours |
Fewer than 5 hours More than 9 hours |
The amount of sleep we get varies across the lifespan. When we are very young, we spend up to 16 hours a day sleeping. As we grow older, we sleep less. In fact, a meta-analysis, which is a study that combines the results of many related studies, conducted within the last decade indicates that by the time we are 65 years old, we average fewer than 7 hours of sleep per day (Ohayon, Carskadon, Guilleminault, & Vitiello, 2004).
4.1 TEST YOURSELF
4.2 Sleep and Why We Sleep
LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Describe areas of the brain involved in sleep
• Understand hormone secretions associated with sleep
• Describe several theories aimed at explaining the function of sleep
• Name and describe three theories about why we dream
We spend approximately one-third of our lives sleeping. Given the average life expectancy for U.S. citizens falls between 73 and 79 years old (Singh & Siahpush, 2006), we can expect to spend approximately 25 years of our lives sleeping. Some animals never sleep (e.g., some fish and amphibian species); other animals sleep very little without apparent negative consequences (e.g., giraffes); yet some animals (e.g., rats) die after two weeks of sleep deprivation (Siegel, 2008). Why do we devote so much time to sleeping? Is it absolutely essential that we sleep? This section will consider these questions and explore various explanations for why we sleep.
What is Sleep?
You have read that sleep is distinguished by low levels of physical activity and reduced sensory awareness. As discussed by Siegel (2008), a definition of sleep must also include mention of the interplay of the circadian and homeostatic mechanisms that regulate sleep. Homeostatic regulation of sleep is evidenced by sleep rebound following sleep deprivation. Sleep rebound refers to the fact that a sleep-deprived individual will fall asleep more quickly during subsequent opportunities for sleep. Sleep is characterized by certain patterns of activity of the brain that can be visualized using electroencephalography (EEG), and different phases of sleep can be differentiated using EEG as well.
Sleep-wake cycles seem to be controlled by multiple brain areas acting in conjunction with one another. Some of these areas include the thalamus, the hypothalamus, and the pons. As already mentioned, the hypothalamus contains the SCN—the biological clock of the body—in addition to other nuclei that, in conjunction with the thalamus, regulate slow-wave sleep. The pons is important for regulating rapid eye movement (REM) sleep (National Institutes of Health, n.d.).
Sleep is also associated with the secretion and regulation of a number of hormones from several endocrine glands including: melatonin, follicle stimulating hormone (FSH), luteinizing hormone (LH), and growth hormone (National Institutes of Health, n.d.). You have read that the pineal gland releases melatonin during sleep (Figure 4.6). Melatonin is thought to be involved in the regulation of various biological rhythms and the immune system (Hardeland et al., 2006). During sleep, the pituitary gland secretes both FSH and LH which are important in regulating the reproductive system (Christensen et al., 2012; Sofikitis et al., 2008). The pituitary gland also secretes growth hormone, during sleep, which plays a role in physical growth and maturation as well as other metabolic processes (Bartke, Sun, & Longo, 2013).
Given the central role that sleep plays in our lives and the number of adverse consequences that have been associated with sleep deprivation, one would think that we would have a clear understanding of why it is that we sleep. Unfortunately, this is not the case; however, several hypotheses have been proposed to explain the function of sleep.
Adaptive Function of Sleep
One popular hypothesis of sleep incorporates the perspective of evolutionary psychology. Evolutionary psychology is a discipline that studies how universal patterns of behavior and cognitive processes have evolved over time as a result of natural selection. Variations and adaptations in cognition and behavior make individuals more or less successful in reproducing and passing their genes to their offspring. One hypothesis from this perspective might argue that sleep is essential to restore resources that are expended during the day. Just as bears hibernate in the winter when resources are scarce, perhaps people sleep at night to reduce their energy expenditures. While this is an intuitive explanation of sleep, there is little research that supports this explanation. In fact, it has been suggested that there is no reason to think that energetic demands could not be addressed with periods of rest and inactivity (Frank, 2006; Rial et al., 2007), and some research has actually found a negative correlation between energetic demands and the amount of time spent sleeping (Capellini, Barton, McNamara, Preston, & Nunn, 2008).
Another evolutionary hypothesis of sleep holds that our sleep patterns evolved as an adaptive response to predatory risks, which increase in darkness. Thus we sleep in safe areas to reduce the chance of harm. Again, this is an intuitive and appealing explanation for why we sleep. Perhaps our ancestors spent extended periods of time asleep to reduce attention to themselves from potential predators. Comparative research indicates, however, that the relationship that exists between predatory risk and sleep is very complex and equivocal. Some research suggests that species that face higher predatory risks sleep fewer hours than other species (Capellini et al., 2008), while other researchers suggest there is no relationship between the amount of time a given species spends in deep sleep and its predation risk (Lesku, Roth, Amlaner, & Lima, 2006).
It is quite possible that sleep serves no single universally adaptive function, and different species have evolved different patterns of sleep in response to their unique evolutionary pressures. While we have discussed the negative outcomes associated with sleep deprivation, it should be pointed out that there are many benefits that are associated with adequate amounts of sleep. A few such benefits listed by the National Sleep Foundation (n.d.) include maintaining healthy weight, lowering stress levels, improving mood, and increasing motor coordination, as well as a number of benefits related to cognition and memory formation.
Cognitive Function of Sleep
Another theory regarding why we sleep involves sleep’s importance for cognitive function and memory formation (Rattenborg, Lesku, Martinez-Gonzalez, & Lima, 2007). Indeed, we know sleep deprivation results in disruptions in cognition and memory deficits (Brown, 2012), leading to impairments in our abilities to maintain attention, make decisions, and recall long-term memories. Moreover, these impairments become more severe as the amount of sleep deprivation increases (Alhola & Polo-Kantola, 2007). Furthermore, slow-wave sleep after learning a new task can improve resultant performance on that task (Huber, Ghilardi, Massimini, & Tononi, 2004) and seems essential for effective memory formation (Stickgold, 2005). Understanding the impact of sleep on cognitive function should help you understand that cramming all night for a test may be not effective and can even prove counterproductive.
Getting the optimal amount of sleep has also been associated with other cognitive benefits. Research indicates that included among these possible benefits are increased capacities for creative thinking (Cai, Mednick, Harrison, Kanady, & Mednick, 2009; Wagner, Gais, Haider, Verleger, & Born, 2004), language learning (Fenn, Nusbaum, & Margoliash, 2003; Gómez, Bootzin, & Nadel, 2006), and inferential judgments (Ellenbogen, Hu, Payne, Titone, & Walker, 2007). It is possible that even the processing of emotional information is influenced by certain aspects of sleep (Walker, 2009).
4.2 TEST YOURSELF
4.3 Stages of Sleep
LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Differentiate between REM and non-REM sleep
• Describe the differences between the three stages of non-REM sleep
• Understand the role that REM and non-REM sleep play in learning and memory
Sleep is not a uniform state of being. Instead, sleep is composed of several different stages that can be differentiated from one another by the patterns of brain wave activity that occur during each stage. These changes in brain wave activity can be visualized using EEG and are distinguished from one another by both the frequency and amplitude of brain waves (Figure 4.7). Sleep can be divided into two different general phases: REM sleep and non-REM (NREM) sleep. Rapid eye movement (REM) sleep is characterized by darting movements of the eyes under closed eyelids. Brain waves during REM sleep appear very similar to brain waves during wakefulness. In contrast, non-REM (NREM) sleep is subdivided into four stages distinguished from each other and from wakefulness by characteristic patterns of brain waves. The first three stages of sleep are NREM sleep, while the fourth and final stage of sleep is REM sleep. In this section, we will discuss each of these stages of sleep and their associated patterns of brain wave activity.
The first stage of NREM sleep is known as stage 1 sleep. Stage 1 sleep is a transitional phase that occurs between wakefulness and sleep, the period during which we drift off to sleep. During this time, there is a slowdown in both the rates of respiration and heartbeat. In addition, stage 1 sleep involves a marked decrease in both overall muscle tension and core body temperature.
In terms of brain wave activity, stage 1 sleep is associated with both alpha and theta waves. The early portion of stage 1 sleep produces alpha waves, which are relatively low frequency (8–13Hz), high amplitude patterns of electrical activity (waves) that become synchronized (Figure 4.8). This pattern of brain wave activity resembles that of someone who is very relaxed, yet awake. As an individual continues through stage 1 sleep, there is an increase in theta wave activity. Theta waves are even lower frequency (4–7 Hz), higher amplitude brain waves than alpha waves. It is relatively easy to wake someone from stage 1 sleep; in fact, people often report that they have not been asleep if they are awoken during stage 1 sleep.
As mentioned earlier, REM sleep is marked by rapid movements of the eyes. The brain waves associated with this stage of sleep are very similar to those observed when a person is awake, as shown in Figure 4.11, and this is the period of sleep in which dreaming occurs. It is also associated with paralysis of muscle systems in the body with the exception of those that make circulation and respiration possible. Therefore, no movement of voluntary muscles occurs during REM sleep in a normal individual; REM sleep is often referred to as paradoxical sleep because of this combination of high brain activity and lack of muscle tone. Like NREM sleep, REM has been implicated in various aspects of learning and memory (Wagner, Gais, & Born, 2001; Siegel, 2001).
The hypnogram below (Figure 4.12) shows a person’s passage through the stages of sleep.
LINK TO LEARNING: View this video about the various stages of sleep to learn more.
Dreams
Dreams and their associated meanings vary across different cultures and periods of time. By the late 19th century, German psychiatrist Sigmund Freud had become convinced that dreams represented an opportunity to gain access to the unconscious. By analyzing dreams, Freud thought people could increase self-awareness and gain valuable insight to help them deal with the problems they faced in their lives. Freud made distinctions between the manifest content and the latent content of dreams. Manifest content is the actual content, or storyline, of a dream. Latent content, on the other hand, refers to the hidden meaning of a dream. For instance, if a woman dreams about being chased by a snake, Freud might have argued that this represents the woman’s fear of sexual intimacy, with the snake serving as a symbol of a man’s penis.
Freud was not the only theorist to focus on the content of dreams. The 20th century Swiss psychiatrist Carl Jung believed that dreams allowed us to tap into the collective unconscious. The collective unconscious, as described by Jung, is a theoretical repository of information he believed to be shared by everyone. According to Jung, certain symbols in dreams reflected universal archetypes with meanings that are similar for all people regardless of culture or location.
The sleep and dreaming researcher Rosalind Cartwright, however, believes that dreams simply reflect life events that are important to the dreamer. Unlike Freud and Jung, Cartwright’s ideas about dreaming have found empirical support. For example, she and her colleagues published a study in which women going through divorce were asked several times over a five-month period to report the degree to which their former spouses were on their minds. These same women were awakened during REM sleep in order to provide a detailed account of their dream content. There was a significant positive correlation between the degree to which women thought about their former spouses during waking hours and the number of times their former spouses appeared as characters in their dreams (Cartwright, Agargun, Kirkby, & Friedman, 2006). Recent research (Horikawa, Tamaki, Miyawaki, & Kamitani, 2013) has uncovered new techniques by which researchers may effectively detect and classify the visual images that occur during dreaming by using fMRI for neural measurement of brain activity patterns, opening the way for additional research in this area.
Alan Hobson, a neuroscientist, is credited for developing activation-synthesis theory of dreaming. Early versions of this theory proposed that dreams were not the meaning-filled representations of angst proposed by Freud and others, but were rather the result of our brain attempting to make sense of (“synthesize”) the neural activity (“activation”) that was happening during REM sleep. Recent adaptations (e.g., Hobson, 2002) continue to update the theory based on accumulating evidence. For example, Hobson (2009) suggests that dreaming may represent a state of protoconsciousness. In other words, dreaming involves constructing a virtual reality in our heads that we might use to help us during wakefulness. Among a variety of neurobiological evidence, John Hobson cites research on lucid dreams as an opportunity to better understand dreaming in general. Lucid dreams are dreams in which certain aspects of wakefulness are maintained during a dream state. In a lucid dream, a person becomes aware of the fact that they are dreaming, and as such, they can control the dream’s content (LaBerge, 1990).
4.3 TEST YOURSELF
4.4 Sleep Problems and Disorders
LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Describe the symptoms and treatments of insomnia
• Recognize the symptoms of several parasomnias
• Describe the symptoms and treatments for sleep apnea
• Recognize risk factors associated with sudden infant death syndrome (SIDS) and steps to prevent it
• Describe the symptoms and treatments for narcolepsy
Many people experience disturbances in their sleep at some point in their lives. Depending on the population and sleep disorder being studied, between 30% and 50% of the population suffers from a sleep disorder at some point in their lives (Bixler, Kales, Soldatos, Kaels, & Healey, 1979; Hossain & Shapiro, 2002; Ohayon, 1997, 2002; Ohayon & Roth, 2002). This section will describe several sleep disorders as well as some of their treatment options.
Insomnia
Insomnia, a consistent difficulty in falling or staying asleep, is the most common of the sleep disorders. Individuals with insomnia often experience long delays between the times that they go to bed and actually fall asleep. In addition, these individuals may wake up several times during the night only to find that they have difficulty getting back to sleep. As mentioned earlier, one of the criteria for insomnia involves experiencing these symptoms for at least three nights a week for at least one month’s time (Roth, 2007).
It is not uncommon for people suffering from insomnia to experience increased levels of anxiety about their inability to fall asleep. This becomes a self-perpetuating cycle because increased anxiety leads to increased arousal, and higher levels of arousal make the prospect of falling asleep even more unlikely. Chronic insomnia is almost always associated with feeling overtired and may be associated with symptoms of depression.
There may be many factors that contribute to insomnia, including age, drug use, exercise, mental status, and bedtime routines. Not surprisingly, insomnia treatment may take one of several different approaches. People who suffer from insomnia might limit their use of stimulant drugs (such as caffeine) or increase their amount of physical exercise during the day. Some people might turn to over-the-counter (OTC) or prescribed sleep medications to help them sleep, but this should be done sparingly because many sleep medications result in dependence and alter the nature of the sleep cycle, and they can increase insomnia over time. Those who continue to have insomnia, particularly if it affects their quality of life, should seek professional treatment.
Some forms of psychotherapy, such as cognitive-behavioral therapy, can help sufferers of insomnia. Cognitive-behavioral therapy is a type of psychotherapy that focuses on cognitive processes and problem behaviors. The treatment of insomnia likely would include stress management techniques and changes in problematic behaviors that could contribute to insomnia (e.g., spending more waking time in bed). Cognitive-behavioral therapy has been demonstrated to be quite effective in treating insomnia (Savard, Simard, Ivers, & Morin, 2005; Williams, Roth, Vatthauer, & McCrae, 2013).
EVERYDAY CONNECTION
Solutions to Support Healthy Sleep
Has something like this ever happened to you? My sophomore college housemate got so stressed out during finals sophomore year he drank almost a whole bottle of Nyquil to try to fall asleep. When he told me, I made him go see the college therapist.
Many college students struggle getting the recommended 7–9 hours of sleep each night. However, for some, it’s not because of all-night partying or late-night study sessions. It’s simply that they feel so overwhelmed and stressed that they cannot fall asleep or stay asleep. One or two nights of sleep difficulty is not unusual, but if you experience anything more than that, you should seek a doctor’s advice.
Here are some tips to maintain healthy sleep:
- Stick to a sleep schedule, even on the weekends. Try going to bed and waking up at the same time every day to keep your biological clock in sync so your body gets in the habit of sleeping every night.
- Avoid anything stimulating for an hour before bed. That includes exercise and bright light from devices.
- Exercise daily.
- Avoid naps.
- Keep your bedroom temperature between 60 and 67 degrees. People sleep better in cooler temperatures.
- Avoid alcohol, cigarettes, caffeine, and heavy meals before bed. It may feel like alcohol helps you sleep, but it actually disrupts REM sleep and leads to frequent awakenings. Heavy meals may make you sleepy, but they can also lead to frequent awakenings due to gastric distress.
- If you cannot fall asleep, leave your bed and do something else until you feel tired again. Train your body to associate the bed with sleeping rather than other activities like studying, eating, or watching television shows.
Parasomnias
A parasomnia is one of a group of sleep disorders in which unwanted, disruptive motor activity and/or experiences during sleep play a role. Parasomnias can occur in either REM or NREM phases of sleep. Sleepwalking, restless leg syndrome, and night terrors are all examples of parasomnias (Mahowald & Schenck, 2000).
Sleepwalking
In sleepwalking, or somnambulism, the sleeper engages in relatively complex behaviors ranging from wandering about to driving an automobile. During periods of sleepwalking, sleepers often have their eyes open, but they are not responsive to attempts to communicate with them. Sleepwalking most often occurs during slow-wave sleep, but it can occur at any time during a sleep period in some affected individuals (Mahowald & Schenck, 2000).
Historically, somnambulism has been treated with a variety of pharmacotherapies ranging from benzodiazepines to antidepressants. However, the success rate of such treatments is questionable. Guilleminault et al. (2005) found that sleepwalking was not alleviated with the use of benzodiazepines. However, all of their somnambulistic patients who also suffered from sleep-related breathing problems showed a marked decrease in sleepwalking when their breathing problems were effectively treated.
DIG DEEPER
A Sleepwalking Defense?
On January 16, 1997, Scott Falater sat down to dinner with his wife and children and told them about difficulties he was experiencing on a project at work. After dinner, he prepared some materials to use in leading a church youth group the following morning, and then he attempted to repair the family’s swimming pool pump before retiring to bed. The following morning, he awoke to barking dogs and unfamiliar voices from downstairs. As he went to investigate what was going on, he was met by a group of police officers who arrested him for the murder of his wife (Cartwright, 2004; CNN, 1999).
Yarmila Falater’s body was found in the family’s pool with 44 stab wounds. A neighbor called the police after witnessing Falater standing over his wife’s body before dragging her into the pool. Upon a search of the premises, police found blood-stained clothes and a bloody knife in the trunk of Falater’s car, and he had blood stains on his neck.
Remarkably, Falater insisted that he had no recollection of hurting his wife in any way. His children and his wife’s parents all agreed that Falater had an excellent relationship with his wife and they couldn’t think of a reason that would provide any sort of motive to murder her (Cartwright, 2004).
Scott Falater had a history of regular episodes of sleepwalking as a child, and he had even behaved violently toward his sister once when she tried to prevent him from leaving their home in his pajamas during a sleepwalking episode. He suffered from no apparent anatomical brain anomalies or psychological disorders. It appeared that Scott Falater had killed his wife in his sleep, or at least, that is the defense he used when he was tried for his wife’s murder (Cartwright, 2004; CNN, 1999). In Falater’s case, a jury found him guilty of first degree murder in June of 1999 (CNN, 1999); however, there are other murder cases where the sleepwalking defense has been used successfully. As scary as it sounds, many sleep researchers believe that homicidal sleepwalking is possible in individuals suffering from the types of sleep disorders described below (Broughton et al., 1994; Cartwright, 2004; Mahowald, Schenck, & Cramer Bornemann, 2005; Pressman, 2007).
REM Sleep Behavior Disorder (RBD)
REM sleep behavior disorder (RBD) occurs when the muscle paralysis associated with the REM sleep phase does not occur. Individuals who suffer from RBD have high levels of physical activity during REM sleep, especially during disturbing dreams. These behaviors vary widely, but they can include kicking, punching, scratching, yelling, and behaving like an animal that has been frightened or attacked. People who suffer from this disorder can injure themselves or their sleeping partners when engaging in these behaviors. Furthermore, these types of behaviors ultimately disrupt sleep, although affected individuals have no memories that these behaviors have occurred (Arnulf, 2012).
This disorder is associated with a number of neurodegenerative diseases such as Parkinson’s disease. In fact, this relationship is so robust that some view the presence of RBD as a potential aid in the diagnosis and treatment of a number of neurodegenerative diseases (Ferini-Strambi, 2011). Clonazepam, an anti-anxiety medication with sedative properties, is most often used to treat RBD. It is administered alone or in conjunction with doses of melatonin (the hormone secreted by the pineal gland). As part of treatment, the sleeping environment is often modified to make it a safer place for those suffering from RBD (Zangini, Calandra-Buonaura, Grimaldi, & Cortelli, 2011).
Other Parasomnias
A person with restless leg syndrome has uncomfortable sensations in the legs during periods of inactivity or when trying to fall asleep. This discomfort is relieved by deliberately moving the legs, which, not surprisingly, contributes to difficulty in falling or staying asleep. Restless leg syndrome is quite common and has been associated with a number of other medical diagnoses, such as chronic kidney disease and diabetes (Mahowald & Schenck, 2000). There are a variety of drugs that treat restless leg syndrome: benzodiazepines, opiates, and anticonvulsants (Restless Legs Syndrome Foundation, n.d.).
Night terrors result in a sense of panic in the sufferer and are often accompanied by screams and attempts to escape from the immediate environment (Mahowald & Schenck, 2000). Although individuals suffering from night terrors appear to be awake, they generally have no memories of the events that occurred, and attempts to console them are ineffective. Typically, individuals suffering from night terrors will fall back asleep again within a short time. Night terrors apparently occur during the NREM phase of sleep (Provini, Tinuper, Bisulli, & Lagaresi, 2011). Generally, treatment for night terrors is unnecessary unless there is some underlying medical or psychological condition that is contributing to the night terrors (Mayo Clinic, n.d.).
Sleep Apnea
Sleep apnea is defined by episodes during which a sleeper’s breathing stops. These episodes can last 10–20 seconds or longer and often are associated with brief periods of arousal. While individuals suffering from sleep apnea may not be aware of these repeated disruptions in sleep, they do experience increased levels of fatigue. Many individuals diagnosed with sleep apnea first seek treatment because their sleeping partners indicate that they snore loudly and/or stop breathing for extended periods of time while sleeping (Henry & Rosenthal, 2013). Sleep apnea is much more common in overweight people and is often associated with loud snoring. Surprisingly, sleep apnea may exacerbate cardiovascular disease (Sánchez-de-la-Torre, Campos-Rodriguez, & Barbé, 2012). While sleep apnea is less common in thin people, anyone, regardless of their weight, who snores loudly or gasps for air while sleeping, should be checked for sleep apnea.
While people are often unaware of their sleep apnea, they are keenly aware of some of the adverse consequences of insufficient sleep. Consider a patient who believed that as a result of his sleep apnea he “had three car accidents in six weeks. They were ALL my fault. Two of them I didn’t even know I was involved in until afterwards” (Henry & Rosenthal, 2013, p. 52). It is not uncommon for people suffering from undiagnosed or untreated sleep apnea to fear that their careers will be affected by the lack of sleep, illustrated by this statement from another patient, “I’m in a job where there’s a premium on being mentally alert. I was really sleepy… and having trouble concentrating…. It was getting to the point where it was kind of scary” (Henry & Rosenthal, 2013, p. 52).
There are two types of sleep apnea: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea occurs when an individual’s airway becomes blocked during sleep, and air is prevented from entering the lungs. In central sleep apnea, disruption in signals sent from the brain that regulate breathing cause periods of interrupted breathing (White, 2005).
One of the most common treatments for sleep apnea involves the use of a special device during sleep. A continuous positive airway pressure (CPAP) device includes a mask that fits over the sleeper’s nose and mouth, which is connected to a pump that pumps air into the person’s airways, forcing them to remain open, as shown in Figure 4.13. Some newer CPAP masks are smaller and cover only the nose. This treatment option has proven to be effective for people suffering from mild to severe cases of sleep apnea (McDaid et al., 2009). However, alternative treatment options are being explored because consistent compliance by users of CPAP devices is a problem. Recently, a new EPAP (expiratory positive air pressure) device has shown promise in double-blind trials as one such alternative (Berry, Kryger, & Massie, 2011).
In sudden infant death syndrome (SIDS) an infant stops breathing during sleep and dies. Infants younger than 12 months appear to be at the highest risk for SIDS, and boys have a greater risk than girls. A number of risk factors have been associated with SIDS including premature birth, smoking within the home, and hyperthermia. There may also be differences in both brain structure and function in infants that die from SIDS (Berkowitz, 2012; Mage & Donner, 2006; Thach, 2005).
The substantial amount of research on SIDS has led to a number of recommendations to parents to protect their children (Figure 4.14). For one, research suggests that infants should be placed on their backs when put down to sleep, and their cribs should not contain any items which pose suffocation threats, such as blankets, pillows or padded crib bumpers (cushions that cover the bars of a crib). Infants should not have caps placed on their heads when put down to sleep in order to prevent overheating, and people in the child’s household should abstain from smoking in the home. Recommendations like these have helped to decrease the number of infant deaths from SIDS in recent years (Mitchell, 2009; Task Force on Sudden Infant Death Syndrome, 2011).
Unlike the other sleep disorders described in this section, a person with narcolepsy cannot resist falling asleep at inopportune times. These sleep episodes are often associated with cataplexy, which is a lack of muscle tone or muscle weakness, and in some cases involves complete paralysis of the voluntary muscles. This is similar to the kind of paralysis experienced by healthy individuals during REM sleep (Burgess & Scammell, 2012; Hishikawa & Shimizu, 1995; Luppi et al., 2011). Narcoleptic episodes take on other features of REM sleep. For example, around one third of individuals diagnosed with narcolepsy experience vivid, dream-like hallucinations during narcoleptic attacks (Chokroverty, 2010).
Surprisingly, narcoleptic episodes are often triggered by states of heightened arousal or stress. The typical episode can last from a minute or two to half an hour. Once awakened from a narcoleptic attack, people report that they feel refreshed (Chokroverty, 2010). Obviously, regular narcoleptic episodes could interfere with the ability to perform one’s job or complete schoolwork, and in some situations, narcolepsy can result in significant harm and injury (e.g., driving a car or operating machinery or other potentially dangerous equipment).
Generally, narcolepsy is treated using psychomotor stimulant drugs, such as amphetamines (Mignot, 2012). These drugs promote increased levels of neural activity. Narcolepsy is associated with reduced levels of the signaling molecule hypocretin in some areas of the brain (De la Herrán-Arita & Drucker-Colín, 2012; Han, 2012), and the traditional stimulant drugs do not have direct effects on this system. Therefore, it is quite likely that new medications that are developed to treat narcolepsy will be designed to target the hypocretin system.
There is a tremendous amount of variability among sufferers, both in terms of how symptoms of narcolepsy manifest and the effectiveness of currently available treatment options. This is illustrated by McCarty’s (2010) case study of a 50-year-old woman who sought help for the excessive sleepiness during normal waking hours that she had experienced for several years. She indicated that she had fallen asleep at inappropriate or dangerous times, including while eating, while socializing with friends, and while driving her car. During periods of emotional arousal, the woman complained that she felt some weakness on the right side of her body. Although she did not experience any dream-like hallucinations, she was diagnosed with narcolepsy as a result of sleep testing. In her case, the fact that her cataplexy was confined to the right side of her body was quite unusual. Early attempts to treat her condition with a stimulant drug alone were unsuccessful. However, when a stimulant drug was used in conjunction with a popular antidepressant, her condition improved dramatically.
4.4 TEST YOURSELF
4.5 Substance Use and Abuse
LEARNING OBJECTIVES
By the end of this section, you will be able to:
• Describe the diagnostic criteria for substance use disorders
• Identify the neurotransmitter systems impacted by various categories of drugs
• Describe how different categories of drugs affect behavior and experience
While we all experience altered states of consciousness in the form of sleep on a regular basis, some people use drugs and other substances that result in altered states of consciousness as well. This section will present information relating to the use of various psychoactive drugs and problems associated with such use. This will be followed by brief descriptions of the effects of some of the more well-known drugs commonly used today.
Substance Use Disorders
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is used by clinicians to diagnose individuals suffering from various psychological disorders. Drug use disorders are addictive disorders, and the criteria for specific substance (drug) use disorders are described in DSM-5. A person who has a substance use disorder often uses more of the substance than they originally intended to and continues to use that substance despite experiencing significant adverse consequences. In individuals diagnosed with a substance use disorder, there is a compulsive pattern of drug use that is often associated with both physical and psychological dependence.
Physical dependence involves changes in normal bodily functions—the user will experience withdrawal from the drug upon cessation of use. In contrast, a person who has psychological dependence has an emotional, rather than physical, need for the drug and may use the drug to relieve psychological distress. Tolerance is linked to physiological dependence, and it occurs when a person requires more and more drug to achieve effects previously experienced at lower doses. Tolerance can cause the user to increase the amount of drug used to a dangerous level—even to the point of overdose and death.
Drug withdrawal includes a variety of negative symptoms experienced when drug use is discontinued. These symptoms usually are opposite of the effects of the drug. For example, withdrawal from sedative drugs often produces unpleasant arousal and agitation. In addition to withdrawal, many individuals who are diagnosed with substance use disorders will also develop tolerance to these substances. Psychological dependence, or drug craving, is a recent addition to the diagnostic criteria for substance use disorder in DSM-5. This is an important factor because we can develop tolerance and experience withdrawal from any number of drugs that we do not abuse. In other words, physical dependence in and of itself is of limited utility in determining whether or not someone has a substance use disorder.
Drug Categories
The effects of all psychoactive drugs occur through their interactions with our endogenous neurotransmitter systems. Many of these drugs, and their relationships, are shown in Table 4.2. As you have learned, drugs can act as agonists or antagonists of a given neurotransmitter system. An agonist facilitates the activity of a neurotransmitter system, and antagonists impede neurotransmitter activity.
Drugs and Their Effects
|
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|---|---|---|---|---|
| Class of Drug | Examples | Effects on the Body | Effects When Used | Psychologically Addicting? |
| Stimulants | Cocaine, amphetamines (including some ADHD medications such as Adderall), methamphetamines, MDMA (“Ecstasy” or “Molly”) | Increased heart rate, blood pressure, body temperature | Increased alertness, mild euphoria, decreased appetite in low doses. High doses increase agitation, paranoia, can cause hallucinations. Some can cause heightened sensitivity to physical stimuli. High doses of MDMA can cause brain toxicity and death. | Yes |
| Sedative-Hypnotics (“Depressants”) | Alcohol, barbiturates (e.g., secobarbital, pentobarbital), Benzodiazepines (e.g., Xanax) | Decreased heart rate, blood pressure | Low doses increase relaxation, decrease inhibitions. High doses can induce sleep, cause motor disturbance, memory loss, decreased respiratory function, and death. | Yes |
| Opiates | Opium, Heroin, Fentanyl, Morphine, Oxycodone, Vicoden, methadone, and other prescription pain relievers | Decreased pain, pupil dilation, decreased gut motility, decreased respiratory function | Pain relief, euphoria, sleepiness. High doses can cause death due to respiratory depression. | Yes |
| Hallucinogens | Marijuana, LSD, Peyote, mescaline, DMT, dissociative anesthetics including ketamine and PCP | Increased heart rate and blood pressure that may dissipate over time | Mild to intense perceptual changes with high variability in effects based on strain, method of ingestion, and individual differences | Yes |
Alcohol and Other Depressants
Ethanol, which we commonly refer to as alcohol, is in a class of psychoactive drugs known as depressants (Figure 4.15). A depressant is a drug that tends to suppress central nervous system activity. Other depressants include barbiturates and benzodiazepines. These drugs share in common their ability to serve as agonists of the gamma-Aminobutyric acid (GABA) neurotransmitter system. Because GABA has a quieting effect on the brain, GABA agonists also have a quieting effect; these types of drugs are often prescribed to treat both anxiety and insomnia.
With repeated use of many central nervous system depressants, such as alcohol, a person becomes physically dependent upon the substance and will exhibit signs of both tolerance and withdrawal. Psychological dependence on these drugs is also possible. Therefore, the abuse potential of central nervous system depressants is relatively high.
Drug withdrawal is usually an aversive experience, and it can be a life-threatening process in individuals who have a long history of very high doses of alcohol and/or barbiturates. This is of such concern that people who are trying to overcome addiction to these substances should only do so under medical supervision.
Stimulants
Stimulants are drugs that tend to increase overall levels of neural activity. Many of these drugs act as agonists of the dopamine neurotransmitter system. Dopamine activity is often associated with reward and craving; therefore, drugs that affect dopamine neurotransmission often have abuse liability. Drugs in this category include cocaine, amphetamines (including methamphetamine), cathinones (i.e., bath salts), MDMA (ecstasy), nicotine, and caffeine.
Cocaine can be taken in multiple ways. While many users snort cocaine, intravenous injection and inhalation (smoking) are also common. The freebase version of cocaine, known as crack, is a potent, smokable version of the drug. Like many other stimulants, cocaine agonizes the dopamine neurotransmitter system by blocking the reuptake of dopamine in the neuronal synapse.
DIG DEEPER
Methamphetamine
Methamphetamine in its smokable form, often called “crystal meth” due to its resemblance to rock crystal formations, is highly addictive. The smokable form reaches the brain very quickly to produce an intense euphoria that dissipates almost as fast as it arrives, prompting users to continuing taking the drug. Users often consume the drug every few hours across days-long binges called “runs,” in which the user forgoes food and sleep. In the wake of the opiate epidemic, many drug cartels in Mexico are shifting from producing heroin to producing highly potent but inexpensive forms of methamphetamine. The low cost coupled with lower risk of overdose than with opiate drugs is making crystal meth a popular choice among drug users today (NIDA, 2019). Using crystal meth poses a number of serious long-term health issues, including dental problems (often called “meth mouth”), skin abrasions caused by excessive scratching, memory loss, sleep problems, violent behavior, paranoia, and hallucinations. Methamphetamine addiction produces an intense craving that is difficult to treat.
Amphetamines have a mechanism of action quite similar to cocaine in that they block the reuptake of dopamine in addition to stimulating its release (Figure 4.16). While amphetamines are often abused, they are also commonly prescribed to children diagnosed with attention deficit hyperactivity disorder (ADHD). It may seem counterintuitive that stimulant medications are prescribed to treat a disorder that involves hyperactivity, but the therapeutic effect comes from increases in neurotransmitter activity within certain areas of the brain associated with impulse control. These brain areas include the prefrontal cortex and basal ganglia.
Stimulant users seek a euphoric high, feelings of intense elation and pleasure, especially in those users who take the drug via intravenous injection or smoking. MDMA (3.4-methelynedioxy-methamphetamine, commonly known as “ecstasy” or “Molly”) is a mild stimulant with perception-altering effects. It is typically consumed in pill form. Users experience increased energy, feelings of pleasure, and emotional warmth. Repeated use of these stimulants can have significant adverse consequences. Users can experience physical symptoms that include nausea, elevated blood pressure, and increased heart rate. In addition, these drugs can cause feelings of anxiety, hallucinations, and paranoia (Fiorentini et al., 2011). Normal brain functioning is altered after repeated use of these drugs. For example, repeated use can lead to overall depletion among the monoamine neurotransmitters (dopamine, norepinephrine, and serotonin). Depletion of certain neurotransmitters can lead to mood dysphoria, cognitive problems, and other factors. This can lead to people compulsively using stimulants such as cocaine and amphetamines, in part to try to reestablish the person’s physical and psychological pre-use baseline. (Jayanthi & Ramamoorthy, 2005; Rothman, Blough, & Baumann, 2007).
Caffeine is another stimulant drug. While it is probably the most commonly used drug in the world, the potency of this particular drug pales in comparison to the other stimulant drugs described in this section. Generally, people use caffeine to maintain increased levels of alertness and arousal. Caffeine is found in many common medicines (such as weight loss drugs), beverages, foods, and even cosmetics (Herman & Herman, 2013). While caffeine may have some indirect effects on dopamine neurotransmission, its primary mechanism of action involves antagonizing adenosine activity (Porkka-Heiskanen, 2011). Adenosine is a neurotransmitter that promotes sleep. Caffeine is an adenosine antagonist, so caffeine inhibits the adenosine receptors, thus decreasing sleepiness and promoting wakefulness.
While caffeine is generally considered a relatively safe drug, high blood levels of caffeine can result in insomnia, agitation, muscle twitching, nausea, irregular heartbeat, and even death (Reissig, Strain, & Griffiths, 2009; Wolt, Ganetsky, & Babu, 2012). In 2012, Kromann and Nielson reported on a case study of a 40-year-old woman who suffered significant ill effects from her use of caffeine. The woman used caffeine in the past to boost her mood and to provide energy, but over the course of several years, she increased her caffeine consumption to the point that she was consuming three liters of soda each day. Although she had been taking a prescription antidepressant, her symptoms of depression continued to worsen and she began to suffer physically, displaying significant warning signs of cardiovascular disease and diabetes. Upon admission to an outpatient clinic for treatment of mood disorders, she met all of the diagnostic criteria for substance dependence and was advised to dramatically limit her caffeine intake. Once she was able to limit her use to less than 12 ounces of soda a day, both her mental and physical health gradually improved. Despite the prevalence of caffeine use and the large number of people who confess to suffering from caffeine addiction, this was the first published description of soda dependence appearing in scientific literature.
Nicotine is highly addictive, and the use of tobacco products is associated with increased risks of heart disease, stroke, and a variety of cancers. Nicotine exerts its effects through its interaction with acetylcholine receptors. Acetylcholine functions as a neurotransmitter in motor neurons. In the central nervous system, it plays a role in arousal and reward mechanisms. Nicotine is most commonly used in the form of tobacco products like cigarettes or chewing tobacco; therefore, there is a tremendous interest in developing effective smoking cessation techniques. To date, people have used a variety of nicotine replacement therapies in addition to various psychotherapeutic options in an attempt to discontinue their use of tobacco products. In general, smoking cessation programs may be effective in the short term, but it is unclear whether these effects persist (Cropley, Theadom, Pravettoni, & Webb, 2008; Levitt, Shaw, Wong, & Kaczorowski, 2007; Smedslund, Fisher, Boles, & Lichtenstein, 2004). Vaping as a means to deliver nicotine is becoming increasingly popular, especially among teens and young adults. Vaping uses battery-powered devices, sometimes called e-cigarettes, that deliver liquid nicotine and flavorings as a vapor. Originally reported as a safe alternative to the known cancer-causing agents found in cigarettes, vaping is now known to be very dangerous and has led to serious lung disease and death in users.
Opioids
An opioid is one of a category of drugs that includes heroin, morphine, methadone, and codeine. Opioids have analgesic properties; that is, they decrease pain. Humans have an endogenous opioid neurotransmitter system—the body makes small quantities of opioid compounds that bind to opioid receptors reducing pain and producing euphoria. Thus, opioid drugs, which mimic this endogenous painkilling mechanism, have an extremely high potential for abuse. Natural opioids, called opiates, are derivatives of opium, which is a naturally occurring compound found in the poppy plant. There are now several synthetic versions of opiate drugs (correctly called opioids) that have very potent painkilling effects, and they are often abused. For example, the National Institutes of Drug Abuse has sponsored research that suggests the misuse and abuse of the prescription pain killers hydrocodone and oxycodone are significant public health concerns (Maxwell, 2006). In 2013, the U.S. Food and Drug Administration recommended tighter controls on their medical use.
Historically, heroin has been a major opioid drug of abuse (Figure 4.17). Heroin can be snorted, smoked, or injected intravenously. Heroin produces intense feelings of euphoria and pleasure, which are amplified when the heroin is injected intravenously. Following the initial “rush,” users experience 4–6 hours of “going on the nod,” alternating between conscious and semiconscious states. Heroin users often shoot the drug directly into their veins. Some people who have injected many times into their arms will show “track marks,” while other users will inject into areas between their fingers or between their toes, so as not to show obvious track marks and, like all abusers of intravenous drugs, have an increased risk for contraction of both tuberculosis and HIV.
Codeine is an opioid with relatively low potency. It is often prescribed for minor pain, and it is available over-the-counter in some other countries. Like all opioids, codeine does have abuse potential. In fact, abuse of prescription opioid medications is becoming a major concern worldwide (Aquina, Marques-Baptista, Bridgeman, & Merlin, 2009; Casati, Sedefov, & Pfeiffer-Gerschel, 2012).
EVERYDAY CONNECTION
The Opioid Crisis
Few people in the United States remain untouched by the recent opioid epidemic. It seems like everyone knows a friend, family member, or neighbor who has died of an overdose. Opioid addiction reached crisis levels in the United States such that by 2019, an average of 130 people died each day of an opioid overdose (NIDA, 2019).
The crisis actually began in the 1990s, when pharmaceutical companies began mass-marketing pain-relieving opioid drugs like OxyContin with the promise (now known to be false) that they were non-addictive. Increased prescriptions led to greater rates of misuse, along with greater incidence of addiction, even among patients who used these drugs as prescribed. Physiologically, the body can become addicted to opiate drugs in less than a week, including when taken as prescribed. Withdrawal from opioids includes pain, which patients often misinterpret as pain caused by the problem that led to the original prescription, and which motivates patients to continue using the drugs.
The FDA’s 2013 recommendation for tighter controls on opiate prescriptions left many patients addicted to prescription drugs like OxyContin unable to obtain legitimate prescriptions. This created a black market for the drug, where prices soared to $80 or more for a single pill. To prevent withdrawal, many people turned to cheaper heroin, which could be bought for $5 a dose or less. To keep heroin affordable, many dealers began adding more potent synthetic opioids including fentanyl and carfentanyl to increase the effects of heroin. These synthetic drugs are so potent that even small doses can cause overdose and death.
Large-scale public health campaigns by the National Institutes of Health and the National Institute of Drug Abuse have led to recent declines in the opioid crisis. These initiatives include increasing access to treatment and recovery services, increasing access to overdose-reversal drugs like Naloxone, and implementing better public health monitoring systems (NIDA, 2019).
Hallucinogens
A hallucinogen is one of a class of drugs that results in profound alterations in sensory and perceptual experiences (Figure 4.18). In some cases, users experience vivid visual hallucinations. It is also common for these types of drugs to cause hallucinations of body sensations (e.g., feeling as if you are a giant) and a skewed perception of the passage of time.
DIG DEEPER
Medical Marijuana
The decade from 2010–2019 brought many changes in laws regarding marijuana. While the possession and use of marijuana remain illegal in many states, it is now legal to possess limited quantities of marijuana for recreational use in eleven states: Alaska, California, Colorado, Illinois, Maine, Massachusetts, Michigan, Nevada, Oregon, Vermont, and Washington. Medical marijuana is legal in over half of the United States and in the District of Columbia (Figure 4.19). Medical marijuana is marijuana that is prescribed by a doctor for the treatment of a health condition. For example, people who undergo chemotherapy will often be prescribed marijuana to stimulate their appetites and prevent excessive weight loss resulting from the side effects of chemotherapy treatment. Marijuana may also have some promise in the treatment of a variety of medical conditions (Mather, Rauwendaal, Moxham-Hall, & Wodak, 2013; Robson, 2014; Schicho & Storr, 2014).
Until recently, the United States Department of Justice routinely arrested people involved and seized marijuana used in medicinal settings. In the latter part of 2013, however, the United States Department of Justice issued statements indicating that they would not continue to challenge state medical marijuana laws. This shift in policy may be in response to the scientific community’s recommendations and/or reflect changing public opinion regarding marijuana.
4.5 TEST YOURSELF
4.6 Other States of Consciousness
LEARNIG OBJECTIVES
By the end of this section, you will be able to:
• Define hypnosis and meditation
• Understand the similarities and differences of hypnosis and meditation
Our states of consciousness change as we move from wakefulness to sleep. We also alter our consciousness through the use of various psychoactive drugs. This final section will consider hypnotic and meditative states as additional examples of altered states of consciousness experienced by some individuals.
Hypnosis
Hypnosis is a state of extreme self-focus and attention in which minimal attention is given to external stimuli. In the therapeutic setting, a clinician may use relaxation and suggestion in an attempt to alter the thoughts and perceptions of a patient. Hypnosis has also been used to draw out information believed to be buried deeply in someone’s memory. For individuals who are especially open to the power of suggestion, hypnosis can prove to be a very effective technique, and brain imaging studies have demonstrated that hypnotic states are associated with global changes in brain functioning (Del Casale et al., 2012; Guldenmund, Vanhaudenhuyse, Boly, Laureys, & Soddu, 2012).
Historically, hypnosis has been viewed with some suspicion because of its portrayal in popular media and entertainment (Figure 4.20). Therefore, it is important to make a distinction between hypnosis as an empirically based therapeutic approach versus as a form of entertainment. Contrary to popular belief, individuals undergoing hypnosis usually have clear memories of the hypnotic experience and are in control of their own behaviors. While hypnosis may be useful in enhancing memory or a skill, such enhancements are very modest in nature (Raz, 2011).
- The participant is guided to focus on one thing, such as the hypnotist’s words or a ticking watch.
- The participant is made comfortable and is directed to be relaxed and sleepy.
- The participant is told to be open to the process of hypnosis, trust the hypnotist and let go.
- The participant is encouraged to use his or her imagination.
These steps are conducive to being open to the heightened suggestibility of hypnosis.
People vary in terms of their ability to be hypnotized, but a review of available research suggests that most people are at least moderately hypnotizable (Kihlstrom, 2013). Hypnosis in conjunction with other techniques is used for a variety of therapeutic purposes and has shown to be at least somewhat effective for pain management, treatment of depression and anxiety, smoking cessation, and weight loss (Alladin, 2012; Elkins, Johnson, & Fisher, 2012; Golden, 2012; Montgomery, Schnur, & Kravits, 2012).
How does hypnosis work? Two theories attempt to answer this question: One theory views hypnosis as dissociation and the other theory views it as the performance of a social role. According to the dissociation view, hypnosis is effectively a dissociated state of consciousness, much like our earlier example where you may drive to work, but you are only minimally aware of the process of driving because your attention is focused elsewhere. This theory is supported by Ernest Hilgard’s research into hypnosis and pain. In Hilgard’s experiments, he induced participants into a state of hypnosis, and placed their arms into ice water. Participants were told they would not feel pain, but they could press a button if they did; while they reported not feeling pain, they did, in fact, press the button, suggesting a dissociation of consciousness while in the hypnotic state (Hilgard & Hilgard, 1994).
Taking a different approach to explain hypnosis, the social-cognitive theory of hypnosis sees people in hypnotic states as performing the social role of a hypnotized person. As you will learn when you study social roles, people’s behavior can be shaped by their expectations of how they should act in a given situation. Some view a hypnotized person’s behavior not as an altered or dissociated state of consciousness, but as their fulfillment of the social expectations for that role (Coe, 2009; Coe & Sarbin, 1966).
Meditation
Meditation is the act of focusing on a single target (such as the breath or a repeated sound) to increase awareness of the moment. While hypnosis is generally achieved through the interaction of a therapist and the person being treated, an individual can perform meditation alone. Often, however, people wishing to learn to meditate receive some training in techniques to achieve a meditative state.
Although there are a number of different techniques in use, the central feature of all meditation is clearing the mind in order to achieve a state of relaxed awareness and focus (Chen et al., 2013; Lang et al., 2012). Mindfulness meditation has recently become popular. In the variation of mindful meditation, the meditator’s attention is focused on some internal process or an external object (Zeidan, Grant, Brown, McHaffie, & Coghill, 2012).
Meditative techniques have their roots in religious practices (Figure 4.21), but their use has grown in popularity among practitioners of alternative medicine. Research indicates that meditation may help reduce blood pressure, and the American Heart Association suggests that meditation might be used in conjunction with more traditional treatments as a way to manage hypertension, although there is not sufficient data for a recommendation to be made (Brook et al., 2013). Like hypnosis, meditation also shows promise in stress management, sleep quality (Caldwell, Harrison, Adams, Quin, & Greeson, 2010), treatment of mood and anxiety disorders (Chen et al., 2013; Freeman et al., 2010; Vøllestad, Nielsen, & Nielsen, 2012), and pain management (Reiner, Tibi, & Lipsitz, 2013).
4.6 TEST YOURSELF
Summary
4.1 What is Consciousness?
States of consciousness vary over the course of the day and throughout our lives. Important factors in these changes are the biological rhythms, and, more specifically, the circadian rhythms generated by the suprachiasmatic nucleus (SCN). Typically, our biological clocks are aligned with our external environment, and light tends to be an important cue in setting this clock. When people travel across multiple time zones or work rotating shifts, they can experience disruptions of their circadian cycles that can lead to insomnia, sleepiness, and decreased alertness. Bright light therapy has shown to be promising in dealing with circadian disruptions. If people go extended periods of time without sleep, they will accrue a sleep debt and potentially experience a number of adverse psychological and physiological consequences.
4.2 Sleep and Why We Sleep
We devote a very large portion of time to sleep, and our brains have complex systems that control various aspects of sleep. Several hormones important for physical growth and maturation are secreted during sleep. While the reason we sleep remains something of a mystery, there is some evidence to suggest that sleep is very important to learning and memory.
4.3 Stages of Sleep
The different stages of sleep are characterized by the patterns of brain waves associated with each stage. As a person transitions from being awake to falling asleep, alpha waves are replaced by theta waves. Sleep spindles and K-complexes emerge in stage 2 sleep. Stage 3 and stage 4 are described as slow-wave sleep that is marked by a predominance of delta waves. REM sleep involves rapid movements of the eyes, paralysis of voluntary muscles, and dreaming. Both NREM and REM sleep appear to play important roles in learning and memory. Dreams may represent life events that are important to the dreamer. Alternatively, dreaming may represent a state of protoconsciousness, or a virtual reality, in the mind that helps a person during consciousness.
4.4 Sleep Problems and Disorders
Many individuals suffer from some type of sleep disorder or disturbance at some point in their lives. Insomnia is a common experience in which people have difficulty falling or staying asleep. Parasomnias involve unwanted motor behavior or experiences throughout the sleep cycle and include RBD, sleepwalking, restless leg syndrome, and night terrors. Sleep apnea occurs when individuals stop breathing during their sleep, and in the case of sudden infant death syndrome, infants will stop breathing during sleep and die. Narcolepsy involves an irresistible urge to fall asleep during waking hours and is often associated with cataplexy and hallucination.
4.5 Substance Use and Abuse
Substance use disorder is defined in DSM-5 as a compulsive pattern of drug use despite negative consequences. Both physical and psychological dependence are important parts of this disorder. Alcohol, barbiturates, and benzodiazepines are central nervous system depressants that affect GABA neurotransmission. Cocaine, amphetamine, cathinones, and MDMA are all central nervous stimulants that agonize dopamine neurotransmission, while nicotine and caffeine affect acetylcholine and adenosine, respectively. Opiate drugs serve as powerful analgesics through their effects on the endogenous opioid neurotransmitter system, and hallucinogenic drugs cause pronounced changes in sensory and perceptual experiences. The hallucinogens are variable with regards to the specific neurotransmitter systems they affect.
4.6 Other States of Consciousness
Hypnosis is a focus on the self that involves suggested changes of behavior and experience. Meditation involves relaxed, yet focused, awareness. Both hypnotic and meditative states may involve altered states of consciousness that have potential application for the treatment of a variety of physical and psychological disorders.
Critical Thinking Questions
- Healthcare professionals often work rotating shifts. Why is this problematic? What can be done to deal
with potential problems? - Generally, humans are considered diurnal which means we are awake during the day and asleep during the night. Many rodents, on the other hand, are nocturnal. Why do you think different animals have such different sleep-wake cycles?
- If theories that assert sleep is necessary for restoration and recovery from daily energetic demands are correct, what do you predict about the relationship that would exist between individuals’ total sleep duration and their level of activity?
- How could researchers determine if given areas of the brain are involved in the regulation of sleep?
- Differentiate the evolutionary theories of sleep and make a case for the one with the most compelling evidence.
- Freud believed that dreams provide important insight into the unconscious mind. He maintained that a dream’s manifest content could provide clues into an individual’s unconscious. What potential criticisms exist for this particular perspective?
- Some people claim that sleepwalking and talking in your sleep involve individuals acting out their dreams. Why is this particular explanation unlikely?
- One of the recommendations that therapists will make to people who suffer from insomnia is to spend less waking time in bed. Why do you think spending waking time in bed might interfere with the ability to fall asleep later?
- How is narcolepsy with cataplexy similar to and different from REM sleep?
- The negative health consequences of both alcohol and tobacco products are well-documented. A drug like marijuana, on the other hand, is generally considered to be as safe, if not safer than these legal drugs. Why do you think marijuana use continues to be illegal in many parts of the United States?
- Why are programs designed to educate people about the dangers of using tobacco products just as important as developing tobacco cessation programs?
- What advantages exist for researching the potential health benefits of hypnosis?
- What types of studies would be most convincing regarding the effectiveness of meditation in the treatment for some type of physical or mental disorder?
Personal Application Questions
- We experience shifts in our circadian clocks in the fall and spring of each year with time changes associated with daylight saving time. Is springing ahead or falling back easier for you to adjust to, and why do you think that is?
- What do you do to adjust to the differences in your daily schedule throughout the week? Are you running a
sleep debt when daylight saving time begins or ends? - Have you (or someone you know) ever experienced significant periods of sleep deprivation because of simple insomnia, high levels of stress, or as a side effect from a medication? What were the consequences of missing out on sleep?
- Researchers believe that one important function of sleep is to facilitate learning and memory. How does knowing this help you in your college studies? What changes could you make to your study and sleep habits to maximize your mastery of the material covered in class?
- What factors might contribute to your own experiences with insomnia?
- Many people experiment with some sort of psychoactive substance at some point in their lives. Why do you think people are motivated to use substances that alter consciousness?
- Under what circumstances would you be willing to consider hypnosis and/or meditation as a treatment option? What kind of information would you need before you made a decision to use these techniques?
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awareness of internal and external stimuli
result of insufficient sleep on a chronic basis
internal cycle of biological activity
biological rhythm that occurs over approximately 24 hours
state of equilibrium—biological conditions, such as body temperature, are maintained at optimal levels
area of the hypothalamus in which the body’s biological clock is located
brain’s control of switching between sleep and wakefulness as well as coordinating this cycle with the outside world
characterized by high levels of sensory awareness, thought, and behavior
collection of symptoms brought on by travel from one time zone to another that results from the mismatch between our internal circadian cycles and our environment
work schedule that changes from early to late on a daily or weekly basis
result of insufficient sleep on a chronic basis
study that combines the results of several related studies
sleep-deprived individuals will experience shorter sleep latencies during subsequent opportunities for sleep
hormone secreted by the endocrine gland that serves as an important regulator of the sleep-wake cycle
discipline that studies how universal patterns of behavior and cognitive processes have evolved over time as a result of natural selection
period of sleep characterized by brain waves very similar to those during wakefulness and by darting movements of the eyes under closed eyelids
period of sleep outside periods of rapid eye movement (REM) sleep
first stage of sleep; transitional phase that occurs between wakefulness and sleep; the period during which a person drifts off to sleep
type of rbrain wave characteristic during the early part of NREM stage 1 sleep, which has fairly low amplitude and a frequency of 8–12 Hz
type of brain wave characteristic of the end of stage 1 NREM sleep, which has a moderately low amplitude and a frequency of 4–7 Hz
second stage of sleep; the body goes into deep relaxation; characterized by the appearance of sleep spindles
rapid burst of high frequency brain waves during stage 2 sleep that may be important for learning and memory
very high amplitude pattern of brain activity associated with stage 2 sleep that may occur in response to environmental stimuli
third stage of sleep; deep sleep characterized by low frequency, high amplitude delta waves
type of brain wave characteristic during stage 3 NREM sleep, which has a high amplitude and low frequency of less than 3 Hz
the increased frequency, depth, and intensity of rapid-eye-movement (REM) sleep following sleep deprivation or significant stressors.
storyline of events that occur during a dream, per Sigmund Freud’s view of the function of dreams
hidden meaning of a dream, per Sigmund Freud’s view of the function of dreams
theoretical repository of information shared by all people across cultures, as described by Carl Jung; also, common psychological tendencies that have been passed down from one generation to the next
dreams reflect the random activation of the brain stem during REM sleep.
people become aware that they are dreaming and can control the dream’s content
consistent difficulty in falling or staying asleep for at least three nights a week over a month’s time
psychotherapy that focuses on cognitive processes and problem behaviors that is sometimes used to treat sleep disorders such as insomnia
one of a group of sleep disorders characterized by unwanted, disruptive motor activity and/or experiences during sleep
(also, somnambulism) sleep disorder in which the sleeper engages in relatively complex behaviors
sleep disorder in which the muscle paralysis associated with the REM sleep phase does not occur; sleepers have high levels of physical activity during REM sleep, especially during disturbing dreams
endocrine structure located inside the brain that releases melatonin
sleep disorder in which the sufferer has uncomfortable sensations in the legs when trying to fall asleep that are relieved by moving the legs
sleep disorder in which the sleeper experiences a sense of panic and may scream or attempt to escape from the immediate environment
sleep disorder defined by episodes during which breathing stops during sleep
sleep disorder defined by episodes when breathing stops during sleep as a result of blockage of the airway
sleep disorder with periods of interrupted breathing due to a disruption in signals sent from the brain that regulate breathing
device used to treat sleep apnea; includes a mask that fits over the sleeper’s nose and mouth, which is connected to a pump that pumps air into the person’s airways, forcing them to remain open
infant (one year old or younger) with no apparent medical condition suddenly dies during sleep
sleep disorder in which the sufferer cannot resist falling to sleep at inopportune times
lack of muscle tone or muscle weakness, and in some cases complete paralysis of the voluntary muscles
changes in normal bodily functions that cause a drug user to experience withdrawal symptoms upon cessation of use
variety of negative symptoms experienced when drug use is discontinued
emotional, rather than a physical, need for a drug which may be used to relieve psychological distress
state of requiring increasing quantities of the drug to gain the desired effect
drugs that tends to suppress central nervous system activity
a group of conditions that can occur in a person who was exposed to alcohol before birth. These effects can include physical problems and problems with behavior and learning.
a set of mental and physical disorders that can include mental retardation, brain dysfunction, physical abnormalities, learning disabilities, and psychological disorders that occurs as a result of prenatal exposure to alcohol.
drug that tends to increase overall levels of neural activity; includes caffeine, nicotine, amphetamines, and cocaine
type of amphetamine that can be made from pseudoephedrine, an over-the-counter drug; widely manufactured and abused
feelings of intense elation and pleasure from drug use
one of a category of drugs that has strong analgesic properties; opiates are produced from the resin of the opium poppy; includes heroin, morphine, methadone, and codeine
synthetic opioid that is less euphorigenic than heroin and similar drugs; used to manage withdrawal symptoms in opiate users
uses methadone to treat withdrawal symptoms in opiate users
opiate with relatively low potency often prescribed for minor pain
one of a class of drugs that results in profound alterations in sensory and perceptual experiences, often with vivid hallucinations
state of extreme self-focus and attention in which minimal attention is given to external stimuli
clearing the mind in order to achieve a state of relaxed awareness and focus