The importance of viewing sleep as a 'practice'.

Abstract

There is now a growing body of work which highlights how sleep can affect addiction/dependence and vice versa. Irwin and colleagues add further, valuable, detail to this. Individuals conceptualize sleep very differently depending on their experiences and circumstances, and this should be taken into account in future research and treatment discussions. It is well documented that sleep problems can contribute to the development of dependence, are made worse by chronic use, can persist into abstinence and are implicated in relapse 1. The current paper by Irwin and colleagues 2 adds further detail to this, most notably with the suggestion that cocaine and alcohol dependence accelerate age-related loss of stage 3 sleep and that this is much more pronounced in cocaine-dependent subjects. Reductions in sleep continuity—which usually accompany age-related reductions in slow wave activity 3are not observed. As the authors note, further studies are needed to determine clinical and prognostic significance. In moving forward, however, we need to acknowledge the multi-disciplinary nature of sleep and its study. Recent sociological research has, for example, argued that sleep is best considered as a ‘body technique’ or ‘practice’. By this, sociologists mean that sleep is more than a simple biological necessity and that how we sleep, when we sleep, where we sleep and the meanings and values we accord sleep are all historically and patterned socio-culturally 4. Viewing sleep in this way, rather than as an individualized health ‘behaviour’, frames it as something that emerges out of actions and interactions in specific contexts 5. For example, in one of the few studies to apply this framework to sleep and recovery, Nettleton and colleagues argue that the drive to avoid significant others and fraught social relationships can lead heroin-dependent individuals to be active during the night and sleep during the day. This non-adherence to diurnal sleep patterns can continue for decades, and the processes of reversing it can become a symbolic and pragmatic indicator of recovery 6. Viewing sleep in this wider frame feeds directly back to some of the important issues raised by Irwin et al.’s paper: first, sleep and dependence are complex and located within changing contexts. Irwin et al. begin to capture this. However, longitudinal data, talking to people about their past lives and sleep practices would assist further in understanding these and other findings 6. Secondly, Irwin et al. add to earlier research which finds that cocaine-dependent individuals often report their sleep subjectively as fine, even when accompanied by deterioration in objectively reported sleep parameters—a phenomenon described previously as ‘occult insomnia’ 7. They also raise interesting questions about sleep propensity within this population. Studies of older adults have suggested that age-related changes in slow wave sleep/slow wave activity may reflect a reduction in the amount of sleep needed by older adults to function well 3. Sociologists also remind us that individual meanings and values of sleep can vary. Venn & Arber 8, for example, highlight the different ways people talk about daytime sleep and how each of these carries specific meanings and connotations. In their research, daytime sleep was rarely spoken of as a ‘nap’, because this signified unwelcome ageing. Rather, where it did occur, daytime sleep was acknowledged as a ‘doze’ and not really sleeping. Studies have yet to explore fully the meanings and values of sleep within cocaine and alcohol dependence, but it may be that we need to think differently about subjective measures of sleep quality and ask ‘what is sleep’ a little more. Finally, cognitive–behavioural therapy for insomnia (CBT-I) may improve homeostatic sleep regulation and therefore has the potential to rebuild deficiencies in slow wave sleep 9. However, CBT-I has had limited success when used in alcohol-related disorders, in large part, it is suggested, because there remains a need to understand experiences throughout recovery 10. Treatment options bring more opportunities for multi-disciplinary discussion. If we accept that sleep is a complex practice which emerges out of actions and interactions within specific contexts, we need to draw upon a range of disciplines to best capture detailed patient experiences of both sleep and treatment options. None.