Review Article - Neuropsychiatry (2017) Volume 7, Issue 2
Insomnia and self-destructiveness in adolescence: A French psychoanalytic perspective
- Corresponding Author:
- Yuichiro Abe
Department of psychiatry, Tokyo Medical and Dental University, Japan
E-mail: [email protected]
Sleep disorders are the focus of numerous physiological, psychological and psychiatric studies, most of which are based on cognitive, behavioral and developmental models. The psychoanalytic model is not often used in contemporary research, in spite of the fact that dreams are central in psychoanalysis. This article aims to heighten awareness to the relevance of psychoanalytic perspectives in the research on sleep disorders. Indeed, the complexity of sleep disorders calls for a confrontation between different health disciplines and specialties. Adolescence is a particularly sensitive period and complaints of sleep disturbance frequent.
Even though physical, hormonal and behavioral changes have an undeniable impact on sleep, we underscore the importance of exploring the intrapsychic conflicts characteristic of this period. The resurgence of sexual and aggressive impulses must to be worked through in order to fully understand the underpinnings of disturbed sleep. Based on research we are conducting at present, we first focus on the regression that takes place during sleep, with its corollary, passivity. We find that adolescents prone to sleep disturbances resist the passive position that comes with regression. We then show how this resistance to passivity is linked to a difficulty in expressing internalized aggressiveness and how the excessive retention and repression of these affects can transform them into destructiveness and self-destructive behavior.
Sleep has a constructive and organizing function that is essential to dreaming, and dreaming is a container for the symbolization of sexual and aggressive fantasies. Sleep disorders hinder this symbolization and thus, the processing of intrapsychic conflicts. Working through these conflicts is however necessary, as otherwise they re-emerge and disturb sleep. This vicious cycle amplifies the self-destructive impact of sleep disorders. Lastly, we underscore the fear of death that is linked to sleep disorders and the unconscious associations between death and sleep.
Adolescence, Insomnia, Aggressiveness, Passivity, Identification, Fear of death
We spend a third of our life sleeping. Sleep is a vital physiological need and has a homeostatic function regulating immunity, body temperature and growth in children. At all ages, sleep allows us to organize information gathered during the day. Lack of sleep has multiple and immediate consequences, including a negative impact on academic performance. Sleep protects cognitive integrity, which is the capacity for memorization and learning .
Although an international consensus on the definition of insomnia is still under debate, it is classed as a distinct disorder in the DSM-5. The diagnostic criteria include marked dissatisfaction with sleep quantity or quality, with one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, and resistance to going to sleep . Persons suffering from insomnia also complain of fatigue or lack of energy, daytime drowsiness, cognitive disturbance (attention, concentration, memory), mood disturbance (irritability, dysphoria) or behavioral problems (hyperactivity, impulsivity, aggressiveness), with an adverse effect on social or academic functioning.
Puberty, with its host of hormonal, biological, behavioral and psychological changes, modifies sleep. Sleep is challenged during adolescence, often by the teen himself . Everything is a pretext for avoiding sleep: homework, telephone calls with friends, television, social networking, and video game. These distractions deregulate biological rhythms and a quasi-permanent deficit of sleep . In France, 50% of teens complain of difficulty initiating sleep and insomnia . This complaint is symptomatic of a public health issue that is probably underestimated.
Y. Abe and N. de Kernier  look at sleep disorders during adolescence and explore the link between nightmares and suicidal ideation or gestures as well as the link between insomnia and depression. This research was based on international epidemiological studies that show a correlation between complaints of insomnia or sleep disturbance and increased frequency in suicidal ideation , sometimes leading to suicidal behavior [8,9]. The link between insufficient sleep and an increased risk of acting out, especially when comorbid with depression, is more and more frequently highlighted . Research underscores that numerous psychological, physical and environmental factors must be taken into account .
We propose here to examine the origin of sleep disorders during adolescence through the lens of psychoanalysis, all the while taking into account the psychodynamic singularity of each case. This approach is complementary to the other psychological, psychiatric and neuropsychiatric perspectives used to understand sleep disorders. Freud  underscores the regression induced by sleep. This regression is both temporal and instinctual. Ego organization regresses to a state closer to the Id. On an instinctual level, the libido regresses to a state of primary narcissism. A weakening of repression during sleep enables the instinctual activity of the Id and this state gives birth to dreams, in which repressed desires are satisfied through hallucination. According to psychoanalytic theory therefore, sleep plays a fundamental structuring and organizing role. The role of dream phenomena is to connect the psychic life of the previous day to unconscious fantasies. The regression specific to sleep implies passivity: an attitude in which letting go and receptivity dominate, as for the baby receiving care from its mother. Based on the ideas of Chabert , we can briefly define passivity as the acknowledgement and acceptance of the effects of the other in the self. These effects must be worked through. Research using projective methodology  with an insomniac population concludes that “repeated insomnia could be symptomatic of an impossibility to regress to a passive position because of the anxiety reactivated by this regression . These authors understand insomnia as a sign of a difficulty in getting distance from real-life tensions as well as from the intrapsychic conflicts that these tensions and anxieties generate.
Adolescents tend to avoid regression because it brings them closer to the primary object, with whom they are striving to create distance. Regression is even more intolerable if the relationship with the primary object was fraught with dissatisfaction, frustration or on the contrary, too much excitement. Moreover, during adolescence, passivity and passivation (also called passivity-distress by A. Green  which refers to being forced to be passive, like the infant dependent on the parent’s care) are often intertwined, and can evoke death during a period where it is vital for the adolescent to feel alive and active. Insomniacs can experience falling asleep as a fantasy threat of dying: “falling asleep is a critical moment for some: being alone in the dark and far from the outside world can trigger fear of death”  and the associated infantile state of distress described by Freud , the “Hilflosigkeit”. Ph. Jeammet explores the relationship between activity and passivity and affirms that aggressiveness and violence are “narcissistic defense behaviors” (1997, p.7) or “self-sabotaging behaviors” (1980, p.16), in reaction to the physical transformations of adolescence. These transformations, beyond the control of the adolescent, trigger an experience of passivity or even passivation, reactivating a feeling of infantile impotence that the teen thought was in the past. The adolescent must work through this experience of passivity to transform it. The teen’s room is the place where he will engage very concretely in deconstructing and reorganizing old ways of life, including the family ritual of bedtime, rising, meals and weekend schedules. Night and sleep can be viewed as an interface that is both social but also unique to the adolescent in transformation. It is also a space for experiences and confrontations.
What are the underpinnings of adolescent insomnia when the etiology is not purely organic? We could posit that these underpinnings are linked to the fact that adolescents have difficulty working through and connecting sexual excitation and aggressive drives. However, we know that this difficulty is common during adolescence and can be expressed in ways other than insomnia. Winnicott  stresses that since adolescents need to feel “real”, they therefore may more or less unconsciously fear that sleeping would be like dying, or at least equivalent to feeling powerless. Unconsciously avoiding or preventing sleep would be like refusing to “die” symbolically during this period where the adolescent must combat the feeling of not existing and convince himself that he is alive by being awake. Thus, the adolescent cannot invest in a transitional space. Winnicott defines this space as an in-between zone, which is an extension of the in-between zone of infancy, where through play with “not-me” objects in a sufficiently holding environment, the child explores the space between subject and object and learns to be in relationship with self and others. This narrowing of the transitional space prevents the adolescent from listening to his inner world.
In order to mobilize narcissistic investment and go through the process of individuation , the adolescent who is unable to work through his aggressive and sexual drives subjects himself to a bodily and psychological experience in avoiding the transitional space of sleep. The consequences of insomnia (fatigue, achiness, awaking during the night, and obsessive behavior to ward off sleep and anxiety) are part of this experience.
Our study is based on questionnaires including the Insomnia Severity Index [20,21], the Flinders Fatigue Scale  as well as projective methodology, outlined in an article to be published . It leads us to consider adolescent insomnia as a manifestation of aggressiveness that is impossible to express in words and that risks evolving into destructiveness. Using clinical interviews and projective methodology, we explored in depth certain intrapsychic conflicts and in particular, the way aggressiveness is expressed. The exploratory study highlights specific psychical organizations shared by subjects in spite of diverse functioning on other levels. Hypervigilance, seeking control over the object, conflict avoidance-in particular conflicts involving identification-and expressing instincts either in a very uninhibited (with the risk of disorganization) or a very inhibited way, are shared characteristics. An in-depth case study shows how insomnia can be a way of combatting depression and the experience of passivity.
The significant but necessary psychical reorganization typical of adolescence triggers in teens the need to feel alive by seeing themselves through the eyes of others but also by persuading themselves that they exist. They must ward off the insecurity of neither completely belonging to the other nor being totally outside of the family, and also avoid feelings of nonbeing. Ph. Jeammet  posits that the narcissistic-object gap generates violence and even self-sabotaging behaviors, often silent but powerful.
Winnicott  illustrates how dream life can hold aggressiveness. In children, dreams can provide a constructive space for working through fantasies of destruction and murder [19,26]. Given the importance of dreams in the process of working through violent fantasies, what happens when dream activity is impeded? Dream activity transforms raw sensory materiel into unconscious elements that are linked together to produce the unconscious imagery of the dream. W.R. Bion  proposed a model for this transformation of raw sensory impressions into emotional experience. Using this theory, T. H. Ogden  distinguishes different types of dreams. Certain dreams (including nightmares) support psychical working through whereas others, that he calls “nondreamed dreams” that do not generate psychical working through.
Listening to adolescents complaining of insomnia leads us to understand that nonexpressed, destructive aggressiveness hinders falling asleep, alters the quality of sleep and prevents dreams that could contain this violence. Thus, the aggressiveness turned against the self can make it difficult to give in to sleep. Giving in to sleep implies regression and a lowering of vigilance, letting worries and anxieties rise to the surface. According to the Freudian model, regression and lowered vigilance allow preconscious thought to take over. Fear of solitude can reduce REM sleep and obstruct access to dreaming. The intrapsychic conflicts that often generate anxiety cannot be resolved and daily events cannot be processed, generating a risk of psychical imbalance. The discharge function described by Freud also seems hampered, creating the risk of traumatic overflow. Following Winnicott’s model, if the capacity to dream is inhibited then so is the capacity to invest new objects. D. Houzel  highlights the link between dream paucity and a heightened risk of academic failure, loss of short-term memory, lack of discernment and comprehension difficulties. We can see a vicious circle emerge: when sleep, and therefore dream activity, is hindered, irritability and depression increase, it becomes difficult to concentrate and vigilance is decreased. The insomniac can develop depressive disorders .
The more the aggressiveness is destructive, the more difficult it is for the adolescent to put it into words. The silent accumulation of this aggressiveness leads to turning it against the self as in melancholic depression [13,31,32] and deadly isolation or a violent discharge in acting out. When the adolescent feels aggressive impulses along with anxious affect or when confronted with aggressive scenes, he may more or less unconsciously feel the threat of death because he cannot acknowledge or tolerate this potentially destructive aggressiveness. In Greek mythology, Hypnos, the god of Sleep is the twin brother of Thanatos, the god of Death. Both are the sons of Nyx, the Night. Throughout the ages and across cultures, the connection between death and sleep reveals the fear of disappearing during sleep. The word “cemetery” comes from the Greek “koimêtêrion” which means “place where one sleeps”. Could teens experiencing difficulty falling asleep unconsciously confuse the bed and the grave? When one fears slipping from sleep to death, it is difficult to relax into the arms of Morpheus, who is the god of Dreams but also the son of Hypnos and the nephew of Thanatos. It may indeed feel threatening to fall into these arms. Perhaps like the parental arms that once held the child and that where not sufficiently welcoming and reassuring? If sleep is not perceived as safe and welcoming, the intimate confrontation with the self that happens in the silence of the night is frightening. The obstacle to sleep could signal, on a deeper level, the fear that Thanatos will replace Hypnos [33-35].
This research was supported in part by Grantsin- Aid of TMDU Society for Psychiatrists.
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