Dr. Michael DeSanctis, PhD, LP, ABPP, DBSM
This is a commentary on the sleep issues presumed to exist among a very neglected and ignored sub-population in America: the many tens of thousands of our citizens struggling to survive on the street and leading nomadic existences in the shadow of our economic mainstream.
Until recent times, sleep disorders have traditionally been off the main radar in primary care, but academic and research efforts have pushed sleep health into the mainstream of health service delivery. On the other hand, data analytic research on evaluation and treatment of sleep disorders in the homeless is relatively scarce. There are a few studies in the scientific literature, in part because this group of souls is hard to study – for obvious reasons. Not only are the homeless nomadic, but they are understandably leery of any authority or institution attempting to identify them, and examining their sleep and waking habits. Utilizing randomized control designs of any meaningful sample size would be very difficult to implement.
Achieving and maintaining restorative sleep is clearly an elusive and inconsistent process for the homeless – this adds to disparities and differences in health outcomes given sleep’s pivotal role as a pillar of good physical and mental health. Two recent studies examining sleep trends in this sub-population include Gonzalez & Tyminski, (2020) and Leger, Beck and Richard (2017). The latter survey, conducted with a sample of several thousand homeless and/or sheltered populations in France, indicated significant levels of daytime fatigue and sleep disturbance and as one would expect, homeless folks reported diminished total time asleep, signaling cumulative sleep debt. The Gonzalez & Tyminski (2020) survey and self-assessment from a small sample of homeless people in America suggested higher levels of diurnal fatigue and sleep disturbance associated in part with a perceived loss of control over one’s circumstances and self-medication with street chemicals.
Living on the streets or spending brief intervals in homeless shelters means dwelling in unpredictable risks amid the constant need for vigilance and protecting personal and family member’s safety and property. Nocturnal life in shelters is brimming with chaotic interactions of strangers-a community in constant flux with the only norms imposed by shelter or community requirements and regulations.
The homeless person, beleaguered by a train of adverse life exposures, is at high risk for compounding PTSD, with inevitable disruptions of sleep due to nocturnal hyperarousal, restless leg, nightmares, flashbacks and hallucinatory phenomena. The precarious sense of shelter and short-lived comfort lend themselves to further conditioning of fear and anxiety. Upheavals occur daily and randomly. There is no psychological or physical grounding, a fundamental element of trauma healing in human beings.
Sleeping in the streets, in abandoned vehicles, tents, or on roadsides underneath highways means one is at the whims and caprices of noise and commotion created by local trade and business activity, including abrupt and unceremonious highway construction, traffic, pedestrian movement, aircraft or recycling/trash collection efforts. Any attempt to maintain a stable internal clock is usually in vain. Reliable wristwatches may be a luxury, so a homeless person may have to gauge time from solar, not local clock cues and perhaps miss out on scheduled shelter or food donation programs.
So, the homeless are not only hungry, hyperalert and on the move, they are perpetually depleted, with reduced situational cognitive and working memory functional capacity. Dr. Van der Kolk (2014) in his seminal volume on trauma, The Body Keeps the Score, discussed how chronic trauma exposure undermines self-understanding and interferes with executive decision making. The homeless are vulnerable to re-victimization or exploitation, fueled by states of learned helplessness and adaptational exhaustion. Motivation falls by the wayside.
Even those fortunate enough to secure shelter for more than a night or two will find restorative sleep elusive. By sleeping on cots, being jammed into a large building, exposed to some degree of illumination all night, one’s personal space can be invaded at any time. Curfews may be imposed by community shelters, but in this crowded, non-partitioned environment, with few physical boundaries, unsettling arguments, yelling and loud conversation may persist well into the night. Good sleep habits solidify only when one’s environment can be reasonably constant for an extended period of time.
Clearly, any medically pertinent sleep issues, such as apnea, narcolepsy, or REM enactments, are left to languish; access to other than emergency care is diminished and there are no remedies found among the street pharmacopeia. THC may provide some temporary mitigation of anxiety or may dull the senses, and stimulant use might energize someone for a short time but inevitably these are dead ends to feeling better and moving out of the homeless space. This population has a relatively high proportion of mental illness and substance dependence/abuse at baseline.
Sleep deprivation, lack of routine and erratic sleep-wake cycles add to a sense of confusion, disorientation, and a sense of purposelessness. Chronically disrupted internal circadian rhythm increases the risk of metabolic and inflammatory conditions, as well as adverse cardiovascular outcomes. Internal clock time, local clock time and solar time are frequently misaligned, to the detriment of one’s well-being.
Unfortunately, the homeless problem remains at disturbingly high levels, despite local and Federal resources allocated to communities and the tireless and yeoman efforts of volunteers and aid agencies. Rising rates of eviction, climate-induced displacement from one’s home or apartment, job loss, downward mobility in an increasingly digitized electronic society and the economic impacts of physical and mental illness, all promote despair and disconnection from the mainstream. Clinical depression and sleep disturbances, especially Insomnia, go hand-in-hand. The dismal circumstances of the homeless, the loss of decision-making capacity, trauma-induced anesthesia, and cognitive distortions emanating from chronic sleep debt, together erode resilience and undermine well-intentioned efforts by others to provide stable housing, job training, medical care, mental health therapy and education. This missive weighing in on sleep was intended to highlight one dimension of the multi-faceted health challenges facing the disenfranchised citizens of this country and globally.
Gonzalez, A. & Tyminski, Q. (2020) Sleep deprivation in an American homeless population. Sleep Health, 6(4)489-494. Published 2/13/2020 DOI:https://doi.org/10.1016/jsleh.20202.01.002
Legar, D., Beck, F, & Baptiste, J.R. (2017). Sleep loss in the homeless-An additional factor of precariousness. Survey in a group of homeless people. JAMA Intern. Med, 177(2), 278-279. Doi:0.1001/jamainternmed.2016.7827
Van der Kolk, B. (2014). The Body Keeps the Score. New York, NY: Penguin Books.
Dr. DeSanctis’s blogs are created for educational purposes only and are not intended to replace the reader’s consultation with his/her/their health care provider.