One of the most well-known works about sleep is the booklet published by Elizabeth Mitler and Dr. Merrill Mitler. Done in a simple question and answer format, the booklet is entitled 101 Questions About Sleep And Dreams. Talk About Sleep is pleased to offer you the entire text of this material for your use and continuing self-education about sleep.
By William C. Dement, M.D., Ph.D.
Director, Sleep Disorders Clinic and Research Center
The five billion people living on earth go through the cycle of sleep and wakefulness at least once every 24 hours. Sadly, many, many of these people do not know the joy of being fully rested and alert after their sleep. The alternation of wakefulness and sleep is one of the most fundamental aspects of the human condition.
However, it is only recently, with the advent of highly technological societies, that poor sleep and substandard levels of wakefulness have been of real interest to humans. Over the past eons of time, natural selection may have been gentle on prehistoric people who slept poorly. The major killers and shapers of evolution were war, natural enemies and pestilence. These factors were much more influential in deciding who lived to conceive and care for children than were such disorders as sleep apnea. However, the main causes of death now are very different than in prehistoric times.
As we look forward to the 21st century, alertness during the day that comes from healthful rest during the night can be a major life-or-death matter — not only for individual people, but also for whole populations. We know that most heart attacks and strokes occur during sleep or just after waking up.
Studies indicate that the near cataclysmic nuclear accidents at Chernobyl and Three Mile Island were easily avoidable and began when nightshift workers missed or were confused by warning signals on their control panels. Other studies show that nightshift workers get very irregular and poor sleep and, accordingly, have the most difficulty staying alert for long periods of time. In our present society, it is clear that poor and unhealthful sleep can lead to lethal medical and industrial catastrophes. What can we do?
Since about 1953, scientists have been gathering practical knowledge about how we sleep and what can be done if we do not sleep. Much is already known that was not even imagined twenty years ago. For example, sleep is not always safe or good. Alcohol can destroy restful sleep. There are two periods in the 24-hour day when accidents are most likely to occur and these are the two periods when the human body is physiologically most ready for sleep.
This booklet, in a simple Question and Answer format, leads us through the fascinating story of sleep by posing and answering the most common questions about sleep and dreams. The Mitlers’ answers are faithful to solid scientific fact, yet as easy to understand as the daily newspaper. Earlier editions of 101 Questions About Sleep and Dreams have been widely read by people with sleep problems, interested lay people, and as assigned reading for high school and college students. Truly, no home should be without a copy of ‘101 Questions’.
Sleep and dreams have captured the imagination and interest of man since recorded history. Modern science has discovered much about what goes on when we sleep and the effects of sleep loss.
The National Commission on Sleep Disorders Research reported to The United States Congress that approximately 40 million Americans suffer from chronic problems with sleep and wakefulness, 20 – 30 million people experience intermittent sleep problems, and millions of others obtain inadequate sleep as a result of their work schedules or lifestyles.
The consequences of these sleep problems are increased risk of sickness, accidents and death as well as decreased quality of life. It is for these reasons that the National Institutes of Health established The National Center for Sleep Disorders Research. The Center funds research on sleep and sleep disorders, disseminates information about sleep to the public and fosters improved communication between governmental agencies on policy issues that relate to sleep and sleep disorders.
Imagine trying to stay awake for 24 hours straight. Dr. Mary Carskadon and her colleagues asked a group of people to do just that and found that they failed to stay awake 278 times. Here is when, according to the twelve consecutive 2-hour intervals throughout the day, those 278 unwanted naps happened.
The numbers on the vertical axis refer to the number of naps that occurred in each of the 2-hour intervals. The timing of these naps shows when the biological tendency for humans to fall asleep is the greatest.
Now look at 437,511 times of death from a large series of death certificates of people who died from medical conditions, such as heart disease and cancer. The numbers shown on the vertical axis refer to thousands of deaths. It is easy to see that the peak times when people succumb to disease seem to coincide with the peak times for sleep.
The timing of 6,052 unexplained traffic accidents indicates that there is also some relationship between sleep and other types of problems. The numbers on the vertical axis refer to hundreds of accidents. These accidents were collected from studies around the world and are the kind in which investigators could find no drug, alcohol or mechanical problems.
Because sleep influences such fundamentally important aspects of our lives as resistance to disease and safety on the roads, all sorts of people ranging from students, to doctors, to public policy makers are asking many questions about sleep. How does someone become familiar with the important personal and public health issues involving sleep?
The story of sleep and dreams is long and complicated. This book, however, succinctly answers the most commonly asked questions about sleep and dreams. Just a glance through ‘101 Questions’ will let you see why it has become one of the most popular books on the subject of sleep. Read all over the world, ‘101 Questions’ is also available in the German, Greek, Korean and Spanish languages.
The questions are organized in a logical manner that introduces the most important concepts of modern sleep research and underscores the challenges to modern society presented by man’s biologic need for sleep. The answers are brief and understandable. The information in this book will satisfy natural curiosity as well as suggest sensible courses of action for those with sleep problems.
Readers who find that they want more information than is offered will be referred to web sites on the world wide web and several more advanced texts on the subject of sleep, sleep disorders, shift work and dreams.
Chapter 1 – Normal Sleep
Sleep is a behavioral state characterized by little physical activity and almost no awareness of the outside world. Most scientists think that sleep does something important — something vital for life, although research has not yet identified the purpose for sleep. Nevertheless, we all know when we need to sleep — we can feel this need. We also know when sleep has done its work — we feel rested and that we have slept enough. Another important feature of normal sleep is that it can end quickly. Although a sleeper may appear to be unconscious; unlike someone who is actually knocked-out, anesthetized or in a coma; a sleeping person can be easily awakened and can resume normal waking activity within a minute or two.
Sleep is an active, highly organized sequence of events and physiological conditions. Sleep is actually made up of two separate and distinctly different states: ‘non-rapid eye movement sleep’ (NREM sleep) and ‘rapid eye movement sleep’ (REM sleep) or dreaming sleep. The NREM and REM types of sleep are as different from one another as both are different from wakefulness.
NREM sleep is further divided into stages 1 – 4 based on the size and speed of the brain waves generated by the sleeper. Stages 3 and 4 of NREM sleep have the biggest and slowest brain waves. These big, slow waves are called delta waves and stages 3 and 4 sleep, combined, are often called ‘slow-wave sleep’ or ‘delta sleep’.
During REM sleep you can watch the sleeper’s eyes move around beneath closed eyelids. Some scientists think that the eyes move in a pattern that relates to the visual images of the dream. We are almost completely paralyzed in REM sleep — only the heart, diaphragm, eye muscles and the smooth muscles (such as the muscles of the intestines and blood vessels) are spared from the paralysis of REM sleep.
Doctors have tried to determine what type of sleep is the deepest sleep. To do this, they measure how much noise or other alerting stimulation is required to awaken a sleeper from the various types of sleep. It is always possible to awaken someone who is sleeping, as opposed to, say, someone who is in a coma. However, people in stages 3 and 4 sleep require the most stimulation to awaken. Therefore, this phase of sleep is often thought of as ‘deep sleep’. Also, large spurts of growth hormone are secreted during stages 3 and 4 NREM sleep. Consequently, these stages of sleep are thought to restore the body from the wear and tear of waking activity. People in REM sleep also tend to be quite difficult to awaken, but this finding is variable — sometimes even the slightest noise can awaken a person in REM sleep. Nevertheless, because it is often difficult to awaken a person from REM sleep, many doctors think also of REM sleep as a ‘deep’ phase of sleep.
There are many theories about the function of REM sleep and dreaming — ranging from ‘safe, socially acceptable, wish fulfillment’ to ‘consolidation of memories’ to ‘providing necessary stimulation to the entire nervous system during development’. Researchers used to think that REM sleep was necessary for normal psychological function, because experimental REM deprivation caused some subjects to behave strangely. The notion that we need REM sleep for our mental health is not accepted now, because, among other reasons, people have uneventfully withstood long and almost complete REM deprivation. Some experiments have shown that REM deprivation improves depression. However, REM sleep must still do something, because rats will die after 2 – 3 weeks if they are deprived of REM sleep by a special experimental computer that wakes them up each time REM sleep is achieved. Whatever REM sleep does, it is clear that every aspect of existence from the body’s manufacture of proteins to sexual arousal, including orgasm, is influenced by REM sleep. It is likely that the ultimate explanation of REM sleep will be very broad — not simply focused on one physiologic function.
The chart below is called a hypnogram. Hypnograms are made to summarize sleep laboratory recordings. This particular hypnogram shows how a typical night’s sleep for a young, healthy adult is organized. Notice how the night is structured into the various stages of NREM sleep alternating with REM sleep, with most slow-wave sleep occurring in the first part of the night and most REM sleep occurring in the last part.
We sleep because we get sleepy and we cannot work if we get too sleepy. That is the simplest and yet the most profound answer to this question. The scientific truth is, however, that we do not yet know why we get sleepy. We know that all mammals as well as some birds and reptiles sleep. Many doctors think sleep comes in order to get rid of certain chemicals that build up in our bodies during the day’s activities. Brain research in the 1960’s and 1970’s has identified several molecules involved in cell-to-cell communication within the brain as being important for sleep. More recent work has isolated products of the body’s immune system that seem to be sleep-inducers.
However, feeling sleepy is not the whole story. Some timing mechanism is also involved. We know that every living thing composed of cells with a nucleus has a daily cycle of activity and inactivity (if not actual wakefulness and sleep). The timing and control of the wakefulness-sleep cycle depends on one or more biological clocks in our bodies. These clocks are sensitive to light and have evolved over the ages in close approximation to the 24-hour light-dark cycle of our world. Thus, sleep seems to be an unavoidable part of human behavior. In humans, sleep is physiologically programmed to come each day, either in one long bout (about 6 – 8 hours each night) or in two shorter bouts (a 5 – 6 hour sleep at night and a 1 – 2 hour nap in the afternoon). The timing of sleep and wakefulness is controlled to a great extent by our exposure to the natural light and dark cycles of the earth. All humans tend to sleep in the dark and move about in the light. It takes the human body several days to change to a different light-dark schedule such as when one flies from New York to New Dehli. In fact, the influence of light on the timing of sleep is so powerful that doctors are now using exposure to bright light as a treatment to reset the sleep clock of people who have somehow disrupted their schedule.
In the extreme, sleep does seem to be necessary for life. Experimental rats die if they are completely deprived of sleep for longer than 1 – 4 weeks. However, do not worry. The experimental deprivation was done by means of special computers and alarm systems — it is not possible for even the poorest of human sleepers to lose so much sleep that life is threatened.
There is no ‘normal’ amount of sleep. The average amount of sleep for adults is 7 – 8 hours. But the range of nighttime sleep duration must be expanded to between 6 – 9 hours in order to include the large majority of people. Therefore, a few people feel fine with as little as 5 hours of sleep, while others require more than 10 hours to feel refreshed and alert throughout the day. The amount of sleep you need is that optimum amount which allows you to function throughout the day without feeling drowsy when you sit quietly and try to pay attention to something.
We cannot, for very long, force ourselves to sleep much less or much more than this optimum amount. Several nights of sleeping an hour less than our usual amount will leave us sleepy and ineffective in the day. Conversely, several nights of staying in bed and trying to sleep an hour more than our optimum amount will leave us sleeping poorly with more awakenings — particularly in the early morning. Doctors believe that the optimum amount of sleep each person needs to remain alert during the day is biologically different from person to person. To a great degree, our optimum sleep need is determined by heredity. Scientists have found, for instance, that strains of mice can be selectively bred to sleep considerably more or considerably less than the average mouse.
Probably not. It seems that during infancy and in adolescence there are increases in sleep need, perhaps brought on by developmental changes. However, the best research available indicates that healthy elderly people sleep about as much as they did when they were young adults. The common belief that the elderly sleep less probably comes from the fact that elders often have medical conditions that interfere with their sleep. This is why most elderly people are ‘light sleepers’ at night, yet they frequently dose-off during the day.
This type of light sleep and dozing pattern is what sleep researchers would expect if a person is awakened again and again while they try to sleep. In fact, research on repetitive sleep disruption, called ‘sleep fragmentation’, has shown that the rate of sleep disruptions determines whether or not the sleep is felt to be satisfactorily restorative, and whether or not there is proper alertness the next day. These kinds of studies show that disruptions every minute will greatly reduce the restorative value of sleep. However, disruptions every five minutes will affect restoration much less — even when total sleep time is the same for the one-per-minute and five-per-minute rates of disruption. Thus, scientists believe that for refreshing sleep, it is not just the total amount of sleep that is important. Sleep must be continuous as well.
Most vertebrate animals exhibit yawning. A yawn consists of widely opening the mouth with a slow inspiration at the beginning and a quick expiration at the end. Yawning is a reflex behavior that can be only partially controlled by our own volition. The behavior occurs most often when we feel sleepy, bored, and, perhaps, physically fatigued. Yawning can also be triggered by drugs and has been used as a medical index because there are changes in the frequency of yawning in certain disease states. Scientists have not identified a function of yawning, but, at least in humans, it does seem to be contagious since observers are more likely to yawn when they watch someone else yawn. In this sense, yawning is a type of social behavior that is largely involuntary and controlled by the brain.
People sleep best when they are comfortable, physically and mentally. There is no universal formula for physical and mental comfort. It is best to explore bedroom temperature, mattress, bedclothes, etc. until you find bedroom conditions under which you feel that you sleep the best.
Similarly, there is no single ideal sleeping position. Most people move through many sleeping postures in the course of a normal night’s sleep. Scientists think such movement is good because it prevents pressure-related restriction of circulation. However, conditions such as pregnancy, arthritis and other medical conditions will obviously exclude certain sleeping positions with no ill effects. Furthermore, avoiding some sleeping postures can be helpful. For example, people with breathing problems associated with airway obstruction breathe irregularly and sleep poorly when lying on their backs. Such people often sleep sitting-up as a matter of preference until the condition is effectively treated.
Yes, we can make up for lost sleep, but only to a certain extent. Suppose a man, who usually sleeps 7 hours a night, loses 2 nights of sleep. He will not sleep 21 hours (14 hours longer than usual) on the third night, when he is able to sleep. After significant sleep loss, we may have more slow-wave sleep for the next couple of nights, but we rarely sleep more than 2 – 4 hours longer than usual. This is because our wakefulness-sleep cycle depends on both our sleep need and our internal timing mechanisms. Furthermore, experiments with shift work have shown that people who stay awake for a single night and then go to bed at 8 AM, instead of their usual 11 PM, will not simply move their normal sleep to an interval 9 hours later. Rather, their sleep beginning at 8 AM will be shorter and more broken because it is occurring at a biological time when activity usually occurs. This inability to sleep during certain periods of the day is due to the alerting influences of the biological clock located in the brain’s hypothalamus. What our ancestors previously thought of as a ‘second wind’, is now understood by sleep scientists as clock-dependent alerting. It is because of complex interplay between sleep deprivation and clock dependent alerting, that sleep losses or shifts in sleep time will have effects for several days.
The figure illustrates this interplay and shows over a period of 48 hours, a two-peak pattern for each day. There is a period with markedly increased sleep tendency in the early morning hours between 3 and 6 AM and a smaller but reliable afternoon peak between 1 and 3 PM. This is the so-called siesta effect or afternoon slump. Both periods of increased sleep tendency can be exaggerated by sleep promoting factors such as alcohol consumption and sleep deprivation. Errors and reduced productivity peak at the times of maximum sleep tendency.
Certain cultures use the siesta very successfully. However, siesta cultures are relatively consistent in napping. In most western cultures, napping is not consistent day after day. If you want to nap, nap at the same time each day and for the same duration, particularly if you are prone to insomnia. Many people complain about Sunday-night insomnia. What usually happens in these cases is that the person napped on Sunday from, say, 2 to 5 in the afternoon and then could not get to sleep at the usual time Sunday night. That is why keeping a consistent schedule is the best strategy.
With respect to occasional napping, one important advantage is that even a 30 – 60 minute nap greatly helps a person counter sleep loss. Studies have shown that the first hour or so of sleep is most potent in relieving the effects of missing a night’s sleep.
Meditation probably will not affect sleep in any significant way. In its most common forms, meditation involves the practice of sitting in some prescribed position with the eyes closed and ‘saying’ (either audibly or only mentally) a prescribed word or set of words, called mantras. There are a variety of meditation techniques that are taught by trained individuals for the purpose of improving waking functioning as well as spiritual and physical well-being. These meditation techniques are also claimed to have various effects on sleep such as ‘improving sleep’, ‘reducing the need for sleep’ and being an ‘alternative to sleep’. However, scientific studies on meditators have found that most meditation is characterized by the brain wave pattern of quiet, relaxed wakefulness with occasional bouts of NREM sleep. Thus, the best current studies suggest that any meditation-related shortening of nocturnal sleep probably occurs because the meditator is getting daytime sleep (i.e. is napping) during the act of meditation. There is no evidence that meditation will reduce a person’s overall need for sleep.
No. There is no study that shows efficient learning during sleep. The brain needs to be awake in order to learn, as learning is usually defined. When new information is presented to someone while they sleep, the amount of information that they remember the next morning depends on how long and how many times they were awake during the night — not on how well they slept.
The answer is yes, but only partially yes. The experience which we would all agree constitutes dreaming involves a good deal of action and several senses such as vision, hearing and touch. This type of experience occurs most often in REM sleep.
Here is why the answer is only partially yes: First, some dreamlike experiences can occur during other phases of sleep besides REM sleep. Second, REM sleep cannot really be considered our ‘deepest sleep’. The depth of a particular phase of sleep is best defined in terms of how difficult it is to awaken someone when they are in that particular phase of sleep. What phase of sleep requires the loudest noise, for example? The two phases of sleep that are ‘deepest’ — that is the hardest to wake up from — are ‘slow wave sleep’ (stages 3 and 4 of NREM sleep combined, is called ‘slow wave sleep’ because of the big, slow brain waves seen then) and REM sleep. Dreams rarely occur in slow wave sleep and frequently occur in REM sleep.
The basic physiology of human sleep does not seem to vary much from race to race or culture to culture. However, there are effects of culture and climate. For example, many equatorial cultures have the institution of an afternoon siesta which breaks sleep into a short afternoon bout and a longer nighttime bout. People in siesta cultures seem to sleep about the same amount as those in other cultures. There also are studies showing profound seasonal changes in sleep. The largest seasonal changes occur in the polar regions, where there are great changes over the year in the length of the light interval in the day with long light periods increasing the tendency for the daily schedule to have two sleep bouts.
There seems to be no direct effect of body size on sleep. Assuming that the length and width of the sleeping surface is of appropriate dimensions, small people sleep just as much as, and just as well as, large people of comparable ages. However, if body size restricts the normal body movements during sleep or the ability of the diaphragm to move during respiration, such as is common with extremely overweight people, then sleep can be profoundly disturbed.
Here are ten sensible rules for a good night’s sleep:
- Stick to a regular schedule of going to bed and getting up at the same time every day.
- Be consistent about taking naps: Take one every afternoon or none at all. People who take a nap once in a while usually find they do not sleep well that night.
- Exercise regularly in the morning or early afternoon, but do not engage in strenuous physical activity just before bedtime.
- Stay away from drinks containing caffeine after about 4 PM.
- Avoid alcohol after the dinner hour. Instead of promoting sleep, a nightcap actually disturbs sleep patterns and can cause early morning awakenings.
- Be careful about sleeping pills. Under most circumstances, these medications should not be taken for more than four weeks. Longer use leads to increased insomnia.
- Find the right room temperature for you and maintain it throughout the night.
- Try to relax before going to bed: Take a warm bath, read a light novel, listen to music, avoid stressful thoughts.
- Do not eat heavily just before going to bed.
- If you cannot sleep at night, do your best to preserve your usual 24-hour cycles of activity-rest and exposure to light and dark. For example, do not get up, turn on bright lights and read or exercise. It is best to remain reclining in the dark and listen to music or an audio book.
Chapter 2 – Dreams
15. Q: I never dream. Am I abnormal? Will I go insane if I do not dream?
As far as scientists know, everyone dreams but some people do not remember their dreams. Because they do not remember, they believe that they do not dream. Not remembering dreams is no cause for concern.
For most people who have their principal period of wakefulness during the day and their principal period of sleep at night, NREM sleep starts the night off and alternates with REM sleep every 80 – 100 minutes. It is during REM sleep that the thought patterns we know as dreaming occur. People in sleep laboratories — even those who say they never dream — do remember dreams vividly, provided that they are awakened during a REM sleep period. Under these special laboratory circumstances, the sleeper can recall much more of the action, color and sensations of a dream than they can when they wake up in the morning.
There is no reason to think that someone will go insane if they do not dream. It is true that some early experiments on deprivation of REM sleep led to temporary personality changes in volunteer subjects. However, today doctors use certain drugs and procedures because they reduce the time spent in REM sleep. Such treatments are effective for depression and certain medical problems that get worse during REM sleep.
The reason we dream is unknown. However, dreaming is an integral part of sleep and appears to be unavoidable. Scientists have many possible explanations of why we dream. Dreaming, for example, may provide necessary stimulation to the brain from within the brain itself, thereby compensating for the loss of stimulation from the environment that is all-but-eliminated while we lie in bed asleep. Many psychiatrists and psychologists think that dreaming may be a safe and socially acceptable way to fulfill our wishes and desires. Specialists in learning have done experiments showing that dreaming is important for transferring what we have learned during wakefulness from short-term memory to long-term memory thereby allowing us to remember things for years and years. This transfer may be accomplished within brain cells by the manufacture during dreaming sleep of special protein molecules. Other scientists such as the Nobel Laureate, Francis Crick, think that dreaming may activate groups of brain cells in certain combinations and sequences in a way that does not occur during wakefulness and thereby help us remain flexible in our behavior and thought.
The drawing shows a cut-away view of the human brain with lines pointing to the various locations involved in sleep, biological timing, and dreams. Two important areas for promotion of sleep are the forebrain and pons. The biological clock is situated in the hypothalamus. The stimulation we know as dreaming comes from other areas in the pons. There are also other areas in the pons and the medulla that cause and maintain the muscle paralysis of REM sleep. Damage to these muscle paralysis areas can cause humans and animals to act out their dreams.
Whatever dreaming actually does, the sleep in which dreaming occurs, REM sleep, seems to be necessary for life itself. Experiments in rats that were automatically awakened just as they began to have REM sleep found that life cannot continue after complete REM sleep deprivation for longer than 1 – 2 months. For this level of REM sleep deprivation, very special equipment is required that detects the particular brain wave patterns of REM sleep and then causes an awakening. These experiments should not frighten people who think they are getting little REM sleep. The extremes of REM sleep deprivation created in the rat experiment are not possible in humans, even when sleep is very disturbed.
During REM sleep, our body is almost completely paralyzed. The heart and other automatically controlled muscles still function, but our head and limbs really cannot move very much. Also during REM sleep, there is intense stimulation getting to those parts of our brain that interpret what we see, hear and feel. However, this stimulation is coming from within the brain itself. And, the stimulation is occurring at a time when the muscles we use to move about and orient our eyes and ears to stimulation are inoperative. Even under these conditions, our mind does its job and tries to make sense of what it ‘sees, hears and feels’. Our mind ‘making sense’ of stimulation coming from inside the brain, while our muscles are paralyzed, leads to the bizarre experiences we know as dreams. Doctors believe that many common features of dreams stem from the physiological paralysis that occurs during REM sleep. For example, many people dream about falling, being unable to get away from a pursuer or being unable to move fast enough to prevent some accident. All these kinds of dreams have the common feature of movement impairment which may stem from the brain’s recognition of paralysis during REM sleep.
18. Q: I have the same horrid dream every night that someone close to me is going to be killed. Is this a premonition — will it happen?
No one can answer this kind of question with certainty. Many doctors believe that the subject matter of dreams can reveal important information about the way we think and feel. People who frequently have disturbing dreams may have a psychological problem that requires professional attention. Repetitive nightmares involving a constant frightful theme are usually a sign of psychiatric or psychological problems. This is a rather common phenomenon in combat veterans, for instance. Such patients may be treated with medications that block REM sleep, which is when nightmares occur.
Many people believe that we can solve problems during dreams. The uniqueness of REM sleep as a behavioral state has suggested to some doctors that REM sleep may enhance powers of the mind. There are many stories of dream-like mentation during sleep suggesting solutions to problems in waking life. The great chemist, Friedrich August Kekulé von Stradonitz told of a dream that gave him a mental image leading to the correct molecular structure of benzene — a ring of six carbon atoms joined together by double bonds. Kekulé’s dream was of the ancient alchemist’s symbol known as Ourobouros — the self-devouring snake which is drawn as a spiny-backed serpent with a dark-colored head biting its own light-colored tail. The dream’s symbolism was on-target. It easy to see the relationship between a snake biting its tail and a ring. But also, ancient alchemists used Ourobouros to represent the unity of nature, and benzene can be viewed as a unifying compound since the benzene ring is a component in the molecular structures of over two-thirds of all known organic chemicals!
There are also experiments showing that patterns in dream content can predict the degree to which women will cope with the loneliness and frustration stemming from a life crisis. Dreams with themes of independence and self-reliance, on the one hand, correlate well with successful resolution of troublesome situations such as a divorce. Dreams with themes of dependency and helplessness, on the other hand, correlate well with unsuccessful resolution of such situations. These kinds of phenomena may very well be at the root of the age-old advice for someone with a problem, ‘sleep on it’.
20. Q: I have read that dreams have meanings beyond the things we remember when we awaken. Is this true?
Yes. Some psychiatrists and psychologists have specialized training in dream interpretation. By careful review of someone’s dreams, these trained doctors can learn much about the person’s personality, as well as gain insight into what problems are being faced and how well the person is coping. In this respect, doctors use dreams in the same way they use Rorschach ink-blots and other projective tests.
The original term means ‘a dream in which there is an ejaculation of seminal fluid’. Many males report dreams involving sexual arousal and orgasm prior to awakening and finding seminal fluid in their pajamas or on the bed. Sometimes there is no dream recall at all, just evidence of an ejaculation. The term ‘wet dream’ is sometimes applied to a similar phenomenon in females. At least one third of all women experience orgasm during sleep. Many others experience awakenings from a dream to find vaginal wetness. As with males, there may also be no dream recall, just secretions. Such experiences are not abnormal, but can perplex, or even upset, young boys and girls on the verge of sexual maturity. Even though they may have been taught about human sexuality, without an understanding of the physiology behind these sleep-related experiences, there may be unwarranted disturbance and concern. The reason for ‘wet dreams’ is that during REM sleep there is intense activity in areas of the brain that control the autonomic nervous system. Heartbeat and breathing, for example, can be quite irregular during REM sleep. In the course of the autonomic activity of REM sleep, there is normally an activation of the erectile system of the penis and the secretory and erectile systems of the vagina. In some cases, the self-stimulatory activity of REM sleep may also lead to the an orgasm and an activation of the ejaculatory system in males.
Chapter 3 – Sex
22. Q: My bedpartner’s penis sometimes gets erect when he sleeps. This happens even after we have had sex. Does this mean he is not satisfied or wants someone else?
Males normally have erections (penile tumescence) during their sleep. The erections come 4 – 5 times a night about the time when dreaming or REM sleep occurs. As far as scientists know, the subject matter of the dream does not predict whether or not there will be an erection. The erections are a normal part of REM sleep for males of all ages. Doctors may record the circumference of a man’s penis all night long to check for the presence, size and duration of erections. Such erections are called episodes of Nocturnal Penile Tumescence (NPT). It is now recognized that erectile dysfunction (impotence) may be caused by a variety of physiological conditions – such as damage to the nerves that regulate blood flow into the penis. NPT recordings may be done to determine, independent of psychological factors, the extent of a man’s erectile capability. This information can be used to select from the many treatments now available for erectile dysfunction, including, but not limited to, sildenafil (Viagra).
The relationship between REM sleep and erections is also the reason that men frequently wake up in the morning with an erection without having the desire to engage in sexual activity. There is a commonly held, but incorrect, belief that morning erections are due to a full urinary bladder. This belief really makes no sense. For example, men do not get erections during the day before urination. The correct explanation for morning erections involves the way nighttime sleep is organized. We have most of our REM sleep in the early morning, usually between 4 – 7 AM. Therefore, each morning we are very likely to awaken directly from REM sleep or, at the very least, soon after a long morning REM period has ended. Thus, men are very likely to awaken in the morning with a REM sleep-related erection.
There does seem to be a female counterpart to penile tumescence during REM sleep. A number of studies indicate that vaginal and clitoral swelling do occur during the night in about the same time relationship to REM sleep as has been observed for penile erections in males. There are also reports that vaginal secretions increase during REM sleep. Moreover, there are reliable data showing that the rate of contractions of the uterus is highest during REM sleep and lowest during slow wave sleep. Doctors are now working on ways to use recordings of uterine contractions during sleep in their clinical evaluations of female sexual function, just as they use NPT in evaluations of male sexual function.
Yes, at least, sex seems to help men sleep. Many men report that they use orgasm, either through sexual relations or masturbation, to aid in falling asleep. In male rats, there is an active inhibition of sexual behavior following ejaculation. During this period, the male rat emits an ultrasonic vocalization and the rat’s EEG shows sleep-like activity. For women, the effect of sexual activity and orgasm is unpredictable. Many women report that sexual activity is alerting, rather than relaxing. Scientists have observed that, in female rabbits during their sexually receptive phases, sleep is increased after sexual intercourse with a male rabbit and after mechanical stimulation of the vagina without intercourse. However, women report that after sexual activity leading to orgasm, they feel more alert and sometimes annoyed with male partners who, after sex, seem simply to collapse and begin snoring. These different effects in men and women can lead to some discord in relationships. Appreciation that these differences are due to biological factors, rather than personality and insensitivity, may help heal hurt feelings.
25. Q: I have heard that women have more insomnia than men. Men seem to be less excitable than women. Do men sleep better than women?
This question sounds sexist, and even a bit silly. However, the answer is really much more serious than the question. Among people who complain of chronic insomnia over age 40, there are 7 or 8 women to 1 man. The reasons for the disproportionate number of women are not known. Menopause, grown children leaving home (the so-called, ’empty nest syndrome’) and other life-cycle effects have been offered as explanations.
This most important point in connection with this question, however, is that across all ages, on the average, males sleep much worse than females. One of the main reasons is that many more males are prone to sleep-related breathing disorders than females. From birth on, male babies have more respiratory difficulties and succumb more often to sudden infant death syndrome than female babies. Physicians think that this is partly because the female hormone, progesterone, somehow protects females from respiratory difficulties during sleep. The man who brags that he can ‘sleep through a bombing’ may actually be abnormal. Rather than being so ‘in control and relaxed’ that he can ‘sleep fine anywhere, anytime’, this man may have such poor breathing and sleep disruption that he is too sleepy to stay fully alert. Such men cannot restrict their sleep to appropriate times of the 24-hour day. Finally, with age, the statistical score between the sexes evens up. As women pass through menopause, a variety of hormonal changes occur that seem to bring on sleep problems. Menopausal and post-menopausal women complain more of insomnia than men of comparable age. And, after the age of 65, the male-female differences for sleep-related breathing disorders become much smaller.
Chapter 4 – Children
26. Q: Does pregnancy alter your sleep?
Yes. Women feel that they want to sleep more during the first, and particularly during the second trimester. This desire for more sleep is thought to be related to increased energy demands associated with the growth of the fetus. Women in their third trimester of pregnancy will notice frequent disruptions in sleep and increased restlessness. The sleep problems during the last trimester are thought to be due to pregnancy-related changes in anatomy causing discomfort in certain sleeping postures. An important feature of the third trimester is weight gain of the mother. Large weight gains have been linked to an increased tendency for pregnant women to snore and to have breathing pauses during sleep (sleep apnea).
27. Q: My baby is almost 3 months old. He wakes up crying dozens of times a night. My husband and I cannot get any sleep and he is thinking about moving out. What can I give my baby to help him sleep?
This is an extremely serious situation. The problem, however, is usually not with the baby. Most babies do not sleep through the night until 3 – 9 months of age. If the doctor finds nothing wrong with the baby, then you need to find ways to live through the period while your baby develops the ability to sleep through the night. Get professional advice if your baby does not learn to get to sleep without someone in the room keeping him company. It is also important to get help if your marriage cannot stand the stress. Do not blame the baby.
Doctors do not really know. But it is interesting to note that not only rocking, but many other kinds of repetitive stimulation seem to have calming and sleep-promoting effects. There are experiments showing that babies prefer rhythmic sounds to complete silence. Scientists are testing whether or not the early experience of hearing the beat of the mother’ heart is related to preferences for rhythmic sounds. It is common for mothers to find that their babies like to sleep with the sound of a fan — or even the much louder sound of a vacuum cleaner. Many babies, as well as much older people, find the rhythmic motion of riding in a car or a train to be very soporific (sleep-promoting). Other babies may rock themselves to sleep with rhythmic leg or head movements. An extreme form of this self-stimulation may be the sleep disorder known as ‘head banging’, which many doctors consider to be an abnormal exaggeration of rhythmic self-stimulation performed for comfort and to promote sleep.
29. Q: My 4-year-old wakes up in the middle of the night and the only way she will go back to sleep is in bed with my husband and me. Is it harmful to allow her to do this?
Most doctors do not believe that it is harmful for a young child to sleep in the same bed with the parents. Of course, Western cultures regard it as an entirely different matter if the child can, thereby, witness sexual activities between the parents. In most Western cultures, concerns about the need for parental privacy usually lead families to get the child out of the parents’ bed. If your child gets into bed with you frequently — say, more than once a week — then you may want to discuss the matter with your daughter. Try to determine if there are psychological problems at the root of her behavior. If not, then she can learn to get herself back to sleep if you gently but firmly refuse to let her come into your room. Plan on having to walk or carry her back to her own bed several times a night for a while. If you have no success after a month of consistent efforts, then seek professional help.
The related question of an infant or very young child sleeping in the same bed as the mother and/or father has more complex answers. The nursing mother may wish to have the infant close by to minimize the disturbance of breast feeding to their own sleep. Fathers who get up during the night to feed infants have expressed similar views. Working mothers and fathers may consider bedtime as the only time when they can be close to their young children. Such practical and emotional factors should be balanced against the fact that, for a child to sleep well, it is necessary to learn to settle and sleep alone in bed. In the case newborns and young infants, some authorities cite the risk of crushing or smothering as a reason for separate sleeping arrangements. Amidst such conflicting considerations, parents must select the sleeping arrangements that best fit their current needs. A bit of personal experimentation with various same room and same bed sleeping arrangements can be helpful in deciding what is best for you and your family.
Sleepwalking or ‘somnambulism’ is common in children. These symptoms occur during stages 3 and 4 NREM sleep, when the brain waves show a high-voltage slow pattern. During this kind of brain wave pattern, there can be little reliable sensory and movement activity. Many people mistakenly believe that sleepwalkers will not get hurt and that they can avoid obstacles. People can be injured while sleepwalking. Sleepwalkers have broken through glass doors, fallen down stairs and been burned after walking into hot fireplaces. So, the sleep environment should be made safe by locking doors and windows that open on to dangerous areas. Sleepwalkers may be very difficult to awaken and very confused if they awaken during a bout of sleepwalking. However, there is no real danger if a child wakes up while sleepwalking.
31. Q: My 3-year-old will only go to sleep on the sofa while watching television. After she is asleep, my husband must carry her to bed. Should we put an end to this and, if so, how?
People have trouble sleeping when they do not feel secure. Your 3-year-old can learn to get to sleep alone. The most common way to accomplish this learning is to firmly insist that the child go to bed and sleep there. Reassure the child at bedtime as to the safety of the room. The first week or so may be tough on the child and the parents, but the result of your child being able to sleep undisturbed in her own bed is worth the bother.
32. Q: My twins are afraid to sleep in the dark and insist on sleeping with the light on. Can they get their proper rest from sleeping in the light?
There is probably no short-term problem with sleeping in the light. However, sleep and wakefulness are controlled by an internal clock that is sensitive to light-dark cycles. The clock works better if the light-dark information throughout the 24-hour day is clear and consistent. Sleeping in the light may ultimately confuse the body and lead to sleep problems. You may try to use progressively dimmer and dimmer lights in the twins’ room until they are comfortable sleeping in the dark.
33. Q: My 5-year-old wets the bed. I have tried to limit her fluids after dinner and I have made her responsible for cleaning up her mess. But we are still at odds and her bed wetting continues. What can I do?
Bed wetting (enuresis) is far more common than most people think. The necessary neurological control of the bladder sphincter can come as late as 12 – 15 years of age. It is best not to make an issue out of bed wetting in children under 6 or 7 who have never been dry for more than a few nights in a row. For older kids, there are several training methods that involve gentle alarms that do work quite well. For kids who have been dry for a number of months or years and begin to wet the bed again, parents should get a physician’s opinion. Reappearance of bedwetting can mean genito-urinary problems, psychological problems or even neurological problems such as epileptic seizures.
34. Q: My little boy has the habit of waking up and asking us for a drink of water at 1 AM. What can we do to break this habit?
There is probably much more than thirst involved in your child’s request for water. Fear of being alone and need for parental attention are two possibilities. It is best to firmly refuse to get the water and encourage the child to return to sleep. Try not to get involved in exactly how the child adapts to your refusal. Depending on the child’s personality and age, the child can get his own water for a while, cry and act out, or just go back to sleep.
35. Q: My brother and his wife lost their baby to crib death and it has just about ruined their lives. I am expecting our first child next month. Does crib death run in families? What should I do?
Crib death or Sudden Infant Death Syndrome (SIDS) is a tragic problem that is often related to an abnormal degree of immaturity in the systems that control the heart and lungs. It is common for such immaturity to cause problems only during sleep. There is a small tendency for SIDS to run in families. Doctors suggest that babies who are closely related to a SIDS case, be examined regularly. If your baby stops breathing or has irregular breathing during sleep, tell your doctor immediately. The sleeping position of new babies may is also important in SIDS. Studies in England have shown that ‘Back to sleep’ which refers the practice of putting newborns and infants into their cribs on their backs, significantly reduces the rate of crib death. Doctors now advise having babies sleep on their backs.
36. Q: My 11-year-old stays up late reading or talking on the phone because he just is not sleepy, but he cannot get up and get going in the morning. What can I do?
The body cycle that controls our wakefulness and sleep runs on about a 24-hour clock — but not quite. That is why scientists term the cycle ‘a circadian rhythm’ which means ‘about a day’. Actually the cycle is usually longer than 24 hours by 15 – 75 minutes depending on such factors as age and random variation among people. The cycle tends to be longer in young people and to shorten as we age. Thus, left without any information about time or the need to get up in the morning, most people will go to bed later and later each successive night and get up later and later each successive morning. It may be that your son has a particularly long wakefulness-sleep cycle. He may benefit from more and stronger time signals from our 24-hour day to override his internal 25+ hour day. The best signals are bright light and vigorous activity in the morning. The extreme form of this problem is called ‘phase delay insomnia’ and can lead to problems in school or on the job. The condition can be treated by sleep disorders specialists.
Chapter 5 – Sleep and Things You Put in Your Body
37. Q: Does diet make a difference in your sleep? For example, is warm milk at bedtime a good idea?
The effect of diet on sleep has not been researched with good laboratory techniques. All of us certainly hear many personal observations and testimonials concerning the sleep benefits of various diets and health foods. However, there is no systematic research on, for example, whether people eating a high protein diet sleep differently night after night than people eating a high carbohydrate diet.
There is some information on several dietary substances, though. We know of one published study on a malted-milk product that may have sleep-promoting effects. Conversely, there are studies showing that caffeine-containing substances really do disturb sleep.
Americans spend billions of dollars each year or health foods and dietary supplements. It is wise to remember that the research supporting the use of non-prescription compounds and dietary supplements is of poor quality or non-existent. By contrast, the laws governing the safety and efficacy of prescription drugs are rigorous. When a prescription drug reaches the market, the consumer can be confident that the safety of the drug and the claims of effectiveness have been scientifically demonstrated. This situation is no better illustrated than in the case of melatonin versus prescription sleeping pills. Melatonin, because its manufacture and distribution are not subject to the laws and policies of the U.S. Food and Drug Administration, continues to be sold in health food stores as a sleep aid. This situation continues despite scientific studies showing that melatonin is not effective as a sleep promoter or as a treatment for jet lag. Further more melatonin’s long-term safety is still in question, particularly with respect to its effects on hormonal and reproductive systems. Yet, many people seem to believe that, because melatonin is sold as a dietary supplement in health food stores, it is a safe and effective sleep aid, and that prescription sleeping pills are dangerous drugs. The reality is just the reverse.
If it is an alcoholic drink, absolutely not. Alcohol is actually an organic solvent and depressant of the central nervous system that disrupts normal sleep. A drink may make you drowsy, but it also distorts the normal pattern of NREM and REM sleep. And, when the alcohol wears off (in 2 – 4 hours) you may wake up and have difficulty getting back to sleep. People who drink significant amounts of alcohol between dinner and bedtime are among the worst of sleepers.
An additional concern is that alcohol causes relaxation of the muscles in the throat and upper airway and also interferes with breathing. As a result, people who rarely snore when they do not drink may snore quite loudly after nighttime drinking. Furthermore, people with mild sleep-related breathing problems, such as sleep apnea, may get much worse even after small amounts of alcohol. In fact, many sleep clinics use bedtime alcohol as a test to determine how bad a person’s breathing difficulties can get.
There is no single answer to this question. Obviously, if the eating leads to intestinal discomfort and indigestion, sleep will be disrupted. Small amounts of light food may help some people feel comfortable and, thereby, assist sleep. Furthermore there are a few studies showing that malted milk and foods rich in tryptophan may promote sleep.
Probably not. Melatonin is a hormone produced by the pineal gland located in the center of the brain. Using input from the eyes, the brain links melatonin production to the light-dark cycle of the environment. Melatonin levels in the body are highest during the hours of darkness. Synthetic forms of melatonin are available as dietary supplements in health food stores. However, studies have failed to show that melatonin affects sleep in any way. Furthermore, there is no definitive research indicating that melatonin treats the symptoms of jet-lag.
Some studies do indicate that taking melatonin at bedtime is helpful for the insomnia blind people experience because they cannot receive light-dark signals from the environment. And, the sleep of people who have diseases causing a deficiency in natural melatonin is improved by bedtime melatonin. However, there is reason for caution. Melatonin’s effects on other hormone systems are fully not known. In animals, melatonin rises are associated with the seasonal shrinking of testes and ovaries. The effects of melatonin on the human reproductive systems have not been thoroughly studied.
Melatonin is chemically related to another brain chemical, serotonin. Research has also linked serotonin to sleep. Since the brain chemically changes tryptophan into serotonin and melatonin, pure tryptophan has also been studied as a natural sleep inducer. Early studies showed that 3 – 5 grams of tryptophan, manufactured in tablet form, helped some people who take a long time to fall asleep and wake up frequently. However, it is not likely that the amount of tryptophan in a normal meal, even of a tryptophan-rich food, will affect subsequent sleep. Some years ago many people used tryptophan tablets to help with relaxation and sleep. However, in the late 1980’s, more than 1500 cases of a painful and sometimes fatal disease called eosinophilia-myalgia was linked to an impurity in the tryptophan produced by the Japanese company, Showa Denko. During the search for the cause of the disease, all tryptophan tablets were recalled. Costs of product liability and impurity-free production have blocked the return of tryptophan tablets to the market.
41. Q: I have just stopped drinking coffee. Now I can’t stay awake and I get terrible headaches. Am I hooked on coffee?
It may very well be that you are having withdrawal symptoms. Somnolence and headaches are two common symptoms of caffeine withdrawal. However, if these symptoms are due to getting off coffee, do not worry — the symptoms will pass quickly. Unlike more powerful and addictive stimulants such as amphetamine, the symptoms of caffeine withdrawal seem to disappear in a few days without serious complications.
42. Q: I have just stopped smoking. Now I can’t stay awake and I get terrible headaches. What should I do?
The effects of nicotine withdrawal that come from stopping a tobacco habit can include both nervousness and somnolence as well as the more well-known symptoms of increased appetite and weight gain. Nicotine can act as a mild stimulant which explains the sleep problems associated with withdrawal.
The most active compound in marijuana is delta-9 tetrahydrocannabinol or ‘THC’. This compound alters brain chemicals involved in sleep and produces changes in brain wave patterns. Sleep changes with long term use include increased time in getting to sleep and reduced REM sleep. It is not considered to be a good sleep aid.
Cocaine is a stimulant that produces a sense of euphoria followed in several hours by a sense of depression. Cocaine potentiates certain brain chemicals. Cocaine’s arousing and addictive influences stem from its effects on the brain chemical, dopamine, which is involved in wakefulness and body movement. Sleep changes include reduced stage 3 and stage 4 NREM sleep and reduced REM sleep. When cocaine is discontinued, the individual becomes very sleepy and may feel that more cocaine is necessary just to function. Cocaine is addictive particularly when used in the very short-acting form known as ‘crack’.
Amphetamine and amphetamine-like drugs are also known as ‘speed’ or ‘crank’. They are powerful stimulants that are not unlike cocaine in many respects. Amphetamines also potentiate brain chemicals involved in wakefulness and produce changes in brain wave patterns. Sleep changes include reduced stage 3 and stage 4 NREM sleep and reduced REM sleep as well as decreased tendency to fall asleep and stay asleep. When amphetamine is discontinued, the individual becomes very sleepy and may feel that more amphetamine is necessary just to function. Also, discontinuation of amphetamine leads to greatly increased REM sleep known as ‘REM rebound’ which may be accompanied by nightmares. However, amphetamine and related drugs are medically useful in controlling the disabling sleepiness of sleep disorders such as narcolepsy.
Heroin is a depressant that retards intellectual and motor functioning as well as reaction to pain. The drug also interferes with breathing because it is a powerful respiratory suppressant. Heroin decreases stage 3 and stage 4 NREM sleep and reduces REM sleep. Heroin also disturbs sleep by causing frequent shifts to stage 1 NREM sleep and wakefulness. When discontinued, there can be withdrawal symptoms such as intense pain, runny nose and craving for more heroin. During withdrawal from heroin, there may be ‘REM rebound’ that is often accompanied by terrible nightmares.
47. Q: My husband has been put on a medication to reduce pain and swelling. Since he started taking the drug, he has complained of insomnia. Could there be a connection?
Yes. Many drugs, even when properly used, can have disruptive effects on sleep. Steroids (for example, prednisone which is used to treat inflammation) and respiratory stimulants (for example, theophylline which is used to treat breathing disorders) often cause insomnia as a side effect. The best approach to insomnia caused by the use of a needed medication is to adjust the time of the day that the drug is taken and the dose of the medication in hopes of keeping the desired effect and reducing the side effect of sleep disruption. Another possibility is to have the doctor prescribe a different drug in the same class of medications. It is always unwise to make any changes in the way prescribed medication is taken without the doctor’s supervision.
Chapter 6 – Poor Sleep (Too Little or Too Much)
48. Q: How many Americans have trouble falling asleep or other complaints of insomnia?
A 1991 Gallup poll found that 36% of American adults have some type of insomnia and 9% have chronic sleep difficulty. For the 36% with insomnia, 72% complain of waking up in the morning feeling drowsy or tired. Other common complaints include waking up during the night, difficulty getting back to sleep and difficulty falling asleep. In addition to this 36%, almost everyone experiences difficulties with poor sleep from time to time when facing problems such as a family crisis, death of a loved one or loss of a job. These are situations in which it is quite common — maybe even normal — to have difficulty with sleep.
It is only recently that physicians and other health care workers have begun to take the complaint of insomnia seriously. This change in attitude has come about because of the vast numbers of people with sleep problems and the fact that people with chronic insomnia report significantly more problems meeting their work and family responsibilities and have over twice as many auto accidents as people without sleep problems.
49. Q: I have always been a light sleeper. Lately, though, things are really bad. The smallest noise awakens me and I cannot get back to sleep. My friend has told me to get out of bed when I cannot sleep and exercise until I am so tired I will have to sleep. I am exhausted already. When I get home from work, I fall asleep in my easy chair. What should I do?
Sleep experts tell us that the first thing people with this problem should do is develop a regular schedule of sleep and wakefulness so as to maximize the natural tendency to sleep during the night. Get up at the same time every day, 7 days a week. Try to sleep only at night — no naps. Do not worry about one or two bad nights. Eventually, you will be sleepy enough to sleep at the appropriate time and feel rested when you wake up. Avoid stimulating foods and drinks, particularly after dinner. Do not use alcohol for sleep — alcohol is a very poor sleep aid because, while it may help you feel drowsy, it wears off in 2 – 4 hours and actually wakes you up once it has been partially eliminated by the body’s metabolic processes. Alcohol is the leading cause of waking up too early and being unable to get back to sleep.
If you do wake up at three in the morning and cannot get back to sleep, try to do something quiet and, preferably, in the dark so as not to disrupt your body’s clock. Listening to relaxing music is a sensible choice. Avoid exercise and other stimulating activities at these hours so that, even if your 24-hour wakefulness-sleep cycle is disturbed, your activity-inactivity cycle is preserved. If insomnia persists after schedule regularization, get professional help.
50. Q: We have moved near a major airport. The noise of the jets is really loud. I seem to be able to sleep all right, but my wife is miserable at night with insomnia. What should we do?
Loud noises during sleep such as the noises from an airport have been shown to disrupt sleep to some extent even in people who say that the noises do not keep them awake. This is because the normal brain always reacts to stimuli such as sounds or touches even during sleep. However, it is obviously true that people have lived near airports for years with few measurable problems. If your wife’s problem persists after a couple of months, the logical thing to do is to improve your sound insulation by insulating the bedroom, using ear plugs, or both. If your wife still cannot acclimate to your new location even with these measures, you had better think about moving. There is really no long-term remedy that would be preferable to finding a quieter location.
For those who have occasional difficulty falling asleep, the best advice is to do whatever helps and avoid whatever makes matters worse. There are many reasons why someone may have trouble falling asleep ranging from ‘nerves’, to trying to sleep at the wrong time in the body’s daily wakefulness-sleep cycle. So, sleep aids that work for one person may do nothing at all for someone else. Many people use warm baths. Quiet soporific tasks are also common — like counting sheep. On the other hand, it is probably not a good idea to engage in exciting activity or intense physical exercise (other than sexual activity) before bed.
52. Q: My friend bought a record of sounds and special music that is supposed to help beat insomnia. Do such records really work?
There is really no way to answer in general. If the record works for you, then use it. Almost all scientific information about things that help sleep, comes from studies of drugs. Scientifically valid laboratory research has identified many drugs that help people sleep. Drug companies must do this type of research before they can market a drug that they claim to be an effective treatment for insomnia. However, this kind of work takes years to complete and the evaluation of a typical sleeping pill may cost several million dollars. For obvious reasons, such laboratory research has rarely been conducted on self-help remedies such as audio recordings. This does not mean that such remedies do not work. Rather, it means that our consumer protection and economic systems have led to proper sleep laboratory evaluation only of drugs that are manufactured and sold for the complaint of insomnia.
Sleep specialists would revise this old advice from Benjamin Franklin. A better rule is ‘consistently to bed and consistently to rise makes one healthy, wealthy and wise.’ Some individuals claim to be ‘night people’ and others ‘morning people’. But if both types are free to sleep undisturbed, night people sleep about the same as morning people — only at different hours. The night person sleeps beautifully after falling asleep at 2 AM, while the day person does quite well retiring at 10 PM.
54. Q: I have always heard that 1 hour of sleep before midnight is worth 2 hours of sleep after midnight. What is the basis of this old adage?
Sleep is an active, highly organized sequence of events and physiological conditions. Sleep is actually made-up of two separate and distinctly different states: ‘non-rapid eye movement sleep’ (NREM sleep) and ‘rapid eye movement sleep’ (REM sleep) or dreaming sleep. NREM sleep is further divided into stages 1 – 4 based on the size and speed of the brain waves generated by the sleeper. Stages 3 and 4 NREM sleep have the biggest and slowest brain waves and it is hard to wake people up from Stages 3 and 4 sleep. Large spurts of growth hormone are secreted during stages 3 and 4 NREM sleep. Because of these and other characteristics of stages 3 and 4 of NREM sleep, this type of sleep is thought to be particularly restful. If we go to bed at, say, 10 or 11 PM, we will perceive that our most restful sleep occurs before midnight. However, the main point is that the type of sleep that we believe is most restful occurs in the first few hours of sleep — whatever the clocktime of the sleep might be.
55. Q: My wife has arthritis and can manage pretty well during the day, but she is so miserable at night because she cannot sleep. Is there anything that can be done?
Your wife’s problem is very common and will become more common as our population continues to age. There are a number of medications that help with pain and acceptance of pain. Some of these interfere with sleep more than others. It may be helpful to ask a sleep specialist to review your wife’s medications to see if changes can be made to minimize the unavoidable sleep disturbances caused by her pain.
56. Q: I have been on rotating shift work for ten years and never had problems with my sleep. Lately, though, the graveyard shift is just murder for me and I cannot seem to sleep during the day. Where have I gone wrong?
Chances are that you have not gone wrong — you have just gotten older. People are very different in the way they handle irregularities in their work and sleep schedules. Some people can never stand swing or graveyard shifts. Others manage reasonably well on the night shift for years. The newest studies show that humans can never completely adapt to working nights and sleeping days. The best we can do is get through periods of night work with a minimum of sleep loss. Besides individual differences, age is the most important factor in tolerating night work. Statistically, the older you are, the tougher it is to handle any deviation from a day work – night sleep schedule.
Because we are all biologically night sleepers, a number of industries that operate around the clock are experimenting with bright illumination of the work environment at night in order to help push the nighttime sleep tendency to another clocktime. While this approach is promising and has helped NASA astronauts prepare for early morning launches, it can be prohibitively expensive in many industries and impossible in others. Until a general method is found to fool our sleep clock into letting us be alert all night, shift workers will have to find individual solutions. Examine your schedule and activities. If you cannot explain the sudden inability to handle the graveyard shift in other ways, then you should think about arrangements to work only the day shift.
57. Q: I make frequent short trips to the East Coast from the West Coast. Is it best to try to stay on West Coast time, or to adapt to East Coast time?
If the trips are short and you can schedule your business during normal West Coast business hours, do not try to adapt to East Coast time. Adaptation would take longer than the duration of your trip. There are other strategies that you may consider as well. For example, if you know of an important East Coast meeting at, say, 7:00 AM — which corresponds to 4 AM in your West Coast body, plan to go east several days before the meeting to adapt. Alternatively, try to use East Coast time at your home for a few days before traveling east.
58. Q: My husband and I have a cabin in the mountains. We have been enjoying vacations there for years. Now my husband finds that he cannot sleep in the cabin and has grown to hate the place. He wants to sell. How can he break his insomnia, so we can again enjoy our second home?
If your husband sleeps all right at home, you should take your husband’s cabin insomnia seriously. The first thing to check is his breathing when he sleeps in the cabin. Check to see if his breathing is smooth and regular when he sleeps. If his breathing is irregular with alternation between shallow breaths and deep gasps, his insomnia is probably related to periodic breathing during sleep and a physician should be consulted. Because the oxygen level in the air is reduced as altitude increases, breathing problems of this kind develop in all individuals at altitudes above 10,000 feet or so. However, people with respiratory disorders such as emphysema or shortness of breath related to obesity can develop such sleep-related breathing problems when they go from sea level to as low as 4000 – 5000 feet. For mild cases, doctors prescribe respiratory stimulants until people acclimate to altitude. For serious cases, high altitudes should be avoided.
No, probably not. For all humans there is a physiological tendency to have a major sleep bout once every 24 hours. Most of us begin this sleep bout between 10 PM and 1 AM. Any behavior that alerts us, such as vigorous exercise or intense intellectual and emotional activity, will act to delay the sleep bout. People who never have trouble falling asleep are probably oblivious to this effect. However, for those who are frequently troubled by difficulty falling asleep, it is wise to avoid any bedtime activity that leaves one physiologically or mentally aroused.
60. Q: My husband is always falling asleep around the house. He seems to get a lot of sleep at night. How can I get him to be more alert and pay more attention to me and the family?
Falling asleep at times when one should not fall asleep is a dangerous symptom. If nighttime sleep is really sufficient, unintended bouts of sleep in the day should not occur. The two most common reasons for falling asleep inappropriately are sleep apnea and narcolepsy. Both of these conditions can be successfully treated once a doctor has made the diagnosis. If someone in your family falls asleep inappropriately, get them to a doctor. If untreated, this kind of problem can lead to car accidents, loss of job and ruined marriages.
61. Q: I feel as though I have not slept a wink for days. I drag through the day without any energy. If I do not get some sleep tonight, I am going to go crazy. What can I do?
This type of sleep problem can be caused by many different things going on in your body or in your life. Trouble getting to sleep is very common after a crisis such as losing a loved one or a job. This kind of insomnia may also stem from alerting compounds in your diet such as too much, or increased sensitivity to, caffeine. Increased sensitivity or excessive use of tobacco has also been implicated as a reason for the symptom of insomnia. Many medicines prescribed for medical conditions such as arthritis, asthma and heart disease can cause insomnia. If the problem persists, see your doctor. Physicians are taking the complaint of insomnia more seriously these days because people with insomnia have an increased rate of problems at work and an increased rate of accidents on the road. Find out what is keeping you awake.
62. Q: I fall asleep quickly, but I wake-up at 3 or 4 in the morning and cannot get back to sleep. I am exhausted by 6 o’clock and fall asleep just in time to be awakened by my alarm for work. What do I do?
The two most common reasons for this type of insomnia, called sleep maintenance insomnia, are depression and too much alcohol before bed. People who are depressed may not recognize any other problem except early morning awakening. Most doctors can diagnose depression and begin therapy after one or two visits. The most widely accepted theory about depression is that it is a biological imbalance among the brain chemicals, called neurotransmitters, that are used by brain cells to signal one another. Imbalances in these chemicals almost always affect sleep as well as mood. When the depression is controlled, the sleep problem usually goes away. If the early morning awakenings are due to too much alcohol before bed, the best first approach is to stop drinking.
63. Q: We just had a death in the family and a lot of the problems have been left for me to solve. I have not been sleeping well and the doctor prescribed some sleeping pills. Do these things work? Will I get ‘hooked’ on them?
Sleep problems at the time of a personal crisis are very common and may be even considered a normal part of the grief process. Modern sleeping pills of the benzodiazepine or imidazopyridine type are often used in such ‘situational insomnia’. These kinds of drugs are safe and effective when used as directed. In fact, short-term use during a crisis may prevent a chronic insomnia problem from developing.
64. Q: My husband wants to buy a new water bed because he read that people sleep best on this type of surface. Is this really true?
In general, people sleep best on the surface that feels most comfortable to them. However, the best sleep research available shows that, after a night or two of adaptation, most people can sleep as well on a thin pad over a concrete floor as they can on the most elaborate mattress available. Of course, this is only true for people who do not have muscle or skeleton problems that require particularly soft or particularly firm surfaces to avoid discomfort.
While research has not shown that the cost or physical properties of sleeping surfaces are major factors determining sleep quality, other psychological factors will influence what people believe about sleeping surfaces. For example, the more money and time invested in a particular mattress and/or bed, the stronger will be the belief in the superiority of this particular sleeping surface.
The first thing to consider in this situation is your weekend schedule of sleep and activity. If you are staying up later to play and party and sleeping late on Saturday and Sunday mornings, you are setting up perfect conditions for Sunday night insomnia. Try to go to bed at the same time every night, seven nights a week. The body clock controls when we are ready to sleep and when we are ready to be active. For most of us, it is easy to delay sleep and the next day’s activity. However, our clocks are hard to set forward again so that we feel like going to sleep earlier, say, on Sunday night. If schedule irregularity is not to blame, the next thing to consider is whether you have some apprehension about Monday’s activities.
There are more and more studies coming out on the relationship between sleep and disease. Some studies indicate that our body’s defenses against viral and bacterial infection are increased during sleep. Studies have shown that, after a period of experimental sleep deprivation, some components of the body’s immune system become overactive and then return to normal after recovery from sleep deprivation. Other studies have shown that the cells and chemicals of our immune system, released as our body fights off invading germs, actually do make us sleepy. So there may be some truth to this old adage.
Sleep deprivation studies have shown repeatedly that the early signs of not getting enough sleep are progressive slowing of reactions and increased numbers of brief attention lapses. If you have been cutting back on sleep for a day or two or if you are trying to stay up for a whole night, you are likely to miss the early signs of not getting enough sleep. However, when you do something sedentary for more than 10 minutes or so, particularly something that demands sustained attention, you are likely to perform poorly.
The effects of too little sleep increase relentlessly from the time you last slept. Brain imaging studies of volunteers who have lost about one night’s sleep show significant reductions in basal activity especially in the frontal areas. However, other studies have found that when sleep deprived subjects are engaged in mental work, such as trying to recall a previously memorized list of words, the frontal and parietal brain areas become more active than during comparable mental work when the subjects are normally rested. This increased activity during work indicates that the brain is able to compensate to some extent for the deleterious effects of sleep loss. But, the compensation is certainly not perfect. One study compared the effects of sleep deprivation with the effects of drinking alcohol. After 17 hours of continued wakefulness, a person’s performance lapses become as frequent as they are for a person who has a blood alcohol level of 0.08 percent — i.e. someone who is legally drunk.
If you are sleep deprived night after night, the main tip-off is overwhelming daytime sleepiness and inability to function effectively. At sleep disorders centers, this is the first thing doctors look for: Is the person impaired during the daytime? That is the basis for deciding whether or not to intervene with drugs and other therapy. With extreme sleep deprivation, you have frequent loss of attention, frequent lapses in performance and accidents. Many people experience a burning of the eyes and increased irritability. In extreme cases, sleep during the day becomes unavoidable and people experience sleep attacks. When they merely sit down, they fall asleep. Such patients must force themselves to be active in order to stay awake.
Chapter 7 – Things that Go Wrong in the Night (Part 1)
68. Q: Just what can cause insomnia?
Any one of some 40 different conditions have been identified. The most common is a psychological or psychiatric abnormality. That is true of about half the insomniacs who come to sleep disorders centers. The other half are people with more specific medical abnormalities. Here are some of the most common:
– breathing difficulty during sleep such as sleep apnea
– periodic twitching of the legs and arms that disturbs sleep
– overuse of sedatives or alcohol that disrupts sleep
– stomach problems such as reflux or indigestion
– physical pain such as with arthritis or rheumatism
Once a specific diagnosis is made, proper treatment is aimed at the cause of the insomnia. For example, people with insomnia secondary to respiratory difficulty may take drugs to improve respiration during sleep. People who have insomnia associated with overuse or abuse of alcohol must stop drinking, and so on. Sleeping pills are best reserved for patients who have insomnia as a reaction to some crisis. Sleeping pills should be of the prescription variety, not the over-the-counter kind, because there are no good studies to show that non-prescription sleeping pills work as advertised. This is true, in part, because over-the-counter medications are not subject to the strict requirements that the U.S. Food and Drug Administration sets up for prescription drugs. Sleeping pills should be taken over not more than a three-week period — and preferably not every night. Furthermore, the use of sleeping pills should be supplemented with other techniques to promote sleep, such as a regular wake-sleep schedule, regular activity after getting up in the morning and abstinence from caffeine-containing drink and food. The caffeine in coffee, tea or even several pieces of chocolate after dinner can be sufficient to keep a sensitive person awake for hours.
Absolutely. There is no question that abuse of sleeping pills leads to destruction of normal sleep and increased insomnia. For example, a barbiturate taken for too long can eventually make sleep much worse than it was during the period of insomnia that prompted taking the drug in the first place.
Furthermore, when the patient discontinues the medication or runs out of it, terrible insomnia follows. The person cannot sleep at all for days, and after finally falling asleep may have terrible nightmares. This predisposes the patient to return to the barbiturate and you have a vicious cycle of dependency and withdrawal. Still, if it is a matter of getting a good night’s sleep before a difficult examination or during a brief family crisis, a good sleeping pill may be very useful.
71. Q: How soon will it be before science develops a natural, non-addictive sleeping pill that acts like the natural sleep-producing chemicals in the brain?
This is an area of intense investigation, but it is too early to tell what the results will be. Scientists are somewhat less optimistic about a super sleeping pill than they used to be. Sleep and wakefulness are complementary periods in a natural 24-hour cycle that cannot be manipulated on the spur of the moment. When we fly across the Atlantic from New York to Paris, our sleep structure as well as our work productivity adjust slowly, over several days, to this time shift. So, it is unlikely that taking a single pill could quickly reschedule all aspects of our natural body rhythms.
One disappointing ‘natural’ approach for insomnia and other problems related to jet-lag has been the specially timed use of melatonin, a natural chemical manufactured by certain brain cells. Melatonin is thought to be involved in regulating our body clock. Experiments giving melatonin to people at specific times each day for several days prior and after a long flight east or west have failed to show any improvement.
Another approach to sleep rescheduling is exposure to bright light at a particular time. The light should be in the form of regular sunlight or special artificial light with an intensity of about 2500 lux (the intensity of daylight just after dawn). Research indicates that people who need to sleep at a time later than their habitual time — either because some disorder has shifted their schedule or because they must work on a new schedule — can shift by sitting in bright light for several hours before they would normally go to bed. On the other hand, if one wants to shift their sleep to an earlier time, light exposure should occur just after awakening. The light is thought to reset the biological clock. Bright light’s shifting effect requires at least 2 hours of properly scheduled exposure to a light source that is as least as bright as dawn sunlight for 2 or 3 consecutive days.
It is important to remember that there are many causes for the symptom of insomnia. Behavioral approaches are unlikely to work if the cause of insomnia is, for example, sleep apnea or respiratory irregularity associated with altitude. Behavioral techniques, particularly of the self-help variety, can be dangerous when they delay proper diagnosis and treatment. Do not be too quick to ‘psychologize’ your sleep problem — it could be a treatable physical condition.
However, if medical problems are ruled out and the sleep problem is chronic and psychophysiological, behavior modification often is the best choice. There are many approaches: relaxation therapy, biofeedback, meditation, improvement of sleep habits. A patient who does not respond to one approach may respond to another one, so sleep experts advise patients to continue trying until they find the technique that works best for them, rather than to rely on exclusively pills.
Yes, if it is done consistently. One day a week of exercise is likely to disturb rather than promote sleep during the following night. But consistent, daily exercise, preferably in the morning or at least well before dinner, helps promote a regular wake-sleep cycle and improves chances for a good night’s sleep.
That depends on the individual, which is why the decision as to what to do should be guided by a professional. One approach is to behave exactly as you would normally behave during sleeping hours — lie in bed and try to relax. Do not get up and do push-ups. But, if by remaining in bed you only create a great deal of anxiety and misery for yourself, then you should get up and try to engage in some activity to reduce anxiety and tension. However, there is always the risk that in getting up you may further disturb the natural 24-hour cycle of activity and rest that is necessary for good sleep.
75. Q: I wake up at about 3 AM every morning. Once I am awake, it is hard or impossible for me to go back to sleep. What causes this?
The most common reason for this symptom is drinking too much alcohol too late in the evening. While alcohol near bedtime may help with getting to sleep, its effects wear off quickly leaving one awake, dehydrated and uncomfortable 2 – 4 hours later.
The next most common reason for early morning awakening is depression. There are data from almost every sleep laboratory in the country indicating that early morning awakening without being able to return to sleep is one of the hallmarks of depression. Sleep laboratories have found that another sign of depression is the premature onset of REM sleep. The normal interval between falling asleep and the first period of REM sleep is 80 – 100 minutes. Doctors think that a premature REM sleep period — say, 15 – 30 minutes after sleep begins, is a sign of depression. When depression underlies the symptom of insomnia, treatment is focused on the depression rather than the insomnia. Once such depression is adequately treated, problems with insomnia improve greatly.
The third most common reason is a time shift in the natural sleep period so that one feels ready for bed at about 8 PM, rather than the normal 10 to 11 PM. Then, an early morning awakening marks the normal end of the sleep period. Such time shifting is especially common in people over the age of 50 and is thought to be related to the effects of aging on biological timing systems. If this is the cause of early morning awakening, then establishing a consistent schedule of going to bed no earlier than 11 PM or so, should help.
76. Q: I have heard that someone can actually wake up to answer the phone, talk sensibly and yet not remember the call in the morning. Can this really happen?
Yes, this kind of occurrence is really rather common. Sleep research and clinical experiences point out four key factors which influence the type of behavior that follows such a nighttime arousal: (1) the phase of sleep during which the arousal occurs, (2) the level of alertness that results from the arousal, (3) the duration of the arousal and (4) the psychological make-up of the sleeper. A number of possibilities result from these four factors. Most common is that a sleeper awakens completely, the subsequent behavior is quite typical of the sleeper’s personality, and the incident is remembered the next day. If, however, the activity during an arousal is brief and the person goes back to sleep quickly, there may be no recall of the event.
There are several other, more exotic possibilities. Suppose the sleeper is in slow-wave sleep and does not awaken completely when aroused. Under these circumstances people essentially can sleepwalk and sleeptalk. The general term for these phenomena is ‘nocturnal confusional arousal’. Under circumstances of nocturnal confusional arousal, people may do things that make sense or do things that make no sense. For example, many doctors, most particularly young, sleep-deprived doctors, have been awakened by phone, given proper instructions and then been unable to recall the telephone conversation.
People with histories of severe psychological stress, such as war veterans, have been known to partially wake up and then act out past battle activities, sometimes wrecking the room and even hurting the bedpartner, with no recall of the incident in the morning.
This is the stuff that mystery novels are made of — the wealthy man signing a new will and never remembering, etc. Do not get any ideas, though. While it is possible for someone to make another person do something that is not in their best interests during a confusional arousal, chances are great that the victim will fully awaken, protest vigorously and remember everything in the morning.
77. Q: My 82-year-old mother lives alone across town. She gets along pretty well during the day but says that she cannot sleep at night. We have been telling her that older people have trouble sleeping and to try and do something instead of worrying about it. Well, lately the neighbors have said that she is up and about all hours of the night. She is even out on the street at 3 AM! What can we tell her to do?
Nighttime sleeplessness, wandering and confusion are very frightening and dangerous symptoms. These symptoms are increasingly common in our population’s elderly and a leading reason for admission to nursing homes. There are several possible reasons why older persons develop sleeplessness and wandering at night. These symptoms can be a sign of Alzheimer’s Disease or other forms of dementia. Such symptoms can also develop with conditions of severely disrupted sleep, such as sleep apnea and periodic limb movements during sleep, in which the patient reports little or no sleep but actually alternates between sleep and confused wakefulness hundreds of times per night. Certain medications taken for chronic medical conditions may also contribute to the problem. The symptoms described in this question are serious and termed ‘nocturnal wandering’. Consult a physician.
78. Q: Aside from the many problems leading to the symptom of insomnia, what are some of the other major sleep disorders?
Insomnia or poor sleep is the most common complaint concerning sleep. However, the most common reason people go to sleep specialists is not for insomnia but for difficulty staying awake. The two most common problems causing difficulty staying awake are sleep apnea and narcolepsy. Sleep apnea (stoppage of breath or difficulty in breathing during sleep) is quite common. Sleep laboratory studies on a random sample of middle-aged adults in Wisconsin showed that the prevalence of clinically significant sleep apnea at night with the symptom of sleepiness during the day was 2 percent for women and 4 percent for men. Randomized studies in California indicate that as many as 1 out of every 4 people over the age of 65 is affected with sleep apnea. Narcolepsy involves sudden ‘sleep attacks’ during the day and brief periods of muscle weakness brought on by laughter. Some 250,000 Americans, about equally divided between men and women, suffer from narcolepsy. While the sleepiness in sleep apnea stems from disrupted sleep and in narcolepsy, from a chronic neurological disorder; if either condition goes untreated, the symptoms can be disabling.
The most common signs are loud, irregular snoring and daytime sleepiness. In the apnea patient, breathing during wakefulness may seem entirely normal. However, during sleep the brain’s control of breathing and of muscles changes and apneas occur as the walls of the airway close-in during the act of breathing in (i.e. during inspiration). The patient struggles for air, the airway opens somewhat and air rushes in, causing loud snoring. The patient tosses about and goes back to sleep. This cycle is repeated hundreds of times throughout the night, each time disrupting sleep and contributing to the patient’s excessive sleepiness during the daytime.
Very. The condition can be particularly dangerous if it is combined with any significant heart or lung abnormality. In all major metropolitan areas there are medical facilities that evaluate sleep problems, and most have had the experience of an apnea patient dying at home in bed before treatment was given — most commonly while the center’s evaluation had yet to be completed or after the patient had refused treatment for sleep apnea.
If, as a result of apnea, a patient falls asleep inappropriately during the daytime, this symptom also can be life-threatening or cause serious injury and property damage. Consider the potential harm, for example, of a pilot or a school bus driver who falls asleep on the job.
The most important single factor is narrowing at one or more points in the anatomy (shape) of the airway. The narrowing may be no problem at all during waking hours. During sleep however, because of changes in the way breathing is regulated and because we are usually lying horizontally, the narrowing leads to sleep apnea. Narrowing can be anywhere along the airway from the back of the nose and throat (nasopharyngeal airway) to the point where the wind pipe (trachea) divides into the two tubes (bronchi) leading to the lungs. Narrowing could stem from hereditary influences in the way the body’s bones and muscles grow. Narrowing can also result from fat deposits or other types of extra flesh around the walls of the airway. The important thing is that the anatomical problem acts to partially reduce the size of the airway. Most sleep specialists now use an x-ray procedure, or some other imaging technique, to locate all places where the airway is too narrow.
Probably the most common reason for sleep apnea is extra tissue in the oropharyngeal airway — the spot between the base of the tongue and the Adam’s apple. Such extra tissue is common in overweight men with short muscular necks. The extra tissue reduces the opening in the airway available for breathing. The typical apnea patient is a man who is in his 40’s or 50’s, overweight, with a short, muscular neck, and history of snoring and progressively worsening sleepiness. Another common type of patient is someone with a jaw abnormality — like someone with a large overbite due to a receding chin. Such problems with facial structure can have the same effect on the airway during sleep as problems with extra tissue in the oropharyngeal airway.
Sleep apnea tends to run in families. This is because the shape of the face tends to be passed on from parents to children. The positioning of facial tissue and certain bones in the head and jaw greatly affect the size of the upper airway and thereby the likelihood of sleep apnea.
Alcohol and sedatives, by depressing the central nervous system and relaxing the airway muscles, can also contribute to sleep apnea. So can age — older people snore more, presumably because the airway tissues are more limp and therefore more likely to close in during intake of air.
82. Q: How is this disorder treated?
Physicians usually treat sleep apnea by providing pressure support for the walls of the airway during sleep with a technique called continuous positive airway pressure given through the nose – ‘nasal CPAP’ for short. Patients on nasal CPAP use a mask that fits over the nose to force air into the airway through the nostrils. Nasal CPAP works by creating a pneumatic (air pressure) splint to keep the airway open and has become a very successful treatment, if the device is used consistently. While the idea of wearing such a mask all night long might seem unappealing, most patients learn to use CPAP quickly and adapt to wearing the device whenever they sleep. The benefits of having their sleep apnea controlled seem to far outweigh CPAP’s inconveniences.
For some cases, surgery is indicated. An early approach was to perform a tracheostomy which consists of a permanent alternative airway below the Adam’s apple in the form of a tube that can be opened while sleeping and closed during waking hours. This treatment for sleep apnea is rarely used today except in short term or emergency situations. More recently, doctors have moved away from the disfigurement of tracheostomy by performing a surgical widening of the oropharyngeal airway. In some cases, the tissue is removed with a surgical knife in a procedure called a uvulopalatopharyngeoplasty (UPPP). When skeletal abnormalities are involved, many patients undergo surgical repositioning of the lower jaw, the hyoid bone and the upper jaw. If snoring is more of a problem than sleep apnea, oropharyngeal tissue can be repositioned by one or more treatments with a surgical laser in a procedure called a laser assisted uvulopalatoplasty (LAUP). The most recent surgical advance is called somnoplasty and entails temporarily inserting, into the tissue in the tongue and the walls of the upper airway, small needles that emit of radio-frequency energy. This bloodless and relatively painless process causes mucosal and fatty tissue beneath the skin to die and shrink away, thereby widening the air passage.
For less serious cases, there are dental devices that fit onto the teeth to reposition the lower jaw forward during sleep. This repositioning reduces the apneas and can also cut down on snoring.
Snoring is the sound made by air passing through irregularities and narrowings in the throat and windpipe. Snoring can occur when someone breathes in or breathes out. Snoring in itself is not dangerous, but it can be the first stage in the development of apnea. Weight gain, sedation or anything else that further constricts the oropharyngeal airway could turn a chronic snorer into a sleep apnea patient. Also, there are some data to suggest that chronic and severe snoring may lead to high blood pressure and cardiac changes. Doctors in Italy have reported that chronic snorers tend to have a greater incidence of high blood pressure (hypertension). More recently, researchers in Finland and Israel have also found the same strong relationship between snoring and hypertension.
84. Q: My husband snores so loudly that I have not been able to sleep in the same room with him for years. Recently our next door neighbors have complained to us about the noise he makes. They said there was an operation that could cure the problem. Is this true?
There is an operation that has been used for years, first in Japan and then throught the world, to eliminate or reduce snoring by removing excess tissues from the upper airway. With a wider, more regular opening, the air makes less noise as it goes by. The operation has also been used as a treatment for sleep apnea caused by airway blockage during sleep. Studies show that, in patients who have excess and obstructing tissue in the back of the throat, the operation does reduce snoring and sleep apnea. The operation is known as a uvulopalatopharyngeoplasty (UPPP). In a similar procedure, known as laser assisted uvulopalatoplasty (LAUP), oropharyngeal tissue is repositioned or removed by one or more treatments with a surgical laser. Another approach to reducing extra tissue in the upper airway is somnoplasty which involves shrinking tissue by radio frequency stimulation through a needle that is positioned by a surgeon to target areas with the greatest amount of extra tissue.
In most cases, no – unless there are cardiopulmonary consequences such as high blood pressure or episodes of sleep apnea. But, there may be ways of reducing a person’s snoring without major medical intervention. There is nothing wrong, for example, with trying to ask an otherwise healthy snorer to change sleeping positions. As a matter of fact, it is a good sign if a change of position – rolling over on the side, for instance – will stop a person’s snoring. Position-dependent snoring usually indicates that the person’s airway is less likely to obstruct than the airway of someone who snores regardless of sleeping position. Even some people with mild sleep apnea can breathe better when they sleep on their sides rather than on their backs. To insure that someone sleeps on their side, some doctors suggest special pillows or a soft, but lumpy, object – like a tennis ball – sewn into the back of the pajama top.
86. Q: When my husband sleeps, he stops breathing for a few seconds and starts again with a loud snort. The family used to laugh at the noise he made. But now I am so bothered by the noise that I lay awake worrying that he might forget to breathe and die. Am I being silly?
No. What you describe is sleep apnea (stoppage of breathing during sleep). The body controls breathing differently during sleep, and in your husband’s case, the control is not working properly during sleep. He should be evaluated at a sleep disorders center. He may require treatment with medicines or even an operation. Other signs of sleep apnea are daytime fatigue and sleepiness, morning headache, obesity and high blood pressure.
Narcolepsy is a disorder involving a chemical imbalance in the brain cells that control wakefulness and sleep. The disorder can run in families or appear as an isolated problem affecting only one individual in a family. The patient suffers sudden daytime sleep attacks – at mealtime, at the theater – really anywhere. Narcoleptics also experience abnormally timed components of REM sleep such as paralysis and hallucination. The paralysis depends on the brain mechanism that blocks muscle activity during REM sleep. Narcoleptic paralysis is involuntary and can come under two circumstances: (a) cataplexy – sudden muscle weakness leading to partial or complete collapse during the excitement of anticipation such as when telling a joke or catching a fish; (b) sleep paralysis – an often frightening inability to move just before falling asleep. The hallucinations of narcolepsy are known as hypnagogic hallucinations. These hallucinations also depend on REM sleep mechanisms and come as sometimes benign, sometimes terrifying apparitions just as the narcoleptic falls asleep. Animal forms of narcolepsy exist and can be passed genetically from parents to offspring, complete with abnormal sleepiness and cataplexy. Narcolepsy has been described in species such as dogs and horses. There are also reports of people getting narcolepsy after a disease or an injury to the brain. But the few carefully-studied cases of this ‘acquired narcolepsy’, indicate that there is no single disease of ‘acquired narcolepsy’, just various medical conditions with few real and sustained similarities to narcolepsy.
Exciting genetic discoveries have recently been made involving animal models of narcolepsy. Stanford University scientists identified a mutant gene that causes narcolepsy in dogs. The normal gene is called the hypocretin receptor 2 gene. The abnormal gene disrupts communications between neurons that use the neurotransmitter, hypocretin 2.
Working independently, a group in Dallas, TX and Boston, MA created a mouse strain that cannot produce hypocretin. This knock-out mouse has the symptoms of narcolepsy. It is expected that, because of the high degree of conservation across species in the hypocretin system, genetic defects affect hypocretin communication will be found to cause narcolepsy in some humans. However, it is not likely that defects in the hypocretin system will explain all narcolepsy because there are familial forms, non-familial forms and post traumatic forms.
The new anti-narcolepsy drug, modafinil, is chemically different from other drugs used to treat the sleepiness of narcolepsy. Modafinil, as well as older stimulant drugs activate hypocretin-containing neurons. These drug effects support the idea that hypocretin is somehow involved in the control of sleep.
Narcolepsy, after sleep apnea, is the second most common cause of the symptom of disabling daytime sleepiness. Narcolepsy is not rare in humans. Afflicting about 1 of every 2000 people throughout the world, narcolepsy is about as common as Multiple Sclerosis. Recent genetic studies have linked narcolepsy to certain genes at a particular location, called the Major Histocompatibility Complex, on chromosome number 6. The two genes most often studied because of their linkage with narcolepsy are those that produce the HLA-DR15 and HLA-DQ6 antigens found on the surface of white blood cells. Exhaustive research indicates that the gene which produces the specific HLA-DQ antigen called, HLA-DQB*0602, seems to be a true narcolepsy susceptibility gene. However, about 20 – 30 percent of the population have this gene and only about 0.05 percent of the population have narcolepsy. This means that other genes or environmental factors are necessary for narcolepsy to develop in people with the HLA-BQB*0602 gene. Since several genes in the Major Histocompatibility Complex have been linked to diseases of the immune system, there is currently much research on the genetic and the immunological make-up of narcoleptics and their families. To date, family studies of patients with narcolepsy have shown that in families where multiple members have narcolepsy, the HLA-DQB*0602 gene tends not to be present, indicating that familial forms of narcolepsy are caused by another gene or genes.
There is no cure, as yet, for narcolepsy. The symptoms of narcolepsy are controlled with a ‘double barreled’ approach: (a) Several daytime naps and stimulants, such as amphetamines, control the abnormal tendency to fall asleep at inappropriate times; (b) Other drugs that suppress REM sleep such as antidepressants, help control the symptoms of cataplexy, sleep paralysis and hypnagogic hallucinations.
This symptom is called ‘sleep paralysis’ and occurs without serious additional problems in 1 of every 20 people. Some people with sleep paralysis have the uncomfortable sensation of falling and ‘wake up with a start’ before they feel completely paralyzed. Waking up with a start is often called ‘hypnic jerk’. Scientists think that this paralytic condition is an incomplete triggering of a REM sleep period that brings on the profound muscle relaxation of REM sleep. The fright is sometimes overpowering even when the person completely understands the temporary and harmless nature of the paralysis. In extreme cases, drugs that block REM sleep are used to treat the condition.
89. Q: My father and his brother both have asthma. My father has difficulty mainly during the day. But my uncle was taken to the hospital two times in the past month for asthma attacks during the night. Does asthma get worse when we sleep?
Asthma is a serious medical condition that should be managed by a physician knowledgeable in respiratory medicine. Asthma attacks involve spasmodic contractions of the muscular walls of the air passages in the bronchi and lungs. Many attacks are brought on by allergic and/or emotional reactions. It is rare for someone to have attacks only during sleep – most attacks occur during wakefulness. Attacks during wakefulness can often be avoided or self-treated with inhaled medications. Sleep’s role in asthma attacks is not completely understood. One of the main reasons why asthmatic attacks may ‘break through’ during sleep is that the therapeutic effects of anti-asthmatic medications taken during the waking hours may not last throughout the sleeping hours.
However, there are several other reasons why sleep may be directly involved in bringing on asthmatic attacks: (a) We do know that sleep decreases the size of everyone’s air passages and this decrease may play a role in some asthmatic attacks during sleep. (b) During REM sleep, there can be brief bouts of irregular heart and lung function similar to that which occurs during activity or excitement. This irregularity during REM sleep may also bring on asthmatic attacks. (c) Many doctors believe that sleep-related esophageal reflux, which occurs to some extent in all of us, can bring on bronchospasms in asthmatic patients. (d) Finally, there is the fact that asthmatics may not be able to self-medicate as quickly after the first signs of an attack, if the attack comes during sleep.
90. Q: During the night my wife wakes me up by thrashing and moving. She seems to stay asleep, but she jumps and kicks. We like to share the same bed, but I cannot sleep with this kind of activity. What do I do?
Twitching of the legs or arms during the night, referred to as periodic limb movements during sleep, is a common, but little understood, problem. Many people with this condition are unaware of the twitches and do not have disturbed sleep, but for others, the movements seem to repeatedly disrupt sleep. Your wife could have periodic movements during sleep. People who have this problem may complain of insomnia or of daytime fatigue and sleepiness. The condition seems to be more common in women than in men and is often seen in patients with kidney or liver disease. The leg movements are often noticed after a pregnancy or a back injury. In many cases, the movements may disturb only the bedpartner and therefore, moving into separate beds in the same room ends up being the best solution.
There is another condition, known as REM behavior disorder, that involves abnormal movements during sleep. But, these movements are very different from nocturnal myoclonus. With REM behavior disorder, the arms and head may be involved as well as the legs. The movements may be quite violent and tend to occur in the early morning hours – when most REM sleep occurs. The condition is caused by changes in brain areas which maintain the muscle paralysis of REM sleep. Patients behave as if they were acting out a dream about some threatening situation.
Both periodic leg movements during sleep and REM behavior disorder can be treated with medications. Patients who have many disturbing movements and uncomfortable feelings of restlessness in the legs can improve with small doses of drugs usually used to treat Parkinson’s disease. The sleep disruptions associated with periodic movements is also helped by sedative drugs. Patients with REM behavior disorder stop acting out their dreams when they take low doses of the anti-epileptic seizure drug, clonazepam.
Persistent night sweats is a ‘red flag’ for physicians because it is a sign of several serious diseases. The best first step is to consider whether there is a medical problem causing these sweats. For example, night sweats can be signs of such diseases as tuberculosis and diabetes. Night sweats are also frequent in menopause. You should also check your temperature carefully several times throughout a 24-hour period to see if you are running a fever. If there is a possibility of a medical problem, you should go to a doctor and have a work-up.
If there is no pathological condition present, then there are two sleep-related phenomena that may explain such sweating. First, it is possible that the autonomic activity during REM sleep has brought on perspiration by much the same mechanism that one might perspire when anxious. The second possibility also concerns physiological changes of REM sleep. During REM sleep, because of the generalized muscle paralysis, our ability to maintain normal body temperature, by shivering and perspiring, is almost completely blocked. After a REM period, one’s core body temperature may have changed enough for a significant bout of perspiration for cooling down or shivering for warming up to occur in the following minutes of wakefulness or NREM sleep.
92. Q: I have heard that most people die in their sleep. Is this true? And isn’t it a blessing to die so peacefully?
Most disease-related deaths probably do occur during the usual hours of sleep. But, such a death may be far from a blessing; many deaths during sleep may even be avoidable. Man has expressed concern about mortal and morbid events related to sleep and the night since recorded history. The Bible says that Solomon’s bed was guarded by 60 valiant men because of fear in the night. The ancient poets, Homer and Virgil, referred to sleep as a “blood relative” of death. There are modern examples too. Shakespeare, referred to sleep as “death’s counterfeit”. F. Scott Fitzgerald wrote with respect to psychological distress: “In the real dark night of the soul it is always three o’clock in the morning”. These ancient concerns may reflect a deep-seated belief that humans are somehow more vulnerable to catastrophe at night.
There are medical studies to indicate that such concerns are more than superstition. Early morning peaks in human mortality were described in medical records as early as the late 1800’s. Modern scientists know that, excluding traumatic deaths, the largest number of deaths do occur during the hours from midnight to 8 AM. However, it is not known how many of these deaths actually occur during sleep. Some diseases do worsen during sleep. Diseases such as emphysema, coronary artery disease and some high blood pressure conditions are most troublesome during the night when we sleep. Exacerbations of these diseases may be due to sleep-related decreases in the efficiency of breathing, irregularities in the control of heart function during REM sleep, as well as to problems stemming from lying in the horizontal position all night long.
Yes, definitely. Most patients with narcolepsy and sleep apnea, for example, come to doctors for help because they are having difficulty staying alert while driving or working. However, dangerous sleepiness can occur in anyone, not just people with serious sleep disorders. A study by the Center for Traffic Safety at the University of North Carolina Highway Safety Research Center determined that as many as 15% of all vehicle accidents are due to falling asleep, or fatigue-related inattentiveness, at the wheel.
Traffic accidents are a major cause of death, injury and property loss. More and more studies are finding that falling asleep at the wheel is a major factor, perhaps the most important after alcohol, in causing traffic accidents. Fatigue-related traffic accidents usually involve no more than one or two vehicles. Yet, they are the most destructive of all to life and property, probably because the drivers are so inattentive that they do not slow down before the crash. The time at which fatigue-related traffic accidents occur shows a pattern with two peaks: one between midnight and 3 AM and one between 2 and 5 PM. When scientists asked people to try and fall asleep periodically throughout the day, they found that sleep tendency in normal humans also has the same two-peak pattern with an early morning and a late afternoon high point. When we get too little sleep or take any substance that causes sleepiness, these periods of increased sleep tendency can be transformed into periods when bouts of unintentional sleep occur. These bouts of sleep may be experienced as harmless, brief lapses in attention, but they can also lead to disaster.
Modern day problems of sleep-related accidents extend beyond highway travel to industry as well. Throughout recorded history, many people have decided, or been forced, to cut back on their sleep and have often fallen asleep on the job. What is worrisome is that today, as opposed to as little as a hundred years ago, so many more people can be hurt by a sleepy or inattentive worker. For example, when a train driver or a nuclear power engineer falls asleep on the job, the result can be catastrophic in terms of the loss of life and property. When a stagecoach driver fell asleep on the job in the 1800’s, the lapse might even have gone unnoticed. The major reason for increased interest in sleep is that, in the 1900’s, too much sleep in the work environment and too little sleep at home have become dangerous to all of us. In industries where people must work round the clock, scientists find that workers – particularly those workers on evening and graveyard shifts – may not always be sufficiently rested to function with necessary alertness. The nuclear accidents at Three Mile Island and Chernobyl both arose from mistakes that occurred between midnight and 3 AM. And, the decision to launch, which lead to the Space Shuttle disaster on January 28, 1986, came during this same early morning peak in sleepiness. Moreover, the NASA officials involved in those decisions were seriously overworked and sleep-deprived. Thus, on the road and in the work place, it is important to respect your sleep need and recognize the signs of excessive sleepiness, such as lapses in attention, that may actually be unintentional bouts of sleep.
Teeth grinding or bruxism is a dysomnia which means that it is an abnormal behavior occurring during sleep. Bruxism, when extreme, can cause damage to teeth and jaws. Physicians sometimes use medication to control bruxism. Dentists may prescribe a mouthpiece or other appliance that is worn during sleep to prevent tooth damage.
There are many reasons why someone might wake up with a headache. The most important possibilities to think about are sleep-related breathing disorder and sleep-related vascular headache. People with sleep-related breathing disorders do not get enough oxygen in their blood during the night and may awaken with headache and grogginess. Tell-tale signs of sleep-related breathing disorder are snoring, obesity, high blood pressure and chronic heart disease. People with sleep-related vascular headache experience spasms in the muscles in and around the blood vessels of the head. These spasms occur most often during REM sleep. Both conditions are treatable once the diagnosis is made.
There is no single answer to this question. A good rule of thumb is to see a specialist if your sleep problem persists for a month or more despite following your doctor’s advice and prescriptions. However, you should get expert help immediately if you have experienced dangerous symptoms such as (a) waking up with chest pain and/or shortness of breath, (b) falling asleep at an inappropriate time such as while at an enjoyable party, or at a dangerous time such as while driving a car.
Specialists in sleep disorders medicine are physicians with a staff and a laboratory for diagnosing and treating patients with all sleep-related disorders. These disorders include difficulties in falling asleep, staying asleep or remaining awake. The most serious symptoms of sleep disorders are daytime sleepiness, excessive use of sleeping pills, nighttime chest pains, morning headaches, heavy snoring and breathing irregularities during sleep. Diagnostic and treatment services are provided by professionals experienced in sleep-related and sleep-exacerbated diseases. Other physicians with expertise in neurology, pulmonary medicine, psychiatry and psychology are always available to the sleep disorders specialist. Many large hospitals and medical schools have sleep disorders facilities. To locate a sleep disorders specialist, consult your regular physician or write:
American Academy of Sleep Medicine
6301 Bandel Road, Suite 101
Rochester, Minnesota 55901
Telephone: (507) 287-6006
web site: http://www.aasmnet.org/
The Academy provides locations of sleep disorders centers throughout the country that have been accredited as meeting the Academy’s standards of care as well as names and addresses of doctors certified by the American Board of Sleep Medicine as specialists in the diagnosis and treatment of sleep disorders.
98. Q: For people who do feel they need professional help, what can they expect from a sleep disorders center?
The first step is an initial interview with one or more physicians – pulmonary specialists, neurologists, psychiatrists – depending on what seems to be the nature of the problem. This interview includes the gathering of a detailed medical history and physical examination. The case is then reviewed by the center’s medical staff, who are assisted, if necessary, by other consulting physicians such as endocrinologists, ear, nose and throat specialists, etc. After reviewing the material from patient’s medical history and physical examination, the physician will decide whether or not to order a polysomnographic session at the laboratory and what such a session might entail.
99. Q: I have seen people all wired-up for sleep labs. What happens if I cannot sleep in the lab and what are all those wires for anyway?
Remember that the polysomnogram is a medical test. It will not seem like a normal night at home, but this rarely matters. The purpose of the polysomnogram is to measure physiological functions during sleep. Testing usually involves sleeping one or two nights in a sleep laboratory where all aspects of sleep are carefully monitored. The procedure is safe and painless. It is carried out in a comfortable, private room by a trained technician under the supervision of a physician. Sensors are attached to the patient’s head, on either side of the eyes, near the heart and under the chin to pick up brain waves, eye movements, heart and muscle activity, respectively. Other instruments are positioned to monitor breathing, blood oxygen levels and any additional physiological measures that may have been ordered by the patient’s doctor. All leads are connected to a polygraph machine that keeps track of the data on one, unbroken piece of paper that is nearly a mile long. Nighttime recordings are often followed by daytime tests, such as The Multiple Sleep Latency Test or The Maintenance of Wakefulness Test, to determine whether the sleep disorder involves abnormal tendency to fall asleep. Daytime tests are very important because they help the doctor decide on any necessary precautions for driving and work safety.
With all this going on, no one expects the patient to sleep as well in the lab as they would at home in their own bed. However, in most cases, as little as 3 hours of nighttime sleep is sufficient for diagnostic purposes. This is because sleep specialists need only monitor patients during representative intervals of both NREM sleep and REM sleep. The chances are better than 1000 to 1 that a patient will sleep well enough for a diagnosis to be made. Sleep disorders patients very rarely have problems in the laboratory because most have long histories of sleep difficulties and consider one or two more nights of disturbed sleep to be well-worth the benefit of getting an accurate diagnosis for their sleep problem. In truth, most patients are surprised at how well they actually do sleep in the lab.
After the session in the sleep lab, the resulting polysomnographic data must be evaluated page by page for sleep phases and for pathological events. This process involves several hours of a technician’s time and 1 – 2 hours of a physician’s time, as well as extensive use of laboratory computing equipment. The evaluation and interpretation is usually completed in about 5 working days. Then, laboratory findings are reviewed and considered in light of the doctor’s findings from the medical history and physical examinations. Sleep specialists can then make a diagnosis and make recommendations for treatment. The patient can be treated either at the sleep disorders center or by the personal physician. A complete work-up at a sleep disorders center and initiation of treatment will require between 1 and 3 visits to the center. Depending on the patient’s schedule and the backlog at the center, the process usually takes between 7 – 21 days.
Professional fees and laboratory charges vary considerably throughout the country according to contractual arrangements, local pay scales and overhead costs. If your insurance company or if you alone are entirely responsible for your healthcare expenses, expect the initial consultation and related office procedures to cost between $200 – $500. Individual costs will vary depending on the complexities of the problem, the pertinence of past medical records and whether or not additional medical tests are needed. Laboratory testing, if ordered by the sleep disorders physician, is an additional and significant cost. An all-night sleep recording runs between $700 – $1600 depending on the costs of medical care in your location and exactly what type of recordings are done. A daytime recording to determine whether or not there is impairment in ability to stay alert runs between $500 – $800. So, the overall cost of a sleep disorders center evaluation can vary between $200 – $3000.
Nowadays, in the midst of healthcare reform, there is no simple answer to this question. If you have good outpatient insurance that covers diagnostic procedures such as x-rays and blood tests, and if your sleep problem is organically based, such as sleep apnea or narcolepsy, then your coverage should be very good. On the other extreme, if you are on Medicare or Medicaid and your sleep problem is psychologically-based, such as anxiety with insomnia, then you should expect little financial help from your health insurance. In most common managed healthcare plans, some provisions are made to provide sleep disorders services, particularly for sleep apnea. This is done either by specially trained physicians working within your healthcare system or through a contract between your healthcare plan and an independent sleep disorders center. In all cases, it is important for you to begin getting help by clearly presenting your sleep related symptoms, including any problems you may have staying awake at work or while driving, to your primary care physician. In some cases, great persistence on the part of the patient may be necessary in order to get the healthcare plan to provide sleep disorders services.