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Sleep Questions - download this document in Microsoft Word format

Q: What is sleep?
A: Sleep is a behavioral state characterized by very 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 specifically what sleep does. Nevertheless, we all know 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 spare 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 altering stimulation is required to awaken a sleeper from 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 of REM sleep as a 'deep' phase of sleep too.

There are many theories about the function of REM sleep and dreaming - ranging from 'safe, socially acceptable, wish fulfillment' to maintenance of memories'. 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 widely 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. The Nobel Laureate, Francis Crick, thinks that REM sleep "detunes" the brain, ridding it of overused associations, thereby improving cognitive abilities during the day. 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 on the next page is called a hypnogram. Hypnograms are made to summarize sleep laboratory recordings. This particular hypnogram shows how a typical nights 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.

Q: Why do we sleep?
A: 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 communications 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, felling 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).

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 system - it is not possible for even the poorest of sleepers to lose so much sleep that life is threatened.

Q: How much sleep should I get?
A: 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 hour 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 to feel refreshed and alert during 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 sleeping 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.

Q: Is it true that we need less sleep as get older?
A: 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 idea 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 someone is forced to wake-up again and again when they sleep. In fact, research on repetitive sleep disruption, called 'sleep fragmentation', has shown that the rate of sleep disruptions determines whether or not sleep is felt to be satisfactory 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.

Q: What is yawning?
A: Yawning, as we all have observed in ourselves, and others, consists of widely opening the mouth. 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. Scientist have caused yawning in animals and in people by experimentally reducing oxygen levels in the air they breath. This experimentally-induced yawning can be stopped by stimulation to increase breathing. Yawning can also can be triggered by drugs that promote sleep and by certain brain chemicals involved in the control of sleep and wakefulness. The brain areas that seem to control yawning are located in the lower portions of the brain, known as the brainstem, very near the brain areas that control breathing.

Q: What about bedroom temperature and sleeping position? Can these things affect sleep?
A: 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 temperatures, 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 sleep night. Scientists think such movement is good because it prevents pressure-related restriction of circulation. However, some 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 breath 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.

Q: Can we make up for lost sleep?
A: Yes, we can make up for lost sleep, but only to a certain extent. Suppose a man, who usually sleeps 7 hours a night, looses 2 nights of sleep. He will certainly 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. Thus, a major sleep disruption or a major shift in sleep time will have effects for several days on any sleep that follows.

Q: Are there any advantages to taking a nap?
A: Certain cultures use 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, particularly if 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.

Q: Does meditation change sleep?
A: Meditation probably will not affect sleep in any significant way. In most common forms, meditation involves the practice of sitting in some prescribed position with the eyes closed '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 meditation have found that most meditation is characterized by the brain wave pattern of quiet, relaxed wakefulness with occasional bouts of NREM sleep. Thus, the 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.

Q: Can we learn better during sleep?
A: 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.

Q: DO we dream during our deepest sleep?
A: 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.

Q: Do people in other countries and cultures sleep differently?
A: 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 long 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 light interval in the day with long light periods bringing on a daily schedule that contains two sleep bouts.

Q: Does your body size affect sleep?
A: There seems to be no direct effect of body size on sleep. Small people sleep just as much as large people of comparable ages. However, if body size secondarily restricts movement or respiration, such as is common with extremely overweight people, then sleep can be profoundly disturbed.

Q: What are the best ways for most of us to get a good night sleep?
A: Here are nine sensible rules for a good night's sleep:

1. Stick to a regular schedule of going to bed and getting up at the same time every day.
2. 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.
3. Exercise regularly in the morning or early afternoon, but do not engage in strenuous physical activity just before bedtime.
4. Stay away from caffeine-containing drinks after about 4 PM.
5. Avoid alcohol after the dinner hour. Instead of promoting sleep, a nightcap actually disturbs sleep patterns and can cause early morning awakenings.
6. Be careful about sleeping pills. These medications should not be taken for more than four weeks. Longer use leads to increased insomnia.
7. Find the right room temperature for you and maintain it throughout the night.
8. Try to relax before going to bed: Take a warm bath, read a light novel, listen to music, avoid stressful thoughts.
9. Do not eat heavily just before going to bed.

Q: Does diet make a difference in your sleep? For example, is warm milk at bedtime a good idea?
A: The effect of diet on sleep has been researched with good laboratory techniques. All of us certainly hear many personal observations and testimonials concerning the energy and 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. Finally, much research suggests that sleep may be improved with the use of tryptophan, a Naturally occurring amino acid which is found in many foods. Be careful with tryptophan tablets that are available in health food stores, because too much tryptophan can cause nausea and other gastrointestinal problems.

Q: Will a 'night cap' aid in sleeping?
A: 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 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 great 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.

Q: Is it bad to eat just before going to bed?
A: There is no single answer to this question. Obviously, heavy foods and/or foods leading to indigestion will disrupt sleep. Small amounts of light food may help some people feel comfortable and, thereby, assist sleep. New research indicates that we burn less of the calories in food eaten before bed than food eaten before we begin our day's activity. So, for those few of us who are trying to gain weight, a bedtime meal is the most efficient. Conversely, bedtime is the worst time for weight watchers to eat.

Q: Does tryptophan really help in getting to sleep?
A: Tryptophan is an essential amino acid that was sold in super markets and health food stores. Many people have used tryptophan 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 disease, all tryptophan was removed from the market. At this writing, tryptophan is expected to soon be available in stores without the offending impurity.

There is good reasons why tryptophan might help sleep. Reasearch has linked a brain chemical called, serotonin, to sleep. Since the body chemically changes tryptophan into serotonin, tryptophan has been studied as a natural sleep inducer. Many studies show that 1-5 grams of tryptophan can help some people who take a long time to fall asleep and wake up frequently. There is also research that indicates tryptophan is useful in the elderly who have mild sleep-related breathing problems.It is not likely that the amount of tryptophan in a normal meal, or even a trptophan-rich food, will affect subsequent sleep. Studies show that tryptophan is needed in quantities of up to 5 grams per night for reliable sleep-enhanced effects. Watch out, though, for tryptophan's side effects of nausea and diarrhea. Finally, if you are taking it without a doctor's supervision and if it does not noticeably help, stop taking it.

Q: I have just stopped drinking coffee. Now I can't stay awake and I get terrible headaches. Am I hooked on coffee?
A: 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.

Q: I have just stopped smoking. Now I can't stay awake and I get terrible headaches. What should I do?
A: The effects of nicotine withdrawal that come from stopping 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.

Q: What does marijuana do to your sleep?
A: 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 getting to sleep and reduced REM sleep. It is not considered to be a good sleep aid.

Q: What does cocaine do to your sleep?
A: 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 stages 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'.

Q: What does amphetamine do to your sleep?
A: 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.

Q: What does heroin do to your sleep?
A: Heroin is a depressant that retards intellectual and motor function 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.

Q: My husband has been put on medication to reduce pain and swelling. Since he started taking the drug, he has complained of insomnia. Could there be a connection?
A: 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 a doctor's supervision.

Q: How many Americans have trouble falling asleep or other complaints of insomnia?
A: Most people complain from time to time about difficulties with poor sleep, but if you narrow the question down to those with serious complaints, you have about 120 million people with frequent, short-lived insomnia caused by 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. Then you have another 20 million people who suffer from chronic insomnia throughout their lives. Experts estimate that about 70 percent of chronic insomnia seek medical help. These are mostly the people whose sleep problems lead to difficulties during daytime - not just at night.

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?
A: Sleep experts tell us that the first thing people with this problem should do is become regular and try to maximize the natural tendency to sleep once a day. 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 bad sleep aid because, while it may help you feel drowsy, it wears off in 3 or 4 hours and actually wakes you up once it has been partially eliminated by the body's metabolic processes. Alcohol is second only to depression as the leading cause of waking up too early and being unable to get back to sleep.

If you do wake up at 3in 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.

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?
A: 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 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
Q: would it help to take a hot bath or read a dull book before going to bed?
A: 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 your 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.

Q: My friend bought a record of sounds and special music that is supposed to help beat insomnia. Do such records work?
A: 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 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 system have led to proper sleep laboratory evaluation only of drugs that are manufactured and sold for the complaint of insomnia.

Q: What about the old 'early to bed, early to rise' axiom?
A: Sleep specialists would revise this old advice from Benjamin Franklin. A better rule is 'consistency to bed and consistency to rise makes one healthy, wealthy and wise.' Some people 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.

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?
A: Sleep is an activity, 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 NREM sleep, this type of sleep is thought to be particularly restful. If we go to bed at, say, 10 or 11 PM, we 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.

Q: My wife has arthritis and can manage pretty well during the day, but she is miserable at night because she cannot sleep. Is there anything that can be done?
A: 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 the 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.

Q: I have been on rotating shift work for ten years and never had a problem with sleep. Lately, though, the graveyard shift is just murder for me and I cannot seem to sleep in the day. Where have I gone wrong?
A: Chances are that you have not gone wrong - just gotten older. People are very different in the way they handle work-sleep irregularities. Some people can never stand swing or graveyard shifts. Others enjoy the changes! Besides individual differences, the most important factor in people adapting to shift work is age. Statistically, the older you are, the tougher shift work is to handle. 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 day shift.

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?
A: 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.

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?
A: 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.

Q: Is it good to exercise before going to bed?
A: 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 alters 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.

Q: My husband is always falling asleep around the house. He seems to get a lot of sleep at night. 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?
A: 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 a 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.

Q: I feel as though I have not slept a wink in 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?
A: 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 altering 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. But, relax. As far as doctors know, nobody ever died from insomnia. Find out what is keeping you awake.

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?
A: 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 problems 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.

Q: We just had a death in the family and a lot of the problems have left up to 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?
A: Sleep problems at the time of personal crisis are very common and may be even considered a normal part of the grief process. Modern sleeping pills of the benzodiazepine class 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.

Q: My husband wants to buy a new waterbed because he read that people sleep best on this kind of surface. Is this true?
A: The best research available on the subject of sleeping surfaces shows that most people can sleep as well on a concrete floor as on the most elaborate mattress available. All that is needed is a few days of adaptation. People sleep best when they are comfortable, but is seems that what you sleep on is not a major factor in the quality of your sleep.

Q: I think I have insomnia, but it is only on Sunday night. Why is this?
A: The first thing to consider in this situation is your weekend schedule of sleep and activity. If you are staying up later to play or party and sleeping late on Saturday and Sunday mornings, you are setting up perfect conditions for Sunday night insomnia. 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 sleeping earlier, say, on Sunday night. The next thing to consider is weather you have some apprehension about Monday's activities.

Q: Are we really more likely to get sick if we do not sleep enough?
A: 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. Other studies show that the cells and chemicals of our immune system, released as our body fights off invading germs, actually do make us sleep. So there may be some truth to this old adage.

Q: What are sighs indicating that someone is not getting enough sleep?
A: The main tip-off is daytime sleepiness - the inability to function effectively during the day. 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.

Q: What can cause insomnia?
A: 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.
- Abnormal leg twitching 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.

Q: What are the best ways to treat these problems?
A: Once a specific diagnosis is made, proper treatment is aimed at the cause of the insomnia. For example, people with insomnia secondary to respiratory difficulties 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. Such pills should be taken over not more than a three-week period - and preferably not every night. They 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.

Q: Can sleeping pills make matters worse?
A: 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 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.

Q: How long will it be before science develops a natural, non-addictive sleeping pill that acts like the natural sleep-producing chemicals in the brain?
A: 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 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 exciting new approach for insomnia and other problems related to jet-lag has been use of melatonin, a natural chemical manufactured by certain brain cells. Melatonin is thought to be involved in regulating our body clock. Scientists are experimenting with giving melatonin to people at specific times each day for several days prior to a long flight east or west. Preliminary work found that melatonin pretreatment can somehow reduce the symptoms of jet-lag.

Another promising approach to sleep rescheduling is the use of bright light at a particular time of night. Doctors think that people who need to sleep at a time different than their habitual time - either because a disorder has shifted their schedule or because they must work on a new schedule - can shift their sleep time later by sitting, for several hours before they would normally go to bed, in front of a bright light. The light is thought to reset the biological clock. However, you should not try this on your own. For one thing, the research is too preliminary. For another, usual home lighting will not do. The delaying effect requires at least 2-3 nightly, 4-hour exposures to lighting as bright as dawn sunlight.

Q: Can behavior modification cure insomnia?
A: 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 tying until they find the technique that works best for them, rather than to rely on pills.

Q: Is exercise helpful?
A: 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 good night's sleep.

Q: If one has trouble falling asleep, is it better to get up or stay in bed and 'count sheep'?
A: 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.

Q: Is waking up too early a sigh of depression?
A: Yes. 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 symptoms of insomnia, treatment is focused on the depression rather than the insomnia. Once such depression is adequately treated, problems with insomnia improve greatly.

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?
A: 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 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. However, activity during the 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 interest during a confusional arousal, chances are great that the victim will fully awaken, protest vigorously and remember everything in the morning.

Q: My 82-year-old mother lives alone across town. She still 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?
A: Nighttime sleeplessness, wandering and confusion are very frightening 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 sigh 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 nocturnal myoclonus, 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.

Q: Aside from the many problems leading to the symptom of insomnia, what are some of the other major sleep disorders?
A: Insomnia or poor sleep is the most common complaint concerning sleep. However, the most common reason people go to sleep specialists is difficulty staying awake. The two most common problems causing difficulty staying awake are narcolepsy and sleep apnea. Narcolepsy involves sudden 'sleep attacks' during the day. Some 250,000 people, about equally divided between men and women, suffer from narcolepsy. Sleep apnea (stoppage of breath or difficulty in breathing during sleep) appears to be more common, but scientists have no good estimate of prevalence for the entire population. However, doctors do know that this condition affects mostly men until the age of 50 or so. But by age 60, women are nearly as likely as men to be affected. In people over the age of 65, there are scientifically valid studies indicating that as many as 1 out of every 4 people is affected with clinically significant sleep apnea.

Q: What are the signs of sleep apnea?
A: The most common signs are loud, irregular snoring and daytime sleepiness. The apnea comes from the walls of the airway closing on inspiration during sleep. 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.

Q: Can sleep apnea be dangerous?
A: Very. If it is combined with any significant heart abnormality and reduction of oxygen levels in the blood, it could result in death. There are some 300 sleep disorders centers in the country, and most have had the experience of an apnea patient dying at home in bed before treatment was given - either because the center's evaluation was yet to be completed or because the patient had refused the recommended treatment.

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.

Q: What causes sleep apnea?
A: 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) leads into the lungs. Narrowing could stem from hereditary influences in the way the body's bones and muscle grow. Narrowing can also result from fat deposits or tumor 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 around the face and neck 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.

Alcohol and sedatives, by depressing the central nervous system and relaxing the airway muscles, can also be contributing factors. So can age - older people snore more, presumably because the airway tissue are more limp and therefore more likely to close during intake of air.

Q: How is this disorder treated?
A: For serious cases, surgery is often indicated. One approach has been 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. More recently, doctors have tried to get away from the disfigurement of tracheostomy, if possible, by performing a surgical widening of the oropharyngeal airway, called a uvulopalatalpharyngeoplasty (UPPP). When structural abnormalities of the jaw and face are involved, surgical reconstructive approaches are sometimes used.
Recently, doctors have used a nonsurgical treatment called continuous positive airway pressure through the nose or 'nasal CPAP'. Patients on this treatment use a mask that fits over the nose to force continuous air pressure 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.

For less serious cases, less radical treatments are available: Weight reduction, respiratory stimulants, drugs to increase muscle tone, or devices that position the tongue forward during sleep.

Q: What causes snoring?
A: 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 Bologna, Italy have reported that chronic snorers tend to have a greater incidence of high blood pressure (hypertension). More recently, doctors in Helsinki, Finland also found the same strong relationship between snoring and hypertension.

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 noises he makes. They said there was an operation that could cure the problem. Is this true?
A: There is an operation that has been used for years in Japan to eliminate or reduce snoring by removing excess tissue from the upper airway. With a wider, more regular opening, the air makes less noise as it goes by. The operation was introduced from Japan to the United States about 10 years ago as a treatment for snoring and as a treatment for sleep apnea caused by airway blockage during sleep. In patients who have excess and obstructing tissue in the back of the throat, the operation does reduce snoring and sleep apnea.

Q: Should snoring be treated?
A: 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.

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 noises 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?
A: 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 right 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 headaches, obesity and high blood pressure.

Q: What is narcolepsy?
A: Narcolepsy is a congenital or genetic disorder involving a chemical imbalance in the brain cells that control wakefulness and sleep. As a result, 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 hypnogogic 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.

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 1000 people throughout the world, narcolepsy is about 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 known as the HLA-DRw15 and HLA-DQw6. Since other genes in the Major Histocompatibility Complex have been linked to disease of the immune system, there is currently much research on the genetic and the immu8nological make-up of narcoleptics and their families.

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 hypnogogic hallucinations.

Q: Just before I fall asleep, I have the frightening feeling that I cannot move. Is this abnormal?
A: 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.

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. Will my father get it this bad too?
A: 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 the night.

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?
A: Leg twitching during the night, referred to as nocturnal myoclonus or periodic leg movements during sleep, is a common problem. Most people are unaware of these twitches and do not have disturbed sleep, but for others, the movements seem to repeatedly disrupt sleep. Your wife may have these 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 men. The leg movements are often noticed after a pregnancy or a back injury.

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 medication. The drugs for REM behavior disorder are usually quite effective in getting the patient and the bedpartner quietly through the night.

Q: I often wake up dripping with sweat. What can cause this?
A: Persistent night sweats is a 'red flag' for physicians because it is a sigh of several serious disease. 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 disease as tuberculosis and malaria. 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 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.

Q: I have heard that most people die in their sleep. Is this true? And isn't it a blessing to die so peacefully?
A: 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.

Q: Can sleep disorders really cause enough sleepiness to make driving and work unsafe?
A: Yes, definitely. Most patients with narcolepsy and sleep apnea, for example, come to doctors for help because they have difficulty staying alert while driving or working. However, dangerous sleepiness can occur in anyone, not just people with serious sleep disorders.

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 harmlessly brief lapses in attention, but they can also lead to disaster.

The problem of sleep-related accidents extends beyond highway travel to industry as well. For example, 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. For example, the nuclear accident 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 the 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.

Q: My 16-year-old son grinds his teeth only when he sleeps. What should I do?
A: 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.

Q: Many mornings I wake up with a headache. I am not a drinker. What can cause this?
A: 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 disorders 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.

Q: When should someone consult a specialist for a sleep problem?
A: There is no perfect answer for 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 while driving a car.

Q: How do I find a specialist in sleep disorders?
A: Specialists in sleep disorders medicine are physicians with a staff and 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 disease. Other physicians with expertise in neurology, pulmonary medicine, psychiatry and psychology are always available to the sleep disorders specialist, contact your regular physician or write:

American Sleep Disorders Association
604 Second Street Southwest
Rochester, Minnesota 55902
Telephone: (507) 287-6006

The association will send a complete list of facilities specializing in sleep disorders throughout the country.

Q: For people who do feel they need professional help, what can they expect from a sleep disorders center?
A: 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 suck a session might entail.

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?
A: 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, 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 wonderfully in the lab. However, in most cases, as little as 3 hours of nighttime sleep is sufficient for diagnostic purposes. This is because doctors need to monitor patients during both NREM sleep and REM sleep. The chances are better than 1000 to 1 patient will sleep well enough for the doctor to make a diagnosis. 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 phase 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 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.

Q: How much will an evaluation cost?
A: Professional fees and laboratory charges vary considerable throughout the country according to the local pay scales and overhead costs. You should expect the initial consultation and related office procedures to cost between $150 - $500. Your particular charge may vary depending on the complexities of your problem, the pertinence of your past medical records and the recency of any medical tests you may have had before coming to the sleep disorders center. Laboratory testing, if ordered by the sleep disorders physician, is an additional and significant cost. An all-night sleep recording runs between $700 - $1600. A daytime recording to determine whether or not there is impairment in ability to stay alert runs between $400 - $700. So the overall evaluation can vary between $150 - $2700.

Q: Will my health insurance pay for a sleep disorders evaluation?
A: In general yes. The insurance reimbursement average across the country is between 70% - 90% of the actual bill. In most cases, you will be responsible for any portion of your bill left unpaid by tour insurance company. Individual insurance companies vary in their reimbursement policies. 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, 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.







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