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
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
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
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
6. Be careful about sleeping pills. These medications should not
be taken for more than four weeks. Longer use leads to increased
7. Find the right room temperature for you and maintain it throughout
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
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
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
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
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
Q: What are sighs indicating that someone is not getting enough
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
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
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
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
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
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
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
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
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
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
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
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
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
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.