Discuss the origins and implications of Hippocrates' medical theories on sleep and dreams in relation to modern sleep studies.

Hippocrates proposed that sleep was due to blood movement from the limbs to the central body, contrasting with Alcmaeon's theory of blood filling the brain to induce sleep . Aristotle, another ancient thinker, suggested sleep was caused by "fumes" from food affecting the brain . These early ideas reflect attempts to understand sleep chemically and vascularly . In contrast, modern sleep studies rely on neurophysiology and have identified distinct sleep stages, including REM, associated with dreaming and demonstrating that the brain remains active during sleep . The discovery of REM sleep in 1953 by Aserinsky and Kleitman marked a significant shift towards understanding the electrophysiological aspects of sleep, showing that dreams occur during this state . Current research also involves interdisciplinary approaches linking sleep to various physiological and psychological processes, recognizing sleep as an active state vital for overall health . Consequently, while ancient theories laid the groundwork by associating bodily processes with sleep, modern studies have expanded to a detailed understanding of brain function during sleep.

Critically compare the role of religious and rational institutions in the evolution of medicine from ancient to early modern times.

The evolution of medicine from ancient to early modern times shows significant influence from both religious and rational institutions. Religious institutions, like monasteries and temples, played a major role through their establishment of care facilities for the sick, following mystical and superstitious beliefs. Monasteries in the West emphasized prayer and religious practices over scientific medical teachings, as evident in places like Monte Cassino, founded by St. Benedict . Similarly, the Asclepian temples in ancient Greece focused on healing through rituals and faith, incorporating ceremonial acts and faith-based cures, which were often effective due to the psychological and environmental impact rather than scientific reasons . On the other hand, rational institutions contributed significantly to the advancement of medicine through observation and scientific methods. For example, Greek philosophers like Alcmaeon and Empedocles introduced concepts focusing on natural processes and bodily balances rather than supernatural causes, laying groundwork for more scientific approaches in medicine . The rise of universities, like those at Salerno and Montpellier, showcased a move towards scientific inquiry and clinical observation over religious mysticism, fostering environments where rational thought and medical science could flourish . By the 17th and 18th centuries, medicine saw a shift towards scientific inquiry with figures like Von Haller and Descartes advancing physiological and anatomical knowledge, breaking away from mystical explanations and practices . Thus, while religious institutions provided essential care infrastructure and a faith-based approach to healing, rational institutions propelled medicine into a more empirical and scientific discipline.

Analyze the shift from philosophical to empirically based medical practices from ancient Greek times through the 17th century.

The transition from philosophical to empirically based medical practices saw significant shifts. Initially, Greek philosophers like Thales and Pythagoras integrated observational methods with philosophical concepts . By the 17th century, figures like René Descartes promoted mechanistic and experimental approaches, challenging the notion of humors and advancing the scientific method as advocated by contemporaneous thinkers like Francis Bacon . This period marked a transition from theoretical speculation to empirical observation and experimentation, foundational to modern medical practices .

Discuss the evolution of sleep theories from Alcmaeon's time to Hippocrates' perspective and the subsequent impact on medical practices.

Alcmaeon in the 5th century B.C. posited that sleep resulted from the brain filling with blood, a theory that connected sleep with the physiological state of the brain, similar to apoplexy-induced stupor . Hippocrates proposed a contrasting view, suggesting that sleep was due to blood moving from the limbs to the body's core, which inverted Alcmaeon's ideas . These early theories laid the foundation for later vascular theories of sleep, debated extensively into the 19th century but eventually overshadowed by chemical and behavioral theories . The early focus on the physical movement of blood reflected a broader Greek medical tradition incorporating humoral balance, evolving to influence medical practices like bloodletting and therapeutic diets . Modern sleep research has largely moved beyond these ancient theories, embracing neurochemical and neurophysiological perspectives that integrate complex brain functions, as evidenced by the work of Flourens and Rolando in detailing the brain's role in sleep .

How did the different perspectives on the function of the brain and heart by Alcmaeon and Aristotle impact subsequent medical theories?

Alcmaeon's view that the brain was the central part of the body essential for memory and thought laid a foundation for neurological theories. His idea that sleep was caused by blood filling the brain was a precursor to later vascular theories, supported by figures like von Haller and others who believed in brain congestion leading to sleep . In contrast, Aristotle's belief that the heart was the seat of thought influenced the humoral theory of medicine and emphasized the role of the heart in maintaining life processes, thereby diverting attention from brain-centric theories . These conflicting perspectives on brain-heart functions influenced subsequent medical theories by creating a dichotomy between neurological and cardiocentric models of understanding bodily functions and diseases, which persisted into more modern times with the development of different sleep theories and neurological discoveries .

How did the philosophical approaches to medicine by Plato and Aristotle lead to different medical traditions during their time?

Plato's speculative conceptions fostered a dogmatic medical practice, emphasizing theoretical knowledge often detached from practical patient evaluation . His influence resulted in medical dogmatism, which maintained itself through drastic treatments like purging. On the other hand, Aristotle proposed theories based on physiological observations, such as the digestive process influencing sleep, leading to a more empirical tradition of medicine . This juxtaposition laid the groundwork for diversified pathways in medical thinking, balancing between philosophical speculation and empirical observation, which evolved into distinct medical disciplines .

How did Hippocrates influence the shift in medical practices towards rational diagnostic principles, and how did these ideas contrast with the practices at the Cnidos and Cos schools of medicine?

Hippocrates played a pivotal role in moving medical practices towards more rational and observational diagnostic principles. He emphasized the importance of clinical observation and a methodological approach to medicine, distinguishing his methods from previous systems that were heavily influenced by religious and mystical beliefs . This was in contrast to the Cnidos and Cos schools of medicine that existed at the time. The Cnidos school emphasized an elaborate classification system, where diseases were associated with specific symptoms, often lacking a comprehensive understanding of the patient's full condition . In contrast, the school at Cos, where Hippocrates was highly influential, favored rational treatments and diagnostics, focusing on a more holistic understanding of the patient's health . This approach marked a shift from the mystical and segmented views prevalent in earlier medical traditions, leaning towards a systematic and empirical study of medicine .

Evaluate how the concept of humoralism established in the 5th century B.C. shaped the understanding of health and illness.

The concept of humoralism, established in the 5th century B.C., shaped the understanding of health and illness by proposing that health was the balance of four body fluids or humors: blood, phlegm, yellow bile, and black bile. This balance was seen as essential for maintaining health, while any imbalance led to disease. This theory was central to medical practice for centuries, influencing treatments such as bloodletting and purging aimed at restoring balance among the humors . Additionally, humoral theory was part of a broader system of thought that believed sleep and other bodily functions were also affected by the balance of these humors, thereby intertwining concepts of mental and physical health with the regulation of these fluids ."}

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THE ENCYCLOPEDIA OF

SLEEP AND
SLEEP DISORDERS
THE ENCYCLOPEDIA OF

SLEEP AND
SLEEP DISORDERS
Third Edition

Charles P. Pollak, M.D.

Michael J. Thorpy, M.D.
Jan Yager, Ph.D.
The Encyclopedia of Sleep and Sleep Disorders, Third Edition

Copyright © 2001, 1991 by Michael J. Thorpy, M.D., and Jan Yager

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage or retrieval
systems, without permission in writing from the publisher. For information contact:

Facts On File
An imprint of Infobase Publishing
132 West 31st Street
New York NY 10001

Library of Congress Cataloging-in-Publication Data

Pollak, Charles.
The encyclopedia of sleep and sleep disorders / Charles Pollak, Michael J. Thorpy and Jan Yager.
—3rd ed., updated and rev.
p. cm.
Thorpy’s name appears first on the earlier edition.
Includes bibliographical references and index.
ISBN-13: 978-0-8160-6833-3 (acid-free paper)
ISBN-10: 0-8160-6833-X (acid-free paper)
ISBN: 978-1-4381-2577-0 (e-book) 1. Sleep disorders—Encyclopedias.
2. Sleep—Encyclopedias. I. Thorpy, Michael J. II. Yager, Jan, 1948– III. Thorpy, Michael J.
Encyclopedia of sleep and sleep disorders. IV. Title.
RC547.Y34 2008
616.8'498003—dc22 2007030682

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This book is printed on acid-free paper and contains 30 percent postconsumer recycled content.
CONTENTS
Preface to the Third Edition vii
Preface to the Second Edition ix
Preface to the First Edition xi
Acknowledgments xiii
Important Note and Disclaimer xv
History of Sleep and Man, by
Michael J. Thorpy, M.D. xvii
The Sociology of Sleep, by
Jan Yager, Ph.D. xxxix
Psychology and Sleep: The Interdependence
of Sleep and Waking States, by
Arthur J. Spielman, Ph.D.;
Paul D’Ambrosio, Ph.D.; and
Paul B. Glovinsky, Ph.D. xlix
Entries A to Z 1
Appendix I: Sources of Information 264
Appendix II: Research Organizations 266
Appendix III: Selected Sleep Centers 269
Bibliography 271
Sociology of Sleep Bibliography 283
Index 285
About the Authors 309
PREFACE TO THE THIRD EDITION
S ince the second edition of The Encyclopedia of
Sleep and Sleep Disorders was published in 2001,
sleep has emerged as a major growth industry. It
These social scientists are taking a fresh look at
sleep and are asking questions such as: What is the
sociological significance of where and when we
has also become a topic of keen interest among sleep? How do sleep patterns change over the life
researchers around the world and in a variety of cycle? What do our attitudes toward sleep or sleep-
disciplines including sociology, sleep medicine, related disorders say about today’s society? What
psychiatry, and psychology. From an activity do the current architectural trends in the relative
that previously received little attention com- sizes of bedrooms suggest about family roles in
pared to other health topics, sleep has become modern culture?
an issue that is discussed frequently on TV and Included in this third edition are essays from
in magazines, newspapers, and online publica- the previous editions, “History of Sleep and Man,”
tions. Fueling the concern that the public and by Michael J. Thorpy, M.D.; and “Psychology and
the health community have a better understand- Sleep: The Interdependence of Sleep and Wak-
ing of sleep is the growing awareness that some ing States,” by Arthur J. Speilman, Ph.D.; Paul
sleep disorders, such as sleep apnea, are linked to D’Ambrosio, Ph.D.; and Paul B. Glovinsky, Ph.D.
an increased likelihood of stroke, hypertension, Charles P. Pollak, M.D., coauthored this preface
or heart failure and that too little sleep can lead with Jan Yager, reviewed the A–Z section, recom-
to mistakes or accidents at work, mood swings, mended the editing of certain entries that had
greater chance of obesity, and drowsy driving, been found to be less effective than previously
which is associated with traffic accidents, injuries, thought, expanded others, and coauthored new
and fatalities. According to the National Institutes entries with Jan Yager.
of Health (NIH), sleep disorders cost consumers The list of sleep centers and clinics throughout
$15 billion in health care expenses and $50 bil- the United States included in this third edition is
lion in lost productivity. much shorter than in previous editions. This is
New to the third edition of this encyclopedia in recognition of the increased importance of the
are longer entries on sleep, sleep disorders, aging Internet in providing up-to-date information, espe-
and sleep, drugs and sleep, and treatment of sleep cially since changes occur with rapid speed. The
disorders. These are arranged alphabetically in American Academy of Sleep Medicine (AASM),
the A–Z section. Also new to this third edition is which accredits sleep centers and laboratories,
an original essay, on The Sociology of Sleep, by offers updated listings free of charge through its
coauthor and sociologist Jan Yager, Ph.D. Her essay site: www.sleepcenters.org. The National Sleep
brings a multidimensional perspective to the topic Foundation also offers a list of sleep centers
as she discusses recent groundbreaking studies by through its Web site: www.sleepfoundation.org.
sociologists both in the United States and abroad. The reference sections in the back of the book

vii
viii The Encyclopedia of Sleep and Sleep Disorders

have also been updated: sources of information, Encyclopedia of Sleep and Sleep Disorders is being
resource organizations, and the bibliography. published nearly two decades after the first edi-
When the first edition of this encyclopedia was tion found its way onto the shelves of public and
published in 1991 it became part of Facts On File’s medical school libraries and bookstores, as well as
Library of Health and Living series. That series has into personal or professional reference book col-
continued to grow and now includes more than lections throughout the United States, and, more
55 titles on a wide range of health issues from recently, electronically, through Facts On File’s
Alzheimer’s to diabetes, heart disease to cancer. online database.
We are pleased that there has been a continued —Charles P. Pollak, M.D.
interest in this book so that a third edition of The —Jan Yager, Ph.D.
Preface to the Second Edition
S ince the first edition of The Encyclopedia of Sleep
and Sleep Disorders was published in 1991, there
has been a great expansion in the national aware-
treat obstructive sleep apnea syndrome and other
disorders that produce tiredness and fatigue, such
as multiple sclerosis.
ness of sleep disorders and an increase in services Along with the increased availability of sleep
for patients. Terms such as narcolepsy, insomnia, sleep specialists, sleep disorders centers, and current
apnea, and excessive daytime sleepiness are commonly treatments for sleep disorders, there has been
used and understood by a greater percentage of the growth in public knowledge of sleep disorders, in
population than before. Laypersons have become part through the efforts of such national organi-
more aware that there is help available if they suf- zations as the National Sleep Foundation (NSF).
fer from a sleep disorder. This increased awareness The NSF has helped to propagate information on
is a positive development. Better understanding innovative advances in sleep medicine as well as
of the symptoms and features of a sleep disorder helping corporate America understand the impli-
leads to more rapid recognition and treatment of cations of sleep disorders and sleepiness in the
the disorder. workplace.
The Encyclopedia of Sleep and Sleep Disorders has Appendix II, the American Academy of Sleep
been updated to reflect the current science and Medicine (AASM)—Member Sleep Centers and
understanding of sleep disorders and includes Laboratories, is an updated list. (Further updates
the addition of numerous entries that reflect new are available at the AASM’s Web site: http://www.
terms, drugs, and procedures introduced in the aasmnet.org.) Sources that provide further infor-
last decade. Recent advances in the understanding mation about sleep disorders have been updated
of the pathophysiology of sleep and wakefulness, with Web site addresses, if available. The entries
including the recognition of a neurochemical sys- and bibliography have also been updated with new
tem involved in the control of sleep and wakeful- popular and scholarly books and articles that have
ness, the orexin system, are covered in this second been published since the first edition.
edition. Revised entries reflect the advances in In the A–Z section, words or terms in small
our understanding and treatment of disorders capital letters within an entry indicate that there
such as sleep apnea, insomnia, and narcolepsy. is a separate entry for that term, concept, or dis-
Modafinil, recently approved in the United States, order. For further information, you are directed to
is a major breakthrough medication for the treat- that separate entry, arranged alphabetically.
ment of disorders of tiredness, fatigue, sleepiness, —Michael J. Thorpy, M.D.
and narcolepsy. This medication is being used to —Jan Yager, Ph.D.

ix
PREFACE TO THE FIRST EDITION
T he Encyclopedia of Sleep and Sleep Disorders is
intended for laypersons as well as health care
professionals. We have tried to use clear, under-
walking, sleep terrors, and obstructive sleep apnea
syndrome.
Although this volume is intended to stand alone,
standable language, without distorting the mean- it appears as a new volume in a well-regarded
ings of the terms and conditions we describe. We series, begun by Facts On File, that now includes
hope this volume is useful to laypersons who are The Encyclopedia of Alcoholism by Robert O’Brien and
experiencing a sleep-related problem or who have Dr. Morris Chafetz; The Encyclopedia of Drug Abuse by
a family member or friend who has sleep con- Robert O’Brien and Dr. Sidney Cohen, M.D.; The
cerns; to students at a variety of undergraduate Encyclopedia of Suicide by Glen Evans and Norman
and graduate levels; to the administrative staff and Fabrow, M.D.; The Encyclopedia of Child Abuse by
technicians of sleep disorder centers, psychologists, Robin Clark and Judith Freeman Clark; The Encyclo-
and specialists in sleep disorders medicine as well pedia of Marriage, Divorce and the Family by Margaret
as physicians of all specialties. DiCanio, Ph.D., among other titles.
Sleep is an area of increasing interest as the We have tried to be as up-to-date in our informa-
connection between physical and mental well- tion as possible. However, any project of this kind is
being and sleep disorders becomes clearer to a continuing effort, as new information is acquired
clinicians and laypersons alike. Such problems and new treatment modalities are developed and
as insomnia or excessive sleepiness affect a large put into practice. New research studies will provide
percentage of the population and are of concern additional knowledge or refute or confirm previously
not only to patients but also to family members held ideas. Future editions will take into account
and employers. The relationship among alcohol, any additional information on sleep and sleep disor-
alertness, alcohol-related driving accidents, and ders unavailable or unknown at this time.
sleep and sleep disorders affects the community We have included lists of sleep centers and labo-
as a whole. ratories that are members of the American Sleep
This volume contains descriptions of the most Disorders Association (ASDA) and of organizations
common as well as the more obscure sleep-related and agencies that provide additional sleep-related
disorders. We have described the most commonly information, as well as a bibliography of popular
prescribed medications and “home” remedies for and scholarly books, journal or magazine articles,
sleep and alertness, listing their advantages and and newspaper references, to help readers to fur-
disadvantages. Also included are case histories for ther explore this key subject.
common sleep disorders, among them insomnia, —Michael J. Thorpy, M.D.
elderly sleep, anxiety disorders, narcolepsy, sleep- —Jan Yager, Ph.D.

xi
ACKNOWLEDGMENTS
A n enormous project like this rests upon the
efforts of more than the authors alone. First
and foremost, we want to thank James Cham-
Ph.D., and Charles P. Pollak, M.D., would like to
thank Dr. Michael J. Thorpy for his efforts in the
first and second editions of this encyclopedia.
bers, our editor for the second and third editions. Dr. Thorpy appreciates, in preparing his intro-
Thanks also to Fred Yager for his help as a writer ductory essay, the careful review by Dr. William
and editor in this third edition. Dement and Dr. Steven Martin, the library assis-
We would also like to thank sleep experts Arthur tance of Vernon Bruette, Josephina Lim, Deborah
J. Spielman, Ph.D., Paul D’Ambrosio, Ph.D., and Green and Andreas Lamerz, and the secretarial
Paul B. Glovinsky, Ph.D., for providing their origi- assistance of Elaine Ullman.
nal essay on the psychology of sleep. Jan Yager,

xiii
IMPORTANT NOTE AND DISCLAIMER
T his book is not intended to take the place of
medical advice from a medical professional or
psychological or psychiatric advice from a thera-
substitute for appropriate medical or psychologi-
cal diagnosis or treatment. If you or someone you
know has a sleep-related concern or a persistent
pist. Readers are advised to consult a physician, problem, consult your physician or a qualified
psychologist, psychiatrist, or other qualified health health care professional at one of the sleep disor-
or psychological professional regarding treatment der centers listed in Appendix III or the selected
of any sleep, health, or psychological problems. list from the American Academy of Sleep Medi-
Neither the publisher nor the authors take any cine (AASM), which continually updates its list
responsibility for any possible consequences from of accredited sleep disorders centers (http://www.
any treatment, action, or application of medicine sleepcenters.org) or the National Sleep Foundation
or preparation by any person reading any of the (http://www.sleepfoundation.org).
information in this book. Throughout this book, you will find contact
Before you make any changes in your or some- information for associations or organizations,
one else’s sleep or health care regimens, or take including Web sites. Since this information may
any medications described in this book, make change at any time, including even the name
sure you consult a licensed physician, preferably of the association or the existence of a Web site
a sleep expert. While this book provides general on the Internet, neither the publishers nor the
information on sleep strategies and disorders, since authors take any responsibility for the accuracy of
every person is unique, it is not intended to be a any listings.

xv
HISTORY OF SLEEP AND MAN
Michael J. Thorpy, M.D.
“Sleep; King of all the gods and of all mortals, has inadvertently produced several new disorders.
hearken now, prithee, to my word; and if ever Thomas Edison’s electric lightbulb has allowed
before thou didst listen, obey me now, and I will the light of day to be extended into night so that
ever be grateful to thee all my days.” shift work can now occur around the clock—but
—Homer, fourteenth book of the Iliad at the expense of circadian rhythm disruption and
sleep disturbance. Similarly, international travel by

F ew physiological conditions have received as

much attention through the ages by poets,
novelists, scholars, and scientists as sleep. From
plane has enabled the rapid crossing of time zones,
which also can lead to a disruption of circadian
rhythms and sleep disturbance.
Aristotle and Ovid, to Shakespeare and Dante, Scientific investigation has produced more
writers have been fascinated with sleep and its information on the physiology and pathophysiol-
impact upon emotions, behavior, and health. The ogy of sleep in recent years than ever before. This
cause and reason for sleep have been pondered by rapid advance in sleep research and the develop-
some of the world’s greatest minds, including Hip- ment of sleep disorders medicine are producing
pocrates and Freud, who attempted explanations answers to questions that date from antiquity
of the physiological basis of sleep and dreams. regarding the third of our day that is spent in the
Not only has sleep and waking behavior changed mysterious state of sleep.
through the ages but the environment for sleep
has also undergone a change. From communal
sleeping rooms with beds of twigs, straw, or skins,
Sleep in Prehistoric and
the bedroom has evolved in the 21st century into a Ancient Times
private place with electronic equipment, including “Sleep’s the only medicine that gives ease.”
computers, remote-controlled television, thermo- —Sophocles, Philoctetes
stats, and lighting.
A rudimentary understanding of insomnia and The sleep patterns and sleep disorders of prehistoric
sleepiness was known in ancient times, but specific man are unknown, and therefore we must specu-
sleep disorders, such as narcolepsy, began to be late from the comparative physiology of animals
recognized only in the late 19th century. Differen- and from evidence of other behaviors and illnesses.
tiation between causes of sleepiness and insomnia Theories on the phylogenetic development of sleep
has reached a peak within the last 50 years since stages in mammals have been developed from
the development of sophisticated technology for information available on the mammal-like reptiles.
the investigation of sleep. The earliest form of life developed about 600 mil-
Although most sleep disorders have probably lion years ago in the pre-Cambrian period, and
been present since man evolved, modern society mammal-like reptiles evolved approximately 250

xvii
xviii The Encyclopedia of Sleep and Sleep Disorders

million years ago. It was about 180 million years There is evidence from studies of animal fos-
ago, when slow wave sleep is believed to have sils that disease was present even before humans
appeared, that the monotremes (egg-laying mam- evolved. It is known that dinosaurs and prehis-
mals) evolved as a separate line from the therian toric bears commonly suffered arthritic changes in
(live-bearing) mammals; REM sleep (paradoxical their bones (called cave gout). Changes suggestive
sleep) appeared about 50 million years later. Recent of tuberculosis have also been seen in Neolithic
sleep research on one of the three surviving mono- bones. However, although it must have occurred,
tremes, the Australian short-nosed echidna, has there is no evidence of disease outside of the skel-
provided some of the evidence for the evolution of eton in humans, as no soft tissue parts have been
sleep stages. The echidna does not have paradoxical discovered that are earlier than 4,000 years B.C.
sleep, which suggests that the reptilian ancestors Medical evidence of illnesses such as pneumonia,
also may not have had paradoxical sleep. arteriosclerosis, and parasitic disease has been
The pattern of sleep and waking behavior in found in the mummies of early Egypt, and it is
prehistoric man can be deduced from studies reasonable to expect that the presence of disease
of nonhuman primates, such as apes and Old in early man was associated with changes in sleep
World monkeys, the animal groups phylogeneti- and wakefulness in a similar manner as is seen
cally closest to man. Sleep-wake patterns in non- today. However, evidence also suggests that man’s
primates consist mainly of polyphasic episodes of lifetime was much shorter during the Paleolithic
rest and activity with frequent (up to 12) cycles and early Neolithic periods, averaging only about
of wakeful activity throughout the 24-hour day. 30 to 40 years. The sleep disturbances of concern
Man has the most developed monophasic pat- to the elderly today may not have been a problem
tern, with one episode of consolidated sleep and in prehistoric man.
one main episode of wakefulness. Some animals It seems reasonable that prehistoric man would
have a biphasic sleep-wake pattern, with a nap have attempted to treat sleep disturbances, but
taken during the daytime, the pattern present, how early man treated these disorders is unknown.
for instance, in the chimpanzee. The chimpanzee Therapy probably resembled that utilized by sick
has a rather prolonged sleep episode from dusk to animals, such as the removal of infective agents,
dawn of approximately 10 hours; however, dur- eating various plants to induce emesis, and possibly
ing this time there are frequent, brief awakenings. even bloodletting. Certainly, bloodletting became
The daytime is characterized by two long episodes an increasingly frequent therapeutic means for
of wakefulness and an approximately five-hour treating disease, including sleep disorders, in more
midday nap, which also includes frequent brief advanced ancient civilizations. Primitive societies,
wakefulness episodes. even today, consider many illnesses and diseases
An early polyphasic sleep pattern seems likely to be caused by gods, magic, and spirits, and there-
to have been characteristic of earliest man, par- fore various forms of divination, such as the cast-
ticularly if man also attempted to sleep between ing of bones, moving of beads, charms, fetishes,
dusk and dawn. There would have been frequent chanting, or the use of elaborate ceremonies, are
awakenings during the major sleep episode, as a invoked for therapeutic reasons. Such forms of
single sleep episode of more than 10 hours appears treatment probably were applied by prehistoric
unlikely. It is reasonable to predict that man first man for disturbances of sleep and wakefulness.
began to develop a monophasic sleep-wake pat- Mesopotamians (ca. 3000 B.C.) thought illness
tern in the Neolithic period (since 10,000 B.C.). was produced by irate gods, and so their gods were
The chimpanzee’s sleep pattern probably was named for specific diseases, such as Tiu, the god of
similar to that present in man prior to the Neolithic headache, and Nergel, the god of fever. Treatment
period; Neanderthal Man (70,000 to 40,000 B.C.) largely consisted of determining what misdeed had
may well have been in a transitional stage between been committed by the sufferer, and then perform-
a polyphasic sleep pattern and the monophasic ing divination in an attempt to appease the gods.
pattern seen today. Plants, oils, minerals, and animal substances were
History of Sleep and Man xix

ingested, inhaled, or given as suppositories or ene- later date; somniferum was derived from the Latin
mas. These agents were usually administered by a word somnus [the Roman god of sleep]. In subse-
priest/physician, and strict codes for payment of quent periods in history opium [laudanum] was
medical services were established, as well as physi- widely used as a treatment for insomnia, and it is
cian punishment for a failure to treat disease ade- likely that it was used as far back as the Sumerian
quately. It is likely that many punishments were age, which suggests that opium may have been the
administered for failure to relieve sleep disorders first hypnotic medication used.)
that would have been chronic and often difficult to Bloodletting was commonly performed by the
cure, such as insomnia and narcolepsy. ancient Egyptians for the treatment of a variety of
The ancient medical papyruses of Egypt provide ailments and illnesses and was likely to have been
most of our current knowledge of ancient Egyptian used for sleep disorders, particularly for those dis-
medicine. The Chester Beatty papyrus, which was orders that produced excessive sleepiness or stu-
written around 1350 B.C., contains information on por. Medical treatment was widely available; the
the interpretation of dreams. Dreams were regarded names of several hundred physicians have been
as being contrary predictions; for example, a dream documented in ancient Egypt. Herodotus (fifth
of death meant a long life. However, the Georg century B.C.) wrote of the Egyptians:
Ebers papyrus (1600 B.C.), an extensive text on a
variety of medical subjects, including treatment, Medicine with them is distributed in the follow-
ing way: every physician is for one disease and
has not been reported to contain any information
not for several, and the whole country is full of
on sleep disturbances. Ancient Egyptian medical physicians for the eyes; others of the head; oth-
practice consisted largely of praying to the gods and ers of the teeth; others of the belly, and others of
invoking the help of these divine healers. Thoth, obscure diseases.
who was a physician to the gods, and Imhotep
were important gods of healing at that time. The It appears likely that some physicians special-
ancient Egyptians were known for their attention ized in insomnia, and possibly even in disorders
to hygiene and cleanliness, and it is likely that such that produced excessive sleepiness. There certainly
attention was also paid to sleeping habits. were physicians who specialized in dream inter-
Medical opinion at the time held that the body pretation, for example Artemidorus of Daldis who
was made up of a system of channels (Metu), which wrote the major work on dreams, Oneirocritica.
conveyed air to all parts of the body. Because they Other civilizations that developed around the
believed that bodily fluids could enter this system of same time were those of ancient India and China.
channels, the ancient Egyptians were particularly Early Indian medicine mainly consisted of magical
concerned about feces entering the Metu. Hence and religious practices but also featured soundly
the treatment of many illnesses was carried out by based, rational treatments. Over 700 Indian veg-
purging and enemas. Infective illnesses, including etable medicines have been documented from
malaria, parasitic infections, smallpox, and leprosy, ancient times and include the plant called Rauwolfia
were common at that time. Wine and other mildly serpentina (reserpine). Rauwolfia was used for the
alcoholic drinks (as compared to distilled alco- treatment of anxiety, among other disorders, and is
holic products) were consumed in large amounts likely to have been used to treat insomnia. In India,
and were probably the earliest treatments for as in Egypt, infective illnesses were common, and
insomnia but also may have been important in its therefore physicians, who were largely from the
development. Medicinal plants were utilized, par- Brahman or priestly caste, were viewed with great
ticularly the product of the opium poppy (Papaver importance. Effective treatment of most illnesses is
somniferum), and hyoscyamine and scopolamine, reported to have been dependent upon four major
derived from belladonna and nightshade. (The factors: the physician, the patient, the medicine,
word “opium” is derived from the Greek word for and the nurse. Asoka (273–232 B.C.), a ruler of
“juice,” as the drug is derived from the juice of the the Mauryan dynasty, reported that hospitals were
poppy. Papaver somniferum was coined at a much established as early as the third century B.C.
xx The Encyclopedia of Sleep and Sleep Disorders

The ancient Chinese believed in the importance which was used for stimulation as well as sedat-
of the universe and environment in producing all ing purposes. Although opium was commonly
things, including behavior and health. The basic employed by the Greeks at this time it does not
principles of life were thought to derive from appear to have been used in ancient China. Acu-
the interplay of two basic elements in nature, puncture was widespread and is believed to have
the active, light, dry, warm, positive, masculine been developed by the Yellow Emperor (Huang Ti)
Yang, and the passive, dark, cold, moist, negative around 2600 B.C. Acupuncture and moxibustion
Yin. The proportions of Yin and Yang determined were used for treating virtually every illness and
the Tao (the way), which determined right and symptom and therefore are likely to have been
wrong, good and bad, health or illness, etc. The administered for sleep disorders.
basic Yin-Yang symbol is attributed to Fu Hsi (ca. In ancient China, physicians were also highly
2900 B.C.), who originated the concept of eight regarded and were grouped into five categories,
interacting conditions, the “Pa kua.” The Yin-Yang the chief physician, food physicians, physicians for
has since become the symbol for sleep and wake- simple diseases, ulcer physicians, and physicians
fulness. (This Yin-Yang symbol has been adopted for animals. They were rated according to their
by the American Academy of Sleep Medicine as treatment results, and each doctor had to report
its emblem.) Chinese views on physiology were his therapeutic successes and failures. Sleep was
similar to those of the ancient Greeks; they also regarded by the Chinese as a state of unity with
believed in a humoral system of physiology. The the universe and therefore was regarded as very
palpation of the pulse was important in the diag- important for health. The Chinese philosopher
nosis of disease, and in order to determine whether Chuang Tzu (300 B.C.) said “everything is one;
a patient had upset the Tao, not only were the during sleep the soul, undistracted, is absorbed
patient’s symptoms taken into consideration but into the unity; when awake, distracted, it sees the
also the social and economic status, the weather, different beings.”
and particularly the patient’s dreams, as well as the Much of what we know about early Greek
dreams of other family members. medicine is derived from the Iliad and Odyssey of
The most important medical compendium of Homer, a collection of traditions, legends, and
the time was that produced by Yu Hsiung (ca. epic poems. Homer (ca. 900 B.C.) based his epic
2600 B.C.), the Nei Ching (Canon of medicine), works on the life of the ancient Greeks in the days
which mentioned five important methods of treat- of the Mycenaean Citadel of about 1200 B.C. The
ment: curing the spirit, nourishing the body, the Mycenaeans, who came from mainland Greece
administration of medications, treating the whole about 1600 B.C., conquered the Minoans, who had
body, and the use of acupuncture and moxibus- established a well-developed civilization in Crete
tion (counter-irritation by moxa, a combustible at Knossus. This civilization was the setting for
substance that is burned on the skin). It is most Homer’s epics, which concerned an earlier period,
likely that these latter forms of therapy were but his writings included medical details that were
applied to the sleep disorders. Massage and breath- probably derived from his own era. However,
ing exercises were also commonly employed, in a Homer’s view of medicine in early Greece, called
manner similar to that of Yoga. Herbal medicines Homeric medicine, is the best representation of
were plentiful and consisted of extracts of virtually early Greek medical practices. The quotation from
anything available, including minerals and metals, the Iliad stated at the beginning of this introduc-
animal-derived products, and waste products. tion reflects the importance that Homer ascribed
Two important Chinese remedies existed. One to good, quality sleep. The god of sleep, Hypnos,
was ephedra (ma huang), a stimulant that con- from whom the terms hypnotic and hypnotism have
tained ephedrine, derived from the “horsetail” developed, was first reported in the 14th book of
plant and first described by the Red Emperor, the Iliad by Homer, and was mentioned again in
Shen Nung (ca. 2800 B.C.). The second common the Theogony of Hesiod (ca. 700 B.C.) about two
medicinal herb was ginseng (a man-shaped root), centuries later.
History of Sleep and Man xxi

Also mentioned in Homer was the chieftain not inspired by mythological or religious beliefs
Asclepios and his two sons: Machanon, who in but rather by observing natural processes of the
subsequent centuries became known as the father environment. Around the same time, Pythagoras
of surgery, and Podalirios, the father of internal (ca. 530 B.C.) was born on an island off the coast of
medicine. In subsequent years, Asclepios became Asia Minor and developed a school of medicine at
known as the god of healing, and temples were Crotona in southern Italy. Pythagoras developed a
erected in his honor, the first being established philosophical approach to medicine that was based
about the sixth century B.C. in Thessaly or Ipid- on the science of numbers and the spiritual uni-
auros. The Asclepieian temples were a collection verse, but the importance of diet, exercise, music,
of several buildings that in many cases were very and meditation was emphasized.
elaborate and ornate. They consisted of a tholos, a Alcmaeon (fifth century B.C.), of the Crotona
round building that contained water for purifica- school of medical thought, concentrated on man,
tion, and a main temple, which were separated and his basic belief was that health was harmony
by a building called the abaton. The abaton was a and disease was a disturbance of harmony. He
most important structure as it was the site where considered the brain essential for memory and
ill patients were placed for a cure. The cure con- thought, a belief that Aristotle, who believed that
sisted of an “incubation” ceremony in which the the mind resided in the heart, would reject 100
cure took place in each worshipper’s dreams. The years later. Alcmaeon proposed what was prob-
medical ceremony began at dusk and the ill patient ably the first theory on the cause of sleep, when
lay on a bed of skins to await a visit by Asclepios, he postulated that sleep occurred when the blood
the god for healing. During the night the priest vessels of the brain filled with blood; withdrawal
would visit each patient and administer a treat- of blood from the brain was associated with wak-
ment, which often consisted of medicines derived ing. However, his major contribution to medicine
from such animals as snakes and geese. Upon was the detailed description of the optic pathways
awakening the next morning after dreaming of at the base of the brain. His much more rational
Asclepios, the patient was expected to have been concepts of medicine have led some to consider
cured. This treatment was clearly the forerunner him the first true medical scientist.
of sleep therapy, which has been practiced through Around the time of Alcmaeon, a center of medi-
the ages until the present day, particularly in cine was established in Sicily, and Empedocles (ca.
eastern countries. Although Asclepieian medicine 493–ca. 443 B.C.) was credited with the original
was used to treat any type of illness, it was most concept that all things are comprised of four basic
effective for those of a psychological nature. Much elements: water, air, fire, and earth (the importance
of the healing was probably related to the impres- of these four elements had been established ear-
sive ceremony and the relaxation that occurred lier). Empedocles believed that sleep occurs when
in conjunction with the setting. The priest-physi- the fire in the blood cools, thus separating one of
cians instilled faith in the cures—not only in their the four elements from the others. He believed
patients but also in themselves. However, many that illnesses were due either to separation of the
attempted cures were in the realm of magic and four elements or alterations in their balance. The
fantasy. principle of the balance of body humors, known as
A more rational style of medicine developed humoralism, became established medical doctrine
around the fifth century B.C. largely due to the around this time. Humoralism considered health
influence of the Greek scientist-philosophers, such to be due to the balance of four body fluids: blood,
as Thales and Pythagoras. phlegm, yellow bile, and black bile. These fluids
Thales of Miletos (640–546 B.C.), who believed were usually seen during severe illnesses and dis-
that water was an important basic element of all appeared when the crises were over.
animal and plant life, made many contributions not Two other major schools of medicine were
only to medicine, but also to geometry, astronomy, developed in the fifth century B.C., one at Cni-
and mathematics. His direction in medicine was dos and the other at Cos. At Cnidos an elaborate
xxii The Encyclopedia of Sleep and Sleep Disorders

classification system for diseases resulted in each but proposed a theory of sleep based upon the
specific disease being ascribed to one symptom. effect of food ingestion. He proposed that food
The school at Cos did not develop elaborate diag- once eaten induced fumes that were taken into
noses but depended largely upon the development the blood vessels and then transferred into the
of rational treatments and rational diagnostic brain where they induced sleepiness. The fumes
principles. subsequently cooled and returned to the lower
parts of the body taking heat away from the
In whatever disease sleep is laborious, it is a brain, thereby causing sleep onset. The sleep pro-
deadly symptom.
—Hippocrates, Aphorisms, II
cess continued as long as food was being digested.
Following the Hippocratic era of medicine, Greek
Hippocrates (460–370 B.C.) was born on the medicine began to develop in Rome, along with
island of Cos and was responsible for that school temples to Asclepios in 300 B.C.
of medicine’s direction. No individual in history Atomism, the concept that all physical objects
has had more influence upon medicine than Hip- are comprised of atoms in an infinite number that
pocrates, who produced many of the basic tenets undergo random motion, was first developed by
that underlie the practice of modern medicine. Democritus of Abdera (ca. 420 B.C.) and Leucippus
Hippocrates produced numerous works that are of Miletus (ca. 430 B.C.). Leucippus regarded sleep
gathered under the title Corpus Hippocraticum, as a state caused by the partial or complete split-
which comprises not only his own writings but ting-off of atoms. Democritus considered insomnia
also the writings of others of the time. His approxi- the result of an unhealthy diet and daytime sleep-
mately 72 books covered all aspects of medicine, ing as being a sign of ill health. Epicurus (ca. 300
including medical ethics, and are most widely B.C.) revived the theory of atomism and wrote
known for the Hippocratic oath. In his writings, extensively on sleep and dreams, although his
Hippocrates discussed not only his theory of the own works have been lost. The Roman poet Titus
cause of sleep, but he also made suggestions on Lucretius Carus (ca. 50 B.C.) wrote of the teachings
the cause of dreams, which he considered to be of Epicurus on atomism, sleep, and dreams, in a
of “medical” origin. Hippocrates stated that “sleep poem entitled “De rerum natura.” In this poem,
is due to blood going from the limbs to the inner the loss of central control that leads to loss of
regions of the body.” This statement was based peripheral muscle control and relaxation forms the
upon the recognition of the importance of the foundation of a neural theory of sleep that took
blood being warmed by the inner part of the body 2,000 years to be expanded upon:
in order to produce sleep—a theory contrary to
that proposed by Alcmaeon. Hippocrates believed And so, when the motions are changed, sense
withdraws deep within. And since there is nothing
that narcotics derived from the opium poppy could which can, as it were, support the limbs, the body
be useful in treatment; therefore, they were most grows feeble, and all the limbs are slackened; arms
likely applied to treat insomnia at that time. and eyelids droop, and the hams, even as you lie
Following Hippocrates, the philosophers Plato down, often give way, and relax their strength.
and Aristotle had an important influence upon
medicine. Plato (ca. 429–347 B.C.), a teacher Asclepiades of Bithynia (ca. 120–ca. 70 B.C.),
of Aristotle, developed many medical specula- another figure in Roman medicine, believed that
tions. He influenced the practice of medicine to the physician was more important in curing dis-
the extent that medical practice became more ease than was nature. He used the term “phreni-
dogma rather than patient evaluation. For this tis” for mental illness and invoked treatment that
reason physicians who supported his doctrines consisted of hygiene, opium, and wine. He was
were called “dogmatists” and their therapeutic also the first to popularize the tracheostomy as a
endeavors largely included drastic purgings and treatment for upper airway obstruction.
bleedings. Aristotle (384–322 B.C.) believed that Cornelius Celsus (ca. A.D. 20) and Caius Pliny
dreams were important predictors of the future the elder (A.D. 23–79) substantially documented
History of Sleep and Man xxiii

medical practice of their time. De Medicina, the It is already the hour for you to awake from sleep,
work of Celsus, covered a wide range of topics, for now our salvation is nearer than at the time
including history, preventative medicine, surgery, that we became believers. The night is well along;
the day has drawn near. Let us therefore put off
and anatomy. Pliny produced Historia Naturalis, a
the works belonging to darkness and let us put on
work that contained virtually every piece of medi- the weapons of the light: as in the daytime let us
cal information available. walk decently, not in revelries and drunken bouts,
Although Pliny’s writings were regarded as the not in illicit intercourse and loose conduct, not in
mainstay of medicine right through the Middle strife and jealousy.
Ages, the Greek Galen (A.D. 129–ca. 200) had a
greater impact on the subsequent development of Sleep was often used as a term in place of death.
medicine. Galen’s detailed writings substantially In ancient Rome and Greece the similarity between
contributed to the knowledge of anatomy, and he death and sleep was often emphasized. “Sleep and
outlined the important elements of diagnosis and death, who are twin brothers,” Homer said in the
treatment. He believed bloodletting was impor- Iliad (ca. 850 B.C.); and Ovid (43 B.C.–A.D. 17) in
tant in the treatment of many illnesses, but he the Amores II, “What else is sleep but the image of
also encouraged conservative treatments, such as chill death?” In the Bible there were numerous
diet, rest, and exercise. He utilized many herbal references to death being similar to sleep in that it
medicines, often in complicated combinations. was God who caused people to awaken from sleep,
The anatomical works of Galen reigned supreme otherwise they would never wake up (Psalms
in medicine until the works of Vesalius in the 16th 76:6). However, death was contrasted with sleep
century. in the example of a dead girl, where Jesus Christ
said “the little girl did not die but she is sleeping”
(Matthew 9:24; Mark 5:39; Luke 8:52). This refer-
Sleep in the Bible ence may have referred to the fact that she could
The Bible contains numerous references to sleep be resurrected from death as one is awakened
and dreams, which were largely regarded as being from sleep.
predictors of the future (but less significant than in Dreams played an important part in the Bible as
previous eras). The Bible emphasized the impor- a means of communicating between God and man.
tance of sleep and rest: the essential elements for The first book of the Bible, Genesis (28:10–16),
good sleep were regarded as being hard work, a reports communication between Jacob and God:
clear conscience, freedom from anxiety, and trust
And Jacob went out from Beresheeba, and went
in Jehovah (Ecclesiastes 5:12; Psalms 3:5, 4:8; Prov- toward Haran.
erbs 3:24–26). Sleep disturbance was less likely to
occur if one was content with life’s lot, and sleep- And he lighted upon a certain place, and tarried
there all night, because the sun was set; and he
lessness would result from excessive worry about took one of the stones of that place and put them
material possessions (Ecclesiastes 5:12). for his pillows, and laid down in that place to
However, the Bible also indicated that wrong- sleep.
doings made people unnecessarily content, “they
And he dreamed, and behold a ladder set up on
do not sleep unless they do badness, and their the earth, and the top of it reached to heaven: and
sleep has been snatched away unless they cause behold the angels of God ascending and descend-
someone to stumble” (Proverbs 4:16). Excessive ing on it.
sleeping was regarded as being unacceptable as And, behold, the Lord stood above it, and said, I
it produced laziness and could subsequently lead am the Lord God of Abraham thy father, and God
to poverty. “Laziness causes a deep sleep to fall” of Isaac: the land whereon thou liest, to thee will
(Proverbs 6:9–11, 10:5, 19:15, 20:13, 24:33–34). I give it and to thy seed;
The apostle Paul emphasized (Romans 13:11–13) and thy seed shall be as the dust of the earth, and
the importance of being active in order to spread thou shalt spread abroad to the west, and to the
the word of God: east, and to the north, and to the south: in thee
xxiv The Encyclopedia of Sleep and Sleep Disorders

and in thy seed shall all the families of the earth superstition and magic swept the western world,
be blessed. some physicians with skill in observation and
And behold I am with thee, and will keep thee in deduction slowly advanced medical knowledge,
all places whither thou goest, and will bring thee such as Alexander of Tralles (A.D. 525–605).
again into this land; for I will not leave thee, until In the Moslem world, a similar religious
I have done that which I have spoken to thee of.
approach to medicine occurred. Although in Islam
And Jacob awaked out of his sleep, and he said, disease is regarded as a punishment by Allah, hos-
surely the Lord is in this place; and I knew it not. pitals in Moslem countries were very much better
than those in the West because of their improved
Many other examples of dreams are presented sanitation and better and more spacious facilities.
in the Bible, such as Joseph’s dream to take Mary
Although physicians were largely of the Christian
as his wife, his dream to flee to Egypt with his fam-
and Jewish faiths, Moslem practitioners gradually
ily, the dream that it was safe to return home, and
helped spread medicine in the East. The Persian
the dream of the Magi.
Razi (A.D. 850–ca. 923) (also known as Rhazes in
the West) wrote more than 200 books on many top-
Sleep in the Middle Ages and the ics, including medicine. Avicenna (A.D. 980–1037),
Renaissance who also contributed to medical understanding,
was regarded both in Islam and Christendom as
Long sleep at after-noones by stirring fumes
being of equal importance to Galen.
Breeds Slouth, and Agues
Aking heads and Rheumes. A little later, Moses ben Maimon (A.D. 1135–
—School at Salerno, Regimen: Sanitatis 1204), also known as Maimonides, emerged as
Salernitanum (1095–1224) the most influential Jewish physician in Arabic
medicine. He appeared to combine the thoughts
The time from the fall of Rome in A.D. 476 until the of Hippocrates, Galen, and Avicenna but his pri-
fall of Constantinople in A.D. 1453 is often referred mary focus was on philosophy. Maimonides had
to as the Middle Ages, the first 500 years being his own view of how much and when a person
the Dark Ages. Both ages comprise the Medieval should sleep:
period, the Age of Faith, a time when medicine
The day and night consist of 24 hours. It is suffi-
was greatly influenced by the rise of Christianity.
cient for a person to sleep one third thereof which
With the spread of the word of Christianity, is eight hours. These should [preferably] be at
man was convinced that the day of judgment was the end of the night so that from the beginning
about to come, and disease was considered to be of sleep until the rising of the sun will be eight
due to God’s punishment. Prayer and good deeds hours. Thus he will arise from his bed before the
were considered to be important for cures and to sun rises.
prevent illness. Concern for “thy neighbor” led to —Misheneh Torah, “Hilchoth De’oth”
the establishment of facilities for the care of the ill, (Ch. IV, no. 4)
most of which were run with religious motives.
Medicine involved strong religious mysticism, and In the 10th century A.D., several medical schools
there was a loss of the rational, clinical observa- came into prominence. Perhaps the oldest was
tion and management of disease that had begun to that established at Salerno, not far from Monte
develop in earlier years. Monasteries that cared for Cassino. The school at Salerno developed a prac-
the sick were developed, but they scorned scien- tical scientific approach to medicine, eschewing
tific, medical teaching. One of the first to be estab- its neighbors’ concentration on philosophy and
lished was Monte Cassino in Italy by St. Benedict religious mysticism. Several universities in France,
of Nursia (A.D. 480–554). It was in these times that including those at Montpellier and Paris, were also
the Temples of Asclepios were also popular for highly regarded. At Paris, the school had a medical
the treatment of illnesses by Incubatio. Although rather than a surgical bias, being more influenced
History of Sleep and Man xxv

by the church. At Montpellier, Greek practices In the 17th century, medicine underwent a major
were more in evidence. change from the doctrines that had influenced it
By A.D. 1000, at the end of the Dark Ages, up to that time, such as Aristotelianism, Galen-
monastic medicine began to decline as the influ- ism, and Paracelsianism, to more scientifically
ence of the universities increased. Many hospitals directed theories, with the underlying teleological
developed that are well known today, such as St. desire to accumulate knowledge on the way things
Thomas’s and St. Bartholomew’s in England and work. This time was known as the age of scientific
the Hotel-Dieu in Paris. Here diet was regarded as revolution and included the major medical devel-
an important form of treatment, as were medica- opments of Francis Bacon, William Harvey, and
tions, particularly those derived from plant materi- Marcello Malpighi.
als. One of the most commonly used medications The scientific revolution began with the theo-
at this time was theriac, which had been developed ries of René Descartes (1596–1650), who rejected
in the first century A.D.; it consisted of many sub- Aristotle’s doctrines and developed theories based
stances derived from plants and animals, including on mechanisms. In this regard he was similar
snake flesh. Theriac would have been used for to Francis Bacon (1561–1626), who espoused
the treatment of a variety of sleep disorders, par- experimentation and utilitarianism. Descartes
ticularly those thought to be caused by poisons. developed a hydraulic model of sleep, which con-
Mysticism and astrology were important elements sidered that the pineal gland maintained fullness
of medicine in the Middle Ages. Often the most of the cerebral ventricles for the maintenance of
important treatment to be considered was exor- alertness. The loss of “animal spirits” from the
cism; however, purgatives and bloodletting were pineal causes the ventricles to collapse, thereby
treatments that were still commonly employed. inducing sleep.
In the 15th and 16th centuries, the works of Even Shakespeare made innumerable refer-
Hippocrates were revived. Paracelsus (1493–1541), ences to sleep in his writings, and it has been
known as the father of pharmacology, began using considered that the playwright’s clear descriptions
metals in treatment, often producing some outstand- of insomnia suggest that he himself suffered from
ing cures. Although illnesses such as leprosy and the this malady.
plague had largely disappeared, venereal diseases
such as gonorrhea and syphilis were rampant. . . . O sleep, O gentle sleep, Nature’s soft nurse,
Art and medicine became allied, as evidenced in how have I frighted thee, That thou no more wilt
the anatomical drawings of Michelangelo Buonar- weight my eyelids down and steep my senses in
forgetfulness . . .
roti (1475–1564) and Albrecht Dürer (1471–1528).
Andreas Vesalius (1514–64) produced one of the Medicine was now being viewed as an advance-
greatest medical books in history, entitled De Humani ment in man’s control over nature and was more
Corporis Fabrica. The detailed anatomical drawings soundly based on scientific principles. However, it
surpassed those of Galen, and Fabrica became the was still a time to be speculative and philosophical
anatomical cornerstone in the development of sci-
about medicine:
entific medicine in the centuries to come.
He sleeps well who knows not that he sleeps ill.
—Francis Bacon, Ornamentata Rationalia, IV
Sleep in the 17th and 18th Centuries (quote from Publilius Syrus, Sententiae)
Methought I heard a voice cry, “Sleep no more!
Macbeth does murder sleep,” the innocent sleep, The chemical principles of Paracelsus were
Sleep that knits up the ravell’d sleave of care, The advanced in the 17th century, and medicines,
death of each day’s life, sore labour’s bath, Balm including the use of mercurials, began to take
of hurt minds, great nature’s second course, Chief over from treatments such as purging and blood-
nourisher in life’s feast. letting. Illness was now considered to be some-
—Shakespeare: Macbeth, Act II (ca. 1605) thing that attacked the body in a distinct manner,
xxvi The Encyclopedia of Sleep and Sleep Disorders

and the Galenic and earlier concepts that disease Willis also discovered that laudanum, a solution
was a derangement of humors, the essential ele- of powdered opium, was effective in treating the
ments of the body, were starting to fade. Atom- restless legs syndrome.
ism, which had been proposed by Democritus, Due to the generally unhygienic living condi-
Leucippus, and Epicurus several centuries before tions, epidemics—mainly the plague, measles,
the time of Christ, underwent a revival in the smallpox, scarlet fever, and chicken pox—contin-
17th century and was supported by the findings ued to rage through Europe at this time. Therapy
of Jan Baptista Van Helmont (1577–1644), who was still largely based on practices of the past, such
coined the term “gas” and recognized that air as purging, bloodletting, dietary restriction, exer-
was composed of a variety of gases. Robert Boyle cise, and the use of potions, such as theriac.
(1627–91) demonstrated the importance of air for Although the 18th century is largely regarded
life and the effect of gases under pressure, which as being a period when the scientific foundation
led to the discovery that the reddening of venous of medicine was extended from the principles laid
blood occurred because of exposure of blood to down in the 17th century, this was not entirely the
gases contained in the air. However, the major situation. Some medical theorists played an influ-
discovery of the 17th century was that of William ential role in maintaining concepts of vitalism.
Harvey (1578–1657), who was the first to dem- George Stahl (1660–1734) was a strong propo-
onstrate that blood was pumped around the body nent of the animal spirits concept of earlier years
by the heart. and decried Descartes’s theory of a machinistic
It was against this background that the great approach to medicine. Stahl also expounded his
neurologists, Thomas Willis (1621–75) and Thomas enthusiasm for treatments such as bloodletting to
Sydenham (1624–89), developed the principles get rid of the unwanted spirits.
and practice of clinical neurology. Willis made a Despite some setbacks, a scientific approach to
number of contributions to the knowledge of vari- medicine continued with the works of Linnaeus
ous disorders in sleep, including restless legs syn- and Von Haller. Karl von Linné (1707–78), called
drome, nightmares, and insomnia. He recognized Linnaeus, made important contributions to the
that a component contained in coffee could pre- classifications of botany, zoology, and medicine.
vent sleep and that sleep was not a disease but pri- He emphasized the important of cyclical changes
marily a symptom of underlying causes. His book in botany, which was nowhere more clearly pre-
The Practice of Physick (1692) devoted four chapters sented than in his flower-clock. The flower-clock
to disorders producing sleepiness and insomnia. was developed upon the principle that different
As with Descartes, he considered that the animal species of flowers open their leaves at various
spirits contained within the body undergo rest times of the day. Therefore, a garden of flowers
during sleep. However, he believed that those arranged in a circular pattern could give an esti-
animal spirits residing in the cerebellum became mate of the time of day by the pattern of flower
active during sleep to maintain a control over and leaf openings and closings. Linnaeus’s finding
physiology. He believed that some of the animal was an important early milestone in the develop-
spirits became intermittently unrestrained, leading ment of the science of biological rhythms in plants
to the development of dreams. He also described and animals. As far back as ancient Greece, there
restless legs syndrome, which he considered to be had been some recognition of variation in the
an escape of the animal humors into the nerves behavior of plants and animals, not only on a sea-
supplying the limbs: sonal basis but also on a daily basis. Even the Bible
makes mention of seasonal change in the follow-
when being a bed, they betake themselves to ing passage from Ecclesiastes (3:1): “To everything
sleep, presently in the arms and legs, leapings and
contractions of the tendons, and so great a rest-
there is a season and a time to every purpose
lessness and tossings of their members ensue, that under the heavens.”
the diseased are no more able to sleep, than if they One of the first chronobiological experiments
were in a place of the greatest torture. was that of Sanctorious (ca. 1657), who measured
History of Sleep and Man xxvii

the cyclical pattern of change in a number of the name “oxygen” and recognized its impor-
his own physiological variables. His experimental tance in the maintenance of living tissue. Despite
apparatus has been regarded as the first “laboratory the important advances in clinical medicine that
for chronobiology.” Subsequently the intrinsic pat- occurred in the 17th century, there were very few
tern of circadian activity was demonstrated in the therapeutic advances. Medications still consisted of
experiment performed by Jacques De Mairan in potions developed from plant and animal tissues,
1729, which was reported by M. Marchant. De Mai- and opium was still the main form of sedation, in
ran placed a heliotrope plant in a darkened closet a common formulation called “Hoffmann’s Ano-
and observed that the leaves continued to open in dyne of Opium.” However, the ancient practices of
darkness, at the same time of day as they had in bleeding and purging continued to be widely pre-
sunlight. This experiment illustrated the presence scribed throughout the 18th century. One medica-
of an intrinsic circadian rhythm in the absence of tion that was particularly important was discovered
environmental lighting conditions. De Mairan also as a herbal brew from the foxglove plant, Digitalis
recognized the importance of this observation for purpurea. This medication, found by William With-
understanding the behavior of patients: “this seems ering in 1785, was most helpful in the treatment of
to be related to the sensitivity of a great number of dropsy (swelling of the limbs) caused by heart dis-
bed-ridden sick people, who, in their confinement, ease. This was also the time of the French Revolu-
are aware of the differences of day and night.” tion, following which it was recognized that more
During the 17th and 18th centuries, medical humane care was necessary for people with psychi-
schools had rapidly expanded throughout Europe, atric disease; Phillipe Pinel (1745–1826), who was
with those north of the French-Italian Alps begin- a supporter of vitalism, has been considered to be
ning to gain in prominence. The Swiss-born sci- the founder of modern psychiatry.
entist Albrecht Von Haller (1708–77), a pupil Despite the important advances in the science
of Boerhaave of the University of Leiden, an of medicine and in scientifically based principles
important medical center in Europe, made major of treatment, it was still a time of hoaxes and
contributions to many scientific topics, including charlatanism. On the fringe of quackery was Franz
medicine. Von Haller performed numerous experi- Anton Mesmer (1734–1815), who utilized “animal
ments on the nervous system and demonstrated magnetism” for a hypnotic treatment that led to
the sensitivity of nerve and the irritability of mus- the term mesmerism. He attracted the gullible to
cle; in doing so he dispelled much of the mysticism undergo treatment in his darkened rooms, which
of previous eras. Von Haller produced a major work were regarded as cradles of immorality. Mesmer
entitled Elementa Physiologiae in which he devoted was subsequently banished from Paris, despite
36 pages to the physiology of sleep and proposed a producing some effective cures of hysteria by the
theory for its cause. In a vascular concept similar use of hypnotic suggestion.
to that of Alcmaeon in the fifth century B.C., he Perhaps the greatest advance made in the
believed that sleep was caused by the flow of blood development of sleep medicine occurred in Bolo-
to the head, which induced pressure on the brain, gna with Luigi Galvani’s (1737–98) demonstration
thereby inducing sleep. Von Haller’s theory was of electrical activity of the nervous system. His
expanded in the 19th century into the congestion findings led to the subsequent development of the
theory of the causes of sleep, a theory that was still field of electrophysiology, and the gradual destruc-
believed into the early part of the 20th century. He tion of the humoralist theory of nervous activity.
also considered dreams to be a symptom of disease, With the development of the scientific approach
“a stimulating cause, by which the perfect tranquil- to medicine, the discovery of atomism, animal
ity of the sensorium is interrupted.” electrophysiology, the advances in respiratory and
The late 17th century was also the time of the cardiovascular physiology, as well as treatment
discovery of oxygen by Karl Scheele (1742–86) advances, such as quinine for malaria and digitalis
and Joseph Priestley (1733–1804), but it was for heart disease, medicine was about to enter its
Antoine-Laurent Lavoisier (1743–94) who coined modern era, the 19th century.
xxviii The Encyclopedia of Sleep and Sleep Disorders

Sleep in the 19th Century aspects of sleep. Much of what was known about
insomnia and its causes, however, was only a
“What probing deep
slight expansion of earlier knowledge.
Has ever solved the mystery of sleep?”
The theories of the cause of sleep can be placed
—Thomas Aldrich (1836–1907),
into four main groups: vascular (mechanical,
Human Ignorance
anemic, congestive), chemical (humoral), neural
(histological), and a fourth group, which explains
Medicine made rapid advances in the 19th cen- the reason for sleep rather than the physiological
tury, largely due to the discovery of anesthesia, cause of sleep, the behavioral (psychological, bio-
the practice of surgery, and the finding that micro- logical) theories.
organisms were a major cause of disease. This was The vascular theories of sleep were those most
the time of the Industrial Revolution; people came widely disputed in the early part of the 19th cen-
from the depressed countryside to the abhorrent tury. They were based upon the first rational theory
working conditions and slums of the cities to be for the cause of sleep, proposed by Alcmaeon in
employed in factories. Although sanitation, as well ancient Greece in the fifth century B.C. Alcmaeon
as preventive medicine, was important, epidemics believed that sleep was due to blood filling the
continued to rage in both Europe and the United brain, and waking associated with the return of
States. Cholera and typhoid fever were just two blood to the rest of the body, a concept consistent
of several infective illnesses that claimed many with the notions of ancient times, when it was rec-
victims. ognized that brain disorders such as apoplexy were
There were major advances in understanding associated with stupor (karos). Hippocrates had an
the cause of sleep, and in the latter half of the alternative theory in that he believed that sleep was
century a number of specific sleep disorders were due to blood going in the opposite direction, from
recognized. The anatomy of sleep and wakefulness the limbs to the central part of the body. Von Haller
was partially revealed through the animal experi- in the 18th century agreed with Alcmaeon’s concept
ments of two outstanding neuroanatomists of the and proposed that blood going to the head caused
time, Luigi Rolando (1773–1831) and Marie-Jean- the brain to be pressed against the skull, thereby
Pierre Flourens (1794–1867). inducing sleep by cutting off the “animal spirits.”
Rolando in 1809 demonstrated that a state of Von Haller derived his beliefs from the views of his
sleepiness occurred when the cerebral hemispheres mentor Hermann Boerhaave (1667–1738), who
of birds were removed, and his experiments were had presented a similar theory a few years earlier.
replicated by Flourens in 1822 with the ablation of Johann Friedrich Blumenbach (1752–1840), a pro-
the cerebral hemispheres of pigeons: fessor at Göttingen, who is regarded as the founder
of modern anthropology, was the first to observe
Just imagine an animal which has been con- the brain of a sleeping subject in 1795. He noted
demned to be permanently asleep, one that has
been devoid even of the ability to dream dur-
that the surface of the brain was pale during sleep
ing sleep; this is more or less the situation of compared with wakefulness; contrary to earlier
the pigeon in which I had ablated the cerebral theories, he proposed that sleep was caused by the
hemispheres. lack of blood in the brain. It was against this back-
ground of early sleep theories that the 19th-century
The 19th century could be regarded as the “age researchers looked for the cause of sleep.
of sleep theories” as some of the greatest physi- The theory that sleep was due to congestion of
cians, psychologists, and physiologists turned their the brain was the most accepted vascular theory in
attention to explanations of the cause of sleep. the first half of the 19th century. Robert MacNish
Advances were made in the clinical recognition of in 1834 wrote a seminal volume on sleep and its
sleep disorders, particularly the causes of daytime disorders, entitled The Philosophy of Sleep. MacNish
sleepiness, and several comprehensive books were supported the previous concept that sleep was
written entirely on the physiological and clinical due to pressure on the brain by blood. In 1846
History of Sleep and Man xxix

Johannes Evangelistica Purkinje (1787–1869), the brain was responsible for cerebral anemia. Hill
an outstanding neuroanatomist and professor of extensively studied the cerebral circulation, and in
physiology and pathology at Breslau (Wroclaw, 1896 he reported the absence of a change in cere-
in modern Poland), proposed a slightly different bral blood pressure during sleep. He believed that
theory for the cause of sleep that was consistent the brain did not become anemic or congested dur-
with the congestive concept. Purkinje proposed ing sleep, and he showed that intracranial pressure
that the brain pathways (corona radiata) become was normal during sleep compared with during
compressed by blood congestion of the cell masses wakefulness.
of the brain (basal ganglia), thereby severing neu- By the end of the 19th century the vascular
ral transmission and inducing sleep. James Cappie sleep theories, based on congestion or anemia of
in 1860 wrote in detail about the circulation of the brain, were less enthusiastically supported.
the brain and was one of the last supporters of the Subsequent research showed that changes during
congestion theory, which was finally contradicted sleep of both cerebral blood flow and intracranial
by the findings of the outstanding clinical neurolo- pressure do occur, but it was no longer believed
gist John Hughlings Jackson (1835–1911). In 1863 that these changes were responsible for the cause
Jackson observed the optic fundi during sleep and of sleep.
reported that the retinal arteries became pale dur- The neural theories for the cause of sleep were
ing sleep, which was consistent with Blumenbach’s based upon mid-19th-century developments in
earlier findings. He therefore reasoned that brain the histological understanding of the central ner-
congestion was not a cause of sleep. vous system. Camillo Golgi (1843–1926) dem-
The main alternative to the congestion theory onstrated the first clear picture of the nerve cell
was that sleep was due to insufficient blood in and its processes. His studies were extended by
the brain (anemia). William Alexander Hammond Heinrich Waldeyer (1837–1921), who first named
(1828–1900), the noted American physician, in the nerve cell—the neuron—and demonstrated an
1854 was the first in the 19th century to direct afferent axon and efferent dendrites. In 1890, Rabl
attention to the anemia theory, after observing Ruckhardt developed a hypothesis, called “neu-
the brain of a patient who had a traumatic skull rospongium,” in which he believed that during
injury. In 1855, Alexander Fleming supported sleep there was a partial paralysis of the neuron
the anemia theory after he performed an experi- prolongations, which prevented communication
ment in which he occluded the carotid arteries with adjacent nerve cells. Subsequently, Raphael-
and induced a sleeplike state. One of the strongest Jacques Lepine (1840–1919) of Paris in 1894
advocates for the anemia theory was Frans Cor- and Marie Mathias Duval (1844–1907) in 1895
nelius Donders (1818–89), a professor at Utrecht proposed similar theories, agreeing that sleep was
in Holland, who carefully observed the cerebral produced by retraction of amoeboid processes of
circulation in animals through windows placed the nerve cell. The outstanding histologist San-
in the skull. Donders and, subsequently, Angelo tiago Ramon y Cajal (1852–1934) proposed that
Mosso (1826–1910), who observed the cerebral small cells termed neuroglia interacted between
circulation in humans with skull defects, believed neurons and were able to promote or inhibit the
that at sleep onset blood passed from the brain to transfer of information from one cell to another.
the skin. Arthur Edward Durham (1833–95), who Cajal, who in 1906 was awarded the Nobel Prize
wrote extensively on the topic in 1860, believed along with Golgi for his work on neurohistology,
that the blood passed from the brain during sleep suggested that the alteration in the transference of
not only to supply the skin but also to supply information by neuroglia could explain not only
the internal organs. The final advocates for the sleep but also the effect of hypnotic medications.
anemia theory of sleep were the physiologists Wil- Ernesto Lugaro in 1899 proposed an alternative
liam Henry Howell (1860–1945) and Sir Leonard histological theory that sleep was due to expan-
Erskine Hill (1866–1952). Howell believed that sion of the neuron processes. He believed that
the change in arterial blood pressure at the base of neural impulses inducing sleep passed through
xxx The Encyclopedia of Sleep and Sleep Disorders

expanded processes (gemmules) to allow transmis- behavioral theories were proposed over the years,
sion between cells. (In the early 20th century, the the inhibition theory was the most popular; it
theories relating movements to parts of the neuron was first alluded to in 1889 by Charles-Edouard
were largely discredited and theories based upon Brown-Sequard (1817–94), an outstanding clini-
synaptic transmission of neurotransmitters became cal neurologist and physiologist. Brown-Sequard,
the prominent neural explanation for changes of who believed that most glands had secretions that
sleep and wakefulness.) pass into the bloodstream, is also known as the
The chemical theories of sleep originated with father of endocrinology. Based upon the previous
Aristotle who believed that sleep was due to the work of Rolando (1809) and Flourens (1822), who
effects of “fumes” taken into the blood vessels had demonstrated that the removal of the cere-
following the ingestion of food. He believed that bral cortex was accompanied by a sleeplike state,
the fumes were transferred to the brain where Brown-Sequard proposed that sleep was due to
they caused sleepiness. Wilhelm Sommer in 1868 an inhibitory reflex. The inhibitory theory of sleep
proposed that sleep was due to the lack of oxygen. was advanced with the experiment of Heubel, of
Sommer’s theory was developed from the work of Kiev University in Russia, who proposed that sleep
Carl Voit and Max Pettenkofer, who had shown was due to the loss of peripheral sensory stimula-
in 1867 that the body absorbed more oxygen dur- tion, which was essential for the maintenance of
ing sleep than during the day. Eduard Friedrich alertness. Subsequently, the inhibitory theory of
Wilhelm Pfluger (1829–1910) became the main sleep was greatly expanded by the work of Ivan
advocate for the oxygen hypothesis in 1875. Thi- Pavlov in the early 20th century. Marie de Man-
erry Wilhelm Preyer (1841–97) in 1877 believed ceine in 1897, in his book entitled Sleep: Physiology,
that the accumulation of lactic acid during daytime Pathology, Hygiene and Psychology, regarded sleep as
fatigue led to a deficiency of oxygen in the brain at being the “resting state of consciousness,” which
night, thereby causing hypoxemia and subsequent was an appealing truism, although it provided little
sleep. This theory led to several others on the information on the mechanism of sleep.
accumulation of toxic substances, which included A few researchers believed that a specific site
cholesterol and other toxic waste products. in the body was capable of inducing sleep. The
Perhaps the most widely disseminated theory thyroid had been considered to be a sleep-induc-
was that of Leo Errera of Brussels. Errera believed ing gland, until it was recognized that removal
that the accumulation of poisonous substances of the thyroid was not associated with insomnia.
called “leucomaines” induced sleep by passing Jonathon Osborne in 1849 proposed that the cho-
from the blood to the brain. The leucomaines roid plexus was the “organ of sleep.” He reasoned
were believed to be gradually broken down during that congestion of the choroid kept the ventricles
sleep, thereby leading to subsequent wakefulness. distended to produce sleep, and that contraction of
Emil Du Bois-Reymond (1818–96) in 1895 pro- the choroid was associated with wakefulness.
posed that sleep was a result of carbon dioxide tox- In the latter part of the 19th century two
icity, which in small amounts during wakefulness neurologists, Maurice-Edouard-Marie Gayet and
led to sleep, but large accumulations during sleep Ludwig Mauthner, reported clinical findings that
induced wakefulness. Abel Bouchard (1833–99) in eventually led to the discovery of the brain stem’s
1886 proposed that sleep was due to toxic agents, role in sleep and wakefulness. In 1875 Gayet pre-
excreted in the urine during sleep, that he called sented a patient with lethargy and associated eye
“urotoxins”; he also believed that diurnally pro- movement paralysis who had upper brain stem
duced urine contained toxic agents that produced pathology at autopsy, which led Gayet to believe
wakefulness. The chemical theories continued to that the lethargy was due to a thalamic defect that
be popular at the end of the 19th century. produced impaired transmission from the brain
The behavioral theories of sleep developed stem to the cerebral hemispheres. Mauthner in
from those of ancient times when general expla- 1890 reported a similar association between an
nations were given for sleep. Although many eye movement disorder and sleepiness but placed
History of Sleep and Man xxxi

the site of the deficit at the brain stem level. These ogy was not able to keep up with the rapid devel-
findings received little attention at the turn of the opment of clinical medicine. The first medication
century because of the more popular vascular and introduced specifically as a hypnotic was bromide
chemical sleep theories. in 1853, and other hypnotic medications intro-
The science of chronobiology made a few duced before 1900 included paraldehyde, ure-
advances in the 19th century, largely through thane, and sulfonal.
the studies of plant biologists such as Augustin- Although the theories regarding the cause of
Pyramus de Candolle (1778–1841), who demon- sleep were the focus of attention in the second half
strated in 1832 that plants in constant conditions of the 19th century, important contributions were
had a rhythm that differed slightly from 24 hours. made to sleep disorders medicine. Hammond, who
Wilhelm Friedrich Phillip Pfeffer (1845–1920) in was well known for his contributions to medicine
1875 confirmed De Mairan’s finding that plants during the Civil War, wrote a book entitled Sleep
had their own intrinsic rhythm when devoid of and Its Derangements in 1869, based on his series of
environmental influences. In 1845 James George publications on the topic of insomnia. Silas Weir
Davy (1813–95) reported circadian rhythms of his Mitchell (1829–1914), a well-known and influ-
own core body temperature, and in 1866 William ential neurologist in America, wrote a number of
Ogle performed similar experiments: clinical articles on sleep, including the recognition
of abnormal respiration during sleep, night terrors,
There is a rise in the early morning while we are nocturnal epilepsy, and the effect of stimulants on
still asleep, and a fall in the evening while we are insomnia.
still awake, which cannot be explained by refer- Perhaps the greatest clinical contribution in
ence to any of the hitherto mentioned influences.
the field of sleep disorders medicine was the first
They are not due to variations in light; they are
probably produced by periodic variations in the description in 1880 of narcolepsy by Jean Bap-
activity of the organic functions. tiste Edouard Gelineau (1828–1906), who derived
“narcolepsy” from the Greek words narkosis (a
The 19th century was a time of rapid clinical benumbing) and lepsis (to overtake). The term
advances in medicine. The mesmerism of the early “cataplexy,” for the emotionally induced muscle
part of the 19th century gave way to hypnotism, a weakness (a prominent symptom of narcolepsy),
term coined in 1843 by James Braid (1791–1860). was subsequently coined in 1916 by Richard Hen-
Subsequently ether, nitrous oxide, and chloro- neberg. Although Gelineau was the first to clearly
form were used to induce anesthesia for surgery. describe the clinical manifestations of narcolepsy,
Although at this time the main focus of academic several patients had previously been described by
medicine was in Europe, medical practice in the Caffe in 1862, Carl Friedrich Otto Westphal (1833–
United States developed rapidly, and the major 90) in 1877, and Franz Fischer in 1878.
American university medical centers were estab- The leading sleep disorder of the 20th century,
lished by the end of the 19th century. Medical obstructive sleep apnea syndrome, was described
practice became specialized with the development in 1836, not by a clinician but by the novelist
of ophthalmology, otolaryngology, and urology; Charles Dickens (1812–70). Dickens published a
neurology and psychiatry did not become separate series of papers entitled The Posthumous Papers of
specialties until the beginning of the 20th century. the Pickwick Club in which he described Joe, the
Bacteriology developed as a specialized area of fat boy, who was always excessively sleepy. Joe, a
medicine, and disease was no longer viewed as loud snorer, who was obese and somnolent, may
being due to supernatural causes but mainly as the have had right-sided heart failure that led to his
result of infection. This was the time of Louis Pas- being called “young dropsy.”
teur (1822–95) who firmly established the associa-
Mr. Lowton hurried to the door . . . The object
tion between disease and microorganisms. that presented itself to the eyes of the astonished
Pharmacology was well established, although clerk was a boy—a wonderfully fat boy—. . .
herbal cures were still given because pharmacol- standing upright on the mat, with his eyes closed
xxxii The Encyclopedia of Sleep and Sleep Disorders

as if in sleep. He had never seen such a fat boy, The 20th Century
in or out of a traveling caravan; and this, coupled
with the utter calmness and repose of his appear- The interpretation of dreams is the royal road to
ance, so very different from what was reasonably a knowledge of the part the unconscious plays in
to have been expected of the inflicter of such the mental life.
knocks, smote him with wonder. —Sigmund Freud,
“What’s the matter?” inquired the clerk.
The Interpretation of Dreams (1905)
The extraordinary boy replied not a word; but
he nodded once, and seemed, to the clerk’s imagi-
nation, to snore feebly. Medicine in the 20th century is radically different
“Where do you come from?” inquired the from that of previous eras. The major advances
clerk. have been the development of new diagnostic
The boy made no sign. He breathed heavily, means, the recognition of infectious disease, the
but in all other respects was motionless. development of antibiotic medications, the elimi-
The clerk repeated the question thrice, and
receiving no answer, prepared to shut the door,
nation of most global epidemics, the development
when the boy suddenly opened his eyes, winked of surgery, and the treatment of cancer.
several times, sneezed once, and raised his hand For the first time objective diagnostic procedures
as if to repeat the knocking. Finding the door complemented the physician’s skill. X-rays were
open, he stared about him with astonishment, discovered in 1895 by Wilhelm Konrad Roentgen
and at length fixed his eyes on Mr. Lowton’s (1845–1923) and the first clinical application was
face.
reported in 1896. Widespread routine use of X-
“What the devil do you knock in that way for?”
inquired the clerk, angrily. ray procedures began in the early 20th century;
“Which way?” said the boy, in a slow, sleepy sophisticated brain imaging techniques, such as
voice. computerized axial tomography (CAT scan) and
“Why, like forty hackney-coachmen,” replied nuclear magnetic resonance (NMR) scanning,
the clerk. began in the second half of the century.
“Because master said I wasn’t to leave off The vascular theories of the cause of sleep were
knocking till they opened the door, for fear I
should go to sleep” said the boy.
no longer popular, and although the chemical
theories were briefly of interest due to the findings
More than 100 years followed Charles Dickens’s of René Legendre and Henri Pieron in 1907, they
description before the obstructive sleep apnea syn- were overshadowed largely by the behavioral the-
drome became a well-recognized clinical entity. ory of Ivan Petrovitch Pavlov (1849–1936). Pavlov,
However, a number of writers in the 19th century who is regarded as one of the greatest physiologists
did allude to some of the features of sleep apnea of all time, published his initial lectures on con-
in their publications. William Wadd, surgeon to ditional reflexes in 1927. There he believed that
the king of England, in 1816 wrote about the rela- sleep was due to widespread cortical inhibition:
tionship between obesity and sleepiness. George
Sleep . . . is an inhibition which has spread
Catlin, a lawyer, in 1872 described the breathing over the great section of the cerebrum, over the
habits of the American Indian in his book entitled entire hemispheres and even into the lower lying
Breath of Life; he graphically portrayed the effects mid-brain.
of obstructed breathing during sleep. William
Henry Broadbent (1835–1907) in 1877 was the Pavlov’s studies on dogs showed that a continu-
first physician to report the clinical features of the ous and monotonous stimulus would be followed
obstructive sleep apnea syndrome, and William by drowsiness and sleep. He reasoned that the
Hill in 1889 observed that upper airway obstruc- continuous stimulus acts at a certain point of the
tion contributed to “stupidity” in children. The central nervous system and leads to inhibition
most notable description was by William Hughes with resulting sleepiness. Although Pavlov’s theo-
Wells (1854–1919) in 1878; he cured several ries on conditioning were interesting, they held
patients of sleepiness by treatment of upper airway little information on physiological mechanisms.
obstruction. Vladimir Michailovitch Bekhterev (1857–1927)
History of Sleep and Man xxxiii

published his findings on human reflexology and The most significant advance in the chemical
sleep in 1894 (translated into English in 1932). theories came in 1907 when Legendre and Pieron
Bekhterev also believed that sleep was a general provided evidence for an agent, called “hypno-
inhibition due to a loss of higher-level reflexes: toxin,” that was derived from the blood serum
of sleep-deprived dogs. When introduced in dogs
[Sleep is] a reflex which has been biologically who were not sleep-deprived, hypnotoxin induced
evolved for the purpose of protecting the brain
sleep. Although attempts to replicate Legendre’s
from further poisoning by the products of metabo-
lism, and which may be evoked, as an association work were often unsuccessful, in 1967 John Pap-
reflex, and the conditions of fatigue. penheimer and colleagues induced sleep with
cerebrospinal fluid obtained from sleep-deprived
Bekhterev’s theory, similar to that of Edouard goats. The transmissible chemical, called “Factor
Claparede, who in 1905 viewed sleep as an S,” was subsequently identified as a muramyl pep-
“instinct,” was subsequently influenced by the tide in 1982 and is thought to act via the leucocyte
work of Legendre and Pieron; it believed that the monokine Interleukin-1. Finding alternative sleep
biochemical processes leading to the inhibition of factors has met with mixed success; the number of
the brain were the “hypnotoxins.” Since that time putative sleep factors has grown enormously in the
electrophysiological studies have demonstrated last 20 years. However, in 1988 Osamu Hayaishi
that the passive, cortical inhibition proposed by discovered that prostaglandin PGD2, found in the
Pavlov and Bekhterev does not occur; instead, the preoptic nuclei, was capable of inducing sleep in
brain maintains its activity during sleep, particu- rats, leading to the speculation that the preoptic
larly during REM sleep. nucleus is the site of the perennial and elusive
Since the days of ancient Greece, it had been “sleep center.”
recognized that sleep consisted of two different
states, one associated with dreaming and the Electrophysiology
other with quiet sleep. Willis in the 17th cen-
Feeble currents of varying direction pass through
tury had noticed the difference and believed that the multiplier when electrodes are placed on two
dream sleep was associated with release of the points of the external surface [of the brain] . . .
“animal spirits” from the cerebellum. However, —Richard Caton (1875)
the physiological changes of dreaming sleep were
not reported until 1868 when Wilhelm Griesinger The most useful objective diagnostic means for
(1816–68) noted the associated eye movements. sleep disorders has proven to be electrophysiologi-
Sigmund Freud in 1895, before the publication of cal techniques. Following Galvani’s demonstration
his first book on dreams in 1900, recognized that of the electrical activity of the nervous system in the
paralysis of skeletal muscles during dream sleep late 18th century, Richard Caton (1842–1926) in
prevented the dreamer from acting out dreams. 1875 demonstrated action potentials in the brains
Sleep research, both basic and clinical, had its of animals, an important step in the development
greatest period of growth during the second half of of the electroencephalograph. In 1929, Johannes
the 20th century. The advances in neurochemistry, [Hans] Berger (1873–1941), the first to record elec-
electrophysiology, neurophysiology, chronobiol- trical activity of the human brain, demonstrated
ogy, pathology of sleep, sleep disorders medicine, differences in activity between wakefulness and
and the development of sleep societies are too sleep. Berger’s discovery led to the development
many to list but a summary is presented below. of the electroencephalograph as a clinical tool for
the diagnosis of brain disease. The electroencepha-
Neurochemistry lograph was applied to determine different sleep
Our studies have established that the states in 1937, when Alfred L. Loomis, E. Newton
accumulation of the hypnotoxin produces an Harvey (1887–1959), and Garret Hobart were able
increasing need for sleep. to classify sleep into five stages, from A to E.
—Henri Pieron, Le Probleme Physiologique du Dreaming sleep was characterized in 1953 by
Sommeil (1913) Eugene Aserinsky and Nathaniel Kleitman, who
xxxiv The Encyclopedia of Sleep and Sleep Disorders

demonstrated the occurrence of rapid eye move- erroneous, as it disavows the most simple prin-
ments during a stage of sleep that they called ciples of physiology.
“rapid eye movement (REM) sleep.” In 1957 Kleit-
man and William Dement discovered a recurring Lhermitte was supported in 1914 by a pio-
pattern of REM sleep and non-REM sleep during neer of brain localization, Joseph-Jules Dejerine,
overnight electroencephalographic monitoring—a who said, “Sleep cannot be localized.” However,
finding that made it clear that sleep no longer in 1929, Constantin Von Economo (1876–1931)
could be regarded as a homogeneous state. In 1968, proposed a “center for regulation of sleep” based
Allan Rechtschaffen and Anthony Kales developed on anatomical and clinical studies of “Encephalitis
a scoring manual, A Manual of Standardised Termi- Lethargica” at the Psychiatric Clinic of Wagner
nology, Techniques and Scoring System for Sleep Stages Von Jauregg in Vienna. Viral encephalitis reached
of Human Subjects, which has become the standard epidemic proportions between 1916 and 1920,
in the field. The first report of an effective measure and Von Economo had the opportunity to cor-
of daytime alertness was by Gary Richardson, et relate the clinical features of sleep disturbance
al., in 1978. This study compared narcoleptics with with the central nervous system pathology. His
normals by applying the Multiple Sleep Latency studies demonstrated inflammatory lesions in the
Test (MSLT) that had been conceived and devel- posterior hypothalamus in patients with excessive
oped by Mary Carskadon working with William sleepiness and lesions in the preoptic area and
Dement at Stanford University. anterior hypothalamus in patients with insomnia.
Von Economo, influenced by the studies by Pieron
Neurophysiology and Pavlov, suggested that the “sleep regulating
center” was controlled by substances circulating in
. . . analysis of hypnogenic mechanisms has
the blood. These substances caused the sleep cen-
thus underlined the paramount importance of
ter to exert an inhibitory influence on the cerebral
inhibition and disinhibition in the determination
cortex, thereby leading to sleep. The same year in
of sleep onset and maintenance—a striking
Zurich, Walter Rudolph Hess (1881–1973), who
illustration of Sherrington’s visionary concepts.
was awarded the Nobel Prize with Egas Moniz for
—Frederic Bremer (1977)
his work in neuroanatomy, confirmed Von Econo-
mo’s findings by demonstrating that stimulation of
In the early part of the 20th century, two schools
the central gray matter in the region of the thala-
of thought emerged regarding the neurophysi-
mus induced sleep.
ological basis of sleep and wakefulness. One char-
Kleitman in 1929 regarded the cerebral cortex
acterized sleep as due to disinhibition with release
as being the source of wakefulness and believed
of an active “sleep center,” and the other as due to
that sleep due to inactivity of the central nervous
a passive event, the result of inhibition of a “wak-
system was brought about by a reduction in periph-
ing center.” The theories proposed at the end of
eral stimulation because of fatigue. His hypothesis
the 19th century by Mauthner and others assumed
conformed to the “deafferentation” theory. Steven
an interruption of peripheral sensory stimulation,
Walter Ranson (1880–1942) in 1932 demonstrated
thereby allowing the cerebral cortex to produce
that lesions placed at the top of the brain stem
sleep. This “deafferentation” theory had been sug-
produced sleepiness; experimentally, this was con-
gested first by Purkinje in 1846. The notion of a
sistent with Von Economo’s findings.
specific sleep center did not receive much support,
In 1935, Frederic Bremer, of the University of
as illustrated by the comment of the prominent
Brussels, experimentally gave support to the deaf-
clinical neurologist Jacques-Jean Lhermitte (1877–
ferentation theory. Bremer completely transected
1959) in 1910:
the midbrain, producing the “cerveau isole” prepa-
We absolutely object to the thought of the exis- ration—an isolation of the cerebrum—and was
tence of a nerve center attributed to the function able to show characteristic sleep patterns on the
of sleep. The conception of a center for sleep is electroencephalogram. The studies up until this
History of Sleep and Man xxxv

time were consistent with the concept that a lesion sleep. Following the electrophysiological docu-
that prevented transmission of peripheral stimu- mentation of REM sleep, Michel Jouvet in 1959
lation was important in the production of sleep. demonstrated REM sleep–related muscle atonia,
However, Ranson in 1939 showed that lesions of and in 1967 he demonstrated that the brain stem,
the lateral hypothalamus, in the absence of upper serotonin-containing neurons of the raphe nuclei
brain stem lesions, were associated with sleep were important in the maintenance of sleep. Sub-
due to a loss of the “waking center.” A few years sequently, Jouvet demonstrated that the rostral
later, Walle Jetz Harinx Nauta demonstrated that raphe nucleus was important for non-REM sleep,
posterior hypothalamic lesions produced sleepi- whereas the caudal raphe nucleus was important
ness whereas anterior hypothalamic lesions pro- in the maintenance of REM sleep. In 1975, Robert
duced insomnia, thereby supporting the concept William McCarley and J. Allan Hobson proposed
of a waking center in the posterior hypothalamus a reciprocal interaction model of REM and non-
and a sleep center in the anterior hypothalamus. REM sleep, with rostral REM “on” cells and caudal
According to Nauta: REM “off” cells.

Whereas Ranson and his collaborators held that Chronobiology

periods of sleep were caused by more or less Despite the multiplicity of its constituents, the
intrinsic periodic decreases in activity of the
waking center, we are inclined to attribute these
circadian system often behaves like one unit
decreases to the inhibitory influence of a sleep which is characterized by the durability of its
center. oscillations and its internal temporal order.
—Juergen Aschoff (1981)
Horace W. Magoun and Ruth Rhines, at the
Northwestern University Medical School in Chi- Auguste-Henri Forel (1848–1931), a Swiss physi-
cago, demonstrated in 1946 that the lower por- cian, is credited with stimulating the investigation
tion of the brain stem reticular formation was of circadian rhythms as important time measur-
responsible for inhibiting skeletal muscle tone. ing systems. His studies in 1910 on the accurate
This function of the lower brain stem had earlier timing system of bees were consistent with those
been alluded to by the clinical studies of Jackson of Linnaeus in the 18th century on the opening
in 1897. That the lower reticular formation could of the flower petals at a given time of day. The
have an inhibitory function through descending circadian behavior of rodents was first reported
pathways led to Guiseppe Moruzzi and Magoun’s by Curt P. Richter in his Ph.D. thesis in 1922; and
finding in 1949 that the brain stem reticular for- Erwin Bunning in 1935 was able to demonstrate
mation also had ascending pathways. This resulted the genetic origin of circadian rhythms in plants
in the discovery of the “ascending reticular activat- and subsequently developed a concept of “biologi-
ing system,” which led to a new emphasis in the cal clocks.” In the early 1960s Richter searched for
physiological investigation of sleep. Stimulation of the biological clock in extensive studies that culmi-
the ascending reticular activating system produced nated with the report in 1965 that lesions placed
electroencephalographic patterns of wakefulness. in the anterior-ventral hypothalamus produced
It was now recognized that the brain stem tran- disruption of circadian rhythms. Two groups acting
section studies did not produce sleep because of independently in 1972, Robert Y. Moore and Victor
“deafferentation” of peripheral sensory input, but B. Eichler, and F. K. Stephan and Irving Zucker, dis-
because of the loss of the wakefulness stimulus covered the “clock” to be two small, bilateral nuclei
from the ascending reticular activating system. in the anterior hypothalamus, which were subse-
As a result, sleep became regarded as a passive quently called the suprachiasmatic nuclei (SCN).
phenomenon. Human circadian rhythms were investigated
At the beginning of the second half of the 20th in the absence of environmental time cues
century, research concentrated on determining the by Jules Aschoff and Kurt Wever in 1962 in
neurophysiological basis for non-REM and REM an underground laboratory in Munich. They
xxxvi The Encyclopedia of Sleep and Sleep Disorders

demonstrated a free-running pattern of sleep and barbital was introduced in 1903. The 1960s saw
wakefulness with a period length of greater than the introduction of the benzodiazepine hypnot-
24 hours. A similar free-running pattern was ics, which largely replaced the barbiturates in the
demonstrated in field experiments in 1974 by late 1970s. However, the 1980s saw a decline in
the speleologist Michel Siffre, who lived for three the use of hypnotics with increased physician and
months in the absence of time cues on an ice gla- public awareness of the disadvantages of chronic
cier deep in the Franco-Italian mountains. Many hypnotic use. Insomnia became recognized as a
human biological rhythms have recently been symptom rather than a diagnosis, and treatment
discovered, such as the 24-hour episodic secre- was directed to the underlying physical or psycho-
tory pattern of cortisol that was reported by Elliot logical causes.
David Weitzman (1929–83) in 1966. In 1978, Several books on sleep had a major influence
Weitzman and Charles Czeisler demonstrated the on the development of sleep disorders medicine.
internal organization of temperature, neuroen- Pieron’s Le Probleme Physiologique du Sommeil in
docrine rhythms, and the sleep-wake cycle, in 1913 summarized the scientific sleep literature
subjects who were monitored in an environment at that time. A similar approach was taken by
free of time cues for periods of up to six months. Nathaniel Kleitman, who produced his monumen-
Sutherland Simpson (1863–1926) and J. J. Gal- tal treatise Sleep and Wakefulness in 1939 (updated
braith in 1906 had demonstrated that the light- in 1963 to contain 4,337 references). The Associa-
dark cycle could influence mammal behavior; tion of Sleep Disorder Centers classification com-
however, it was not until the 1980s that Czeisler mittee chaired by Howard Roffwarg produced the
and colleagues demonstrated the importance of Diagnostic Classification of Sleep and Arousal Disorders
the light-dark cycle in the entrainment of human in 1979; it ushered in the modern era of sleep
circadian rhythms. diagnoses and became the first classification to
be widely used. The Principles and Practices of Sleep
Pathology of Sleep Disorders Medicine, edited by Meir Kryger, William
Five billion people go through the cycle of sleep Dement, and Thomas Roth in 1989, was the first
and wakefulness every day, and relatively few of comprehensive textbook on basic sleep research
them know the joy of being fully rested and fully and clinical sleep medicine.
alert all day long. Increased knowledge about sleep and sleep dis-
—William Dement (1988) orders in general has resulted from the research of
a few core sleep disorders, which include narco-
Sleep disorders were poorly described at the turn lepsy, obstructive sleep apnea syndrome, and the
of the century, and, other than narcolepsy and insomnias.
sleeping sickness, few specific sleep disorders were Following Gelineau’s description in the late 19th
recognized. In addition to general medical illness, century, narcolepsy was brought to general recog-
environmental effects and anxiety were viewed nition in 1926 by the Australian-born neurologist
as the main causes of sleep disturbance. However, William John Adie (1886–1935), and stimulants
a gradual recognition of the multiplicity of sleep were first used for treatment by Otakar Janota
diagnoses began to parallel progress in psychiatry. in 1931. In 1941 John Burton Dynes and Knox
Freud’s book The Interpretation of Dreams led to the H. Findley applied the electroencephalograph to
development of psychoanalysis, which was applied the diagnosis of narcolepsy, and the character-
to the treatment of insomnia until the evolution istic sleep-onset REM period of night sleep was
of a more “organic” or “biological” psychiatric discovered in 1960 by Gerald Vogel. Dement and
approach. colleagues at Stanford University developed a nar-
Psychoactive medications became widely used coleptic dog colony in the 1970s, which advanced
with the introduction of the phenothiazines in the understanding of the biochemical and neu-
the 1950s, but hypnotic medications, particularly roanatomical bases of the disorder. The Multiple
the barbiturates, had been in common usage since Sleep Latency Test was applied to the diagnosis by
History of Sleep and Man xxxvii

Richardson in 1978, and the documentation of a hypnotic medications. Frederick Snyder in the
strong association between the histocompatability 1960s recognized and promoted the importance of
antigen HLA-DR2 and narcolepsy was made by psychiatric disorders in sleep medicine, especially
Yutaka Honda and colleagues in 1984. depression: “Troubled minds have troubled sleep,
Following the reports of snoring, sleepiness, and troubled sleep causes troubled minds.” The
and obesity in the 19th century, Sir William Osler polysomnograph was applied to the investigation
(1849–1919) in 1907 referred to Dickens’s descrip- of patients with insomnia following the discovery
tion of Joe: “An extraordinary phenomenon in of obstructive sleep apnea in 1965, and objective
excessively fat young persons is an uncontrollable measures of hypnotic effectiveness were developed
tendency to sleep—like the fat boy in Pickwick.” by Kales in 1969. The concept of a conditioned
Charles Sidney Burwell in 1956 brought general insomnia (psychophysiological insomnia) was first
recognition to obstructive sleep apnea syndrome, presented in Diagnostic Classification of Sleep and
which he called the “Pickwickian Syndrome”; and Arousal Disorders in 1979 and subsequently became
the first objective documentation of polysomno- recognized as a common form of insomnia. The
graphic features was reported by Henri Gastaut behavioral technique “stimulus control” devel-
in 1965. Although the tracheotomy had been oped by Richard Bootzin in 1972 was an effective
performed since the time of Asclepiades (first cen- treatment of insomnia, as was “sleep restriction
tury B.C.), Wolfgang Kuhlo and Erich Doll in 1972 therapy,” developed by Arthur Spielman in 1987.
reported that it provided an effective treatment of Circadian rhythm sleep disorders were recog-
the obstructive sleep apnea syndrome. Tanenosuke nized in the late 1970s, partly due to recognition
Ikematsu in 1964 popularized uvulopalatopha- of the chronobiological features of “jet lag” and
ryngoplasty (UPP) surgery for the treatment of “shift work.” Thomas A. Edison, who was respon-
snoring, which was subsequently applied to the sible for the development of the electric lightbulb,
obstructive sleep apnea syndrome by Shiro Fujita which allowed shift work to occur, had his own
in 1981. The same year, nasal continuous positive views on sleep:
airway pressure (CPAP) treatment was described
by Colin Sullivan and subsequently became the In my opinion sleep is a habit, acquired by the
treatment of choice. environment. Like all habits it is generally car-
Another sleep-related breathing disorder called ried to extremes. The man that sleeps four hours
soundly is better off than a dreamy sleeper of eight
“Ondine’s Curse” was first reported by John W.
hours.
Severinghaus and Robert A. Mitchell in 1962.
Named after the water nymph in Jean Giraudoux’s The atypical, sleep-onset insomnia called the
play Ondine (1939), this disorder was characterized “delayed sleep phase syndrome,” discovered by
by the failure of automatic ventilation that could Elliot Weitzman and colleagues in 1981, led to a
lead to fatal apnea during sleep. radically different form of treatment called “chro-
Live! It’s easy to say. If at least I could work up a
notherapy,” which was based on chronological
little interest in living—but I’m too tired to make principles.
the effort. Since you left me, Ondine, all the things Many other sleep disorders have been discov-
my body once did by itself, it now only does by ered in the 20th century, including REM sleep
special order . . . I have to supervise five senses, behavior disorder by Carlos Schenk in 1986;
two hundred bones, a thousand muscles. A single paroxysmal nocturnal dystonia in 1981 and fatal
moment of inattention, and I forget to breathe.
familial insomnia in 1986 by Elio Lugaresi; and
He died, they will say, because it was a nuisance
to breathe. food allergy insomnia by Andre Kahn in 1984.
—Jean Giraudoux, Ondine, Act III (1939) General and medical awareness of sleep disorders
has dramatically increased since the 1970s through
Insomnia received more interest in earlier cen- the contributions of sleep disorders clinicians and
turies than in the first half of the 20th century, the sleep societies. In addition to those mentioned,
probably because of the availability of effective a few of the many who have contributed to this
xxxviii The Encyclopedia of Sleep and Sleep Disorders

recognition include: Roger Broughton, Michel Bil- to the Diagnostic Classification of Sleep and Arousal
liard, Christian Guilleminault, Peter Hauri, J. David Disorders. In 1978, the Association of Polysomno-
Parkes, the late Pierre Passouant, and Bedrich graphic Technologists, founded by Peter Anderson
Roth. McGregor, set standards of practice for polysom-
nographic technologists. In 1983 the Association
Sleep Disorders Medicine for the Psychophysiological Study of Sleep was
. . . we have created a new clinical specialty, sleep renamed the Sleep Research Society (SRS) and in
disorders medicine, whose task is to watch over 1984 the Clinical Sleep Society (CSS) was founded
all of us while we are asleep. as the membership branch of the Association of
—William Dement (1985) Sleep Disorder Centers. In 1986, the Association of
Sleep Disorder Centers, the Clinical Sleep Society,
Organized sleep disorders medicine in the United the Sleep Research Society, and the Association
States began with the founding of the Asso- of Polysomnographic Technologists formed a fed-
ciation for the Psychophysiological Study of Sleep eration called the Association of Professional Sleep
(APSS) in 1961, an association comprised of sleep Societies (APSS). The Association of Sleep Disorder
researchers, many with clinical interests. Sleep Centers changed its name to the American Sleep
research led to the investigation of sleep disor- Disorders Association in 1987 and to the American
ders, which resulted in the establishment in the Academy of Sleep Medicine (AASM) in 1999.
early 1970s of clinical sleep disorder centers for With the increased recognition of the impor-
the diagnosis and treatment of patients. In 1976, tance of sleep disorders medicine many interna-
the Association of Sleep Disorder Centers (ASDC) tional sleep societies have been founded, beginning
was founded. The first sleep disorder center to be with the European Sleep Research Society (ESRS)
engaged in active patient evaluations and treat- in 1971, the Japanese Society for Sleep Research
ment was that established at Stanford University (JSSR) in 1978, the Belgian Association for the
in California by William Dement. An accreditation Study of Sleep (BASS) in 1982, the Scandinavian
process for sleep disorders centers was established Sleep Research Society (SSRS) in 1985, the Latin
by the ASDC, and the first to be accredited in 1977 American Sleep Society (LASS) in 1986, the Sleep
was the Sleep-Wake Disorders Unit, headed by Society of Canada (SSC) in 1986, and the British
Elliot Weitzman, at Montefiore Medical Center in Sleep Society (BSS) in 1989.
New York. In 1978, the medical journal Sleep was (Selected references for the introduction are
created to present research and clinical articles on included in the bibliography at the end of this
sleep, and in 1979 a complete issue was devoted volume.)
THE SOCIOLOGY OF SLEEP
Jan Yager, Ph.D.

W e spend approximately one-third of each

day sleeping. However, it is only in the last
decade that sleep has become a topic of concerted
• What are some of the social changes in the way
sleep deprivation is viewed, especially in regard
to drowsy driving and its link to car accidents?
research by a small but growing group of sociolo- • What do our attitudes toward sleep or sleep-
gists, especially in the United Kingdom. related disorders say about a society?
Ancient philosophers and writers have addressed
sleep for centuries. Psychologists and psycho- • How can we introduce certain sleep-related cus-
analysts have been studying sleep from their own toms that scientists are now finding are linked
perspectives since around the turn of the 20th cen- to better health, such as napping during the day,
tury, when Sigmund Freud published The Interpre- even if it is not the cultural norm?
tation of Dreams. The medical profession, as far back
as Hippocrates in the fifth century B.C., has been My approach to the sociology of sleep began
concerned with why we sleep as well as treat- by reviewing the groundbreaking work of sociolo-
ments for insomnia. The breakthrough discovery gist colleagues in the United Kingdom and United
in 1952 of REM sleep by Nathaniel Kleitman, States, as well as corresponding via e-mail with
along with Eugene Aserinsky, and, later, William many of the sociologists exploring this area. This
Dement, M.D., hailed the beginning of modern distinguished group includes Professor Simon J.
sleep research. And now, sociologists are studying Williams of the University of Warwick, U.K.; Pro-
sleep through the lens of their unique discipline. fessor Sara Arber, codirector, Centre for Research
Just some of the questions about sleep that soci- on Aging and Gender (CRAG), University of Sur-
ologists seek to answer are: rey, U.K.; Drs. Rob Meadows, Jenny Hislop, and
Sue Venn, CRAG, University of Surrey; Dr. Pam
• What is the sociological significance of where Lowe, Aston University, Birmingham, U.K.; and
sleep takes place and with whom? Professor Paul Rosenblatt. I also reviewed the
• How do daytime social interactions affect how earlier writings in this emerging field; namely,
long or how soundly you sleep? the works of Vilhelm Aubert and Harrison White
(1959), Barry Schwartz (1970), Murray Melbin
• What are the gender, racial, or socioeconomic
(1978), and Brian Taylor (1993).
similarities and differences in sleep patterns?
My background includes more than two decades
• How do sleep patterns change over the life as a sociologist (Ph.D. in sociology, The City Uni-
cycle? versity of New York Graduate Center, 1983),
• What are the roles that men and women play researcher, and coauthor of two books on sleep
when they are awake, and how do their roles (coauthor with Michael J. Thorpy, M.D., of Sleep-
affect how they sleep? ing Well, Checkmark Books, 2001, and coauthor

xxxix
xl The Encyclopedia of Sleep and Sleep Disorders

with Michael J. Thorpy, M.D., of The Encyclopedia injuries in addition to costing millions of dollars in
of Sleep and Sleep Disorders, Facts On File, 1991, 2nd environmental cleanup and damaged equipment.
edition, 2001, and of this 3rd edition with Charles Too little sleep is also linked to jeopardized jobs
P. Pollak, M.D.). because of the mood swings that can result from
In March and April 2007, I conducted a survey exhaustion and personal relationships suffer when
on the sociology of sleep by sending queries to “I’m too tired” is the reason for postponing talking
three Internet lists I’m on related to publishing, or physical intimacy.
books, nutrition, and health, as well as by asking Just how widespread is sleep deprivation in
selected work or personal associates to participate. America today? Based on the National Sleep
Although this is not a scientific sample, I found the Foundation (NSF) 2008 poll of 1,000 randomly
47 responses to the 40 sleep-related questions, as selected American men and women, the average
well as the 22 questions regarding the background number of hours of sleep during the workweek
and demographics of each respondent, useful in is six hours, 40 minutes, at least half to one hour
the preparation of this essay. The sample included less each night than the recommended seven to
eight males and 39 females between the ages of nine hours of sleep. My own survey of 47 men
21 and 84. and women found that the average number of
hours for that sample was six hours, 30 minutes,
a night during the workweek, compared to an
Sleep and Time average of seven hours, 30 minutes, a night over
My additional research into time management over the weekend.
the last two decades has led to the observation that
an increasing number of people in industrialized
nations are feeling a severe time crunch, especially Adult Women
those who are working and raising children or In their 2003 article in Sociology entitled “Sleep-
taking care of aging parents. More and more, the ers Wake! The Gendered Nature of Sleep Disrup-
complaint is that there are not enough hours in the tion among Mid-Life Women,” sociologists Jenny
day to get everything done that needs to be done, Hislop and Sara Arber discuss their in-depth
both at work and even during leisure hours. research using six focus groups of midlife women
Skimping on sleep is a growing problem in the in a medium-sized city in southern England in
United States as a way of trying to get more hours the spring of 2001. There were 48 women in the
out of the day. In a 2008 telephone survey of 1,000 study with the majority (30) married or living as
men and women conducted by the National Sleep married. Thirty-four women had one or more chil-
Foundation, 16 percent of those surveyed reported dren, but only 18 still had children living at home.
sleeping fewer than six hours on workdays despite The majority of women were working full time
the recommendation of seven to nine hours a (27) or part time (10).
night of sleep. Those who are sleep deprived expe- Hislop and Arber found that the women in their
rience daytime sleepiness at least several days a sample expected to have their sleep interrupted even
week (26 percent), versus 12 percent of those who though they considered it an undesirable situation.
sleep longer hours. The researchers grouped the women’s responses
Too few hours of sleep at night can have a nega- to sleep disruption into several coping strategies:
tive impact on the next day’s activities, sometimes behavioral methods to help them get to sleep includ-
with grave consequences—including an increased ing exercising, spending time alone, engaging in
number of work-related accidents due to exhaus- activities that are associated with relaxation such
tion and falling asleep at the wheel, causing as listening to music, writing in a journal, reading,
accidents or fatalities. Several major nuclear and or deep breathing, or relocating to another bed
environmental disasters during the last 25 years although sharing a double bed was typical for the
have been linked to sleep deprivation, as well as women who were studied even if sharing the bed
train, plane, and boat crashes causing deaths or was the reason for more disturbed sleep. According
The Sociology of Sleep xli

to Hislop and Arber, relocation as a solution was cent) to report snoring at least a few nights per
either a permanent or temporary way of coping. week during the previous year. This is important
The 2007 NSF Sleep in America poll focused on because frequent or loud snoring is a symptom of
women and sleep and was based on a survey con- sleep apnea, and untreated sleep apnea has been
ducted in the fall of 2006 that addressed women’s identified as a risk factor for such life-threaten-
sleep patterns. As the 2006 NSF telephone poll ing conditions as stroke, hypertension, and heart
of 1,003 women between the ages of 18 and 64 disease. According to this poll, men (56 percent)
discovered, the majority of American women are are more likely to drive while they are drowsy or
sleep deprived. One of the sleep problems reported tired compared to women (45 percent), and they
by the women was insomnia; 68 percent of single are almost twice as likely as women to fall asleep at
working women, 72 percent of working moms, the wheel (22 percent versus 12 percent).
and 74 percent of stay-at-home moms.
In the NSF survey, sleep-related problems also
seemed to increase with age. Only 33 percent of
Other Factors Affecting Sleep:
women between the ages of 18 and 24 reported Change or Grief
a sleep problem, whereas 48 percent of those One of the questions in my survey was whether
between the ages of 55 and 64 reported a sleep- the respondents found it easy or difficult to fall
related concern. (According to the NSF study, the asleep in a hotel room. The responses were: 26
percentage of women evidencing a sleep concern found it “easy to fall asleep in a hotel room”; 17
steadily increases with age. From ages 25 to 34, it found it “difficult to fall asleep in a hotel room”;
is 36 percent, from ages 35 to 44, it is 44 percent, three responded it “depends”; and one did not
and from 45 to 54, it is 46 percent.) Eighty per- answer the question.
cent of the women polled noted that they keep For those who find it difficult to fall asleep in
going despite their exhaustion, relying on coffee a hotel room, the reasons might range from the
and other caffeinated beverages to stay awake. change itself in the physical aspects of sleep includ-
The most sleep-deprived women were those who ing the size or quality of the mattress to the type of
were pregnant, new mothers, or those with mood pillows that are used. Another change could be if
disorders. Women who slept with their signifi- the person is staying in a hotel because of a busi-
cant other—not a child or a pet—were also less ness trip, which might mean he or she is used to
likely to report that they suffered from insomnia. sleeping with a partner or even a pet and is now,
In research reported to the British Sleep Society temporarily, trying to adjust to sleeping alone.
in September 2007, Professor Francesco Cappuc- Or the difficulty could be tied to the changes in
cio, a researcher at the Warwick Medical School the time of day or the body’s adjustment to the
of the University of Warwick in Warwick, United trip itself by car, train, or airplane. For those who
Kingdom, discovered that women who slept noted that the ease or difficulty in falling asleep
five hours or less were twice as likely to suffer in a hotel “depends,” factors included how much
from hypertension (high blood pressure) than noise there was in the hallway, whether or not he
women who slept seven or more hours nightly. or she was tired, and a state that was “in between”
By contrast, for the men in their study of 6,500 easy and difficult, resulting in the ability to fall
participants (more than 4,000 men and more asleep “but not as comfortably.”
than 1,500 women), sleeping fewer than five Grief or loss is another change that can cause
hours or more than seven was not a factor in sleep problems that may be short-lived or could
hypertension. indicate the beginning of a long-term problem.
Unlike the difficulty in falling asleep associated
with a hotel room, which is usually cured by sim-
Adult Men ply returning to the regular sleep environment and
The 2002 NSF Sleep in America poll found males routine, a grief-related sleep problem could take
(42 percent) more likely than females (31 per- weeks, months, or even years to resolve.
xlii The Encyclopedia of Sleep and Sleep Disorders

Work-Related Stress and antianxiety medications, her sleep problems

subsided. However, she knows “many people with
When I conduct interviews about work, it is not
sleep problems related to PTSD.”
uncommon for a respondent to share with me
how insomnia was one of the consequences of
his or her work-related relationship or project Sleeping in the Same Residence—
problems. Insomnia is an example of the vicious the Cornerstone of the Family
cycle that can occur: An inability to fall, and stay,
asleep because of work-related stress could lead to One of the earliest essays on the sociology of sleep
exhaustion, which may cause poorer work perfor- is by Vilhelm Aubert and Harrison White. Entitled
mance, a bad mood, or a shorter temper, which “Sleep: A Sociological Interpretation,” it was pub-
can in turn exacerbate the strained workplace rela- lished in two parts in 1959 in Acta Sociologica.
tionships or situations that are causing the stress in Along with the 1970 essay in Sociological Quarterly
the first place. Breaking the cycle is the first step by Barry Schwartz, “Notes on the Sociology of
before workplace accidents or mistakes occur. As Sleep,” followed by the 1993 article by Brian Tay-
a 57-year-old registrar for a continuing education lor, “Unconsciousness and Society: the Sociology
program who has insomnia noted in my sleep sur- of Sleep,” published in the International Journal of
vey: “I often have trouble getting to sleep initially. Politics, Culture, and Society, these are some of the
Can’t ‘turn off’ the day or worries about the needs key sociological writings on sleep before the burst
of the coming day.” of sociological research that began in 1998 with
Work issues may appear in dreams, as notes Simon Williams and Gillian Bendelow’s The Lived
a 58-year-old editor: “Heck, I dream about work Body and which continues today.
whether there are problems or not. I often dreamed Aubert and White, in Part 2 of their study,
and tried to put whatever was in the dream in the state “. . . the nuclear family is in most societies
form of computer if/then/else statements.” A 53- organized around the criterion of residence. An
year-old pharmacy technician, who snores and important, actually one of the most stable, func-
gets only six hours of sleep on a typical work night tions of the family is the provision of a common
and who has work-related concerns that can lead sleeping group for its members.” That statement
to insomnia, notes: “Usually the problem is coming is even truer today than it was in 1959. Today
up with a reasonable/believable reason to call in sleeping in the same residence has become one of
sick the next day.” the rare times that nuclear families in the United
States gather together since the family meal is less
frequent, especially during the workweek, and
Post-Traumatic Stress Disorder many children are fed by caregivers because their
and Sleep Problems working parents may not return home until 7:00
Post-traumatic stress disorder (PTSD) is a reaction or 8:00 at night. In some households in the United
to a trauma that occurred recently or in the past States, it is also common today that once teenagers
but that is being relived in the present—such as achieve more independence, it is harder to insist
soldiers who relive their war traumas. This can that they participate in regular family meals, espe-
manifest in sleep problems such as insomnia. A 53- cially on weekends.
year-old writer, who has been living with her boy- But even today, except for children or teens
friend for more than 29 years, shared with me that who attend boarding school, sleep-away camp, or
she was the victim of incest by her father when are away at college, sleeping in the same residence
she was in her late teens. She had sleep problems defines the family unit. Indeed, for many families, it
for many years afterward, but in her mid-forties is only when the child has his or her first sleepover,
an incident occurred that triggered the PTSD and or other unrelated children sleep at the child’s home
caused her sleep patterns to go “to hell again.” or apartment, that the exclusivity of the family as a
After several years of therapy, antidepressants, sleeping unit is temporarily suspended. In time,
The Sociology of Sleep xliii

sleeping outside of the home will occur frequently logical interest.” Meadows then discovered that
for children and teens as they bond with their peers, University of Warwick sociologist Simon Williams
on the road to setting up a permanent residence had been researching the sociology of sleep for
separate from their nuclear family. several years, as had University of Surrey sociolo-
Family roles become apparent if one assesses gists Jenny Hislop and Sara Arber, with whom he
the relative size of the bedrooms in the typical began working.
apartment or house in the United States. The par- Professor Williams, author of the 2005 book
ents’ bedroom is usually much larger today than Sleep and Society: Ventures into the (Un)Known, shares
the children’s bedrooms, even if larger families his research into the sociology of sleep in the fol-
have two or three children of the same sex resid- lowing personal communication.
ing together in separate beds in the same bedroom.
As for why I became interested in sleep, many
The parents’ bedroom may have a private bath-
people ask whether or not I have a sleep disor-
room, but the children’s bathroom more typically der, which I don’t (to the best of my knowledge,
is in the hallway, shared with other children as that is). I guess I got interested in sleep because
well as with guests. I was working in the new area of the sociology
As an extension of the trend toward a more of the body/sociology of embodiment, and sleep
child-centric culture in the United States, it is of course is a key (yet neglected) aspect of our
embodiment: we are sleeping as well as waking
interesting to note that the architectural design of
beings. Hence a sociology of the body that did
newer homes, especially in higher income brack- not engage with sleep was missing a significant
ets, reflect this change: children’s bedrooms are part of embodied life. Similarly, the discipline of
almost the same size as the master bedroom and sociology as a whole was missing a significant
some even have a private bathroom. part of our lives by neglecting or dismissing
There are also competing contemporary trends sleep, given its predominant waking concerns
and preoccupations. I wanted to challenge and
at work with master suites for parents sometimes
correct this.
located on separate floors, so that the adults can Some of my colleagues thought (and still
have more privacy when they sleep. The ability to think) that sleep was/is a bit of a joke, or at the
have an auditory or even video intercom in the very least that it was not a very serious or weighty
baby’s room, which allows parents to hear and topic to study compared to say structure, agency,
see their sleeping infant, provides some comfort so identity, inequalities, etc. This I think is thankfully
now beginning to change, although there is still
that this privacy can be achieved while still being
a lot to do in order to challenge these past omis-
able to respond quickly to their crying infant or sions, misconceptions if not prejudices. . . .
toddler.
Professors Sara Arber and Simon Williams
The Growing Sociological Study cochaired six seminars on the sociology of sleep at
the University of Warwick from December 2004
of Sleep through December 2006. Some of the key issues
As sociologist Robert Meadows of the Univer- that sociologists are addressing in their studies of
sity of Surrey in the United Kingdom said in a sleep include gender differences in sleep patterns,
private communication, “I think it [sleep] has whether or not there is a tendency to insomnia,
been a neglected topic largely because sociology bed-sharing customs and what they mean, as well
is predominantly concerned with ‘action’ and as sleep throughout the life cycle.
common-sense depicts sleep as a time of asocial
inaction (cf. Taylor 1993).” Meadows’s own inter-
est in sleep was initiated after he began working The Role of the Sleeper
in a sleep clinic. He writes, “As a sociologist I felt Other sociological sleep concerns are fitting sleep
slightly out of place, but after a few discussions, it into the framework of some of the groundbreak-
became apparent that much of sleep is of socio- ing concepts in sociology, such as Talcott Parsons’s
xliv The Encyclopedia of Sleep and Sleep Disorders

concept of the sick role, as discussed in his classic of North Carolina at Greensboro and Megan Brown
The Social System, which Simon Williams applies to and Paul Rosenblatt at the University of Minnesota,
the role of the sleeper in his 2002 article, “Sleep among others. As Professor Rosenblatt, who has
and Health: Sociological Reflections on the Dor- researched couples and their sleeping patterns and is
mant Society.” Here are the “rights, duties and the author of Two in a Bed: The Social System of Couple
obligations” of the sleeper, according to Williams. Bed Sharing, notes in a personal communication:

Rights Bed sharing is a complicated social process and

an achievement of a couple’s interaction and
1. Freedom from noise and interference from oth-
coordination. A big part of the complexity is that
ers, except in times of emergency. it is impacted by a vast array of social institutions
2. Exemption from normal role obligations/relin- (work, medicine and health care, television, taste
quishing of conscious involvement in society. making in advertising, etc.).
3. No loss of waking role status while asleep.
According to an article by Tracie Rozhon in the
Duties/Obligations New York Times, a survey by the National Associa-
4. To sleep at night and therefore to conform tion of Home Builders points out that architects
to the general pattern of sleep time, unless and builders surmise that by 2015, more than 60
legitimate social circumstances, such as work percent of homes that are built to owner specifica-
arrangements, dictate otherwise. tions will request two master bedrooms instead of
5. To sleep in a bed, or similar device, in a private just one. Having separate bedrooms, which used to
place, away from public view, in proper attire be a practice for some members of the upper class,
(i.e., pyjamas, night-dress, etc.) . . . seems to be a growing trend across several classes.
The most common reasons for separate bedrooms
were sleep-related issues (e.g., snoring), lifestyle
The Right to Sleep differences, such as one person working late into
In the 1931 issue of the Journal of Educational Soci- the night, which would keep the other bed part-
ology, in her article “The Value of Rest and Sleep,” ner awake, or one half of the couple waking up
Ethel A. Grosscup wrote, “The right of all adults to earlier so that, too, would interrupt the partner’s
8 hours of tranquil repose in full unconsciousness sleep. However, according to the study, few
every night should be held as inalienable as their wanted to discuss the issue of separate bedrooms,
right to exist.” That’s as true now as it was then, and Rozhon reported that designers and architects
and yet so many children, teens, and adults of all shared that their clients felt embarrassed to admit
ages fail to get the necessary number of hours of that they were sleeping separately.
sleep each night that they need for their individual
temperaments and their stages in life. The qual-
ity of sleep will affect how each individual feels Changes in Attitudes toward Sleep
and performs the next day including school or job What college student hasn’t experienced—at least
performance. Creativity can be helped or hindered once—that time-honored tradition of pulling an all
from lack of sleep. Training researchers and writ- nighter whereby you study through the night in a
ers to better record the thoughts, images, and ideas mad dash to cram as much information into your
that emerge during sleep could result in a direct mind as possible and then, without sleep, drag
association among innovation, education, and the yourself to class to try to get a good grade, even
physical act of sleeping. hope to ace the test, often only to find that your
memory has turned to mush because it is sleep
deprived? Rather than ace the exam, you probably
Bed-Sharing Customs do worse than you might have done if you studied
In the United States, researchers into the sociology just a few hours less but gotten a good night’s sleep
of sleep include Steve Kroll-Smith at the University or at least some sleep.
The Sociology of Sleep xlv

How about the project manager, writer, or artist daytime drowsiness) three years earlier, but he did
burning the midnight oil, trying to pack as much nothing about it. The trooper at the preliminary
work time as possible into the wee hours of the hearing in Salina County District Court testi-
morning? Saying you stayed up all night to finish fied, “It’s my opinion the driver fell asleep at the
up a project was, until recently, considered a badge wheel.” By contrast, the driver’s account is that
of corporate courage, a symbol of your dedication he was eating and lost consciousness because he
to the company, even if it meant sacrificing your began choking on food.
sleep. In addition to reconsidering the way that drowsy
Alas, until lately, sleep deprivation has been driving is assessed or judged, sleep deprivation in
romanticized. For some, it’s as if needing sleep is to general is getting more consideration. Studies
admit weakness. What? Sleep? Everyone else may conducted in the United Kingdom and the United
need it but you only sleep if you have to. States in 2004 and 2006 have linked too little sleep
But the times are changing, to paraphrase the to a greater risk of obesity or high blood pressure
famous song. We live in an era that is seeing dra- or hypertension. This is important because hyper-
matic changes in how sleep deprivation is viewed, tension increases the risk for a stroke or a heart
especially in regard to drowsy driving. You might attack. A study released in 2006 by Columbia
even say that the shift in how driving drowsy is University’s Mailman School of Public Health and
viewed is somewhat akin to how DUI (driving the College of Physicians and Surgeons reported in
under the influence) used to be viewed until the Hypertension: Journal of the American Heart Associa-
1980s when MADD (Mothers Against Drunk Driv- tion finds that 24 percent of people between the
ing) was founded. An offense for which previously ages of 32 and 59 who slept five or fewer hours a
a driver might have gotten a slap on the wrist is night developed hypertension compared to only
now considered a crime, especially if someone dies 12 percent of those who got seven or eight hours
because of a DUI-related driving incident, with of sleep.
convictions leading to a suspended license, com- There is also a growing awareness that sleep
munity service, or even prison time. deprivation puts jobs and even relationships at
Tolerance of drowsy driving has also been greater risk since being too tired does not allow
diminishing as the public has become more optimal performance. A first step is for people to
aware of the hazards that it presents. The report, become more aware of just how they feel when
“Drowsy Driving and Automobile Crashes,” pub- they wake up and think about how that relates
lished by the National Highway Traffic Safety to the number of hours they slept. Then they can
Administration, cited a 1996 report that states consider possible behavior changes to increase
“. . . there have been about 56,000 crashes annu- the number of hours they sleep to achieve a bet-
ally in which drive drowsiness/fatigue was cited ter result. For example, in my survey I asked
by the police. Annual averages of roughly 40,000 the respondents to describe how they felt when
nonfatal injuries and 1,550 fatalities result from they woke up that morning. They chose from
these crashes.” among the following responses: (a) refreshed; (b)
The consequences to a drowsy driver, especially exhausted; (c) could have slept another hour or
if there was a car-accident-related death associated two; and (d) other.
with the driver falling asleep at the wheel, have Originally I thought it was a mistake that I
moved beyond considering it a stigma or just an began my survey on a Saturday, and the first 15
accident. For example, in Nebraska in 2007 a truck men and women to reply were referring to a lei-
driver who was involved in a May 2005 crash sure night/day. After that, the remaining 26 men
near Salina that killed a Salina mother and her and women were describing a work night. What
10-month-old son was sentenced to six months could have been a mistake turned out to be a
in prison. The prosecution argued that the driver researcher’s joy of discovery: 12 out of the 15 men
knew he had been diagnosed with sleep apnea and women woke up refreshed and they woke up
(a sleep disorder that made him more prone to naturally. The two who were exhausted, although
xlvi The Encyclopedia of Sleep and Sleep Disorders

they woke up naturally, had slept only 6 1/4 hours decide what time you want to wake up and work
or 6 1/2 hours, and the one person who wrote that backward from that time, taking into account the
she could have slept one to two more hours woke number of hours that is needed.
up naturally but only slept 4 hours. If insomnia occurs—the kind that leads to
As soon as it became a workday, however, and waking up one or more times throughout the
respondents began to use an alarm clock, the sur- night—there are sleeping aids that a physician
vey results were astoundingly different. Of the 14 could prescribe. However, as noted in various sec-
respondents who used an alarm clock to wake up, tions in this encyclopedia, there are limitations or
the findings are reversed from the first group who possible side effects to each medication that must
woke up refreshed and naturally. By contrast, nine be considered. These limitations include the risk
of the alarm clock users could have used one to of dependency or addiction, how the sleep aid
two more hours of sleep, two others who used an will combine or counteract any other medica-
alarm clock reported being exhausted when awak- tions someone is taking, as well as many other
ening, and only three alarm clock users reported concerns.
waking up refreshed, and all three reported sleep- Counting sheep is an age-old natural way to
ing eight hours. The other four respondents who deal with insomnia. A 66-year-old librarian from
also reported needing one to two hours more sleep Ohio who participated in my sleep survey has
upon awakening did not use an alarm clock but suffered from insomnia for years. She shared her
were still awakened in ways other than naturally, variation on counting sheep:
including a phone call, a sudden thought, birds,
[I] run through the states and capitals in alpha-
and a dream.
betical order or start with A and try to think of
It is clear from this small sample that if you ten places in Ohio, then ten in the rest of the U.S.
want to see how much sleep your body needs and finally 10 in the world. I usually get through
and if you want to wake up refreshed, you should just a couple of letters before I fall asleep. I also do
allow yourself to wake up naturally without an the presidents [of the United States]. I also have
alarm clock on the weekend and then try as hard a sound soother which I always keep on thun-
as possible to adjust your weekday habits so you derstorm. . . . I finally figured out that it wasn’t a
good idea to read or get on the computer when I
can still go to sleep at a time that will allow you to awaken during the night. However, I still tend to
awaken when you have to for work or school. It is do this when it’s over an hour that I can’t sleep.
ironic that over the weekend, when activities are
less stressful, men and women get more sleep and Research into sleep by sociologists will con-
wake up naturally and refreshed, compared to the tinue to shed important light on this phenomenon
work or school days when being refreshed is more from a sociological, rather than just a medi-
important for performance. cal, neurological, psychological, psychoanalytical,
anthropological, philosophical, or even literary
perspective. It is, of course, significant that soci-
Insomnia ologists continue to explore sleep from the per-
The most common sleep disorder is insomnia, the spective of our discipline since we have a unique
inability to sleep through the night or, for some, to viewpoint dealing with roles, norms, sanctions,
get to sleep in the first place. For some, the cure for socioeconomic status, gender, social systems, and
insomnia may be as simple as changing the time cultural considerations. However, an interdisci-
that they go to bed. For example for the retired plinary approach to sleep, including a research
or elderly who may have a lot of unstructured collaboration of sleep physicians, gerontologists,
time on their hands, getting into bed too soon pediatricians, neurologists, psychologists, psycho-
could be a cause of insomnia. Individuals should analysts, anthropologists, and sociologists, may
determine the optimum number of hours of sleep yield comprehensive and far-reaching results to
that is right for them. Once that number is known, many of the sleep disorders that plague such a
The Sociology of Sleep xlvii

large percentage of the population. An interdis- the sociology of sleep becomes as widely accepted
ciplinary research team might even help find the a field as the sociology of emotion, race, class, gen-
answer to the elusive question of why humans der, or culture. The next decade promises to be an
need sleep in the first place. exciting time for sociologists who conduct studies
Sociologists and other social scientists and physi- on sleep! I will be pursuing research into how to
cians continue to look for the causes (and cures) of prevent drowsy driving as well as continuing to
insomnia, sleep apnea, narcolepsy, and restless leg increase public awareness about its consequences.
syndrome, as well as to suggest more effective ways I will also be researching the relationship among
to develop healthy sleep habits (sleep hygiene) and creativity, dreams, and nightmares. (The latter is
design the places where sleep takes place to more fueled, in part, by a very powerful dream expe-
optimally facilitate this mysterious everyday activ- rience I once had. Upon awakening, I recorded
ity that takes up one-third of our lives. my dream in detail, and it became the plot and
By pairing sociologists with sleep researchers characters of my second thriller, Just Your Everyday
and physicians well versed in the stages of sleep, People, coauthored with Fred Yager.) Another area
it might also be possible to get more detailed of research into the sociology of sleep that I have
insights into just what is occurring during those been pursuing further is the impact on sleep of
stages—non-REM sleep, stage one (thetawaves), post-traumatic stress disorder, especially among
stage two (sleep spindles), stage three (slow wave war veterans as well as adult survivors of child-
sleep), stage four (deepest sleep), and REM sleep hood or teenage sexual abuse and those experienc-
(when dreaming occurs)—gathering information ing grief.
that might help couples who sleep together in the Sleep is far from the time of inaction that it
same bed, roommates, or even those who have to used to be considered as the questions of where
sleep in hotels for business or leisure trips to sleep one sleeps, with whom one sleeps, how long one
more effectively. sleeps, why one can or cannot sleep, and what
dreams or nightmares occur (or are recorded) dur-
ing sleep are just a few of the many considerations
The Future of the Sociology during this four- to eight-hour period that sociolo-
of Sleep gists are finally studying.
Much about sleep has been explored by sociolo- (References for this chapter are included in the
gists, and it is definitely a growing subspecialty in back of this book in a separate bibliography follow-
sociology. But there is much more to accomplish as ing the main bibliography.)
PSYCHOLOGY AND SLEEP:
THE INTERDEPENDENCE OF
SLEEP AND WAKING STATES
Arthur J. Spielman, Ph.D., Paul D’Ambrosio, Ph.D.,
and Paul B. Glovinsky, Ph.D.

T he focus of psychology is behavior, which at

first glance might be thought to cease during
sleep. Certainly most psychological investiga-
The Interaction of Sleep and
Wakefulness
tions have focused on waking behavior, whether Events transpiring during sleep and wakefulness
are interwoven, each serving as an antecedent
it be an easily observed action or mental activ-
and consequent condition. Wakefulness can take
ity inferred from behavior or verbal report. Of
on a multitude of casts, from normal renderings
course, neither the mind nor the body truly
through aberrant forms. As the night follows the
ceases activity during sleep. Far from turning
day, so will sleep reflect this variation.
off, the brain in sleep generates a variety of
states, accompanied by predictable physiological
changes and typical forms of mentation. Physi- Psychopathology Influences Sleep
ological indicators of hyperarousal in individuals
It is so common as to be a staple of clinical wisdom
with insomnia include beta activity in the elec- that emotional disturbance precedes and produces
troencephalogram (EEG), increased whole body sleep disturbance. Practical and ethical consider-
metabolism, and elevated nocturnal cortisol (a ations have precluded a systematic study of this
hormone). Moreover, this nocturnal activity is causal relationship. However, few would disagree
not totally separate from waking thought and with the assumption.
action. Daytime experience has a direct effect The Diagnostic and Statistical Manual of Mental
on what transpires during sleep, and both the Disorders (4th ed.) contains 18 different disorders
psychology and physiology of sleep in turn have that are associated with insomnia or hypersomnia.
profound influences on waking life. Major diagnostic categories, such as major depres-
If sleep and wakefulness are interdependent, sion, mania, generalized anxiety, and dysthymic
this interdependence is embedded in the endog- disorder, employ insomnia as a possible diagnostic
enous rhythmic alternation that governs both criterion. The nocturnal agitation of the manic
states. The clock that influences the appearance of state, the early morning awakening of the major
sleep and wakefulness may itself be reset by psy- depressive, and the sleeplessness of the prodrome
chological processes. Whether by the sleeplessness of the schizophrenic reaction are common clini-
of distress or the prolonged wakefulness of creative cal examples of sleep disturbance associated with
output, the appearance and timing of an array of psychopathology.
associated physiological rhythms can be affected It has been shown that the prevalence of sleep
by psychological states. disturbance among psychiatric patients is three

xlix
l The Encyclopedia of Sleep and Sleep Disorders

times higher than in a control population. Further- reduced postural muscle activity due to weightless-
more, a large survey of different medical specialties ness, had significant difficulty falling asleep. While
has discovered approximately twice the prevalence there may have been more than one reason for
of insomnia in psychiatric practice compared to the hyperalertness while orbiting the Earth, controlled
average of other specialties. studies at sea level have shown that vigorous
The well-documented evidence for a particular exercise during the day will increase the amount
psychometric profile of depression and anxiety in of slow wave sleep that night. Furthermore, this
insomniacs has generated a theory stating that indi- increase in deep sleep is obtainable only when
viduals who deal with emotional distress by inter- physically fit subjects exercise. It appears that
nal processes are more vulnerable to insomnia. fit people can exercise at a high rate for longer
Investigations of the significant sleep distur- periods of time and as a result increase their body
bance associated with major depressive disorders temperature for longer durations. The discovery
has revealed a number of intrasleep anomalies. that body temperature is one factor that mediates
In addition to the nonspecific disturbance of the the effects of physical activity on sleep provides a
continuity of sleep, REM sleep abnormalities have vivid illustration of how behavior and physiology
been identified that may be biological markers of interact within the sleep-wake cycle.
major depression. The group at Pittsburgh have
been leaders in studies showing that a shortened
latency from sleep onset to the first appearance
Sleep Affects Psychological
of REM sleep and increased rapid eye movement Well-Being
activity is characteristic of primary depression. Numerous studies of sleep deprivation have con-
Reduced slow wave sleep preceding the first REM sistently shown that sleep loss affects daytime
period, another sleep characteristic of depres- performance, sleepiness, and mood. Sleep loss
sion, may be involved in the disinhibition of REM does not have to be large-scale to produce demon-
sleep. A recent population sample of ambulatory strable effects. Reductions in sleep duration, if
American adults has highlighted the increased suffered nightly, will accumulate and produce day-
prevalence of insomnia in individuals suffering time decrements. One of the first capacities to be
emotional distress. The finding of elevated anxi- affected is the ability to produce creative solutions
ety and depression is accompanied by a markedly to problems. Sleep loss also leads to the inability
increased prevalence of insomnia. to maintain vigilance. Individuals cannot attend
Psychological disturbance does not have to to ongoing tasks and will exhibit lapses in perfor-
attain a magnitude warranting formal diagnosis mance. Sleepiness and brief sleep episodes, irrita-
before its effects on sleep become apparent. All bility, and dysphoric mood also impair functional
individuals must cope with varying degrees of capacity and quality of life.
stress originating from a variety of sources. The Alertness and attention represent the gateway
physical environment may contain numerous to cognitive processing, and thus a wide range
stressors, such as noise and crowded conditions. of mental and emotional dysfunction is possible.
One’s body may present discomfort or pain to be Eventually the sleep-disturbed individual’s self-
endured. Social etiquette may make demands that image and self-esteem must deal with the fact of
are perceived as stressful. Any of these sources lowered effectiveness and achievement. Patients
of stress has the potential of precipitating a sleep start to refer to themselves as insomniacs, avoid-
disturbance directly, without need of a mediating ing challenges, explaining away mistakes, and
psychopathological process. generally taking refuge in the sick role. They are
ever wary that insufficient sleep will erode their
capacities.
Physical Activity Influences Sleep The self-attribution of “I’m an insomniac” may
The Neurolab astronauts aboard the space shuttle serve as a focus for self-deprecatory ideas. A wid-
who spent many days orbiting the Earth, with ening circle of thoughts surrounds the belief that
Psychology and Sleep li

“I cannot sleep well.” Examples of these might maintain a “team player” attitude at work and
include, “I’m not up to hosting Thanksgiving” carefully restrict any expression of hostility there.
or “I’d better maintain a low profile because I’m His wife notices growing irritability in the evening;
not capable of as much work as my colleagues.” rather than being a respite from work pressures,
Eventually, these ideas may produce a degree the evening hours at home become tainted from
of helplessness and hopelessness that, according these pressures. A sleep-onset insomnia devel-
to cognitive theorists, forms the basis of a mood ops. Our manager becomes preoccupied with
disturbance. perceived or actual slights endured during the
day; only after two or more hours of such obsess-
ing is he exhausted enough to drop off to sleep.
The Vicious Cycle of Insomnia He cannot afford to come into the office late, so
and Anticipatory Anxiety he diligently sets two alarm clocks and begins to
The interaction of disturbances in sleep and wake- build up a significant sleep loss. Daytime irritabil-
fulness is clearly seen in the mutually reinforcing ity mounts until one day a snide comment from a
experiences of sleepless nights and anxious days. recently promoted colleague triggers an explosive
Transient insomnia is nearly a universal experi- outburst.
ence. The tossing and turning, the racing mind This scenario could be subjected to several
and half-completed thoughts, the frustration at straightforward analyses. One formulation would
being unable to bring oneself relief, all of these take as its context the pressures of the workplace
experiences are extremely unpleasant and avoided and see the insult as sufficient to produce the out-
if possible. During the day, insomniacs will wonder burst. A somewhat wider scope would include the
whether these experiences are again in store. A development of the insomnia in its purview. This
dread of the night to come may appear as evening formulation would hold both the insomnia and
approaches. This anticipation of a sleepless night the outburst to be secondary to emotional turmoil.
produces anxiety and physiological arousal. Thus, The denial of promotion has stirred up feelings
fear of insomnia has itself produced sufficient of inadequacy and dependency that produce an
arousal to perpetuate the sleep disturbance. extensive disturbance, with both daytime and noc-
This vicious cycle persists despite occasional turnal manifestations.
nights of good sleep. Variability of sleep from night Our analysis would underscore the mutual
to night is characteristic of insomnia. This renders interaction between mood and sleep: The insom-
the sleep of insomnia unpredictable and provides nia both reflects the underlying emotional state
the basis for the insomniac’s worry. and influences this state. Heightened cognitive and
physiological activation during the evening hours
interferes with sleep onset at our patient’s usual
Insomnia as a Pathology of bedtime. He is less cognizant of this change in
Sleep and Wakefulness evening demeanor but acutely aware of the expe-
The problem of insomnia has been alluded to rience, a few hours later, of lying wide-eyed in
many times in the foregoing discussion, since the bed, restless and angry. He reaches back to the last
interaction of sleep and wakefulness is perhaps salient cue of change—slights at the workplace—in
most clearly illustrated when the smooth transition order to fix blame for his sleeplessness.
between these states is disrupted. In narrowing the During the day our patient has to contend with
focus to the evaluation and treatment of insomnia, increased irritability, diminished powers of concen-
the practical application of this psychological view- tration, and other mood and performance deficits
point in clinical practice will be illustrated. resulting directly from sleep loss. In addition, the
Let us take, for example, the case of a mid- experience of insomnia has added an overlay: a
level manager who has been denied promotion. sense of lost control, feelings of incompetence, and
He is seething with resentment, yet, in order to concerns regarding health consequences. Against
preserve his chances for the next review, he must this backdrop, our patient’s tolerance for assault on
lii The Encyclopedia of Sleep and Sleep Disorders

his self-esteem is especially low, and his successful poorly, in the middle of the day she will take a
colleague’s comment especially stinging. nap. These changes weaken the synchroniza-tion
The course of insomnia is determined by the of circadian rhythms that is sustained by a regu-
interacting sequence of daytime and nocturnal lar sleep-wake cycle. While she may believe that
experiences. Either an understandably bad day or nothing can be done about her sleeplessness until
inexplicably bad night may serve as the first link in after the deadline, strict structuring of her bedtime
a chain of experiences and compensatory adapta- may substantially improve the sleep problem.
tions that result in chronic insomnia. Examining
and categorizing these individual links in the chain TABLE
of insomnia results in a clearer formulation and COMMON PRACTICES AND RESPONSES TO INSOMNIA
THAT PERPETUATE SLEEPLESSNESS
more directed treatment plan.
• Irregular timing of retiring and arising
• Excessive time in bed
The Three P Model of Insomnia: • Napping at irregular times
Predisposing, Precipitating, and • Worry that insomnia will produce daytime deficits
Perpetuating Factors in Insomnia • Expectation of a bad night’s sleep
The nosological scheme of the International Clas- • Increased caffeine consumption
sification of Sleep Disorders (revised edition) has • Use of hypnotic medication and alcohol
produced a clear and consistent description of the • Maladaptive conditioning
sleep disorder’s clinical phenomena. Interven- • “Sleeping in” on weekends
tion strategies are not automatically derived from
diagnosis. With regard to the insomnias, we have Insomnia may last for decades. When it per-
urged the use of a simple categorization of case sists beyond a transient period, the clinician may
material that helps focus on the roles of different have to go beyond the uncovering of predisposing
factors in the pathogenesis of the disorder, thereby and precipitating factors. As insomnia becomes a
assisting in a rational approach to treatment. chronic experience, the individual may instigate
In the development of insomnia, characteristics compensatory practices to deal with the problem.
of the person may serve as predisposing factors by Returning to the frantic grant writer, if a habit
increasing the vulnerability to develop a sleep dis- of napping at irregular hours continues after the
turbance. These characteristics might include sus- deadline is long past, this may maintain her insom-
ceptibility to anxious worrying or activation at night. nia. Or if she increases her caffeine consumption
Environmental features, such as noise and morning to buttress her flagging alertness and then contin-
light exposure, may also predispose to insomnia. By ues this habit, her insomnia may persist. In these
definition, these characteristics are not sufficient to cases, the precipitating circumstance has long
produce an insomnia, but they may set the stage for subsided yet the secondary factors are sufficient to
the development of a particular form of insomnia. maintain the insomnia. Perpetuating factors may
Interventions that address these factors will help go unnoticed, especially when clear predisposing
ameliorate the current insomnia and forestall the and precipitating aspects are still present. There-
development of insomnia in the future. fore, one must thoroughly evaluate the common
The factors that trigger an insomnia are at the practices and experiences (SEE TABLE ABOVE) that
center of the initial clinical evaluation. An under- may accrue onto any insomnia so that a compre-
standing of the factors that precipitate a sleep hensive treatment plan may be designed.
disturbance is often sufficient for developing a
successful treatment plan. For example, a scientist
may become increasingly keyed up and alter her
Cognitive Behavioral Treatment
bedtime hours as the deadline for submission of of Insomnia
a grant application approaches. When writing is The following four sections cover the components
going well, she will stay up late; when it is going of what has become the gold standard in the non-
Psychology and Sleep liii

pharmacological treatment of insomnia. These signal that sleep is the appropriate and expected
treatments all arose as stand-alone approaches behavior.
with some efficacy. The multimodal cognitive Stimulus control instructions were developed
behavior therapy version is quite effective and by Richard Bootzin and consist of a short set of
applicable to a wide range of insomnia diagnostic rules to reestablish the connection between bed-
entities. A 2005 National Institutes of Health “State room cues and sleep. Excerpted, these rules are as
of the Science” conference concluded that cogni- follows:
tive behavior therapy for insomnia is as effective
as pharmacological treatments. The most typical 1. Use the bed only for sleep (sex is exempt from
combination of treatments in cognitive behavior this rule).
therapy for insomnia is stimulus control instruc- 2. Go to bed only when sleepy.
tions, cognitive therapy, and sleep restriction. 3. If you do not fall asleep within about 15 min-
utes of getting into bed, then get out of bed. Do
Treatment Based on Conditioning not return to bed until you are sleepy or feel
The role of conditioning in sleep was extensively you can fall asleep.
discussed by Pavlov. More recent demonstrations 4. When you return to bed abide by rule number
of the classical conditioning of sleep onset in cats 3. The following additional rules keep sleep in
have been conducted by Sterman and Clemente line with principles of good sleep hygiene:
and colleagues. These investigators paired a neu- 5. Get up at the same time every morning.
tral tone with electrical stimulation of the pre- 6. Do not nap.
optic basal forebrain. The electrical stimulation of
the pre-optic basal forebrain was capable of rapidly Following these instructions leads to repeated
producing high voltage slow waves and sleep. experiences of rapidly falling asleep after getting
After a number of pairings, the formerly neutral into bed. Sleep improves, according to the theory,
tone was capable of independency eliciting high because the bedroom cues regain their discrimina-
voltage slow waves and sleep. In this section we tive properties and exert control over the sleep
present preliminary data in humans suggesting process.
that pairing contextual cues with the sleep-pro-
moting properties of a hypnotic medication pro- Treatment Based on Increasing the
duces a conditioned response of rapid sleep onset. Drive to Sleep
One of the most widely tested and efficacious Analogous to the idea that there are individual
behavioral treatments of insomnia is based on the differences in nocturnal sleep duration, differ-
rationale that associative mechanisms can exert ences in basal sleep propensity may reflect a trait.
control over the sleep onset process. In normal A range of habitual sleep times, approximating
conditions cues such as darkness, sleep rituals, the a bell-shaped curve with a mean of about 7.5
bed, quiet, and recumbency are regularly associ- hours, has been reported by Daniel F. Kripke et
ated with rapid sleep onset. Repeated experiences al. This trait characteristic is distinct from state-
render these cues as discriminative stimuli for evoked changes (e.g., increasing or decreasing
sleep. In other words, these cues signal that sleep is the amount of time spent in bed yields com-
the appropriate response given the situation. If an mensurate changes in sleep duration). Applying
individual engages in behaviors other than sleep this familiar example of coexisting state and trait
in association with these cues, then these stimuli aspects of sleep duration, let us assume that day-
will lose their discriminative properties. This is time sleep latency also distributes normally, with
what happens, for example, when an individual a mean of about 12 to 14 minutes. In this view,
uses the bed as a dining table, TV viewing plat- the fact that, more or less, sleep affects sleepiness
form, telephone booth, and so on. In this case, the does not negate the possibility that sleepiness
bed, bedroom environment, and rituals have lost or activation may have a relatively stable trait
their control over the sleep process; they no longer influence.
liv The Encyclopedia of Sleep and Sleep Disorders

If we have two traits of nocturnal sleep time muscle group and holding the tension in order to
and diurnal sleep propensity, the question arises heighten awareness. Next, the patient relaxes the
as to how these traits might be related. Although muscle and focuses on the tension waning. These
a positive correlation between nocturnal sleep two steps—tensing and relaxing—are repeated for
time and diurnal sleep latency is tacitly assumed all the major muscle groups. This training helps
to exist in individuals, there is surprisingly little patients avoid and counteract the tonic muscular
evidence to this effect. Mary A. Carskadon and tension that is a barrier to sleep. To assist with
colleagues, for example, in elderly noncomplain- the fine discrimination of behavioral states that
ing individuals obtained a nonsignificant positive relaxation training requires, biofeedback devices
correlation between night sleep and day sleepi- are used, such as those that produce an audi-
ness. However, recent evidence suggests that indi- tory signal corresponding to the level of frontalis
viduals with insomnia may exhibit an inverse muscle tone.
relationship between nocturnal sleep and daytime
sleep latency. Seidel and the Stanford group have Cognitive Treatments
shown that despite sleeping less than normal at The mind can be its own worst enemy when it
night, insomniacs are no sleepier by day. Stepanski comes to sleep. The same ability to solve problems,
and colleagues at Henry Ford Hospital have shown plan ahead, and generate options, which is so adap-
a strong association (r = -.67) between sleep and tive for waking life, becomes maladaptive when it
daytime sleep latency. Therefore, a reduced drive is exercised at the expense of sleep. In addition to
for sleep, during both the night and day, appears to the arousing properties of the sheer buzz of a rac-
contribute to the difficulties facing insomniacs. ing mind at night, certain mental content appears
Sleep restriction therapy (see Spielman, et al.) to be particularly counterproductive. So-called
aims to increase sleep drive in insomniac patients. dysfunctional cognitions include thoughts that
An initial sleep loss is produced by curtailing amount to catastrophizing and worry over next
time in bed to an amount approximating the day performance deficits. Cognitive therapies have
patient’s subjective report of sleep time. The sleep been devised that train patients to exert more
loss heightens sleep propensity and increases the control over the content and timing of thought
likelihood that most of the short time allotted for processes. Specific time can be set aside for worry,
sleep will be spent actually sleeping. Anticipatory the mind can be guided through a sequence of
anxiety is reduced, sleep onset is rapid, sleep is less relaxing images, or thoughts can be restructured
interrupted, and sleep duration is more consistent so as to minimize the importance of distressing
across nights. As sleep improves, the patient is experiences. These and other similar techniques
allowed to spend progressively more time in bed. aim at ensuring a reasonably calm state for the
Some insomniacs who may be deficient in sleep relatively short time it takes to fall asleep, when
drive will require continued mild sleep restric- all else is in place.
tion to maintain this improvement. Others can be
returned to a schedule that does not impose sleep
loss because the treatment has addressed factors
The Rhythm of Sleep and
other than a deficient sleep drive, such as anticipa- Wakefulness
tory anxiety or irregular sleep-wake scheduling. Daytime functioning is affected not only by the
amount of sleep attained the night before, but also
Relaxation and Biofeedback Training by the time at which parameters such as mood,
The clinical impression of increased autonomic alertness, and performance capacity are assessed.
activity and muscle tension has been documented This distinction points to the importance of a new
in such studies of insomniacs as Monroe’s. The goal regulatory principle, that of circadian organiza-
of progressive muscle relaxation is to increase the tion, which has taken its place alongside the clas-
patient’s awareness of high and low muscle ten- sic homeostatic view (the system by which the
sion. The patient practices contracting a particular body maintains a steady-state or balanced internal
Psychology and Sleep lv

milieu). The homeostatic view is that optimal With regard to phase relationship, the coor-
functioning occurs within a circumscribed range dinated sequence of increasing sleepiness, fall in
of physiological values; deviations from this range body temperature, and sleep onset regularly recurs
are aberrant and will mobilize mechanisms to at approximately the same time of night under
reestablish the basal levels. For example, a body normal conditions. In contrast to this synchrony,
temperature of 98.6 degrees Fahrenheit is the the timing of rhythmic processes may be displaced,
normal value that is maintained by a variety of so that there is an inappropriate interval between
thermoregulatory mechanisms. the fall of the temperature cycle and sleep onset.
The biological rhythm perspective holds that This is commonly experienced, for example, when
certain deviations from normal values are endog- eastbound airline passengers who have crossed
enously generated and periodic. An important five time zones try to go to sleep at a time that
group of biological rhythms have period lengths matches the nighttime in their new surroundings.
(the duration of a complete cycle) of about one Under these new conditions, bedtime is before the
day, and hence are called circadian rhythms. For fall in body temperature, and falling asleep will
example, body temperature has a regular endog- likely be difficult.
enous variation of about one and a half degrees We have seen how the vicissitudes of sleep
Fahrenheit and a period length of about 24.2 and wakefulness can be conceptualized within a
hours. This regular fluctuation about a mean value framework that emphasizes their mutual interde-
of 98.6 degrees Fahrenheit does not represent pendence. Both of these states are comprised of
error in the biological system but is, rather, a key a myriad of behaviors, each capable of reflecting
structural factor. the past and influencing the future. These behav-
Rhythmic systems are characterized by the iors are in turn influenced by the timing of their
amplitude of variation and period length of a given occurrence with respect to the sleep-wake cycle.
parameter and the phase relationship between Conceptualization of insomnia along these lines is
different parameters. In the context of sleep and particularly instructive, in that waking life, sleep
wakefulness, amplitude might refer to the range behavior, circadian timing, physiological and psy-
of arousal experienced. Ideally, there should be chological predispositions, maladaptive learning,
a great range between peak alertness during the and environmental influences are all relevant to
daytime and minimal alertness at night. This range the genesis, course, and treatment of this prevalent
appears restricted in some chronic insomniacs. health problem.
Arousal in this group is heightened both day and (Selected references for this chapter are included
night. in the bibliography.)
ENTRIES A TO Z
A
abnormal swallowing syndrome, sleep-related malities in either the swallowing reflex, its motor
Disorder that occurs during sleep in which there component, or the protective mechanism guarding
is aspiration of saliva that produces coughing and the larynx are considered to be possible causes.
choking episodes, due to inadequately swallowed Treatment is largely symptomatic, and one can
saliva that collects in the pharynx and erroneously consider the use during sleep of anticholinergic
passes into the larynx and trachea. This choking agents, such as amitriptyline (see ANTIDEPRES-
and coughing can cause INSOMNIA. SANTS), which reduce upper airway secretion.
This disorder was first described by Christian
Guilleminault in 1976 as an unusual cause of
insomnia. The patient described by Guilleminault accidents, sleep related Common in persons with
had frequent episodes of coughing and gagging SLEEP DISORDERS, especially those who suffer from
that were associated with “gurgling” sounds, prob- EXCESSIVE SLEEPINESS. Sleepiness produces impaired
ably due to the pooling of saliva in the lower part ALERTNESS and awareness, and this can be a prob-
of the pharynx. Because of the frequent aspira- lem for those who operate dangerous machinery or
tion, patients with this disorder may be prone to drive cars.
respiratory tract infections that can be worsened Motor vehicle driving is particularly hazard-
by increased use of HYPNOTICS, which may be pre- ous in persons who are sleepy, since riding in a
scribed to help the insomnia. motor vehicle has a SOPORIFIC effect and will bring
Polysomnographic studies have demonstrated a out underlying sleepiness. Excessive sleepiness
very disturbed sleep pattern with frequent awak- as a cause of crashes is often unrecognized either
enings occurring throughout all the sleep stages; because the individual is wide awake once an
however, deep SLOW WAVE SLEEP does not occur. accident occurs or does not survive to report the
This disorder needs to be differentiated from sleepiness. It is not uncommon to find that people
other disorders that cause choking episodes dur- who suffer from sleepiness while driving (DROWSY
ing sleep, in particular, OBSTRUCTIVE SLEEP APNEA DRIVING) will open the window to get fresh air, turn
SYNDROME. Episodes of SLEEP-RELATED GASTRO- the radio on loud, or employ other techniques,
ESOPHAGEAL REFLUX can also lead to coughing and such as moving around in the seat, to increase
choking during sleep, but daytime episodes of acid alertness. There may be frequent stops to get a cup
reflux associated with heartburn, chest pain, and of coffee or to walk around to get refreshed. Some
other features indicative of reflux are usually pres- may also use OVER-THE-COUNTER MEDICATIONS con-
ent in such patients. Patients with SLEEP-RELATED taining CAFFEINE to increase alertness while driv-
LARYNGOSPASM may appear to have a disorder ing. Naps taken in the car at the side of the road
similar to sleep-related abnormal swallowing syn- are also common for persons who have moderate
drome; however, the episodes of laryngospasm are to severe daytime sleepiness. However, the driver
rare, and between episodes patients are typically does not always appreciate the degree of sleepiness
asymptomatic. while driving, and therefore motor vehicle acci-
The pathology of sleep-related abnormal swal- dents often result. Falling asleep while waiting for
lowing syndrome is unknown; however, abnor- a red light or in traffic jams, veering to the side of

1
2 accreditation standards for sleep disorder centers

the road and driving onto the road shoulder com- army colleagues when they stuffed socks in his
monly occur. mouth in order to stop his snoring. Another patient
Sleepiness, and accidents caused by sleepiness, with sleep-related epileptic SEIZURES so frightened
can be exacerbated by the ingestion of alcohol, his wife that she thought her life was in danger; she
particularly if the amount of sleep the night before hit him over the head with a bedpost causing him
was less than required. Alcohol can also increase to require numerous scalp sutures.
the severity of OBSTRUCTIVE SLEEP APNEA SYNDROME,
a common disorder in middle-aged males, thereby
leading to increased sleepiness (and the greater accreditation standards for sleep disorder centers
possibility of accidents) the next day. In 1975, the Association of Sleep Disorder Centers
In addition to motor vehicle accidents due to (ASDC) began to develop guidelines and standards
sleepiness, people with sleep disorders are at risk for the practice of SLEEP DISORDERS MEDICINE. These
of injuring themselves, even when sleeping in bed standards resulted in the accreditation of the first
at home. Some sleep disorders, especially those sleep disorder center in 1977. Since that time, the
associated with abnormal movement, such as the Association of Sleep Disorder Centers has merged
obstructive sleep apnea syndrome or REM sleep with the Clinical Sleep Society (CSS) to form
BEHAVIOR DISORDER (RBD), can cause an individual the American Sleep Disorders Association (now
to fall out of bed or hit a nightstand. The violent called the AMERICAN ACADEMY OF SLEEP MEDI-
movements during sleep may also injure a bed CINE [AASM]), which is responsible for producing
partner, and excessive movement during sleep is a guidelines for sleep disorder centers. An accredita-
common cause of a couple moving to separate beds tion committee visits sites and ensures that sleep
in order to prevent injuries. disorder centers throughout the United States meet
Some disorders can be associated with very appropriate standards for the practice of sleep dis-
violent activity, such as SLEEP TERRORS, which are orders medicine. The standards involve a review of
often characterized by a rush from the bed in a the following areas: the relationship of the center
violent and uncontrolled panic. People with sleep to the host medical institution to ensure that there
terrors have occasionally gone through glass doors is a stable relationship among the medical structure
or fallen out of windows during their intense panic. of the sleep disorder center, the physical environ-
Also, sleepwalkers can suffer from accidents during ment, and the personnel; the way in which patient
their nocturnal wanderings. A fall from a window referrals and evaluation procedures are handled;
is not uncommon as a result of sleepwalking, and the polysomnographic and other monitoring pro-
walking into furniture or other objects can cause cedures; the interpretation and documentation
injuries (see SLEEPWALKING). of the polysomnographic data; and the physical
When sleep terror and sleepwalking coexist, equipment of the recording laboratory.
even death can be the consequence of an individual In order to become accredited, a comprehensive
running or walking out of the house and rushing in application for accreditation must be completed by
front of a passing car or falling from a window. the applying sleep disorder center. If the informa-
Sometimes accidental injury can be produced tion presented indicates that the center meets the
indirectly. Snorers have reported accidents related standards for accreditation, a site visit is organized.
to their snoring. One woman broke her arm as a Two official site visitors go to the sleep disorder
result of her husband’s SNORING. Used to sleeping in center to observe a patient undergoing polysom-
a double bed where she could touch her husband to nographic evaluation and to review with the center
get him to change position whenever he was snor- its procedures and the ability to diagnose and treat
ing, she fell out of bed when staying in a separate sleep disorders. Upon completion of a site visit, the
bed in a hotel; her husband commenced snoring, visitors recommend to the national chairman of the
she stretched out to touch him and, not realizing accreditation committee whether or not to accredit
she was in a separate bed, fell and broke her arm. the center. If favorable, the sleep disorder center is
Another loud snorer was almost suffocated by his given full accreditation status for five years.
acromegaly 3

Accreditation status can be contingent upon the Many medications that affect the central nervous
sleep disorder center meeting a number of provi- system have anticholinergic properties, and the
sions, if all aspects of the center’s activity do not blockage of acetylcholine accounts for many of the
conform entirely to the standards and guidelines. adverse reactions that are seen. The medications that
Then, after a period of five years, the sleep disorder have most pronounced anticholinergic effects are the
center must reapply for accreditation. (By 2006, tricyclic ANTIDEPRESSANTS, such as IMIPRAMINE, which
792 sleep disorder centers had been accredited by are often used in sleep medicine for the treatment
the American Academy of Sleep Medicine.) In this of sleep disturbance in patients with DEPRESSION.
way, the development of sleep disorder centers in The anticholinergic tricyclic antidepressants are also
the United States has proceeded in an orderly and used for the treatment of CATAPLEXY in patients with
appropriate manner, with the highest standards of NARCOLEPSY. The adverse reactions of the medica-
patient care being maintained. (See also ACCRED- tions include dry mouth, constipation, and urinary
ITED CLINICAL POLYSOMNOGRAPHER [ACP], SLEEP DIS- retention and can produce restlessness, irritability,
ORDER CENTERS.) disorientation, hallucinations, and even DELIRIUM.
The tricyclic antidepressants are now largely being
replaced by the selective serotonin reuptake inhibi-
accredited clinical polysomnographer (ACP) In- tors (SSRIs) such as fluoxetine (Prozac).
dividual trained and tested to administer the poly- Acetylcholine is also believed to be involved
somnograph, the test that measures sleep activity in the maintenance of muscle tone in REM sleep.
and other physiological variables by recording Acetylcholine blockers, such as atropine, can pro-
brain, eye, and muscle activity in sleep (see POLY- duce a profound loss of muscle tone resembling
SOMNOGRAPHY). In order to become an ACP, candi- that seen during REM sleep.
dates study basic physiology of sleep and its clinical
ramifications and pass a test administered by the
American Sleep Disorders Association (now called acromegaly A hormonal disorder that results
the AMERICAN ACADEMY OF SLEEP MEDICINE). This from overproduction of growth hormone (hGH) by
examination is now administered by the AMERICAN a benign overgrowth of cells of the pituitary gland,
BOARD OF SLEEP MEDICINE, and those who pass called a pituitary adenoma. Symptoms usually
the exam are no longer called ACPs but are board result from the hormonal effects of abnormally high
certified in sleep medicine. Clinicians who pass levels of hGH but may also result from the growth
the examination become fellows of the American of the adenoma. Hormonal effects include abnormal
Academy of Sleep Medicine. enlargement of the hands and feet, skull (especially
the brow and lower jaw), and tongue (macroglos-
sia) and heart failure. OBSTRUCTIVE SLEEP APNEA
acetazolamide (Diamox) See RESPIRATORY SYNDROME is related at least in part to macroglossia.
STIMULANTS. The drug octreotide can decrease tongue volume,
with resulting improvement in sleep apnea. As the
adenoma grows, it may cause headache and com-
acetylcholine A neurotransmitter involved in the press parts of the visual system (optic chiasm, lead-
regulation of sleep and WAKEFULNESS. Acetylcholine ing to loss of peripheral vision). It may also impair
is found in the central and peripheral nervous sys- the release of other pituitary hormones causing loss
tem and is synthesized from acetaldehyde and cho- of menstruation, breast discharge in women and
line. The effect of the release of acetylcholine from impotence in men (loss of testosterone). Additional
the nerve endings is modified by the enzyme acetyl- effects may include diabetes mellitus, HYPERTENSION,
cholinesterase. Inhibition of the acetylcholinesterase seborrhea, and palm sweating.
enzyme leads to prolonged wakefulness in animals; Much less often, acromegaly is caused by hGH-
however, the same inhibitors administered during or GHRH-secreting tumors of organs other than the
sleep will enhance the appearance of REM sleep. pituitary (pancreas, lungs, or adrenal glands).
4 acroparesthesia

In children hGH excess causes pituitary gigan- activated sleep See ACTIVE SLEEP.
tism and, if left untreated, may be fatal such as
the case of wrestler Andre the Giant and actor
Richard Kiel (known as “Jaws” in the James Bond active sleep The low voltage, mixed frequency
movies). ELECTROENCEPHALOGRAM (EEG) and RAPID EYE MOVE-
MENT (REM) activity. This term, a phylogenetic and
ontogenetic term for REM SLEEP, is synonymous
acroparesthesia See CARPAL TUNNEL SYNDROME. with the term “activated sleep.”

acrophase The peak of a biological rhythm in activity monitors Devices used to detect motion
contrast to the NADIR, the lowest point of a biologi- as a way of differentiating periods of WAKEFULNESS
cal rhythm. (See also BIOLOGICAL CLOCKS, CHRONO- or rest. (See also ACTIGRAPHY.)
BIOLOGY, CIRCADIAN RHYTHMS.)

activity-rest cycle Term used to describe the

actigraphy A biomedical instrument capable of cyclical pattern of activity that alternates with
monitoring motor activity in order to identify the rest in animals and humans; it is commonly con-
presence or absence of body motion during sleep sidered to be the same as WAKEFULNESS and sleep.
or WAKEFULNESS. Activity monitoring by means of The activity-rest cycle is usually determined in
an actigraph is useful in detecting sleep episodes animal research studies of CHRONOBIOLOGY and
and differentiating periods of sleep and rest from CIRCADIAN RHYTHMS; it is more easily measured
periods of wakefulness. than sleep and wakefulness. The activity-rest pat-
Actigraphy is commonly employed for long-term terns of rodents alternate wheel running activity
CIRCADIAN RHYTHM studies to document the pattern with rest periods.
of sleep and wakefulness with little inconvenience In addition to the 24-hour pattern of activity and
to the patient. A typical actigraph has a simple-to- rest there is a BASIC REST-ACTIVITY CYCLE (BRAC)
wear, easily programmable microprocessor device, that has a shorter PERIOD LENGTH, of approximately
which is usually attached to the nondominant three hours, than the activity-rest cycle. BRAC is
wrist, but can also be attached to one or both legs. believed to be indicative of an underlying ultradian
The device works on the principle that movement of cycle that is manifest during sleep by the NREM-
the nondominant wrist is correlated with wakeful- REM SLEEP CYCLE.
ness, whereas long, quiescent periods are associated
with rest or sleep. Studies have demonstrated an
88.9 percent correlation of accuracy with polysom- adaptive servo-ventilation (ASV) This is the
nographically measured sleep. Special computer most sophisticated method of treating breathing
programs interpret the information recorded, and it abnormalities during sleep. It is the most effective
can be displayed in many different formats. (possibly the only effective method) of treating
New forms of actigraphs include light-detect- central sleep apnea (CSA), including CHEYNE-
ing monitors for measuring light exposure and STOKES RESPIRATION. Ordinary CPAP, by contrast,
actigraphs that include radio frequency transmit- while highly effective for obstructive apneas, may
ters for relaying information cordlessly to a distant induce or worsen CSA, especially at higher pres-
computer. sures. ASV was developed for improved treatment
Wrist activity monitors have also been used to of congestive heart failure, which is often associ-
measure abnormal movements that can occur in ated with CSA. It requires specialized equipment
patients suffering neurological disease, such as and may not be available at all sleep disorders
Parkinson’s disease or other types of movement clinics. It works by adjusting the rate and magni-
disorders. (See also SHIFT-WORK SLEEP DISORDER.) tude of pressurized air, reducing them whenever
adrenocorticotrophin hormone 5

it senses that apnea has been induced. As a result, adjustment sleep disorder INSOMNIA resulting
ASV is much more comfortable than even bilevel from an acute emotional STRESS that can be related
CPAP. It has been shown to be effective in heart to conflict, loss, or a perceived threat, for example,
failure and Cheyne-Stokes respiration, thereby a death in the family, an upcoming examination,
holding out the promise of life extension for those marital, financial, or work stress. Typically, adjust-
with these disorders, though such a benefit has yet ment sleep disorder lasts for a few days, and always
to be established. less than three weeks, after which the SLEEP PAT-
TERN returns to normal.
Features of adjustment sleep disorder are pro-
adenoids Lymphoid tissue present in the poste- longed sleep latency (see SLEEP LATENCY), frequent
rior nasopharynx. Adenoids are similar to tonsils awakenings, or EARLY MORNING AROUSAL. There may
and are involved in the immune system during also be a tendency for EXCESSIVE SLEEPINESS during
childhood. The adenoids are typically enlarged in the day. In acute circumstances, there can be loss
the prepubertal age group and gradually decrease of the ability to maintain normal social activities
in size, with very little tissue present in most or employment until the acute reaction is over.
adults. In childhood, enlarged adenoidal tissue Intense ANXIETY or DEPRESSION may be associated
can cause UPPER AIRWAY OBSTRUCTION, predisposing with the stress response and the sleep disturbance.
the child to upper respiratory tract infections and The sleep pattern returns to normal with the reso-
the OBSTRUCTIVE SLEEP APNEA SYNDROME. Enlarged lution of these acute psychological symptoms.
adenoidal tissue in adults can also contribute to POLYSOMNOGRAPHY or MULTIPLE SLEEP LATENCY
upper airway obstruction. TESTING may help diagnose a condition either of
An assessment of the extent of adenoid and HYPERAROUSAL or of EXCESSIVE DAYTIME SLEEPINESS.
tonsillar tissue is required in patients who have Treatment is essential soon after the sleep dis-
the obstructive sleep apnea syndrome; if indicated, turbance begins to prevent its development into
surgical removal may be necessary. (See also SUR- chronic PSYCHOPHYSIOLOGICAL INSOMNIA. Hypnotic
GERY AND SLEEP DISORDERS, TONSILLECTOMY AND medication therapy, lasting only several days, is
ADENOIDECTOMY.) recommended. Attention to good SLEEP HYGIENE is
essential, not only during the time of the stress reac-
tion, but also in the days immediately following.
adenosine A nucleoside, comprising the purine, Adjustment sleep disorder, synonymous with
adenine, attached to a sugar (ribose) by a β-N9- transient psychophysiological insomnia and situ-
glycosidic bond. As a drug, it is a potent anti- ational insomnia, is the preferred term.
inflammatory agent, as well as a vasodilator
(relaxation of smooth muscle in artery walls) and
is antiarrhythmic. When injected, it can induce adrenocorticotrophin hormone (ACTH) Hor-
apparently normal sleep. When WAKEFULNESS is mone secreted by the pituitary gland that controls
prolonged, adenosine levels increase and then the secretion of CORTISOL from the adrenal gland.
slowly decrease during recovery sleep. The pro- ACTH secretion occurs throughout the day with
duction and concentration of adenosine is pro- about 10 secretory episodes and is mainly secreted
portional to neuronal metabolic activity and is at the end of the sleep period, at the time of AWAK-
much greater during wakefulness, when neuronal ENING. The resulting large increase in cortisol at this
metabolism is greater. It has therefore been pro- time is important for the maintenance of metabolic
posed that adenosine mediates the sleep-inducing integrity and therefore physical activity.
effects of prolonged wakefulness. The purine, CAF- Reduction of ACTH release can occur due
FEINE, binds to the same receptors in the CENTRAL to pituitary tumors and leads to FATIGUE and
NERVOUS SYSTEM as adenosine, thereby inhibiting weight loss. Excessive production of ACTH leads to
its effects and thereby explaining caffeine’s stimu- weight gain and HYPERTENSION, producing a disor-
latory effects. der called Cushing’s syndrome (overactive adrenal
6 advanced sleep phase syndrome

glands). (See also GROWTH HORMONE, MELATONIN, an inability to stay awake till the desired BEDTIME,
PROLACTIN.) and an inability to remain asleep till the desired
time of the morning. The disorder must be present
for at least a three-month period. When the person
advanced sleep phase syndrome A CIRCADIAN is not required to remain awake till the desired
RHYTHM SLEEP DISORDER characterized by difficulty bedtime (that is, goes to bed early), then the sleep
in remaining awake until the desired bedtime, and episode is of normal quality and duration. The final
getting up too early, or early morning INSOMNIA. awakening is always earlier than desired.
This disorder, which is seen typically in elderly Mild disturbances can be treated by close atten-
persons, often causes embarrassment due to an tion to maintaining a regular sleep onset and
inability to remain awake in social situations in the waketime. Incremental delays of sleep onset on
mid-evening hours. The patient may also be at risk a daily basis, by 15 to 30 minutes, may assist in
of accident, for instance, by falling asleep at the delaying the sleep pattern. One patient has been
wheel of a car. After a late night out, the inability reported to have been treated by CHRONOTHERAPY,
to delay the time of the final AWAKENING often which involved advancing the sleep pattern by
produces a tendency to DAYTIME SLEEPINESS. Inap- three hours per day. The sleep pattern was rotated
propriate daytime napping may result. around the clock so that a more appropriate sleep
Polysomnographic studies have demonstrated onset time was reached. Exposure to bright light
an early onset in the timing of the low point of the prior to sleep onset may assist in producing a more
circadian body temperature rhythm. SLEEP ONSET normal sleep onset time. (See also LIGHT THERAPY.)
time occurs at a time earlier than desired, and a
normal duration and quantity of sleep follows. The
spontaneous awakening is typically earlier than affective disorders Term describing mental disor-
desired. ders characterized by mood disturbances, typically
The origin of advanced sleep phase syndrome DEPRESSION or mania. More recently, the terms
is unknown, but, as it seems more common in MOOD DISORDERS and ANXIETY DISORDERS have been
the elderly, it has been suggested that it is due to applied to this group of psychiatric disorders.
degeneration of the nerve cells of the circadian
pacemaker, so that the circadian pacemaker is
unable to induce a delay of the SLEEP PATTERN. age and sleep There are distinct changes in sleep
As with the DELAYED SLEEP PHASE SYNDROME, the patterns from infancy through old age. Some hor-
advanced sleep phase syndrome may be due to an mones, such as GROWTH HORMONE, are produced in
abnormality of the PHASE RESPONSE CURVE. The dis- amounts that are essential for normal growth in
order is apparently rare. childhood, but may be absent in the elderly. High
Advanced sleep phase syndrome differs from amounts of stage three and stage four sleep (see
other causes of early morning awakening. Mood SLEEP STAGES) are usually present in preadolescent
disorders, particularly DEPRESSION, are associated children and altogether absent in the elderly. Some
with early morning awakening but are also associ- SLEEP DISORDERS, such as REM SLEEP BEHAVIOR
ated with sleep onset and sleep maintenance diffi- DISORDER (RBD), are more commonly seen in per-
culties. The advanced sleep phase syndrome needs sons over 60 years of age, whereas SLEEPWALKING
to be differentiated from INSUFFICIENT SLEEP SYN- and SLEEP TERRORS are more commonly seen in
DROME, which typically can also produce evening children.
sleepiness but is caused by a forced early morning
awakening. Individuals who are classified as SHORT Infancy
SLEEPERS may have an early morning awakening Infant sleep is characterized by a long total sleep
but do not have evening sleepiness. time of up to 20 hours a day. At birth, most full-
The diagnosis of advanced sleep phase syn- term babies will sleep between 16 and 18 hours
drome is usually made by the typical complaint of a day; premature infants may sleep longer. Their
age and sleep 7

sleep episodes, however, tend to last just two to disturbances. Colic, when an infant is in distress
four hours at a time. There may be as much wake- for no apparent reason, produces crying; an infant
fulness at night as there is sleep during daytime. may be inconsolable. Fortunately, colic tends to
When an infant awakens, he or she may need disappear by the time an infant is three to four
to be fed, but large feedings at night may actually months old. However, the sleep cycle disruption
contribute to more frequent AWAKENINGS. Frequent may persist after that time, and there may be more
feedings mean extra fluid intake that causes wet frequent awakenings.
diapers and increased discomfort that can unsettle The other disorder that may cause an infant to
an infant. awaken is a food allergy insomnia possibly caused
Three key concerns for new parents are how by an allergy to cow’s milk. But when treated by
their infant is eating, responding to the environ- milk protein formulas, the sleep disturbance tends
ment, and sleeping. Indeed, the ability to sleep to resolve itself.
through the night is seen as a developmental vic- Sleep disorders that can occur in infancy are most
tory for parents who may be struggling to adapt to commonly related to sleep-disordered breathing,
their infant’s demands. such as INFANT SLEEP APNEA which may be caused
The infant’s sleep pattern gradually becomes by a central nervous system lesion or upper airway
more consolidated during the nocturnal hours obstruction. Other medical illnesses, such as infec-
so that by six weeks of age the majority of sleep tion, cardiorespiratory disease, metabolic changes,
occurs during the nocturnal half of the day. How- or neurological disorders, may cause respiratory
ever, daytime naps are frequent. disturbance in infancy. Sleep-related epilepsy can
Fortunately, by six months of age, most infants also occur, although usually epileptic SEIZURES in
have started to sleep through the night, and the this age group occur during wakefulness.
longer sleep episode is now increased to six hours Because an infant’s respiratory system is imma-
in duration. The night is usually made up of two ture and small, infants are predisposed to lung
long sleep episodes interrupted by a brief awaken- collapse and airway obstruction. The muscles are
ing for a nighttime feeding. However, sleep disrup- relatively weak and are more susceptible to fatigue.
tions tend to become more prominent after the first The high percentage of REM sleep may also predis-
six months of life. It is at this time that good sleep pose the infant to more sleep-related breathing dis-
habits are very important in ensuring that a child orders because of the associated ATONIA that affects
will continue to sleep well. When the child is put the accessory muscles of respiration.
down at night, it should be in a quiet environment BENIGN NEONATAL SLEEP MYOCLONUS, a disorder
that is conducive to good sleep. Of course, during that occurs during non-REM sleep, causes muscle
the daytime there should be adequate stimulation jerking that usually spontaneously resolves itself
so that the infant is alert and active at times when within the first few weeks of life. Irregular sleep
it is appropriate. The periods of wakefulness during patterns, characterized by frequent awakenings,
the daytime gradually lengthen and consolidate, are common around six months of age.
and they are only briefly interrupted by a short By 12 months of age, the infant will have one
sleep episode. or two daily naps, but most of the day will be
Infancy is an important time for the establish- spent awake. Brief awakenings still occur at night,
ment of a stable sleep-wake pattern and the devel- and it is important that the parents realize that
opment of good SLEEP HYGIENE in the child. Limits these are normal awakenings and that the infant
need to be instituted so that the majority of sleep will naturally return to sleep. If the parent inter-
occurs during the nocturnal hours and not dur- venes because of excessive concern, an increase in
ing the daytime. LIMIT-SETTING SLEEP DISORDER is awakenings may occur, and the child may come to
a common problem in this age group and can be expect some intervention during the night. In most
corrected by behavioral means. cases, less is better. That is, the infant should be left
In the otherwise healthy infant, two conditions alone when it briefly awakens, even if there are
may increase the frequency of awakenings and brief episodes of crying or disturbance during sleep
8 age and sleep

at night. Generally, the infant will fall back to sleep about, especially if they place their infant on its
again, and this will help promote a healthy pattern back when sleeping. Previously it was thought that
of sleeping. some infants with sudden infant death syndrome
If the parents interact excessively, the child will had obstructive sleep apnea syndrome, but this is
start to develop what is known as a SLEEP ONSET most unlikely and is only a very rare cause of sud-
ASSOCIATION DISORDER that may continue through den infant death. In most cases, infants with sleep
the next few years of life. That is, the child now apnea can be easily recognized because of their dif-
becomes dependent upon a certain association ficulty in breathing, with gasping and choking that
with the episodes of wakefulness. Associations is evident soon after birth. Co-sleeping, which is
with rocking the child, giving the child a pacifier, or sharing the parents’ bed, has been reported to be a
other interventions may become a necessary part cause of accidental smothering of the infant. How-
of the child’s life. The most important thing is to ever, this rarely happens and in some cultures co-
have the child learn that sleep can occur without sleeping is normal behavior. Some doctors believe
these particular associations. co-sleeping can reduce the risk of SIDS.

Sudden Infant Death Syndrome Children

Of particular concern in the first year of life is In addition to sleep onset association disorder,
the possibility of SUDDEN INFANT DEATH SYNDROME described above, the young two- or three-year-old
(SIDS). This condition tends to peak between the child may develop a limit-setting sleep disorder.
ages of two and four months. Fortunately, there This is due to efforts of the young child to delay
have been major advances in our understanding going to bed at night. The child may refuse to
of sudden infant death syndrome, and its inci- either remain in bed or try to fall asleep. The child
dence is decreasing. It has become recognized that may stand up in the crib, or an older child may
the infant may smother when placed facedown, come out of the bedroom and call out to the par-
particularly if there is soft or loose bedding. The ents. The parents have to be firm and not give in
recommendation now is that the infant should to this behavior because every time they give in to
be placed on its back to sleep. The possibility of it, the behavior is reinforced. Limits have to be set,
sudden infant death syndrome is greatly reduced even if this means allowing a child to cry briefly for
by doing this simple manipulation. In 2005, the a few minutes. Setting the rules and limits of sleep
American Academy of Pediatrics (AAP) released a time are very important in these first two or three
policy statement on reducing the risk of SIDS. The years of life.
Eunice Kennedy Shriver National institute of Child The older child may also develop various fears
Health and Human Development (NICHD) incor- and nightmares that can be associated with sleep
porated the AAP recommendation in its Back to disturbance. These may take the form of monsters
Sleep campaign. Since the Back to Sleep campaign or intruders in the bedroom. Again, limit setting is
advising parents and caregivers of the significance very important to children in this situation. How-
of placing infants on their backs to sleep, the rate of ever, the child also needs support and there may be
SIDS has been reduced by more than 50 percent. various rewards for staying in bed during this time.
There is also evidence that some infants can If the anxieties and concerns become intense, then
have a cardiac abnormality that can be detected seeking help from a child psychologist or therapist
by an electrocardiograph. The Q-T interval on the may be necessary.
electrocardiograph is prolonged in infants with The older child will typically establish a sleep
greater risk of SIDS. pattern at night consisting of 10 to 12 hours of
Other than the electrocardiographic changes, nocturnal sleep and a short nap of one to two
there are no features that readily identify the child hours. Circadian patterns of growth hormone, COR-
who is at risk of sudden infant death syndrome. TISOL and PROLACTIN, start to establish a fixed pat-
Fortunately the risk is very low, and it is not tern with the sleep-wake cycle. Between the ages
something that most parents need to be concerned of four and six years, the amount of REM sleep
age and sleep 9

diminishes, and the percentage of SLOW WAVE SLEEP Of course children may also develop uncom-
increases to maximum levels. mon sleep disorders. An example of this was 12-
The most common sleep disorders in the prepu- year-old Sam whose parents worried about what
bescent child include CONFUSIONAL AROUSALS (brief the night would bring since his sleep had become
arousals or awakenings that occur during slow more and more bizarre over the last two years.
wave sleep), sleepwalking, and sleep terrors. Sleep Sam had become increasingly restless during sleep.
onset association disorder may occur from infancy He did not have INSOMNIA, but his body would
to preadolescent ages so that a child may be unable start unusual twisting, writhing movements dur-
to fall asleep without the presence of a particular ing sleep that were affecting all of his limbs. After
behavior or object, such as a teddy bear. extensive neurological testing, the cause of his
OBSTRUCTIVE SLEEP APNEA is a common occur- problem remained unknown so he was sent to a
rence in the prepubescent child due to enlarged sleep center for help.
tonsils and ADENOIDS and may be an indication for At the sleep center, sleep studies showed that
tonsillectomy or adenoidectomy (see TONSILLEC- the activity would occur out of non-REM sleep,
TOMY AND ADENOIDECTOMY). Other sleep disorders, and the movements were termed choreic and ath-
such as NARCOLEPSY and PERIODIC LIMB MOVEMENT etotic. These were signs of the rare disorder called
DISORDER, rarely occur before puberty. paroxysmal nocturnal dystonia. Although there is
The young child may have a disorder character- no known cure, the medication clonazepam helped
ized by repetitive body activity during sleep called to reduce the activity.
HEADBANGING. This type of rhythmical behavior
slows down around the age of four years; some Bed-wetting
cases may persist until adulthood. Most of the time, BED-WETTING (sleep enuresis) is defined as episodes
intervention is unnecessary unless it persists into of urinating in the bed that occur in a child of at
the preteen years. Some form of rhythmical rock- least five years of age. In most cases, it is not asso-
ing or movements during sleep is commonly seen ciated with a physical disorder. Usually, the infant
in healthy children. will grow out of the behavior. About 15 percent of
Confusional arousals usually appear as episodes children will improve with each year of age.
of confusion when the child wakes up during the There are some medical causes of enuresis, and
night. Fortunately, in most cases the child can be these should be suspected in the child who has
consoled so that he or she will easily return to not been bed-wetting but starts bed-wetting for no
sleep. Sleepwalking episodes may occur when the apparent reason. Conditions such as urinary tract
child is in the deepest stage of sleep and therefore infections, epilepsy, diabetes, and sleep apnea are
not aware of what is happening. There may be no possible causes. Treatment of bed-wetting is either
memory of the episode next morning. Treatment is by pharmacological agents or behavioral treat-
usually to ensure that the bedroom environment ments. Behavioral treatments usually are safer and
is free of anything that may cause the child injury. more effective. Using a urinary alarm that awakens
Usually the episodes will subside as the child gets the child is the most common means of treating
older. bed-wetting. For example, John’s parents were
Sleep terror episodes can be very disturbing to concerned because he was still bed-wetting at the
parents as the child may suddenly scream in the age of six. They were also worried because they
middle of the night. Again, these episodes occur tried to awaken him in the middle of the night to
out of the deepest slow wave sleep and fortunately take him to the bathroom but found that he was
tend to resolve as the child gets older. In children, almost impossible to awaken. His pediatrician reas-
sleep terror is not associated with an underlying sured them that the difficulty in awakening John
psychiatric disorder; a parent can be reassured was normal and not reflective of any abnormal
that these are normal behavioral phenomenon sleep problems. John would have been in the deep
that generally spontaneously end as the child gets slow wave sleep, a time when it is very difficult to
older. awaken anyone.
10 age and sleep

To treat John’s bed-wetting, his parents were falling asleep before 11 o’clock at night, and by the
advised to get him a urine sensor with an alarm time he was 16 he was unable to get to sleep before
to attach to his underwear during the night. The 2 A.M. Consequently, he had difficulty awakening
alarm awoke John when he first started to uri- in the morning, and he was often late for school.
nate, and he would go to the bathroom to finish. His grades began to suffer. His parents took him
Over a nine-month period, John’s bed-wetting to a sleep center where he was diagnosed as having
was reduced, and it rarely occurred by the time he delayed sleep phase syndrome. This disorder occurs
turned seven. in a child who can’t fall asleep before midnight,
Other behaviors, such as stream interruption, even though bedtime is early. In some cases, the
which requires stopping the urine flow at least child cannot fall asleep until 3 A.M., 4 A.M., or even
once during the daytime, helps by strengthening 5 A.M. Consequently, there is great difficulty in get-
the appropriate muscles. Medications that have ting up for school the next day. This delay in the
been used are tricyclic ANTIDEPRESSANTS, such as sleep pattern can be corrected by various manipula-
Tofranil, that reduces the contraction of the blad- tions that might involve delaying the sleep pattern
der muscle. Unfortunately, adverse side effects can around the clock, the use of bright light therapy,
occur with medications, and they should be used or even melatonin. If the sleep pattern cannot be
strictly under the guidance of a physician. Alterna- reestablished by setting regular limits to the time of
tives to antidepressants are antidiuretics such as going to bed and the time of waking in the morn-
DDAVP. However, the effectiveness of DDAVP is not ing, then professional help should be sought. He
clear, and the treatment is also very expensive. This was placed on a regular schedule and advised to
compound replaces a normal agent called vasopres- get plenty of bright light exposure first thing in the
sin that prevents urination during sleep at night. morning. He was also told to take melatonin at 6
P.M. at night.
Adolescence Gradually his sleep pattern improved to the
Around the time of puberty, growth hormone point where he could fall asleep more easily at 11
production and gonadotrophin reach high levels. P.M. He recognized the importance of keeping more
Sleep is very efficient, with few awakenings occur- regular hours, with little late night TV watching
ring during nocturnal sleep and maximal alertness or listening to music. His grades improved, and he
during the daytime. During adolescence there is a awoke more refreshed in the morning.
tendency for a later sleep onset time and difficulty Fortunately, most adolescents sleep well,
in awakening in the morning. although their time of going to bed tends to get
Obstructive sleep apnea syndrome, due to later. It is important for parents to recognize that
enlarged tonsils, continues to be a major cause of as children go through puberty they often require
sleep-related breathing disorders in adolescents. more sleep and can need as much as nine or 10
DELAYED SLEEP PHASE SYNDROME, causing difficulty hours of sleep on a nightly basis. If they do not
in falling asleep at an early hour and trouble awak- achieve this amount of sleep, they can be exces-
ening in the morning for school, also becomes a sively sleepy during the daytime. Again, setting
common problem. Psychological or psychiatric limits by the parents is important to ensure that
disorders, characterized by ANXIETY and DEPRES- the teen gets an adequate amount of sleep at night
SION, are also seen in this age group and may cause and does not stay up late watching television or
disturbed sleep. playing music. Control of sleep habits before the
Michael was a typical 15-year-old who enjoyed time of puberty will help parents as their children
rollerblading in the summer and snowboarding go through adolescence.
in the winter. He was an excellent student, but Although the most common cause of sleepiness
he liked to stay out late with his friends on the in adolescents is insufficient sleep, there can be
weekend and often would listen to music or watch other possibilities, such as narcolepsy. Narcolepsy
videos after doing his homework during the week. often will become a problem before puberty, but
He found that he was having increasing difficulty most commonly it presents around the age of 16.
age and sleep 11

The child may erroneously be diagnosed as having disturbance related to the transition from school to
attention deficit disorder, because the sleepiness college or an employment situation is typical, with
makes the child misbehave at school. There may psychiatric disorders such as anxiety and depres-
be difficulty concentrating, as well as studying and sion as contributing factors.
memory difficulties. If the parent recognizes that In college, Jason had no difficulty sleeping. In
the child sleeps well at night and yet is sleepy dur- fact, he usually slept soundly and would need an
ing the daytime, then professional help should be alarm clock to awaken. After leaving college and
sought since a diagnosis of narcolepsy may be the getting his first job, Jason developed difficulty in
reason. Another symptom that may be seen by falling asleep and would have frequent awakenings
parents is an abnormal weakness in the child when at night. His physician recognized that the stress of
he or she becomes emotional, a symptom called Jason’s new job and moving to an unfamiliar city
CATAPLEXY. The presence of this symptom in a teen were important factors in the development of the
who is sleepy should immediately cause concern, sleep disturbance. He prescribed a sleeping medica-
and the parent should bring it to the attention of tion for Jason to use until he settled down to the
a physician. new environmental changes and gave Jason some
Fortunately insomnia is rare in adolescents. relaxation exercises to do before bedtime. After
However, if insomnia does occur, and the teen several months, Jason adapted to his new envi-
reports difficulty falling asleep as well as frequent ronment and was able to sleep without the sleep
awakenings at night and early morning awakening, medication.
this raises the possibility of an underlying stressful Jason is typical in that the primary sleep com-
situation or psychiatric disorder. Professional help plaints of adulthood consist of insomnia or exces-
should be sought as depression is important to treat sive daytime sleepiness. Insomnia is more common
in the adolescent. Fortunately, there are very effec- in women than in men and is most often seen in
tive medications available for depression. Coun- the young adult female. Typically the insomnia is
seling may also be required; a visit with a child associated with stress, anxiety, or depression. Life-
psychologist or psychiatrist may be indicated. style changes that occur because of leaving home
Around the time of puberty, snoring and gasping and entering the workplace are contributing factors
episodes may occur during sleep. This may occur in to insomnia. Maintaining regular sleep hygiene is
association with large tonsils and raises the possibil- very important in preventing this stress-related
ity of obstructive sleep apnea syndrome. If a parent insomnia from becoming chronic. If there are ele-
is concerned about the possibility of this condition, ments of depression, they may need to be treated
they should mention it to their pediatrician. It may with specific antidepressant therapy.
be necessary for the child to have an all-night sleep In males, excessive daytime sleepiness is most
study to determine their breathing pattern dur- often associated with either sleep deprivation,
ing sleep at night. Treatment in the child usually because of social and/or work commitments, or
involves removing the tonsils, although in some obstructive sleep apnea syndrome. Young adults
situations when the tonsils are not the cause of tend to reduce the amount of time available for sleep
the breathing disturbance, an artificial ventilation by staying up later at night and getting up early for
device such as a CONTINUOUS POSITIVE AIRWAY PRES- work in the morning. Sleep is usually made up on
SURE CPAP machine may be necessary. the weekends when the individual will stay in bed
longer on Saturday or Sunday mornings.
Adulthood Obstructive sleep apnea syndrome becomes
Sleep often becomes less efficient in young adults associated with a long-standing history of chronic
with an increased number of awakenings and a nasal breathing difficulties and increasing body
greater tendency for EXCESSIVE SLEEPINESS. SLEEP weight. Treatment may involve mechanical means,
DEPRIVATION is a common cause. Obstructive sleep such as CPAP, or surgical means, such as upper
apnea and narcolepsy are other common causes airway surgery. Weight management is always
of pathological sleepiness in this age group. Sleep important.
12 age and sleep

In women, sleep will be disturbed because of POLYSOMNOGRAM. The test showed that she stopped
pregnancy and childbirth. Initially in pregnancy breathing 105 times for as long as 40 seconds,
there may be a tendency for increased tiredness and the oxygen level in the blood dropped to 85
and sleepiness during the daytime. Then, toward percent. She was diagnosed as having obstructive
the last trimester, this gives way to sleep disrup- sleep apnea and advised to lose weight and com-
tion, in part related to pain and discomfort because mence treatment with a CPAP machine. Although
of the pregnancy. After delivery, sleep disturbance Angela was unable to lose weight, the CPAP
is common, as a result of frequent nocturnal machine allowed her to sleep more restfully. For
awakenings to nurse the infant. In some patients, women with sleep disorders in menopause, treat-
postpartum depression may play a part. Not only ment may produce some improvement in feelings
mothers, but also fathers, are affected by the arrival of well-being and reduction of daytime tiredness.
of a new member in the family. Throughout early
adulthood, sleep is often disrupted because of chil- Elderly
dren-related factors such as night fears or children The elderly have less efficient sleep with a short
coming into the bedroom. total sleep time during the nocturnal hours, a
tendency for daytime napping, less deep sleep
Middle Age with more light stage one and stage two sleep, and
In middle age, sleep reduces even further in effi- often the complete absence of slow wave sleep.
ciency so that a shorter total sleep time with more Growth hormone secretion may be absent in the
frequent awakenings is common. In males between elderly. Other circadian rhythm patterns, such
the ages of 40 and 60, obstructive sleep apnea as body temperature or cortisol secretion, may
syndrome is likely to occur. Insomnia is the main be flatter than those seen in middle age. How-
cause of sleep disturbance in females of middle age. ever, prolactin secretion seems to be fairly well
Patterns of growth hormone secretion are reduced established into old age. Gonadotrophin hormone
in this age group as is the amount of slow wave secretion is reduced, and sexual difficulties, such
sleep. With the development of other medical dis- as impotence, are more often encountered in this
orders or psychiatric disturbances, sleep disorders age group. Among the middle-aged to the elderly,
are commonly encountered in middle age and are SLEEP-RELATED PENILE ERECTIONS become less fre-
more typical in the elderly. quent, and organic causes of impotence are com-
In middle age, menopause is a factor related to monly encountered.
sleep disruption in women. Loss of ovarian hor- Sleep-related breathing disorders are common
mones is associated with frequent awakenings, in causes of disturbed sleep in the elderly, particularly
part related to hot flashes. Sleep disturbance may CENTRAL SLEEP APNEA SYNDROME due to a central
be improved by replacement hormonal therapy, nervous system or cardiovascular cause. Obstruc-
although for most women the sleep disturbance is tive sleep apnea syndrome is also present in this
only temporary and generally settles. With meno- age group and is more typically associated with
pause there may also be an increased tendency for the complaint of insomnia than it is in younger
snoring and obstructive sleep apnea syndrome. This age groups. Periodic limb movement disorder and
time of life may also be associated with increasing general nonspecific sleep disruption is also frequent
weight gain. Loud snoring and excessive daytime in the middle-aged and elderly.
sleepiness around the time of menopause should More recent research, however, has indicated
raise the suspicion of sleep apnea syndrome. For that the healthy elderly sleep as well as those who
example, Angela had always been a little over- are younger. It is the prevalence of disease and
weight, but after menopause she was unable to the medications taken to treat it that causes the
control her weight gain. She began to snore loudly, increased senior sleep disturbances. As psychiatry
and her husband noticed that she had irregular professor and sleep researcher Dr. Sonia Ancoli-
breathing during sleep. Her physician sent her to Israel noted in a New York Times article by Gina
a sleep center where she underwent an overnight Kolata, “The Elderly Always Sleep Worse, and
airway obstruction 13

Other Myths of Aging,” “The more disorders older particularly in the wheelchair-bound or bedridden
adults have, the worse they sleep. If you look at elderly patient.
older adults who are very healthy, they rarely have Although sleep apnea may be a significant fac-
sleep problems.” tor in the elderly, generally because of increasing
In the elderly, medical and psychiatric disorders, weight loss as one becomes elderly, the tendency
including depression, are also very common and for sleep apnea lessens.
may be the cause of insomnia. Mildred, who is in The need to take prescription medications for a
her mid-70s, has sleep problems that are typical of variety of medical disorders causes sleep to become
the elderly who are more likely to have sleep dis- disrupted, and many medications can lead to day-
turbances characterized by difficulty falling asleep time tiredness and sleepiness. Medical disorders,
and frequent awakenings at night. Her high blood particularly Parkinson’s disease, can be associated
pressure was under control with medication, but with a disrupted sleep wake pattern.
her severe arthritis limited her ability to get out In addition to degenerative neurological dis-
of the house in the daytime. She would take fre- orders, cardiac and respiratory disorders are also
quent daytime naps. To help Mildred with her major factors in causing sleep disruption. Assisted
sleep-related problems, her physician put her on breathing devices such as CPAP machines may be
a regular sleep schedule and advised her to reduce necessary in those elderly who have impairment of
the amount of time spent in daytime napping. She ventilation during sleep at night. Cardiac disorders
was also advised to get more exposure to bright can also be associated with variation in breathing
light during the daytime and told to keep herself tendency throughout sleep, and optimum manage-
as active as possible during the day. Her blood ment of the cardiac disorder may be necessary to
pressure medication was changed to one that did improve sleep quality at night.
not adversely affect her sleep and a small dose of In the elderly, death is more likely to occur dur-
a sleeping pill helped to get her back into a more ing sleep. (See also SLEEP EFFICIENCY, SLEEP NEED,
regular nighttime sleep pattern. TOTAL SLEEP TIME.)
As men and women age, the potential for sleep- Finally, dementia is usually associated with dis-
related pathologies gets much greater. There is also ruption of the sleep-wake process leading to noc-
an increase in obstructive sleep apnea syndrome turnal confusion and wandering that is sometimes
or periodic leg movements in sleep, contribut- called the sundown syndrome. Sleep becomes frag-
ing to sleep disruption. The elderly also have a mented and difficult to attain at night and there
decreased ability to remain in deep sleep during the may be an increased tendency for tiredness and
night; therefore, sleep becomes lighter and more sleepiness during the daytime. Sleep medications
disrupted with frequent awakenings. In addition, become less useful in this age group and around
daytime sleepiness gradually increases and the ten- the clock nursing care is often necessary. The dis-
dency to nap during the day becomes more com- ruption of the sleep-wake pattern is a major reason
mon. If the elderly individual is not careful, sleep for institutionalization of the demented elderly.
may occur intermittently throughout the 24-hour
period with long awakenings at night and frequent
daytime naps. This tendency needs to be corrected airway obstruction The predominant cause of
by insuring that regular sleep onset and wake times OBSTRUCTIVE SLEEP APNEA SYNDROME. This disorder
are maintained and that most of the sleep occurs is associated with obstruction at any site from the
during the nocturnal hours. nose to the larynx. Upper airway obstruction is
With advancing age, it is important that elderly assessed by means of CEPHALOMETRIC RADIOGRAPHS
individuals are exposed to plenty of bright light, and FIBER-OPTIC ENDOSCOPY; treatment may be
an important factor in maintaining regular sleep by surgical or mechanical means. (See also CON-
patterns. In addition, exercise during the wak- TINUOUS POSITIVE AIR PRESSURE, HYOID MYOTOMY,
ing portion of the day is important. Keeping very MANDIBULAR ADVANCEMENT SURGERY, SURGERY AND
active with frequent social interaction is important, SLEEP DISORDERS, TONSILLECTOMY AND ADENOIDEC-
14 alcohol

TOMY, TRACHEOSTOMY, UPPER AIRWAY OBSTRUCTION, and the oxygen desaturation to be more severe.
UVULOPALATOPHARYNGOPLASTY.) The association of alcohol with exacerbation of
obstructive sleep apnea may lead to serious cardio-
vascular consequences that could prove fatal.
alcohol Drinking alcohol in the evening may Treatment of obstructive sleep apnea syndrome
help SLEEP ONSET, but headaches upon AWAKEN- often involves use of a CONTINUOUS POSITIVE AIRWAY
ING the next morning are typical, particularly with PRESSURE DEVICE (CPAP), and alcohol ingestion can
excessive alcohol use. The routine use of alcohol as be a common cause of failure of an adequate CPAP
a sedative produces an improved sleep onset time, response. A patient who consumes alcohol on a
often with a deeper sleep in the first third of the nightly basis may fail to do so in a sleep laboratory
night, but then sleep becomes lighter and more and therefore the adjustment phase of CPAP may
fragmented. lead to an inadequate pressure setting. Following
ALCOHOL-DEPENDENT SLEEP DISORDER occurs in alcohol ingestion, a higher than usual pressure
people who chronically use alcohol for its sleep- may be required in order to overcome the apneic
inducing effects. This disorder is not associated events. There is also evidence that alcohol can pro-
with heavy alcohol ingestion during the daytime duce obstructive sleep apnea syndrome in persons
and is not a symptom of alcoholism; as toler- who otherwise would not have apneic events.
ance develops, the amount of alcohol ingested Alcohol can exacerbate other sleep disorders,
increases, but persons with alcohol-dependent such as JET LAG and SLEEP-RELATED EPILEPSY. Epi-
sleep disorder usually do not go on to become lepsy may also be exacerbated by the disruptive
alcoholics. Alcohol will shorten the SLEEP LATENCY sleep pattern caused by alcohol, which leads to
and increase the amount of stage three and four SLEEP DEPRIVATION and possibly the precipitation of
SLEEP (see SLEEP STAGES), but REM SLEEP is reduced epileptic seizures.
and becomes fragmented. Awakenings frequently
intrude into the second half of the nocturnal sleep
episode. alcohol-dependent sleep disorder Disorder char-
It is commonly recognized that alcohol will acterized by the chronic drinking of ALCOHOL for its
increase the amount and loudness of SNORING, but SOPORIFIC effect. The self-prescribed use of ethanol
it can also exacerbate OBSTRUCTIVE SLEEP APNEA SYN- (alcohol) as a SEDATIVE is the cause of this disorder
DROME. ALCOHOLISM is associated with an increased that often results from an underlying INSOMNIA,
number of sleep-related disturbances, such as noc- such as an ADJUSTMENT SLEEP DISORDER or INADE-
turnal enuresis, NIGHT TERRORS, AND SLEEPWALKING. QUATE SLEEP HYGIENE. Typically, alcohol is drunk late
Alcohol has detrimental effects on daytime in the evening, a few hours before bedtime, usually
ALERTNESS. The sleep fragmentation and disruption in quantities of up to eight drinks. However, in this
at night can lead to excessive SLEEPINESS and dimin- disorder, the alcohol ingestion is rarely associated
ished alertness during the daytime. The effects of with excessive alcohol intake during the daytime,
alcohol upon performance, particularly driving, or the development of chronic ALCOHOLISM.
may be greatly influenced by the amount of the The sedative properties of the alcohol are great-
prior night’s sleep so that accidents due to alcohol est at the onset of the pattern of alcohol ingestion.
abuse are often, in part, related to the SOPORIFIC However, with chronic usage, tolerance develops,
effects of alcohol. and there is a loss of the sleep-inducing effect.
The effects of alcohol are exacerbated by the In addition, WITHDRAWAL effects occur in the sec-
ingestion of other DRUGS, particularly sedatives. ond half of the nocturnal sleep episode, so that a
This combination may be dangerous and lead to pattern of frequent AWAKENINGS and difficulty in
stupor and even COMA or death. maintaining sleep often results. Other symptoms of
Alcohol will impair the AROUSAL and ventilatory alcohol withdrawal, such as headaches, dry mouth,
response to the apneic episodes in obstructive sleep FATIGUE, and tiredness upon awakening, may also
apnea syndrome, causing the APNEAS to be longer occur.
alertness 15

In addition to the ingestion of alcohol, other increased muscle tone can occur during REM
sedative agents may be taken, although more sleep.
typically the alcohol is the sole sedative ingested. Associated features of alcoholism include an
The use of alcohol is generally long-standing and increased incidence of BED-WETTING, SLEEP TERRORS,
most often occurs in individuals after the age of SLEEPWALKING, nightmares, and exacerbation of
40 years. SNORING and OBSTRUCTIVE SLEEP APNEA SYNDROME.
Polysomnographic monitoring shows an increase Alcoholic liver disease and encephalopathy with
in stage three and four sleep (see SLEEP STAGES) and the development of a Korsakoff psychosis are com-
a short SLEEP ONSET latency; however, REM SLEEP mon results of chronic alcohol ingestion. The direct
fragmentation is present with frequent awaken- effect of these disorders can also contribute to sleep
ings, sometimes with early morning awakening. disturbances. (See also ALCOHOL for other effects of
Treatment of the alcohol dependency is the chronic drinking.)
same as for any other drug dependency. A gradual The alcoholic, when withdrawing from alcohol,
drug withdrawal, with the institution of SLEEP can develop delirium tremors within a week of
HYGIENE measures, is essential to prevent further stopping the alcohol intake. This state is marked by
sleep disruption. In some situations, it may be nec- severe autonomic hyperactivity, with tachycardia,
essary to supplant the alcohol with a more effec- sweating, and tremulousness. Withdrawal seizures,
tive HYPNOTIC agent during the alcohol withdrawal called “rum fits,” can occur within the first few
phase, and then the prescribed hypnotic can be days of alcohol withdrawal and always precede the
gradually withdrawn. development of delirium. During the time of delir-
ium and hallucinosis, sleep is severely disrupted.
There may be an excessive amount of REM
alcoholism Chronic alcohol intake with alcohol sleep that occurs in the first few days after alcohol
abuse and dependency. Sleep disturbances are a withdrawal, although it may be fragmented. Slow
common feature of alcoholism, particularly INSOM- wave sleep can be reduced and may recover very
NIA as well as EXCESSIVE SLEEPINESS during the day. gradually following abstinence from alcohol, often
Alcohol produces an increased tendency for never returning to pre-alcohol levels. Disturbed
sleepiness that lasts for approximately four hours sleep may continue to be present for up to two
after drinking (depending upon the amount actu- years following complete abstinence.
ally consumed). When taken before bedtime, it Treatment of the alcohol-induced sleep distur-
will reduce the SLEEP LATENCY and reduce WAKE- bance is usually restricted to managing alcohol
FULNESS in the first third of the night, but as the abstinence and may involve the use of short-term
alcohol is metabolized, there can be WITHDRAWAL HYPNOTICS to reduce the severe sleep disruption.
effects, with increased SLEEP FRAGMENTATION. Indi- Attention to good SLEEP HYGIENE is essential. (See
viduals who drink chronically and excessively find also ALCOHOL-DEPENDENT SLEEP DISORDER.)
that sleep disruption occurs with abstinence from
alcohol, and very often alcohol is used to improve
sleep. The chronic alcohol abuser may also suffer alertness Opposite of SLEEPINESS. Ideally, alertness
from NIGHTMARES and other REM phenomena as a should be full for the approximately two-thirds of
result of REM sleep fragmentation during chronic the day when we are awake. Persons who have
ingestion of alcohol as well as abstinence. Alco- sleep disorders often notice an increased tendency
holics are susceptible to other sleep-disrupting for sleepiness in the midafternoon, an exaggerated
factors, such as environmental stimuli. Alcohol in form of a natural dip in alertness that occurs at that
alcoholics will often induce increased amounts of time. This midafternoon dip is part of the biphasic
SLOW WAVE SLEEP in the first half of the night, and CIRCADIAN RHYTHM of sleep, which is reflected in
REM fragmentation and decrease is typically seen the major sleep episode at night and the increased
in the second half of the night. Sleep becomes so tendency for sleepiness that occurs 12 hours later,
fragmented that STAGE TWO SLEEP SPINDLES and in the midafternoon. Some cultures take advantage
16 alpha activity

of this decreased alertness by scheduling a SIESTA sures the ability to remain awake and is performed
for several hours. The decrease in alertness also can in a manner similar to the multiple sleep latency
be exacerbated by a large lunch or the ingestion of test.
ALCOHOL. Measurement of alertness following treatment
Subjective measures of alertness include the of some sleep disorders can be valuable in estab-
STANFORD SLEEPINESS SCALE (SSS), which rates the lishing whether or not an individual is sufficiently
degree of alertness and sleepiness on a scale from alert to drive a motor vehicle or operate dangerous
one to seven, and the EPWORTH SLEEPINESS SCALE machinery, for instance. (See also EXCESSIVE SLEEPI-
(ESS). Objective alertness measures include PUPIL- NESS, VIGILANCE.)
LOMETRY, a measure of fluctuations in pupil diame-
ter size that reflects changes in alertness. Decreased
pupil size and oscillations of the pupil indicate alpha activity A sequence of alpha waves of
decreased alertness. The most widely used objec- eight to 13 HERTZ (Hz) (cycles per second) seen in
tive measure of alertness, however, is the MULTIPLE recordings on an ELECTROENCEPHALOGRAM (EEG).
SLEEP LATENCY TESTING (MSLT), which measures Alpha activity is an indication of lightening of
at two-hour intervals the tendency to fall asleep sleep and becomes more prevalent as WAKEFULNESS
throughout the day. Five NAPS tests are scheduled approaches. This activity is a faster rhythm than
from 10 A.M. to 6 P.M. and the electrophysiological that seen during SLEEP STAGES, which most typically
measures of sleep are monitored for SLEEP STAGES. consist of theta and delta activity. (See also ALPHA
A short SLEEP LATENCY to the first epoch of sleep RHYTHM.)
indicates decreased alertness and the presence of
sleepiness, particularly if the mean sleep latency
over the five naps is 10 minutes or less. alpha-delta activity Term describing the presence
Daytime alertness can be influenced by a number of the alpha EEG rhythm, which occurs simultane-
of factors, including the quality and quantity of the ously with the slower delta EEG pattern of sleep.
prior night’s sleep, as well as medications or drugs Alpha-delta activity is typically seen in disorders
taken during the daytime. CAFFEINE found in coffee that disrupt nocturnal sleep, such as INSOMNIA and
and many sodas is a commonly used CENTRAL NER- is also a characteristic feature of the FIBROSITIS SYN-
VOUS SYSTEM stimulant that will increase daytime DROME. (See also ALPHA RHYTHM.)
alertness. STIMULANT MEDICATIONS, often used to
improve alertness in persons with excessive sleepi-
ness due to disorders such as NARCOLEPSY, include alpha intrusion Also known as alpha infiltration,
AMPHETAMINES, and methylphenidate hydrochlo- alpha insertion or alpha interruption. This is a
rides. These agents improve alertness but have less brief superimposition of ALPHA ACTIVITY upon sleep
of an effect on multiple sleep latency measures of activities during SLEEP STAGES. Alpha intrusion is
sleepiness. Methylphenidate and amphetamines characteristic of sleep disorders where the sleep-
have been objectively shown to produce a reduc- wake pattern is disrupted and is also a characteris-
tion in sleepiness. tic feature of FIBROSITIS SYNDROME.
The cycle of daily alertness appears to be inde-
pendent of the cycle of daytime sleepiness. This is
most evident in a person’s ability to maintain alert- alpha rhythm ELECTROENCEPHALOGRAM (EEG)
ness unless placed in an environment conductive to wave activity that occurs with a frequency of eight
sleep, where severe sleepiness may readily become to 13 HERTZ (HZ) (cycles per second) in adults. This
apparent. The findings on the multiple sleep latency activity occurs in the central to posterior portions
test for the effects of stimulant medications tend to of the head and is indicative of the awake state in
support this notion of two independent processes. humans. ALPHA ACTIVITY is usually present during
For this reason, the MAINTENANCE OF WAKEFUL- relaxed WAKEFULNESS when visual input is reduced
NESS TEST (MWT) was developed. This test mea- (for instance, when the eyes are closed). The activ-
Ambien 17

ity tends to be slower in children and the elderly be improved by breathing a high level of inspired
compared to young and middle-aged adults. It may oxygen. After a few days at altitude, changes in
occur during SLEEP STAGES if sleep is disrupted, as body chemistry occur that lead initially to alkalosis,
is seen in the many disorders of INSOMNIA. Alpha but the condition gradually corrects itself. Severe
activity during SLOW WAVE SLEEP is a particular hypoxemia at altitude may lead to the development
characteristic of the FIBROSITIS SYNDROME. (See also of cardiac complications, with acute pulmonary
ALPHA INTRUSION.) edema, and lead to compensatory changes such as
a stimulation of red blood cell production.
Altitude insomnia can be differentiated from
alprazolam (Xanax) Alprazolam (Xanax) is a high other sleep or respiratory disorders by means of
potency member of the benzodiazepine class. It is polysomnographic investigations. The usual pat-
used for the treatment of anxiety disorders, espe- tern consists of 10 to 20 seconds of apnea followed
cially those associated with depression, as well as by three to five breaths of hyperventilation, with
panic disorder, including panic attacks occurring associated arousals or awakenings. Arterial blood
during the night and during sleep. Alprazolam, gases will demonstrate hypoxemia and reduced
more habit forming than other BENZODIAZEPINES, is carbon dioxide levels.
often used recreationally and is the most common The syndrome rapidly resolves itself upon return
benzodiazepine in recreational use. Because of its to lower altitudes. (See also CENTRAL ALVEOLAR
dependency potential, after it has been used for HYPOVENTILATION SYNDROME, CENTRAL SLEEP APNEA
more than a few days or weeks, alprazolam should SYNDROME, OBSTRUCTIVE SLEEP APNEA SYNDROME.
never be abruptly discontinued. It is in Schedule IV
of the Controlled Substances Act.
alveolar hypoventilation Inadequate VENTILATION
of the terminal units of the lungs, the alveoli.
altitude insomnia An acute INSOMNIA that occurs Patients who suffer from alveolar hypoventilation
with the ascent to high altitudes; also known have inadequate gas transfer across the lungs to
as acute mountain sickness. Altitude insomnia and from the blood and therefore have elevated
typically occurs in individuals, such as mountain carbon dioxide and lowered oxygen levels in their
climbers, who ascend to levels higher than 4,000 blood.
meters (13,200 feet) above sea level. Some symp- Alveolar hypoventilation can be produced by
toms may be evident at levels above 2,500 meters disorders that affect the lung directly or harm
(8,250 feet), although the most predominant ventilation because of impaired respiratory drive.
symptoms occur within 72 hours of exposure to Typically, patients with alveolar hypoventilation
higher altitudes. The disorder is characterized by have deterioration of ventilation during sleep. Day-
difficulty in initiating and maintaining sleep, as time alveolar hypoventilation may be due entirely
well as other symptoms, such as headaches and to SLEEP-RELATED BREATHING DISORDERS, such as
FATIGUE. OBSTRUCTIVE SLEEP APNEA SYNDROME, CENTRAL SLEEP
This disturbance appears to be related to the low APNEA SYNDROME, or CENTRAL ALVEOLAR HYPOVENTI-
level of atmospheric oxygen that produces HYPOX- LATION SYNDROME.
EMIA and associated APNEA. The apnea is due to a
post-hypoxemic period of hyperventilation that
lowers the carbon dioxide to produce the central Ambien (Ambien CR, zolpidem) Although zol-
apneic episode. pidem has not emerged as a drug of abuse, it
People with lung disorders, anemia, or impaired shares that potential with other BENZODIAZEPINE-
cardiac function are more likely to develop altitude like drugs. For example, in large doses, it may
insomnia. induce sleepwalking—behaviors resembling those
The disorder may be treated by means of RESPI- of wakefulness for which the sleeper has no mem-
RATORY STIMULANTS, such as acetazolamide, and may ory. (See also HYPNOTICS.)
18 ambulatory monitoring

ambulatory monitoring The continuous mea- Several ambulatory monitoring systems are
surement of physiological variables in a patient currently available in the United States. Typically
who is not confined to bed or a specific room. Typi- they consist of a microcomputer digital system that
cally, ambulatory monitoring employs a portable monitors respiration, oxygen saturation, electro-
recording device that records data while attached cardiography, and body temperature, position and
to the patient. movement. Some monitors are capable of detecting
Ambulatory monitoring techniques have been electroencephalographic activity for the measure-
used for many years for the continuous measurement of sleep.
ment of heart rhythm by Holter monitoring. More Ambulatory monitoring has the potential to
recently, ambulatory techniques have been devel- become the ideal means of recording physiological
oped for the continuous recording of ELECTROEN- information from a patient in his usual environ-
CEPHALOGRAM (EEG) activity to detect SEIZURES. ment. However, present systems are unable to
Ambulatory monitoring devices have also been measure a number of physiological variables accu-
developed for the measurement of a variety of rately, especially given the risk of sensors malfunc-
other physiological variables and the assessment of tioning when the patient is not under constant
sleep disorders. supervision. Another factor limiting its usefulness
Twenty-four-hour ambulatory sleep-wake mon- is that the number of physiological variables that
itoring can determine the presence of the SLEEP can be measured is necessarily limited. When
PATTERN in patients who have INSOMNIA or patients more channels of information are recorded, there
who complain of EXCESSIVE SLEEPINESS. Continuous is a greater chance of either obtaining errone-
monitoring may also be helpful for the daytime ous information or losing information. While the
assessment of unintended sleep episodes in patients device is recording there may be an error (artifact)
with NARCOLEPSY or IDIOPATHIC HYPERSOMNIA. Con- in the signal being monitored, which may not be
tinuous monitoring throughout the 24-hour period recognized until the study is completed and the
has some advantages over the usual intermittent information is played back.
nap testing by means of a MULTIPLE SLEEP LATENCY Because of the major disadvantages of current
TEST, as it detects sleepiness that might be missed ambulatory monitoring, it cannot be applied to the
between NAPS. However, it is less standardized routine clinical evaluation of patients with most
and therefore less useful for comparison purposes sleep disorders. Its usage currently is primarily for
among patients or for comparing a patient’s status screening purposes, follow-up evaluations after
at different times. Ambulatory monitoring is par- treatment has been initiated, research experimenta-
ticularly useful for the documentation of abnor- tion or for determining patterns of rest and activity.
mal events and can be used for screening of such (See also ACTIVITY MONITORS, POLYSOMNOGRAPHY.)
disturbances as episodes of APNEA or PERIODIC LEG
MOVEMENTS during sleep. This form of monitor-
ing can be helpful in detecting events that occur American Academy of Sleep Medicine (AASM) A
infrequently, as patients can wear the monitoring multidisciplinary organization formed in 1983 by
device for several days or even weeks. Activities the union of the Clinical Sleep Society (CSS) and
such as SLEEPWALKING, SLEEP TERRORS, or abnormal the Association of Sleep Disorder Centers (ASDC).
seizure episodes may be detected on ambulatory Previously called the American Sleep Disorders
recorders. Association, in 1999 it was renamed the American
Ambulatory monitoring is also useful for deter- Academy of Sleep Medicine. The individual mem-
mining disturbed patterns of sleep and wakeful- ber branches include: clinicians involved in the
ness, such as are seen in the CIRCADIAN RHYTHM diagnosis and treatment of patients with disorders
SLEEP DISORDERS. It is particularly useful for the of sleep and alertness; scientists involved in basic
detection of the rest-activity cycle of shift workers research of sleep as well as clinical research; and
and individuals who undergo frequent time zone other professionals who are interested in learning
changes (see JET LAG). more about the field of SLEEP DISORDERS MEDICINE.
American Board of Sleep Medicine 19

The association, through its two branches, is active have shown a lifetime contribution to the field of
in professional education, concerns itself over sleep disorders medicine or research. This award
standards of practice, encourages the certification has been held by NATHANIEL KLEITMAN, Ph.D., and
of SLEEP DISORDER SPECIALISTS, and is an accrediting Elio Lugaresi, M.D.
body for SLEEP DISORDERS CENTERS. The AASM confers several awards each year at its
The primary goals of the American Academy annual meeting, including the William C. Dement
of Sleep Medicine are to facilitate information Academic Achievement Award and the NATHANIEL
exchange, educate new professionals, and train KLEITMAN DISTINGUISHED SERVICE AWARD.
new practitioners in the area of sleep and its dis-
orders. It establishes, updates, and maintains stan-
dards for the evaluation and treatment of human American Association of Sleep Technologists
sleep disorders. It also promotes the role of sleep (AAST) Formerly Association of Polysomno-
disorders medicine to health professional organiza- graphic Technologists (APT). Founded in 1978
tions, federal and local regulatory bodies, as well as by Peter A. McGregor, chief polysomnographic
to federal and private health insurers. technologist at the Sleep-Wake Disorders Cen-
Members of the American Academy of Sleep ter of Montefiore Medical Center in New York.
Medicine are eligible for: reduced rates on the An organizational meeting of polysomnographic
INTERNATIONAL CLASSIFICATION OF SLEEP DISOR- technologists was held in April 1978 at the annual
DERS; an annual subscription to the professional convention of the Association for the Psychophysi-
journal SLEEP, an authoritative international peer ological Study of Sleep and the Association of Sleep
review journal of the field of sleep disorders Disorder Centers.
medicine and research; the Journal of Clinical The main aims of the AAST are to develop
Sleep Medicine; an AASM newsletter; a member- standards of professional competence within the
ship certificate; a membership directory; updated area of polysomnographic technology, to provide
information on governmental agency and insur- and administer a registration process for poly-
ance reimbursement policies that affect sleep somnographic technologists, to help technologists
disorders medicine; and reduced fees for the develop the finest possible patient care and safety
annual APSS scientific meeting, and for courses, and produce the highest quality of polysomno-
seminars and workshops related to the practice of graphic data, to provide a means of communication
sleep medicine. among technicians and others working in the field
Membership in the AASM was more than of SLEEP DISORDERS MEDICINE and sleep research,
7,353 at the end of 2006. Categories include regu- to support and advance the professional identities
lar membership, affiliate membership, fellowship, of technologists in health care, and to standardize
and honorary fellowship. Regular membership is polysomnographic procedures.
open to all individuals who hold an M.D., Ph.D., The AAST started with about 50 members in
D.D.S. or other academic degree in the health 1978 and by 2007 had increased its membership to
care field and who are active in sleep disorders more than 4,000.
medicine. An affiliate membership (student) is
offered to individuals enrolled in formal train-
ing programs that upon completion would make American Board of Sleep Medicine In 1978 the
them eligible for regular membership. Fellowship ASSOCIATION OF SLEEP DISORDER CENTERS formed
in the American Academy of Sleep Medicine is a committee to produce an examination for the
open only to individuals who have success- purpose of establishing and maintaining stan-
fully completed the AMERICAN BOARD OF SLEEP dards of individual proficiency in clinical POLY-
MEDICINE examination, which demonstrates their SOMNOGRAPHY. This committee, which became
competency in sleep disorders medicine and POLY- the Examination Committee of the American
SOMNOGRAPHY. Honorary fellowship in the asso- Sleep Disorders Association, directed by Helmut
ciation is reserved for exceptional individuals who S. Schmidt, M.D., had certified 432 physicians
20 American Sleep Disorders Association

and Ph.D.s as ACCREDITED CLINICAL POLYSOMNOG- of Family Physicians of Canada, or the equiva-
RAPHERS (ACPs) by the middle of 1991. By 2006, lent board for osteopathic medicine.
3,445 sleep specialists had been board certified in 4. One year of training (PGY 3 or later) in sleep
sleep medicine. medicine under the supervision of a diplomate
Culminating many years of planning, the Amer- of the American Board of Sleep Medicine or
ican Board of Sleep Medicine was incorporated by in an accredited fellowship training program.
WILLIAM C. DEMENT, M.D., Ph.D., as an indepen- (Waivers may apply.) Graduates of fellowship
dent, nonprofit, self-designated board on January programs in pulmonary medicine or clinical
28, 1991. The 11 directors of the board are nomi- neurophysiology can satisfy this requirement
nated by the AMERICAN ACADEMY OF SLEEP MEDI- with six full-time months (or the equivalent
CINE (formerly called the American Sleep Disorders part-time) of training in a sleep medicine within
Association) and other professional associations their subspecialty fellowship, plus six months of
that have a significant role in sleep medicine. In full-time training in sleep medicine.
order to reflect the fact that sleep medicine is based 5. Knowledge of the fundamentals in interpreta-
on a broad medical field, the board has discontin- tion and quality assurance of procedures related
ued the term ACP and, instead, refers to its diplo- to sleep medicine. As a guideline, a minimum
mates—those individuals certified both before and experience of interpretation and review of the
after its establishment as an independent board—as raw data of 200 POLYSOMNOGRAMS and 25 MUL-
board certified SLEEP SPECIALISTS. TIPLE SLEEP LATENCY TESTS is suggested. The appli-
The board directs all aspects of the certifying cant should have seen a broad range of patients
process. Committees of the board review appli- with different sleep disorders encompassing a
cants’ credentials and produce and evaluate the minimum of 200 new patients and 200 follow-
two-part examination. Part I is a multiple-choice up patients.
written exam which tests general knowledge of 6. A fully completed application, including a satis-
sleep medicine and polysomnography. It is divided factory evaluation from a board-certified sleep
into three sections: the basic science of sleep, clini- specialist, and three letters of reference.
cal sleep disorders and polysomnogram recogni-
tion. Applicants can take Part II when Part I has
been successfully completed. Part II consists of American Sleep Disorders Association (ASDA) See
clinical and polysomnographic data interpretation AMERICAN ACADEMY OF SLEEP MEDICINE (AASM).
and patient management skills. It consists of record
review, questions, and essays. Successful comple-
tion of both Part I and Part II leads to certification amitriptyline (Elavil, Endep) See ANTIDEPRESSANTS.
in the specialty of sleep medicine.
To be eligible to apply for board certification in
sleep medicine, applicants must have the following amphetamines (Adderal) See STIMULANT MEDICA-
qualifications: TIONS.

1. A medical degree (M.D. or D.O.) and an unlim-

ited license to practice medicine in a state, com- Anafranil (clomipramine) See ANTIDEPRESSANTS.
monwealth or territory of the U.S. or Canada.
2. Successful completion of a residency program
accredited by the Accreditation Council for analeptic medications A group of medications
Graduate Medical Education, or its equivalent. that stimulate the CENTRAL NERVOUS SYSTEM. The
3. Certification by a primary board that is recog- term was derived from the Greek word analepsis
nized by the American Board of Medical Spe- meaning “to repair.” But the term “analeptics”
cialties (ABMS), the Royal College of Physicians most commonly applies to those medications that
and Surgeons of Canada, the Certificate College stimulate AROUSAL, in particular CAFFEINE and
antidepressants 21

the AMPHETAMINES, and other stimulants such as Do animals other than man ever develop insom-
strychnine and the RESPIRATORY STIMULANTS doxa- nia? It may seem strange to think about insomniac
pram and nikethimide. The central nervous system animals since they cannot really complain of sleep
stimulants that produce arousal are usually used difficulty. Not only that, but as far as we know, they
for the treatment of disorders of excessive sleepi- do not have expectations of sleeping continuously
ness, such as NARCOLEPSY and IDIOPATHIC HYPERSOM- or for a certain length of time.
NIA, whereas the respiratory stimulants are used
for disorders such as INFANT SLEEP APNEA. (See also
STIMULANT MEDICATIONS.) anorectics See STIMULANT MEDICATIONS.

angina decubitus See NOCTURNAL CARDIAC ISCHEMIA. anticholinergic effects Side effects sometimes seen
with the use of tricyclic antidepressants. The side
effects include dry mouth, anorexia, sweating,
animals and sleep Most people are familiar with hypotension, tachycardia, urinary retention, con-
the term catnap, referring to the light sleep pattern stipation, blurred vision, and sexual dysfunction.
that is characteristic of cats, which may take up as These side effects limit the usefulness of the tricy-
many as 16 hours of their 24-hour day. But only clic antidepressants in many patients.
one-quarter of that time is in deep sleep. The rest
of the time, cats experience light sleep, or catnaps,
when they may awaken quickly and may not even antidepressants Medications used for the treat-
seem to be asleep to observers. ment of the psychiatric disorders associated with
Giraffes have been known to go weeks without DEPRESSION. These disorders, previously called affec-
sleep, while dogs normally sleep in short bouts and tive disorders and currently called mood disorders,
do not have the multihour, unbroken sleep periods can have pronounced effects upon sleep. INSOMNIA
of humans, as noted in “Animals’ Sleep: Is There is a typical feature of mood disorders, as are altered
a Human Connection?” an article published in sleep-wake patterns. Antidepressant medications
Sleepmatters, a newsletter published by the National can be useful for treating not only the predominant
Sleep Foundation. As a result, “broken” or “frag- mood disorders but also the underlying sleep dis-
mented” sleep has little meaning in canines. turbance. The group of antidepressant medications
Primates such as gorillas have been observed to most commonly used are the serotonin reuptake
awaken occasionally; presumably, they recognize inhibitors; however, other medications, including
the anomalous nature of their awakening from the the tricyclic antidepressants and the MONOAMINE
fact that their companions remain asleep. They, OXIDASE (MAO) INHIBITORs, are frequently recom-
too, promptly return to sleep unless it is time to mended. In addition to their role in treating sleep
rise (e.g., the rest of the troop begins to show signs disturbance related to depression, the antidepressant
of stirring). medications are commonly used for the treatment of
As for onset insomnia, the fact is that studies CATAPLEXY in patients who have NARCOLEPSY.
to measure the time of sleep onset in a group of Selective serotonin reuptake inhibitors (SSRIs)
animals have not been conducted, to Dr. Pollak’s are a group of medications used for the treatment
knowledge. It would be expected, however, that of depression. These antidepressant medications are
the latency from sleep onset in the first animal to classified on the basis of their selective blockade or
that of the last would be short in relation to the neuronal reuptake of SEROTONIN (5HT). The SSRIs
normal duration of sleep. The sleep-wake cycle include agents such as fluoxetine, sertraline, and
is normally tightly synchronized with the circa- paroxetine. These newer antidepressants generally
dian time cues to which that species normally have fewer side effects than the older antidepres-
responds; most often, it is the solar light-dark sants. The side effects, if they occur, happen at the
cycle. start of treatment or after dosage increases.
22 antidepressants

The SSRIs have little effect upon monoamine Amitriptyline typically will suppress the sleep onset
uptake systems other than serotonin, and they REM period that is commonly seen in patients with
cause only minimal inhibition of muscarinic cho- depression.
linergic, histaminergic, or adrenergic receptors. Amitriptyline is given in doses from 10 mil-
Blocking the reuptake of 5HT increases the time ligrams to 150 milligrams per day, higher doses
that 5HT molecules remain in the synapse and being preferred for the treatment of endogenous
therefore increases the chance that they will bind depression, whereas the lower dosages are often
with 5HT receptors. effective in treating insomnia that is unrelated to
The SSRIs are as effective as the tricyclic anti- primary depression.
depressants but have a better benefit-to-risk ratio Side effects of daytime sedation, and anti-cho-
because they are relatively safe if overdosed and linergic effects that are typical of all the tricy-
are not cardiotoxic. The most common side effects clic antidepressants, include dry mouth, anorexia,
of the SSRIs are nausea, loose stools, tremor, dry sweating, HYPOTENSION, TACHYCARDIA, urinary
mouth and sexual dysfunction, including reduced retention, constipation, blurred vision and sexual
libido, delayed ejaculation in men and anorgasmia dysfunction; such side effects can commonly occur.
in women. Several adverse effects are dose-related, As with the other tricyclic antidepressants, amitrip-
such as anxiety, agitation, akathisia, tremor and tyline can be cardiotoxic and can induce CARDIAC
nausea. ARRHYTHMIAS in patients with cardiac disease.
The tricyclic antidepressants are medications This drug is not used for the treatment of cata-
with a three-ringed biochemical structure. Their plexy because of its tendency for side effects and
primary use is in improving depression, but they its sedation. Other tricyclic antidepressants, such
are also used for other psychiatric illnesses, such as protriptyline and clomipramine, that have little
as panic attacks. The main tricyclic antidepressants sedating effects, are more useful for the treatment
used are amitriptyline, clomipramine, imipramine, of cataplexy. However, the serotonin reuptake
and protriptyline. inhibitors such as Prozac are commonly used.
The tricyclics are also commonly used for the Amitriptyline also suppresses ALPHA ACTIVITY in
treatment of insomnia. Sedating tricyclic medica- the electroencephalogram (EEG). Consequently, the
tions can be used to improve the quality of night- drug has been used in the treatment of patients with
time sleep by reducing AWAKENINGS. The stimulating nonrestorative sleep due to FIBROSITIS SYNDROME.
tricyclic medications, such as protriptyline, can be
used during the daytime to reduce the psychomo- Clomipramine (Anafranil)
tor retardation that often occurs in patients with A tricyclic antidepressant and a potent serotonin
depression. They may also reduce the tendency for uptake blocker used for the treatment of depres-
daytime lethargy and napping in such patients. sion and the cataplexy caused by narcolepsy,
The tricyclic antidepressants have a pronounced clomipramine is given in divided doses during
REM sleep suppressant effect. Once the medication the day, with dosages ranging from 10 to 20 mil-
is stopped, there can be a rebound of REM sleep ligrams per day. It is limited by its side effects,
with enhancement of REM sleep-related phenom- which include sedation, dry mouth, anorexia (loss
ena, such as NIGHTMARES, SLEEP PARALYSIS, or HYP- of appetite), hypertension, sweating, tachycardia,
NAGOGIC HALLUCINATIONS. urinary retention, constipation, blurred vision and
sexual dysfunction.
Amitriptyline (Elavil) Clomipramine is commonly used outside of the
A tricyclic antidepressant with sedating effects that United States for the treatment for cataplexy in
is commonly used in the treatment of insomnia patients with narcolepsy. As this agent has power-
due to depression. This medication has been shown ful REM-suppressant effects, it is an effective agent
to decrease the number of awakenings, increase for treatment of REM-sleep phenomena. It appears
the amount of stage four sleep (see SLEEP STAGES) to be more successful in treating cataplexy than
and markedly reduce the amount of REM sleep. most other tricyclic antidepressants.
antidepressants 23

Imipramine (Tofranil) effect on either sleep stages or by its anticholinergic

One of the first tricyclic antidepressants to be used. effects.
It appears to act by stimulation of the central ner-
vous system and blocks the uptake of norepineph- Protriptyline (Vivactil)
rine at nerve endings. This medication is primarily A tricyclic antidepressant medication used for the
used for the relief of the symptoms of depression, treatment of depression and cataplexy in patients
especially endogenous depression. However, it is with narcolepsy because of its effectiveness and its
also used for the treatment of childhood enuresis advantageous stimulant effects. Protriptyline is com-
and narcolepsy. monly given in divided doses during the daytime in
Imipramine is available in tablets of 10, 25 and a dose from 15 to 30 milligrams per day. Although
50 milligrams. Doses of up to 100 milligrams per patients report an alerting effect of protriptyline, this
day are usually required in adults. As the potential has not been confirmed by objective testing.
for cardiac toxicity is greater in children, it should As with the other tricyclic antidepressants,
be used in childhood only with caution. Over- the predominant side effects include the typical
dosage in childhood has been reported to cause anticholinergic effects; the tendency to these side
death. effects limits its usefulness in some patients with
The medication produces mild sedation and cataplexy.
therefore can be given prior to sleep at night, Protriptyline reduces REM sleep at night but
where it can help the quality of sleep by improving also, because of the stimulant effect, can produce
deep stage three/four sleep (see sleep stages). But an increased number of awakenings and lead to
there is a marked reduction in REM sleep. Sud- insomnia if given before nocturnal sleep. It can
den WITHDRAWAL of the medication is frequently induce cardiac arrhythmias and should be given
accompanied by an increase in REM sleep, with the with caution to patients with cardiac disease.
development of nightmares and other REM sleep
phenomena, such as sleep paralysis and hypnago- Femoxetine
gic hallucinations. Has been shown to be useful in the treatment of
The main adverse reactions of imipramine are cataplexy in patients with narcolepsy. This agent is
related to its cardiotoxicity and ANTICHOLINERGIC less effective than the tricyclic antidepressants but
EFFECTS, such as dry mouth, blurred vision, consti- has the advantage of lacking anticholinergic side
pation and urinary retention. In addition, central effects, such as dry mouth, anorexia, hypertension
nervous system effects, such as confusion and and sweating. This medication is not yet avail-
disorientation with exacerbation of insomnia, can able in the United States but is available for use
occur. in Europe, although it is believed that it has only
When used for the treatment of cataplexy, the a small role to play in the treatment of cataplexy,
medication is usually given in divided doses during because more effective agents are available, such
the daytime. However, the side effect of sedation as protriptyline.
limits its usefulness in treating narcolepsy. Other
more stimulating tricyclic antidepressants, such as Fluoxetine (Prozac)
protriptyline or the serotonin reuptake inhibitors, A reuptake blocker. Sixty milligrams given in a
are more useful. Also, because methylphenidate single morning dose has been shown to be effec-
(Ritalin) can inhibit the metabolism of imipramine, tive in reducing cataplexy in some patients. How-
the dose of imipramine may have to be reduced in ever, there have been rare reports of an increase in
patients receiving both medications. cataplexy on this medication, and its use may be
A nighttime dose of 25 to 50 milligrams has limited by the side effect of nausea. Fluoxetine is
been effective in suppressing nocturnal enuresis in limited in its usefulness of the treatment of cata-
childhood. This effect is believed to be produced by plexy because other more effective agents, such as
delaying the time of urinating till the final morning protriptyline, are available. Fluoxetine is an effec-
awakening and is not thought to be produced by its tive antidepressant.
24 antihistamines

Fluvoxamine (Fluvox) sleepiness leads to its use by parents for the treat-
A potent serotonin uptake blocker that is used for ment of childhood INSOMNIA as a sedative agent.
the treatment of cataplexy in patients with narco- However, diphenhydramine has pronounced anti-
lepsy. It is an antidepressant medication with slight cholinergic effects (constipation, dry mouth, urine
sedative effects, but little anticholinergic effect. It is retention, and hypotension), and its sedative effect
less effective in treating cataplexy than the tricyclic is a side effect of the histamine blocker. It is not
medication protriptyline. recommended for routine use as a hypnotic agent.
Other, more specific hypnotics, the BENZODIAZ-
Sertraline (Zoloft) EPINES, are preferable for patients who have sleep
A serotonin reuptake inhibitor that can disturb disturbance.
sleep. It also can produce REM-sleep suppression
and BRUXISM.
antipsychotic medication See NEUROLEPTICS.
Paroxetine (Paxil)
A serotonin reuptake inhibitor that can induce
rapid eye movements in NREM sleep. It is useful anxiety A feeling of dread and apprehension
for daytime anxiety disorders. regarding one or more life circumstances. A com-
mon cause of sleep disturbance, anxiety may be
Nefazodone (Serzone) a short-lived, acute STRESS, such as that related
This medication is a sedative and can be useful for to an examination or a marital, financial or work
treating insomnia. It can increase REM sleep. problem. Acute anxiety in these situations can lead
to an ADJUSTMENT SLEEP DISORDER, which typically
Mirtazapine (Remeron) resolves itself within a few days of the acute anxi-
It produces mild sedation and can suppress REM ety, but it may persist for several weeks. Chronic
sleep. anxiety often indicates an ANXIETY DISORDER and
may lead to an enduring and pervasive sleep
Venlafaxine (Effexor) disorder.
It can induce sedation or insomnia. Individuals with chronic sleep disorders, such as
PSYCHOPHYSIOLOGICAL INSOMNIA, may become anx-
ious as a secondary feature of the sleep disorder.
antihistamines Medications that block the effect Treatment of the underlying sleep disorder in these
of HISTAMINE, an irritant agent released in response situations usually leads to resolution of the anxiety.
to trauma or an allergic reaction. Antihistamines, (See also PANIC DISORDER.)
particularly diphenhydramine, have sedative prop-
erties and are sometimes used as HYPNOTICS. How-
ever, their primary use is as blockers of acute anxiety disorders Psychiatric disorders character-
allergic reactions, such as allergic skin reactions, ized by symptoms of anxiety and dread and avoid-
nasal allergies, gastrointestinal allergies or for the ance behavior. Sleep disturbance commonly occurs
treatment of severe whole body allergic reactions, in association with anxiety disorders. Anxiety
such as anaphylaxis or angioedema. Other anti- disorders include PANIC DISORDER, with or without
histamine agents do not have sedative properties agoraphobia, phobias, obsessive-compulsive dis-
and are effective in inhibiting gastric acid secre- order, post-traumatic stress disorder, and general
tion. They are commonly used for the treatment of anxiety disorder.
peptic ulcers. Patients with general anxiety disorder typi-
cally have a sleep onset or maintenance INSOMNIA,
Diphenhydramine (Benadryl) with frequent AWAKENINGS that may be associated
Antihistamine primarily used for allergic reactions. with anxiety dreams. Typically there is ruminative
Its pronounced tendency to induce sedation and thinking that occurs at sleep onset or during the
anxiety disorders 25

awakenings. Individuals often complain of being CONTROL THERAPY or SLEEP RESTRICTION THERAPY, are
unable to “turn off their minds” because of the usually necessary in patients with sleep disturbance
flood of thoughts and concerns, many of which because of anxiety disorders.
are trivial in nature. Following the disturbed night
of sleep, there may be feelings of unrest, tired- Case History
ness, FATIGUE, and SLEEPINESS. Often during the A 39-year-old male high school teacher had a long
daytime there is intense anxiety over the thought history of sleep disturbance, a condition that had
of another impending night of inadequate sleep. deteriorated in the prior three years. In addition to
Associated with the daytime anxiety is evidence of teaching, he also had a part-time job as a landlord,
increased muscle tension, restlessness, shortness of which contributed a number of anxieties and rather
breath, palpitations, dry mouth, dizziness, trem- complicated his life. His sleep pattern was disrupted
bling and difficulty in concentration. Most patients by a constant feeling that he couldn’t turn off his
with anxiety disorders have little ability to take mind. He became very annoyed and angry at his
daytime NAPS, as the difficulty in being able to fall inability to fall asleep. Occasionally, he would per-
asleep persists around the clock. form RELAXATION EXERCISES before getting into bed
The anxiety disorders characteristic of early at night and would avoid any activities that might
adulthood are more common in females than in be stimulating or disruptive to his sleep. He usu-
males. There appears to be a familial tendency for ally was unable to sleep for more than an hour at
general anxiety disorder. Polysomnographic stud- a time before awakening, and then he would be in
ies demonstrate a prolonged SLEEP LATENCY, with and out of sleep for the rest of the night. Occasion-
frequent awakenings during the night, reduced ally he tried drinking a small amount of ALCOHOL to
sleep efficiency and increased amount of lighter improve his sleep but stopped this when he found
stages one and two sleep, with reduced slow wave it did not produce any benefit. Upon awakening in
sleep. REM SLEEP latencies are normal although the morning, he would be tired and had difficulty
REM sleep may be reduced in percentage (see SLEEP in maintaining concentration, which affected his
STAGES). conversations. He found that he would often have
The chronic nature of anxiety differentiates to repeat himself. He became slightly depressed and
patients with anxiety disorders from those who irritable because of the sleep disturbance.
are experiencing an ADJUSTMENT SLEEP DISORDER, His problem with initiating and maintaining
which is typically seen in association with acute sleep was finally diagnosed as secondary to chronic
stress. Sleep disturbance associated with anxiety anxiety and DEPRESSION. There was no evidence of
disorders should be distinguished from that seen in major depression; the anxiety features were more
patients who have PSYCHOPHYSIOLOGICAL INSOMNIA; prominent. Treatment was initiated by schedul-
the anxiety in psychophysiological insomnia is less ing his time for sleep within the limits of 10:45 at
generalized and is more focused on the sleep dis- night with an awakening at 6:45 in the morning.
turbance, which, when effectively treated, leads to With 0.5 milligrams of alprazolam (Xanax; see
resolution of the anxiety. Patients with generalized BENZODIAPENES), the sleep disturbances abated but
anxiety disorders have more pervasive anxiety that were not resolved. After several weeks of treat-
may persist even though the sleep disturbance is ment, combined with close attention to his hours,
otherwise resolved. a small dose of sedating antidepressant medication
Anxiety disorders are treated either by phar- was added to his treatment. He commenced 50
macological means or through counseling and milligrams of amitryptiline (Elavil; see ANTIDEPRES-
psychotherapy. Pharmacological agents used to SANTS) taken one hour before sleep.
treat anxiety disorders include HYPNOTICS and BEN- On the new treatment regime, he dramatically
ZODIAZEPINES; the use of ANTIDEPRESSANTS may be improved and the quality of sleep was the best he
required if elements of depression coexist. Good had had in years. In addition, the intermittent feel-
SLEEP HYGIENE and treatment of the sleep distur- ings of daytime depression were eliminated and he
bance by behavioral means, such as STIMULUS did not suffer from fatigue and tiredness. He was
26 apnea

maintained on the medications with strict adher- nea index is a more reliable measure of apnea
ence to a regular sleeping-waking schedule. severity than the APNEA INDEX because it monitors
all three types of respiratory irregularity during
sleep. The apnea-hypopnea index is sometimes
apnea Derived from the Greek word that means referred to as the RESPIRATORY DISTURBANCE INDEX
“want of breath,” apnea has occurred if breathing (RDI).
stops for at least 10 seconds, as detected by airflow
at the nostrils and mouth. Respiratory movement
may or may not be present during an apneic epi- apnea index A measure of APNEA frequency most
sode. Typically there are three forms of apnea, commonly used in determining the severity of
depending upon the degree of respiratory move- respiratory impairment during sleep. The number
ment activity: obstructive, central, and mixed. of obstructive, central, and mixed apneic episodes
Obstructive apnea is associated with UPPER AIR- is expressed per hour of total sleep time as mea-
WAY OBSTRUCTION and is characterized by loss of air- sured by all-night POLYSOMNOGRAPHIC recording.
flow while respiratory movements remain normal. Occasionally an obstructive apnea index, which is
Airflow is usually measured by means of a nasal a measure of the obstructive apneas per hour of
THERMISTOR (a temperature-sensitive metal strip) total sleep time, or a central apnea index, is stated.
that records changes in air temperature with inspi- Typically an apnea index of 20 or less is regarded
ration and expiration, whereas respiratory muscle as mild apnea, an index of 20 to 50 as moderate
movement activity can be measured by means of and above 50 as a severe degree of apnea. The
the ELECTROMYOGRAM (EMG), strain gauges or by term “apnea index” is only one index of apnea
a bellows pneumograph. Obstructive apnea is usu- severity because the duration of apneic episodes
ally accompanied by sounds of SNORING. and severity of associated features, such as oxygen
Central apnea is cessation of airflow associated saturation and the presence of electrocardiographic
with complete cessation of all respiratory move- abnormalities, are also important in determining
ments. The diaphragm and chest muscles are apnea severity.
immobile. This type of apnea can occur among If the number of episodes of shallow breathing
those who have diseases such as poliomyelitis during sleep (HYPOPNEA) are added to the apneas
(polio) or spinal-cord injuries. in calculating the index, then an APNEA-HYPOPNEA
Mixed apnea typically has an initial central INDEX is produced, an index preferred by many
apnea component for about 10 seconds followed by clinicians.
an obstructive component.
Apnea during sleep can produce a lowering of the
blood oxygen level, increased blood carbon dioxide apnea monitor A biomedical device developed
levels, CARDIAC ARRHYTHMIAS, and sleep disruption primarily for detection of episodes of cessation of
with resulting EXCESSIVE SLEEPINESS. If the number breathing that occur in infants and young children.
of apneas becomes frequent enough to produce An apnea monitor detects respiratory movement
clinical symptoms and signs, then the patient may and heart rhythm. Typically, an apnea monitor
have either an OBSTRUCTIVE SLEEP APNEA SYNDROME is set to signal a breathing pause of 20 seconds
or CENTRAL SLEEP APNEA SYNDROME. or greater, or an episode of slowing of the heart
rhythm, a rate that is determined according to the
age of the child.
apnea-hypopnea index The number of obstruc- Apnea monitors are usually recommended for
tive, central, and mixed APNEA episodes, plus the use on children who have been known to stop
number of episodes of shallow breathing (HYPOP- breathing in their sleep. Any subsequent events
NEA), expressed per hour of total sleep time, as can be detected and will set off an alarm so that
determined by all-night POLYSOMNOGRAPHIC record- the parent can check the condition of the child.
ing. Most clinicians believe that the apnea-hypop- With infants, it often occurs that the alarm will
arginine vasotocin 27

sound and by the time the parents get to the The majority of infants born before 31 weeks of
infant, the child has recommenced breathing. gestation will have this form of apnea; the preva-
However, in some situations the child may need to lence falls to less than 15 percent of infants born
be stimulated to start respiration, particularly those after 32 weeks of gestation and older.
children with sleep-related BREATHING DISORDERS, Episodes of apnea may occur infrequently (once
such as the CENTRAL SLEEP APNEA SYNDROME. Apnea a week) or can occur several times per hour. The
monitors are not useful for detecting upper airway course of the disordered breathing is shorter the
obstruction in association with the OBSTRUCTIVE older the child is at birth, and typically the course
SLEEP APNEA SYNDROME. is less than four weeks for infants older than 31
Apnea monitors do not replace the use of more weeks gestation.
extensive POLYSOMNOGRAPHIC evaluation when Apnea of prematurity can be demonstrated
sleep-related breathing disorders are suspected. by POLYSOMNOGRAPHIC monitoring, which shows
Polysomnographic monitoring has the advantage apneic episodes occurring during both QUIET SLEEP
of being able to detect upper airway obstructive and inactive sleep. However, the most severe epi-
events as well as determining whether alterations sodes occur during ACTIVE SLEEP, often in association
in ventilation occur during sleep or specific SLEEP with CARDIAC ARRHYTHMIAS, such as bradycardia.
STAGES. In addition, polysomnographic monitor- The disorder may produce severe HYPOXEMIA
ing is able to detect other physiological variables and require ventilatory support. There is some sug-
that may be associated with a respiratory pause, gestion that infants with apnea of prematurity may
for example, the electroencephalographic pattern be at high risk of developing SUDDEN INFANT DEATH
in a child who has epileptic SEIZURES as a cause of SYNDROME (SIDS).
respiratory cessation. Treatment is mainly supportive. Assisted ven-
tilation and constant respiratory monitoring in a
neonatal intensive care unit may be necessary.
apnea of prematurity (AOP) Episodes of inter- (See also CENTRAL ALVEOLAR HYPOVENTILATION SYN-
rupted breathing present in otherwise healthy, DROME, CENTRAL SLEEP APNEA SYNDROME, INFANT
prematurely born infants. The breathing pauses are SLEEP, INFANT SLEEP APNEA, OBSTRUCTIVE SLEEP APNEA
typically greater than 20 seconds in duration; how- SYNDROME.)
ever, shorter pauses may be associated with cyano-
sis, abrupt pallor or hypotonia. The majority of the
apneic episodes occur during sleep; however, some apoptosis Refers to a type of regulated, pro-
are associated with movement when the infant is grammed cell death. Although it may result from
awake. Up to 10 percent of the apneic episodes cell damage or infection, apoptosis is distinct from
are purely obstructive, with the site of obstruction the necrosis (death of body tissue) that results from
being in the pharynx. The episodes always termi- acute (severe) tissue injury. It is a component of
nate spontaneously and, if necessary, stimulation normal development in which cellular proliferation
can assist in promoting ventilation. is balanced against cell loss. Apoptotic cells undergo
Immaturity of the respiratory system is believed an orderly series of morphological changes that
to be the primary cause of apnea of prematurity. result from the activation of specialized enzymes
However, this form of apnea can be precipitated (caspases) ending in phagocytosis (engulfment by
by general anesthesia or the use of other CENTRAL immune cells, breakdown, and disposal). Apoptosis
NERVOUS SYSTEM depressant medications. may underlie some forms of brain injury that result
Normal healthy infants can have brief apneic from SLEEP APNEA.
pauses, typically between five and 10 seconds in
duration; however, these episodes are not of clini-
cal significance and it is the longer apneas associ- arginine vasotocin (AVT) A peptide that was
ated with cyanosis and reduction of cerebral blood initially discovered in the PINEAL GLAND. This agent
flow that are of particular concern. has a variety of effects, including modification of
28 Argonne anti-jet-lag diet

conditioned behavior, inhibition of gonadotro- SYNDROME). Armodafinil is in a class of medications

phin hormone (sex gland stimulating hormone) called wakefulness-promoting agents. In approxi-
release and the stimulation of SLOW WAVE SLEEP. mately 1,000 patients with one of these disorders,
Very low doses of AVT are reported to be effective armodafinil resulted in significant improvements
in increasing slow wave sleep in animals. (It is in MAINTENANCE OF WAKEFULNESS TEST (MWT),
thought that the effects may be mediated through MULTIPLE SLEEP LATENCY TESTING, and physician rat-
the gamma-aminobutyric acid pathways to seroto- ing of Clinical Global Impression-Change without
nergic neurons.) disturbing the subjects’ intended SLEEP SCHEDULE.
There is evidence in humans to suggest that AVT The safety profile is good and is similar to that of
is released during sleep into the cerebrospinal fluid. modafinil (Provigil). It acts for a longer duration of
Recent evidence in patients with NARCOLEPSY and time than modafinil. When released in 2007 it was
other disorders of EXCESSIVE SLEEPINESS has shown classified as a Schedule IV controlled substance.
that sleep, and particularly SLEEP ONSET REM peri- Avoid driving or any other activities that require
ods, can be increased by the administration of AVT. alertness until the effect of the drug is clear. Pos-
These studies suggest that AVT may be involved sible side effects include a skin rash from mild to
primarily in the regulation of REM sleep. (See severe enough to require hospitalization, head-
also GAMMA-AMINOBUTYRIC ACID, SEROTONIN, SLEEP- ache, sore throat, or fever. Do not take this drug if
INDUCING FACTORS.) you are allergic to armodafinil or modafinil.

Argonne anti-jet-lag diet Developed by Dr. arousal A change in the sleep state to a lighter
Charles Ehret of Argonne’s Division of Biologi- stage of sleep. Typically, arousal will occur from
cal and Medical Research as part of his studies of a deep stage of non-REM sleep to a lighter non-
biological rhythms. The Argonne anti-jet-lag diet REM sleep stage, or from REM sleep to stage one
is based upon the finding that high carbohydrate or wakefulness (see SLEEP STAGES). Arousals some-
food, such as pasta, fruit, and some desserts, will times result in a full awakening and are often ac
produce an increased level of energy for about one companied by body movement and an increase in
hour and subsequently will produce tiredness and heart rate.
sleepiness. Conversely, high protein foods, such Arousals occurring from stage three and four
as fish, eggs, dairy products, and meat, will give sleep may be accompanied by the characteristic
a sustained increased level of energy, possibly by features of AROUSAL DISORDERS, namely, SLEEPWALK-
its metabolism to catecholamines such as adrena- ING, SLEEP TERRORS, and CONFUSIONAL AROUSALS. In
line. In addition, caffeine-containing drinks, such these disorders, arousal is followed by an incom-
as coffee, can advance or delay the sleep pattern, plete waking and the persistence of electroenceph-
depending upon the time they are taken. alographic patterns of sleep.
The Argonne anti-jet-lag diet consists of a pat-
tern of feasting and fasting for four days prior to
departure. The effectiveness of the Argonne anti- arousal disorders Disorders of normal AROUSAL.
jet-lag diet has been questioned. In 1968, Roger J. Broughton described four impor-
tant common sleep disorders as abnormalities of
the arousal process: SLEEP ENURESIS (bed-wetting),
armodafinil (Nuvigil) Single-isomer formulation somnambulism (SLEEPWALKING), SLEEP TERRORS,
(R-enantiomer) of racemic modafinil, the WAKE- and NIGHTMARES. At that time, it was believed that
FULNESS-promoting pharmaceutical marketed as all four of these disorders shared common electro-
Nuvigil is used to encourage wakefulness in the physiological and clinical features.
treatment of narcolepsy and other disorders asso- Two of the disorders, somnambulism and sleep
ciated with excessive daytime sleepiness (SHIFT- terror, most consistently demonstrate the classical
WORK SLEEP DISORDER, OBSTRUCTIVE SLEEP APNEA feature of the arousal disorders. They occur dur-
asthma, sleep-related 29

ing an arousal from SLOW WAVE SLEEP, rather than as well as the cerebral regions involved in the pro-
REM SLEEP. Since Broughton’s original description, duction of sleep, thereby producing the SLEEP-WAKE
a third disorder, the nightmare, has been shown CYCLE. The Ascending Reticular Activating System
to occur more typically from REM sleep; and sleep anatomically consists of the brain stem reticular
enuresis, although occurring from slow wave sleep, formation, including that of the medullary, pon-
can also occur out of other SLEEP STAGES. tine and midbrain levels, as well as the subhypo-
In addition to the sleep stage association, the thalamic and thalamic regions. Excitation of these
other major features of the four arousal disorders areas leads to cortical activity by means of a diffuse
are: (1) the presence of mental confusion and dis- thalamic projection system that covers the entire
orientation during the episode; (2) automatic and cerebral cortex.
repetitive motor behavior; (3) reduced reaction In addition to the sleep-related functions, the
and insensitivity to external stimulation; (4) diffi- reticular formation of the brain stem contains those
culty in coming to full WAKEFULNESS despite vigor- neurons involved in the respiratory, cardiovascular,
ous attempts to awaken the individual; (5) inability and other autonomic systems.
to recall the event the next morning (retrograde
amnesia); and (6) very little dream recall associated
with the event. Aserinsky, Eugene Considered one of the pioneers
Although mentioned by Broughton in his origi- of modern sleep research, Dr. Aserinsky (1921–98),
nal article, the disorder of CONFUSIONAL AROUSALS in 1952, while a graduate student at the University
has recently been established as another arousal of Chicago working in the laboratory of his adviser
disorder. NATHANIEL KLEITMAN in the department of physiol-
ogy, discovered the presence of the RAPID EYE MOVE-
MENT (REM) phase of sleep. His thesis was entitled
artifact Interfering electrical signals that occur “Eye Movements During Sleep.”
during the recording of sleep. An artifact may be
caused by the person being studied or by envi-
ronmental interference, sometimes from the sleep asthma, sleep-related Frequent asthmatic attacks
lab itself, and can obscure the information being that occur during sleep. Typically these episodes
recorded. will lead to an arousal or an awakening from sleep.
Too much artifact may make a sleep recording The awakenings are characterized by difficulty in
impossible to score and analyze and therefore ren- breathing, wheezing, coughing, gasping for air,
der it useless. and chest discomfort. Often there may be excessive
Sixty HERTZ activity, often due to nearby elec- mucus produced during these episodes. Typically
trical appliances or cables, is a common cause of the patient will use a medication, such as a bron-
artifact during sleep recordings. chodilator, that relieves the acute episodes.
Asthma attacks during sleep appear to be more
common in children, and it is reported that up to
Ascending Reticular Activating System (ARAS) A 75 percent of asthmatic patients have some night-
portion of the brain stem and cerebrum involved time episodes. Generally the severity of the sleep-
in the maintenance of WAKEFULNESS. The cells in related asthma parallels the severity of daytime
this area consist of a loose network that forms the asthma.
central gray matter of the brain stem. The cause of sleep-related asthma is unknown;
In the 1940s, Morruzi and Magoun discovered however, circadian factors are thought to play a
that electrical stimulation of the brain stem reticu- part. There is a circadian variation in bronchial
lar formation produced an increase in cortical acti- resistance, which tends to be increased in the early
vation indicative of wakefulness. The ascending morning hours, and there may also be a circadian
reticular formation interacts with the brain stem change in the intensity of airway inflammation at
regions for the induction and maintenance of sleep, night. There are also nighttime reductions in the
30 asymptomatic polysomnographic finding

serum level of epinephrine (chemical produced by input, such as when a nerve is severed; it is also
the adrenal gland) and CORTISOL (hormone pro- seen as a characteristic feature of REM sleep when
duced by adrenal gland) that may predispose an all skeletal muscles, except for the inner ear mus-
individual to an asthmatic attack. In addition, the cles, the eye muscles and the respiratory muscles,
effect of medications during the daytime may wear have absent tone. In general, muscle tone is highest
off during the nocturnal sleep episode. in WAKEFULNESS, reduces as sleep becomes deeper
Polysomnographic evaluation of persons with and is typically absent during REM sleep.
sleep-related asthma tends to show that episodes
are more likely to occur during the second half of
the sleep episode. However, there does not appear atypical antipsychotics A group of medications
to be a specific SLEEP STAGE relationship. usually called atypical antipsychotics or neurolep-
Episodes of acute difficulty in breathing at night tic drugs used to treat schizophrenia by reducing
need to be differentiated from a variety of other hallucinations and delusions. These drugs include
BREATHING DISORDERS, as well as GASTROESOPHA- aripiprazole (Abilify), risperidone (Risperdal), clo-
GEAL REFLUX, LARYNGOSPASM or the SLEEP CHOKING zapine (Clozaril), olanzapine (Zyprexa), quetiapine
SYNDROME. (Seroquel), and ziprasidone (Geodon). The side
Treatment of sleep-related asthma involves effects of these drugs are supposed to be less severe
appropriate management of daytime asthma. Suit- than the conventional antipsychotics that were
able treatment of the acute sleep-related attacks introduced starting in the 1950s such as chlor-
is also required. In addition, elimination of any promazine (Thorazine), fluphenazine (Prolixin),
potential bedroom allergens may reduce the fre- haloperidol (Haldol), thiothixene (Navane), trifluo-
quency of sleep-related asthma. perazine (Stelazine), perphenazine (Trilafon), and
thioridazine (Mellaril). There are conditions when
taking one or more of the atypical antipsychotics is
asymptomatic polysomnographic finding Any contraindicated. Ziprasidone, for example, should
asymptomatic abnormality detected by polysom- not be taken if someone has had a recent heart
nography that when present in other patients can be attack or has certain heart rhythm irregularities.
symptomatic. For example, PERIODIC LEG MOVEMENT There are also possible side effects that range from
can produce symptoms associated with INSOMNIA or very mild to severe so check with your health care
EXCESSIVE SLEEPINESS; however, in many otherwise professional before starting to take any atypical
healthy individuals, periodic leg movements may antipsychotics. Also be careful about combining
be asymptomatic. These asymptomatic features these drugs with other medications; let your health
may be detected during polysomnographic moni- care professional know about all the medications
toring performed for other reasons, for example, you are taking including any OTC (over-the-coun-
for impotence or for unrelated sleep disorders, ter) medications.
such as nocturnal epilepsy or SLEEPWALKING. Other
asymptomatic polysomnographic findings include
infrequent episodes of obstructive or CENTRAL SLEEP autoCPAP Nasal CPAP (continuous positive air-
APNEA and FRAGMENTARY MYOCLONUS. way pressure) is a device for treating OBSTRUCTIVE
SLEEP APNEA SYNDROME by means of raised upper
airway pressure. It consists of a mask that makes
atonia The absence of muscle activity. Skeletal a seal with the face around the nose plus an
muscle, even in the resting state, has a degree electronically operated blower that is connected
of muscle activity that maintains the tension in to the mask by a hose. When properly fitted and
muscles (muscle tone). A reduction in muscle tone adjusted to provide sufficient pressure, nasal
causes the muscle to relax and to become weak and CPAP reduces and often eliminates APNEAS. Mask
unable to maintain tension. Atonia is typically seen fitting and pressure adjustment are done while
in a muscle that is removed from its neurological sleep and breathing are being monitored in the
awakening epilepsies 31

sleep laboratory. AutoCPAP automatically adjusts SLEEP-RELATED EPILEPSY. Automatic behavior can
the pressure by means of feedback responses also occur with normal activities, such as driving,
to apneas, HYPOPNEAS, and other sometimes ill- and is seen in patients with NARCOLEPSY and other
defined changes in airflow. Direct comparison of forms of severe sleepiness. In automatic behavior,
autoCPAP with fixed-pressure CPAP has shown an individual may perform complex normal activi-
that autoCPAP is often equally effective. There is ties, yet have amnesia for these acts.
no difference in side effects or patient compliance,
and only a few patients express a preference for
one or the other, despite reports that automatic awakening A change from non-REM or REM
variations in mask pressure can disturb sleep. In sleep to the awake state or WAKEFULNESS. Wakeful-
the absence of clear evidence of superior efficacy, ness is characterized by fast, low-voltage EEG activ-
autoCPAP cannot be recommended in preference ity with both alpha waves and beta waves. There
to fixed-pressure CPAP. is an increase in tonic EMG activity and RAPID EYE
MOVEMENTS, and eye blinks occur. An awakening
is always accompanied by a change in the level of
autogenic training A behavioral technique used consciousness to the alert state. (See also NREM-
in the treatment of INSOMNIA. A form of self- REM SLEEP CYCLE.)
hypnosis, autogenic training conditions patients
to concentrate on sensations of heaviness and
warmth in the limbs, thus inducing sleepiness. awakening epilepsies Term referring to epilep-
Although some studies have questioned how effec- tic SEIZURES that occur during WAKEFULNESS as
tive this technique is for all patients, it seems that compared to epilepsies that occur during sleep.
at least some are helped by it. (See also BEHAVIORAL The most common form of awakening epilepsies
TREATMENT OF INSOMNIA, DISORDERS OF INITIATING are generalized epilepsies, such as tonic-clonic
AND MAINTAINING SLEEP, HYPNOSIS, PSYCHOPHYSI- epilepsy or petit mal epilepsy. In addition, some
OLOGICAL INSOMNIA.) forms of juvenile myoclonic epilepsy occur upon
awakening.
The awakening epilepsies are contrasted with
automatic behavior Unconscious psychologi- the sleep epilepsies, which primarily consist of gen-
cal and physical actions. Such behavior includes eralized tonic-clonic SEIZURES or complex partial
repetitive movements typical of some forms of seizures. (See also EPILEPSY, SLEEP-RELATED.)
B
background activity An ELECTROENCEPHALOGRAM Tolerance to the beneficial hypnotic effect of the
(EEG)-related term that refers to the electrical medication generally occurs within two weeks of
activity of the brain that is normally seen in the continuous use. There are variable effects of the
awake patient. It is called ALPHA ACTIVITY, and its rebound in slow wave and REM sleep after termi-
frequency is 8–12 Hz. nation of barbiturate use.
The development of a cycle of tolerance, abuse,
and dependence is the main cause for the with-
barbiturates Medications used as hypnotic agents drawal of barbiturates from common prescription
since the turn of the century; about 50 are avail- use. Barbiturates can also depress respiration and
able commercially. Since the 1960s, barbiturates may exacerbate SLEEP-RELATED BREATHING DISOR-
have largely been replaced by the BENZODIAZEPINES DERS. Another effect of barbiturates is the induc-
because the latter have less potential for drug tion of microsomal enzymes, which degrade or
addiction and a reduced risk of death from over- otherwise alter other medications a patient may
dose. Yet, despite disadvantages of barbiturates, be taking.
they are effective hypnotic agents although rarely Typical side effects of barbiturates include: the
prescribed now. The most commonly prescribed sedative effects, which may impair performance for
barbiturates include amyobarbital (Amytal), pento- up to 24 hours after their administration; excite-
barbital (Nembutal), and secobarbital (Seconal). ment, with an intoxicated or euphoric feeling;
Barbiturates depress the central nervous system and irritability and temper changes. These effects
and therefore can be very toxic in high doses, pro- are paradoxical in that barbiturates can induce
ducing coma and even death. Clinically they produce excitement rather than sedation; they are a more
a range of effects from mild sedation through sleep common problem in the geriatric age group (see
induction. Phenobarbital is commonly used as an ELDERLY AND SLEEP). (See also HYPNOTICS.)
effective anticonvulsive agent. Short-acting, intrave-
nous barbiturates are used for general anesthesia.
Hypnotic barbiturates have profound effects bariatric surgery Intended to promote weight
upon sleep. They decrease SLEEP LATENCY, reduce loss in those with extreme (morbid) obesity. Mor-
the number of sleep stage shifts to WAKEFULNESS, bid obesity is defined by a body mass index (BMI)
and reduce stage one sleep (see SLEEP STAGES). The of 40 or more. BMI is calculated by dividing body
drug also increases the amount of fast EEG beta weight in kilograms (2.2 pounds per kilogram)
activity throughout the sleep recording. SLOW WAVE by the square of height in meters (39.37 inches
SLEEP is generally reduced in amount; however, per meter). Someone standing 66 inches tall and
phenobarbital sometimes increases stage four sleep weighing 211 pounds would, therefore, have a
in healthy individuals. The REM sleep latency BMI of 34.1.
is increased, and there is reduction in the total Because complications of bariatric surgery are
amount of REM sleep, the number of REM sleep common (over 10 percent), patients are required to
cycles, and the density of rapid eye movements meet stringent requirements to qualify for this sur-
during REM sleep. gery. These include either a BMI over 40 or a BMI
32
beds 33

between 35 and 39.9 plus a serious obesity-related This basic rest-activity cycle is believed to be
health problem such as diabetes, heart disease, or determined by a central nervous system mecha-
severe SLEEP APNEA. A high prevalence of night eat- nism. Studies in cats have shown that lesions in
ing syndrome, binge-eating disorder, and related the basal forebrain of cats will alter the period of
psychological disorders has been found among the sleep-wake cycle but do not alter the basic
those who seek bariatric surgery. rest-activity cycle, suggesting that the underlying
Operations are of three types: (1) those that basic rest-activity cycle is independent of sleep and
reduce the absorption of nutrients (malabsorption); wakefulness.
(2) those that reduce the size of the stomach (stom-
ach stapling or banding); (3) combinations of the
two (Roux-en-Y gastric bypass, sleeve gastrectomy, beds There was probably a time in the early
others). Gastric bypass is the best-established and Neolithic period when a transition occurred from
most common surgical procedure to treat obesity sleeping on the ground to sleeping in a bed. The
in the United States. change to sleeping in a bedroom occurred around
Clinical improvement or resolution has been the time of the Sun King of France, Louis XIV, who
reported in 85 percent of patients with obstructive developed a separate room for sleeping, which was
sleep apnea and other comorbidities. in a very prominent position in his palace. Prior to
that time, most people would sleep in a commu-
nal room. Louis XIV would hold court while lying
baseline Term describing the usual or normal in his bed, which was placed in a key position in
state of an investigative variable. The baseline state his palace so it was more like a public room. At
implies that there is a change in amplitude in the that time, beds became more elaborate and were
variable, typically due to an experimental manipu- often regarded as prized items to be passed down
lation. The term is often used for the first night of through the family.
POLYSOMNOGRAPHY prior to the application of a CON- The kings and queens of ancient days often had
TINUOUS POSITIVE AIRWAY PRESSURE device (CPAP). varied types of beds, ranging from flat tables with
wooden headrests to cushions on the floor or beds
encrusted with gold and jewels. In the Middle
basic rest-activity cycle (BRAC) In 1960, NATHAN- Ages, the typical bed consisted of pallets of straw;
IEL KLEITMAN first suggested that a cycle of activity however, the wealthy developed ornate canopied
and rest occurs throughout a 24-hour period. His beds with thick hangings to prevent drafts in oth-
original suggestion was based upon recognizing a erwise austere castles.
periodicity in the feeding intervals of infants. Kleit- Nowadays, beds are used for a variety of activi-
man had noticed that there were four cycles of ties, including writing, reading, watching television,
feeding and rest during the day, and five at night. and sexual intimacy, as well as sleeping. Charles
Similar cycles of behavior have been demonstrated Darwin is reported to have written his Origin of
in adults for many activities, such as eating, drink- Species while lying in bed, and Benjamin Franklin
ing and smoking. The NREM-REM SLEEP CYCLE of is reported to have had four beds in his bedroom
approximately 90 minutes in nocturnal sleep and so he could move to a fresh bed whenever he felt
the cycle of alertness as determined by pupillary the need. Lawrence of Arabia is reported to have
measures are other examples. usually slept in a sleeping bag, and Charles Dickens
The periodicity of the basic rest-activity cycle rearranged the bed so that the head was always
may vary among species and appears to be 23 min- pointing to the north.
utes in cats, which correlates with the self-feeding In recent years, the bed has undergone some
cycle as well as the non-REM-REM sleep cycle. The modern changes. Mattresses have been improved
longer cycle of 72 minutes has been determined with the use of inner springs. The more typical
in monkeys. The human basic rest-activity cycle is single-sized (twin) or full bed has given way to
approximately 96 minutes in adults. queen- or king-size beds.
34 bedtime

It is evident that if someone needs to sleep, he or is improved if they sleep on their sides. (See also
she can sleep on any surface. During wartime, sol- SLEEP HYGIENE.)
diers have slept under the most arduous conditions
in trenches, exposed to the weather and the noise
of gunfire. In many primitive cultures, the bed bedtime The time when an individual attempts
consists of a matting placed on the floor of a room to fall asleep, not the time when an individual gets
inside a dwelling or even on the ground exposed to into bed, which may not be the same. Typically,
the environment. bedtime is associated with the time that the bed-
For most westerners, selecting a bed or a pillow room light is turned off in anticipation of sleep.
is a matter of personal preference. However, certain Especially for young children, bedtime rituals
physical concerns, such as height, should be taken are thought to ease the transition from WAKEFUL-
into consideration; very tall or heavyset persons NESS to sleep. Activities to help the child wind
may need larger beds to comfortably accommodate down from wakefulness to sleep include soft music,
their body size. The firmness or softness of a mat- such as lullabies, either prerecorded and played on
tress is also a matter of taste. (See SLEEP SURFACE.) a CD or MP3 player or sung by a parent, or reading
Whether or not sheets are used on a bed, as well or telling a story. Children or adults may find that
as the type of material (cotton, satin, combination taking a bath immediately before bedtime can pro-
fabrics), is another matter of personal taste, as well duce relaxation and assist the ability to fall asleep.
as whether both a bottom and top, or just a bottom, The ideal bedtime is tied to the anticipated wake
sheet are used. up time the next morning. Thus, on a weekday
Since persons adapt to their typical bed, a change bedtime may be earlier than over the weekend.
in a bed may require a period of adjustment. Hence Consistency in the precise bedtime, however, helps
vacationers will complain they failed to get a good to regulate sleep and wakefulness. Too wide a
night’s sleep, even in the most comfortable bed in variation in bedtime hours—say, from 11 P.M. for
the finest hotel, simply because the bed is unfamil- adults on a workday night to 1 or 2 A.M. on week-
iar. Similarly, infants changing from a crib to a bed end nights, or for children from 8 P.M. on a school
for the first time may require a period of time to night to 11 P.M. on a weekend night—may make
adjust to the new bed and mattress. adjusting to the weekday bedtime hour difficult
If someone has difficulties initiating sleep, it on Sunday night. The resulting difficulty in falling
may be better to restrict the number of non-sleep- asleep on Sunday night is often called SUNDAY NIGHT
related activities that are associated with the bed. INSOMNIA, and the difficulty awakening on Mon-
For example, children who have difficulty falling day morning is called the MONDAY MORNING BLUES.
asleep may need to have distracting toys or books Too much variation in bedtime or waketime may
removed from their beds, or from the area imme- cause a form of INSOMNIA called INADEQUATE SLEEP
diately surrounding the bed. HYGIENE, if mild, or IRREGULAR SLEEP-WAKE PATTERN,
Finding a comfortable position in bed for sleep- if severe.
ing can be influenced by such factors as pregnancy Bedtimes for a young child have to be set by the
or back problems. During pregnancy, it may be parent or caretaker, as these children are too young
necessary to use pillows under the stomach and to understand the need to ensure an adequate
between the knees and thighs to enable a woman duration of sleep. If the parent does not establish
to sleep on her side, a more comfortable position appropriate bedtimes and waketimes, LIMIT-SETTING
for some than sleeping on the back. A larger bed SLEEP DISORDER may result.
may also help the pregnant woman to spread out If a child finds a particular bedtime ritual help-
more as her increasing size makes a smaller bed ful in getting to sleep, such as clutching a special
uncomfortable. Those with back problems might stuffed animal or a blanket, using a night-light in
be in less agony if they avoid sleeping on their the room, or listening to a particular kind of music,
stomachs and sleep on a firm surface, and those it may be helpful to bring those props along when
with breathing problems might find their breathing sleeping away from home for any period of time.
benign neonatal sleep myoclonus 35

But if a particular bedtime ritual becomes a major percent of children with the abnormal encepha-
endeavor and sleep is markedly disturbed without lographic pattern. A typical pattern consists of
it, then a form of insomnia called SLEEP ONSET ASSO- focal spikes that occur at a rate of five to 10 per
CIATION DISORDER may result. minute, which can be present during WAKEFULNESS
and REM sleep but increase in frequency during
non-REM sleep. In non-REM sleep, the manifesta-
bed-wetting See SLEEP ENURESIS. tions can become generalized, causing the clinical
seizures. In addition to the focal spikes, there can
be spike activity, with slow waves, that appears like
behavioral treatment of insomnia The use of the more typical spike and slow wave pattern char-
nonpharmacological techniques to improve night- acteristic of absence or petit mal epilepsy.
time sleep. Behavioral treatments can be useful for Benign epilepsy with Rolandic spikes may have
most patients who have INSOMNIA, even if it is due a hereditary predisposition and usually is a benign
to a physical or organic cause. However, these treat- form of epilepsy, lasting only about four years. Its
ments are most useful for the psychophysiological course appears to be independent of whether the
forms of insomnia or insomnia related to psychiat- disorder is treated or not.
ric disorders, particularly ANXIETY DISORDERS. The clinical features of the epilepsy include gen-
Behavioral treatments include SLEEP HYGIENE, eralized tonic-clonic seizures that occur in about 25
specific sleep behavior programs, RELAXATION EXER- percent of patients; more commonly, focal seizures
CISES to reduce arousal, and techniques to reduce involve the face, with twitching on one side and
excessive rumination during sleep, including COGNI- sometimes jerking movements of a limb.
TIVE FOCUSING, SYSTEMIC DESENSITIZATION, PARADOXI- If a treatment is required, phenytoin is regarded
CAL TECHNIQUES, and SLEEP RESTRICTION THERAPY. as the most effective anticonvulsant and is pre-
There is an increase in the use of behav- ferred over the use of BARBITURATES. (See also EPI-
ioral techniques in the management of chronic LEPSY, SLEEP-RELATED.)
insomnia as physicians become warier of hypnotic
medications. In fact, hypnotic medications are
now recommended only for transient use, particu- benign epileptiform transients of sleep (BETS)
larly in patients who have situational or transient Small, sharp EEG waves or spikes that may appear
insomnia. Behavioral techniques get to the source during nonrapid eye movement (NREM) sleep.
of the sleep disturbance and prevent the continua- They usually originate in the temporal of frontal
tion of poor practices that maintain the insomnia. lobes of the brain. Though resembling the abnor-
Typically these techniques are utilized along with mal waves associated with epilepsy, they have no
other treatments, particularly in patients with PSY- association with seizures.
CHIATRIC DISORDERS who may need specific medica-
tions to treat the psychiatric disorders. (See also
AUTOGENIC TRAINING, BIOFEEDBACK.) benign neonatal sleep myoclonus An abnormal
form of jerking that occurs in newborn infants.
This asynchronous jerking (MYOCLONUS) occurs
Benadryl (diphenhydramine) See ANTIHISTAMINES. primarily during quiet or SLOW WAVE SLEEP, in clus-
ters of four or five at a time, and recurs approxi-
mately once every second throughout sleep. Each
benign epilepsy with Rolandic spikes (BERS) An myoclonic episode lasts between 40 and 300 mil-
unusual form of epilepsy that occurs primarily liseconds and causes jerking of the arms or legs,
during non-REM sleep (see SLEEP STAGES). This particularly the distal muscle groups. More major
disorder, which is more common in children, has movements can cause the whole body to move.
an onset between four and 13 years of age, and Usually the jerks occur asynchronously in a pattern
produces clinically-obvious SEIZURES in about 60 that varies among infants.
36 benign snoring

This jerking usually lasts for only a few days or, epines and GABA is mediated through the ben-
at the most, a few months. It always has a benign zodiazepine receptors, and that this interaction is
course, and its cause is unknown. It can affect both important in the induction and maintenance of
male and female infants and usually occurs within sleep.
the first week of life. No treatment is necessary
since this disorder always spontaneously resolves.
There is no evidence of any underlying bio- benzodiazepines Benzodiazepines were first
chemical or neurological abnormality. introduced in the 1960s, primarily for their anti-
Benign neonatal sleep myoclonus needs to be anxiety effect. The first agent to be introduced was
differentiated from neonatal epileptic SEIZURES that chlordiazepoxide, which had little hypnotic effect
most commonly occur in association with bio- but appeared to be an effective antianxiety agent.
chemical or infective causes. Drug withdrawal can The benzodiazepines were preferred over the previ-
also be a cause of similar movements. ously used barbiturate sedative medications because
Other forms of jerking, such as infantile spasms, of a decreased tendency to produce fatal central
commonly occur after the first month of life and nervous system depression, drug abuse, and toxic
therefore can be easily differentiated from benign side effects. The term “benzodiazepine” refers to the
neonatal sleep myoclonus. Infantile spasms also group structure, which is composed of a benzene
have a specific electroencephalographic pattern ring fused to a seven-membered diazepine ring.
termed hypsarrhythmia, which does not occur in The first primarily hypnotic benzodiazepine,
benign neonatal sleep myoclonus. introduced in 1970, was flurazepam. The three
Additional movement disorders that occur dur- major benzodiazepine hypnotic agents currently
ing sleep include the benign infantile myoclonus in use in the United States are the long-acting
of Lombroso and Fejerman, which usually appears flurazepam (Dalmane), the intermediate-acting
after the third month of life and during wakeful- temazepam (Restoril) and the short-acting tri-
ness, not during sleep. PERIODIC LIMB MOVEMENT azolam (Halcion).
DISORDER is typically seen in older children and In addition to their hypnotic effect, benzodi-
adults; the movements are of longer duration and azepines are also effective muscle relaxants, anti-
are not true myoclonic episodes. The FRAGMENTARY epileptic medications, and can be used to induce
MYOCLONUS of non-REM sleep produces a similar general anesthesia. Other benzodiazepine hypnot-
twitch-like muscle jerk; however, this disorder ics commonly used outside of the United States
persists during non-REM sleep and is not typically include flunitrazepam, nitrazepam, brotizolam,
associated with observable movements such as is midazolam, and quazepam.
seen in benign neonatal sleep myoclonus. The benzodiazepine effect on the waking EEG is
characterized by a decrease in ALPHA ACTIVITY with
an increase in the low-voltage, fast beta activity. The
benign snoring See PRIMARY SNORING. increase in beta activity appears to correlate with
the antianxiety effects of the benzodiazepines.
In general, the benzodiazepines tend to decrease
benzodiazepine receptors Specific receptors for SLEEP LATENCY and reduce the number of awaken-
the benzodiazepine medications appear to exist in ings and the amount of wakefulness that occurs
different areas of the central nervous system, pri- during the major sleep episode. The amount of
marily in the cerebral cortex. These receptors are stage one sleep is usually decreased and the time
associated with GAMMA-AMINOBUTYRIC ACID (GABA) spent in non-REM stage two sleep is increased. The
receptors, and it appears that the BENZODIAZEPINES amount of stage three and four (slow wave) sleep
modulate GABAergic transmission. It is believed is reduced as is the total amount of REM sleep.
that there may be two types of benzodiazepine REM sleep latency is usually increased and the fre-
receptor, although this is unclear. However, it quency of the rapid eye movements during REM
appears that the interaction between benzodiaz- sleep is reduced.
benzodiazepines 37

The effect of benzodiazepines on sleep gradually short-term insomnia and are best avoided in
diminishes over a few nights of consecutive use. the management of long-term chronic insomnia.
If the medication is abruptly stopped after several Transient forms of insomnia, such as those due to
weeks of chronic use there may be a REBOUND JET LAG or SHIFT-WORK SLEEP DISORDER, and sleep
INSOMNIA that typically lasts one or two nights. This disturbance associated with acute situational stress
effect can be minimized by instituting a gradual or anxiety, for example an ADJUSTMENT SLEEP DIS-
withdrawal of medication. ORDER, can also be helped by a short course of a
The benzodiazepines appear to have their central hypnotic benzodiazepine.
nervous system effect by increasing neural inhibi-
tion that is mediated by gamma-aminobutyric acid Flurazepam (Dalmane)
(GABA). The safety of the benzodiazepine hypnot- A long-acting benzodiazepine hypnotic agent. The
ics over the barbiturates may be because of this medication is available in 15 and 30 milligrams,
effect upon the GABA inhibitory neurotransmit- and a typical dose is 15 or 30 milligrams before bed-
ters, whereas the barbiturates have their effect by time. Flurazepam reduces sleep latency, increases
inhibiting excitatory neurotransmitter action. total sleep time, and reduces intermittent wakeful-
The benzodiazepines have a slight effect on ness. Subjective reports indicate that flurazepam
suppression of respiration and are particularly can improve sleep quality, depth, and duration.
contraindicated in the treatment of patients with The most pronounced effects of flurazepam can be
SLEEP-RELATED BREATHING DISORDERS. There are demonstrated for the first one or two nights, and
only minor cardiovascular effects of the benzodi- longer term studies have shown improved sleep for
azepines, such as reduction of blood pressure and at least four weeks.
increase in heart rate. Flurazepam has a long-acting metabolite, desal-
The effectiveness of the benzodiazepine hyp- kylflurazepam, which has a half-life of between 40
notics depends upon their rapidity of onset of and 103 hours. The hypnotic effects of flurazepam
action, which is effected by absorption and pas- are partly related to the activity of this metabolite
sage through the blood brain barrier. Ideally the and therefore residual effects are likely; accumula-
benzodiazepine hypnotics should be eliminated by tion of the metabolite can occur with continuous
the next morning; however, a slow rate of elimi- ingestion. Accumulation is of particular concern in
nation and metabolism of long-acting metabolites the elderly in whom excretion of the drug may be
may be a disadvantage of some benzodiazepine slowed. Conversely, the long-acting effect may be
hypnotics, such as flurazepam. Untoward effects useful in some patients, who have a high degree
of the benzodiazepines include light-headedness, of anxiety, where mild daytime sedation is useful.
fatigue, reduced reaction time, motor incoordina- However, the adverse effects of flurazepam are pri-
tion, ataxia, and impaired mental and psychomo- marily related to the excessive daytime sedation.
tor functions. There can be confusion, dysarthria,
retrograde amnesia, dry mouth, and a bitter taste. Temazepam (Restoril)
Benzodiazepines may interact with alcohol to pro- An intermediate-acting benzodiazepine hypnotic
duce more severe sedation, and this effect of the medication used primarily for the treatment of
benzodiazepines may be most prominent in the insomnia. The majority of patients who take
elderly. temazepam find that they initially have a good or
Benzodiazepines have a low incidence of abuse very good response; however, there is not a consis-
and dependency; however, increasing dosages and tently beneficial response. This drug is processed in
the development of a HYPNOTIC-DEPENDENT SLEEP two forms, one with a soft gelatin capsule, which
DISORDER can occur. enhances the onset of action and therefore is of
The benzodiazepines are most commonly used most benefit for sleep onset insomnia, and a hard
for the treatment of either insomnia related to gelatin capsule form, which has a slower rate of
anxiety or PSYCHOPHYSIOLOGICAL INSOMNIA. The absorption and therefore daytime sedative effects
medications are preferably used for transient or can occur. The soft capsule form is currently avail-
38 benzodiazepines

able only in Europe; the hard capsule form is avail- Clonazepam (Klonopin)
able in the United States. Temazepam is available in A long-lasting benzodiazepine commonly used for
15 or 30 milligram capsules, and the usual dose is the treatment of epilepsy. However, clonazepam is
either 15 or 30 milligrams taken before bedtime. also used for the treatment of some sleep disorders,
Polysomnographic studies have demonstrated such as periodic limb movement disorder and REM
that temazepam produces a reduced sleep latency SLEEP BEHAVIOR DISORDER.
and increased total sleep time. The number of The main side effects of clonazepam are drowsi-
waking episodes is decreased. The hypnotic effects ness, sleepiness, fatigue, and lethargy. Incoordina-
of temazepam appear to be reduced after several tion, ataxia, dizziness, and behavioral disturbances
nights of continuous usage; however, benefits have have also been described.
been demonstrated up to at least five weeks. Clonazepam is available in 0.5, 1, and 2 mil-
The most common side effects of temazepam are ligram tablets. The usual starting dose is 0.5
due to the residual effects of the medication at or milli gram and the usual maintenance dose is 1
soon after the time of awakening in the morning. milligram.
These effects are the usual sedative effects of the
benzodiazepine hypnotics. Alprazolam (Xanax)
A benzodiazepine that has been used for the treat-
Triazolam (Halcion)
ment of anxiety and is effective in suppressing
A short-acting benzodiazepine hypnotic medica-
panic attacks.
tion used for the treatment of insomnia. Triazolam
is available in tablets of 0.0625, 0.125, and 0.25
Diazepam (Valium)
milligram. The rapid onset of action is particularly
useful for sleep-onset insomniacs, and its short A benzodiazepine that is utilized as a sedative
half-life of 2.6 hours is beneficial in preventing agent. It has little hypnotic properties, although it
daytime sedation. Patient studies have generally has been demonstrated to be effective in the treat-
shown a benefit on sleep latency and the quality of ment of insomnia due to anxiety disorders. Diaz-
nighttime sleep; however, early morning awaken- epam has a long half-life, and in the elderly it may
ing may show little improvement with triazolam. accumulate and produce daytime effects, such as
Polysomnographic studies have demonstrated lethargy and sleepiness. Diazepam is used primar-
a reduction in SLEEP LATENCY, an increase in total ily for sleep disturbances associated with anxiety
sleep time, and reduced wake time during the disorders and is rarely used today for its hypnotic
night. SLEEP EFFICIENCY is increased. properties.
Triazolam can improve alertness during the day
following the night of administration, as demon- Nitrazepam (Mogodon)
strated by MULTIPLE SLEEP LATENCY TESTING. How- A benzodiazepine hypnotic medication used for
ever, there are also reports of triazolam increasing the treatment of INSOMNIA. It is not available in the
anxiety, and retrograde amnesia can occur, but United States but is commonly used in Europe.
typically with the 0.5 milligram dosage. The rec- Nitrazepam has been shown to increase total
ommended dosage for geriatric patients is 0.125 sleep time and reduce the number of nocturnal
milligram or less per night. awakenings. There is also a reduction in body
Triazolam has also been shown to be effective movement during sleep. The sleep stages are
in a variety of sleep disorders other than insomnia, altered by nitrazepam, with an increase in SPINDLE
such as suppression of the parasomnia activity, sleep and spindle rate, and electroencephalographic
SLEEP TERRORS, and somnambulism (SLEEPWALK- beta activity. Total REM sleep is initially decreased
ING), for instance. It also appears to be an effective by nitrazepam with an increase in the REM sleep
agent for treatment of PERIODIC LIMB MOVEMENT latency and a reduction in REM density. There is
DISORDER, particularly when it is associated with also an increase in electroencephalographic beta
EXCESSIVE SLEEPINESS. activity during REM sleep.
biofeedback 39

bereavement It is not unusual for the death of a tions, such as BARBITURATES and BENZODIAZEPINES.
loved one to be the precipitating cause of SHORT- Beta activity, when seen in association with high
TERM INSOMNIA. If a spouse with whom one has ELECTROMYOGRAM (EMG) activity and a low voltage
shared a bed or a bedroom has died, a person may mixed frequency ELECTROENCEPHALOGRAM (EEG), is
find it hard to fall asleep alone. This type of short- indicative of wakefulness. With relaxed wakeful-
term insomnia, an ADJUSTMENT SLEEP DISORDER, ness, the EEG frequency slows, and if the eyes are
usually resolves itself within a few weeks. Contin- closed, alpha activity of 13 hertz or lower is typi-
ued insomnia may produce conditioned associa- cally seen. (See also ALPHA RHYTHM.)
tions and lead to a PSYCHOPHYSIOLOGICAL INSOMNIA.
Bereavement is one indication for the use of short-
term HYPNOTICS to prevent such a conditioned in BETS See BENIGN EPILEPTIFORM TRANSIENTS OF SLEEP.
somnia from developing. Coping with the bereave-
ment may be helped by joining a bereavement
group or consulting with a therapist. biofeedback Also known as mind-body therapy,
biofeedback uses a variety of sensors that detect
changes in activity such as muscle tension, heart
Berger, Hans The first person to measure and rate, skin temperature, and blood pressure and
record brain electrical activity, Hans Berger (1873– then transmit this information to the brain in order
1941) reported the first human ELECTROENCEPHA- to help you gain control over your body. For exam-
LOGRAM (EEG) in 1929. Berger began to study ple, a biofeedback specialist will use feedback from
electrical activity in animals in 1910 at a hospital in a variety of monitoring procedures and equipment
Germany. In 1924, he first studied electrical activity to try to teach you how to control certain involun-
in the brains of humans, particularly of those who tary body responses. Once you learn to recognize
had skull defects where the needles could be placed and control these responses, you can use biofeed-
directly on the surface of the brain. His original back to help treat a wide range of mental and
report of alpha waves, recorded with the patient’s physical health problems such as headaches, high
eyes closed, was presented in 1929. The presence blood pressure, asthma, and CARDIAC ARRHYTHMIAS.
of alpha waves did not find general recognition Biofeedback may also help you relax in order to
until 1933, when Berger’s work was publicized by fall asleep. An ELECTROMYOGRAM (EMG) using elec-
the physiologist Lord Adrian, who called the ALPHA trodes to measure muscle tension can alert you to
RHYTHM the Berger rhythm. muscle tension so you can learn to recognize the
Berger’s discovery led to the subsequent recog- feeling early on and try to control it right away. An
nition of differences in the electroencephalogram EMG may also be used to treat illnesses in which
during WAKEFULNESS and sleep, and this forms the the symptoms tend to worsen under stress, such
basis of the electroencephalographic determination as asthma and ulcers. Another biofeedback tech-
of SLEEP STAGES. nique uses skin temperature, which is measured
by sensors that are attached to your fingers or feet.
Your skin temperature drops when you are under
Berger rhythm See ALPHA RHYTHM. stress and a low reading can prompt you to begin
relaxation techniques. Temperature biofeedback
can also help treat certain circulatory disorders,
BERS See BENIGN EPILEPSY WITH ROLANDIC SPIKES. such as Raynaud’s disease, or reduce the frequency
of MIGRAINES. Galvanic skin sensors measure the
activity of your sweat glands and the amount of
beta rhythm Electroencephalographic frequency perspiration on your skin, alerting you to ANXI-
of 13 to 35 HERTZ that is typically seen during ETY. This information can be useful in treating
alert wakefulness. This activity may be associated emotional disorders such as phobias, anxiety, and
with the ingestion of a variety of different medica- stuttering.
40 biological clocks

biological clocks The periodic oscillation that bodyrocking One of three disorders—bodyrock-
occurs in a wide variety of biological systems; the ing, HEADBANGING, and HEAD ROLLING—that involve
frequency of the oscillations serves an internal tim- repetitive movement of the head and occasionally
ing system. Virtually all plants and animals have of the whole body. These disorders are now known
an internal timing system, or biological clock, and under the collective name RHYTHMIC MOVEMENT
there may be several of these processes that control DISORDER.
different aspects of the physiology of the biological Bodyrocking may occur during times of rest,
systems. The biological clocks measure time and drowsiness or sleep, as well as during full wake-
synchronize an organism’s internal processes with fulness. It is usually performed on the hands and
daily environmental events. The site of the major knees with the whole body rocking in an anterior/
biological clock in humans is believed to be the posterior direction, with the head being pushed
SUPRACHIASMATIC NUCLEUS (SCN). (See also CHRO- into the pillow.
NOBIOLOGY, CIRCADIAN RHYTHMS.) The disorder most commonly occurs in chil-
dren below the age of four years, with the high-
est incidence at six months of age. Treatment is
biorhythm A recurrent pattern of change in a usually unnecessary when the condition occurs in
physiological variable, such as a CIRCADIAN RHYTHM. infancy as it typically disappears within 18 months.
However, the term biorhythm more commonly has Bodyrocking can persist into older childhood,
become associated with the astrological prediction adolescence, and, rarely, adulthood. Behavioral or
of life events and is not scientifically based. Bio- pharmacological treatment may then be required.
rhythm is rarely used in CHRONOBIOLOGY; the term (See also INFANT SLEEP DISORDERS.)
biological rhythm is preferred.

body temperature See TEMPERATURE.

blue light It has long been known that the

light-dark cycle sets the biological clock and, brachialgia parasthetica nocturna See CARPAL
consequently, those biological rhythms, including TUNNEL SYNDROME.
sleep-WAKEFULNESS, that are governed by the clock.
This effect of light depends on specialized pathways
of the brain. These pathways use specialized, non- bradycardia When someone’s heart beat is below
image-forming cells of the retina and light-sensi- 60 beats a minute. A normal heart beats between
tive pigments (cryptochromes, melanopsin) that 60 to 100 times a minute. If a heart beats fewer
are maximally sensitive to blue light (wavelength, than 50 times a minute, enough blood may not be
460 nm). Therefore, it is blue light that has the sent to the organs, which can lead to various symp-
strongest effect on the timing of circadian rhythms, toms including sleep disturbances, heart palpita-
nocturnal melatonin secretion, alerting, heart rate, tions, fatigue, dizziness, and shortness of breath.
and thermoregulation.

brain-wave rhythms A lay term that is often used

body clock The everyday cycle of sleep and to describe electroencephalographic patterns. EEG
WAKEFULNESS is systematized by the body’s clock. wave is the preferred term. (See also ELECTROENCE
Practically all plants and animals have an internal PHALOGRAM [EEG]).
timing system. A plant experiment conducted by
JEAN-JACQUES D’ORTOUS DE MAIRAN in 1729 was
significant because it demonstrated the presence of breathing disorders, sleep-related This term
biological rhythms even when the ENVIRONMENTAL applies to breathing disorders that are induced or
TIME CUES of light and dark were missing. exacerbated during sleep. Although many differ-
bruxism 41

ent respiratory disorders are affected by sleep, the from behavioral techniques, such as weight loss, the
three main syndromes associated with sleep are use of RESPIRATORY STIMULANTS, the use of mechani-
the OBSTRUCTIVE SLEEP APNEA SYNDROME, CENTRAL cal devices to prevent upper airway obstruction,
SLEEP APNEA SYNDROME, and the CENTRAL ALVEOLAR or assisted ventilation, to surgical treatments (see
HYPOVENTILATION SYNDROME. SURGERY AND SLEEP DISORDERS) ranging from TONSIL-
The obstructive sleep apnea syndrome is char- LECTOMY to TRACHEOSTOMY, in order to relieve the
acterized by UPPER AIRWAY OBSTRUCTION that occurs upper airway obstruction.
during sleep, leading to a change in the arterial
blood gases. HYPOXEMIA produces cardiac effects
and disrupts sleep, leading to the development of bromocriptine (Parlodel) A medication that is
EXCESSIVE SLEEPINESS during the day. used to suppress the production of GROWTH HOR-
Central sleep apnea syndrome is characterized MONE in the treatment of ACROMEGALY, a disorder
by cessation of breathing that occurs without upper characterized by an enlargement of the skeletal and
airway obstruction and leads to blood gas changes soft tissues of the body. Individuals with acromeg-
that also can produce disrupted sleep and daytime aly have an increased incidence of SLEEP-RELATED
sleepiness. BREATHING DISORDERS, particularly OBSTRUCTIVE
Central alveolar hypoventilation syndrome is SLEEP APNEA SYNDROME.
due to shallow breathing that occurs during sleep,
with associated blood gas changes. Typically there
is the development of daytime sleepiness but some- bruxism A stereotyped movement disorder char-
times a complaint of INSOMNIA. acterized by grinding or clenching of teeth that can
The sleep-related breathing disorders can occur occur during sleep or WAKEFULNESS. When bruxism
at any age, from infancy through old age, and can happens predominantly during sleep, it is termed
have a spectrum of severity ranging from very mild SLEEP BRUXISM. Bruxism can be associated with
to life threatening. discomfort of the jaw and may produce abnormal
Treatment varies depending upon the primary destruction of the cusps of the teeth.
cause of the respiratory disturbance but can range
C
caffeine Probably one of the first medications canthus, one electrode is placed slightly above the
used for the treatment of EXCESSIVE SLEEPINESS, outer canthus, and the other electrode slightly
caffeine is used to increase the level of alertness below the outer canthus, in order to detect both
and is usually taken in the form of drinks, most vertical and horizontal movements. (See also ELEC-
commonly tea, coffee, cola, or energy drinks. A TROOCULOGRAM [EOG].)
typical cup of coffee contains about 100 milligrams
caffeine, a bottle of cola drink about 50 milligrams.
Also, OVER-THE-COUNTER MEDICATIONS containing carbamazepine (Tegretol) It was first employed
caffeine are available (Vivarin, 200 milligrams caf- as an antiepileptic agent but has had a variety of
feine; NoDoz, 100 milligrams caffeine). uses since that time. It is still a major drug for the
Caffeine can disturb the quality of nighttime treatment of epilepsy, particularly partial complex
sleep if ingested prior to bedtime. Sleep onset and and generalized tonic-clonic epilepsy. Carbamaze-
sleep maintenance difficulties are not uncommon pine is also used for the treatment of some sleep
due to the effects of caffeine; even some individu- disorders. It is chemically related to the tricyclic
als who believe that they sleep well after a cup of antidepressants.
coffee have been shown to have increased sleep Its primary toxicity is hematological, with the
disturbance with frequent awakenings and reduced potential for producing aplastic anemia and agran-
total sleep time. ulocytosis. Initial reports of the common occur-
Caffeine is not recommended for the treatment rence of these hematological effects have largely
of daytime tiredness or sleepiness. It has a general been displaced and such adverse reactions are
stimulant effect that can produce cardiac stimula- now considered to be rare. Carbamazepine has
tion with palpitations and HYPERTENSION as well as been used for the treatment of pain disorders and
increased nervousness, irritability, and tremulous- is occasionally used for the management of REST-
ness. Other more effective STIMULANT MEDICATIONS, LESS LEGS SYNDROME. It is also used as a treatment
such as methylphenidate or AMPHETAMINES, are of NOCTURNAL PAROXYSMAL DYSTONIA, which is not
available for the treatment of sleepiness in patients thought to have an epileptic basis even though it is
who have disorders of excessive sleepiness. responsive to this anticonvulsive medication.
Withdrawal of caffeine may produce an increased Carbamazepine is available in 100 milligram and
feeling of tiredness and lethargy during the first few 200 milligram tablets, as well as a 100 milligram/5
days, which may lead to resumption of the caffeine milliliter suspension. The usual adult dose is 600
intake. Therefore, excessive caffeine intake may be milligrams per day.
the cause of symptoms of excessive sleepiness.

carbon dioxide Gas produced as a result of body

canthus The corner of the eye. Typically, the metabolism. This metabolic product is eliminated
electrodes associated with measuring eye move- from the body through the lungs during a process
ment are placed just lateral to the outer canthus of of exchange with oxygen from the atmosphere.
each eye. When electrodes are placed at each outer Alterations of ventilation can cause a retention
42
cardiovascular symptoms, sleep-related 43

of carbon dioxide in the body and a reduction of tation of a cardiac peacemaker in order to prevent
blood oxygen. complete cardiac arrest.
Carbon dioxide and oxygen are the two most Another disorder that may be associated with
important blood gases in the regulation of respi- cardiac irregularity is SUDDEN UNEXPLAINED NOC-
ration. The SLEEP-RELATED BREATHING DISORDERS TURNAL DEATH SYNDROME (SUND), which had been
commonly will affect lung ventilation, thereby seen in Southeast Asian refugees, first noted in
producing an increased carbon dioxide level 1977. In this disorder, sudden death occurs during
(HYPERCAPNIA) and a lowering of oxygen (HYPOX- sleep, and a cardiac cause is suspected. Ventricular
EMIA). Some patients with OBSTRUCTIVE SLEEP tachycardia has been detected in the few patients
APNEA SYNDROME may have an increased level of who have been resuscitated.
carbon dioxide detectable during WAKEFULNESS, Patients who have cardiac arrhythmias due
which is in part due to a resetting of the regula- solely to heart disease often have an improvement
tion of ventilation. Most patients with obstruc- in the cardiac irregularity during sleep, particularly
tive sleep apnea syndrome have only a transient during non-REM sleep, when the heart rate slows
elevation of carbon dioxide in association with the and the rhythm becomes more stable. During REM
apneic episodes. SLEEP there can be an exacerbation of cardiac irreg-
Increased levels of carbon dioxide produce a body ularity, particularly during the episode of phasic
acidosis that may be irritating to the heart, produc- rapid eye movement activity. (See also BREATHING
ing CARDIAC ARRHYTHMIAS. An elevated carbon DISORDERS, SLEEP RELATED.)
dioxide level also stimulates ventilation through its
chemoreceptors, thereby causing a lowering of the
level by means of a feedback mechanism. cardiovascular symptoms, sleep-related Symp-
toms that arise from a variety of cardiac disorders,
including those that affect cardiac rhythm and car-
cardiac arrhythmias Heart rhythm irregularities. diac output. The symptoms are primarily discom-
The most common cause of sleep-related arrhyth- fort or pain in the chest, or respiratory difficulty.
mias is OBSTRUCTIVE SLEEP APNEA SYNDROME, which One of the most common symptoms related to
produces a pattern of slowing and speeding up of cardiovascular disease is PAROXYSMAL NOCTURNAL
the heart (brady-tachycardia). This pattern may DYSPNEA, which is shortness of breath related to
be picked up on a 24-hour electrocardiographic recumbency (lying down), which is usually associ-
recording (for instance, during Holter monitoring). ated with sleep. This symptom is indicative of heart
The presence of brady-tachycardia during sleep, failure as a result of either myocardial or valvular
and its absence during WAKEFULNESS, is a character- disease and features difficulty in breathing and a
istic feature of obstructive sleep apnea syndrome. sensation of suffocation that induces the patient to
Other cardiac arrhythmias that can occur in asso- sit up or get out of bed. There may be a sensation of
ciation with the obstructive sleep apnea syndrome needing air, “air hunger,” and persons may need to
include episodes of sinus arrest, lasting up to 15 open a window in order to inspire cooler air. Due
seconds in duration, and tachyarrhythmias, such as to the difficulty in breathing when lying down, a
ventricular tachycardia (see VENTRICULAR ARRHYTH- large proportion of the night may be spent sleeping
MIAS). Cardiac arrhythmias due to obstructive sleep in a semi-reclining or sitting position. The short-
apnea are believed to be a cause of sudden death ness of breath while lying flat is called ORTHOPNEA.
during sleep. Chest pain may occur during sleep. The terms
Other disorders that can produce cardiac irregu- “nocturnal angina” or NOCTURNAL CARDIAC ISCH-
larity during sleep include REM SLEEP–RELATED EMIA have been used to describe the chest pain
SINUS ARREST. This disorder is characterized by that occurs in sleep at night. Precipitation of chest
episodes of cardiac pause, lasting several seconds, pain during sleep may be the result of REM sleep
that occur during REM sleep in otherwise healthy features, such as variability in blood pressure and
individuals. This disorder may require the implan- heart rate. It is also possible that the lowering of
44 carpal tunnel syndrome

blood pressure during SLOW WAVE SLEEP may pre- which typically causes pain and discomfort in the
cipitate coronary artery insufficiency, leading to hands upon awakening. The discomfort in the
angina. hands is exacerbated by the lack of movement of
Sleep disorders, such as the SLEEP-RELATED the hands during sleep, allowing fluid to accumulate
BREATHING DISORDERS, in particular the OBSTRUC- in the sheaves of the tendons in the carpal tunnel.
TIVE SLEEP APNEA SYNDROME, are also believed to be Typically, individuals with carpal tunnel syndrome
a cause of nocturnal angina and cardiac ischemia will shake or rub their hands together in order to
during sleep. CARDIAC ARRHYTHMIAS may also be restore normal sensation, which occurs within a
precipitated by sleep-related breathing disorders few minutes of awakening. Pressure in the carpal
and may induce symptoms of chest discomfort or tunnel presses on the median nerve at the wrist.
shortness of breath. Eventually sensation is lost in the median nerve
Some cardiovascular disorders during sleep are distribution of the hand, and weakness and atrophy
essentially asymptomatic; for example, REM SLEEP- of the muscles occur. The hand often feels swollen,
RELATED SINUS ARREST generally does not have any stiff, clumsy and numb, even throughout the day.
sleep-related symptoms. Individuals who die from The disorder is more commonly seen in people who
SUDDEN UNEXPLAINED NOCTURNAL DEATH SYNDROME are overweight and those who have hypothyroid-
(SUND) are asymptomatic prior to the terminal ism. In mild cases, weight loss or intermittent ste-
event. roid injections into the tendon sheaves in the carpal
Patients with sleep-related cardiovascular tunnel can relieve the symptoms. However, the
symptoms need to undergo electrocardiography most effective treatment is surgical decompression
throughout sleep, in association with POLYSOMNOG- of the carpal tunnel. The lining of the fluid-filled sac
RAPHY, to determine oxygen saturation levels and around the tendons becomes inflamed, swollen and
the presence of sleep-related breathing disorders. thickened and is surgically removed.
Correction of the sleep-related breathing disorders
can reduce symptoms during sleep and reduce the
likelihood of a catastrophic cardiovascular event. Carskadon, Mary A. First woman president of
Patients with REM sleep-related sinus arrest may the North American Sleep Research Society (SRS)
require the insertion of a permanent pacemaker as and cofounder of the Northeastern Sleep Society
a preventative measure. (NESS), Dr. Carskadon (1947– ) is director of
Chest discomfort during sleep may be due to a chronobiology and sleep research at E. P. Bradley
number of different sleep disorders. SLEEP-RELATED Hospital in Providence and an associate professor of
GASTROESOPHAGEAL REFLUX commonly produces psychiatry and human behavior at Brown Univer-
chest discomfort that may be difficult to distinguish sity School of Medicine.
from that of a cardiac cause. Difficulty in breathing Dr. Carskadon obtained her Ph.D. with distinc-
at night is commonly produced by the sleep-related tion in neuro- and biobehavioral sciences from
breathing disorders, such as obstructive sleep Stanford University in 1979. Her dissertation topic
apnea syndrome, CENTRAL SLEEP APNEA SYNDROME was “Determinants of Daytime Sleepiness: Ado-
and CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME. lescent Development, Extended and Restricted
Occasional awakening with the sensation of the Nocturnal Sleep.” A major focus of Dr. Carskadon’s
heart having stopped is not uncommon in patients subsequent research has been the development
who have ANXIETY DISORDERS, PANIC DISORDER, or and application of a standardized measure of day-
SLEEP TERRORS. Choking episodes during sleep can time sleep tendency, the MULTIPLE SLEEP LATENCY
also be seen in patients with the SLEEP CHOKING TEST. Her primary areas of interest continue to be
SYNDROME or LARYNGOSPASM, SLEEP-RELATED. patterns of daytime sleepiness and adolescent sleep
behavior, as well as the exploration of olfactory
sensitivity during sleep. Dr. Carskadon is a Fellow
carpal tunnel syndrome Disorder characterized of the AMERICAN ACADEMY OF SLEEP MEDICINE (for-
by compression of the median nerve at the wrist, merly the American Sleep Disorders Association),
central alveolar hypoventilation syndrome 45

which honored her with the NATHANIEL KLEITMAN at rest); however, in patients with CAHS the tidal
DISTINGUISHED SERVICE AWARD in 1991. volume greatly decreases. The reduction in tidal
volume leads to an increase in the carbon dioxide
level in the blood as well as reduced blood oxygen
cataplexy A sudden loss of muscle power in saturation. This change in the arterial blood gases
response to an emotional stimulus. Cataplexy is (carbon dioxide and oxygen) can produce arousals
typically seen in persons suffering from NARCOLEPSY, that increase respiratory drive. The arousals disturb
which is characterized by EXCESSIVE SLEEPINESS dur- sleep quality and therefore sleep may be character-
ing the day. Cataplexy will usually cause a reduction ized by a complaint of insomnia. If the arousals and
in muscle power, leading either to complete collapse awakenings are frequent enough, excessive sleepi-
or, more typically, a drooping of the head, weakness ness may develop. CAHS is due to an abnormal-
of the facial muscles, weakness of the arms or sag- ity of the central nervous system control of lung
ging at the knees. Cataplexy is most often induced ventilation.
by laughter, but anger, surprise, startle, pride, ela- Other features of sleep-related hypoventilation
tion or sadness can also induce episodes. include morning headaches caused by the change
Cataplexy is an ATONIA (loss of muscle tone) in blood gases during sleep. The sleep-related
that is normal of REM sleep. However, cataplexy breathing disturbance is typically exacerbated
is produced by an emotional change and not due during REM SLEEP when ventilation is entirely
to sleepiness. If episodes of cataplexy are long in dependent upon diaphragmatic function. CARDIAC
duration, typical REM sleep occurs, with the usual ARRHYTHMIAS commonly occur, particularly slowing
change of the EEG activity and associated rapid eye of the cardiac rhythm. There may be tachycardia at
movements. the time of the awakening, leading to premature
Individuals who have pronounced episodes of ventricular contractions. Typically the episodes of
cataplexy may suffer injuries due to a sudden col- sleep-related hypoventilation are long, sometimes
lapse to the ground. Episodes of cataplexy usually several minutes or several hours in duration. The
last a few seconds. If the emotional stimulus con- long episodes of low oxygen saturation are liable to
tinues, a state of continuous cataplexy can occur, induce the development of pulmonary hyperten-
termed STATUS CATAPLECTICUS. Cataplexy can be sion and heart failure, which is more commonly
effectively treated by the use of tricyclic ANTIDEPRES- seen in this disorder than in the OBSTRUCTIVE
SANTS, such as imipramine or protriptyline or the SLEEP APNEA SYNDROME or CENTRAL SLEEP APNEA
serotonin reuptake inhibitors such as fluoxetine. SYNDROME.
The respiratory disturbance in central alveolar
hypoventilation syndrome is exacerbated by obe-
catatonia A rigidity of the limbs so that when sity, which impairs diaphragmatic function.
they are placed in a particular position, that posi- This disorder also occurs in infants and is known
tion is maintained for a long period of time. This by the name “congenital central alveolar hypoven-
is most commonly associated with hysteria or tilation syndrome.” These children are also liable to
schizophrenia. develop pulmonary hypertension and right-sided
heart failure, as well as brain damage due to the
low oxygen saturation. CENTRAL NERVOUS SYSTEM
central alveolar hypoventilation syndrome (CAHS) insults at birth can contribute to the development
A breathing disorder that results in arterial oxygen of acquired central alveolar hypoventilation syn-
desaturation during sleep. CAHS occurs in persons drome, such as infection, brain stem trauma, hem-
with normal mechanical properties of the lungs, orrhage or the presence of brain tumors.
such as intact ribs, muscles and lung fields. During Patients with central alveolar hypoventilation
sleep in healthy individuals there is a normal slight syndrome may also have central or obstructive
reduction in TIDAL VOLUME (the amount of air usu- sleep apneas; however, these are not the primary
ally taken into the lungs during a normal breath cause of the clinical features. The disorder in
46 central nervous system

infants and children may improve as the respira- nerve cells (neurons). Although most of these are
tory system matures; however, some children affected by the states of sleep and WAKEFULNESS,
require artificial ventilation. only a small number are directly concerned with
The incidence of this disorder is not known but sleep as a function. The other nervous system is
it appears to be quite rare. There is some evidence the peripheral nervous system (PNS) comprised of
to suggest that it is more common in males. sensory nerves and motor nerves, sending infor-
Studies of ventilation during wakefulness have mation to the spinal cord, brain, and other parts
demonstrated a nonresponsiveness to elevated of the body.
CARBON DIOXIDE LEVELS or HYPOXIA. The idiopathic
form of central alveolar hypoventilation syndrome
is believed to be due to a defect of the medullary central sleep apnea syndrome Disorder marked
chemoreceptors controlling ventilation. by a cessation of ventilation during sleep, usu-
The nature of this disorder can best be demon- ally associated with oxygen desaturation with an
strated by means of POLYSOMNOGRAPHY. Episodes absence of airflow that lasts 10 seconds or more in
of reduced tidal volume lasting several minutes in adults, 20 seconds or more in infants.
duration are commonly associated with sustained This syndrome is typically associated with the
oxygen desaturation or elevation of carbon dioxide complaint of INSOMNIA, particularly in older adults,
levels. The disorder is exacerbated during REM or a complaint of EXCESSIVE SLEEPINESS during the
sleep; however, in infants it may be at its worst day. Typically, patients will awaken several times
during slow wave sleep. Frequent awakenings at night, often with the sensation of gasping or
and arousals may be associated with the oxygen choking during sleep. Not uncommonly, episodes
desaturation, and MULTIPLE SLEEP LATENCY TESTING of apnea will be asymptomatic, and if the episodes
may demonstrate excessive sleepiness. are frequent enough to cause disruption of much
Patients with this disorder require investigative of the sleep episode, then daytime sleepiness will
testing of respiratory and central nervous system result. In children, central apneas are usually
function. Brain CT scanning, MRI scanning, nerve accompanied by a change in their facial color, such
conduction testing, electromyography, muscle as cyanosis (bluish) or pallor, and there may also be
biopsy, pulmonary function tests and cardiac func- marked changes of the muscle tone with general-
tion tests may be required. Blood tests may demon- ized body limpness.
strate an elevated hemocrit and hemoglobin level Central sleep apnea syndrome is most com-
reflecting POLYCYTHEMIA as a result of the severe monly seen in patients with neurological disorders
HYPOXEMIA. that affect the control of respiration. Spinal cord
Central alveolar hypoventilation syndrome is lesions or lesions of the brain stem commonly will
treated with RESPIRATORY STIMULANTS, for instance, produce central sleep apnea. Ventilation can be
doxapram or almitrine in children and medroxy pro- normal during WAKEFULNESS; however, complete
gesterone, acetazolamide or protriptyline in adults. cessation of breathing can occur during sleep and
Many patients require the use of assisted ventila- the patient may be able to breathe only during
tion either by means of CONTINUOUS POSITIVE AIRWAY AROUSALS or wakefulness. This inability to breathe
PRESSURE, a negative pressure ventilator such as a during sleep has been called ONDINE’S CURSE and, if
cuirass ventilator or, if the disorder is severe enough, left untreated, may have a fatal outcome.
a positive pressure ventilator applied through either If the brain stem and lower neurological control
a TRACHEOSTOMY or a nasal mask. Weight reduction of respiration is intact, patients may have central
is essential for any overweight patient who has cen- apneas that occur in conjunction with CHEYNE-
tral alveolar hypoventilation syndrome. STOKES RESPIRATION, which is characterized by a
crescendo, decrescendo respiratory pattern. Central
apneas usually occur during non-REM sleep, and
central nervous system (CNS) The brain and the regular rhythmical ventilation occurs during REM
spinal cord constitute the CNS, with millions of sleep. Disorders affecting the cerebral hemispheres,
central sleep apnea syndrome 47

such as cerebrovascular disease or cardiovascular APNEA SYNDROME. In some patients, it may be nec-
disorders that produce an increased circulation essary to insert an intraesophageal balloon in order
time, are typically associated with the Cheyne- to measure pressure changes so that obstructive
Stokes pattern of ventilation. Such patients may apneic events can be differentiated from central
have complaints of insomnia due to the arousals apneas, because standard polysomnography may
that are associated with the crescendo ventilatory not clearly differentiate the two disorders.
pattern. Other causes of insomnia must be distinguished
Central apnea is apt to occur in infants who from insomnia due to the central sleep apnea syn-
are prematurely born, or for unexplained reasons drome, particularly in elderly patients. As patients
in the neonatal period. Such central sleep apnea with NARCOLEPSY have an increase