101 QUESTIONS ABOUT SLEEP AND DREAMS

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FRONT COVER
101 QUESTIONS
ABOUT
SLEEP AND DREAMS
Elizabeth A. Mitler
and
Merrill M. Mitler

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©Merrill M. Mitler, Ph.D.
Bethesda, Maryland
Registration Number TX 1 971 268
1986, 1988, 1990, 1993, 1995, 2000, 2002, 2011, 2016
First Edition: November, 1986
Second Edition: September, 1988
Third Edition: September, 1990
Fourth Edition: May, 1993
Fifth Edition: October, 1995
Sixth Edition worldwide web version: January, 2000
Sixth Edition print version: April, 2002; September, 2002
Seventh Edition: January, 2012
Special Edition, March, 2016

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SPECIAL EDITION
March 31, 2016
101 QUESTIONS
ABOUT
SLEEP AND DREAMS
ELIZABETH A. MITLER and MERRILL M. MITLER

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TABLE OF CONTENTS
Foreword 6
William C. Dement, M.D., Ph.D.
Introduction 7
About The Authors 9
Chapter 1. Normal Sleep 11
Questions 1 - 14.
Chapter 2. Dreams 21
Questions 15 - 21.
Chapter 3. Sex 26
Questions 22 - 25.
Chapter 4. Children 29
Questions 26 - 36.
Chapter 5. Sleep And Things You Ingest or Inject 34
Questions 37 - 47.
Chapter 6. Poor Sleep (Too Little or Too Much) 41
Questions 48 - 67.
Chapter 7. Things That Go Wrong in the Night 51
Questions 68 - 101.
Other Resources 72
Index 77

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FOREWORD
The five billion people living on earth go through the cycle of sleep
and wakefulness at least once every 24 hours. Sadly, many, many of
these people do not know the joy of being fully rested and alert after
their sleep. The alternation of wakefulness and sleep is one of the
most fundamental aspects of the human condition. However, it is only
recently, with the advent of highly technological societies, that poor
sleep and substandard levels of wakefulness have been of real interest
to humans. Over the past eons of time, natural selection may have
been gentle on prehistoric people who slept poorly. The major killers
and shapers of evolution were war, natural enemies and pestilence.
These factors were much more influential in deciding who lived to
conceive and care for children than were such disorders as sleep
apnea. However, the main causes of death now are very different than
in prehistoric times.
As we look forward to the 21st century, alertness during the day that
comes from healthful rest during the night can be a major life-or-
death matter -- not only for individual people, but also for whole
populations. We know that most heart attacks and strokes occur
during sleep or just after waking up. Studies indicate that the near
cataclysmic nuclear accidents at Chernobyl and Three Mile Island
were easily avoidable and began when nightshift workers missed or
were confused by warning signals on their control panels. Other
studies show that nightshift workers get very irregular and poor sleep
and, accordingly, have the most difficulty staying alert for long
periods of time. In our present society, it is clear that poor and
unhealthful sleep can lead to lethal medical and industrial
catastrophes. What can we do?
Since about 1953, scientists have been gathering practical knowledge
about how we sleep and what can be done if we do not sleep. Much is
already known that was not even imagined twenty years ago. For
example, sleep is not always safe or good. Alcohol can destroy restful
sleep. There are two periods in the 24-hour day when accidents are
most likely to occur and these are the two periods when the human
body is physiologically most ready for sleep.
This booklet, in a simple Question and Answer format, leads us
through the fascinating story of sleep by posing and answering the

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most common questions about sleep and dreams. The Mitlers' answers
are faithful to solid scientific fact, yet as easy to understand as the
daily newspaper. Earlier editions of 101 Questions About Sleep and
Dreams have been widely read by people with sleep problems,
interested lay people, and as assigned reading for high school and
college students. Truly, no home should be without a copy of '101
Questions'.
William C. Dement, M.D., Ph.D.
Lowell W. and Josephine Q. Berry Professor
Department of Psychiatry and Behavioral Sciences
Stanford University
Director, Sleep Disorders Clinic and Research Center
Stanford University

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101 QUESTIONS ABOUT
SLEEP AND DREAMS
INTRODUCTION
Sleep and dreams have captured the imagination and interest of man
since recorded history. Modern science has discovered much about
what goes on when we sleep and the effects of sleep loss. The
National Commission on Sleep Disorders Research reported to The
United States Congress that approximately 40 million Americans
suffer from chronic problems with sleep and wakefulness, 20 - 30
million people experience intermittent sleep problems, and millions of
others obtain inadequate sleep as a result of their work schedules or
lifestyles. The consequences of these sleep problems are increased
risk of sickness, accidents and death as well as decreased quality of
life. It is for these reasons that the National Institutes of Health
established The National Center for Sleep Disorders Research. The
Center funds research on sleep and sleep disorders, disseminates
information about sleep to the public and fosters improved
communication between governmental agencies on policy issues that
relate to sleep and sleep disorders.
Imagine trying to stay awake for 24 hours straight. Dr. Mary
Carskadon and her colleagues asked a group of people to do just that
and found that they failed to stay awake 278 times. Here is when,
0
10
20
30
40
50
Midnight Noon 10 PM
UNWANTED NAPS
0
2
4
6
8
10
12
Midnight Noon 10 PM
UNEXPLAINEDTRAFFICACCIDENTS

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according to the twelve consecutive 2-hour intervals throughout the
day, those 278 unwanted naps happened. The numbers on the vertical
axis refer to the number of naps that occurred in each of the 2-hour
intervals. The timing of these naps shows when the biological
tendency for humans to fall asleep is the greatest.
Now look at 437,511 times of death from a large series of death
certificates of people who died from medical conditions, such as heart
disease and cancer. The numbers shown on the vertical axis refer to
thousands of deaths. It is easy to see that the peak times when people
succumb to disease seem to coincide with the peak times for sleep.
The timing of 6,052 unexplained traffic accidents indicates that there
is also some relationship between sleep and other types of problems.
The numbers on the vertical axis refer to hundreds of accidents. These
accidents were collected from studies around the world and are the
kind in which investigators could find no drug, alcohol or mechanical
problems.
Because sleep influences such fundamentally important aspects of our
lives as resistance to disease and safety on the roads, all sorts of
people ranging from students, to doctors, to public policy makers are
asking many questions about sleep. How does someone become
familiar with the important personal and public health issues
involving sleep?
The story of sleep and dreams is long and complicated. This book,
however, succinctly answers the most commonly asked questions
about sleep and dreams. Just a glance through '101 Questions' will let
you see why it has become one of the most popular books on the
subject of sleep. Read all over the world, '101 Questions' is also
30
32
34
36
38
40
42
Midnight Noon 10 PM
DISEASE RELATED DEATHS

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available in the German, Greek, Korean and Spanish languages. The
questions are organized in a logical manner that introduces the most
important concepts of modern sleep research and underscores the
challenges to modern society presented by man's biologic need for
sleep. The answers are brief and understandable. The information in
this book will satisfy natural curiosity as well as suggest sensible
courses of action for those with sleep problems. Readers who find that
they want more information than is offered it this book are referred to
sites on the world wide web and several more advanced texts on the
subject of sleep, sleep disorders, shift work and dreams.
ABOUT THE AUTHORS
Elizabeth Mitler is a registered nurse who ran the central office of The
Association of Sleep Disorders Centers (now known as The American
Academy of Sleep Medicine) for 10 years. Prompted by the many
questions she was asked, she wrote the first edition '101 Questions' in
1986. Over the intervening years, her book has evolved through six
editions into one of the most popular introductions to sleep in the
world.
Dr. Mitler is a leading authority and consultant on sleep, fatigue and
sleep disorders research. He has lectured throughout the world on
topics related to sleep, circadian rhythms and fatigue as well as their
interactions with prescription drugs and alcohol. Dr. Mitler earned a
B.A. in Psychology from the University of Wisconsin, Madison,
Wisconsin in 1967. He then earned an M.A. in Child Psychology
from Michigan State University, East Lansing, Michigan in 1968 and
a Ph.D. in Developmental Psychology from Michigan State
University, East Lansing, Michigan in 1970. Subsequently, he trained
for 3 years in The Developmental Psychobiology of Sleep at Stanford
University Medical School in Palo Alto, California and earned a
postdoctoral certificate in 1973. He served on the teaching and
research faculties of Stanford University from 1973 to 1978 and The
State University of New York Stony Brook from 1978 to 1983. From
1983 to 2003, he was Professor in The Department of
Neuropharmacology at The Scripps Research Institute and as a
Psychologist at The Scripps Clinic in San Diego, CA. He also was
Clinical Professor in The Department of Psychiatry at The University
of California, San Diego. In his academic positions, he was awarded
continuous funding in the form of fellowships and research grants

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awarded through competitive, peer-reviewed mechanisms by the
National Institutes of Health from 1968 to 2002. These awards
allowed him to study various aspects of sleep physiology, sleep
disorders, circadian rhythms, the effects of sleep loss and the effects
of various drugs on sleep and wakefulness. He has published over 200
articles in scientific journals or books. From 2002 to 2013, he was
Program Director for extramural research on homeostatic mechanisms
at The National Institute of Neurological Disorders and Stroke, within
The National Institutes of Health in Bethesda, Maryland. The research
supported by Dr. Mitler's program centered on cellular and
neurochemical mechanisms of sleep regulation, circadian rhythms and
neurologically based sleep disorders. Currently, Dr. Mitler is a
member of the Speakers Bureau for Merck Pharmaceuticals and a
consultant to the Commonwealth Health Research Board, for the
Commonwealth (State) of Virginia.
From 1983 to the present, Dr. Mitler maintained a private practice in
forensic examination specialized in sleep, fatigue and
neuropharmacology as they pertain to transportation and industrial
mishaps and associated litigation. A forensic examiner is a
professional who performs an orderly analysis, investigation, inquiry,
test, inspection, or examination in an attempt to obtain the truth and
form an expert opinion. Almost every scientific and technical field
has a forensic application. A forensic examination refers to that part
of a professional's practice that is carried out to provide an expert
opinion. Dr. Mitler has been a frequent consultant to the U.S.
Department of Transportation on matters related to fatigue and hours
of service for commercial truck drivers. He was the sleep researcher
responsible for the acquisition and processing of sleep and
performance data in the DOT's 1996 study on driver fatigue and
alertness which is the world's largest objective study of fatigue in
commercial truck drivers.

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CHAPTER 1. NORMAL SLEEP
1.
Q: What is sleep?
A: Sleep is a behavioral state characterized by little physical activity
and almost no awareness of the outside world. Most scientists think
that sleep does something important -- something vital for life,
although research has not yet identified the purpose for sleep.
Nevertheless, we all know when we need to sleep -- we can feel this
need. We also know when sleep has done its work -- we feel rested
and that we have slept enough. Another important feature of normal
sleep is that it can end quickly. Although a sleeper may appear to be
unconscious; unlike someone who is actually knocked-out,
anesthetized or in a coma; a sleeping person can be easily awakened
and can resume normal waking activity within a minute or two.
Sleep is an active, highly organized sequence of events and
physiological conditions. Sleep is actually made up of two separate
and distinctly different states: 'non-rapid eye movement sleep'
(NREM sleep) and 'rapid eye movement sleep' (REM sleep) or
dreaming sleep. The NREM and REM types of sleep are as different
from one another as both are different from wakefulness.
NREM sleep is further divided into stages 1 - 4 based on the size and
speed of the brain waves generated by the sleeper. Stages 3 and 4 of
NREM sleep have the biggest and slowest brain waves. These big,
slow waves are called delta waves and stages 3 and 4 sleep,
combined, are often called 'slow-wave sleep' or 'delta sleep'.
During REM sleep you can watch the sleeper's eyes move around
beneath closed eyelids. Some scientists think that the eyes move in a
pattern that relates to the visual images of the dream. We are almost
completely paralyzed in REM sleep -- only the heart, diaphragm, eye
muscles and the smooth muscles (such as the muscles of the intestines
and blood vessels) are spared from the paralysis of REM sleep.
Doctors have tried to determine what type of sleep is the deepest
sleep. To do this, they measure how much noise or other alerting
stimulation is required to awaken a sleeper from the various types of
sleep. It is always possible to awaken someone who is sleeping, as
opposed to, say, someone who is in a coma. However, people in
stages 3 and 4 sleep require the most stimulation to awaken.

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Therefore, this phase of sleep is often thought of as 'deep sleep'. Also,
large spurts of growth hormone are secreted during stages 3 and 4
NREM sleep. Consequently, these stages of sleep are thought to
restore the body from the wear and tear of waking activity. People in
REM sleep also tend to be quite difficult to awaken, but this finding is
variable -- sometimes even the slightest noise can awaken a person in
REM sleep. Nevertheless, because it is often difficult to awaken a
person from REM sleep, many doctors think also of REM sleep as a
'deep' phase of sleep.
There are many theories about the function of REM sleep and
dreaming -- ranging from 'safe, socially acceptable, wish fulfillment'
to 'consolidation of memories' to 'providing necessary stimulation to
the entire nervous system during development'. Researchers used to
think that REM sleep was necessary for normal psychological
function, because experimental REM deprivation caused some
subjects to behave strangely. The notion that we need REM sleep for
our mental health is not accepted now, because, among other reasons,
people have uneventfully withstood long and almost complete REM
deprivation. Some experiments have shown that REM deprivation
improves depression. However, REM sleep must still do something,
because rats will die after 2 - 3 weeks if they are deprived of REM
sleep by a special experimental computer that wakes them up each
time REM sleep is achieved. Whatever REM sleep does, it is clear
that every aspect of existence from the body's manufacture of proteins
to sexual arousal, including orgasm, is influenced by REM sleep. It is
likely that the ultimate explanation of REM sleep will be very broad -
- not simply focused on one physiologic function.
The next figure is called a hypnogram. Hypnograms are made to
summarize sleep laboratory recordings. This particular hypnogram
shows how a typical night's sleep for a young, healthy adult is
organized. Notice how the night is structured into the various stages
of NREM sleep alternating with REM sleep, with most slow-wave
sleep occurring in the first part of the night and most REM sleep
occurring in the last part.
SEE RELATED material in Chapter 6, Question 54.
1
2
3
4
REM
WAKE
1 2 3 4 5 6 7 8
HOURS OF SLEEP
HYPNOGRAM
STAGES
OF
SLEEP

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2.
Q: Why do we sleep?
A: We sleep because we get sleepy and we cannot work if we get too
sleepy. That is the simplest and yet the most profound answer to this
question. The scientific truth is, however, that we do not yet know
why we get sleepy. We know that all mammals as well as some birds
and reptiles sleep. Many doctors think sleep comes in order to get rid
of certain chemicals that build up in our bodies during the day's
activities. Brain research in the 1960's and 1970's has identified
several molecules involved in cell-to-cell communication within the
brain as being important for sleep. More recent work has isolated
products of the body's immune system that seem to be sleep-inducers.
However, feeling sleepy is not the whole story. Some timing
mechanism is also involved. We know that every living thing
composed of cells with a nucleus has a daily cycle of activity and
inactivity (if not actual wakefulness and sleep). The timing and
control of the wakefulness-sleep cycle depends on one or more
biological clocks in our bodies. These clocks are sensitive to light and
have evolved over the ages in close approximation to the 24-hour
light-dark cycle of our world. Thus, sleep seems to be an unavoidable
part of human behavior. In humans, sleep is physiologically
programmed to come each day, either in one long bout (about 6 - 8
hours each night) or in two shorter bouts (a 5 - 6 hour sleep at night
and a 1 - 2 hour nap in the afternoon). The timing of sleep and
wakefulness is controlled to a great extent by our exposure to the
natural light and dark cycles of the earth. All humans tend to sleep in
the dark and move about in the light. It takes the human body several
days to change to a different light-dark schedule such as when one
flies from New York to New Dehli. In fact, the influence of light on
the timing of sleep is so powerful that doctors are now using exposure
to bright light as a treatment to reset the sleep clock of people who
have somehow disrupted their schedule.
In the extreme, sleep does seem to be necessary for life. Experimental
rats die if they are completely deprived of sleep for longer than 2 - 4
weeks. The cause of death is not at all clear. The animals undergo
multiple organ failure and lose weight despite eating greater than
normal amounts of food. The experimental deprivation in rats was
done by means of special computers and alarm systems -- it is thought

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to be impossible for even the poorest of generally healthy human
sleepers to lose so much sleep that life is threatened. However, even
moderate sleep loss may not be harmless. Findings from Dr. Eve Van
Cauter's lab at the University of Chicago on the effects of sleep
restriction give a striking new perspective. She and her collaborators
report that after as few as 6 days of restricting sleep to 4 hours per
night, normal volunteers show altered metabolism of carbohydrates.
Tests on insulin and leptin levels indicate that the sleep restriction
down to 4 hours per night can cause a metabolic pattern best
described as prediabetic with increased appetite for foods rich in
carbohydrates.
SEE RELATED material in Chapter 5, Question 37 and Chapter 7,
Question 71.
3.
Q: How much sleep should I get?
A: There is no 'normal' amount of sleep. The average amount of sleep
for adults is 7 - 8 hours. But the range of nighttime sleep duration
must be expanded to between 6 - 9 hours in order to include the large
majority of people. Therefore, a few people feel fine with as little as 5
hours of sleep, while others require more than 10 hours to feel
refreshed and alert throughout the day. The amount of sleep you need
is that optimum amount which allows you to function throughout the
day without feeling drowsy when you sit quietly and try to pay
attention to something.
We cannot, for very long, force ourselves to sleep much less or much
more than this optimum amount. Several nights of sleeping an hour
less than our usual amount will leave us sleepy and ineffective in the
day. Conversely, several nights of staying in bed and trying to sleep
an hour more than our optimum amount will leave us sleeping poorly
with more awakenings -- particularly in the early morning. Doctors
believe that the optimum amount of sleep each person needs to remain
alert during the day is biologically different from person to person. To
a great degree, our optimum sleep need is determined by heredity.
Scientists have found, for instance, that strains of mice can be
selectively bred to sleep considerably more or considerably less than
the average mouse.

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4.
Q: Is it true that we need less sleep as we get older?
A: Probably not. It seems that during infancy and in adolescence there
are increases in sleep need, perhaps brought on by developmental
changes. However, the best research available indicates that healthy
elderly people sleep about as much as they did when they were young
adults. The common belief that the elderly sleep less probably comes
from the fact that elders often have medical conditions that interfere
with their sleep. This is why most elderly people are 'light sleepers' at
night, yet they frequently dose-off during the day.
This type of light sleep and dozing pattern is what sleep researchers
would expect if a person is awakened again and again while they try
to sleep. In fact, research on repetitive sleep disruption, called 'sleep
fragmentation', has shown that the rate of sleep disruptions determines
whether or not the sleep is felt to be satisfactorily restorative, and
whether or not there is proper alertness the next day. These kinds of
studies show that disruptions every minute will greatly reduce the
restorative value of sleep. However, disruptions every five minutes
will affect restoration much less -- even when total sleep time is the
same for the one-per-minute and five-per-minute rates of disruption.
Thus, scientists believe that for refreshing sleep, it is not just the total
amount of sleep that is important. Sleep must be continuous as well.
SEE RELATED material in Chapter 6, Questions 55 and 56.
5.
Q: What is yawning?
A: Most vertebrate animals exhibit yawning. A yawn consists of
widely opening the mouth with a slow inspiration at the beginning
and a quick expiration at the end. Yawning is a reflex behavior that
can be only partially controlled by our own volition. The behavior
occurs most often when we feel sleepy, bored, and, perhaps,
physically fatigued. Yawning can also be triggered by drugs and has
been used as a medical index because there are changes in the
frequency of yawning in certain disease states. Scientists have not
identified a function of yawning, but, at least in humans, it does seem
to be contagious since observers are more likely to yawn when they
watch someone else yawn. In this sense, yawning is a type of social
behavior that is largely involuntary and controlled by the brain.

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6.
Q: What about bedroom temperature and sleeping position? Can
these things affect sleep?
A: People sleep best when they are comfortable, physically and
mentally. There is no universal formula for physical and mental
comfort. It is best to explore bedroom temperature, mattress,
bedclothes, etc. until you find bedroom conditions under which you
feel that you sleep the best.
Similarly, there is no single ideal sleeping position. Most people
move through many sleeping postures in the course of a normal
night's sleep. Scientists think such
movement is good because it prevents pressure-related restriction of
circulation. However, conditions such as pregnancy, arthritis and
other medical conditions will obviously exclude certain sleeping
positions with no ill effects. Furthermore, avoiding some sleeping
postures can be helpful. For example, people with breathing problems
associated with airway obstruction breathe irregularly and sleep
poorly when lying on their backs. Such people often sleep sitting-up
as a matter of preference until the condition is effectively treated.
7.
Q: Can we make up for lost sleep?
A: Yes, we can make up for lost sleep, but only to a certain extent.
Suppose a man, who usually sleeps 7 hours a night, loses 2 nights of
sleep. He will not sleep 21 hours (14 hours longer than usual) on the
third night, when he is able to sleep. After significant sleep loss, we
may have more slow-wave sleep for the next couple of nights, but we

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rarely sleep more than 2 - 4 hours longer than usual. This is because
our wakefulness-sleep cycle depends on both our sleep need and our
internal timing mechanisms. Furthermore, experiments with shift
work have shown that people who stay awake for a single night and
then go to bed at 8 AM, instead of their usual 11 PM, will not simply
move their normal sleep to an interval 9 hours later. Rather, their
sleep beginning at 8 AM will be shorter and more broken because it is
occurring at a biological time when activity usually occurs. This
inability to sleep during certain periods of the day is due to the
alerting influences of the biological clock located in the brain’s
hypothalamus. What our ancestors previously thought of as a ‘second
wind’, is now understood by sleep scientists as clock-dependent
alerting. It is because of complex interplay between sleep deprivation
and clock dependent alerting, that sleep losses or shifts in sleep time
will have effects for several days. The figure illustrates this interplay
and shows over a period of 48 hours, a two-peak pattern for each day.
There is a period with markedly increased sleep tendency in the early
morning hours between 3 and 6 AM and a smaller but reliable
afternoon peak between 1 and 3 PM. This is the so-called siesta effect
or afternoon slump. Both periods of increased sleep tendency can be
exaggerated by sleep promoting factors such as alcohol consumption
and sleep deprivation. Errors and reduced productivity peak at the
times of maximum sleep tendency.
8.
Q: Are there any advantages in taking a nap?
A: Certain cultures use the siesta very successfully. However, siesta
cultures are relatively consistent in napping. In most western cultures,
napping is not consistent day after day. If you want to nap, nap at the
same time each day and for the same duration, particularly if you are
prone to insomnia. Many people complain about Sunday-night
insomnia. What usually happens in these cases is that the person
napped on Sunday from, say, 2 to 5 in the afternoon and then could
not get to sleep at the usual time Sunday night. That is why keeping a
consistent schedule is the best strategy.
With respect to occasional napping, one important advantage is that
even a 30 – 60 minute nap greatly helps a person counter sleep loss.
Studies have shown that the first hour or so of sleep is most potent in
relieving the effects of missing a night’s sleep.
SEE RELATED material in Chapter 1, Questions 1, 2, and 12.

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9.
Q: Does meditation change sleep?
A: Meditation probably will not affect sleep in any significant way. In
its most common forms, meditation involves the practice of sitting in
some prescribed position with the eyes closed and 'saying' (either
audibly or only mentally) a prescribed word or set of words, called
mantras. There are a variety of meditation techniques that are taught
by trained individuals for the purpose of improving waking
functioning as well as spiritual and physical well-being. These
meditation techniques are also claimed to have various effects on
sleep such as 'improving sleep', 'reducing the need for sleep' and being
an 'alternative to sleep'. However, scientific studies on meditators
have found that most meditation is characterized by the brain wave
pattern of quiet, relaxed wakefulness with occasional bouts of NREM
sleep. Thus, the best current studies suggest that any meditation-
related shortening of nocturnal sleep probably occurs because the
meditator is getting daytime sleep (i.e. is napping) during the act of
meditation. There is no evidence that meditation will reduce a
person's overall need for sleep. SEE RELATED material in Chapter 7,
Question 72.
10.
Q: Can we learn during sleep?
A: No. There is no study that shows efficient learning during sleep.
The brain needs to be awake in order to learn, as learning is usually
defined. When new information is presented to someone while they
sleep, the amount of information that they remember the next morning
depends on how long and how many times they were awake during
the night -- not on how well they slept.
11.
Q: Do we dream during our deepest sleep?
A: The answer is yes, but only partially yes. The experience which we
would all agree constitutes dreaming involves a good deal of action
and several senses such as vision, hearing and touch. This type of
experience occurs most often in REM sleep.
Here is why the answer is only partially yes: First, some dreamlike
experiences can occur during other phases of sleep besides REM
sleep. Second, REM sleep cannot really be considered our 'deepest

19
sleep'. The depth of a particular phase of sleep is best defined in terms
of how difficult it is to awaken someone when they are in that
particular phase of sleep. What phase of sleep requires the loudest
noise, for example? The two phases of sleep that are 'deepest' -- that is
the hardest to wake up from -- are 'slow wave sleep' (stages 3 and 4 of
NREM sleep combined, is called 'slow wave sleep' because of the big,
slow brain waves seen then) and REM sleep. Dreams rarely occur in
slow wave
sleep and frequently occur in REM sleep.
12.
Q: Do people in other countries and cultures sleep differently?
A: The basic physiology of human sleep does not seem to vary much
from race to race or culture to culture. However, there are effects of
culture and climate. For example, many equatorial cultures have the
institution of an afternoon siesta which breaks sleep into a short
afternoon bout and a longer nighttime bout. People in siesta cultures
seem to sleep about the same amount as those in other cultures. There
also are studies showing profound seasonal changes in sleep. The
largest seasonal changes occur in the polar regions, where there are
great changes over the year in the length of the light interval in the
day with long light periods increasing the tendency for the daily
schedule to have two sleep bouts.
13.
Q: Does your body size affect your sleep?
A: There seems to be no direct effect of body size on sleep. Assuming
that the length and width of the sleeping surface is of appropriate
dimensions, small people sleep just as much as, and just as well as,
large people of comparable ages. However, if body size restricts the
normal body movements during sleep or the ability of the diaphragm
to move during respiration, such as is common with extremely
overweight people, then sleep can be profoundly disturbed.
SEE RELATED material in Chapter 7, Questions 80, 81 and 82.
14.
Q: What are the best ways for most of us to get a good night's
sleep?
A: Here are ten sensible rules for a good night's sleep:

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1. Stick to a regular schedule of going to bed and getting up at the
same time every day.
2. Be consistent about taking naps: Take one every afternoon or none
at all. People who take a nap once in a while usually find they do not
sleep well that night.
3. Exercise regularly in the morning or early afternoon, but do not
engage in strenuous physical activity just before bedtime.
4. Stay away from drinks containing caffeine after about 4 PM.
5. Avoid alcohol after the dinner hour. Instead of promoting sleep, a
nightcap actually disturbs sleep patterns and can cause early morning
awakenings.
6. Be careful about sleeping pills. Under most circumstances, these
medications should not be taken for more than four weeks. Longer
use leads to increased insomnia.
7. Find the right room temperature for you and maintain it throughout
the night.
8. Try to relax before going to bed: Take a warm bath, read a light
novel, listen to music, avoid stressful thoughts.
9. Do not eat heavily just before going to bed.
10. If you cannot sleep at night, do your best to preserve your usual
24-hour cycles of activity-rest and exposure to light and dark. For
example, do not get up, turn on bright lights and read or exercise. It is
best to remain reclining in the dark and listen to music or an audio
book.

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CHAPTER 2. DREAMS
15.
Q: I never dream. Am I abnormal? Will I go insane if I do not
dream?
A: As far as scientists know, everyone dreams but some people do not
remember their dreams. Because they do not remember, they believe
that they do not dream. Not remembering dreams is no cause for
concern.
For most people who have their principal period of wakefulness
during the day and their principal period of sleep at night, NREM
sleep starts the night off and alternates with REM sleep every 80 - 100
minutes. It is during REM sleep that the thought patterns we know as
dreaming occur. People in sleep laboratories -- even those who say
they never dream -- do remember dreams vividly, provided that they
are awakened during a REM sleep period. Under these special
laboratory circumstances, the sleeper can recall much more of the
action, color and sensations of a dream than they can when they wake
up in the morning.
There is no reason to think that someone will go insane if they do not
dream. It is true that some early experiments on deprivation of REM
sleep led to temporary personality changes in volunteer subjects.
However, today doctors use certain drugs and procedures because
they reduce the time spent in REM sleep. Such treatments are
effective for depression and certain medical problems that get worse
during REM sleep.
16.
Q: Why do we dream?
A: The reason we dream is unknown. However, dreaming is an
integral part of sleep and appears to be unavoidable. Scientists have
many possible explanations of why we dream. Dreaming, for
example, may provide necessary stimulation to the brain from within
the brain itself, thereby compensating for the loss of stimulation from
the environment that is all-but-eliminated while we lie in bed asleep.
Many psychiatrists and psychologists think that dreaming may be a
safe and socially acceptable way to fulfill our wishes and desires.
Specialists in learning have done experiments showing that dreaming
is important for transferring what we have learned during wakefulness

22
from short-term memory to long-term memory thereby allowing us to
remember things for years and years. This transfer may be
accomplished within brain cells by the manufacture during dreaming
sleep of special protein molecules. Other scientists such as the Nobel
Laureate, Francis Crick, think that dreaming may activate groups of
brain cells in certain combinations and sequences in a way that does
not occur during wakefulness and thereby help us remain flexible in
our behavior and thought.
The drawing shows a cut-away view of the human brain with lines
pointing to the various locations involved in sleep, biological timing,
and dreams. Two important areas for promotion of sleep are the
forebrain and pons. The biological clock is situated in the
hypothalamus, indicated by the second arrow in from the right. The
stimulation we know as dreaming comes from other areas in the pons.
There are also other areas in the pons and the medulla that cause and
maintain the muscle paralysis of REM sleep. Damage to these muscle
paralysis areas can cause humans and animals to act out their dreams.
Whatever dreaming actually does, the sleep in which dreaming
occurs, REM sleep, seems to be necessary for life itself. Experiments
in rats that were automatically awakened just as they began to have
REM sleep found that life cannot continue after complete REM sleep
deprivation for longer than 1 - 2 months. For this level of REM sleep
deprivation, very special equipment is required that detects the
particular brain wave patterns of REM sleep and then causes an
awakening. These experiments should not frighten people who think
they are getting little REM sleep. The extremes of REM sleep
deprivation created in the rat experiment are not possible in humans,
even when sleep is very disturbed.

23
17.
Q: Why are dreams so strange and silly?
A: During REM sleep, our body is almost completely paralyzed. The
heart and other automatically controlled muscles still function, but our
head and limbs really cannot move very much. Also during REM
sleep, there is intense stimulation getting to those parts of our brain
that interpret what we see, hear and feel. However, this stimulation is
coming from within the brain itself. And, the stimulation is occurring
at a time when the muscles we use to move about and orient our eyes
and ears to stimulation are inoperative. Even under these conditions,
our mind does its job and tries to make sense of what it 'sees, hears
and feels'. Our mind 'making sense' of stimulation coming from inside
the brain, while our muscles are paralyzed, leads to the bizarre
experiences we know as dreams. Doctors believe that many common
features of dreams stem from the physiological paralysis that occurs
during REM sleep. For example, many people dream about falling,
being unable to get away from a pursuer or being unable to move fast
enough to prevent some accident. All these kinds of dreams have the
common feature of movement impairment which may stem from the
brain's recognition of paralysis during REM sleep.
18.
Q: I have the same horrid dream every night that someone close
to me is going to be killed. Is this a premonition -- will it happen?
A: No one can answer this kind of question with certainty. Many
doctors believe that the subject matter of dreams can reveal important
information about the way we think and feel. People who frequently
have disturbing dreams may have a psychological problem that
requires professional attention. Repetitive nightmares involving a
constant frightful theme are usually a sign of psychiatric or
DREAM STIMULATION
SLEEP

24
psychological problems. This is a rather common phenomenon in
combat veterans, for instance. Such patients may be treated with
medications that block REM sleep, which is when nightmares occur.
19.
Q: Can you solve problems by dreaming about them?
A: Many people believe that we can solve problems during dreams.
The uniqueness of REM sleep as a behavioral state has suggested to
some doctors that REM sleep may enhance powers of the mind. There
are many stories of dream-like mentation during sleep suggesting
solutions to problems in waking life. The great chemist, Friedrich
August Kekulé von Stradonitz told of a dream that gave him a mental
image leading to the correct molecular structure of benzene -- a ring
of six carbon atoms joined together by double bonds. Kekulé's dream
was of the ancient alchemist's symbol known as Ourobouros -- the
self-devouring snake which is drawn as a spiny-backed serpent with a
dark-colored head biting its own light-colored tail. The dream's
symbolism was on-target. It easy to see the relationship between a
snake biting its tail and a ring. But also, ancient alchemists used
Ourobouros to represent the unity of nature, and benzene can be
viewed as a unifying compound since the benzene ring is a
component in the molecular structures of over two-thirds of all known
organic chemicals!
There are also experiments showing that patterns in dream content
can predict the degree to which women will cope with the loneliness
and frustration stemming from a life crisis. Dreams with themes of
independence and self-reliance, on the one hand, correlate well with
successful resolution of troublesome situations such as a divorce.
Dreams with themes of dependency and helplessness, on the other
hand, correlate well with unsuccessful resolution of such situations.
These kinds of phenomena may very well be at the root of the age-old
advice for someone with a problem, 'sleep on it'.
20.
Q: I have read that dreams have meanings beyond the things we
remember when we awaken. Is this true?
A: Yes. Some psychiatrists and psychologists have specialized
training in dream interpretation. By careful review of someone's
dreams, these trained doctors can learn much about the person's

25
personality, as well as gain insight into what problems are being faced
and how well the person is coping. In this respect, doctors use dreams
in the same way they use Rorschach ink-blots and other projective
tests.
21.
Q: What is a 'wet dream'?
A: The original term means 'a dream in which there is an ejaculation
of seminal fluid'. Many males report dreams involving sexual arousal
and orgasm prior to awakening and finding seminal fluid in their
pajamas or on the bed. Sometimes there is no dream recall at all, just
evidence of an ejaculation. The term 'wet dream' is sometimes applied
to a similar phenomenon in females. At least one third of all women
experience orgasm during sleep. Many others experience awakenings
from a dream to find vaginal wetness. As with males, there may also
be no dream recall, just secretions. Such experiences are not
abnormal, but can perplex, or even upset, young boys and girls on the
verge of sexual maturity. Even though they may have been taught
about human sexuality, without an understanding of the physiology
behind these sleep-related experiences, there may be unwarranted
disturbance and concern. The reason for 'wet dreams' is that during
REM sleep there is intense activity in areas of the brain that control
the autonomic nervous system. Heartbeat and breathing, for example,
can be quite irregular during REM sleep. In the course of the
autonomic activity of REM sleep, there is normally an activation of
the erectile system of the penis and the secretory and erectile systems
of the vagina. In some cases, the self-stimulatory activity of REM
sleep may also lead to an orgasm and an activation of the ejaculatory
system in males.
SEE RELATED material in Chapter 3, Questions 22 and 23.

26
CHAPTER 3. SEX
22.
Q: My bedpartner's penis sometimes gets erect when he sleeps.
This happens even after we have had sex. Does this mean he is not
satisfied or wants someone else?
A: Males normally have erections (penile tumescence) during their
sleep. The erections come 4 - 5 times a night about the time when
dreaming or REM sleep occurs. As far as scientists know, the subject
matter of the dream does not predict whether or not there will be an
erection. The erections are a normal part of REM sleep for males of
all ages. Doctors may record the circumference of a man's penis all
night long to check for the presence, size and duration of erections.
Such erections are called episodes of Nocturnal Penile Tumescence
(NPT). It is now recognized that erectile dysfunction (impotence) may
be caused by a variety of physiological conditions – such as damage
to the nerves that regulate blood flow into the penis. NPT recordings
may be done to determine, independent of psychological factors, the
extent of a man’s erectile capability. This information can be used to
select from the many treatments now available for erectile
dysfunction, including, but not limited to, sildenafil (Viagra).
The relationship between REM sleep and erections is also the reason
that men frequently wake up in the morning with an erection without
having the desire to engage in sexual activity. There is a commonly
held, but incorrect, belief that morning erections are due to a full
urinary bladder. This belief really makes no sense. For example, men
do not get erections during the day before urination. The correct
explanation for morning erections involves the way nighttime sleep is
organized. We have most of our REM sleep in the early morning,
usually between 4 - 7 AM. Therefore, each morning we are very
likely to awaken directly from REM sleep or, at the very least, soon
after a long morning REM period has ended. Thus, men are very
likely to awaken in the morning with a REM sleep-related erection.
23.
Q: Is there a female counterpart to erections during sleep in men?
A: There does seem to be a female counterpart to penile tumescence
during REM sleep. A number of studies indicate that vaginal and
clitoral swelling do occur during the night in about the same time

27
relationship to REM sleep as has been observed for penile erections in
males. There are also reports that vaginal secretions increase during
REM sleep. Moreover, there are reliable data showing that the rate of
contractions of the uterus is highest during REM sleep and lowest
during slow wave sleep. Doctors are now working on ways to use
recordings of uterine contractions during sleep in their clinical
evaluations of female sexual function, just as they use NPT in
evaluations of male sexual function.
Question 22.
24.
Q: Is sex good for your sleep?
A: Yes, at least, sex seems to help men sleep. Many men report that
they use orgasm, either through sexual relations or masturbation, to
aid in falling asleep. In male rats, there is an active inhibition of
sexual behavior following ejaculation. During this period, the male rat
emits an ultrasonic vocalization and the rat’s EEG shows sleep-like
activity. For women, the effect of sexual activity and orgasm is
unpredictable. Many women report that sexual activity is alerting,
rather than relaxing. Scientists have observed that, in female rabbits
during their sexually receptive phases, sleep is increased after sexual
intercourse with a male rabbit and after mechanical stimulation of the
vagina without intercourse. However, women report that after sexual
activity leading to orgasm, they feel more alert and sometimes
annoyed with male partners who, after sex, seem simply to collapse
and begin snoring. These different effects in men and women can lead
to some discord in relationships. Appreciation that these differences
are due to biological factors, rather than personality and insensitivity,
may help heal hurt feelings.
25.
Q: I have heard that women have more insomnia than men. Men
seem to be less excitable than women. Do men sleep better than
women?
A: This question sounds sexist, and even a bit silly. However, the
answer is really much more serious than the question. Among people
who complain of chronic insomnia over age 40, there are 7 or 8
women to 1 man. The reasons for the disproportionate number of
women are not known. Menopause, grown children leaving home (the

28
so-called, 'empty nest syndrome') and other life-cycle effects have
been offered as explanations.
This most important point in connection with this question, however,
is that across all ages, on the average, males sleep much worse than
females. One of the main reasons is that many more males are prone
to sleep-related breathing disorders than females. From birth on, male
babies have more respiratory difficulties and succumb more often to
sudden infant death syndrome than female babies. Physicians think
that this is partly because the female hormone, progesterone,
somehow protects females from respiratory difficulties during sleep.
The man who brags that he can 'sleep through a bombing' may
actually be abnormal. Rather than being so 'in control and relaxed'
that he can 'sleep fine anywhere, anytime', this man may have such
poor breathing and sleep disruption that he is too sleepy to stay fully
alert. Such men cannot restrict their sleep to appropriate times of the
24-hour day. Finally, with age, the statistical score between the sexes
evens up. As women pass through menopause, a variety of hormonal
changes occur that seem to bring on sleep problems. Menopausal and
post-menopausal women complain more of insomnia than men of
comparable age. And, after the age of 65, the male-female differences
for sleep-related breathing disorders become much smaller.

29
CHAPTER 4. CHILDREN
26.
Q: Does pregnancy alter your sleep?
A: Yes. Women feel that they want to sleep more during the first, and
particularly during the second trimester. This desire for more sleep is
thought to be related to increased energy demands associated with the
growth of the fetus. Women in their third trimester of pregnancy will
notice frequent disruptions in sleep and increased restlessness. The
sleep problems during the last trimester are thought to be due to
pregnancy-related changes in anatomy causing discomfort in certain
sleeping postures. An important feature of the third trimester is weight
gain of the mother. Large weight gains have been linked to an
increased tendency for pregnant women to snore and to have
breathing pauses during sleep (sleep apnea).
27.
Q: My baby is almost 3 months old. He wakes up crying dozens of
times a night. My husband and I cannot get any sleep and he is
thinking about moving out. What can I give my baby to help him
sleep?
A: This is an extremely serious situation. The problem, however, is
usually not with the baby. Most babies do not sleep through the night
until 3 - 9 months of age. If the doctor finds nothing wrong with the
baby, then you need to find ways to live through the period while
your baby develops the ability to sleep through the night. Get
professional advice if your baby does not learn to get to sleep without
someone in the room keeping him company. It is also important to get
help if your marriage cannot stand the stress. Do not blame the baby.
28.
Q: Why does rocking help babies go to sleep?
A: Doctors do not really know. But it is interesting to note that not
only rocking, but many other kinds of repetitive stimulation seem to
have calming and sleep-promoting effects. There are experiments
showing that babies prefer rhythmic sounds to complete silence.
Scientists are testing whether or not the early experience of hearing
the beat of the mother’ heart is related to preferences for rhythmic
sounds. It is common for mothers to find that their babies like to sleep
with the sound of a fan -- or even the much louder sound of a vacuum
cleaner. Many babies, as well as much older people, find the rhythmic

30
motion of riding in a car or a train to be very soporific (sleep-
promoting). Other babies may rock themselves to sleep with rhythmic
leg or head movements. An extreme form of this self-stimulation may
be the sleep disorder known as 'head banging', which many doctors
consider to be an abnormal exaggeration of rhythmic self-stimulation
performed for comfort and to promote sleep.
29.
Q: My 4-year-old wakes up in the middle of the night and the only
way she will go back to sleep is in bed with my husband and me.
Is it harmful to allow her to do this?
A: Most doctors do not believe that it is harmful for a young child to
sleep in the same bed with the parents. Of course, Western cultures
regard it as an entirely different matter if the child can, thereby,
witness sexual activities between the parents. In most Western
cultures, concerns about the need for parental privacy usually lead
families to get the child out of the parents' bed. If your child gets into
bed with you frequently -- say, more than once a week -- then you
may want to discuss the matter with your daughter. Try to determine
if there are psychological problems at the root of her behavior. If not,
then she can learn to get herself back to sleep if you gently but firmly
refuse to let her come into your room. Plan on having to walk or carry
her back to her own bed several times a night for a while. If you have
no success after a month of consistent efforts, then seek professional
help.
The related question of an infant or very young child sleeping in the
same bed as the mother and/or father has more complex answers. The
nursing mother may wish to have the infant close by to minimize the
disturbance of breast feeding to their own sleep. Fathers who get up
during the night to feed infants have expressed similar views.
Working mothers and fathers may consider bedtime as the only time
when they can be close to their young children. Such practical and
emotional factors should be balanced against the fact that, for a child
to sleep well, it is necessary to learn to settle and sleep alone in bed.
In the case newborns and young infants, some authorities cite the risk
of crushing or smothering as a reason for separate sleeping
arrangements. Amidst such conflicting considerations, parents must
select the sleeping arrangements that best fit their current needs. A bit
of personal experimentation with various same room and same bed

31
sleeping arrangements can be helpful in deciding what is best for you
and your family.
30.
Q: My 6-year-old walks in his sleep. Will it hurt him if he wakes-
up while sleepwalking?
A: Sleepwalking or 'somnambulism' is common in children. These
symptoms occur during stages 3 and 4 NREM sleep, when the brain
waves show a high-voltage slow pattern. During this kind of brain
wave pattern, there can be little reliable sensory and movement
activity. Many people mistakenly believe that sleepwalkers will not
get hurt and that they can avoid obstacles. People can be injured while
sleepwalking. Sleepwalkers have broken through glass doors, fallen
down stairs and been burned after walking into hot fireplaces. So, the
sleep environment should be made safe by locking doors and
windows that open on to dangerous areas. Sleepwalkers may be very
difficult to awaken and very confused if they awaken during a bout of
sleepwalking. However, there is no real danger if a child wakes up
while sleepwalking.
31.
Q: My 3-year-old will only go to sleep on the sofa while watching
television. After she is asleep, my husband must carry her to bed.
Should we put an end to this and, if so, how?
A: People have trouble sleeping when they do not feel secure. Your 3-
year-old can learn to get to sleep alone. The most common way to
accomplish this learning is to firmly insist that the child go to bed and
sleep there. Reassure the child at bedtime as to the safety of the room.
The first week or so may be tough on the child and the parents, but
the result of your child being able to sleep undisturbed in her own bed
is worth the bother.
32.
Q: My twins are afraid to sleep in the dark and insist on sleeping
with the light on. Can they get their proper rest from sleeping in
the light?
A: There is probably no short-term problem with sleeping in the light.
However, sleep and wakefulness are controlled by an internal clock
that is sensitive to light-dark cycles. The clock works better if the
light-dark information throughout the 24-hour day is clear and
consistent. Sleeping in the light may ultimately confuse the body and

32
lead to sleep problems. You may try to use progressively dimmer and
dimmer lights in the twins' room until they are comfortable sleeping
in the dark.
33.
Q: My 5-year-old wets the bed. I have tried to limit her fluids
after dinner and I have made her responsible for cleaning up her
mess. But we are still at odds and her bed wetting continues.
What can I do?
A: Bed wetting (enuresis) is far more common than most people
think. The necessary neurological control of the bladder sphincter can
come as late as 12 - 15 years of age. It is best not to make an issue out
of bed wetting in children under 6 or 7 who have never been dry for
more than a few nights in a row. For older kids, there are several
training methods that involve gentle alarms that do work quite well.
For kids who have been dry for a number of months or years and
begin to wet the bed again, parents should get a physician's opinion.
Reappearance of bedwetting can mean genito-urinary problems,
psychological problems or even neurological problems such as
epileptic seizures.

33
34.
Q: My little boy has the habit of waking up and asking us for a
drink of water at 1 AM. What can we do to break this habit?
A: There is probably much more than thirst involved in your child's
request for water. Fear of being alone and need for parental attention
are two possibilities. It is best to firmly refuse to get the water and
encourage the child to return to sleep. Try not to get involved in
exactly how the child adapts to your refusal. Depending on the child's
personality and age, the child can get his own water for a while, cry
and act out, or just go back to sleep.
35.
Q: My brother and his wife lost their baby to crib death and it
has just about ruined their lives. I am expecting our first child
next month. Does crib death run in families? What should I do?
A: Crib death or Sudden Infant Death Syndrome (SIDS) is a tragic
problem that is often related to an abnormal degree of immaturity in
the systems that control the heart and lungs. It is common for such
immaturity to cause problems only during sleep. There is a small
tendency for SIDS to run in families. Doctors suggest that babies who
are closely related to a SIDS case, be examined regularly. If your
baby stops breathing or has irregular breathing during sleep, tell your
doctor immediately. The sleeping position of new babies may is also
important in SIDS. Studies in England have shown that ‘Back to
sleep’ which refers the practice of putting newborns and infants into
their cribs on their backs, significantly reduces the rate of crib death.
Doctors now advise having babies sleep on their backs.
36.
Q: My 11-year-old stays up late reading or talking on the phone
because he just is not sleepy, but he cannot get up and get going in
the morning. What can I do?
A: The body cycle that controls our wakefulness and sleep runs on
about a 24-hour clock -- but not quite. That is why scientists term the
cycle 'a circadian rhythm' which means 'about a day'. Actually the
cycle is usually longer than 24 hours by 15 - 75 minutes depending on
such factors as age and random variation among people. The cycle
tends to be longer in young people and to shorten as we age. Thus,
left without any information about time or the need to get up in the
morning, most people will go to bed later and later each successive
night and get up later and later each successive morning. It may be

34
that your son has a particularly long wakefulness-sleep cycle. He may
benefit from more and stronger time signals from our 24-hour day to
override his internal 25+ hour day. The best signals are bright light
and vigorous activity in the morning. The extreme form of this
problem is called 'phase delay insomnia' and can lead to problems in
school or on the job. The condition can be treated by sleep disorders
specialists.

35
CHAPTER 5. SLEEP AND THINGS YOU INGEST OR INJECT
37.
Q: Does diet make a difference in your sleep? For example, is
warm milk at bedtime a good idea?
A: The effect of diet on sleep has not been researched with good
laboratory techniques. All of us certainly hear many personal
observations and testimonials concerning the sleep benefits of various
diets and health foods. However, there is no systematic research on,
for example, whether people eating a high protein diet sleep
differently night after night than people eating a high carbohydrate
diet.
There is some information on several dietary substances, though. We
know of one published study on a malted-milk product that may have
sleep-promoting effects. Conversely, there are studies showing that
caffeine-containing substances really do disturb sleep.
Americans spend billions of dollars each year or health foods and
dietary supplements. It is wise to remember that the research
supporting the use of non-prescription compounds and dietary
supplements is of poor quality or non-existent. By contrast, the laws
governing the safety and efficacy of prescription drugs are rigorous.
When a prescription drug reaches the market, the consumer can be
confident that the safety of the drug and the claims of effectiveness
have been scientifically demonstrated. This situation is no better
illustrated than in the case of melatonin versus prescription sleeping
pills. Melatonin, because its manufacture and distribution are not
subject to the laws and policies of the U.S. Food and Drug
Administration, continues to be sold in health food stores as a sleep
aid. This situation continues despite scientific studies showing that
melatonin is not effective as a sleep promoter. It is true that some
research indicates that melatonin has a resetting effect on circadian
rhythms and that well-timed ingestion may help the adjustment to a
new time zone after long flights east or west. However, melatonin’s
long-term safety is still in question, particularly with respect to its
effects on hormonal and reproductive systems. Yet, many people
seem to believe that, because melatonin is sold as a dietary
supplement in health food stores, it is a safe and effective sleep aid,
and that prescription sleeping pills are dangerous drugs. The reality
may just be the reverse.

36
Findings from Dr. Eve Van Cauter's lab at the University of Chicago
on the effects of sleep restriction raise the related question of whether
sleep habits can affect diet. It has been known for some time that
people who habitually sleep less than 6 hours per night have altered
sensitivity to insulin. More recent studies found that after 6 days of
restricting sleep to no more than 4 hours per night, normal young
volunteers show altered metabolism of carbohydrates and changes in
insulin and leptin levels so that their overall patterns are similar to
persons in their 50’s and 60’s. The changes after sleep restriction can
be described as prediabetic with decreased sensitivity to insulin and
increased appetite for foods rich in carbohydrates. These changes
reverse after several nights without sleep restriction.
SEE RELATED material in Chapter 1, Questions 1 and 14 and
Chapter 6, Question 51.
38.
Q: Will a 'night cap' aid in sleeping?
A: If it is an alcoholic drink, absolutely not. Alcohol is actually an
organic solvent and depressant of the central nervous system that
disrupts normal sleep. A drink may make you drowsy, but it also
distorts the normal pattern of NREM and REM sleep. And, when the
alcohol wears off (in 2 - 4 hours) you may wake up and have
difficulty getting back to sleep. People who drink significant amounts
of alcohol between dinner and bedtime are among the worst of
sleepers.
An additional concern is that alcohol causes relaxation of the muscles
in the throat and upper airway and also interferes with breathing. As a
result, people who rarely snore when they do not drink may snore
quite loudly after nighttime drinking. Furthermore, people with mild
sleep-related breathing problems, such as sleep apnea, may get much
worse even after small amounts of alcohol. In fact, many sleep clinics
use bedtime alcohol as a test to determine how bad a person's
breathing difficulties can get.
Questions 78 and 79.

37
39.
Q: Is it bad to eat just before going to bed?
A: There is no single answer to this question. Obviously, if the eating
leads to intestinal discomfort and indigestion, sleep will be disrupted.
Small amounts of light food may help some people feel comfortable
and, thereby, assist sleep. And, there are a few studies showing that
malted milk and foods rich in tryptophan may promote sleep.
Question 51.
40.
Q: Does melatonin really help in getting to sleep?
A: Probably not. Melatonin is a hormone produced by the pineal
gland located in the center of the brain. Using input from the eyes, the
brain links melatonin production to the light-dark cycle of the
environment. Melatonin levels in the body are highest during the
hours of darkness. Synthetic forms of melatonin are available as
dietary supplements in health food stores. However, studies have
failed to show that melatonin affects sleep in any way and there are
few definitive studies showing that melatonin treats the symptoms of
jet-lag.
There are studies indicating that taking melatonin at bedtime is
helpful for the insomnia some blind people experience because they
cannot receive light-dark signals from the environment. And, the
sleep of people who have diseases causing a deficiency in natural
melatonin is improved by bedtime melatonin. However, there is
reason for caution. Melatonin’s effects on other hormone systems are
fully not known. In animals, melatonin rises are associated with the
seasonal shrinking of testes and ovaries. The effects of melatonin on
the human reproductive systems have not been thoroughly studied.
Melatonin is chemically related to another brain chemical, serotonin.
Research has also linked serotonin to sleep. Since the brain
chemically changes tryptophan into serotonin and melatonin, pure
tryptophan has also been studied as a natural sleep inducer. Early
studies showed that 3 - 5 grams of tryptophan, manufactured in tablet
form, helped some people who take a long time to fall asleep and
wake up frequently. However, it is not likely that the amount of
tryptophan in a normal meal, even of a tryptophan-rich food, will
affect subsequent sleep. Some years ago many people used tryptophan

38
tablets to help with relaxation and sleep. However, in the late 1980's,
more than 1500 cases of a painful and sometimes fatal disease called
eosinophilia-myalgia was linked to an impurity in the tryptophan
produced by the Japanese company, Showa Denko. During the search
for the cause of the disease, all tryptophan tablets were recalled. Costs
of product liability and impurity-free production have blocked the
return of tryptophan tablets to the market.
Question 51, and Chapter 7, Question 71.
41.
Q: I have just stopped drinking coffee. Now I can't stay awake
and I get terrible headaches. Am I hooked on coffee?
A: It may very well be that you are having withdrawal symptoms.
Somnolence and headaches are two common symptoms of caffeine
withdrawal. However, if these symptoms are due to getting off coffee,
do not worry -- the symptoms will pass quickly. Unlike more
powerful and addictive stimulants such as amphetamine, the
symptoms of caffeine withdrawal seem to disappear in a few days
without serious complications.
42.
Q: I have just stopped smoking. Now I can't stay awake and I get
terrible headaches. What should I do?
A: The effects of nicotine withdrawal that come from stopping a
tobacco habit can include both nervousness and somnolence as well
as the more well-known symptoms of increased appetite and weight
gain. Nicotine can act as a mild stimulant which explains the sleep
problems associated with withdrawal.
43.
Q: What does marijuana do to your sleep?
A: The most active compound in marijuana is delta-9
tetrahydrocannabinol or 'THC'. This compound alters brain chemicals
involved in sleep and produces changes in brain wave patterns. Sleep
changes with long term use include increased time in getting to sleep
and reduced REM sleep. It is not considered to be a good sleep aid.

39
44.
Q: What does cocaine do to your sleep?
A: Cocaine is a stimulant that produces a sense of euphoria followed
in several hours by a sense of depression. Cocaine potentiates certain
brain chemicals. Cocaine's arousing and addictive influences stem
from its effects on the brain chemical, dopamine, which is involved in
wakefulness and body movement. Sleep changes include reduced
stage 3 and stage 4 NREM sleep and reduced REM sleep. When
cocaine is discontinued, the individual becomes very sleepy and may
feel that more cocaine is necessary just to function. Cocaine is
addictive particularly when used in the very short-acting form known
as 'crack'.
45.
Q: What does amphetamine do to your sleep?
A: Amphetamine and amphetamine-like drugs are also known as
'speed' or 'crank'. They are powerful stimulants that are not unlike
cocaine in many respects. Amphetamines also potentiate brain
chemicals involved in wakefulness and produce changes in brain
wave patterns. Sleep changes include reduced stage 3 and stage 4
NREM sleep and reduced REM sleep as well as decreased tendency
to fall asleep and stay asleep. When amphetamine is discontinued, the
individual becomes very sleepy and may feel that more amphetamine
is necessary just to function. Also, discontinuation of amphetamine
leads to greatly increased REM sleep known as 'REM rebound' which
may be accompanied by nightmares. However, amphetamine and
related drugs are medically useful in controlling the disabling
sleepiness of sleep disorders such as narcolepsy.
46.
Q: What does heroin do to your sleep?
A: Heroin is a depressant that retards intellectual and motor
functioning as well as reaction to pain. The drug also interferes with
breathing because it is a powerful respiratory suppressant. Heroin
decreases stage 3 and stage 4 NREM sleep and reduces REM sleep.
Heroin also disturbs sleep by causing frequent shifts to stage 1 NREM
sleep and wakefulness. When discontinued, there can be withdrawal
symptoms such as intense pain, runny nose and craving for more
heroin. During withdrawal from heroin, there may be 'REM rebound'
that is often accompanied by terrible nightmares.

40
47.
Q: My husband has been put on a medication to reduce pain and
swelling. Since he started taking the drug, he has complained of
insomnia. Could there be a connection?
A: Yes. Many drugs, even when properly used, can have disruptive
effects on sleep. Steroids (for example, prednisone which is used to
treat inflammation) and respiratory stimulants (for example,
theophylline which is used to treat breathing disorders) often cause
insomnia as a side effect. The best approach to insomnia caused by
the use of a needed medication is to adjust the time of the day that the
drug is taken and the dose of the medication in hopes of keeping the
desired effect and reducing the side effect of sleep disruption. Another
possibility is to have the doctor prescribe a different drug in the same
class of medications. It is always unwise to make any changes in the
way prescribed medication is taken without the doctor's supervision.
Question 55.

41
CHAPTER 6. POOR SLEEP (TOO LITTLE OR TOO MUCH)
48.
Q: How many Americans have trouble falling asleep or other
complaints of insomnia?
A: A 1991 Gallup poll found that 36% of American adults have some
type of insomnia and 9% have chronic sleep difficulty. For the 36%
with insomnia, 72% complain of waking up in the morning feeling
drowsy or tired. Other common complaints include waking up during
the night, difficulty getting back to sleep and difficulty falling asleep.
In addition to this 36%, almost everyone experiences difficulties with
poor sleep from time to time when facing problems such as a family
crisis, death of a loved one or loss of a job. These are situations in
which it is quite common -- maybe even normal -- to have difficulty
with sleep.
It is only recently that physicians and other health care workers have
begun to take the complaint of insomnia seriously. This change in
attitude has come about because of the vast numbers of people with
sleep problems and the fact that people with chronic insomnia report
significantly more problems meeting their work and family
responsibilities and have over twice as many auto accidents as people
without sleep problems.
49.
Q: I have always been a light sleeper. Lately, though, things are
really bad. The smallest noise awakens me and I cannot get back
to sleep. My friend has told me to get out of bed when I cannot
sleep and exercise until I am so tired I will have to sleep. I am
exhausted already. When I get home from work, I fall asleep in
my easy chair. What should I do?
A: Sleep experts tell us that the first thing people with this problem
should do is develop a regular schedule of sleep and wakefulness so
as to maximize the natural tendency to sleep during the night. Get up
at the same time every day, 7 days a week. Try to sleep only at night -
- no naps. Do not worry about one or two bad nights. Eventually, you
will be sleepy enough to sleep at the appropriate time and feel rested
when you wake up. Avoid stimulating foods and drinks, particularly
after dinner. Do not use alcohol for sleep -- alcohol is a very poor
sleep aid because, while it may help you feel drowsy, it wears off in 2
- 4 hours and actually wakes you up once it has been partially

42
eliminated by the body's metabolic processes. Alcohol is the leading
cause of waking up too early and being unable to get back to sleep.
If you do wake up at three in the morning and cannot get back to
sleep, try to do something quiet and, preferably, in the dark so as not
to disrupt your body's clock. Listening to relaxing music is a sensible
choice. Avoid exercise and other stimulating activities at these hours
so that, even if your 24-hour wakefulness-sleep cycle is disturbed,
your activity-inactivity cycle is preserved. If insomnia persists after
schedule regularization, get professional help.
Question 59.
50.
Q: We have moved near a major airport. The noise of the jets is
really loud. I seem to be able to sleep all right, but my wife is
miserable at night with insomnia. What should we do?
A: Loud noises during sleep such as the noises from an airport have
been shown to disrupt sleep to some extent even in people who say
that the noises do not keep them awake. This is because the normal
brain always reacts to stimuli such as sounds or touches even during
sleep. However, it is obviously true that people have lived near
airports for years with few measurable problems. If your wife's
problem persists after a couple of months, the logical thing to do is to
improve your sound insulation by insulating the bedroom, using ear
plugs, or both. If your wife still cannot acclimate to your new location
even with these measures, you had better think about moving. There
is really no long-term remedy that would be preferable to finding a
quieter location.
51.
Q: Will it help to take a hot bath or read a dull book before going
to bed?
A: For those who have occasional difficulty falling asleep, the best
advice is to do whatever helps and avoid whatever makes matters
worse. There are many reasons why someone may have trouble
falling asleep ranging from 'nerves', to trying to sleep at the wrong
time in the body's daily wakefulness-sleep cycle. So, sleep aids that
work for one person may do nothing at all for someone else. Many
people use warm baths. Quiet soporific tasks are also common -- like
counting sheep. On the other hand, it is probably not a good idea to

43
engage in exciting activity or intense physical exercise (other than
sexual activity) before bed.
Question 74.
52.
Q: My friend bought a record of sounds and special music that is
supposed to help beat insomnia. Do such records really work?
A: There is really no way to answer in general. If the record works for
you, then use it. Almost all scientific information about things that
help sleep, comes from studies of drugs. Scientifically valid
laboratory research has identified many drugs that help people sleep.
Drug companies must do this type of research before they can market
a drug that they claim to be an effective treatment for insomnia.
However, this kind of work takes years to complete and the
evaluation of a typical sleeping pill may cost several million dollars.
For obvious reasons, such laboratory research has rarely been
conducted on self-help remedies such as audio recordings. This does
not mean that such remedies do not work. Rather, it means that our
consumer protection and economic systems have led to proper sleep
laboratory evaluation only of drugs that are manufactured and sold for
the complaint of insomnia.
53.
Q: What about the old axiom, 'early to bed, early to rise'?
A: Sleep specialists would revise this old advice from Benjamin
Franklin. A better rule is 'consistently to bed and consistently to rise
makes one healthy, wealthy and wise.' Some individuals claim to be
'night people' and others 'morning people'. But if both types are free to
sleep undisturbed, night people sleep about the same as morning
people -- only at different hours. The night person sleeps beautifully
after falling asleep at 2 AM, while the day person does quite well
retiring at 10 PM.
54.
Q: I have always heard that 1 hour of sleep before midnight is
worth 2 hours of sleep after midnight. What is the basis of this old
adage?
A: Sleep is an active, highly organized sequence of events and
physiological conditions. Sleep is actually made-up of two separate
and distinctly different states: 'non-rapid eye movement sleep'

44
(NREM sleep) and 'rapid eye movement sleep' (REM sleep) or
dreaming sleep. NREM sleep is further divided into stages 1 - 4 based
on the size and speed of the brain waves generated by the sleeper.
Stages 3 and 4 NREM sleep have the biggest and slowest brain waves
and it is hard to wake people up from Stages 3 and 4 sleep. Large
spurts of growth hormone are secreted during stages 3 and 4 NREM
sleep. Because of these and other characteristics of stages 3 and 4 of
NREM sleep, this type of sleep is thought to be particularly restful. If
we go to bed at, say, 10 or 11 PM, we will perceive that our most
restful sleep occurs before midnight. However, the main point is that
the type of sleep that we believe is most restful occurs in the first few
hours of sleep -- whatever the clock time of the sleep might be.
55.
Q: My wife has arthritis and can manage pretty well during the
day, but she is so miserable at night because she cannot sleep. Is
there anything that can be done?
A: Your wife's problem is very common and will become more
common as our population continues to age. There are a number of
medications that help with pain and acceptance of pain. Some of these
interfere with sleep more than others. It may be helpful to ask a sleep
specialist to review your wife's medications to see if changes can be
made to minimize the unavoidable sleep disturbances caused by her
pain.
SEE RELATED material in Chapter 1, Questions 4 and 9 and Chapter
5, Question 47.
56.
Q: I have been on rotating shift work for ten years and never had
problems with my sleep. Lately, though, the graveyard shift is just
murder for me and I cannot seem to sleep during the day. Where
have I gone wrong?
A: Chances are that you have not gone wrong -- you have just gotten
older. People are very different in the way they handle irregularities in
their work and sleep schedules. Some people can never stand swing or
graveyard shifts. Others manage reasonably well on the night shift for
years. The newest studies show that humans can never completely
adapt to working nights and sleeping days. The best we can do is get
through periods of night work with a minimum of sleep loss. Besides
individual differences, age is the most important factor in tolerating

45
night work. Statistically, the older you are, the tougher it is to handle
any deviation from a day work - night sleep schedule.
Because we are all biologically night sleepers, a number of industries
that operate around the clock are experimenting with bright
illumination of the work environment at night in order to help push
the nighttime sleep tendency to another clock time. While this
approach is promising and has helped NASA astronauts prepare for
early morning launches, it can be prohibitively expensive in many
industries and impossible in others. Until a general method is found to
fool our sleep clock into letting us be alert all night, shift workers will
have to find individual solutions. Examine your schedule and
activities. If you cannot explain the sudden inability to handle the
graveyard shift in other ways, then you should think about
arrangements to work only the day shift.
57.
Q: I make frequent short trips to the East Coast from the West
Coast. Is it best to try to stay on West Coast time, or to adapt to
East Coast time?
A: If the trips are short and you can schedule your business during
normal West Coast business hours, do not try to adapt to East Coast
time. Adaptation would take longer than the duration of your trip.
There are other strategies that you may consider as well. For example,
if you know of an important East Coast meeting at, say, 7:00 AM --
which corresponds to 4 AM in your West Coast body, plan to go east
several days before the meeting to adapt. Alternatively, try to use East
Coast time at your home for a few days before traveling east.
58.
Q: My husband and I have a cabin in the mountains. We have
been enjoying vacations there for years. Now my husband finds
that he cannot sleep in the cabin and has grown to hate the place.
He wants to sell. How can he break his insomnia, so we can again
enjoy our second home?
A: If your husband sleeps all right at home, you should take your
husband's cabin insomnia seriously. The first thing to check is his
breathing when he sleeps in the cabin. Check to see if his breathing is
smooth and regular when he sleeps. If his breathing is irregular with
alternation between shallow breaths and deep gasps, his insomnia is

46
probably related to periodic breathing during sleep and a physician
should be consulted. Because the oxygen level in the air is reduced as
altitude increases, breathing problems of this kind develop in all
individuals at altitudes above 10,000 feet or so. However, people with
respiratory disorders such as emphysema or shortness of breath
related to obesity can develop such sleep-related breathing problems
when they go from sea level to as low as 4000 - 5000 feet. For mild
cases, doctors prescribe respiratory stimulants until people acclimate
to altitude. For serious cases, high altitudes should be avoided.
59.
Q: Is it good to exercise just before going to bed?
A: No, probably not. For all humans there is a physiological tendency
to have a major sleep bout once every 24 hours. Most of us begin this
sleep bout between 10 PM and 1 AM. Any behavior that alerts us,
such as vigorous exercise or intense intellectual and emotional
activity, will act to delay the sleep bout. People who never have
trouble falling asleep are probably oblivious to this effect. However,
for those who are frequently troubled by difficulty falling asleep, it is
wise to avoid any bedtime activity that leaves one physiologically or
mentally aroused.
Question 73.
60.
Q: My husband is always falling asleep around the house. He
seems to get a lot of sleep at night. How can I get him to be more
alert and pay more attention to me and the family?
A: Falling asleep at times when one should not fall asleep is a
dangerous symptom. If nighttime sleep is really sufficient, unintended
bouts of sleep in the day should not occur. The two most common
reasons for falling asleep inappropriately are sleep apnea and
narcolepsy. Both of these conditions can be successfully treated once
a doctor has made the diagnosis. If someone in your family falls
asleep inappropriately, get them to a doctor. If untreated, this kind of
problem can lead to car accidents, loss of job and ruined marriages.

47
61.
Q: I feel as though I have not slept a wink for days. I drag
through the day without any energy. If I do not get some sleep
tonight, I am going to go crazy. What can I do?
A: This type of sleep problem can be caused by many different things
going on in your body or in your life. Trouble getting to sleep is very
common after a crisis such as losing a loved one or a job. This kind of
insomnia may also stem from alerting compounds in your diet such as
too much, or increased sensitivity to, caffeine. Increased sensitivity or
excessive use of tobacco has also been implicated as a reason for the
symptom of insomnia. Many medicines prescribed for medical
conditions such as arthritis, asthma and heart disease can cause
insomnia. If the problem persists, see your doctor. Physicians are
taking the complaint of insomnia more seriously these days because
people with insomnia have an increased rate of problems at work and
an increased rate of accidents on the road. Find out what is keeping
you awake.
62.
Q: I fall asleep quickly, but I wake-up at 3 or 4 in the morning
and cannot get back to sleep. I am exhausted by 6 o'clock and fall
asleep just in time to be awakened by my alarm for work. What
do I do?
A: The two most common reasons for this type of insomnia, called
sleep maintenance insomnia, are depression and too much alcohol
before bed. People who are depressed may not recognize any other
problem except early morning awakening. Most doctors can diagnose
depression and begin therapy after one or two visits. The most widely
accepted theory about depression is that it is a biological imbalance
among the brain chemicals, called neurotransmitters that are used by
brain cells to signal one another. Imbalances in these chemicals
almost always affect sleep as well as mood. When the depression is
controlled, the sleep problem usually goes away. If the early morning
awakenings are due to too much alcohol before bed, the best first
approach is to stop drinking.

48
63.
Q: We just had a death in the family and a lot of the problems
have been left for me to solve. I have not been sleeping well and
the doctor prescribed some sleeping pills. Do these things work?
Will I get 'hooked' on them?
A: Sleep problems at the time of a personal crisis are very common
and may be even considered a normal part of the grief process.
Modern sleeping pills of the benzodiazepine, imidazopyridine or
orexin receptor antagonist type are often used in such 'situational
insomnia'. These kinds of drugs are safe and effective when used as
directed. In fact, short-term use during a crisis may prevent a chronic
insomnia problem from developing.
64.
Q: My husband wants to buy a new water bed because he read
that people sleep best on this type of surface. Is this really true?
A: In general, people sleep best on the surface that feels most
comfortable to them. However, the best sleep research available
shows that, after a night or two of adaptation, most people can sleep
as well on a thin pad over a concrete floor as they can on the most
elaborate mattress available. Of course, this is only true for people
who do not have muscle or skeleton problems that require particularly
soft or particularly firm surfaces to avoid discomfort.
While research has not shown that the cost or physical properties of
sleeping surfaces are major factors determining sleep quality, other
psychological factors will influence what people believe about
sleeping surfaces. For example, the more money and time invested in
a particular mattress and/or bed, the stronger will be the belief in the
superiority of this particular sleeping surface.
65.
Q: I think I have insomnia, but it is only on Sunday night. Why is
this?
A: The first thing to consider in this situation is your weekend
schedule of sleep and activity. If you are staying up later to play and
party and sleeping late on Saturday and Sunday mornings, you are
setting up perfect conditions for Sunday night insomnia. Try to go to
bed at the same time every night, seven nights a week. The body
clock controls when we are ready to sleep and when we are ready to

49
be active. For most of us, it is easy to delay sleep and the next day's
activity. However, our clocks are hard to set forward again so that we
feel like going to sleep earlier, say, on Sunday night. If schedule
irregularity is not to blame, the next thing to consider is whether you
have some apprehension about Monday's activities.
66.
Q: Are we really more likely to get sick if we do not sleep enough?
A: There are more and more studies coming out on the relationship
between sleep and disease. Some studies indicate that our body's
defenses against viral and bacterial infection are increased during
sleep. Studies have shown that, after a period of experimental sleep
deprivation, some components of the body’s immune system become
overactive and then return to normal after recovery from sleep
deprivation. Other studies have shown that the cells and chemicals of
our immune system, released as our body fights off invading germs,
actually do make us sleepy. So there may be some truth to this old
adage.
67.
Q: What are the signs indicating that someone is not getting
enough sleep?
A: Sleep deprivation studies have shown repeatedly that the early
signs of not getting enough sleep are progressive slowing of reactions
and increased numbers of brief attention lapses. If you have been
cutting back on sleep for a day or two or if you are trying to stay up
for a whole night, you are likely to miss the early signs of not getting
enough sleep. However, when you do something sedentary for more
than 10 minutes or so, particularly something that demands sustained
attention, you are likely to perform poorly.
The effects of too little sleep increase relentlessly from the time you
last slept. Brain imaging studies of volunteers who have lost about
one night’s sleep show significant reductions in basal activity
especially in the frontal areas. However, other studies have found that
when sleep deprived subjects are engaged in mental work, such as
trying to recall a previously memorized list of words, the frontal and
parietal brain areas become more active than during comparable

50
mental work when the subjects are normally rested. This increased
activity during work indicates that the brain is able to compensate to
some extent for the deleterious effects of sleep loss. But, the
compensation is certainly not perfect. One study compared the effects
of sleep deprivation with the effects of drinking alcohol. After 17
hours of continued wakefulness, a person’s performance lapses
become as frequent as they are for a person who has a blood alcohol
level of 0.08 percent -- i.e. someone who is legally drunk.
If you are sleep deprived night after night, the main tip-off is
overwhelming daytime sleepiness and inability to function
effectively. At sleep disorders centers, this is the first thing doctors
look for: Is the person impaired during the daytime? That is the basis
for deciding whether or not to intervene with drugs and other therapy.
With extreme sleep deprivation, you have frequent loss of attention,
frequent lapses in performance and accidents. Many people
experience a burning of the eyes and increased irritability. In extreme
cases, sleep during the day becomes unavoidable and people
experience sleep attacks. When they merely sit down, they fall asleep.
Such patients must force themselves to be active in order to stay
awake.
Question 79.

51
CHAPTER 7. THINGS THAT GO WRONG IN THE NIGHT
68.
Q: Just what can cause insomnia?
A: Any one of some 40 different conditions have been identified. The
most common is a psychological or psychiatric abnormality. That is
true of about half the insomniacs who come to sleep disorders centers.
The other half are people with more specific medical abnormalities.
Here are some of the most common:
- breathing difficulty during sleep such as sleep apnea
- periodic twitching of the legs and arms that disturbs sleep
- overuse of sedatives or alcohol that disrupts sleep
- stomach problems such as reflux or indigestion
- physical pain such as with arthritis or rheumatism
69.
Q: What are the best ways to treat these problems?
A: Once a specific diagnosis is made, proper treatment is aimed at the
cause of the insomnia. For example, people with insomnia secondary
to respiratory difficulty may take drugs to improve respiration during
sleep. People who have insomnia associated with overuse or abuse of
alcohol must stop drinking, and so on. Sleeping pills are best reserved
for patients who have insomnia as a reaction to some crisis. Sleeping
pills should be of the prescription variety, not the over-the-counter
kind, because there are no good studies to show that non-prescription
sleeping pills work as advertised. This is true, in part, because over-
the-counter medications are not subject to the strict requirements that
the U.S. Food and Drug Administration sets up for prescription drugs.
Sleeping pills should be taken over not more than a three-week period
-- and preferably not every night. Furthermore, the use of sleeping
pills should be supplemented with other techniques to promote sleep,
such as a regular wake-sleep schedule, regular activity after getting up
in the morning and abstinence from caffeine-containing drink and
food. The caffeine in coffee, tea or even several pieces of chocolate
after dinner can be sufficient to keep a sensitive person awake for
hours.

52
70.
Q: Can sleeping pills make matters worse?
A: Absolutely. There is no question that abuse of sleeping pills leads
to disruption of normal sleep and increased insomnia. For example, a
barbiturate taken for too long can eventually make sleep much worse
than it was during the period of insomnia that prompted taking the
drug in the first place.
Frequently, when the patient discontinues the medication or runs out
of it, terrible insomnia follows. The person cannot sleep at all for
days, and after finally falling asleep may have terrible nightmares.
This predisposes the patient to return to the barbiturate and you have a
vicious cycle of dependency and withdrawal. Still, if it is a matter of
getting a good night's sleep before a difficult examination or during a
brief family crisis, a good sleeping pill may be very useful.
71.
Q: How soon will it be before science develops a natural, non-
addictive sleeping pill that acts like the natural sleep-producing
chemicals in the brain?
A: This is an area of intense investigation, but it is too early to tell
what the results will be. Scientists are somewhat less optimistic about
a super sleeping pill than they used to be. Sleep and wakefulness are
complementary periods in a natural 24-hour cycle that cannot be
manipulated on the spur of the moment. When we fly across the
Atlantic from New York to Paris, our sleep structure as well as our
work productivity adjust slowly, over several days, to this time shift.
So, it is unlikely that taking a single pill could quickly reschedule all
aspects of our natural body rhythms.
One disappointing ‘natural’ approach for insomnia and other
problems related to jet-lag has been the specially timed use of
melatonin, a natural chemical manufactured by certain brain cells.
Melatonin is thought to be involved in regulating our body clock.
Experiments giving melatonin to people at specific times each day for
several days prior and after a long flight east or west have failed to
show any improvement.
Another approach to sleep rescheduling is exposure to bright light at a
particular time. The light should be in the form of regular sunlight or
special artificial light with an intensity of about 2500 lux (the

53
intensity of daylight just after dawn). Research indicates that people
who need to sleep at a time later than their habitual time -- either
because some disorder has shifted their schedule or because they must
work on a new schedule -- can shift by sitting in bright light for
several hours before they would normally go to bed. On the other
hand, if one wants to shift their sleep to an earlier time, light exposure
should occur just after awakening. The light is thought to reset the
biological clock. Bright light's shifting effect requires at least 2 hours
of properly scheduled exposure to a light source that is as least as
bright as dawn sunlight for 2 or 3 consecutive days.
72.
Q: Can behavior modification cure insomnia?
A: It is important to remember that there are many causes for the
symptom of insomnia. Behavioral approaches are unlikely to work if
the cause of insomnia is, for example, sleep apnea or respiratory
irregularity associated with altitude. Behavioral techniques,
particularly of the self-help variety, can be dangerous when they delay
proper diagnosis and treatment. Do not be too quick to 'psychologize'
your sleep problem -- it could be a treatable physical condition.
However, if medical problems are ruled out and the sleep problem is
chronic and psychophysiological, behavior modification often is the
best choice. There are many approaches: relaxation therapy,
biofeedback, meditation, improvement of sleep habits. A patient who
does not respond to one approach may respond to another one, so
sleep experts advise patients to continue trying until they find the
technique that works best for them, rather than to rely on exclusively
pills.
73.
Q: Is exercise helpful?
A: Yes, if it is done consistently. One day a week of exercise is likely
to disturb rather than promote sleep during the following night. But
consistent, daily exercise, preferably in the morning or at least well
before dinner, helps promote a regular wake-sleep cycle and improves
chances for a good night's sleep.

54
74.
Q: If one has trouble falling asleep, is it better to get up or stay in
bed and 'count sheep'?
A: That depends on the individual, which is why the decision as to
what to do should be guided by a professional. One approach is to
behave exactly as you would normally behave during sleeping hours -
- lie in bed and try to relax. Do not get up and do push-ups. But, if by
remaining in bed you only create a great deal of anxiety and misery
for yourself, then you should get up and try to engage in some activity
to reduce anxiety and tension. However, there is always the risk that
in getting up you may further disturb the natural 24-hour cycle of
activity and rest that is necessary for good sleep.
75.
Q: I wake up at about 3 AM every morning. Once I am awake, it
is hard or impossible for me to go back to sleep. What causes
this?
A: The most common reason for this symptom is drinking too much
alcohol too late in the evening. While alcohol near bedtime may help
with getting to sleep, its effects wear off quickly leaving one awake,
dehydrated and uncomfortable 2 - 4 hours later.
The next most common reason for early morning awakening is
depression. There are data from almost every sleep laboratory in the
country indicating that early morning awakening without being able
to return to sleep is one of the hallmarks of depression. Sleep
laboratories have found that another sign of depression is the
premature onset of REM sleep. The normal interval between falling
asleep and the first period of REM sleep is 80 - 100 minutes. Doctors
think that a premature REM sleep period -- say, 15 - 30 minutes after
sleep begins, is a sign of depression. When depression underlies the
symptom of insomnia, treatment is focused on the depression rather
than the insomnia. Once such depression is adequately treated,
problems with insomnia improve greatly.
The third most common reason is a time shift in the natural sleep
period so that one feels ready for bed at about 8 PM, rather than the
normal 10 to 11 PM. Then, an early morning awakening marks the
normal end of the sleep period. Such time shifting is especially
common in people over the age of 50 and is thought to be related to
the effects of aging on biological timing systems. If this is the cause

101 QUESTIONS ABOUT SLEEP AND DREAMS

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