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Published:May2010

TheSecretsofSleep
Frombirth,wespendathirdofourlivesasleep.Afterdecadesofresearch,werestillnotsurewhy.

ByD.T.Max

CherylDingesisa29yearoldArmysergeantfromSt.Louis.Herjobistotrainsoldiersinhandtohandcombat.SpecializinginBrazilianjujitsu,Dingessays
sheisoneofthefewwomenintheArmycertifiedatlevel2combat.Level2involvesalotoftrainingwithtwoattackersonone,sheexplains,withthehopeof
youbeingtheoneguygettingoutalive.

Dingesmayfaceanevenharderfightintheyearsahead.Shebelongstoafamilycarryingthegeneforfatalfamilialinsomnia.ThemainsymptomofFFI,as
thediseaseisoftencalled,istheinabilitytosleep.Firsttheabilitytonapdisappears,thentheabilitytogetafullnightssleep,untilthepatientcannotsleep
atall.Thesyndromeusuallystrikeswhenthesuffererisinhisorher50s,ordinarilylastsaboutayear,and,asthenameindicates,alwaysendsindeath.
Dingeshasdeclinedtobetestedforthegene.IwasafraidthatifIknewthatthiswassomethingIhad,Iwouldnottryashardinlife.Iwouldallowmyselfto
giveup.

FFIisanawfuldisease,madeevenworsebythefactthatweknowsolittleabouthowitworks.Afteryearsofstudy,researchershavefiguredoutthatina
patientwithFFI,malformedproteinscalledprionsattackthesufferersthalamus,astructuredeepinthebrain,andthatadamagedthalamusinterfereswith
sleep.Buttheydontknowwhythishappens,orhowtostopit,oreaseitsbrutalsymptoms.BeforeFFIwasinvestigated,mostresearchersdidntevenknow
thethalamushadanythingtodowithsleep.FFIisexceedinglyrare,knowninonly40familiesworldwide.Butinonerespect,itsalotlikethelessserious
kindsofinsomniaplaguingmillionsofpeopletoday:Itsprettymuchamystery.

Ifwedontknowwhywecantsleep,itsinpartbecausewedontreallyknowwhyweneedtosleepinthefirstplace.Weknowwemissitifwedonthaveit.
Andweknowthatnomatterhowmuchwetrytoresistit,sleepconquersusintheend.Weknowthatseventoninehoursaftergivingintosleep,mostofus
arereadytogetupagain,and15to17hoursafterthatwearetiredoncemore.Wehaveknownfor50yearsthatwedivideourslumberbetweenperiodsof
deepwavesleepandwhatiscalledrapideyemovement(REM)sleep,whenthebrainisasactiveaswhenwereawake,butourvoluntarymusclesare
paralyzed.Weknowthatallmammalsandbirdssleep.Adolphinsleepswithhalfitsbrainawakesoitcanremainawareofitsunderwaterenvironment.
Whenmallardduckssleepinaline,thetwooutermostbirdsareabletokeephalfoftheirbrainsalertandoneeyeopentoguardagainstpredators.Fish,
reptiles,andinsectsallexperiencesomekindofreposetoo.

Allthisdowntimecomesataprice.Ananimalmustliestillforagreatstretchoftime,duringwhichitiseasypreyforpredators.Whatcanpossiblybethe
paybackforsuchrisk?Ifsleepdoesntserveanabsolutelyvitalfunction,therenownedsleepresearcherAllanRechtschaffenoncesaid,itisthegreatest
mistakeevolutionevermade.

Thepredominanttheoryofsleepisthatthebraindemandsit.Thisideaderivesinpartfromcommonsensewhoseheaddoesntfeelclearerafteragood
nightssleep?Butthetrickistoconfirmthisassumptionwithrealdata.Howdoessleepinghelpthebrain?Theanswermaydependonwhatkindofsleepyou
aretalkingabout.Recently,researchersatHarvardledbyRobertStickgoldtestedundergraduatesonvariousaptitudetests,allowedthemtonap,then
testedthemagain.TheyfoundthatthosewhohadengagedinREMsleepsubsequentlyperformedbetterinpatternrecognitiontasks,suchasgrammar,
whilethosewhosleptdeeplywerebetteratmemorization.Otherresearchershavefoundthatthesleepingbrainappearstorepeatapatternofneuronfiring
thatoccurredwhilethesubjectwasrecentlyawake,asifinsleepthebrainweretryingtocommittolongtermmemorywhatithadlearnedthatday.

Suchstudiessuggestthatmemoryconsolidationmaybeonefunctionofsleep.GiulioTononi,anotedsleepresearcherattheUniversityofWisconsin,
Madison,publishedaninterestingtwistonthistheoryafewyearsago:Hisstudyshowedthatthesleepingbrainseemstoweedoutredundantor
unnecessarysynapsesorconnections.Sothepurposeofsleepmaybetohelpusrememberwhatsimportant,bylettingusforgetwhatsnot.

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Sleepislikelytohavephysiologicalpurposestoo:ThatpatientswithFFIneverlivelongislikelysignificant.Alotofinteresthasfocusedonwhatexactlykills
them,butwestilldontknow.Dotheyliterallydiefromlackofsleep?Andifnot,towhatextentdoessleeplessnesscontributetotheconditionsthatkill
them?Someresearchershavefoundthatsleepdeprivationimpedeswoundhealinginrats,andothershavesuggestedthatsleephelpsboosttheimmune
systemandcontrolinfection.Butthesestudiesarenotconclusive.

Inthemostfamousattempttofigureoutwhywesleep,inthe1980s,RechtschaffenforcedratstostayawakeinhisUniversityofChicagolabbyplacingthem
onadisksuspendedonaspindleoveratankofwater.Iftheratsfellasleep,thediskwouldturnandthrowtheminthewaterwhentheyfellintothewater,
theyimmediatelywokeup.Afterabouttwoweeksofthisstrictenforcementofsleeplessness,alltheratsweredead.ButwhenRechtschaffenperformed
necropsiesontheanimals,hecouldnotfindanythingsignificantlywrongwiththem.Theirorganswerenotdamagedtheyappearedtohavediedfrom
exhaustionthatis,fromnotsleeping.Afollowupexperimentin2002,withmoresophisticatedinstruments,againfailedtofindanunambiguouscauseof
deathintherats.

AtStanfordUniversityIvisitedWilliamDement,theretireddeanofsleepstudies,acodiscovererofREMsleep,andcofounderoftheStanfordSleep
MedicineCenter.Iaskedhimtotellmewhatheknew,after50yearsofresearch,aboutthereasonwesleep.AsfarasIknow,heanswered,theonly
reasonweneedtosleepthatisreally,reallysolidisbecausewegetsleepy.

Unfortunately,thereverseisnotalwaystruewedontalwaysgetsleepywhenweneedtosleep.Insomniaisatepidemiclevelsinthedevelopedworld.Fifty
to75millionAmericans,roughlyafifthofthepopulation,complainaboutproblemssleeping.Fiftysixmillionprescriptionsforsleepingpillswerewrittenin
2008,up54percentoverthepreviousfouryears.Therevenueforsleepcentersisexpectedtoapproachfourandahalfbilliondollarsby2011.Yet
remarkablylittleisbeingdonetounderstandtherootcausesofinsomnia.Mostmedicalschoolstudentsgetnomorethanfourhoursoftrainingonsleep
disorderssomegetnone.Familydoctorshealthquestionnairesoftendon'tevenaskaboutsleep.

Thesocialandeconomiccostsfromtheundertreatmentofsleeplessnessarehuge.TheInstituteofMedicine,anindependentnationalscientificadvisory
group,estimatesnearly20percentofallseriousmotorvehicleaccidentsareassociatedwithdriversleepiness.Itplacesthedirectmedicalcostofour
collectivesleepdebtattensofbillionsofdollars.Thelossintermsofworkproductivityareevenhigher.Thentherearethesoftercoststhedamagedor
lostrelationships,thejobstiredpeopledon'thavetheenergytoapplyfor,themutingofenjoymentinlifespleasures.

Ifamedicalprobleminsomelessprivate,lessmysteriousbodilyfunctionwerecausingsuchwidespreadharm,governmentswoulddeclarewaronit.Butthe
NationalInstitutesofHealthcontributesonlyabout$230millionayeartosleepresearchcomparabletotheamountthatthemanufacturersofthepopular
sleepingpillsLunestaandAmbienspentinoneseasonontelevisionadvertisingin2008.Themilitaryalsospendsmoneyinvestigatingsleep,butitsprimary
missioniskeepingsoldiersupandreadytofight,notensuringtheygetagoodnightsrest.Asaresultthefightagainstinsomniaislargelylefttodrug
companiesandcommercialsleepcenters.

SleephasbeentheRodneyDangerfieldofmedicine,saysJohnWinkelman,medicaldirectoroftheBrighamandWomensHospitalsSleepHealthCenter
inBrighton,Massachusetts.Itjustgetsnorespect.

OneearlyafternoonlastyearIpaidavisittotheSleepMedicineCenteratStanford.Theclinic,foundedin1970,wasthefirstinthecountrydevotedtothe
problemofinsomnia,anditremainsamongthemostimportant.Thesleepcenterseesover10,000patientsayearanddoesmorethan3,000overnight
sleepstudies.The18bedroomsthatpatientsoccupylookedcomfortable,thebedssoftandcozy.Themonitoringequipmentwashiddeninthefurniture.

Themaindiagnostictoolattheclinicisthepolysomnogram,themainelementofwhichistheelectroencephalograph(EEG),whichcapturestheelectrical
outputfromasleepingpatientsbrain.Asyoufallasleep,yourbrainslowsdown,anditselectricalsignaturechangesfromshortjaggedwavestolonger
rollingones,muchthewaythemovementoftheseasmoothsoutthefartheryougetfromshore.Inthebrainthesegentleundulationsareinterrupted
periodicallybyarenewalofthesuddenagitatedmentalactivityofREMsleep.Forunknownreasons,REMisthetimeduringsleepwhenwedonearlyallour
dreaming.

AstheEEGrecordsthisfitfulvoyage,thepolysomnogramtechniciansalsomeasurebodytemperature,muscleactivity,eyemovement,heartrhythms,and
breathing.Thentheylookoverthedataforsignsofabnormalsleeporfrequentwakeups.Whenapersonhasnarcolepsy,forinstance,heorsheplunges
fromwakefulnessintoREMsleepwithoutanyintermediatesteps.Infatalfamilialinsomnia,thesufferercannevergetpastthefirststagesofsleepbody

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temperaturesoarsandcrashes.

FFIandnarcolepsycannotbediagnosedwithoutEEGsandothermonitoringdevices.ButCleteKushida,theclinicdirector,toldmehecanspotmost
peoplessleepproblemsrightattheintakeinterview:Therearethosewhocannotkeeptheireyesopen,andthosewhojustspeakoftheirexhaustionbut
dontactuallynodoff.Theformeroftenhavesleepapnea.ThelatterhavewhatKushidacallstrueinsomnia.

Inobstructivesleepapneasufferers,themusclerelaxationthatcomeswithsleepallowsthesofttissueofthethroatandesophagustoclose,shuttingoffthe
sleepersairpassage.Whenthebrainrealizesitisnotgettingoxygen,itsendsanemergencysignaltothebodytowakeup.Thesleeperawakes,takesa
breath,thebrainisreplenished,andsleepreturns.Anightssleepforanapneasuffererturnsouttoreallybeahundredmicronaps.Sleepapneaisthe
behemothofthesleepcenterbusiness.BrighamandWomensJohnWinkelmansaysthatathissleepcenter,twothirdsofthoseexaminedarediagnosed
withthecondition.

Apneaisaseriousproblem,implicatedinincreasedriskforheartattacksandstroke.Butitisonlyindirectlyasleepdisease.Trueinsomniacspeople
diagnosedwithwhatsomesleepdoctorscallpsychophysiologicalinsomniaarepeoplewhoeithercantgettosleeporcantstayasleepfornoevident
reason.Theywakeupanddontfeelrested.Theyliedownandtheirbrainswhir.Thisgroupmakesupabout25percentofthoseseeninsleepclinics,
accordingtoWinkelman.TheInstituteofMedicineestimatesthatoverall,thereare30millionpeoplewiththisconditionintheUnitedStates.

Whileapneacanbetreatedwithadevicethatforcesairdownthesleepersthroattokeeptheairwaysopen,thetreatmentofclassicinsomniaisnotsoclear
cut.AcupuncturemayhelpithaslonghadthisroleinAsianmedicineandisbeingstudiedattheUniversityofPittsburghsleepcenternow.

Typically,psychophysiologicalinsomniaistreatedwithatwopartapproach.Firstcomethesleepingpills,mostofwhichworkbyenhancingtheactivityof
GABA,aneurotransmitterthatregulatesoverallanxietyandalertnessinthebody.Thoughsaferthantheyoncewere,sleepingpillscanleadtopsychological
addiction.Manyuserscomplainthattheirsleepingpillsleepseemsdifferent,andtheyfeelhungoverwhentheywakeup.Sleepingpillsarenotanatural
waytosleep,pointsoutCharlesCzeisler,directoroftheHarvardWorkHours,HealthandSafetyGroup.Pillscanmakefutureinsomniaworse,too,a
drawbackcalledreboundinsomnia.

Thesecondstepintreatingtrueinsomniacsisusuallycognitivebehavioraltherapy(CBT).InCBT,aspecializedpsychologistteachestheinsomniactothink
abouthisorhersleepproblemsasmanageable,evensolvablethatsthecognitivepartandtopracticegoodsleephygiene.Goodsleephygienemostly
amountstotriedandtrueadvice:Sleepinadarkroom,gotobedonlywhenyouaresleepy,dontexercisebeforebed.StudieshaveshownthatCBTismore
effectivethansleepingpillsattreatinglongterminsomnia,butmanysufferersarentconvinced.Somepeoplecontinueinmyexperiencetostruggle,says
Winkelman.Theyrenotsupersatisfiedwiththeirsleep.

WinkelmanthinksCBTisbetterathelpingsomekindsofinsomniacsthanothers.Insomniacoversamultitudeofconditions.BetweenFFI,whichis
extremelyrare,andapnea,whichisverycommon,therearealmost90recognizedsleepdisordersandahostofhardertocodifyreasonspeoplecan'tsleep.
Someinsomniacssufferfromrestlesslegssyndrome(RLS),anintensediscomfortintheirlimbsthatpreventsfallingasleep,orperiodiclimbmovement
disorder(PLMD),whichproducesinvoluntarykickingduringsleep.Narcolepticsoftenhavedifficultybothstayingasleepandstayingawake.Thenthereare
peoplewhocantsleepbecauseofdepression,andpeoplewhoaredepressedbecausetheycantsleep.Othershaveproblemssleepingbecauseofdementiaor
Alzheimersdisease.Somewomensleepbadlyduringtheirperiods(womenaretwiceaslikelytohaveinsomniaasmen)andmanyduringmenopause.Older
peopleingeneralsleeplesswellthanyoung.Someinsomniacscantsleepbecausetheyareonmedicationsthatkeepthemawake.Othersareworryingabout
workorsoonhavingnoworkonethirdofAmericansreporttheyhavelostsleepintherecenteconomiccrisis.Ofallthesenonsleepers,patientswith
insomniaderivedfromphysicalinternalcausesprobablyexcessesorscarcitiesofvariousneurotransmittersarelikelytheonesleastabletorespondto
thetreatment.

Yetformostoftheseconditions,CBTisofferedasapotentialcure.Perhapsthisisbecausetheproblemofinsomniawasforalongtimethepurviewmainly
ofpsychologists.Intheireyes,insomniaisgenerallycausedbysomethingtreatablethroughtheirtoolkit,usuallyanxietyordepression.Byextension,
cognitivebehavioraltherapyasksthesleepertothinkaboutwhatheorsheisdoingwrong,notwhatiswrongwithhisorherbody.Winkelmanwishesthat
thetwoaspectsofsleepthephysicalandthementalweremoreoftenconsideredjointly.Sleepisextraordinarilycomplicated,hesays.Whywouldwe
thinkthattherecouldntbesomethinginthewiringthatgoesawrytoo?

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Ifwecantsleep,perhapsitsbecauseweveforgottenhow.Inpremoderntimespeoplesleptdifferently,goingtobedatsunsetandrisingwiththedawn.In
wintermonths,withsolongtorest,ourancestorsmayhavebrokensleepupintochunks.Indevelopingcountriespeoplestilloftensleepthisway.Theybed
downingroupsandgetupfromtimetotimeduringthenight.Somesleepoutside,whereitiscoolerandtheeffectofsunlightonourcircadianrhythmis
moredirect.In2002,CarolWorthmanandMelissaMelbyofEmoryUniversitypublishedacomparativesurveyofhowpeoplesleepinavarietyofcultures.
Theyfoundthatamongforaginggroupssuchasthe!KungandEfe,theboundariesofsleepandwakingareveryfluid.Thereisnofixedbedtime,andno
onetellsanyoneelsetogotosleep.Sleepersgetupwhenaconversationormusicalperformanceintrudesontheirrestandintriguesthem.Theymightjoin
in,thennodoffagain.

Nooneindevelopednationssleepsthiswaytoday,atleastnotonpurpose.Wegotobednearafixedtime,sleepaloneorwithourpartner,onsoftcushions
coveredwithsheetsandblankets.Wesleeponaverageaboutanhourandahalflessanightthanwedidjustacenturyago.Someofourepidemicofinsomnia
orsleeplessnessisprobablyjustourrefusaltopayattentiontoourbiology.Thenaturalsleeprhythmsofteenagerswouldcallforalatemorningwakeup
buttheretheyare,startinghighschoolat8a.m.Thenightshiftworkersleepinginthemorningisfightingancientrhythmsinhisorherbodythatorderhim
orherawaketohuntorforagewhentheskyisfloodedwithlight.Yetheorshehasnochoice.

Wefighttheseforcesatourperil.InFebruary2009acommuterjetenroutefromNewarktoBuffalocrashed,killingall49aboardandoneontheground.
Thecopilot,andprobablythepilot,hadonlysporadicamountsofsleepthedayleadinguptothecrash,leadingtheNationalTransportationSafetyBoardto
concludethattheirperformancewaslikelyimpairedbecauseoffatigue.ThissortofnewsenragesHarvardsCharlesCzeisler.Henotesthatgoingwithout
sleepfor24hoursorgettingonlyfivehoursofsleepanightforaweekistheequivalentofabloodalcohollevelof0.1percent.Yetmodernbusinessethic
celebratessuchfeats.Wewouldneversay,Thispersonisagreatworker!Hesdrunkallthetime!Czeislerwroteina2006HarvardBusinessReview
article.

Startingin2004,Czeislerpublishedaseriesofreportsinmedicaljournalsbasedonastudyhisgrouphadconductedof2,700firstyearmedicalresidents.
Theseyoungmenandwomenworkshiftsthatareaslongas30hourstwiceaweek.Czeislersresearchrevealedtheremarkablepublichealthriskthatthis
sleepdebtentailed.Weknowthatoneoutoffivefirstyearresidentsadmitstomakingafatiguerelatedmistakethatresultedininjurytoapatient,hetold
meinthespringof2009.Onein20admitstomakingafatiguerelatedmistakethatresultedinthedeathofapatient.WhenCzeislercameoutwiththis
information,heexpectedhospitalstothankhim.Insteadmanycircledthewagons.HedespairsofanythingbeingdoneuntilU.S.employersgetserious
aboutinsomniaandsleepiness.Myconvictionisthatonedaypeoplewilllookbackonwhatwillbeviewedasabarbarouspractice.

Nowconsiderthesiesta.Thetimingofthetraditionalsiestacorrespondstoanaturalpostlunchdipinourcircadianrhythms,andstudieshaveshownthat
peoplewhocatnaparegenerallymoreproductiveandmayevenenjoylowerriskofdeathfromheartdisease.ItistheSpanishwhohavemadethesiesta
famous.Unfortunately,Spaniardsnolongerlivecloseenoughtoworktogohomeandnap.Insteadsomeusetheafternoonbreaktogooutforlonglunches
withfriendsandcolleagues.Havingspenttwohoursatlunch,Spanishworkersthencannotfinishworkuntilsevenoreight.Buteventhentheydontalways
gohome.Theygooutfordrinksordinnerinstead.(GotoaSpanishdiscoatmidnightandyourelikelytobedancingalonetheirprimetimeTVshowsare
justending.)

LatelytheSpanishhavebeguntotaketheproblemofsleepdeprivationseriously.Thepolicenowquestiondriversinseriousaccidentsabouthowlongthey
sleptthenightbefore,andthegovernmenthasrecentlymandatedshorterhoursforitsemployeestotrytogetthemhomeearlier.

WhathasmotivatedtheSpanishtotakeactionagainstsleepinessisnotsomuchtheiraccidentratehistoricallyamongthehighestinwesternEuropeas
theirflatproductivity.TheSpanishspendmoretimeatworkandtheirproductivityislessthanmostoftheirEuropeanneighbors.Itsonethingtolog
hours,anothertogetsomethingdone,IgnacioBuquerasyBach,a68yearoldbusinessmanwhohasspearheadedtheattempttogetSpaniardstobed
earlier,lecturedhiscountrymeninaMadridnewspaperrecently.

Everyonceinawhilewehavetocloseoureyes,Buquerastoldme.Werenotmachines.

In2006acommissionformedbyBuquerastochangethingsbecamepartoftheSpanishgovernment.TwoyearslaterIhadoccasiontogotooneofthe
commissionsmeetingsintheannextotheCongresodelosDiputados,thelowerhouseofSpainslegislativebranch.AnassortmentofmodernSpanish
grandeestestifiedtotheproblem.Theyspokeofaccidentsbytiredworkers,Spanishwomendoublyexhaustedbylongworkhoursandhouseholdduties,
andsmallchildrendeprivedoftheirpropertentotwelvehoursofsleep.Memberswereurgedtocontactthetelevisionnetworkstoseeiftheywould

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considermovingprimetimeearlier.

Buqueraskeptthemeetingmoving,exhortingthespeakerstoadheretoatelegraphicbrevity.Butthelightswerelowandtheroomwarm.Intheaudiencea
fewparticipantsheadsbegantoslumptotheirchests,thenpopbackupastheyresisted,thentheireyesclosedmorefully,theirprogramsloweringtotheir
laps,astheybegantopaybacktheirnationssleepdebt.

D.T.Maxsbook,TheFamilyThatCouldntSleep,exploresthemysteryoffatalfamilialinsomnia.MaggieSteberphotographedthestoryonmemoryintheNovember2007issueof
Geographic.

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