THE ENCYCLOPEDIA OF

SLEEP AND
SLEEP DISORDERS
 THE ENCYCLOPEDIA OF

SLEEP AND
SLEEP DISORDERS
Third Edition

Charles P. Pollak, M.D.

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

Copyright © 2010 by Charles P. Pollak, M.D.; Michael J. Thorpy, M.D.; and Jan Yager

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

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Pollak, Charles.
The encyclopedia of sleep and sleep disorders / Charles Pollak, Michael J. Thorpy and Jan Yager.
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ISBN: 978-1-4381-2577-0 (e-book) 1. Sleep disorders—Encyclopedias.
2. Sleep—Encyclopedias. I. Thorpy, Michael J. II. Yager, Jan, 1948– III. Thorpy, Michael J.
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 CONTENTS
Preface to the Third Edition vii
Preface to the Second Edition ix
Preface to the First Edition xi
Acknowledgments xiii
Important Note and Disclaimer xv
History of Sleep and Man, by
Michael J. Thorpy, M.D. xvii
The Sociology of Sleep, by
Jan Yager, Ph.D. xxxix
Psychology and Sleep: The Interdependence
of Sleep and Waking States, by
Arthur J. Spielman, Ph.D.;
Paul D’Ambrosio, Ph.D.; and
Paul B. Glovinsky, Ph.D. xlix
Entries A to Z 1
Appendix I: Sources of Information 264
Appendix II: Research Organizations 266
Appendix III: Selected Sleep Centers 269
Bibliography 271
Sociology of Sleep Bibliography 283
Index 285
About the Authors 309
 PREFACE TO THE THIRD EDITION
S ince the second edition of The Encyclopedia of
Sleep and Sleep Disorders was published in 2001,
sleep has emerged as a major growth industry. It
These social scientists are taking a fresh look at
sleep and are asking questions such as: What is the
sociological significance of where and when we
has also become a topic of keen interest among sleep? How do sleep patterns change over the life
researchers around the world and in a variety of cycle? What do our attitudes toward sleep or sleep-
disciplines including sociology, sleep medicine, related disorders say about today’s society? What
psychiatry, and psychology. From an activity do the current architectural trends in the relative
that previously received little attention com- sizes of bedrooms suggest about family roles in
pared to other health topics, sleep has become modern culture?
an issue that is discussed frequently on TV and Included in this third edition are essays from
in magazines, newspapers, and online publica- the previous editions, “History of Sleep and Man,”
tions. Fueling the concern that the public and by Michael J. Thorpy, M.D.; and “Psychology and
the health community have a better understand- Sleep: The Interdependence of Sleep and Wak-
ing of sleep is the growing awareness that some ing States,” by Arthur J. Speilman, Ph.D.; Paul
sleep disorders, such as sleep apnea, are linked to D’Ambrosio, Ph.D.; and Paul B. Glovinsky, Ph.D.
an increased likelihood of stroke, hypertension, Charles P. Pollak, M.D., coauthored this preface
or heart failure and that too little sleep can lead with Jan Yager, reviewed the A–Z section, recom-
to mistakes or accidents at work, mood swings, mended the editing of certain entries that had
greater chance of obesity, and drowsy driving, been found to be less effective than previously
which is associated with traffic accidents, injuries, thought, expanded others, and coauthored new
and fatalities. According to the National Institutes entries with Jan Yager.
of Health (NIH), sleep disorders cost consumers The list of sleep centers and clinics throughout
$15 billion in health care expenses and $50 bil- the United States included in this third edition is
lion in lost productivity. much shorter than in previous editions. This is
New to the third edition of this encyclopedia in recognition of the increased importance of the
are longer entries on sleep, sleep disorders, aging Internet in providing up-to-date information, espe-
and sleep, drugs and sleep, and treatment of sleep cially since changes occur with rapid speed. The
disorders. These are arranged alphabetically in American Academy of Sleep Medicine (AASM),
the A–Z section. Also new to this third edition is which accredits sleep centers and laboratories,
an original essay, on The Sociology of Sleep, by offers updated listings free of charge through its
coauthor and sociologist Jan Yager, Ph.D. Her essay site: www.sleepcenters.org. The National Sleep
brings a multidimensional perspective to the topic Foundation also offers a list of sleep centers
as she discusses recent groundbreaking studies by through its Web site: www.sleepfoundation.org.
sociologists both in the United States and abroad. The reference sections in the back of the book

vii
viii The Encyclopedia of Sleep and Sleep Disorders

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

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

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

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

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

F ew physiological conditions have received as

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

xvii
xviii The Encyclopedia of Sleep and Sleep Disorders

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Whereas Ranson and his collaborators held that Chronobiology

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

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

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

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

W e spend approximately one-third of each

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

xxxix
xl The Encyclopedia of Sleep and Sleep Disorders

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

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

Work-Related Stress and antianxiety medications, her sleep problems

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

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

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

Rights Bed sharing is a complicated social process and

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

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

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

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

T he focus of psychology is behavior, which at

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

xlix
l The Encyclopedia of Sleep and Sleep Disorders

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

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

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

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

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

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

1
2 accreditation standards for sleep disorder centers

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

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

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

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

activity-rest cycle Term used to describe the

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

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

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

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

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

Sudden Infant Death Syndrome Children

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

body temperature See TEMPERATURE.

blue light It has long been known that the

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

brain-wave rhythms A lay term that is often used

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

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

carbon dioxide Gas produced as a result of body

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

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

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

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

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

such as cerebrovascular disease or cardiovascular APNEA SYNDROME. In some patients, it may be nec-
disorders that produce an increased circulation essary to insert an intraesophageal balloon in order
time, are typically associated with the Cheyne- to measure pressure changes so that obstructive
Stokes pattern of ventilation. Such patients may apneic events can be differentiated from central
have complaints of insomnia due to the arousals apneas, because standard polysomnography may
that are associated with the crescendo ventilatory not clearly differentiate the two disorders.
pattern. Other causes of insomnia must be distinguished
Central apnea is apt to occur in infants who from insomnia due to the central sleep apnea syn-
are prematurely born, or for unexplained reasons drome, particularly in elderly patients. As patients
in the neonatal period. Such central sleep apnea with NARCOLEPSY have an increased incidence of
generally subsides spontaneously in the first six central sleep apnea, consideration must be given to
months of age; however, there is an increased risk this diagnosis in patients presenting with the com-
for SUDDEN INFANT DEATH SYNDROME in infants who plaint of excessive sleepiness.
suffer central sleep apnea syndrome. Treatment of central sleep apnea syndrome is
The prevalence of central sleep apnea syndrome primarily by pharmacological or mechanical means.
in the general population is unknown; but certain Recent reports have indicated that some patients
patient groups have a higher predisposition, such with central sleep apnea syndrome may respond
as those with neuromuscular disorders, and there is favorably to the nasal CONTINUOUS POSITIVE AIRWAY
also an increased prevalence in the elderly. PRESSURE (CPAP) device that typically is used for
The presence of central sleep apnea syndrome is patients with obstructive sleep apnea syndrome. As
usually determined by all-night POLYSOMNOGRAPHY, CPAP is a relatively easily applied treatment, it is
and typically most apneic events last from 10 to worthwhile attempting treatment with this device
30 seconds. However, episodes as long as several before trying other treatment modalities.
minutes in duration can sometimes be seen. Asso- Pharmacological treatments include the use of
ciated with the apneic episodes is a reduction of the RESPIRATORY STIMULANTS such as medroxyprogester-
oxygen saturation value and an increase in CARBON one or acetazolamide. These drugs may be partially
DIOXIDE levels. There may be CARDIAC ARRHYTHMIAS effective but rarely will totally eliminate moderate
that are characterized by BRADYCARDIA during the to severe central sleep apnea syndrome. The tricy-
apneic episodes. Bradycardia is a particular feature clic ANTIDEPRESSANT medication protriptyline may
of central apnea in infants. be helpful in some patients, particularly those who
A MULTIPLE SLEEP LATENCY TESTING may demon- have mainly ventilatory impairment during REM
strate excessive daytime sleepiness if the central SLEEP.
apneas are frequent enough to cause severe sleep Assisted ventilation devices—such as a NEGA-
disruption. TIVE PRESSURE VENTILATOR, the cuirass—are usu-
Obesity will exacerbate central sleep apnea ally required for patients who have severe central
syndrome by impairing the ventilation-perfusion sleep apnea syndrome. This ventilator may induce
because of underperfused basal portions of the obstructive sleep apnea episodes in some patients
lung. Occasionally patients with severe central and therefore should be used with caution. Some
sleep apnea syndrome will have abnormal daytime patients may require the use of a positive pressure
blood gases that are improved by treatment of the ventilator applied either through a TRACHEOSTOMY
SLEEP-RELATED BREATHING DISORDER. As a result of or a nasal mask.
the oxygen desaturation during sleep, pulmonary Treatment of any underlying exacerbating disor-
hypertension and right-sided heart failure may ders should also be encouraged. For example, the
develop, which further impairs circulation time, treatment of cardiac failure may greatly improve
thereby exacerbating the apnea. central sleep apnea syndrome that is due to neuro-
Patients with central sleep apnea syndrome logical disorders. Weight reduction is also an essen-
need to be differentiated from those with other tial part of management for any obese patient who
sleep-related disorders, such as OBSTRUCTIVE SLEEP has a sleep-related breathing disorder.
48 cephalometric radiograph

cephalometric radiograph An X-ray of the head The sleep disturbance can be severe and is often
performed in a standardized manner so that com- associated with increasing severity of the under-
parative skeletal measurements can be made. The lying disorder. As some of these disorders, such
patient is usually placed in a sitting position with as torsion dystonia, occur in childhood, the sleep
the head in a natural position, the teeth together, disturbance can be present from an early age. Typi-
the lips relaxed and the X-ray film placed next to cally the movement disorders are present only in
the left side of the face, with the X-ray beam exactly light, non-REM sleep and are suppressed by the
five feet from the film. These X-rays are used for deeper stages of sleep. In the early stages of some
analysis of cranial and mandibular changes, for the cerebral degenerative disorders, abnormal move-
assessment of skeletal abnormalities and for other ments may be difficult to differentiate from move-
medical and dental evaluations. ments due to hysteria. However, the occurrence of
Cephalometric radiographs are also performed abnormal movements during the lighter stages of
in sleep medicine, primarily for determining skel- sleep is often a diagnostic feature of the movement
etal and soft tissue features in patients who have disorders because voluntary motor activity usually
the OBSTRUCTIVE SLEEP APNEA SYNDROME. Specific decreases with the onset of sleep.
abnormalities that have been seen in obstruc- Other sleep disorders that are characterized by
tive sleep apnea syndrome patients include an abnormal movements are frequently present in
increased mandibular plane to hyoid bone distance patients with cerebral degenerative disorders, such
(MP-H); also, the posterior airway space (PAS) is as FRAGMENTARY MYOCLONUS, PERIODIC LEG MOVE-
often narrowed. The position of the maxillary bone MENTS, and increased muscle activity during REM
and mandible can be determined by two angles sleep, which is seen in the REM SLEEP BEHAVIOR
(the SNA and SNB angles), which, if less than 80 DISORDER. There may also be abnormalities of the
degrees, suggest a maxillary or mandibular defi- upper airway muscles leading to sleep-related
ciency. Such deficiencies may be commonly seen breathing disorders, such as the OBSTRUCTIVE SLEEP
in patients with obstructive sleep apnea syndrome APNEA SYNDROME.
who are not obese. Typically, POLYSOMNOGRAPHY will demonstrate
Many SLEEP DISORDER CENTERS use cephalometric the abnormal movement activity, reduced amounts
radiographs in the routine evaluations of patients of slow wave and REM sleep, and abnormal eye
with obstructive sleep apnea syndrome. This movements, particularly in those degenerative
information is often used to determine whether disorders that affect eye movements. In addition,
corrective surgical treatment, such as UVULOPALA- there may be reduced SLEEP SPINDLE activity, which
TOPHARYNGOPLASTY or MANDIBULAR ADVANCEMENT is commonly seen in patients with Rett syndrome,
SURGERY, is indicated. or there may be increased sleep spindle activity
as has been reported in the dystonias. The spino-
cerebellar degenerations are often associated with
cerebral degenerative disorders Slowly progres- central or obstructive sleep apnea syndrome. Rett
sive disorders of the CENTRAL NERVOUS SYSTEM syndrome may demonstrate an electroencephalo-
that are often associated with abnormal move- graphic pattern that is similar to the changes seen
ments and behaviors. These disorders include in some forms of EPILEPSY.
Huntington’s disease, the dystonias, olivoponto- The cerebral degenerative disorders are diag-
cerebellar degeneration, hereditary ataxias, PAR- nosed by investigations, such as brain imaging or
KINSONISM, dementias and Rett syndrome. Sleep an ELECTROENCEPHALOGRAM (EEG).
disturbances—characterized both by difficulty in The cerebral degenerative disorders need to be
maintaining sleep and by EXCESSIVE SLEEPINESS—are differentiated from PSYCHIATRIC DISORDERS or the
typical of cerebral degenerative disorders. There effects of central nervous system depressant medi-
may be concurrent abnormal movement activ- cations. The abnormal limb activity during sleep
ity that occurs during sleep as well as CIRCADIAN has to be distinguished from other sleep disorders
RHYTHM SLEEP DISORDERS. characterized by limb movement, such as the
 chronic fatigue syndrome 49

PERIODIC LIMB MOVEMENT DISORDER or REM SLEEP istration of a continuous flow of oxygen or the use
BEHAVIOR DISORDER. of RESPIRATORY STIMULANTS, such as acetazolamide.
The treatment of the sleep disorder depends on
the underlying cause of the movement disorder,
but very often the sleep disturbance is pervasive childhood onset insomnia See IDIOPATHIC
and therefore SLEEP HYGIENE measures, plus the use INSOMNIA.
of NEUROLEPTICS, are necessary in order to produce
a state of restfulness at night.
chloral hydrate (Noctec) See HYPNOTICS.

Chase, Michael H. Has a B.A. in zoology and soci-

ology from the University of California at Berkeley cholecystokinin (CCK) A group of peptides, of
and a Ph.D. in physiology from the University of approximately 33 amino acid residues long, that
California at Los Angeles. Professor emeritus in the originally was found in the gastrointestinal tract
Department of Physiology of the School of Medi- but more recently has been discovered to be pres-
cine of the University of California in Los Angeles, ent in the central nervous system. Cholecystokinin
Dr. Chase (1937– ) has conducted extensive sleep (CCK) is primarily found in the cerebral cortex,
research. hypothalamus and the basal ganglia. It has been
Dr. Chase’s term as president of the World shown to reduce SLEEP LATENCY but has very little
Federation of Sleep Research Societies was from effect on SLEEP STAGES. The soporific effect of a big
1988 to 1992. His term as president of the Sleep meal may be mediated through the large increase
Research Society ended in 1990. He was active in of cholecystokinin that occurs following meals.
the Association of Professional Sleep Societies and, Cholecystokinin may have its greatest effect as
from 1987 to 1990, served as a member of the a behavioral SEDATIVE that allows sleep to occur,
Board of Directors and on the Finance and Govern- rather than by any direct effect on inducing sleep.
mental Affairs Committees. (See also DELTA SLEEP INDUCING PEPTIDE, DIET AND
SLEEP, FACTORS, MURAMYL DIPEPTIDE, SLEEP-INDUCING
FACTORS.)
Cheyne-Stokes respiration A pattern of breath-
ing described by John Cheyne and William Stokes
in 1818 that is characterized by a regular crescendo chronic fatigue syndrome (CFS) A condition that
and decrescendo fluctuation in respiratory rate according to the Centers of Disease Control and
and volume. This breathing pattern can occur dur- Prevention affects between 1 million and 4 mil-
ing wakefulness, but it is most commonly seen in lion Americans. It is difficult to diagnose because
DROWSINESS and can persist into non-REM sleep it shares symptoms with many other disorders. For
(see SLEEP STAGES). Cheyne-Stokes breathing usu- example, the primary symptom, FATIGUE, is found
ally does not occur during REM SLEEP. in hundreds of illnesses. However, the fatigue asso-
Cheyne-Stokes respiration has been associated ciated with CFS is not the kind of fatigue patients
with a change in circulation time that may be experience after a particularly busy day or week,
induced by cardiovascular disease. It also has been a sleepless night, or a stressful event. The Centers
associated with intracerebral disease, such as might for Disease Control defines CFS as a “severe, inca-
occur as a result of strokes. The periodic pattern of pacitating fatigue that isn’t improved by bed rest
breathing produces wide fluctuations in blood oxy- and that may be exacerbated by physical or men-
gen and CARBON DIOXIDE levels, which can induce tal activity. It is an all-encompassing fatigue that
an AROUSAL at the peak of the crescendo respira- results in a dramatic decline in both activity level
tory pattern. INSOMNIA, characterized by arousals and stamina.” People with CFS tend to function at
and awakening, may occur due to Cheyne-Stokes a significantly lower level of activity than they were
respiration, and treatment may involve the admin- capable of prior to becoming ill. The illness results
50 chronic insomnia

in a substantial reduction in occupational, personal, order to breathe more easily. Some of the sleep
social, or educational activities. A CFS diagnosis disturbance may be due to MEDICATIONS that are
should be considered in patients who have six required to improve breathing, which often have
months or more of unexplained fatigue accom- a stimulant effect, thereby adding to the complaint
panied by other characteristic symptoms. These of insomnia.
symptoms include cognitive dysfunction, including Typically during sleep, patients with chronic
impaired memory or concentration; postexertional obstructive pulmonary disease will demonstrate a
malaise lasting more than 24 hours (EXHAUSTION and reduction in TIDAL VOLUME, with increasing HYPOX-
increased symptoms) following physical or mental EMIA or elevation of the carbon dioxide level in
exercise; unrefreshing sleep; joint pain (without the bloodstream. This particular pattern is more
redness or swelling); persistent muscle pain; HEAD- common in patients called “blue bloaters,” who
ACHES of a new type or severity; tender cervical or have evidence of right-sided heart failure due to
axillary lymph nodes; and sore throat. In addition pulmonary hypertension and an increase in the
to the eight primary defining symptoms of CFS, a blood hemocrit level. Patients who are blue bloat-
number of other symptoms have been reported by ers usually suffer severe oxygen desaturation dur-
some CFS patients. The frequency of occurrence ing sleep.
of these symptoms varies among patients. These A second group called “pink puffers” charac-
symptoms include psychological problems such as teristically has shortness of breath associated with
DEPRESSION, irritability, mood swings, ANXIETY, and increased lung volumes. The hypoxemia and eleva-
panic attacks, along with weight loss or gain. tion of carbon dioxide levels during sleep is not as
Treatment of CFS symptoms includes taking severe as that seen in blue bloaters.
painkillers to ease the headache, as well as muscle Chronic obstructive pulmonary disease can be
and joint pain; antispasmodics and antidiarrheal due to a variety of disorders, such as respiratory
preparations to relieve various gastrointestinal infections or bronchopulmonary dysplasia; how-
complaints; and antidepressants to improve the ever, the most common cause in adults is chronic
patient’s mood, relieve pain, and help him or her SMOKING.
sleep. Patients can also try gentle exercise, acu- POLYSOMNOGRAPHY demonstrates a prolonged
puncture, massage, deep breathing, meditation, SLEEP LATENCY and frequent awakenings during the
BIOFEEDBACK, yoga, and tai chi. major sleep episode. Some patients may be unable
to lie flat during sleep because of severe shortness
of breath and therefore polysomnography may
chronic insomnia See LONG-TERM INSOMNIA. need to be performed with the patient in a semi-
recumbent position. There is typically a reduction
of SLOW WAVE SLEEP as well as REM sleep with frag-
chronic obstructive pulmonary disease Also mentation of the sleep stages—particularly REM
called CHRONIC OBSTRUCTIVE RESPIRATORY DISEASE; sleep, due to oxygen desaturation. Obstructive and
this is a respiratory disorder characterized by a central apneic events may occur concurrently with
chronic impairment of airflow through the respira- the sleep-related hypoxemia. CARDIAC ARRYTHMIAS
tory tract. This disorder can disrupt sleep due to the may be associated with the hypoxemia or may
altered cardiorespiratory physiology. Persons with occur independently. A MULTIPLE SLEEP LATENCY TEST
chronic obstructive pulmonary disease frequently may demonstrate a reduced mean sleep latency,
will complain of disturbed sleep and INSOMNIA. particularly in patients with frequent nocturnal
The sleep disturbance that occurs is typically sleep disruption or a complaint of EXCESSIVE SLEEPI-
one of difficulty in initiating sleep, and there are NESS during the day.
frequent AWAKENINGS at night, often with the The sleep disturbance of a patient with chronic
sensation of shortness of breath and difficulty obstructive pulmonary disease needs to be dif-
in breathing. There may be excessive coughing ferentiated from other causes of complaints of
during sleep and the need to get out of bed in insomnia. Anxiety and DEPRESSION, or PSYCHOPHYSI-
 circadian rhythms 51

ological insomnia, may coexist with the chronic chronotherapy  Treatment developed by Charles
obstructive pulmonary disease. Acute anxiety due Czeisler in 1981 to correct the displaced sleep period
to an exacerbation of lung disease may produce an of patients with the circadian rhythm sleep disorder
adjustment sleep disorder. of delayed sleep phase syndrome. The treatment
The blue bloater form of chronic obstructive involves a progressive delay of a sleep period so the
pulmonary disease is similar to central alveolar major sleep period is rotated around the clock to an
hypoventilation syndrome. It may be difficult to improved sleep onset time. For example, prior to
differentiate the two disorders if the history of shifting the sleep period an individual who is unable
development of chronic obstructive pulmonary to fall asleep before 3 a.m. would be instructed to
disease is unknown. maintain a regular sleep onset time at 3 a.m., sleep-
Treatment involves ensuring optimum treat- ing for eight hours until 11 a.m., for a period of five
ment of the chronic obstructive pulmonary disease. days. After the five-day stabilization period, the
Stimulant bronchodilator medications, used for the patient would be instructed to go to bed three hours
treatment of the lung disease, should be reduced later, and arise three hours later each day until the
to effective but not excessive doses. If obstructive sleep onset time reaches a more appropriate time
sleep apnea syndrome or central sleep apnea syn- at night. Depending upon the amount of time that
drome is present, or even alveolar hypoventilation, the sleep period is displaced, the process of shift-
the use of a continuous positive airway pressure ing the sleep periods takes about six to seven days.
device (CPAP), with or without the addition of low Once having reached a more desirable sleep onset
oxygen therapy, may be helpful. Such treatment is time, the patient is instructed to maintain a regular
best performed under polysomnographic monitor- bedtime and arise eight hours later so that the sleep
ing. Attention should be given to sleep hygiene period can become stabilized at the new sleep onset
measures, and other lifestyle changes should be and awake times.
strongly recommended, such as weight reduction Some patients find they are able to maintain the
and avoidance of smoking. improved timing of the sleep episode; however,
others will find that they drift to a later period of
time and may require a repeat course of chrono-
chronic obstructive respiratory disease  See therapy in order to reestablish more appropriate
chronic obstructive pulmonary disease. sleep onset and wake times.
The same process of shifting the sleep by three
hours has been applied successfully to one patient
chronic paroxysmal hemicrania (CPH)  A cluster- with advanced sleep phase syndrome, who rotated
like headache more common in females, it consists the sleep period in an anticlockwise direction.
of multiple severe short headaches affecting one
side of the cranium. The pain associated with CPH
may cause someone to wake up from sleep. It is circadian rhythms  The term proposed by Franz
treated with a nonsteroidal antiinflammatory drug Halberg in 1959 to describe endogenous rhythms
such as indomethacin. that had a period length of about 24 hours. The
term was coined from the Latin circa, meaning
“about,” and dies, meaning “a day.” Although most
chronobiology  The scientific study of biological circadian rhythms are 24 hours in duration, the
rhythms. Biological rhythms can have markedly term was originally applied to the endogenous
varying period lengths, from less than a second rhythms that run in humans at a slightly longer
for heart rate to as long as a year for hiberna- period of approximately 25 hours. Environmental
tional cycles in animals. In humans, the biological time cues prevent the true period length of the
rhythms of approximately one day are those that underlying circadian rhythm from becoming mani-
are commonly referred to under the term circa- fest, so the circadian rhythm length is maintained
dian rhythms. at 24 hours. Without environmental time cues
52 circadian rhythm sleep disorders

sleep onset would occur on average one hour later an organism’s internal physiological processes with
and we would awaken one hour later. Therefore, its environmental daily events. (See also BIOLOGI-
we would live on a 25-hour-long day. (See also CAL CLOCKS, CHRONOBIOLOGY, CIRCADIAN RHYTHMS.)
ENDOGENOUS CIRCADIAN PACEMAKER, FREE RUNNING,
TEMPORAL ISOLATION.)
circasemedian rhythm A chronobiological term
applied to a rhythm that has a PERIOD LENGTH
circadian rhythm sleep disorders Previously of about half a day, as opposed to a CIRCADIAN
called sleep-wake schedule disorders, these are dis- RHYTHM, which has a period length of one full day.
orders of the timing of sleep within the 24-hour day. An example of a circasemedian rhythm is seen in
These disorders were originally grouped together in the tendency for sleepiness that peaks not only
the first edition of the “Diagnostic Classification of at night but also in the mid-afternoon. (See also
Sleep and Arousal Disorders,” published in 1979 in CHRONOBIOLOGY.)
the journal Sleep. The disorders were divided into
two groups—transient and persistent.
The main disorders in the transient group clinical polysomnographer Specialist trained in
include TIME ZONE CHANGE (JET LAG) SYNDROME and the clinical interpretation of the results of the
SHIFT-WORK SLEEP DISORDER. The five persistent POLYSOMNOGRAMS of patients with a wide variety
circadian rhythm sleep disorders are: FREQUENTLY of sleep disorders. This term has now been super-
CHANGING SLEEP-WAKE SCHEDULE, DELAYED SLEEP seded by the term “sleep specialist” (see SLEEP SPE-
PHASE SYNDROME, ADVANCED SLEEP PHASE SYNDROME, CIALIST). Most clinical polysomnographers work in
NON-24-HOUR SLEEP-WAKE SYNDROME, and IRREGU- full-service SLEEP DISORDER CENTERS. Certification
LAR SLEEP-WAKE PATTERN. In all of these disorders, in clinical polysomnography was a requirement
there is an alteration in the timing of sleep in that for the accreditation of sleep disorder centers by
it is either advanced, delayed or occurs irregularly the American Sleep Disorders Association (now
during a 24-hour period. Some of these disorders the AMERICAN ACADEMY OF SLEEP MEDICINE). The
are related to an irregularity or disruption of the new examination for sleep specialists is run by the
normal ENVIRONMENTAL TIME CUES and are thereby AMERICAN BOARD OF SLEEP MEDICINE.
thought to be of socio-environmental cause. Other A clinical polysomnographer usually had clini-
circadian rhythm sleep disorders suggest a defect cal training in one of the medical sciences, most
in the intrinsic mechanism of the circadian pace- commonly medicine, but also in psychology or
maker or its mechanism of entrainment (ability other clinical specialties. The American Sleep Dis-
to keep to a set pattern) and hence are thought to orders Association held a CLINICAL POLYSOMNOGRA-
be of endogenous or organic cause. Recently, new PHER EXAMINATION to certify competence in clinical
types of chronobiological tests have become avail- polysomnography. An applicant who successfully
able, such as the CONSTANT ROUTINE, that can deter- passed the examination was certified in clinical
mine whether the abnormality in the circadian polysomnography and received an ACCREDITED
pacemaker is of endogenous etiology. CLINICAL POLYSOMNOGRAPHER (ACP) degree. (See
Some of the circadian rhythm sleep disorders, also ACCREDITATION STANDARDS FOR SLEEP DISORDER
such as delayed sleep phase syndrome, have been CENTERS, AMERICAN ASSOCIATION OF SLEEP TECH-
subtyped into an intrinsic type, in which the circa- NOLOGISTS, ASSOCIATION OF PROFESSIONAL SLEEP
dian pacemaker or its mechanism is believed to be SOCIETIES, POLYSOMNOGRAPHY.)
abnormal, and an extrinsic type, in which socio-
environmental factors appear to be responsible.
clinical polysomnographer examination A test
given by the AMERICAN ACADEMY OF SLEEP MEDICINE
circadian timing system The physiological system (formerly the American Sleep Disorders Associa-
responsible for measuring time and synchronizing tion) in order to assure competence and knowledge
 cognitive focusing 53

of the basic and clinical science of sleep disorders congestion that can exacerbate the OBSTRUCTIVE
medicine. The first examination for clinical poly- SLEEP APNEA SYNDROME.
somnographers was held in 1978 and tests are held
yearly. Applicants who passed the clinical polysom-
nographer examination became ACCREDITED CLINI- codeine Drug shown to improve alertness in
CAL POLYSOMNOGRAPHERS (ACP). The examination patients with EXCESSIVE SLEEPINESS. It can achieve
is now called the board examination in sleep medi- this without the side effects of CENTRAL NERVOUS
cine and is administered by the AMERICAN BOARD SYSTEM or peripheral stimulation. However, side
OF SLEEP MEDICINE. effects such as constipation and the potential for
The clinical polysomnographer examination drug abuse may occur.
consisted of two parts held four months apart. One In doses of 30 to 180 milligrams per day, codeine
part of the examination tested competence in the phosphate is effective in the treatment of NARCO-
basic sciences of sleep, disorders of sleep, biological LEPSY but is rarely used because other STIMULANT
rhythms and CHRONOBIOLOGY, and other medi- MEDICATIONS, such as methylphenidate, dextro-
cal disorders that affect sleep. The other part was amphetamine, and MODAFINIL, are more effective.
a practical examination that tested the ability to However, codeine may be useful for patients who
interpret sleep studies and score sleep recordings. are unable to tolerate these other central nervous
(See also POLYSOMNOGRAPHY, SLEEP DISORDER CEN- system stimulants.
TERS, SLEEP DISORDERS MEDICINE.)

cognitive effects of sleep states Recall of infor-

clomipramine (Anafranil) See ANTIDEPRESSANTS. mation presented during an awakening from SLOW
WAVE SLEEP is not as good as when the information
is presented following an awakening from REM
clonazepam (Klonopin) See BENZODIAZEPINES. sleep. Learned material is better remembered after
a sleep episode than following a similar duration of
WAKEFULNESS. This ability to retain information bet-
cluster headaches Severe unilateral headaches ter following sleep has been seen as support for the
felt behind the eye. The headaches produce auto- interference theory of forgetting (ITF). Some stud-
nomic dysfunction in the region around the eye. ies have suggested that there is better retention for
Cluster headaches predominantly occur in asso- the first half of the night compared with the second
ciation with REM sleep at night. Other symptoms half. However, the difference in the ability to recall
include nasal stuffiness, rhinorrhea and unilat- learned information following sleep compared with
eral forehead sweating. (See also SLEEP-RELATED wakefulness is very small and does not appear to
HEADACHES.) be long-lasting.
Brain activity is high during the REM stage of
sleep and hence DREAM recall is often very vivid
cocaine Drug derived from the leaves of the coca and complex. Some mental activity does occur
plant; used illegally by drug abusers for its euphoric during slow wave sleep but dream recall is greatly
effects. This drug is an amino-alcohol base closely reduced compared with REM sleep. (See also
related to tropine, the amino alcohol in atropine. It LEARNING DURING SLEEP, SLEEP STAGES.)
has been used in medicine for many years as a local
anesthetic, particularly for ophthalmological proce-
dures. Cocaine can have pronounced effects upon cognitive focusing A technique used in the man-
sleep due to its stimulation of the central nervous agement of INSOMNIA that involves focusing on
system; it produces RESTLESSNESS and INSOMNIA. reassuring thoughts. Patients with insomnia typi-
There is also some evidence to suggest that the cally awaken at night and are unable to return
chronic nasal ingestion of cocaine induces a nasal to sleep because they are haunted by recurring
54 coma

unpleasant thoughts. Cognitive focusing involves Another coma pattern is called theta coma and
learning to focus on reassuring thoughts and pleas- is characterized by typical 4-to-7-hertz theta activ-
ant images so that sleep is more likely to occur. ity that is superimposed on a low voltage delta
(See also BEHAVIORAL TREATMENT OF INSOMNIA, DIS- pattern of activity. This particular pattern is often
ORDERS OF INITIATING AND MAINTAINING SLEEP, HYP- indicative of a disruption of brain stem reticular
NOSIS, PSYCHOPHYSIOLOGICAL INSOMNIA.) pathways to the thalamus and is highly predictive
of a poor outcome—typically, death.
With all forms of coma, the occurrence of a
coma A state of psychological unresponsiveness normal sleep-wake pattern, or presence of non-
that is different from sleep or WAKEFULNESS. The REM/REM cycling, is typically associated with
primary difference from sleep is that there is no psy- an improved prognosis. (See also NON-REM-STAGE
chologically understandable response to an external SLEEP, STAGE TWO SLEEP, UNCONSCIOUSNESS.)
stimulus, or to an inner need. Patients in acute coma
may look as if they are asleep; however, this state
never lasts more than two or four weeks, no matter conditioned insomnia An essential part of PSY-
how severe the brain injury. Patients in sleeplike CHOPHYSIOLOGICAL INSOMNIA that develops through
coma then pass into a chronic state of unrespon- a process of negative associations between the
siveness in which they appear to be awake but lack usual sleep environment and sleep patterns. A
cognitive mental ability. This state has variously prior episode of poor quality sleep leads to the
been termed vegetative state, akinetic mutism, coma vigil development of the negative associations, which
or the apallic syndrome. Coma can be the result of produce the conditioned insomnia, a learned pat-
chemical toxicity that affects the whole central ner- tern of poor quality sleep. For instance, if a person
vous system, or it may result from extensive damage has difficulty falling asleep in his or her bedroom,
to the cerebral hemispheres or the brain stem. the person may come to believe sleep is difficult
Normal sleep-wake patterns and cycling of REM or impossible there. Also, a person who frequently
and NREM sleep usually do not occur in patients reads or works in bed may have difficulty in accept-
with acute coma until they pass into the chronic ing the bed as a sleeping place.
vegetative state where the pattern of sleep and
wakefulness usually returns. There are several
forms of coma in which the electroencephalo- confusional arousals Episodes of mental con-
graphic pattern differs. The more typical form of fusion that typically occur during arousals from
acute coma and coma due to metabolic or pharma- sleep. These episodes most often occur with arous-
cological causes has a 1-to-5-HERTZ slow wave EEG als from DEEP SLEEP in the first third of the night.
pattern. A form of coma termed alpha coma has a The individual usually sits forward in bed and feels
pattern of nonreactive alpha activity that is not disoriented in time and space, with behavior that
blocked by eye opening or other sensory stimuli. may be inappropriate, such as picking up a phone
This particular form of coma is most often due to to speak into it in response to a ringing alarm clock.
brain stem lesions at the level of the pons or to There may also be slowness in speech and thought.
post-anoxic encephalopathy. Responses to commands and questions are often
A form of coma called spindle coma occurs in slow and inappropriate. Episodes may last from
approximately 6 percent of all comatose patients; several minutes to several hours.
it is characterized by the presence of 14 hertz SLEEP Confusional arousals were first mentioned by
SPINDLES with vertex sharp waves and K COMPLEXES Roger J. Broughton in 1968 in his classic article on
superimposed on a background of slower delta and the arousal disorders. Other terms that have been
theta activity. The sleep spindle activity resembles applied to confusional arousals are sleep drunken-
that seen in stage two sleep. This form of coma ness, excessive sleep inertia and Schlaftrunkenheit (in
appears to result from interruption of the ascend- the German literature) and l’ivresse du sommeil (in
ing reticulo-thalamo-cortical pathways. the French literature).
 constant routine 55

The confusional arousals are thought to be ries from objects or furniture near the bedside. (See
related to an abnormality of the normal arousal also AROUSAL DISORDERS.)
mechanism during sleep. The abnormality may
be a defect of the ASCENDING RETICULAR ACTIVATING
SYSTEM (ARAS). congenital central alveolar hypoventilation syn-
Confusional arousals are most typical in child- drome (CCHS) See CENTRAL ALVEOLAR HYPOVENTI-
hood, often before puberty, less common in older LATION SYNDROME.
children or adolescents and even rarer in adults.
Episodes may be precipitated by conditions that
predispose the individual to excessive FATIGUE, such congestive heart failure The inability of the
as SLEEP DEPRIVATION or an altered sleep-wake pat- heart to pump blood, with resulting elevation of
tern. MEDICATIONS, particularly depressants of the systemic, venous and capillary pressure and the
central nervous system, can also induce episodes. transudation of fluid into the tissues. Congestive
Sometimes confusional arousals are seen in asso- heart failure can occur as a result of disorders that
ciation with other sleep disorders, such as IDIO- affect cardiac function.
PATHIC HYPERSOMNIA or SLEEP APNEA. More typically, OBSTRUCTIVE SLEEP APNEA SYNDROME can produce
episodes of confusional arousal occur in individuals pulmonary hypertension and result in right-sided
who are predisposed to have SLEEPWALKING or SLEEP heart failure, with the development of liver con-
TERRORS, with a strong familial tendency marking gestion and ankle edema. Treatment of obstructive
all three behaviors. sleep apnea syndrome usually results in improved
Polysomnographic recordings of confusional cardiac function, with correction of the congestion
arousals generally show an arousal occurring from and edema.
the slow wave non-REM sleep (see SLEEP STAGES) Congestive heart failure can produce CHEYNE-
in the first third of the night; the recordings are STOKES RESPIRATION which is a crescendo-decrescendo
characterized by delta activity with mixes of theta pattern of ventilation that can produce AWAKENINGS
and poorly-reactive ALPHA RHYTHMS. due to fluctuations in blood gases. This pattern of
Confusional arousals are a generally benign breathing can lead to LONG-TERM INSOMNIA.
phenomenon, although injuries may occur if the Patients who have impaired cardiac function
individual accidentally knocks into furniture or that results in lung congestion can present symp-
other objects near the bedside. Confusional arous- toms such as ORTHOPNEA or PAROXYSMAL NOCTUR-
als may be considered to be a minor manifestation NAL DYSPNEA when in a recumbent or reclining
of SLEEPWALKING or SLEEP TERRORS. Sleep terrors position during sleep. (See also SLEEP-RELATED
are characterized by an intensely loud scream BREATHING DISORDERS, SLEEP-RELATED CARDIOVASCU-
that heralds the episode, whereas sleepwalking is LAR SYMPTOMS.)
characterized by walking during the event. Other
behaviors that may have some similarities with
confusional arousals are sleep-related epileptic constant routine A biological test of the ENDOGE-
SEIZURES, particularly those of the partial complex NOUS CIRCADIAN PACEMAKER that involves a 36-hour
type. episode of BASELINE monitoring, followed by a 40-
Treatment of confusional arousals is rarely nec- hour episode of monitoring, with the individual on
essary unless the episodes occur in conjunction a constant routine of food intake, position, activity
with other arousal disorders, such as sleepwalking and light exposure. During this time, the sleep
or sleep terrors. In certain circumstances, it may be pattern is monitored as well as the core body TEM-
helpful to use either BENZODIAZEPINES or tricyclic PERATURE. The cycle of the core body temperature
ANTIDEPRESSANTS, such as imipramine, in order to allows a determination of the natural period length
suppress episodes. However, more commonly the of the pacemaker control in body temperature and
only action that need be taken for confusional allows a comparison of the phase position of body
arousals is to secure the bedroom and prevent inju- temperature to other individuals so as to determine
56 continuous positive airway pressure

whether the pattern is advanced or delayed. This occasionally nasal decongestant inhalers may be
test may be useful in determining the timing of necessary. Despite optimum treatment of the nasal
the circadian pacemaker in individuals who suffer irritation, some patients will find relief only by dis-
from CIRCADIAN RHYTHM SLEEP DISORDERS, such as continuing use of the CPAP system.
DELAYED SLEEP PHASE SYNDROME or ADVANCED SLEEP One of the major concerns regarding the use of
PHASE SYNDROME. (See also ENDOGENOUS CIRCADIAN nasal CPAP is that it is very dependent upon patient
PHASE ASSESSMENT; PERIOD LENGTH.) compliance with the treatment recommendations.
Although for most patients the benefits are very
apparent and reinforce the desire to use the system,
continuous positive airway pressure (CPAP) An some patients may not be motivated to utilize the
effective and commonly used treatment for system. This is of particular concern for patients
OBSTRUCTIVE SLEEP APNEA SYNDROME. The system with severe daytime sleepiness, who are employed
was first devised in 1981 by Colin Sullivan of Aus- in positions where sleepiness may put them or oth-
tralia; today a number of commercially developed ers at risk, such as bus drivers. Alternative treat-
systems are available for home use. ments for obstructive sleep apnea may not be readily
The CPAP device consists of an air pump housed available, as the UVULOPALATOPHARYNGOPLASTY sur-
in a small box about one cubic foot in size, which gical procedure is not effective in approximately
is placed at the patient’s bedside. Tubing of approxi- 50 percent of patients who have obstructive sleep
mately one inch in diameter conveys the air to a apnea syndrome. The only effective surgical alterna-
mask, which is placed over the patient’s nose so tive is TRACHEOSTOMY, which is often rejected by the
that the mouth is free. The mask is attached to the patient for cosmetic, social or medical reasons.
head with elasticized straps. The patient puts on the Despite the limitations of nasal CPAP treatment,
CPAP mask, turns on the machine and sleeps with this device has dramatically changed the manage-
the mask in place during the night until awaken- ment of obstructive sleep apnea syndrome and is a
ing, when the mask is removed. This system has major advance in its treatment. (See also CEPHALO-
been demonstrated to relieve severe obstructive METRIC RADIOGRAPH, FIBEROPTIC ENDOSCOPY.)
sleep apnea syndrome, with resumption of normal
quality sleep at night and resolution of the cardiac
features, as well as complete resolution of the asso- convulsions Generalized whole body movements
ciated daytime sleepiness. that occur in association with epileptic activity.
The CPAP system provides an air splint to the SLEEP-RELATED EPILEPSY is a primary cause of con-
upper airway thereby preventing its collapse. During vulsions during sleep.
the inspiratory phase of an obstructive apnea, the
upper airway tissues collapse because of a negative
inspiratory pressure, thereby producing upper air- cortisol A hormone released from the adrenal
way obstruction. The continuous positive air pres- gland in response to stimulation by ACTH (ADRE-
sure device provides a low flow of air with a pressure NOCORTICOTROPHIN HORMONE), which is released
of between 2 and 20 centimeters of water, which from the pituitary gland. The secretion of cortisol
prevents the negative suction effect on the tissues of is reduced during sleep but is greatly increased
the upper airway, thus preventing their collapse. around the time of awakening. It is important
Most patients with obstructive sleep apnea for the maintenance of body metabolism, and its
syndrome are capable of using a CPAP system; absence leads to reduced energy and weight loss.
however, some patients find the mask makes them Cortisol is often measured in the blood to detect
feel claustrophobic, preventing its regular use. The the specific phase of the CIRCADIAN RHYTHM. Shifts
development of chronic nasal irritation due to the of the sleep pattern by 12 hours are usually not
air flow is also a major complication of the device. accompanied by acute shifts of the cortisol cir-
This irritation can be partially relieved by the use of cadian rhythm, which takes up to two weeks to
extra humidification of the inspired air; however, realign with the new time of sleep. The cortisol
 craniofacial disorders 57

rhythm appears to be linked to the body tempera- site for cramps during sleep is in the calf muscles.
ture rhythm, which takes a similar amount of time Cramps may be induced by metabolic changes,
to shift to coincide with the new time of sleep. such as an alteration in the serum electrolytes.
(See also GROWTH HORMONE, MELATONIN, PROLACTIN, Acute cramps can be partially relieved by stretch-
REVERSAL OF SLEEP.) ing the muscle involved. Quinine sulfate is an
effective medication for the prevention of muscle
cramps. (See also NOCTURNAL LEG CRAMPS.)
cot death A term used, mainly in Britain, for
SUDDEN INFANT DEATH SYNDROME (SIDS).
craniofacial disorders A number of genetically-
determined disorders that affect head and face
coughing Coughing during sleep is due to an growth. They typically produce abnormalities of
irritation of the upper airway and typically is the upper airway so that there is obstruction to
associated with abrupt awakening and difficulty air flow, which is worsened during sleep. These
in breathing. Patients with SLEEP-RELATED BREATH- disorders can produce OBSTRUCTIVE SLEEP APNEA
ING DISORDERS are liable to have episodes of chok- SYNDROME.
ing and coughing during sleep, particularly those Achondroplasia, a hereditary disorder that is
with CHRONIC OBSTRUCTIVE PULMONARY DISEASE or characterized by abnormal growth of endochondral
ASTHMA, SLEEP-RELATED. bone, results in dwarfism. Patients with this disor-
Coughing can have many causes, such as inflam- der have abnormalities at the base of the skull and
matory reactions to inhaled allergens, mechanical deficient growth of the mid-facial region. Achon-
irritation due to dust particles, chemical irritation droplastics can also suffer compression of the brain
due to smoke or gas, and thermal irritation due stem and upper spinal cord, which can contribute to
to very hot or cold air. Treatment depends upon impaired control of the pharyngeal muscles. Patients
the cause of the coughing. Specific therapy should with achondroplasia have a higher incidence of
be directed to any underlying medical disorder, obstructive sleep apnea syndrome than the general
such as sleep-related asthma. A cough suppressant population, and this may cause reduced growth as
(antitussive) medication such as CODEINE can be well as the development of EXCESSIVE SLEEPINESS.
of help. If secretions are thick and are the cause Treatment of the obstructive sleep apnea syndrome
of coughing, an ultrasonic nebulizer will allow can improve growth and eliminate the clinical fea-
the secretions to be expectorated. Ipratropium, a tures of obstructive sleep apnea syndrome.
bronchodilator with anticholinergic effects, is help- Pierre-Robin Syndrome, also known as the
ful for coughs due to asthma. (See also BREATHING Robin Sequence, is characterized by head and jaw
DISORDERS, SLEEP-RELATED.) abnormalities. There may be microcephaly and a
small and retroplaced jaw. The tongue can fall back
and obstruct the airway, leading to the develop-
CPAP See CONTINUOUS POSITIVE AIRWAY PRESSURE. ment of obstructive sleep apnea syndrome with
features of inability to thrive and the development
of right-sided heart failure. Treatment may be
“C” process See ENDOGENOUS CIRCADIAN PACE- necessary by either TRACHEOSTOMY or MANDIBULAR
MAKER. ADVANCEMENT SURGERY.
An autosomal dominant condition, termed
Treacher Collins syndrome, is characterized by
CPS See HERTZ. mandibular and mid-face growth abnormalities
as well as mental retardation. Patients are also
liable to suffer obstructive sleep apnea syndrome
cramps Contractions of muscles that typically and may require TRACHEOSTOMY or MANDIBULAR
result in a painful sensation. The most common ADVANCEMENT SURGERY.
58 crib death

The velo-cardio-facial syndrome, which is from Stanford University and his M.D. in 1981 from
also known as Shprintzen’s syndrome, was first the Stanford University School of Medicine. He
described in 1978 in individuals with learning dis- has been on the faculty of Harvard Medical School
abilities, small stature, hearing loss and a retruded since 1983 and has been a professor of medicine
mandible. These patients also have cardiac defects. since 1998.
The craniofacial abnormalities in velo-cardio-facial Working with the late Professor ELLIOT D.
syndrome children may produce obstructive sleep WEITZMAN at the Albert Einstein College of Medi-
apnea syndrome, which can be worsened by repair cine/Montefiore Medical Center in New York, Dr.
of cleft palate, which is commonly seen in this syn- Czeisler established one of the first TEMPORAL ISO-
drome. Tonsillectomy, or mandibular advancement LATION facilities, where the relationship between
surgery, may be indicated to treat the obstructive the episodic secretory pattern of hormones and the
sleep apnea syndrome. output of the ENDOGENOUS CIRCADIAN PACEMAKER
Goldenhars syndrome, also known as oculoauri- was studied. They demonstrated the influence
culo-vertebral dysplasia, is a disorder characterized of that pacemaker on the duration and internal
by eye, ear, and vertebral anomalies. There is an organization of sleep, and in 1981 Czeisler devel-
associated small lower jaw and reduced growth oped CHRONOTHERAPY for DELAYED SLEEP PHASE
of the bony tissues of the face. These patients SYNDROME.
are also liable to develop obstructive sleep apnea Dr. Czeisler is chief of the Division of Sleep
syndrome. Medicine in the Department of Medicine at the
Brigham and Women’s Hospital and director of
the Division of Sleep Medicine at Harvard Medical
crib death Term that has been used, largely in School in Massachusetts. Czeisler carried out one
the United States, for the SUDDEN INFANT DEATH of the first studies to show that shift-work sched-
SYNDROME. ules that disrupt sleep could be improved by apply-
ing circadian principles.
Dr. Czeisler was the first to demonstrate that
cycles per second (CPS) See HERTZ. light exposure could reset the human circadian
clock independent of the timing of the sleep-wake
cycle. He then went on to demonstrate that prop-
Cylert (Pemoline) A drug formerly used for the erly timed light exposure to light and darkness
treatment of ADHD (attention deficit hyperactiv- could effectively treat maladaptation to night shift
ity disorder) that is no longer available in the work. He has applied this research to the sched-
United States (May 2005) owing to its link to liver uling of NASA astronauts and conducted a sleep
failure. experiment on Senator John Glenn during his
1998 return to space flight.
In his 1999 article in Science, in the bibliography,
Czeisler, Charles A. Dr. Czeisler (1952– ) Dr. Czeisler and his associates demonstrated that
received his A.B. degree in 1974 in biochemistry the intrinsic period of the human circadian pace-
and molecular biology from Harvard College, his maker is very close to 24 hours, rather than 25
Ph.D. in 1978 in neuro- and biobehavioral sciences hours as had been previously believed.
 D
Dalmane (flurazepam) See BENZODIAZEPINES. hours with the greatest likelihood of death occur-
ring between 4 A.M. and 7 A.M. The reason for
this circadian variation in deaths is unknown.
D sleep Term sometimes used to describe dream- However, there are several disorders that are
ing sleep or desynchronized sleep. D sleep is synon- believed to increase the likelihood of death during
ymous with REM sleep and should not be confused sleep. SLEEP-RELATED BREATHING DISORDERS, includ-
with the original STAGE D SLEEP. ing OBSTRUCTIVE SLEEP APNEA SYNDROME, have been
reported to be associated with sudden death during
sleep, and in patients with ASTHMA there is a higher
dauerschlaf See SLEEP THERAPY. rate of death during the nocturnal hours compared
to the daytime.
Patients with the obstructive sleep apnea syn-
daydreaming The state of mind associated with drome have a high rate of sleep-related HYPOXEMIA
withdrawal from environmental influences. Sleep and CARDIAC ARRHYTHMIAS related to the apneic
does not occur but there may be DROWSINESS. Full episodes. The cardiac arrhythmias are believed to
alertness to the environment is reduced. Sleepiness be the primary cause for the sudden unexpected
can erroneously be mistaken for daydreaming, death during sleep.
particularly in adolescents who tend to be sleep An American Cancer Society study conducted
deprived and may not concentrate on schoolwork in 1964 (data was analyzed in 1979) of more than
(see EXCESSIVE SLEEPINESS, SLEEP DEPRIVATION). If 1 million people found that men who slept four
other features of sleepiness occur, such as eye clo- hours or less, or more than 10 hours, had a higher
sure, head drooping or even SNORING, then there mortality rate than those who slept a normal six to
should be a consideration of a sleep disorder as a eight hours. This association between sleep length
cause. and death may be related either to underlying
True dream phenomenon (see DREAMS) is a state medical illness, which produces sleep disturbance
associated with pronounced physiological changes, at night, or to disorders, such as sleep apnea,
such as rapid eye movements and loss of muscle that usually produce a prolonged nighttime sleep
tone. Daydreaming does not represent daytime episode.
dreams and therefore should be differentiated from There is also some evidence that people who
true dreaming sleep. take sleeping pills (HYPNOTICS) are more likely to
have a nocturnal death. (See also MYOCARDIAL
INFARCTION.)
daytime sleepiness See EXCESSIVE SLEEPINESS.

deep sleep Term describing STAGE THREE and

deaths during sleep Several extensive epide- STAGE FOUR non-REM (NREM) sleep. This term
miological studies have demonstrated that death was developed because of the increased threshold
is most likely to occur over the usual nocturnal to awakening by various stimuli that occurs during

59
60 delayed sleep phase

these SLEEP STAGES. Rarely, in the older literature, time to go to bed. Because there are attempts
the term was applied to REM sleep, but the term to get up at the desired time in the morning,
is most appropriately applied to stages three and which are only partially successful, the individual
four sleep. with delayed sleep phase syndrome is often sleep
deprived and therefore suffers from symptoms of
excessive daytime sleepiness, such as FATIGUE and
delayed sleep phase Term applied to a delay in tiredness. Episodes of sleep can occur inappropri-
falling asleep as well as final awakening in relation ately during the day whenever the individual is in
to the usual time of sleep, according to the 24-hour a quiet situation, and this can cause school or work
clock; the sleep episode is consequently delayed in difficulties. Children are typically late to school,
relation to underlying circadian patterns of other and adults are frequently late to their jobs.
physiological variables (see CIRCADIAN RHYTHMS). On weekends, because there is usually no need
The delay of the sleep phase can be temporary, to arise early in the morning, these individuals will
such as typically seen with TIME ZONE CHANGE (JET sleep into the day, often sleeping till midday or
LAG) SYNDROME, or can be a chronic state, such as even later. These long sleep episodes on the week-
seen in DELAYED SLEEP PHASE SYNDROME. end help to make up for the chronic sleep depriva-
tion that accumulates during the week.
The diagnosis of delayed sleep phase syndrome
delayed sleep phase syndrome One of the CIR- is made on the complaint of either an inability
CADIAN RHYTHM SLEEP DISORDERS. It is characterized to fall asleep at the desired time, or the inability
by SLEEP ONSET and WAKE TIMES that are usually to awaken at the desired time in the morning.
later than desired, with difficulty in initiating sleep Sometimes the complaint of EXCESSIVE SLEEPINESS
onset. Once sleep onset does occur, sleep is of good during the day will be given. The symptoms will
quality, with few AWAKENINGS until the time of final be present for at least three months, and when not
awakening. This sleep pattern is mainly a difficulty required to maintain a strict schedule, such as on
in falling asleep at night, or a difficulty in awaken- weekends and while on vacations, individuals will
ing in the morning, which prevents fulfilling social have a normal sleep pattern in duration and qual-
or occupational obligations. ity, and will awaken spontaneously at a later time
Delayed sleep phase syndrome was first described than desired.
by ELLIOT D. WEITZMAN and CHARLES CZEISLER in Investigative studies have shown that the circa-
1981. Their analysis of 450 patients who com- dian pattern of body temperature is shifted to a later
plained of INSOMNIA showed that 7 percent ful- time so that the nadir (low point) does not occur at
filled the criteria for having delayed sleep phase the more typical time of 5 A.M. but occurs after 8 or
syndrome. 9 A.M. (see CIRCADIAN RHYTHMS). Polysomnographic
Persons with delayed sleep phase syndrome studies have shown that the sleep period is of short
have great difficulty falling asleep at a desired time. duration when the individual arises at the desired
Attempts to fall asleep earlier are accompanied by time and is characterized by reduced REM sleep.
prolonged periods of lying in bed awake until the When the sleep period is allowed to proceed with-
time that they usually fall asleep. These patients out interruption, such as is seen on the weekend,
are often prescribed MEDICATIONS to aid sleep, but the sleep period is of normal duration, with normal
sleeping medications are ineffective and only add amounts of each sleep stage.
to both the difficulty of awakening and the daytime Although alcohol and hypnotic abuse are com-
sleepiness. monly used in an attempt to correct the problem,
In typical cases of delayed sleep phase syndrome, true psychopathology is not typical. An atypical
the individual will be unable to initiate sleep onset form of DEPRESSION may be present in adolescents
until 2 A.M. or even as late as 6 A.M. In younger with this syndrome. The depression may be directly
children, the sleep onset time may be earlier, but related to the social and functional difficulties
typically occurs two or more hours after the desired induced by the abnormal sleep pattern.
 delta sleep inducing peptide 61

In childhood, other disorders, such as LIMIT- improved by strict attention to regular sleep onset
SETTING SLEEP DISORDER, SLEEP-ONSET ASSOCIATION and awake times. More severe disturbances may
DISORDER, or IDIOPATHIC HYPERSOMNIA, need to be require incremental advances by 15 or 30 minutes
differentiated from delayed sleep phase syndrome. per day until a more appropriate sleep onset time is
The prevalence of the disorder is unknown, but reached. The most severe form of the disorder may
may be as common as 10 percent in the adolescent require making advancements of the sleep pattern
population. Adolescents seem particularly predis- by enforcing a night of sleep deprivation to assist
posed toward developing a delayed sleep pattern in the sleep advance process, or, more effectively,
because of the natural tendency to delay sleep by the use of a technique termed CHRONOTHERAPY,
onset. The onset of the disorder is in late puberty or which involves a three-hour delay in the sleep
early adolescence, although major difficulties are period on a daily basis until the sleep pattern is
not encountered until late adolescence or until the rotated around the clock and sleep onset occurs at
commencement of employment. a more appropriate time.
Although a male predominance of the delayed
sleep phase syndrome is reported in the literature,
this may be because of a referral pattern bias. This delirium A clouded state of consciousness char-
disorder does not appear to be inherited. acterized by disorientation, fear, irritability, a
In many cases of delayed sleep phase syndrome, misperception of sensory stimuli, and often hal-
social and environmental factors in inducing the lucinations. Patients with delirium may alternate
delay of the sleep pattern appear to be the pre- between being relatively unresponsive and being
dominant causes. However, some individuals have mentally very clear. Usually, delirious patients
a circadian pacemaker system that is abnormal are unaware of environmental influences and do
and unresponsive to the usual environmental time not act appropriately; very often such patients are
cues. The time cues are weak stabilizers of the uninhibited and talk in a loud and defensive man-
natural physiological tendency to delay sleep onset. ner, often with paranoid ideation and agitation.
An abnormality of the pacemaker’s PHASE RESPONSE The state of delirium is often of rapid onset,
CURVE has been suggested as a cause. lasting a week in duration, although some mani-
Individuals who have delayed sleep phase syn- festations may last for several weeks or longer. This
drome should be differentiated from those who disorder is often associated with a metabolic toxic
have a pattern of sequential delays of a sleep phase encephalopathy, as with patients with ALCOHOL-
that occur continuously, the disorder known as the ISM, or can be due to more diffuse intracerebral
NON-24-HOUR SLEEP-WAKE SYNDROME. The delayed diseases, as with autoimmune vascular disease.
sleep phase syndrome may be a less severe altera- (See also ALCOHOL, COMA, DEMENTIA, OBTUNDATION,
tion in the phase response curve than the non-24- STUPOR.)
hour sleep-wake syndrome, in which individuals
will rotate the sleep pattern around the clock.
Individuals who have irregularity of the sleep delta sleep Term used to describe the stage of
onset time, with the ability to advance the sleep sleep when the ELECTROENCEPHALOGRAM (EEG)
onset time some days each week, are characterized shows a high voltage, slow wave activity in the
as having INADEQUATE SLEEP HYGIENE rather than delta (up to 4 HERTZ) frequency. The term is syn-
delayed sleep phase syndrome. onymous with STAGE THREE and STAGE FOUR SLEEP.
For the diagnosis, the sleep disturbance should Because of the slow frequency of activity seen on
be illustrated on a SLEEP LOG for a period of at least the EEG, this stage of sleep is also called SLOW WAVE
two weeks, and if there is any doubt about the SLEEP. (See also SLEEP STAGES.)
diagnosis, appropriate polysomnographic monitor-
ing should be performed.
Treatment depends on the severity of the dis- delta sleep inducing peptide (DSIP) First dis-
order. Mild delayed sleep phase syndrome may be covered in 1964 in the blood of rabbits in whom
62 delta waves

electrical stimulation of the thalamic nuclei of the Dement’s additional sleep research has included a
brain induced a sleep-like state. Studies with the study, along with Dr. Christian Guilleminault, of
infusion of DSIP into rabbits have confirmed the 235 hypersomnias.
slow wave sleep-inducing properties of this agent. Dr. Dement was a cofounder of the Association
Some studies have been performed in humans with for the Psychophysiological Study of Sleep, now
INSOMNIA and the total amount of sleep appears to the Sleep Research Society. He was also the found-
be increased; however, this peptide can be given ing president of the Associated Sleep Disorder
only by an intravenous infusion. When adminis- Centers, now the AMERICAN ACADEMY OF SLEEP
tered during the day to patients with NARCOLEPSY, MEDICINE from 1985 to 1987, and a past president
there is some evidence that it has an alerting effect of the Association of Professional Sleep Societies.
with improvement of performance, as tested by dif- A member of the National Academy of Sciences,
ferent evaluative tests. (See also FACTORS, MURAMYL Dr. Dement has twice been the recipient of the
DIPEPTIDE, SLEEP-INDUCING FACTORS.) NATHANIEL KLEITMAN DISTINGUISHED SERVICE AWARD
and in 1991 he was awarded the Distinguished Ser-
vice Award of the Sleep Research Society.
delta waves A cycle of electroencephalographic
activity with a frequency of less than 4 HERTZ (see
ELECTROENCEPHALOGRAM [EEG]). For sleep stage dementia A progressive and degenerative neuro-
scoring the minimum requirements for delta waves logical disease that is associated with loss of mem-
are that the amplitude of the waves must be greater ory and other intellectual functions. Patients with
than 75 microvolts, and the frequency must be less dementia commonly suffer sleep disturbances,
than 2 hertz in duration. Delta waves are seen dur- typically due to behavioral disturbances during the
ing STAGES THREE and FOUR SLEEP, and occasionally sleep period: DELIRIUM, agitation, wandering and
in STAGE TWO SLEEP. (The stage three/four sleep, inappropriate talking often occur during night-
also known as delta sleep, is regarded as the most time hours. These disturbances in behavior begin
important stage of sleep.) (See also DELTA SLEEP, in the evening and therefore the term “SUNDOWN
SLEEP STAGES.) SYNDROME” has been used to describe patients with
this form of sleep disturbance.
Patients suffering dementia commonly become
Dement, William C. Received both his M.D. management problems for their families and often
with honors and a Ph.D. in neurophysiology from require supervision in a facility with severe cases
the University of Chicago. Dr. Dement (1928– ) requiring institutionalization in a nursing home
started the Sleep Laboratory at Stanford University or hospital. The need for sedative medications (see
in 1963, and he later founded, and now directs, the HYPNOTICS) to suppress the behavior often contrib-
Sleep Disorders clinic and laboratory at Stanford utes to the disturbance of sleep and wakefulness
University Medical Center in California. and can lead to further impairment of intellectual
From 1952 to 1957, Dement, while in medical function. Patients may also suffer exaggerated NOC-
school, joined EUGENE ASERINSKY and Professor TURNAL CONFUSION, with the onset of acute medical
NATHANIEL KLEITMAN; together they discovered and illnesses, such as infections. The confusion can also
described rapid eye movement (REM) sleep. be worsened by medications that are given for the
Dement also conducted a series of experi- infective illness.
ments known as dream deprivation studies. The The disturbance in sleep and wakefulness may
first experiments were done in conjunction with be due to a defect of the brain center controlling
Charles Fisher at New York’s Mount Sinai Hospital. the circadian pattern of sleep and WAKEFULNESS;
Dement continued his experiments a few years disorders such as Alzheimer’s disease and multiple
later at Stanford University, first depriving volun- cerebral infarction are typical causes of dementia.
teers of all REM sleep for 16 nights, then, along Polysomnographic studies have tended to show
with Michel Jouvet, depriving cats of REM sleep. nonspecific sleep disruption with reduced SLEEP
 desynchronized sleep 63

EFFICIENCY, and reduced stages of deep sleep (see termed SEASONAL AFFECTIVE DISORDER (SAD). Light
SLEEP STAGES). Some patients can have respiratory therapy has been demonstrated to be an effective
disturbance during sleep, although this is not a treatment for this disorder. Depression can also be
typical feature of patients with dementia. treated by psychotherapy or ANTIDEPRESSANT medi-
The diagnosis of dementia is made clinically and cations that include the tricyclic antidepressants,
by tests such as brain imaging and electroencepha- serotonin reuptake inhibitors and MONOAMINE OXI-
lography. Reversible forms of dementia, for exam- DASE INHIBITORS.
ple, metabolic abnormalities and drug effects, must
be considered. The treatment of sleep disturbance
associated with dementia depends upon initiating depth encephalography A form of electroen-
good SLEEP HYGIENE and assuring that the dementia cephalography that involves the implantation of
patient is fully active during the period of desired electrodes into the brain. This type of EEG is
wakefulness and allowed to sleep in a quiet envi- typically performed prior to seizure surgery. By
ronment during the time of desired sleep. Hypnotic implanting electrodes into the brain, a more precise
medications may have a paradoxical effect and anatomical site of EPILEPSY can be obtained. This
increase activity in some patients. The longer-act- procedure is reserved for patients who have severe
ing hypnotics may cause decreased behavior and epilepsy and in whom surgical treatment of the
alertness during the daytime, which will exacerbate epilepsy is indicated. (See also ELECTROENCEPHALO-
the breakdown of the nighttime sleep pattern and GRAM (EEG), SLEEP-RELATED EPILEPSY.)
therefore should be avoided. NEUROLEPTICS, such
as haloperidol, and phenothiazines may be useful
in some patients. (See also CEREBRAL DEGENERATIVE desynchronization of circadian rhythms Re-
DISORDERS, IRREGULAR SLEEP-WAKE PATTERN.) fers to the loss of synchronized phase relation-
ships between two or more biological rhythms so
that, instead, they have their own period lengths.
depression Emotional condition characterized by Desynchronization of human CIRCADIAN RHYTHMS
an episode of loss of interest or pleasure in most occurs when individuals are in TEMPORAL ISOLA-
daytime activities that lasts two weeks or longer. TION and devoid of any ENVIRONMENTAL TIME CUES.
Most patients with depression have sleep disturbance The underlying body temperature rhythm and the
that is accompanied by INSOMNIA or, less commonly, sleep-wake cycle initially free run, then reach a
by EXCESSIVE SLEEPINESS. Depression is associated point where desynchronization occurs, and each
with other symptoms, such as appetite disturbance, rhythm runs at its own frequency. Typically, the
weight change, decreased energy, feelings of worth- body temperature rhythm will have its own period
lessness and helplessness, excessive and inappropri- length of about 24.5 hours, whereas the sleep-
ate feelings of guilt, difficulty in concentrating and wake cycle may have a period length of 33 hours.
recurrent thoughts of death, with suicidal ideation (See also FREE RUNNING, PERIOD LENGTH.)
or attempts.
The characteristic sleep disturbance seen in
patients with depression is one of EARLY MORNING desynchronized sleep The sleep stage in which
AROUSAL, although this does not invariably occur, there is little evidence of synchronized ELECTRO-
and particularly not in adolescents, where a pro- ENCEPHALOGRAM (EEG) patterns so that slow or
longed nocturnal sleep period is commonly seen. high amplitude waves are not seen. Typically,
Other features of depression include a short REM desynchronized sleep refers to RAPID EYE MOVEMENT
SLEEP LATENCY on all-night POLYSOMNOGRAPHY as (REM SLEEP) and not NON-REM-STAGE SLEEP. A
well as an increased REM density. desynchronized pattern suggests that the coordi-
Depression is one feature of the MOOD DISOR- nation of neuronal firing does not occur and that
DERS. One form of depression recurs at intervals neuronal activity occurs independently throughout
depending upon the seasons of the year and is the central nervous system. The term desynchronized
64 dextroamphetamine

sleep is more often used in ontogenetic or phyloge- despite the overlap with the sleep-wake schedule
netic sleep research when other features indicative disorders, this section was found to be very useful
of REM sleep are not clearly seen, such as rapid in providing a diagnostic differential listing for con-
eye movements, sawtooth waves or loss of muscle sideration of a complaint of excessive sleepiness.
tone. The term REM sleep is preferred when applica- The “circadian rhythm sleep disorders” were listed
ble. (See also REM PARASOMNIAS, SAWTOOTH WAVES.) as a third section because of their common, underly-
ing, pathophysiological mechanisms. This group of
disorders was broken down into transient and per-
dextroamphetamine (Dexedrine) See STIMULANT sistent subgroups. The transient forms include TIME
MEDICATIONS. ZONE CHANGE (JET LAG) SYNDROME and SHIFT-WORK
SLEEP DISORDER due to their episodic and transient
nature. The persistent subgroup included delayed
Diagnostic Classification of Sleep and Arousal sleep phase syndrome, advanced sleep phase syn-
Disorders Classification system first published in drome, and NON-24-HOUR SLEEP-WAKE SYNDROME.
the journal Sleep in 1979 that is the most widely The final section of disorders consists of the
used system in classifying sleep disorders. It was “parasomnias”—dysfunctions associated with
produced by the Diagnostic Classification Commit- sleep, sleep stages or partial arousals. This group-
tee of the ASSOCIATION OF SLEEP DISORDER CENTERS, ing included such disorders as SLEEPWALKING or
chaired by Howard Roffwarg, M.D. SLEEP TERRORS, which in themselves do not primar-
The Diagnostic Classification of Sleep and Arousal ily cause a complaint of insomnia or of excessive
Disorders divides the sleep and arousal disorders daytime sleepiness but rather disrupt or intrude
into four major sections: the DISORDERS OF INITI- into the sleep-wake process.
ATING AND MAINTAINING SLEEP, the DISORDERS OF The Diagnostic Classification of Sleep and Arousal
EXCESSIVE SOMNOLENCE, the SLEEP-WAKE SCHEDULE Disorders has been extensively used in the United
DISORDERS, and the PARASOMNIAS. States and also internationally and has been trans-
The phrase “difficulty in initiating and maintain- lated into many different languages. It is highly
ing sleep” was preferred over the term insomnia regarded as a most useful classification system.
as it indicated that some disorders could produce (The Diagnostic Classification of Sleep and Arousal Dis-
difficulty in initiating sleep, whereas others might orders is reprinted in Appendix IV of this book.)
produce a disorder of maintaining sleep. However, In 1985, the Association of Sleep Disorder Cen-
it was recognized that some disorders not listed in ters initiated a process for the revision of the Diag-
the “disorders in initiating and maintaining sleep” nostic Classification of Sleep and Arousal Disorders that
section could also produce sleep onset insomnia, was produced in early 1990. The newly developed
for example the CIRCADIAN RHYTHM SLEEP DISORDERS. classification is the INTERNATIONAL CLASSIFICATION
DELAYED SLEEP PHASE SYNDROME typically has a com- OF SLEEP DISORDERS; it includes not only a revision
plaint of difficulty in initiating sleep. In addition, of the original diagnostic entries but also adds those
some of the parasomnias could occur frequently disorders that have been recognized since the first
enough to disrupt sleep at night. However, despite edition, such as the REM SLEEP BEHAVIOR DISORDER.
this deficiency, the classification system was felt to be The classification includes more detailed diagnostic
extremely useful in helping physicians understand and coding information. A minor revision of the
the differential diagnosis of the causes of insomnia. ICSD was carried out in 1998.
The “disorders of excessive somnolence” sec-
tion of classification includes disorders that pro-
duce EXCESSIVE SLEEPINESS, such as NARCOLEPSY or Diamox (acetazolamide) See RESPIRATORY
OBSTRUCTIVE SLEEP APNEA SYNDROME. Disorders in STIMULANTS.
other sections could also contribute to excessive
sleepiness, such as delayed sleep phase syndrome
or ADVANCED SLEEP PHASE SYNDROME. However, diazepam (Valium) See BENZODIAZEPINES.
 DIMS 65

diet and sleep Diet can have an important effect Therefore, based on this biochemical evidence,
on the sleep-wake cycle; however, few research the suggestion has been that carbohydrates, which
studies have been performed in this area. initially may induce energy, subsequently have an
It is well recognized that stimulant drinks or effect on promoting sleep, whereas proteins will
foods, such as coffee, energy drinks, or chocolate, be more liable to increase ALERTNESS. The effect of
can increase daytime alertness and reduce the ease carbohydrates and proteins on alertness and sleepi-
of falling asleep at night. Patients with INSOMNIA ness appears to vary from person to person.
find that these agents typically cause them to have Large meals are best avoided immediately before
greater sleep difficulties and are usually advised to sleep as they can produce increased gastrointesti-
avoid the ingestion of CAFFEINE in any form. nal activity that may lead to disrupted nocturnal
The nighttime snack is believed to aid in sleep sleep. In addition, big meals just before sleep can
onset although the exact mechanism for this effect exacerbate OBSTRUCTIVE SLEEP APNEA SYNDROME by
is unknown. It has been suggested that L-trypto- preventing diaphragm action, and are often associ-
phan (see HYPNOTICS), an important constitute of ated with SLEEP-RELATED GASTROESOPHAGEAL REFLUX.
proteins, is useful in promoting sleep as it is known Meals containing spicy foods are also best avoided
to be a precursor of SEROTONIN, a neurotransmitter before sleep because of their stimulating effects.
believed to be involved in initiating and maintain- Several sleep disorders are associated with the
ing sleep. However, research studies on L-tryp- excessive ingestion of food or fluid during sleep at
tophan have shown a mild effect, if any at all, night. The NOCTURNAL EATING (DRINKING) SYNDROME
in persons with insomnia. Furthermore, because is associated with awakenings at night in order
of 30 cases in 1989 (including a few deaths) of to eat food. The desire to eat food becomes over-
eosinophilia-myalgia, a rare blood disorder possibly whelming and the person often cannot stop the
linked to supplements of L-tryptophan, the United behavior. For some people with this syndrome, the
States Center for Disease Control (CDC) requested majority of the caloric intake is taken in the night-
that physicians temporarily stop prescribing L-tryp- time hours. Excessive drinking at night is more
tophan. It was withdrawn but is still available via common in children who are given fluids during
Internet sellers. The effect of the nighttime snack the nighttime hours, particularly infants who have
may not be due to its chemical constituents but frequent nighttime feedings. SLEEP ENURESIS may
through stimulation of the gastrointestinal neural occur in children, especially infants.
pathways, producing a sensation of satiety and Patients with the Kleine-Levin form of RECUR-
relaxation. Food drinks—containing milk products RENT HYPERSOMNIA often eat excessively (mega-
and cereal, such as Ovaltine and Horlicks—are use- phagia) during the cyclical periods of excessive
ful in promoting sleep at night. sleepiness. This syndrome is characterized by recur-
There is some evidence that the gastrointestinal rent episodes of sleepiness that last for about two
effects of food ingestion may be mediated through weeks and occur several times each year in associa-
a hormone called CHOLECYSTOKININ (CCK), which tion with behavioral disorders, such as hypersexu-
is found in both the gastrointestinal tract and the ality and excessive eating.
brain. This hormone is released in response to food
ingestion, and some studies have shown that the
administration of CCK will promote sleep onset. diffuse activity A term frequently used in elec-
The effect of carbohydrates compared to proteins troencephalographic (EEG) recordings to indicate
in sleep initiation has been disputed. Carbohy- that EEG activity is being recorded from multiple
drates will allow L-tryptophan to be taken up more sites on the scalp. The term nonfocal is often used
readily by the central nervous system and there- synonymously with diffuse activity.
fore may potentiate L-tryptophan’s sleep-inducing
effects. Proteins, through their breakdown into
amino acids, are believed to increase the catechol- DIMS See DISORDERS OF INITIATING AND MAINTAIN-
amines, which are agents that increase energy. ING SLEEP(DIMS).
66 diphenhydramine

diphenhydramine (Benadryl) See ANTIHISTAMINES. adults in association with excessive eating and
hypersexuality. Another similar condition that can
produce intermittent excessive sleepiness is related
disorders of excessive somnolence (DOES) A to the MENSTRUAL CYCLE. During ovulation, when
category of the DIAGNOSTIC CLASSIFICATION OF SLEEP the hormone progesterone levels goes up, women
AND AROUSAL DISORDERS published in the journal may become sleepier than customary.
Sleep in 1979. This group consists of disorders that Treatment of the disorders of excessive somno-
primarily produce the complaint of inappropriate lence depends upon the underlying causes and can
and undesirable SLEEPINESS during waking hours. vary from behavioral techniques, such as extending
The sleepiness may produce impaired mental or the amount of time spent in bed at night, to the
work performance, induce a need for daytime use of STIMULANT MEDICATIONS in the treatment of
NAPS, increase the total amount of sleep in a 24- narcolepsy. Mechanical devices, such as CONTINU-
hour day, increase the length of the major sleep OUS POSITIVE AIRWAY PRESSURE (CPAP) devices, may
episode or produce a difficulty in achieving full be used in the treatment of obstructive sleep apnea
AROUSAL upon AWAKENING. The disorders of exces- syndrome.
sive somnolence should be differentiated from
those disorders that produce tiredness and FATIGUE
without an increased physiological drive for sleep, disorders of initiating and maintaining sleep
such as DYSTHYMIA, DEPRESSION or chronic illness. (DIMS) A group of disorders characterized by the
There are 10 major groups among disorders of symptom of INSOMNIA. These sleep disorders may
excessive somnolence that are induced by behav- result in difficulty getting to sleep, frequent awak-
ioral, psychological or medical causes, or may be enings or arousals during the night, EARLY MORNING
induced by drugs or MEDICATIONS. AROUSAL or a complaint of NONRESTORATIVE SLEEP.
The most common cause of EXCESSIVE SLEEPI- The term “disorders of initiating and maintain-
NESS in the general population is insufficient sleep ing sleep” was first publicized in the DIAGNOSTIC
at night; however, other frequent causes of exces- CLASSIFICATION OF SLEEP AND AROUSAL DISORDERS,
sive somnolence include the effects of medications, published in the journal Sleep in 1979. This is one
which either disrupt nighttime sleep or induce of four categories of sleep disorder in the classifica-
sleepiness during the day, and psychiatric disor- tion system, and it consists of a list of nine major
ders, such as depression. However, the majority of groups of disorders. The cause of these sleep disor-
patients who go to SLEEP DISORDER CENTERS with the ders varies greatly and may be due to behavioral,
complaint of excessive sleepiness have the OBSTRUC- psychological, psychiatric, or medical factors or
TIVE SLEEP APNEA SYNDROME. Respiratory impairment may be due to medication and drug effects.
during sleep due to the obstructive sleep apnea syn- In the population as a whole, the most com-
drome, CENTRAL SLEEP APNEA SYNDROME or CENTRAL mon disorder among the disorders of initiating and
ALVEOLAR HYPOVENTILATION SYNDROME are major maintaining sleep is that due to an acute stressful
causes to be considered in any patient presenting event, such as a family, marital, work or other
with the complaint of excessive sleepiness. PERIODIC stress. Because this form of insomnia is usually
LIMB MOVEMENT DISORDER and, rarely, RESTLESS LEGS self-limited and lasts only a few days, patients with
SYNDROME can also produce daytime sleepiness. this type of insomnia usually do not consult sleep
NARCOLEPSY is the most well-known pathological disorder specialists or sleep disorder centers.
disorder inducing daytime sleepiness. This disorder The most common insomnia disorders that are
can be differentiated from IDIOPATHIC HYPERSOMNIA, seen in most sleep disorder centers are either PSY-
which has different clinical and polysomnographic CHOPHYSIOLOGICAL INSOMNIA caused by negative
features. conditioning factors or insomnia due to psychiatric
Recurrent episodes of sleepiness are seen in disorders, such as ANXIETY or DEPRESSION. Respi-
RECURRENT HYPERSOMNIA, such as the KLEINE-LEVIN ratory impairment can contribute to insomnia
SYNDROME, which is most typically seen in young by means of CENTRAL SLEEP APNEA SYNDROME or
 dream anxiety attacks 67

OBSTRUCTIVE SLEEP APNEA SYNDROME. Abnormal An alteration in dopamine metabolism appears

limb activities, such as those seen in the PERIODIC to be present in patients with NARCOLEPSY; conse-
LIMB MOVEMENT DISORDER or RESTLESS LEGS SYN- quently, medications that stimulate the produc-
DROME, are also causes of difficulty in initiating and tion of dopamine may be useful in the treatment
maintaining sleep. of narcolepsy. The CENTRAL NERVOUS STIMULANTS
One form of insomnia, IDIOPATHIC INSOMNIA, such as methylphenidate and AMPHETAMINE have
appears to have a primary central nervous sys- their effect upon narcolepsy through dopamine. L-
tem cause, possibly on a genetic basis or due to Tyrosine (see STIMULANT MEDICATIONS), a precursor
an acquired subtle abnormality, perhaps in neu- of dopamine, has been shown to have a beneficial
rotransmitter function. effect on the clinical symptoms of narcolepsy.
The treatment of DIMS depends upon the
underlying cause of the disorder. For all patients
good SLEEP HYGIENE is an essential part of treat- dopamine agonist A drug that duplicates the
ment. Specific treatments can range from behav- effects of dopamine, a chemical produced by the
ioral treatments of insomnia such as STIMULUS brain. Two dopamine agonists, ropinirole (Requip)
CONTROL THERAPY or SLEEP RESTRICTION THERAPY, to and pramipexole (Mirapex), have been approved
the use of HYPNOTICS or ANTIDEPRESSANTS. Mechani- by the FDA to treat RESTLESS LEGS SYNDROME (RLS).
cal treatments, such as the use of CONTINUOUS However, in May 2005, the FDA issued a report that
POSITIVE AIRWAY PRESSURE (CPAP) devices, may be suggested labeling changes based on warnings, pre-
required for the treatment of obstructive sleep cautions, and adverse reactions. For ropinirole, the
apnea syndrome. warnings included causing someone to fall asleep
during daily activities, especially among those with
Parkinson’s disease. Other warnings were for syn-
disorders of the sleep-wake schedule See CIRCA- cope (fainting or passing out), symptomatic hypo-
DIAN RHYTHM SLEEP DISORDERS. tension (too low blood pressure), or hallucinations.
Pramipexole, another dopamine agonist typically
used in the treatment of Parkinson’s disease, is
diurnal Occurring during the day. Opposite of also used in the treatment of RLS. Before taking
NOCTURNAL. pramipexole, however, patients must discuss cer-
tain conditions with their physicians including the
possibility of an allergic reaction, the possibility of
DOES See DISORDERS OF EXCESSIVE SOMNOLENCE. hallucinations in the elderly, whether the patient
is pregnant or breastfeeding, and potential interac-
tions with other medications or preexisting medical
dopamine A central nervous system neurotrans- conditions, such as eye problems (especially with
mitter that has very important effects upon both the retina) or hypotension (low blood pressure).
the cardiovascular and central nervous systems.
It affects someone’s walking, balance, emotional
reactions, movement, and ability to feel pain or doxylamine (Unisom) See OVER-THE-COUNTER
pleasure. Dopamine is the immediate metabolic MEDICATIONS.
precursor of NOREPINEPHRINE and epinephrine. It
has stimulant effects upon the heart, causing an
increase in heart rate and blood pressure. Dopa- dream anxiety attacks Synonymous with NIGHT-
mine appears to be involved in the maintenance of MARES, the term was first proposed in the DIAG-
WAKEFULNESS; however, it may also have a role in NOSTIC CLASSIFICATION OF SLEEP AND AROUSAL
REM sleep, possibly in its suppression. DISORDERS, published in the journal Sleep in 1979,
Dopamine at low doses promotes sleep; but high as a means of indicating dreams that occurred in
doses delay SLEEP ONSET and increase wakefulness. relationship to anxiety at night.
68 dream content

dream content Since classical Greece, DREAMS The most significant advance in the interpreta-
have been used to gain a better understanding, at tion of dreams occurred with SIGMUND FREUD’s
first of the world and in the last century, of each psychodynamic writings on dreams in his initial
individual. SIGMUND FREUD used dreams to try to publication The Interpretation of Dreams in 1900.
better understand the conflicts of the patients in Wrote Freud: “The Interpretation of Dreams is the
his psychoanalytic practice. His monumental work royal road to a knowledge of the part the uncon-
The Interpretation of Dreams (1900) spells out his scious plays in the mental life.”
complex ideas on the manifest and latent content The first major development in the scientific
of dreams. investigation of dreams occurred in 1953 when
The psychiatrist Carl Gustav Jung in his essay specific physiological changes were documented
“Approaching the Unconscious” delves into the during dreaming sleep and REM (rapid eye move-
importance of dreams and dream symbolism. For ment) sleep. This discovery, made by EUGENE ASE-
Jung, dreams were a way to achieve psychological RINSKY and NATHANIEL KLEITMAN at the University
health and to work through daytime conflicts. Jung of Chicago, led to an intense investigation, by elec-
found Freud’s use of free association with dreams trophysiological means, of the nature of dreams.
too confining and instead he suggested “. . . to It became clear that dreams were more vivid and
concentrate rather on the associations to the dream more easily recalled from awakenings out of REM
itself, believing that the latter expressed something sleep than out of non-REM sleep. Although dreams
specific that the unconscious was trying to say.” occur in non-REM sleep, they contain less clarity
Dreams have contained the idea, or the entirety, and tend to be short sequences of vaguely recalled
of some literary works, composed partly or totally thoughts. The rapid eye movements that occur
during a dream. (See DREAMS AND CREATIVITY.) during REM sleep were initially believed to be
Researchers have discovered that the sex of related to the DREAM CONTENT and led to the devel-
the dreamer influences dream content. Women opment of the scanning hypothesis. Observations
tend to have dreams with indoor settings, with of eye movements under closed or partially opened
less aggression than in male dreams. However, eyelids were recorded and the subject awoken and
these differences may reflect the learned cultural interrogated as to the possible eye movements
traits of males and females rather than true gender that would have occurred during the dream. By
differences. this means, the sequence of eye movements was
Daytime experiences can influence dream con- traced and in some cases was correlated with the
tent; disturbing dreams are often associated with actual eye movements observed in the sleeper. This
daytime stress. (See also NIGHTMARES.) hypothesis has been viewed with skepticism by
many researchers in recent years.
The function of dreams has been explored by
dreams Dreams have fascinated mankind since many researchers. The importance of dreams in the
antiquity. For instance, the Bible contains many development of a mature central nervous system
references to dreams, both in the Old and the New was originally proposed by Howard Phillip Roff-
Testament. Aristotle, one of the first to observe that warg. The significance of REM sleep in consolidat-
the brain can be very active during sleep, placed ing learned material was emphasized by Edmond
little importance upon the role of dreams and M. Dewan and Ramon Greenberg, and a similar
suggested that they were a means of eliminating theory has proposed that REM sleep is important
excessive mental activity. in increasing protein synthesis in the CENTRAL NER-
The scientific investigation of dreams began VOUS SYSTEM for the development of learning and
toward the end of the last century. The study by memory. Some researchers have taken the oppo-
Mary Calkins of Wellesley College in 1893 accu- site approach to explaining dreams in that they
rately documented 205 dreams and confirmed the believe that dreams eliminate unwanted informa-
impression that most dreams were recalled from tion from the central nervous system. Dreaming
sleep that occurred in the latter third of the night. may be important in uncluttering the brain so that
 dreams 69

new information can be more easily retained in or visual stimuli. Incorporation of auditory stimuli
memory. into dream content is rather poor, occurring in
Many famous people have reported that dream- approximately 10 percent of attempts. If water is
ing was important in their development of great sprayed on the face of the dreamer, some content
works of art. (See DREAMS AND CREATIVITY.) regarding water is found in about 40 percent of
Visual input is important for the development recalled dreams. Exposure to light flashes can be
of typical dreaming. People who have been blind incorporated into dream content, but only about
from birth do dream but their dreams contain less 20 percent of the time is it recalled. Experimen-
visual and more auditory content. People who tation by having patients wear colored glasses
have been rendered blind from an early age after throughout the day so that they experience only
the development of visual input tend to retain the color red have led to an increase in the recall
the ability to have visual dreams. The question of of red content in the dreams. Mental activity that
whether people dream in black and white or color occurs immediately prior to the onset of sleep is
was explored by Calvin Hall, and he determined often incorporated into the dream content.
that approximately 30 percent of dreams were REM sleep is associated with a number of pha-
reported to have vivid color content. The content of sic events of which the eye movement is the most
dreams is also influenced by the sex of the dreamer. prominent. In animals, pontogeniculateoccipital
Females tend to have dreams that are more likely (PGO) spikes can be detected by electrodes placed
to be set indoors and are less aggressive than the over the cortex. These spikes occur at the onset of
dreams of males. However, these differences may REM sleep and are thought to be important in the
be related more to personality differences than to initiation of the REM sleep state. Various theories
true sex difference. have been reported as to the importance of PGO
Dream activity within the cerebral hemispheres spikes. Some researchers think they may be related
is believed by some to occur primarily in the right to hallucinatory behavior whereas others believe
hemisphere because of the association with the that they may improve brain function by the elimi-
storage of visual memory. Right-hemisphere func- nation of unwanted memories.
tion in dreaming is supported by reports of patients It has been hypothesized that the human equiv-
with right-hemisphere lesions who have a loss of alent of PGO spikes is more common in patients
dream recall. However, lesions of the posterior with psychiatric disorders characterized by hallu-
region of the brain affecting either hemisphere are cinations, such as schizophrenia. The PGO spikes
also associated with dream loss. are generated in the PONS of the brain stem, which
The ability to dream appears to be present from is believed to be the site of origin for REM sleep.
infancy, and some researchers, such as Howard During REM sleep, activity is relayed from the
Roffwarg, have hypothesized that REM sleep is brain stem to the cortex where it is associated
important for normal brain development. Children with the dreaming. Simultaneously, REM activ-
as young as three years of age report dream content, ity passes down the brain stem to the medullary
although it is often difficult to assess whether the region where stimulation causes an inhibition of
reported dream activity is elaborated upon. Young the spinal cord motoneurons, leading to the loss of
children tend to dream of unpleasant events, such muscle tone during REM sleep. Additional infor-
as being chased, and by age four the dream con- mation on the neurophysiology of REM sleep was
tent appears to include more animal dreams. By discovered with the recognition of the syndrome
age five or six, the dreams include ghosts, physical of REM sleep without ATONIA, which occurs in cats
injury and even death. following pontine lesions. In this syndrome, the
The content of dreams can be influenced by output from the pons to the medullary inhibitory
daytime experiences. Unpleasant dreams are usu- centers is prevented so that the atonia associated
ally associated with daytime psychological stress. with REM sleep does not occur. Cats with such
Researchers have attempted to incorporate mate- lesions tend to “act out” their dreams. This suggests
rial into dreams, including using auditory, tactile that the muscle atonia of REM sleep is a protective
70 dreams and creativity

mechanism to prevent excessive motor activity changes in physiology and the association with
during that sleep stage. nightmares, erectile ability during sleep, REM SLEEP
There is an interest in a phenomenon known BEHAVIOR DISORDER, NARCOLEPSY, and because of its
as LUCID DREAMS where the dreamer is aware of psychoanalytical significance. Investigation into
being asleep and of dreaming. It seems almost as if dreams and their associated pathophysiology is a
the dreamer is awake and asleep at the same time. fertile area of investigation. (See also ALCOHOLISM,
Various techniques, such as posthypnotic sugges- DREAM ANXIETY ATTACKS.)
tions and somatic sensory stimulation during REM
sleep, have been reported to increase the likelihood
of lucid dreaming. It has been suggested that the dreams and creativity History includes several
increased ability to have lucid dreams might be examples of artists who have created works while
useful in stimulating creativity and might even be dreaming, or have dreamed the solution to a cre-
useful in controlling NIGHTMARES. ative problem they were coping with during the
Nightmares are unpleasant dreams that occur day. For instance, the English artist and poet Wil-
in connection with the REM sleep stage. These liam Blake stated that, while searching for a less
episodes can be confused with SLEEP TERRORS, in expensive way to do engraving, he dreamed that
which panic occurs out of slow wave sleep. The his deceased brother came to him and suggested
nightmare, also known as a DREAM ANXIETY ATTACK, that Blake use copper engraving, a method he
produces an abrupt awakening from sleep with immediately began to explore. English poet Samuel
recall of frightening dream content. The nightmare Taylor Coleridge (1772–1834) is reported to have
sufferer can usually recall in detail the DREAM CON- dreamt part of his poem “Kubla Khan.”
TENT—typically, a threat to the dreamer’s safety. Other examples, cited in Patricia Garfield’s book,
Nightmares are more common in the latter third Creative Dreaming, include Guiseppe Tartini, Italian
of the night because of the increased likelihood of violinist and composer; anthropologist Hermann
REM sleep at that time. V. Hilprecht; German chemist Friedrich A. Kekule,
NARCOLEPSY, a disorder of excessive sleepiness who discovered the molecular structure of ben-
and characterized by sleep onset REM periods, is zene in a dream; and English author Robert Louis
also associated with frequent and vivid dreaming, Stevenson (1850–94), who wrote that he dreamed
and there may be a slight increase in a tendency for the essence of the Dr. Jekyll and Mr. Hyde story.
nightmares. The SLEEP ONSET dreams of the narco- Garfield includes a list of “what we can learn from
leptic are often unpleasant. A more extreme form creative dreamers,” including the suggestion that if
of nightmare activity can occur at sleep onset— you have a creative dream, you should “. . . clearly
TERRIFYING HYPNAGOGIC HALLUCINATIONS; however, visualize it and record it in some form as soon as
these can also occur in people without any obvious possible: write it, paint it, play it, make it. Visualize
precipitating disorder. it while you translate it into a concrete form.” (See
The dreaming stage of sleep is associated with also DAYDREAMING, DREAM CONTENT, and DREAMS.)
penile erections in males. Although sexual dream
content is not usually associated with REM SLEEP-
RELATED PENILE ERECTIONS, sexual dreams are com- drowsiness A state of WAKEFULNESS characterized
mon in adolescence. Sexual dreams increase the by brief episodes of sleep, typically lasting only sec-
likelihood of a NOCTURNAL EMISSION (wet dream) onds. The individual is often not aware that sleep
in which ejaculation occurs in association with is actually occurring and perceives the state as one
the penile erection. Nocturnal emissions are more of tiredness and a strong desire for sleep.
likely to occur in males who have abstained from During DROWSINESS, the ELECTROENCEPHALOGRAM
sexual activity for a long period of time and are also (EEG) records an “alpha dropout” with reduced
more common in adolescence. ALPHA ACTIVITY giving way to low-voltage, mixed
The dream stage of sleep is a very important slow and fast activity. Slow waves in the range of 2
sleep stage because of its association with dramatic to 7 HERTZ occur, often mixed with fast activity of
 drowsy driving 71

15 to 25 hertz. As the drowsiness deepens, the elec- the 1,154 adults surveyed by telephone for the
troencephalogram rhythm slows, with more fre- National Sleep Foundation’s (NSF) 2000 poll said
quent episodes of 2 to 3 hertz activity intermixed that they had actually dozed off while driving
with brief episodes of return to alpha activity in drowsy during the previous year. Men were more
response to arousing stimuli. likely than women to drive drowsy (63 percent
Occasionally, when a person experiences drows- versus 43 percent) and younger adults were more
iness, the EEG will show the presence of positive likely than older adults to drive drowsy (60 percent
occipital sharp transients of sleep (POSTS) that of 18-year-olds versus 21 percent of those 65 years
occur in the occipital regions and are most com- and older).
monly seen in adolescents and young adults. In The most common way to deal with drowsy
addition, transient sharp waves, termed benign driving, according to the National Sleep Founda-
epileptiform transients of sleep (BETS), can also tion’s 2000 poll, is to use caffeine (63 percent).
be seen. Roughly one of five drivers (22 percent) said they
Drowsiness is a relaxed state that can be consid- pulled over to take a nap when they feared their
ered an intermediary stage between wakefulness exhaustion might cause them to fall asleep at the
and light sleep. During drowsiness, the individual is wheel.
able to comprehend environmental stimuli and will According to the National Sleep Foundation,
deny being asleep. Not uncommonly, individuals driving when you are sleepy or drowsy may cause
who are in STAGE ONE sleep, which is characterized the following mental and behavioral changes that
by loss of alpha activity and reduced appreciation of can affect driving:
environmental stimuli, will report that they were in
a state of drowsiness and deny being asleep. • impaired reaction time, judgment, and vision
Drowsiness occurs naturally prior to SLEEP • problems with information processing and short-
ONSET, but it can also be brought on by MEDICA- term memory
TIONS prescribed specifically for that purpose or as
• decreased performance, vigilance, and motivation
a side effect of a medication prescribed for another
purpose, such as for motion sickness, hay fever • increased moodiness and aggressive behaviors
or colds (see ANTIHISTAMINES). Certain illicit sub-
stances, such as heroin or marijuana, may also A heightened awareness about the consequences
induce drowsiness. of drowsy driving following the death of Maggie
McDonnell in 1997 led to the passage of MAGGIE’S
LAW: National Drowsy Driving Act of 2002. Ms.
drowsy driving Term applied to driving a vehicle McDonnell was a 20-year-old college student who
when not fully alert. The danger of drowsy driv- was killed in a head-on collision at 11:30 A.M. by
ing, also referred to as driver FATIGUE, is that it may a van driver who admitted he had not slept in 30
lead to falling asleep at the wheel with resultant hours. The law makes it possible to charge a driver
injuries or even fatalities to the driver, passengers, who is driving while sleep impaired with the crime
and any other individuals who come into contact of vehicular homicide, which is punishable by up
with the vehicle, which would be out of control to 10 years in prison and a fine of $100,000. Previ-
due to the sleeping driver. Causes of drowsy driv- ously driving drowsy only meant a charge of care-
ing include SLEEP DEPRIVATION, because of sleeping less driving and a fine of $200.
too few hours, driving while exhausted at the end In a 2006 national survey on the sleep patterns
of an overnight shift, (shift work), certain medica- of U.S. adolescents (ages 11–17) conducted as part
tions that have sleepiness as a side effect, drinking of NSF’s 2006 Sleep in America campaign, 51 percent
alcoholic beverages, eating a large meal, especially of adolescent drivers reported that they had driven
one that has an excess of carbohydrates that cause drowsy during the previous year. Fifteen percent
sleepiness, and the soporific effect of highway of 10th to 12th grade drivers admitted to driving
driving, especially at night. Fifty-one percent of drowsy at least once a week.
72 drugs

In November 2007, the NSF began its annual is currently marketed as Xyrem for the suppres-
Drowsy Driving Prevention Week, which is aimed sion of CATAPLEXY in the sleep disorder narcolepsy.
at educating the public about the potentially lethal GHB production in the United States is illegal for
combination of exhaustion and driving. For more use as a recreational substance, as is Rophypnol,
information visit the NSF Web site at http://www. which is known as a club and date rape drug
DrowsyDriving.org. because it may be added surreptitiously to a drink.
Rophypnol can be addictive and, in large doses,
may induce unconsciousness, respiratory depres-
drugs See ANTIDEPRESSANTS, ANTIHISTAMINES, BAR- sion, and death. Alcohol is commonly consumed
BITURATES, BENZODIAZEPINES, HYPNOTICS, MONOAMINE at bedtime to aid sleep onset and has many of the
OXIDASE INHIBITORS, NARCOTICS, RESPIRATORY STIMU- same drawbacks.
LANTS, STIMULANT MEDICATIONS. Sleep induction may also be the aim of sub-
stances originally prescribed for other purposes,
such as certain ANTIDEPRESSANTS (sedating SELEC-
drugs and sleep Of all of the adverse drug effects TIVE SEROTONIN REUPTAKE INHIBITORS such as Prozac
that are encountered, sleepiness is surely one of or Paxil, as well as antidepressants such as Tra-
the most common. The effects on sleep may be zodone). To what extent these drugs help induce
so strong that certain medications, i.e., antihista- sleep by countering depression and anxiety versus
mines, may be included as the “active ingredients” their sedating effects may be difficult to ascertain.
in medications whose main purpose is to induce Psychiatric sedatives may also be habit forming and
sleep. Nevertheless, such nonprescription hypnot- have unpleasant or dangerous withdrawal effects.
ics are relatively ineffective for sleep induction and Substances that do not require prescriptions, such
maintenance. as diphenhydramine and other antihistaminics,
More effective hypnotic drugs have recently been are common ingredients of nonprescription sleep
developed including zolpidem (Ambien), eszopi- aids but are of questionable value in their ability
clone (Lunesta), zaleplon (Sonata), and ramelteon to induce sleep. The amino acid L-tryptophan is an
(Rozerem). Ramelteon is unique because it acti- essential amino acid that is a constituent of many
vates the brain’s melatonin receptors, and it may, protein-rich foods. Because of some evidence that
therefore, recruit the brain’s own sleep mecha- tryptophan may induce sleepiness, L-tryptophan
nisms. All of these agents represent substantial has been promoted as a natural (and, by implica-
increases in safety and efficacy over the preceding tion safe) sleep aid. However, an outbreak in 1989
generation of sleep aids. Those older agents include of eosinophilia-myalgia syndrome (EMS), an auto-
benzodiazepines such as flurazepam (Dalmane), immune disorder that caused permanent disability
diazepam (Valium), alprazolam (Xanax), triazolam or death in over 1,500 cases, was traced to the
(Halcion), flunitrazepam (Rohypnol), and clonaze- use of L-tryptophan. Although it was never deter-
pam (Klonopin). Benzodiazepines were themselves mined whether these cases of EMS were associated
improvements over older classes of hypnotics such with L-tryptophan itself or with an impurity intro-
as barbiturates (Nembutal, Amytal, Tuinal, Seco- duced in its manufacture, it is clear that the con-
nal), chloral hydrate, methaqualone (Quaalude), centration and packaging of a natural substance
and ethchlorvinyl (Placidyl). The latter rapidly may convert it into something with unnatural and
lost effectiveness (patients developed drug toler- even malign effects.
ance) and could induce dependency with severe Of course sleep is itself a naturally occurring
withdrawal effects. They were in widespread rec- state that arises spontaneously at about 24-hour
reational use in the 1960s and 1970s but are no intervals (the circadian sleep-wake rhythm) and
longer legally produced in the United States. An should no more require active chemical induction
exception is gamma hydroxyburyrate (GHB), a than eating meals requires an appetite stimulant.
sedating, euphoria-producing drug that was once Yet habitual nightly use of a sleep aid may be so
used as a general anesthetic and as an hypnotic. It ingrained that omission may lead to prolonged
 dysthymia 73

TABLE ing unrested, as well as those who are affected

CAFFEINE CONTENT OF FOOD AND DRUGS
by sleep disorders that impair wakefulness (SLEEP
Serving Size Caffeine (mg) APNEA, NARCOLEPSY, and others). Caffeine has been
Coffee called the world’s most widely used psychoactive
Coffee, generic substance and may be unknowingly consumed in a
brewed 8 oz 133 (range 102–200) variety of foods and beverages. (SEE TABLE AT LEFT).
Coffee, generic
decaffeinated 8 oz 5 (range 3–12)
Espresso, generic 1 oz 40 (range 30–90) dustman See SANDMAN.

Tea
Tea, brewed 8 oz 53 (range 40–120) dyssomnia A disorder of sleep or WAKEFULNESS
that is associated with a complaint of difficulty of
Soft drinks
initiating or maintaining sleep or EXCESSIVE SLEEPI-
Mountain Dew 12 oz 71
NESS. Dyssomnia is used, as opposed to the term
Diet Coke 12 oz 47 PARASOMNIA, which refers to a sleep disorder that
Pepsi 12 oz 38 occurs during sleep but does not primarily produce
7-Up 12 oz 0 a complaint of insomnia or excessive sleepiness.
In the older literature, NATHANIEL KLEITMAN
Energy Drinks
used the term dyssomnia to refer to all disorders
Red Bull 8.3 oz 80
of sleep and wakefulness, including parasomnias.
The term dyssomnia is also used as a major head-
Chocolates
ing in the sleep disorders section of the American
Hershey’s Kisses 41g (9 pieces) 9
Psychiatric Association’s section on sleep disorders
Over-the-Counter Drugs in the Diagnostic and Statistical Manual (DSM-IV).
NoDoz 1 tablet 200 In DSM-IV, dyssomnias refer to any disturbance
Vivarin 1 tablet 200
of sleep and wakefulness other than the para-
somnias. In the INTERNATIONAL CLASSIFICATION OF
SLEEP DISORDERS, the term dyssomnia refers only
to the major (primary) sleep disorders that are
associated with insomnia or excessive sleepiness
WAKEFULNESS. Such experiences reinforce the belief and excludes the secondary (other medical and
that the substance in question is essential for sleep psychiatric) causes.
to occur. People who are dependent upon hypnotic
drugs often feel deeply ambivalent about using a
hypnotic drug because they avoid any use of arti- dysthymia A depression that is considered more
ficial substances, yet are convinced that sleep is minor than a clinical depression because someone
impossible unless it is actively induced. Treatment suffering from it does not need to be hospitalized
of hypnotic drug dependency requires systematic and is still able to work. By definition the disorder
reduction of dosages plus simultaneous enforce- has lasted at least two years. Irregular sleep is one
ment of regular, rational sleep hours. of the symptoms of dysthymia, in addition to with-
Similarly stimulants including caffeine may be drawing socially, poor work or school performance,
depended upon to induce or maintain daytime having conflicts with family and friends, and being
alertness, most often by people who awaken feel- irritable or hostile.
 E
early morning arousal Term used to denote final common. The senior years are a time that is associ-
awakening that occurs following the major sleep ated with light and unrefreshing sleep.
episode at a time earlier than desired. The term is Sleep in the elderly is characterized by electro-
commonly used as synonymous with “premature encephalographic changes in sleep stages, as well
morning awakening” and is usually associated with as an increase in the number of AWAKENINGS and
underlying DEPRESSION, although it may be caused WAKEFULNESS during the major sleep periods.
by other medical or psychiatric disorders, such as The amount and percentage of STAGE ONE SLEEP
DEMENTIA or mania. Early morning arousal may increases. The SPINDLE activity of STAGE TWO SLEEP is
also be due to a CIRCADIAN RHYTHM SLEEP DISOR- reduced, and the total amount of STAGE THREE and
DER, such as ADVANCED SLEEP PHASE SYNDROME, in FOUR SLEEP is also reduced. The SLOW WAVE ACTIVITY
which the sleep onset time is early and hence the is reduced in amplitude. REM sleep becomes more
wake time is also early. The early morning arousal fragmented and the density of RAPID EYE MOVE-
is often preceded by numerous brief awakenings MENTS is reduced in the elderly.
before the final awakening. (See also INSOMNIA.) Along with the changes in the polysomno-
graphic features of sleep there is an increase in
complaints regarding the quality of sleep, and sleep
early morning awakening See EARLY MORNING is bound to be less restful. The number of daytime
AROUSAL. NAPS increases and there is a general increase in
SLEEPINESS throughout the waking portion of the
sleep-wake cycle.
ECOG See ELECTROCORTICOGRAM. The sleep-wake pattern can become so disrupted
that there may be the loss of a definite main noc-
turnal sleep episode.
EDS See EXCESSIVE SLEEPINESS. Certain sleep disorders become more prevalent
in the elderly, particularly BREATHING DISORDERS,
SLEEP-RELATED and PERIODIC LEG MOVEMENTS. These
EEG See ELECTROENCEPHALOGRAM. physiological changes contribute to the sleep dis-
ruption and the tendency to increasing daytime
sleepiness.
Elavil (Amitriptyline) See ANTIDEPRESSANTS. The elderly patient is more likely to request
hypnotic medications than a younger patient. HYP-
NOTICS in the elderly may exacerbate sleep-related
elderly and sleep Sleep complaints are common breathing disorders and, because of reduced meta-
in the elderly, usually the inability to fall asleep or bolic clearance, there may be an accumulation of
to remain asleep, but there can also be complaints the hypnotic, which impairs mental performance.
of excessive sleepiness during the daytime. Abnor- Elderly patients are also more likely to have medi-
mal activity during sleep, particularly movements cal illnesses, including psychiatric illness, factors
of the limbs, nightmares and other fears are also that can disrupt nighttime sleep. The DEMENTIAS are
74
 electroencephalogram 75

often associated with NOCTURNAL CONFUSION, which commonly occurs during non-REM sleep, it never
has been called the SUNDOWN SYNDROME. The sun- fills more than 85 percent of slow wave sleep.
down syndrome often leads to the elderly patient Other seizure disorders, such as the Lennox-
being placed in a nursing home where appropri- Gastaut syndrome, may need to be differentiated.
ate observation and control can be instituted at However, this particular form of epilepsy has
night. Medications and alcohol can contribute to typical tonic seizures associated with the abnormal
this sleep disturbance in the elderly and can add to electroencephalographic pattern.
disruption of the sleep-wake pattern, which may Another form of epilepsy associated with lan-
exacerbate mental impairment. guage difficulty is called the Landau-Kleffner syn-
Treatment of sleep disturbance in the elderly drome. This form of epilepsy is associated with
rests primarily upon the institution of good SLEEP clinical features of epilepsy and a typical electroen-
HYGIENE measures and the institution of treatment cephalographic pattern that is localized to one or
for specific sleep disorders. In general, if possible, both temporal lobes.
hypnotics are best avoided. Electrical status epilepticus of sleep is treated by
standard anticonvulsants that include phenytoin.
SESE is an acronym for subclinical electrical status
electrical status epilepticus of sleep (ESES) An epilepticus of sleep, which is synonymous with
abnormal ELECTROENCEPHALOGRAM pattern that electrical status epilepticus of sleep.
occurs during NON-REM-STAGE SLEEP. This rare
disorder is characterized by continuous, slow-
spike-and-wave discharges that occur and persist electrocorticogram (ECoG) The recording of the
throughout non-REM sleep. At least 85 percent electroencephalogram by means of electrodes that
of non-REM sleep is occupied by this abnormal are applied on the cortex directly to the surface
pattern. Electrical status epilepticus of sleep does of the brain. This technique is most often used
not produce direct clinical features of epilepsy and for detecting the site of intractable seizure activity
therefore its name is regarded as slightly inappro- prior to neurosurgical removal of a lesion.
priate. It is really an electrical abnormality, rather
than a true seizure disorder. However, children
with electrical status epilepticus of sleep have sig- electroencephalogram (EEG) Recording of the
nificant cognitive and behavioral disorders that electrical activity of the brain, the term typi-
are believed to be directly related to the electroen- cally applies to measurements made by applying
cephalographic pattern. electrodes to the scalp. The electroencephalo-
ESES is most often seen in childhood around graphic activity is composed of frequencies that
eight years of age and affects males and females are divided into four main groups: those that are
equally. It tends to disappear with increasing age below 3.5 per second (DELTA), 4 to 7.5 per second
and its duration, although difficult to know exactly, (THETA), 8 to 13 per second (ALPHA) and those
appears to be in terms of months or years. Some above 13 per second (BETA). Sleep electroenceph-
children who suffer from ESES also can have more alographic frequencies are usually of the theta
typical epilepsy. Most often, the seizures are a or delta range, except that of REM sleep which
generalized or focal seizure disorder that usually consists of mixed theta and alpha activities. The
predates the discovery of the ESES. deepest stage of sleep, SLOW WAVE SLEEP, has EEG
The abnormal slow wave activity needs to be activity in the delta range.
distinguished from other epileptic disorders, such as EEG waves are also described in terms of their
BENIGN EPILEPSY WITH ROLANDIC SPIKES (BERS). The amplitudes. The amplitude of waves detected at
benign epilepsy of childhood has clinical seizures the scalp is usually 10 to 100 microvolts (mv).
that are usually evident, and the electroencepha- Alpha activity is usually 10 to 20 mv. Beta activ-
lographic pattern is characterized by frequent spike ity is also low amplitude, rarely exceeding 30 mv.
activity. Although benign epilepsy of childhood Theta waves can be higher, up to 50 mv, and delta
76 electroencephalogram
 electrosleep 77

waves are of the highest amplitude, up to 100 mv tronarcosis. Electronarcotic experiments have been
in children. performed on animals since the early 1800s. A
The recording is usually on paper, although it current is passed through electrodes that are placed
is now possible to record on magnetic tape and on the neck of the animal. Starting at a rate of 100
computer disk. Typically the electroencephalogram pulses per second, a current of one to two mil-
is measured along with the ELECTROOCULOGRAM liamperes produces a loss of all motor activity and
and the ELECTROMYOGRAM for the recording of reflexes. This state can be maintained for several
sleep stages and wakefulness. Electrodes for the hours and upon termination of the electrical cur-
measurement of the brain activity to document rent, the animal immediately recovers.
sleep are typically placed at the C3 or C4 positions The first electronarcosis performed on a human
according to the 10–20 system used throughout the was conducted in 1902 by Stephane Armand Nico-
world. Electroencephalograph electrodes can also las Leduc (1853–1939). Leduc, experimenting on
record other electrical signals that come from the himself, maintained consciousness but speech and
body, such as muscle activity or eye movements. movement were lost. The sensation experienced
was not unlike a feeling of paralysis that is experi-
enced with dreams (see SLEEP PARALYSIS).
electromyogram (EMG) The recording of muscle Electronarcosis was used in humans for the treat-
electrical potentials in order to document the level ment of schizophrenia; it was felt to be more ben-
of muscle activity. The electromyogram is usually eficial than treating patients with electroconvulsive
recorded by a polysomnograph machine, along with therapy (ECT). However, electronarcosis can induce
the ELECTROENCEPHALOGRAM and ELECTROOCULO- cerebral convulsions and ventricular arrhythmias
GRAM, in order to stage sleep. The electrodes for the and therefore is no longer regarded as an acceptable
measurement of the electromyogram are typically form of treatment. (See also ELECTROSLEEP.)
placed over the tip of the jaw to record activity in
the mentalis muscle. Sometimes electromyographic
activity is also recorded from other muscle groups electrooculogram (EOG) A recording of eye
to determine other abnormal activity during sleep. movements by means of changes in the electri-
For example, measurements of the masseter muscle cal potentials between the retina and the cornea.
activity are useful for determining the presence of There is a large potential difference, often over 200
BRUXISM (tooth grinding), and activity recorded from microvolts, between the negatively-charged retina
the anterior tibialis muscles can document the pres- and the positively-charged cornea. Electrodes that
ence of PERIODIC LEG MOVEMENTS during sleep. are placed lateral to the outer CANTHUS of the eyes
Electromyographic activity recorded in the poly- record changes in the dipole with movements of
somnogram typically will show an increased level the eyes. Measurement of eye movement activity
of activation during wakefulness; this decreases is essential for staging sleep.
as the subject passes through the non-REM sleep In stage one sleep, there are slow rolling eye
stages (see NON-REM-STAGE SLEEP) to the deeper movements, and the eyes become quiescent (not
stages of sleep, when the chin muscle activity is moving) in deeper stages of non-REM sleep. REM
very low. In REM sleep, electromyographic activ- sleep is characterized by rapid eye movement. Rapid
ity is characterized by a silent background, but eye movements similar to those seen in REM sleep
with brief phasic muscle activity from most muscle can be seen during wakefulness, and the measure-
groups. Background electromyographic activity can ment of other physiological variables, such as the
be increased in REM sleep in association with REM EEG and EMG, help in the differentiation of REM
SLEEP BEHAVIOR DISORDER. sleep from wakefulness. (See also SLEEP STAGES.)

electronarcosis Alteration of the level of con- electrosleep A form of SLEEP THERAPY that involves
sciousness by electrical stimulation is called elec- the induction of sleep by means of an electric
78 EMG

current. A pulsating current lasting 0.2 to 0.3 mil- logram has shown generalized slowing. There is no
lisecond, of voltage 0.5 to 2.5 and milliamperage of known treatment for the primary illness, and its
0.2 to 1.5, has been recorded as being effective in symptoms must be treated symptomatically.
inducing sleep in animals. When the current is ter-
minated, sleep continues. It is believed that electro-
sleep is more effectively produced when low doses endogenous circadian pacemaker An internal
of hypnotics, such as the barbiturates or benzodiaze- mechanism that triggers the periodic processes that
pines, are given concurrently. Electrosleep has been are involved in the human circadian timing sys-
used in the course of sleep therapy for treatment of tem, this structure controls the timing of various
a variety of medical disorders such as schizophrenia. rhythmical processes in the body, such as the sleep-
This form of treatment is widely practiced in Euro- wake cycle, that have a cycle of approximately 24
pean countries, and there are differing opinions on hours. The site of the pacemaker appears to be the
its usefulness. (See also ELECTRONARCOSIS.) SUPRACHIASMATIC NUCLEUS at the base of the third
ventricle in the hypothalamus of the brain.
The endogenous circadian pacemaker appears
EMG See ELECTROMYOGRAM. to have a very stable periodicity that controls the
timing of the CIRCADIAN RHYTHMS in the free-run-
ning condition. A number of physiological param-
encephalitis lethargica A disease suspected to eters, including the core-body temperature, cortisol
be of viral cause, first reported in 1917. It affected release, REM sleep propensity, urinary potassium
thousands of people until 1927, when the disease excretion, alertness, and cognitive and psychomo-
gradually disappeared. Encephalitis lethargica pro- tor performance, are all driven by the endogenous
duced inflammation of various portions of the brain, circadian pacemaker.
including the brain stem and hypothalamus. It was
most prevalent in Austria and France, spreading to
the rest of western Europe and Britain. endogenous rhythm See ENDOGENOUS CIRCADIAN
The primary features of this disorder were stupor, PACEMAKER.
excessive sleepiness, disturbed sleep at night, and
the development of features of Parkinsonism, with
generalized rigidity and abnormal movements. endoscopy A procedure whereby an observa-
Constantin Von Economo (1876–1931) exten- tion can be made anywhere inside the body. In
sively studied patients with encephalitis lethar- sleep disorders medicine, endoscopy commonly
gica and recognized three different sleep patterns: is performed in patients who have UPPER AIRWAY
EXCESSIVE SLEEPINESS, INSOMNIA, and REVERSAL OF OBSTRUCTION in order to determine the site of that
SLEEP. He studied the pathology and determined obstruction. A fiberoptic endoscope (see FIBER-OPTIC
that insomnia primarily occurred in those patients ENDOSCOPY) is placed through the nose so that an
who had basal forebrain lesions whereas exces- observer can view the tissues of the nose and upper
sive sleepiness appeared to result from posterior airway. This procedure can be performed not only
hypothalamus lesions. Although features typical on the awake patient but also on a patient who is
for NARCOLEPSY and CATAPLEXY have been reported asleep or under anesthesia. SOMNOENDOSCOPY is the
in association with encephalitis lethargica, the term applied to the endoscopic evaluation of the
development of true narcolepsy by encephalitis upper airway in the sleeping patient. This proce-
lethargica is questioned. dure is rarely performed in patients with OBSTRUC-
Other features of encephalitis lethargica included TIVE SLEEP APNEA SYNDROME in order to determine
immobility of the eye muscles and oculogyric crises the site of upper airway obstruction because the
(bizarre, uncontrollable eye movements). presence of the endoscope is usually too uncom-
In recent years, encephalitis lethargica has rarely fortable to allow the patient to sleep. Endoscopy
been reported, and polysomnographic testing has performed in the awake patient is a more common
not been performed. However, the electroencepha- procedure.
 epilepsy, sleep-related 79

end-tidal carbon dioxide Term referring to the is synonymous with environmental time cues.
measurement of the carbon dioxide value in (See also CHRONOBIOLOGY, CIRCADIAN RHYTHM SLEEP
expired air, which reflects the level of carbon diox- DISORDERS, NON-24-HOUR SLEEP-WAKE SYNDROME,
ide in the lung alveoli. “End-tidal” refers to the NREM-REM SLEEP CYCLE.)
end, or last portion, of the resting breath (TIDAL
VOLUME). This value is normally detected by means
of sampling air from the nostrils at the end of the EOG See ELECTROOCULOGRAM.
expiration. The gas is analyzed by means of an
infrared gas analyzer.
In addition to providing accurate measurements epilepsy, sleep-related Epilepsy is a disorder char-
of alveolar carbon dioxide levels, the resultant trac- acterized by the sudden occurrence of an excessive
ing can also be used as an accurate measure of ven- cerebral electric discharge. It has a very specific rela-
tilation. The measurement of carbon dioxide values tionship with the sleep-wake cycle, which can lead
is most useful in determining impairment of gas to epilepsy being exacerbated during sleep.
exchange in the lungs, and this can give important The generalized seizures (grand mal), the par-
information on lung function or ventilatory abil- tial or focal motor seizures, and complex partial
ity. (See also SLEEP-RELATED BREATHING DISORDERS, seizures are three forms of epilepsy that can occur
SLEEP APNEA.) during sleep. Although epilepsy can produce sleep
disruption and lead to a complaint of INSOMNIA,
in general the primary complaint is of abnormal
enuresis, sleep-related See SLEEP ENURESIS. movement activity during sleep. Episodes of sud-
den awakening with movements or walking raise a
possibility that the episode is due to epilepsy, par-
environmental sleep disorder A sleep disorder ticularly if there is associated confusion.
that has its roots in a disturbing environmental Because sleep is a powerful activator of epilepsy,
condition that produces a complaint of INSOMNIA sleep is used for diagnostic purposes.
or EXCESSIVE SLEEPINESS. Light and environmental Electroencephalography (see ELECTROENCEPHA-
noise are typical causes of environmental sleep dis- LOGRAM) is often performed after a night of SLEEP
order. Usually the sleep disorder is resolved when DEPRIVATION so that the effects of either sleep loss
the environmental disturbance is eliminated. or the subsequent sleep episode can be utilized to
enhance detection of abnormal epileptic activity.
Sometimes HYPNOTICS such as chloral hydrate are
environmental time cues Environmental factors given to the patient, when epilepsy is suspected, to
that influence a pattern of behavior, such as the enhance the detection of epileptic discharges dur-
sleep-wake cycle, and help to maintain regular 24- ing sleep.
hour periodicity. Maintenance of a 24-hour sleep- The form of epilepsy that causes the most dif-
wake cycle is dependent upon environmental time ficulty in its differentiation from other sleep disor-
cues occurring prior to the onset of the major sleep ders, such as SLEEPWALKING, is the partial complex
episode and also at the time of awakening. Such seizure. In this particular seizure type, a patient
time cues include alarm clocks, light stimuli, social may awaken from sleep, pick at the bedclothes,
interaction and noise stimulus. In an environment have lip-smacking, get out of bed and walk around
free of environmental time cues, an individual and appear to be unaware of other people in the
may free run with a sleep-wake cycle that is lon- environment. Usually the walking is performed
ger than 24 hours, typically 25 hours, causing the in a semi-purposeful manner; however, the indi-
individual to fall asleep one hour later and arise vidual may be difficult to awaken and may go
one hour later on a daily basis. This FREE RUNNING back to bed without assistance. If the person does
pattern of sleep and wakefulness causes the sleep- awaken there is generally confusion followed by
wake pattern to occur out of synchrony with that lethargy. What distinguishes this seizure disorder
of most other people. The German term zeitgeber from sleepwalking episodes is the presence of the
80 epoch

automatic and repetitive type of limb movements electroencephalographic array (arrangement or

and lip-smacking behavior. montage) with 12 to 16 channels of information,
In generalized tonic-clonic seizures that occur coupled to simultaneous audiovisual monitoring.
during sleep, there is little difficulty in diagno- Treatment of the epilepsy depends upon the
sis because of the repetitive jerking of the limbs underlying type of epilepsy, and usually one or
and associated urinary or fecal incontinence. The more anticonvulsant medications are required.
patient is also typically confused following the (See also RHYTHMIC MOVEMENT DISORDER.)
episode.
A focal epilepsy characterized by small jerking
movements of one part of the body needs to be dis- epoch A measure of sleep activity used in order
tinguished from other forms of movement disorder, to stage sleep (see SLEEP STAGES); typically epochs
such as PERIODIC LIMB MOVEMENT DISORDER. Some- are 20- to 30-second samples of sleep that have
times a whole body jerk can occur at SLEEP ONSET, been recorded by POLYSOMNOGRAPHY. Epochs often
due to epilepsy, that is difficult to differentiate from reflect the recording speed of the polysomnograph,
SLEEP STARTS; however, such episodes usually recur and refer to a single page of recording; polysomno-
during sleep, whereas sleep starts are present only graph recordings performed at 15 millimeters per
at sleep onset. second will typically produce a 20-second epoch
A patient who presents with a single epileptic on standard EEG paper, whereas recordings per-
seizure during sleep may not proceed to have fur- formed at 10 millimeters per second will produce
ther episodes; however, most patients will develop 30-second epochs on standard EEG paper. A typical
not only sleep-related epileptic seizures but also polysomnographic recording of sleep will produce
daytime episodes. In the initial stages, a daytime approximately 1,000 epochs of sleep at the stan-
electroencephalogram may help diagnose epilepsy. dard 10 millimeters per second recording rate.
Polysomnographic monitoring with extensive elec-
troencephalographic recording during sleep is nec-
essary in some patients to confirm the diagnosis. Epworth Sleepiness Scale (ESS) A questionnaire
Sometimes epileptic seizures are heralded by that is used to assess whether someone is suffering
a loud cry, followed by a generalized tremor, and from excessive daytime sleepiness. Eight questions
such an episode may be difficult to differentiate are asked and are ranked on a scale of 0 to 3, evalu-
from sleep terrors. However, other behavioral man- ating someone’s chance of dozing in those situ-
ifestations of epilepsy are usually present, such as ations (0+ would never doze; 1=slight chance of
repetitive movements like lip-smacking or jerking dozing; 2=moderate chance of dozing; and 3=high
of the limbs, and there is the absence of the intense chance of dozing).
fear and panic that is characteristic of sleep terrors.
The diagnosis of epilepsy is confirmed if a specific
electroencephalographic pattern is seen during the Situation Chance of Dozing
behavioral event. For tonic-clonic epilepsy, gener- 1. Sitting and reading _______
alized spike and wave activity occurring bilaterally
2. Watching television _______
and in a synchronous manner is diagnostic. These
spike and wave episodes occur with a frequency 3. Sitting inactive in a public place such
as a theater or a meeting _______
that is generally in the delta range (2 to 4 Hz), last-
ing up to five seconds in duration in the interictal 4. As a passenger in a car for an hour
without a break _______
period. Repetitive spike activity, called polyspikes,
5. Lying down to read in the afternoon _______
is also frequently seen during non-REM sleep in
patients with generalized seizure disorders. Abnor- 6. Sitting and talking to someone _______
mal EEG activity is often suppressed during REM 7. Sitting quietly after lunch (when
sleep. Polysomnographic monitoring of patients you’ve had no alcohol) _______
for seizure disorders is aided by using an extensive 8. In a car, when stopped for traffic _______
 esophageal reflux 81

A score of less than 8 means someone does not night before, and typically will stay in bed later on
suffer from excessive daytime sleepiness. A score some mornings, if there has been an inadequate
of 10 or more means that someone is sleepier than amount of sleep, in the hope that more sleep will
he or she should be and may need to think more be obtained. However, some nights, because of
about sleep. A score of 15 or more means someone the feeling of being wide awake, the insomniac
should discuss the results of this test and sleep- may go to bed later than usual; and on some days,
related symptoms with his or her physician. because of awakening early due to the insomnia,
Murray W. Johns, M.D., developed the Epworth the patient may arise earlier than usual. There-
Sleepiness Scale at the Sleep Center at Epworth fore the sleep episodes are spread out over at least
Hospital in Melbourne, Australia. a 10-hour period. There is a breakdown of the
ENVIRONMENTAL TIME CUES that are essential for the
maintenance of a stable sleep-wake pattern, in part
Equalizer A trade name for a dental appliance because of the effect of disrupted sleep on under-
that is inserted in the mouth for the treatment lying CIRCADIAN RHYTHMS. An essential element in
of SNORING. This device consists of two fine tubes treatment of patients with insomnia is to ensure
attached to the mouthpiece to allow air to be that sleep does not occur before a set time at night,
sucked through the mouth to the hypopharynx. for example 11 P.M., or after a set time in the morn-
The Equalizer prevents a negative suction effect ing, such as 7 A.M. Ensuring that all sleep occurs
from occurring in the upper airway, so obstruction between appropriate limits of no longer than eight
does not occur. It is not particularly useful for the hours helps develop a stable sleep-wake cycle.
treatment of OBSTRUCTIVE SLEEP APNEA SYNDROME, Maintaining regular sleep onset and wake times
but can be effective in some patients who have is an important element of STIMULUS CONTROL THER-
primary (benign) snoring. APY for insomnia, as well as SLEEP RESTRICTION THER-
APY. (See also IRREGULAR SLEEP-WAKE PATTERN.)

erections during sleep Penile erections typically

occur during sleep in all healthy males from infancy ESES See ELECTRICAL STATUS EPILEPTICUS OF SLEEP.
through old age. Erections are associated with REM
sleep, not usually with sexual dreams. The erections
occur during each of the episodes of REM sleep and esophageal pH monitoring Episodes of gastro-
can last up to 20 minutes. The presence of penile esophageal reflux of acid can be detected by means
erections during sleep helps differentiate IMPOTENCE of a stomach pH-sensitive electrode, which is
due to psychogenic causes from that due to physical passed by means of a polyurethane tube through
causes, such as a neurological or vascular disorder. the nose into the lower esophagus. The electrode is
(See also IMPAIRED SLEEP-RELATED PENILE ERECTIONS, connected to a strip chart recorder so that continu-
SLEEP-RELATED PAINFUL ERECTIONS.) ous measurements of pH changes can be detected
throughout sleep and often for a 24-hour period.

erratic hours Term applied to varied SLEEP ONSET

and WAKE TIMES. Alterations in the time of going to esophageal reflux Term applied to the regur-
bed at night, and of awakening in the morning, are gitation of gastric contents into the esophagus.
common precipitating factors in the development Esophageal reflux typically occurs in individu-
of INSOMNIA. Regularity in going to bed and awak- als who have some incompetence of the gas-
ening is a key element of good SLEEP HYGIENE. troesophageal sphincter between the esophagus
People who develop insomnia often find that and the stomach. This incompetence may be due
their times of going to bed and waking up start to to a hiatus hernia. Patients with OBSTRUCTIVE
vary greatly. The insomniac will typically go to bed SLEEP APNEA SYNDROME are more likely to have
earlier some nights to catch up on sleep lost the esophageal reflux during the struggle to breathe
82 eszopiclone

that is associated with apneic events. This reflux SLEEPINESS SCALE (ESS), are often used to deter-
may cause an awakening from sleep and produce mine a subject’s level of sleepiness.
gagging or COUGHING, sometimes associated with The causes of excessive sleepiness range from
laryngospasm. OBSTRUCTIVE SLEEP APNEA SYNDROME to NARCOLEPSY,
TIME ZONE CHANGE (JET LAG) SYNDROME or INSOMNIA.
The sleepiness can be caused by an ADJUSTMENT
eszopiclone (Lunesta) See HYPNOTICS. SLEEP DISORDER related to a temporary stressful
event, such as illness or death in the family, mid-
term or final exams at school or anxiety about a
ethchlorvynol (Placidyl) See HYPNOTICS. particular crisis at work. The insomnia and the
excessive sleepiness related to that insomnia clears
up as soon as the interim situation is resolved.
evening person (night person) An individual who Excessive sleepiness can also be chronic, such as
prefers to go to bed later, and arise later, than is that seen in children or adolescents suffering from
typical for the general population. Such persons DELAYED SLEEP PHASE SYNDROME so that every day,
have a delay in their sleep phase and the pattern of especially during the school week, they get too
body TEMPERATURE and other circadian rhythms is little sleep and are tired the next day.
delayed. An evening person is sometimes referred Adults who suffer from INSUFFICIENT SLEEP SYN-
to as a night owl. (See also ADVANCED SLEEP PHASE DROME may have a chronic problem with exces-
SYNDROME, DELAYED SLEEP PHASE SYNDROME, MORN- sive sleepiness that has a negative impact on their
ING PERSON, OWL AND LARK QUESTIONNAIRE.) health, career success, or social relationships.
The consequences of excessive sleepiness may
include mild to severe fatigue, crankiness, depres-
evening shift Work shift from about 3 P.M. to 11 sion and reduced concentration, or even such cata-
P.M. that is before the NIGHT SHIFT. strophic consequences as fatigue-related driving
accidents (DROWSY DRIVING) as well as industrial or
home ACCIDENTS.
excessive daytime sleepiness See EXCESSIVE
SLEEPINESS.
exercise and sleep Exercise can increase or reduce
the quality of sleep, or have no effect at all. It is
excessive sleepiness The inability to remain well recognized that intense exercise performed
awake during the awake portion of an individual’s immediately before sleep will impair the ability to
sleep-wake cycle (see NREM-REM SLEEP CYCLE). fall asleep. The increased autonomic system activa-
Excessive sleepiness is synonymous with EXCESSIVE tion produced by the exercise increases AROUSAL
DAYTIME SLEEPINESS (or EDS) and somnolence but is and therefore sleep onset will be delayed. Good
the preferred term. SLEEP HYGIENE includes avoiding intense exercise
Excessive sleepiness may be present at night right before going to bed at night.
for an individual who has the major sleep period However, a relaxing exercise, such as yoga, may
occurring during the day, for example, a shift be beneficial to sleep by reducing muscle tension.
worker. Excessive sleepiness may be reported sub- Mild relaxing exercises, such as those suggested
jectively or be quantified by means of electrophysi- by Edmund Jacobson, can be beneficial and are a
ological measurements of sleep tendency. Tests well-recommended form of relaxation therapy (see
that can quantify excessive sleepiness include the JACOBSONIAN RELAXATION).
MULTIPLE SLEEP LATENCY TEST, the MAINTENANCE OF There are differing opinions on the role of day-
WAKEFULNESS TEST, PUPILLOMETRY, and VIGILANCE time exercise in improving the quality of night-
TESTING. Subjective rating scales, such as the STAN- time sleep. Initial reports have demonstrated that
FORD SLEEPINESS SCALE (SSS) and the EPWORTH intense daytime exercise will increase the amount
 eye movements 83

of SLOW WAVE SLEEP at night; however, this increase sensation is gone, but the syndrome causes anxiety,
appears to occur only in trained athletes. Initially rapid heart rate and sweating. There is usually a
it was suggested that exercise by means of pro- concern that one has had a stroke, or that it is a
ducing wear and tear on the tissues would lead sign of an intracerebral tumor.
to enhanced deep sleep as a restorative process. No known cause is evident for the disorder;
However, there is no evidence that deep sleep is however, disinhibition of the connection between
restorative after exercise, and studies with invalids the inner ear and the brain has been proposed as
on complete bed rest show little difference in the an explanation.
amount of slow wave sleep present compared with This syndrome does not require a specific treat-
more active populations. ment other than reassurance. (See also SLEEP-
The role of exercise in improving slow wave RELATED HEADACHES.)
sleep in trained individuals is also controversial
as there are some who believe that the increase is
due to a rise in body TEMPERATURE. Trained athletes extrinsic sleep disorders Sleep disorders that
on sustained exercise are more liable to produce originate, develop or arise from causes outside of
an increase in their core body temperature com- the body. Examples of extrinsic sleep disorders
pared with unfit individuals. Other studies looking include environmental sleep disorder, ADJUSTMENT
at the effects of body heating by artificial means SLEEP DISORDER and ALTITUDE INSOMNIA. Removal
have demonstrated that slow wave sleep can be of the external factor usually resolves the sleep
enhanced in the absence of exercise. (See also disturbance unless another sleep problem develops
SLEEP EXERCISES.) in the interim. For example, PSYCHOPHYSIOLOGICAL
INSOMNIA may occur after the removal of the exter-
nal factor, such as stress, that caused the develop-
exhaustion A state of extreme mental or physical ment of an adjustment sleep disorder, so the person
fatigue. Exhaustion is not synonymous with EXCES- becomes conditioned to insomnia. This group of
SIVE SLEEPINESS. Persons can become exhausted from disorders is one of three subcategories of dyssom-
mental strain and feel a tiredness and weakness that nias in the American Sleep Disorder Association’s
has nothing to do with an increased physiologi- INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS.
cal drive for sleep. Similarly, a form of exhaustion (The other two subcategories are INTRINSIC SLEEP
can occur following exercise where fatigue occurs; DISORDERS and CIRCADIAN RHYTHM SLEEP DISORDERS.)
however, acute sudden exercise can lead to a state
of relaxation that will allow an underlying drive for
sleep to become manifest. For example, someone eye movements Typically recorded for the detec-
who is slightly sleepy, due to an insufficient quality tion of sleep stages. Usually, awake persons will
or amount of sleep, may sleep during the day fol- have rapid eye movements; these slow during
lowing exercise as the exercise causes him or her to DROWSINESS so that slow eye movements are a
become relaxed and sleep occurs. common feature of STAGE ONE SLEEP. The eyes
become quiescent during SLOW WAVE SLEEP. The
REM stage of sleep is characterized by rapid eye
exploding head syndrome Disorder in which an movements that are similar to those seen during
awakening is accompanied by a sensation of an wakefulness.
explosion having gone off in the head. This disorder Eye movement activity, in conjunction with
typically occurs in the elderly. The sensation causes the ELECTROENCEPHALOGRAM (EEG) pattern and
intense fear but no pain. The syndrome mainly ELECTROMYOGRAM (EMG), is one of the three main
occurs in women with no neurological or psychiat- physiological variables that are recorded during
ric disorder. The moment the sufferer is awake, the POLYSOMNOGRAPHY.
 F
Factor S A substance discovered in the cerebro- However, infants have died because the sleeping
spinal fluid that appears to have a sleep-inducing parent has accidentally smothered the child.
effect. In 1913, Henri Pieron reported that sub- A child sleep expert, Richard Ferber, advises
stances accumulating in the spinal fluid have sleep- against letting a child sleep with a parent, except
inducing properties. Pieron took spinal fluid from for a night or two when a child is ill or temporarily
sleep-deprived dogs and injected it into the brain upset. As a general rule, a separate bed offers the
ventricles of normal dogs and found that it could child the opportunity to develop independence.
induce sleep for up to 15 hours. Cerebrospinal Children as young as two or three may find a fam-
fluid taken from non-sleep-deprived dogs did not ily bed offers intimacy with their parents that is
have a similar effect. This sleep-inducing substance excessive and overstimulating. Ferber also cautions
was subsequently isolated from huge amounts of against allowing a child into a parent’s bed because
human urine (4.5 tons). Factor S was found to one parent is away, on a business trip out of town,
consist of three amino acids—glutamic, alanine for example.
and diaminopimelic—and the sugar, muriac acid. Ferber suggests that if there are temporary or
Therefore, Factor S appears to be a small glucopep- long-term circumstances that necessitate a child
tide that has been identified as a muramylpeptide. sleeping in a parent’s room—there is only one
Muramylpeptides are found in the cell walls of bac- bedroom, grandparents have taken over the child’s
teria and plants, but are not present in human cells. room or the family is away and sharing a hotel
It has been suggested that the production of mur- room—the child should be given his or her own
amylpeptide comes from bacteria that are taken in place to sleep, even if it is a mattress on the floor
with food and then synthesized into Factor S (see in the corner of the room. If possible, use curtains
MURAMYL DIPEPTIDES). to close off that area.
Factor S induces an increase in SLOW WAVE SLEEP If a child enters a parent’s bed in the middle of
when infused in rabbits. It also increases body TEM- the night, the parent should carry, or walk, the
PERATURE, an effect that is thought to be due to the child back to his or her own room. If the child has
production of INTERLEUKIN-1. (See also DELTA SLEEP- difficulty falling asleep, the parent could comfort
INDUCING PEPTIDE, SLEEP-INDUCING FACTORS.) the child till sleep occurs, or just sit in a nearby
chair, rather than allowing a return to the parent’s
bed. (See also BEDS, INFANT SLEEP, INFANT SLEEP
family bed The practice of having an infant or DISORDERS.)
child sleep in bed with its mother, father, or both
parents. Advocates of the family bed emphasize
that it helps promote bonding among child and par- fast sleep See RAPID EYE MOVEMENT SLEEP.
ents as well as promoting an adult-type sleep-wake
cycle. In the early months or years, if a mother is
breast-feeding, it can minimize the disruption to fatal familial insomnia A rare disorder, primarily
her sleep if she just turns to the nearby infant for seen in people of Italian descent, characterized by
a feeding, rather than going into another room. a severe insomnia associated with degeneration of
84
 fiber-optic endoscopy 85

the central nervous system; it is ultimately fatal. No treatment is known to affect the course of
This disorder is associated with abnormalities of the the underlying disorder. (See also CEREBRAL DEGEN-
autonomic neurological system that produce symp- ERATIVE DISORDERS, DEMENTIA, NOCTURNAL PAROXYS-
toms of insomnia, temperature changes, excessive MAL DYSTONIA.)
salivation, excessive sweating and rapid heart and
breathing rates.
Fatal familial insomnia has insomnia persis- fatigue A state of reduced efficiency due to pro-
tent throughout the course of the disorder. As longed or excessive exertion. Fatigue needs to be
the autonomic symptoms develop, sleep becomes differentiated from EXCESSIVE SLEEPINESS, which
more disrupted and there is usually development is a state of increased drive for sleep. The term
of other neurological features; dysarthria, tremors, “fatigue” is often erroneously interpreted as mean-
muscle jerks (myoclonus) and dystonic posturing ing sleepy; however, individuals can be severely
can occur. The patient has a deteriorating level of fatigued without the ability to fall asleep during a
mental alertness and frequently lapses from wake- day of usual wakefulness. The state of EXHAUSTION
fulness into sleep. Often there can be an “acting is similar to fatigue and indicates primarily a men-
out” of dreams during sleep. The disorder leads to tal rather than a muscular form of fatigue.
coma and finally to death.
Fatal familial insomnia is a disease that primarily
occurs in adults between the fifth and sixth decades femoxetine See ANTIDEPRESSANTS.
of life, affecting males and females equally. It appears
to have a familial transmission as several members of
one family with the disease have been reported. Ferber, Richard A graduate magna cum laude of
Polysomnographic investigations in the early Harvard College in chemistry and physics in 1965,
stages of this disease generally show severely and of Harvard Medical School in 1970. From 1970
disrupted sleep patterns with wakefulness inter- to 1971 and 1973 to 1979, Dr. Ferber (1944– )
vening between short episodes of sleep. There is trained at the Children’s Hospital Medical Center
very disrupted REM sleep with maintenance of in Boston as pediatric intern and resident, psychi-
muscle tone and abnormal movements associated atry research fellow, and pediatric fellow in psy-
with DREAMS. Slow wave sleep diminishes and chosomatic medicine. In 1978, he cofounded the
becomes absent during the course of the disease. Center for Pediatric Sleep Disorders, where he has
The electroencephalogram gradually becomes less been director since 1979. Affiliated with Harvard
reactive to environmental stimuli and progressively Medical School since 1973, he is currently an asso-
decreases in amplitude until death. ciate professor of neurology. Since that time, he
Fatal familial insomnia needs to be differenti- has helped to describe and characterize sleep dis-
ated from other forms of degenerative neurological orders in children, and to develop new methods of
disease such as Creutzfeldt-Jakob disease, which is evaluation and treatment. Dr. Ferber’s major child-
characterized by a progressive deteriorating demen- hood research interests include behavioral aspects
tia and myoclonic jerks. Other forms of dementia, of sleep disorders, sleep apnea, chronobiological
such as Alzheimer’s disease, are relatively easily sleep, and parasomnias.
distinguished from fatal familial insomnia. The
abnormal movements that occur during REM sleep
are similar to those seen in REM SLEEP BEHAVIOR fiber-optic endoscopy Otolaryngological proce-
DISORDER, which does not have a progressively dure typically performed in sleep medicine for the
deteriorating course. Other sleep stages are gen- evaluation of the upper airway. The procedure
erally intact in the REM sleep behavior disorder, involves passing a fiberoptiscope through the nose
whereas in fatal familial insomnia, loss of stage and into the pharynx and hypopharynx for the
three and four sleep, and a severely disrupted sleep visualization of lesions in the upper airway. The
pattern, are characteristic. fiber-optic endoscope, which is a few millimeters
86 fibromyalgia

in diameter, is a flexible tube that can allow an because of the potentially habit-forming nature of
experienced individual to observe the pharynx these medications.
by means of the light transmitted in the optical
fibers of the device. This procedure is performed in
patients with OBSTRUCTIVE SLEEP APNEA SYNDROME fibromyositis syndrome See FIBROSITIS SYNDROME.
in order to determine the site of upper airway
obstruction.
Some examiners perform a test called a muller fibrositis syndrome Syndrome characterized by
maneuver while the fiber-optiscope is in place in diffuse, nonspecific muscle aches and pains that are
order to observe movement of the tissues of the typically associated with complaints of unrefresh-
upper airway. This maneuver is performed by clos- ing sleep at night. The musculoskeletal symptoms
ing the mouth and nares and having the patient are not due to any articular, nonarticular or meta-
inspire so that a negative pressure is exerted on bolic disease.
the upper airway, thereby causing its collapse. This The sleep disturbance is one of frequent arousals
procedure has been reported to be helpful in the and brief awakenings and a feeling upon awaken-
evaluation of the site of upper airway obstruction ing in the morning of being unrefreshed. There
and in predicating a patient’s response to UVULOPAL- may be discomfort in the muscles and joints during
ATOPHARYNGOPLASTY. CEPHALOMETRIC RADIOGRAPHS the night and morning stiffness upon awakening.
are often employed along with fiber-optic endos- Tiredness, fatigue and, rarely, sleepiness may be
copy in the evaluation of the upper airway changes present during the daytime. An increased preva-
in patients with obstructive sleep apnea syndrome. lence of periodic limb movements has also been
(See also SURGERY AND SLEEP DISORDERS.) described.
There is a specific pattern to the muscular dis-
comfort, which primarily affects the muscles of the
fibromyalgia (FM) Fibromyalgia is a chronic pain neck and shoulders. The upper border of the tra-
disorder that includes fatigue, sleep disturbances, pezius, the muscles in the neck, the lumbar spine
and widespread pain as key symptoms. Accord- muscles and the mid-lateral thigh are particularly
ing to the National Fibromyalgia Association, sensitive to pressure. The muscle discomfort is
abnormalities in Stage 4 deep sleep of FM patients rapid in onset and becomes chronic. Usually the
have been documented. There may also be REST- onset of the disorder occurs in early adulthood,
LESS LEGS SYNDROME or nighttime muscle spasms although it may be present for the first time in the
occurring in those with fibromyalgia. The cause of elderly. It is more common in females.
fibromyalgia is still unknown, and it may also be Patients often go through intensive investiga-
difficult to diagnose because other diseases, such tions for other forms of rheumatic disorders, such
as lupus, hypothyroidism, multiple sclerosis, or as rheumatoid arthritis, systemic lupus erythema-
rheumatoid arthritis, must first be ruled out. Some tosis or osteoarthritis, without diagnostic features
possible causes might be viral or bacterial infec- of these disorders being found.
tion, abnormalities of the sympathetic nervous Polysomnographic investigations show a char-
system, or an injury affecting the CENTRAL NERVOUS acteristic pattern of alpha sleep in which ALPHA
SYSTEM. Fibromyalgia tends to occur more often in ACTIVITY occurs superimposed on other sleep stages.
women than in men. When this pattern occurs during slow wave sleep
Treatment may include medications such as it is often termed ALPHA-DELTA ACTIVITY. The sleep
analgesics or ANTIDEPRESSANTS, muscle relaxants, stages are otherwise normal in percentage; how-
or Pregabalin (Lyrica), an antiseizure medication ever, there may be an increased number of brief
that the Food and Drug Administration (FDA) has awakenings and arousals. Patients usually lack evi-
approved to treat fibromyalgia. However, doctors dence of pathological daytime sleepiness.
caution against using either prescription sleep- There is no clear cause or pathology found to
ing pills or BENZODIAZEPINES to treat fibromyalgia explain the discomfort.
 food allergy insomnia 87

Fibrositis syndrome must be differentiated from tion of the sleep-wake cycle. Serotonin is derived
other rheumatic disorders. When the sleep distur- from the amino acid L-tryptophan (see HYPNOTICS),
bance is prominent, other causes of nonrestorative which is present in normal dietary intake, usu-
sleep need to be distinguished, such as psychophys- ally up to two grams per day. Extra L-tryptophan
iological insomnia or insomnia due to psychiatric is sometimes taken by sufferers of insomnia to
disorders. Sleep disturbances due to dysthymic elevate brain serotonin levels in the hope that
disorder or neuromyasthenia may be more difficult this will improve the quality of nocturnal sleep.
to differentiate from the fibrositis syndrome. How- L-tryptophan is believed to have some sleep-
ever, such patients do not have the characteristic inducing properties, although these are considered
alpha sleep finding, and the specific areas of muscle to be mild. A metabolic product of L-tryptophan,
tenderness are not found in these other disorders. which is called 5-hydroxytryptophan, has been
Treatment of the sleep disturbance is with the demonstrated to increase both REM sleep and
tricyclic ANTIDEPRESSANT medication amitriptyline. SLOW WAVE SLEEP. However, this agent is not very
In addition, attention to good SLEEP HYGIENE is help- useful in improving sleep in patients with INSOM-
ful. Typically the anti-inflammatory medications NIA. (See DIET AND SLEEP for cautionary note about
that are used for rheumatic disorders are not effec- L-tryptophan because of a 1989 report of 30 cases
tive in fibrositis syndrome. of eosinophilia-myalgia linked to dietary supple-
Fibrositis syndrome has also been called rheu- ments of L-tryptophan.)
matic pain modulation disorder, fibromyositis syn- The serotonin reuptake inhibitors are a class of
drome or fibromyalgia. antidepressant medications that increase serotonin
at the synapse. (See ANTIDEPRESSANTS.)
Parachlorphenylamine (PCPA) inhibits the pro-
final awakening See WAKE TIME. duction of 5-hydroxytryptamine, thereby leading
to a reduction in brain serotonin levels and, typi-
cally, producing insomnia. But other medications
final wake-up See WAKE TIME. that affect the synthesis, storage and release of
5-hydroxytryptamine have little effect on sleep or
wakefulness.
first night effect A pattern of increased SLEEP
LATENCY, and reduced TOTAL SLEEP TIME on the first
night of a polysomnographic recording in the labo- fluoxetine (Prozac) See ANTIDEPRESSANTS.
ratory. The first night effect is believed to be due
to several factors, including the discomfort to the
subject of the recording electrodes, the new sleep flurazepam (Dalmane) See BENZODIAZEPINES.
environment and psychological effects, including
anxiety regarding a polysomnographic recording.
However, the subject adjusts to the above fac- fluvoxamine (Luvox) See ANTIDEPRESSANTS.
tor, and the disruptive effects on sleep typically
are present only on the first night of recording.
(See also POLYSOMNOGRAPHY, SLEEP-WAKE DISORDERS food allergy insomnia A disorder of initiating
CENTER.) and maintaining sleep that is caused by food
allergy; typically occurring in infants and associated
with irritability, frequent arousals, crying episodes,
5-hydroxytryptamine The biochemical name for and daytime lethargy. Other signs or features of an
SEROTONIN, which is a component of blood that allergic response may be present, but they are usu-
causes constriction of the blood vessels, allowing ally not the predominant feature of the disorder.
the blood to clot. This constricting agent has been For example, skin irritation, gastrointestinal upset,
found in neurons and is involved in the regula- or respiratory difficulties may all occur.
88 fragmentary myoclonus

Although this is a disorder that primarily affects RELATED BREATHING DISORDERS, NARCOLEPSY, PERI-
children, it can also occur in adults who may ODIC LIMB MOVEMENT DISORDER, and other causes
develop an allergy to eggs or fish, with resultant of INSOMNIA.
insomnia. When the disorder occurs in children, This disorder should be differentiated from PERI-
it usually occurs in infancy and resolves spontane- ODIC LEG MOVEMENTS, which are of longer duration
ously by the age of four years at the latest. There and are more typically associated with an EEG
may well be a family history of allergic phenom- arousal or awakening. It should also be differenti-
ena. The allergy most commonly is related to the ated from the physiological REM sleep myoclo-
ingestion of cow’s milk and therefore may occur nus, which typically occurs throughout normal
soon after the introduction of cow’s milk to the REM sleep and can be associated with the eye
diet. movements of REM sleep. Neurological disorders,
Food allergy insomnia should be differenti- such as the degenerative disorders, can produce
ated from infant colic in which sleep disturbance myoclonus, which is typically present throughout
may be associated with acute crying spells that wakefulness and usually decreases during sleep.
occur episodically (gastrointestinal symptoms may More generalized synchronous movements due to
accompany the acute episodes). GASTROESOPHA- sleep starts are easy to distinguish from the asyn-
GEAL REFLUX, SLEEP-RELATED; INFANT SLEEP APNEA; chronous and briefer muscle jerks of fragmentary
and infantile epileptic seizures need to be differen- myoclonus.
tiated from food allergy insomnia. In most situations, fragmentary myoclonus does
Treatment involves removal of the offending not require treatment. However, if frequent EEG
allergen. If necessary, allergy tests may have to arousals are associated with the activity and exces-
be performed to determine the exact allergen, but sive sleepiness is a feature, then suppression of
once it is removed from the diet, the sleep distur- the arousals by means of BENZODIAZEPINES may be
bance usually resolves rapidly. helpful.

fragmentary myoclonus Disorder characterized fragmentation See NREM-REM SLEEP CYCLE.

by clusters of brief muscle jerks that occur pre-
dominantly in NON-REM-STAGE SLEEP. These invol-
untary “twitch-like” contractions can occur in free running A chronobiological term that applies
various skeletal muscles in an asynchronous and to a biological rhythm isolated from ENVIRONMEN-
asymmetrical manner. Muscles of the limbs and TAL TIME CUES such as light, food, temperature,
face and trunk can all be involved. The brief mus- social interactions and clock time. Under these
cle contractions can occur for prolonged periods conditions, the rhythm will continue with its own
throughout sleep. At times, the muscle jerks pro- internal period length, which for CIRCADIAN RHYTHM
duce ELECTROENCEPHALOGRAM (EEG) evidence of is close to, but not exactly, 24 hours in duration.
an AROUSAL with a transient K-COMPLEX; however,
there is usually no change in the EEG in association
with the activity. Freud, Sigmund “Father of Psychoanalysis”
The muscle jerks are very brief, usually 75 to (1856–1939) who viewed DREAMS as doors to the
150 milliseconds in duration, with an amplitude of unconscious, the keys to understanding and even-
about 50 to several hundred microvolts. The activ- tually unblocking repressed sexual and aggressive
ity usually commences soon after sleep onset and forces that motivate and perhaps unconsciously
continues throughout non-REM sleep, including control a person’s behavior. In 1900, Freud pub-
SLOW WAVE SLEEP, and persists into REM sleep. lished his groundbreaking treatise, The Interpretation
Fragmentary myoclonus is associated with EXCES- of Dreams, which explained dreams as the fulfill-
SIVE SLEEPINESS. The activity has been described ment of certain unconscious impulses considered
in other sleep disorders, including the SLEEP- unacceptable on a conscious level.
 Freud, Sigmund 89

Freud believed repressed sexual and aggres- He also believed DREAM CONTENT took two forms:
sive desires are disguised in dreams in three ways: the manifest content, or that part of the dream we
through symbolism, such as by using objects to remember, and the latent content, the true under-
represent sexual organs; by condensation, where lying meaning of the dream.
one dream image represents several aspects of a In their treatment, Freudian psychoanalysts use
person’s life; and by displacement, in which an dream interpretation to help patients gain insight,
unacceptable wish is focused on something other and eventual control, over the unconscious forces
than the real object of the wish. causing conflicts and emotional disturbances.
 G
GABA See GAMMA-AMINOBUTYRIC ACID. period. Gamma-hydroxybutyrate may be useful
in the treatment of cataplexy in patients who are
unable to use the tricyclic ANTIDEPRESSANTS because
gamma-aminobutyric acid (GABA) An inhibitory of anticholinergic side effects. Very few side effects
amino acid neurotransmitter that is widely spread have been recorded with gamma-hydroxybutyrate.
throughout the central nervous system. It is found However, the drug has been abused, and when
in highest concentration in the hypothalamus and combined with benzodiazepines has been called
is believed to be involved in the induction of sleep. the “date rape” drug. One side effect reported is
The BENZODIAZEPINES are known to have their seda- SLEEPWALKING, possibly due to the effect of gamma-
tive action through binding to the GABA receptor. hydroxybutyrate in increasing the amount of slow
In addition, the BARBITURATES bind with GABA in wave sleep.
the brain. Drugs that increase GABA levels in the
brain, such as those that inhibit the breakdown
enzyme of GABA, can increase SLOW WAVE SLEEP. Gardner, Randy San Diego high school senior
GABA is found in neurons that extend from the who, in 1964, made the Guinness Book of World
hypothalamus to the cortex, and the release of Records by staying awake the longest—264 hours,
GABA from the cortex has been shown to be high- or 11 days. Sleep researcher WILLIAM C. DEMENT
est during natural sleep or in lesions that affect the observed Gardner during his ordeal and concluded,
midbrain reticular formation. “staying awake for 264 hours did not cause any
GABA will enhance sleep induced by benzodi- psychiatric problems whatsoever.” In his book The
azepines, and therefore it appears to have an effect Promise of Sleep (1999), however, Dement wondered
on the affinity of benzodiazepines for their final if Gardner may have been sleepwalking for some of
receptor sites; however, its exact role in the induc- the time since, back in 1965, the recording devices
tion of sleep is still undetermined. for monitoring sleep were much less sophisticated
than today’s devices.

gamma-hydroxybutyrate (GHB) The precursor of

the naturally occurring agent gamma-aminobutyric gastroesophageal reflux, sleep-related In this
acid. This agent has been found to be effective in disorder, also known as GERD, patients experience
controlling the auxiliary symptoms of NARCOLEPSY, a foul taste in the mouth, heartburn, or pain in the
primarily the symptom of CATAPLEXY. Gamma- chest that may disturb their sleep. It is explained
hydroxybutyrate has been shown to have little by the reflux or regurgitation of the contents of the
effect in improving daytime sleepiness. It is known stomach into the esophagus. It is sometimes associ-
to increase SLOW WAVE SLEEP, with little effect upon ated with hiatal hernia, a bulging of the abdominal
REM sleep. The medication is given once or twice organs upward through the opening where the
in two- or three-gram doses at night. As the medi- esophagus passes through the diaphragm. The
cation has a short duration of action, it is necessary sleep disorder OBSTRUCTIVE SLEEP APNEA SYNDROME
to give a second dose halfway through the sleep is associated with an increased tendency to have
90
 glottic spasm 91

gastroesphageal reflux. Symptoms can be con- ing and stimulating appetite before meals and
trolled with drugs that control acid secretion by the decreasing after meals.
stomach. (See also HEARTBURN.) Lack of sleep has recently been found to increase
plasma ghrelin levels, reduce leptin levels, and
increase appetite and hunger. Inadequate sleep
Gelineau, J. B. E. Jean-Baptiste-Edouard Gelin- could, therefore, promote excess eating.
eau (1828–1906) was a French physician who is It is unclear whether ghrelin promotes sleep in
credited with first suggesting the term NARCOLEPSY mice and humans or whether ghrelin instead dis-
for a mysterious syndrome characterized by sudden rupts sleep by promoting hunger (sleep and feeding
sleeping, especially at inappropriate times during are mutually exclusive behaviors). Consistent with
the day. Gelineau, in his 1880 article published in the latter, very high ghrelin levels have been found
the Gazette des Hopitaux, proposed the word “narco- in night-eating syndrome. On the other hand,
lepsy” along with a detailed description of a 38-year- ghrelin may be a sleep-promoting factor, as shown
old male wine barrel retailer who had sleep attacks by increased slow-wave sleep after intravenous
and accompanying falls. The falls are now known as administration of ghrelin to normal male subjects.
CATAPLEXY, but Gelineau called them “astasia.” Also intriguing is the role of ghrelin in energy
The next year, in his work “On Narcolepsy,” balance. Ghrelin levels increase before meals and
Gelineau discussed 14 cases of narcolepsy, distin- with food restriction or starvation, and they fall
guishing two types of the syndrome, the first an rapidly after meals. Obesity is associated with
idiopathic syndrome, and the second related to decreased ghrelin levels. Because infusion of ghre-
other illnesses. lin increases hunger in humans, weight reduction
brought about by dieting might often fail owing
to the increase of ghrelin that results from caloric
genetics The science of the biological unit of restriction. Bariatric surgery, by contrast, may
heredity that is transmitted from one cell to another often succeed because of reduced ghrelin levels
during the process of reproduction. Although a that result from the surgically reduced size of the
number of sleep disorders, including SLEEPWALK- stomach, acting as an endocrine gland. (See also
ING and SLEEP TERRORS, are believed to have a NOCTURNAL EATING [DRINKING] SYNDROME.)
genetic origin, with a genetic predisposition passed
on through the family, only NARCOLEPSY has been
demonstrated to have a specific genetic factor, gigantocellular tegmental field One of three
which is present in nearly every patient with the divisions of the reticular formation. (The other two
disease. The human leukocyte antigen DR2 is pres- divisions include the lateral tegmental field, FTL,
ent in more than 90 percent of patients diagnosed and the magnocellular tegmental field, TM.) The
with narcolepsy. The allele HLA DQB1-0602 is the gigantocellular tegmental field consists of large cells
most specific genetic factor also found in more than of the pontine and medullary reticular formation.
90 percent of patients with narcolepsy. (See also The cholinergic cells of the pontine portion of the
HISTOCOMPATABILITY ANTIGEN TESTING, HLA-DR2.) gigantocellular tegmental field have been demon-
strated to increase their activity during the onset of
REM sleep. The cells have been called the REM-ON
GHB See GAMMA-HYDROXYBUTYRATE. CELLS in the reciprocal interaction model of sleep
regulation that was proposed by J. Allan Hobson,
Robert W. McCarley, and Peter W. Wyzinski in
ghrelin Is a 28-amino-acid peptide hormone that 1975. (See also ASCENDING RETICULAR ACTIVATING
is produced by endocrine cells in the stomach and SYSTEM, INTERACTION MODEL OF SLEEP.)
hypothalamus (arcuate nucleus). It targets recep-
tors in the brain (ventromedial hypothalamus,
anterior pituitary gland, arcuate nucleus), increas- glottic spasm See LARYNGOSPASM.
92 growth hormone

growth hormone Secreted from the pituitary the new time of sleep and therefore its relationship
gland in relation to the onset of sleep, with maximal with growth hormone is reestablished.
secretion occurring in the first third of the night. Growth hormone is important for growth, par-
Although originally thought to be primarily related ticularly in childhood. Maximal levels are secreted
to the onset of stages three and four sleep, it is now around the time of puberty and are important in
believed to be more related to the time following the maintenance of normal body size. Absence of
the onset of sleep (see SLEEP STAGES). Growth hor- growth hormone will lead to dwarfism and exces-
mone is tied to the sleep-wake cycle so that acute sive production of growth hormone will lead to
shifts of sleep by 12 hours will cause an acute shift gigantism. However, the removal of the pituitary
of the growth hormone secretory pattern. There is and loss of growth hormone secretion in adults
minimal growth hormone secretion during the day- appears to have few physical effects.
time, with small peaks of production that occur in Although prolactin, which is inhibited by
relation to stress or exercise. A shift of the sleep pat- dopamine, is very much affected by medications,
tern by several hours is immediately accompanied growth hormone secretion during sleep is largely
by a shift of growth hormone secretion. This shift unaffected. Medications that influence the pro-
is not accompanied by an immediate shift in some duction of growth hormone during sleep include
other hormone rhythms, such as cortisol. The corti- cholinergic inhibitory medications, such as meth-
sol circadian rhythm, although related to the sleep- scopolamine, which causes a large increase in the
wake cycle, can become disassociated from sleep sleep-related growth hormone release. (See also
following an acute shift of the timing of sleep. After ADRENOCORTICOTROPHIN HORMONE, CORTISOL, DOPA-
one or two weeks, the cortisol pattern readjusts to MINE, PROLACTIN.)
 H
Halberg, Franz Born in Bistritz, Romania, Dr. ening from sleep. CLUSTER HEADACHE, MIGRAINE
Halberg (1919– ) received his medical degree and CHRONIC PAROXYSMAL HEMICRANIA have been
in 1943. In 1959, Halberg coined the term “circa- demonstrated to have an association with REM
dian rhythm” to describe physiologic rhythms with sleep.
a frequency of one cycle in about 24 (20 to 28) These three headache forms appear to have
hours. The term was created from the Latin words a common pathophysiological basis in that they
circa, meaning “about,” and dies (“a day”). Halberg are all associated with autonomic (involuntary
contributed to the science (logos) of life’s (bios) time neurological system concerned with involuntary
(chronos) structure—CHRONOBIOLOGY. functions) features, especially cluster headache and
chronic paroxysmal hemicrania. Polysomnographic
monitoring has demonstrated that these headache
Halcion (triazolam) See BENZODIAZEPINES. forms are more likely to occur in REM SLEEP, and
chronic paroxysmal hemicrania is more closely tied
to REM sleep than the other two.
Hall, Calvin S. A well-known dream theorist. In These headache forms need to be differenti-
1961, Hall (1909–1985) founded the Institute of ated from the group of headaches termed muscle
Dream Research. He was best known for his cogni- contraction or tension headaches, which may be
tive theory of dreaming and his research into the associated with ANXIETY or HYPERTENSION. Tension
content analysis of DREAMS. One of his surveys of headaches typically begin upon awakening in the
DREAM CONTENT found that only one-third of those morning and do not usually cause an abrupt awak-
surveyed dreamed in color. ening from sleep.
In addition to numerous books on dreams as Treatment of sleep-related headaches depends
well as textbooks on introductory psychology, upon the particular headache form involved and
Jung, and Freud, Hall, in collaboration with G. W. may require the use of medications such as cafer-
Domhoff, K. Blick, and K. Weesner, wrote an arti- got, Midrin, beta-blockers, calcium channel block-
cle in Sleep in 1982 that reaffirmed the results of his ers or morphine derivative analgesics, in the case
research on dream content from 30 years before. of migraine headaches. Cluster headaches may
“The Dreams of College Men and Women in 1950 be treated by steroids, methysergide or oxygen
and 1980: A Comparison of Dream Contents and therapy.
Sex Differences” is a classic contribution in the field Muscle contraction headaches that begin upon
of dream research. awakening in the morning may be helped by relax-
ation therapy, amitriptyline (see ANTIDEPRESSANTS)
or anxiolytic agents. These headaches need to be
headaches, sleep-related Pain or discomfort differentiated from headaches that occur upon
in the head that is usually experienced during awakening in the morning due to OBSTRUCTIVE
wakefulness; however, some headache forms can SLEEP APNEA SYNDROME, which respond to specific
occur during sleep or may be present upon awak- treatment for that syndrome.

93
94 headbanging

headbanging (jactatio capitis nocturna) Also slow wave sleep, although, again, this has rarely
known as rhythmic movement disorder. This behav- been reported. Daytime electroencephalography is
ior is included in a group of three disorders—head- usually normal between episodes.
banging, HEAD ROLLING and BODYROCKING—that The cause of the movements is unknown, but
have as their main characteristic a repetitive move- numerous theories have been proposed. There is
ment of the head and, occasionally, of the whole little evidence to support a psychiatric or organic
body. These disorders may occur during the time neurological disorder to account for the behavior.
of rest, drowsiness, sleep or full wakefulness. The A neurophysiological basis for the activity is the
condition has been reported to occur during deep most likely, related to normal development. It has
slow wave sleep, as well as in REM sleep. The epi- been suggested that the activity may be a pleasur-
sodes occur very frequently, on an almost nightly able sensation, and therefore a form of vestibular
basis, and usually last for about 15 minutes. The self-stimulation.
frequency of the movement can vary, but it typi- Treatment is usually unnecessary when the con-
cally occurs at the rate of 45 episodes per minute dition occurs in childhood, as it typically will disap-
and can be as fast as 120 episodes per minute. pear within 18 months, often at around four years
The disorder was first described clinically in 1905, of age. When the condition persists into adoles-
by Zappert when he coined the Latin term jactatio cence or adulthood, behavioral or pharmacological
capitis nocturna, which is still commonly used. approaches may be needed. Sedative medications
The head movements in the headbanging form of have been beneficial, and some patients have had
this disorder are in an anterior/posterior direction. a favorable response to tricyclic ANTIDEPRESSANTS.
Usually the head is banged into a pillow or a mat- Measures may have to be taken to prevent injury
tress. Occasionally the head movement can be into from the repetitive movements in young children.
solid objects, such as a wall or the side of a crib.
When the head movements occur side to side,
the condition is termed head rolling. head rolling Repetitive movement of the head
Bodyrocking is most often performed on the from side to side, which may occur during rest,
hands and knees. The whole body is rocked in an drowsiness, sleep, or wakefulness; more typical in
anterior/posterior direction, with the head being children below the age of four than in older chil-
pushed into the pillow. dren or adults. (See also HEADBANGING.)
It has been reported that as many as 66 per-
cent of children exhibit some sort of rhythmical
activity at nine months of age, and the prevalence heart attack See MYOCARDIAL INFARCTION.
decreases to approximately 8 percent at four years
of age. It is rare for the condition to occur for the
first time after two years of age; however, it may heartburn Discomfort experienced in the middle
persist through adolescence into adulthood. of the chest. It is associated with reflux of acid
Headbanging is reported to be more common in from the stomach into the esophagus. Heartburn
males than in females, and rarely has been reported commonly accompanies gastroesophageal reflux
to occur in families. The mentally retarded are more and can occur during sleep as a symptom of
likely to exhibit the behavior. The disorder has to be SLEEP-RELATED GASTROESOPHAGEAL REFLUX. Heart-
distinguished from an epileptic disorder and from burn during sleep may be due to the OBSTRUCTIVE
the fine head oscillations of spasmus nutans. SLEEP APNEA SYNDROME during which increased
Polysomnograph studies of the activity usu- abdominal pressure produces a reflux of acid into
ally demonstrate frequent episodes during sleep, the esophagus.
most often in the lighter stages one and two sleep.
Rarely has the condition been reported to occur
only during REM sleep, which may indicate a vari- hemolysis, sleep-related See PAROXYSMAL NOC-
ant of the disorder. Episodes can occur during deep TURNAL HEMOGLOBINURIA.
 HLA-DR2 95

hertz (Hz) Term synonymous with cycles per sec- histocompatability antigen testing A test of the
ond (cps) that refers to a rhythm frequency most genetic constituents that play a role in determining
commonly applied to the ELECTROENCEPHALOGRAM rejection of a tissue graft. The major histocompat-
(EEG). ability complex (MHC) is composed of a group of
genes that are located on chromosome 6, and the
products of these genes are present on cell surfaces.
hibernation A state produced in animals as a The MHC in humans is called the human leukocyte
response to seasonal environmental changes. During antigen (HLA). There are three classes of human
winter, animals are at risk in the environment due leukocyte genes and products, which are called
to the cold and the lack of food. Hibernating animals class I, II, III. The HLA class I and class II products
are typically those who are unable to travel long dis- are located on cell surfaces. HLA class I products
tances to make a major environmental change. are found on most cell surfaces and consist of the
During hibernation, a sleep-like state exists HLA types A, B, C and E. The HLA class II products
with a reduction of metabolic activity and respira- are found on the surface of the immune cells, such
tory and circulatory rates. Body temperature can as lymphocytes. The HLA class II products consist
gradually drop to near freezing point; this is associ- of DR, DQ and DP.
ated with a change in the electroencephalographic The HLA D region has been found to have a
pattern, typically one of SLOW WAVE SLEEP with specific association with the sleep disorder NARCO-
reduced or almost absent REM sleep. During the LEPSY. (See also HLA-DR2.)
hibernation, the animal typically withdraws to its
usual sleeping environment and reserves of stored
fat are used to maintain the metabolic rate at only HLA-DR2 This stands for the human leukocyte
10 percent to 15 percent of its normal rate. During antigen DR2, which is located on chromosome 6.
the depth of the hibernation, the slow wave pat- This particular genetic marker has been reported to
tern of non-REM sleep gives way to a flattening be nearly 100 percent associated with the disorder
of the electroencephalographic pattern, with no NARCOLEPSY. This high association has been found
resemblance to sleep or wakefulness. in Japanese patients, compared to only 85 percent
With the rising environmental temperatures at of African-American patients with narcolepsy. In
the end of hibernation, the electroencephalographic the United States, there is a 95 percent positivity of
patterns revert back to normal as the body tempera- Caucasian patients with the HLA-DR2 antigen. The
ture slowly returns to a level typical during warmer presence of this antigen indicates a genetic factor
seasons. (See also ELECTROENCEPHALOGRAM.) that is important in transmission of the narcolepsy
disorder. It is possible that another factor, possibly
infective or environmental, causes the expression
histamine A naturally occurring substance that of the disease in a susceptible individual. Persons
is released during injury to tissues. The word is who are DR2 negative are believed to be unable to
derived from the Greek word for tissue, histos. His- develop narcolepsy.
tamine appears to act via two distinct receptors, the HLA-DR2 testing may be helpful in the diagnosis
H1 and H2 receptors. The antihistamines have their of narcolepsy because DR2 positivity is supportive
effects primarily through blocking the H1 recep- evidence to other clinical and electrophysiologi-
tors; medications that inhibit gastric secretion work cal features of the disorder. HLA-DR2 negativity
through blocking the H2 receptors. should raise the possibility of a disorder other than
There is some evidence to suggest that histamine narcolepsy to account for the patient’s symptoms.
is involved in the control of arousal and wakeful- HLA-DR2 testing may be useful in predicting
ness. Animal studies have demonstrated that his- whether a child of an affected parent has the likeli-
tamine is increased in the brains of animals during hood of developing narcolepsy at a later date. How-
darkness, and that inhibition of histamine synthe- ever, the presence of HLA-DR2 positivity does not
sis reduces wakefulness. mean that the individual will develop narcolepsy,
96 homeostasis

since approximately 25 percent of the general are several, and the hyoid bone is suspended to
population is also HLA-DR2 positive. the mandible by strips of fascia. Usually the hyoid
Associated with HLA-DR2 positivity is the histo- myotomy is performed in conjunction with an
compatability antigen HLA DQ1. Every individual osteotomy of the tip of the jaw. The tip of the jaw
who is HLA-DR2 positive also has HLA DQ1. Afri- is moved anteriorly to advance the anterior attach-
can-American patients with narcolepsy appear to ment of the muscles of the tongue.
have 100 percent positivity of HLA-DQ1, whereas Many of the patients treated by this surgical
HLA-DR2 positivity is present in only about 85 procedure have also undergone the UVULOPALA-
percent. TOPHARYNGOPLASTY operation, with or without a
HLA-DR2 can be subdivided into two groups: TONSILLECTOMY AND ADENOIDECTOMY.
DR15 and DR16. One-hundred percent of Japanese Hyoid myotomy is rarely performed now as it is
patients with narcolepsy have the DR15 subgroup. not as effective as other surgical procedures.
In addition, if the DR2 is subtyped according to
a cytological and not a serological method; the
subgroup Dw2 is also found in 100 percent of hyperarousal Refers to the objective physiologi-
narcolepsy patients. (See also HISTOCOMPATABILITY cal state that accompanies subjective feelings of
ANTIGEN TESTING.) anxiety, fear, and worry. It is presumed to be
mediated by the ASCENDING RETICULAR ACTIVATING
SYSTEM (ARAS). Its components include air hun-
homeostasis A property of living organisms that ger, hyperventilation, tachycardia, tremor, sweat-
ensures the constancy of the internal physiological ing, exaggerated startle response, and increased or
milieu. As one example, the level of blood sugar inappropriate (e.g., nocturnal) mentation (cogni-
(glucose) is regulated to ensure that it remains nei- tive hyperarousal). It is sometimes associated with
ther too low nor too high. If a meal causes the level PANIC DISORDER. In recent years, there has been an
of glucose to begin to rise, the hormone insulin is upsurge of interest in hyperarousal and its relation
released, causing glucose to be taken up by the to sleep difficulty. When present during sleep, it has
liver, thus reversing the elevated blood sugar level. been hypothesized to underlie CHRONIC INSOMNIA.
This is called negative feedback. It is assumed that The growing body of evidence relating hyperarousal
the amount of sleep is also regulated homeostati- to insomnia is largely but not entirely consistent. It
cally and is why we feel sleepy after a late night also remains unclear whether hyperarousal is usu-
out. For sleep homeostasis, however, the mecha- ally primary or secondary to the insomnia itself.
nisms involved have not yet been identified.

hypercapnia Term describing an elevated blood-

hygiene See SLEEP HYGIENE. gas CARBON DIOXIDE level in the blood. (The carbon
dioxide level during sleep may increase in patients
who have SLEEP-RELATED BREATHING DISORDERS.)
hyoid myotomy A surgical procedure that involves The level of carbon dioxide in the blood can be
a repositioning of the hyoid bone to relieve upper continuously measured during sleep by means of
airway obstruction associated with the OBSTRUCTIVE END-TIDAL CARBON DIOXIDE measurements, using an
SLEEP APNEA SYNDROME. The tongue muscles often infrared carbon dioxide analyzer.
obstruct the airway because they are positioned
posteriorly. The tongue is attached to the hyoid
bone, which is tethered to the skull by several hypernycthemeral sleep-wake syndrome Term
muscles. The hyoid myotomy operation involves synonymous with NON-24-HOUR SLEEP-WAKE SYN-
release of these muscles. DROME. The term hypernycthemeral is derived from
The muscles attached to the hyoid bone, such the Greek word for hyper, meaning “above,” and
as the sternohyoid, thyrohyoid and omohyoid, nycthemeron, meaning “pertaining to both night
 hypnagogic hallucinations 97

and day.” This term was first proposed by Kokkoris, to the presence of snoring, obesity, disturbed sleep
Weitzman and colleagues in 1978. and the occurrence of apneic episodes during sleep
to see if they may have that disorder.

hypernycthemeral syndrome See NON-24-HOUR

SLEEP-WAKE SYNDROME. hyperthyroidism A disorder associated with exces-
sive production of thyroid hormone from the thyroid
gland in the neck. This is usually caused by enlarge-
hypersomnia See EXCESSIVE SLEEPINESS. ment or overactivity of the thyroid gland and pro-
duces characteristic symptoms of insomnia, weight
loss, irritability, diarrhea, weakness, palpitations and
hypertension An elevation of blood pressure typ- tremulousness. Some patients with hyperthyroid-
ically seen in patients who have a diastolic blood ism have a diffuse enlargement of the thyroid gland
pressure greater than 90 millimeters of mercury or associated with antibodies that stimulate the thyroid
a systolic blood pressure greater than 160 millime- gland. This disorder, which is termed Graves’ disease,
ters of mercury. characteristically produces eye protrusion due to
Hypertension has been reported in approxi- accumulation of excessive tissue behind the eyes.
mately 30 percent of patients with the OBSTRUCTIVE The sleep disturbance associated with hyper-
SLEEP APNEA SYNDROME. Studies of groups of hyper- thyroidism is typically one of difficulty in initiat-
tensive patients have demonstrated that between ing and maintaining sleep. Sleep may be more
25 percent and 30 percent have episodes of oxygen restless and frequent arousals may be seen during
desaturation during sleep or an abnormal number polysomnographic testing. However, some patients
of apneic episodes during sleep. have an increase in SLOW WAVE SLEEP.
Treatment of the obstructive sleep apnea syn- Hyperthyroidism is treated by medications that
drome is typically associated with a lowering suppress the activity of the thyroid gland, such
of blood pressure or improved blood pressure as carbimazol, or by radioactive iodine, which
control. destroys a portion of the thyroid gland. Surgical
Hypertension typically is asymptomatic and can treatment may also be indicated. With treatment
be detected only by means of physical examination. of the hyperthyroidism, the sleep disturbance usu-
Because of its association with the development of ally resolves.
cardiac and vascular disease, elevated blood pres- Following treatment for hyperthyroidism, some-
sure requires treatment. times the thyroid gland is rendered incapable of
The majority of patients with hypertension have producing an adequate amount of thyroid hor-
no known cause for the blood pressure elevation; mone, thereby producing a deficiency in thyroid
however, some patients develop hypertension as hormone. As a result, HYPOTHYROIDISM may occur
a result of kidney disease, endocrine disorders or many years after chemical treatment of hyper-
atherosclerosis. thyroidism. Hypothyroidism is associated with the
Some medications used to treat hypertension development of excessive lethargy and sleepiness.
can affect the sleep wake cycle. Beta blockers, such Muscle changes associated with the lack of thyroid
as propranol, can produce sleep disturbance that is hormone can produce impaired respiration dur-
characterized by INSOMNIA; and there is evidence ing sleep, with the development of CENTRAL SLEEP
that beta blockers may even worsen the obstruc- APNEA SYNDROME or hypoventilation during sleep.
tive sleep apnea syndrome. Other antihypertensive
medications, such as clonidine, can produce exces-
sive sleepiness. hypnagogic hallucinations Visual images that
Because of the high association between hyper- occur at sleep onset; most typically associated with
tension and the obstructive sleep apnea syndrome, REM sleep. Hypnagogic hallucinations are a char-
patients with hypertension should be questioned as acteristic feature of the sleep onset REM period
98 hypnagogic hypersynchrony

that occurs in patients with NARCOLEPSY. Occasion- hypnogram This term is synonymous with POLY-
ally the imagery may be extremely frightening, SOMNOGRAM but is less commonly used.
and such situations have been termed TERRIFYING
HYPNAGOGIC HALLUCINATIONS. Images that occur
upon awakening or at wake times are called HYPNO- hypnopompic Characteristic of events that occur
POMPIC hallucinations. in the transition phase from sleep to wakeful-
ness, most commonly at the end of the main sleep
episode. Occasionally, vivid hallucinations will be
hypnagogic hypersynchrony This term applies to perceived at this time, particularly in patients with
rhythmical electroencephalographic activity of 5–6 NARCOLEPSY. The term hynopompic is also commonly
Hz that occurs in the transition from wakefulness to used to apply to seizures that occur at the time of
sleep, which is present in infants after the first six awakening, or immediately thereafter. (See also
months of life. Hypnagogic hypersynchrony usu- HYPNAGOGIC HALLUCINATIONS.)
ally disappears around six years, at which time it is
replaced by increasing theta and delta activity, with
a gradual loss of ALPHA ACTIVITY. The adult form Hypnos The ancient Greek god of sleep. Many
of drowsiness, with alpha “drop out” and mixed words, such as hypnosis, hypnology, and hypnopedia,
frequency, low voltage activity, does not usually have been derived from this Greek word.
develop until early adolescence. (See also BETA
RHYTHM, DROWSINESS, INFANT SLEEP, THETA ACTIVITY.)
hypnosis A mental state induced in individu-
als, who have increased suggestibility, by means
hypnagogic jerk See SLEEP STARTS. of focusing attention and eliminating distracting
environmental stimuli. An individual in the state of
hypnosis does not usually go into sleep, although
hypnagogic reverie Term applied to mentation the relaxation can allow normal physiological sleep
that occurs at sleep onset; may comprise features of to occur. Typically, hypnosis produces a slowing
dream activity. It is most vivid at the onset of REM of the encephalographic pattern; however, typical
sleep but may occur at the onset of non-REM sleep. stage two features, such as SLEEP SPINDLES or the
When frightening hypnagogic reverie occurs, the characteristic delta waves of SLOW WAVE SLEEP, do
term TERRIFYING HYPNAGOGIC HALLUCINATIONS may not occur.
be applied. Some of the features of hypnosis are very similar
to sleep-related phenomena, such as the AUTOMATIC
BEHAVIOR in SLEEPWALKING that typically would be
hypnagogic startle See SLEEP STARTS. seen in deep slow-wave sleep. These features are
associated with the awake electroencephalographic
pattern in hypnosis.
hypnalgia Term used for the occurrence of pain- Hypnosis has been reported to be effective in
ful sensations induced by sleep. Many pains are treating some sleep disorders, such as sleepwalk-
increased in intensity during sleep; however, hyp- ing or SLEEP TERRORS; however, other investigators
nalgias are pains that occur only during sleep. (See have failed to find it a useful treatment.
also CARPAL TUNNEL SYNDROME, SLEEP PALSY.)

hypnotic-dependent sleep disorder A sleep dis-

hypnic jerks See SLEEP STARTS. turbance characterized by the intolerance for, or
withdrawal of, HYPNOTICS. The sleep disturbance
may be due to the chronic ingestion of hypnotic
hypnic myoclonia See SLEEP STARTS. medications or their acute withdrawal. During
 hypnotics 99

chronic ingestion, the hypnotic effect tends to supply of medication, they may receive a month’s
wear off and the underlying INSOMNIA may persist supply. Unless normal sleep occurs, there is little
despite use of the medication. In some patients, inducement to the patient to stop the medication
there may be an increase in the metabolism of the after the first few days following an acute emo-
hypnotic agent so that after an initial hypnotic tional stress.
effect in the first part of the night, there may be an Although hypnotic-dependent sleep disorder
increase in sleep disruption. After chronic ingestion can occur at any age, it is often seen in the geri-
of hypnotics, complete cessation of their ingestion atric population as their sleep tends to be more
leads to one or more nights of increased sleep frag- fragmented than that of younger patients. There-
mentation, which often results in the reinstitution fore sleep disruption upon withdrawal of hypnotic
of hypnotic therapy. medication is more common.
The medications most commonly associated Patients receiving chronic hypnotic medications
with hypnotic-dependent sleep disorder are the typically show alterations in the structure of sleep
BENZODIAZEPINES and BARBITURATES. However, other during polysomnographic monitoring. There may
hypnotic agents may also produce this disorder. be a decrease in the slow wave and REM sleep
Typically, the hypnotic agent is administered stages and an increase in the lighter stage one
for an underlying insomnia disorder. So long as and two sleep. There may be frequent sleep stage
the cause of the insomnia is removed, an acute transitions, reduced K complexes, an increase
course of only a few days usually does not result in spindle activity, and the presence of a greater
in a hypnotic-dependent sleep disorder. However, amount of alpha and beta activity. Hypnotic-
if the drugs continue to be taken and the underly- dependent sleep disorder needs to be differentiated
ing insomnia disorder has not resolved, attempts from insomnia due to other causes, such as the
to stop the medication are often associated with an OBSTRUCTIVE SLEEP APNEA SYNDROME or PERIODIC
increase in the insomnia, leading to a higher dos- LIMB MOVEMENT DISORDER. MALINGERERS seeking
age of medication, or its continuation. Increased CENTRAL NERVOUS SYSTEM depressant medications
dosage often leads to accumulation of the active for drug abuse purposes must be distinguished
drug or its metabolites, particularly in the elderly from patients who have the hypnotic-dependent
population, resulting in daytime side effects. Exces- sleep disorder.
sive sleepiness, fatigue, tiredness, impaired cogni- Treatment of hypnotic-dependent sleep disor-
tive and physical performance are typical features der rests upon gradual reduction and withdrawal
of medication accumulation. of the hypnotic agent, sometimes with the substi-
Withdrawal of the hypnotic agent can lead to tution of a medication with hypnotic properties
drug withdrawal effects during the daytime, such but less dependency effects. For example, a tri-
as nausea, restlessness, nervousness, anxiety, and a cyclic ANTIDEPRESSANT medication might be sub-
rise in sleep disruption following withdrawal, pre- stituted. Encouragement of good SLEEP HYGIENE is
cipitating the patient into a depression, even with essential during the withdrawal process. Patients
suicidal ideation. This psychiatric reaction is more need to be reassured and counseled about a
liable to occur if the patient’s original insomnia was temporary reoccurrence of insomnia during the
related to an underlying DEPRESSION. withdrawal of the medication. (See also REBOUND
As a result of hypnotic-dependent insomnia, INSOMNIA.)
patients are often maintained on hypnotic medi-
cations for many years. This situation can arise
from transient insomnia that may have occurred hypnotics Also known as sleeping pills, sedative
due to underlying stress, such as a bereavement medications and sedative-hypnotic medications,
or hospitalization. Hypnotic agents are often pre- hypnotics are medications that induce drowsiness
scribed in a course that exceeds the typical dura- and facilitate the onset and maintenance of sleep.
tion of an ADJUSTMENT SLEEP DISORDER, so that Typically, hypnotics will induce sleep similar to
instead of patients receiving a three to five day natural sleep in that normal REM/NREM sleep
100 hypnotics

cycling occurs, and the person is able to be easily Other nonbarbiturate, nonbenzodiazepine hyp-
aroused from sleep. notic agents are also available and come from a
Various potions have been used to induce sleep variety of pharmacological groups.
since antiquity; ALCOHOL was one of the most com-
monly used substances. Bromides were used as Chloral Hydrate (Noctec)
hypnotics in the middle of the 19th century, but One of the oldest hypnotics, used for the treat-
chloral hydrate is the only hypnotic agent still in ment of insomnia. It is derived from chloral, a
regular use that was introduced before the turn of trichloroacetaldehyde, an unstable and unpleasant
the century. tasting oil that is produced in the hydrate form
During the first half of the 20th century, the for more pleasant ingestion. As well as being a
most commonly used hypnotic medications were hypnotic agent, chloral hydrate has anticonvulsant
the approximately 50 derivatives of the BARBI- properties.
TURATES. The barbiturates were widely used for This hypnotic has been shown to reduce SLEEP
their central nervous system depressant effects LATENCY and decrease the number of awakenings,
and employed as antiepileptic agents, antianxiety with a variable change in the total sleep time.
medications, muscle relaxants and hypnotics. They There is usually a slight decrease in SLOW WAVE
were also effective in inducing anesthesia and are SLEEP and variable suppression of REM SLEEP. The
currently still used for their anesthetic effect. hypnotic effects of chloral hydrate disappear within
Because of the unwanted sedative and sleep- two weeks of continuous use.
inducing effects of the barbiturates, other non-sed- The main side effect is irritation of the mucous
ative anticonvulsants were discovered in the 1930s membranes and gastrointestinal tract. It can pro-
and 1940s. Subsequently, the BENZODIAZEPINE hyp- duce an unpleasant taste, nausea, vomiting, and
notics were introduced into clinical medicine in the flatulence. There can be undesirable CENTRAL NER-
1960s. The benzodiazepines are effective sedatives, VOUS SYSTEM EFFECTS, such as lightheadedness,
but there are potentially serious side effects. As malaise, ataxia, and NIGHTMARES. Occasionally,
reported in the New York Times, “F.D.A. Asks Stron- allergic reactions can occur and there may be
ger Label on Sleep Pill Under Scrutiny,” some of idiosyncratic reactions, such as paranoid behavior
the reported side effects for the drug Halcion have and SLEEPWALKING. Chloral hydrate is sometimes
included personality disorders, amnesia, seizures, administered rectally because of the unpleasant
and hallucinations. There is also the possibility of taste and gastric irritation. The combination of
becoming dependent on or addicted to a sleep aid. chloral hydrate and alcohol led to the so-called
However, they do have a low potential for pro- Mickey Finn, a potion popularized in movies and
ducing serious central nervous system depression. crime fiction.
The most common benzodiazepine hypnotics in Habitual use of chloral hydrate can result in
the United States include flurazepam (Dalmane), tolerance, dependence, and addiction. Withdrawal
temazepam (Restoril), triazolam (Halcion), and after chronic addiction can lead to SEIZURES that
zolpidem (Ambien). can even result in death. Chloral hydrate is admin-
Although the barbiturates now comprise less istered in doses of 0.5 gram to a maximum of 2
than 10 percent of all prescription hypnotics, they grams. The medication is best taken with milk or
are still very effective hypnotics. Because of their food in order to prevent gastrointestinal upset.
abuse potential, possible interaction with alcohol,
the chance of lethal overdose and their effect Eszopiclone (Lunesta)
of inducing liver enzymes that can increase the Eszopiclone is a short-acting cyclopyrrolone agent
metabolism of many medications, the barbiturates that is a single isomer of racemic zopiclone, which
are of limited usefulness as everyday hypnotics. has been available in Europe since 1992. In 2004,
The barbiturates that have most commonly been the FDA approved eszopiclone for the treatment
used as hypnotics are secobarbital (Seconal), amo- of difficulty falling asleep or maintaining sleep. A
barbital (Amytal), and pentobarbital (Nembutal). six-week clinical trial showed that 3 mg of eszopi-
 hypnotics 101

clone reduced the time to fall asleep and increased matic nuclei (SCN) of the hypothalamus. Unlike
total sleep time. There is also a 2 mg dose, but it other hypnotic drugs, ramelteon is not scheduled
may not improve sleep maintenance. There was by the FDA, and the drug is considered to pose no
no evidence of tolerance (loss of effectiveness) or risk of abuse or dependency. Ramelteon reduces
rebound insomnia after the drug was discontinued. the time taken to fall asleep by 10 to 15 minutes
There was also no impairment of daytime perfor- and is prescribed for patients having difficulty fall-
mance ability, and treatment was generally well ing asleep. Ramelteon remains effective for more
tolerated. The most common adverse event was an than five weeks and is approved for long-term use
unpleasant taste. These findings were confirmed in adults. Although its site of action is the SCN,
in a six-month trial, and eszopiclone has been the master biological clock, its ability to reset the
approved for long-term use. timing of the sleep-wake rhythm has not been
Although eszopiclone is both efficacious and established.
safe in clinical trials, a six-month trial in Norway
that compared racemic zopiclone (a mixture of Triclofos
Lunesta with another stereo isomer) with cogni- Triclofos sodium is the sodium salt of chloral,
tive behavioral therapy (CBT) did not show that which is a hypnotic agent limited in use because of
drug therapy is superior. CBT comprised sleep its mild effects upon sleep and its gastrointestinal
hygiene education (effect on sleep of exercise, irritation. Chloral is more commonly used in the
alcohol, etc), sleep restriction (strict scheduling hydrate form called chloral hydrate.
of bedtimes and rising times), stimulus control
(limiting the bed and bedroom to sleep), cogni- L-tryptophan
tive therapy (correcting mistaken beliefs regarding A naturally occurring amino acid that is a precursor
sleep and sleep loss), and progressive relaxation of the neurotransmitter serotonin (5-hydroxytryp-
technique (learning to control muscle tension). tamine). L-tryptophan (or tryptophan) can induce
The CBT group showed dramatic improvements drowsiness and therefore has been used as a hyp-
in sleep efficiency (the proportion of time in bed notic agent. It typically is available in 500 milligram
spent sleeping) and wake time. Though total tablets, and up to five grams have been necessary
sleep time did not increase in response to CBT, to improve sleep. The effect of L-tryptophan upon
time spent in SLOW WAVE SLEEP sharply rose after sleep is controversial as some studies have shown
treatment and at six months. (In the zopiclone little benefit in insomniac patients, whereas other
group, by contrast, the only improvements were studies have shown a reduced sleep latency and an
in subjective measures of sleep efficiency, total increased depth of sleep. L-tryptophan also tends to
wake time, and total sleep time. For most out- have an irritant effect on the gastrointestinal tract
comes, zopiclone did not differ from a placebo or and can produce nausea and vomiting.
an inert pill.) In general, L-tryptophan has little usefulness
in the management of chronic insomnia. The U.S.
Ethchlorvynol (Placidyl) Centers for Disease Control (CDC) requested physi-
An oral hypnotic used for the management of cians to temporarily stop prescribing L-tryptophan
insomnia for periods of up to one week. Placidyl in 1989 due to reports of 30 cases of eosinophilia-
is available as dark red capsules containing either myalgia (some fatal). Three-quarters of those who
200 milligrams or 500 milligrams of ethchlorvynol, developed this rare blood disorder were discovered
or green capsules containing 750 milligrams of eth- to have been taking supplements of L-tryptophan.
chlorvynol. It can cause gastrointestinal upset and
hypersensitivity reactions. Zaleplon (Sonata)
A pyrazolopyrimidine compound that acts as a
Ramelteon (Rozerem) hypnotic by selectively binding to the BENZODI-
A hypnotic agent that uniquely activated melato- AZEPINE type-1 receptor situated on the alpha
nin (MT1 and MT2) receptors in the suprachias- subunit of the GABA receptor complex. Zaleplon’s
102 hypnotoxin

attributes include: fast sleep onset, short duration, abuse. Chronic insomnia can be managed by
a low incidence of adverse effects and no residual behavioral means, psychotherapy, or non-hypnotic
effects four hours after dosing. Zaleplon has equal medications.
efficacy with TRIAZOLAM and zolpidem in decreas- The most appropriate use of hypnotic medica-
ing time to sleep onset. It has a very low potential tions appears to be in the treatment of transient
for REBOUND INSOMNIA. or SHORT-TERM INSOMNIA, such as JET LAG, where
their use is for a few days only. The selection of a
Zolpidem (Ambien) hypnotic is ideally made according to its duration
A nonbenzodiazepine hypnotic agent that is the of action so that people with daytime tiredness and
most widely used hypnotic in the United States. It fatigue are best treated by means of a short-acting
has few side effects, does not cause rebound insom- hypnotic. Patients with mild features of anxiety are
nia, and is safe if taken in overdose. best treated by an intermediate-acting hypnotic,
whereas patients with more severe anxiety are best
Zopiclone (Imorane) treated by a long-acting hypnotic.
A hypnotic medication derived from cyclopyrro-
lone that is not available in the United States but
is available in Europe. This medication has proper- hypnotoxin Term applied to a substance pre-
ties that are similar to the more commonly-used sumed to be contained in the cerebrospinal fluid,
benzodiazepine hypnotics, and it appears to bind which was able to produce sleep. In 1911, Henri
to the same central nervous system receptor. Zopi- Pieron demonstrated that the cerebrospinal fluid
clone produces an improvement in sleep efficiency, of sleep-deprived animals could induce sleep when
with an increased total sleep time and a decreased injected into non-sleep-deprived animals and that
number of awakenings. It has few side effects but a substance was transmitted capable of producing
can cause a bitter taste in the mouth and difficulty this sleep effect. The term sleep promoting substance
with concentration during the daytime. (SPS) is more commonly used than hypnotoxin.
Other sedative medications that have hypnotic (See also SLEEP-INDUCING FACTORS.)
properties include glutethimide (Doriden), mepro
bamate (Miltown) and methyprylon (Noludar).
Other agents that are now rarely prescribed as hyp- hypocretin (orexin) A peptide first identified in
notics because of their serious side effects include 1998. Produced by prehypocretin mRNA, hypo-
paraldehyde (Paral) and methaqualone. cretin exists as two related peptides: hypocretin-1
A variety of nonprescription hypnotic medica- (orexin A) and hypocretin-2 (orexin B). These
tions are available as OVER-THE-COUNTER MEDICA- neuropeptides are produced in neurons of the
TIONS. Many of these medications are ANTIHISTAMINES hypothalamus and affect two receptors: hypocretin
that have sedative side effects, such as doxylamine, receptor-1 and hypocretin receptor-2. The hypo-
phenyltoloxamine and pyrilamine. These agents cretins are localized in the synaptic vesicles and
are not very effective in the treatment of INSOMNIA, possess neuroexcitatory effects.
can lead to the development of TOLERANCE and An abnormal hypocretin receptor gene has been
prominent residual daytime central nervous system shown to be responsible for canine narcolepsy.
depression, and are not recommended for general Abnormalities of either the hypocretin receptor
hypnotic use. gene or of the production of hypocretins may be
In recent years, there has been the realization responsible for human NARCOLEPSY. Hypocretin cells
that insomnia is not a primary diagnosis but rather are reduced or absent in patients with narcolepsy.
a symptom of many underlying causes. Most of
the causes of insomnia can be treated without the
use of a hypnotic agent. The use of hypnotics for hypopnea An episode of shallow breathing dur-
LONG-TERM INSOMNIA is to be avoided because of ing sleep that lasts 10 seconds or longer; associated
the potential problems of tolerance or for drug with a reduction in airflow of 50 percent or more
 hypoventilation 103

and a fall in the oxygen saturation level. The pres- thyroidism impairs the ventilation responses to
ence of some airflow distinguishes this event from HYPOXIA or HYPERCAPNIA and, in addition, leads to
apneic episodes. Hypopneas are usually seen in increased weight gain and deposition of mucopoly-
persons who have SLEEP-RELATED BREATHING DIS- saccharides in the tissues of the upper airway.
ORDERS, such as CENTRAL SLEEP APNEA SYNDROME Severe hypothyroidism can also produce tired-
or OBSTRUCTIVE SLEEP APNEA SYNDROME. (See also ness, fatigue and sleepiness because of the reduced
APNEA, APNEA-HYPOPNEA INDEX.) body metabolism. The diagnosis is made by the
demonstration of a low free-thyroxine level in the
blood, typically in association with an elevated,
hypothalamus A region at the base of the brain thyroid-stimulating hormone level. A thyroid scan
believed to have an important role in the main- is usually necessary to provide information on the
tenance of sleep and wakefulness. Original inves- function and anatomy of the thyroid gland. If the
tigations by Constantin von Economo on patients thyroid-stimulating hormone level is abnormally
suffering from ENCEPHALITIS LETHARGICA showed low, a brain CT scan, or MRI scan, is necessary to
that the anterior hypothalamus was commonly assess pituitary function.
responsible for INSOMNIA, whereas lesions of the The presence of sleep-related disorders, such
posterior hypothalamus were associated with exces- as obstructive sleep apnea syndrome, can be con-
sive sleepiness. The hypothalamus is also involved firmed by polysomnographic monitoring and the
in many other autonomic processes including ther- degree of daytime sleepiness by MULTIPLE SLEEP
moregulation and control of food and fluid intake. LATENCY TESTING.
The hypothalamus has connections with the The symptoms of hypothyroidism can be quite
retino-hypothalamic tract, which leads from the subtle, and it is therefore an important diagnosis
retina to the optic chiasm, and synapses in the to consider in any patient who has the obstructive
SUPRACHIASMATIC NUCLEI for the control of CIRCA- sleep apnea syndrome. Thyroid levels should be
DIAN RHYTHMS. Isolation of the suprachiasmatic checked in all patients, especially before surgical
nuclei of the hypothalamus will disrupt circadian management of the syndrome.
rhythmicity although the temperature rhythm will Treatment of hypothyroidism involves replace-
continue. Transplantation of fetal suprachiasmatic ment of thyroid hormone, typically with between
nuclei cells into other animals who have had the 50 and 200 micrograms of thyroxine per day.
suprachiasmatic nucleus destroyed will return cir- The symptoms of daytime sleepiness and the fea-
cadian rhythmicity. tures of SLEEP-RELATED BREATHING DISORDERS rapidly
Other experiments of either stimulating or improve with replacement therapy. As hypothy-
lesioning cells of the hypothalamic region have roidism leads to a general increase in body weight,
demonstrated effects on sleep or sleepiness; how- treatment often leads to weight reduction.
ever, the exact role of the hypothalamic centers in Severe hypothyroidism results in MYXEDEMA,
the control of sleep and wakefulness is unknown. which is characterized by generalized mucopoly
saccharide accumulation throughout the body,
resulting in thickening of the facial features and
hypothyroidism A disorder characterized by a doughy induration of the skin. Respiratory depres-
loss of production of thyroid hormone from the sion is common in myxedema as are sleep-related
thyroid gland; caused by an intrinsic abnormality breathing disorders, and the patient can lapse
of the thyroid gland, or by reduced stimulation of into myxedema coma, which is a hypothermic,
the thyroid gland due to the loss of the brain thy- stuporous state. Myxedema coma is frequently
roid-stimulating hormone. Thyroid deficiency can fatal. (See also POLYSOMNOGRAPHY, UPPER AIRWAY
produce respiratory muscle failure with resulting OBSTRUCTION.)
OBSTRUCTIVE SLEEP APNEA SYNDROME or ALVEOLAR
HYPOVENTILATION, which when severe may require
the institution of mechanical ventilation. Hypo- hypoventilation See ALVEOLAR HYPOVENTILATION.
104 hypoxemia

hypoxemia A low level of oxygen in the blood. to adequately diffuse into the blood. Lung disease is
Hypoxemia during sleep typically occurs in patients a common cause of tissue hypoxia due to the defi-
with SLEEP-RELATED BREATHING DISORDERS such as cient oxygenation of the blood (hypoxemia).
the OBSTRUCTIVE SLEEP APNEA SYNDROME. The hypox- Hypoxia due to low inspired levels of oxygen
emia is usually detected by an oximeter, which can produce periodic breathing, which causes an
measures the oxygen saturation of the hemoglo- alternating pattern of hyperventilation and hypo
bin. Hypoxemia can have important effects upon ventilation that is a characteristic feature of ALTI-
the body, particularly the cardiovascular system, TUDE INSOMNIA (acute mountain sickness). Upper
as chronic hypoxemia can produce pulmonary airway obstruction, which occurs in the OBSTRUC-
hypertension that in turn can produce right-sided TIVE SLEEP APNEA SYNDROME, can be associated with
heart failure. Hypoxemia can also cause cardiac a reduction in lung oxygen levels, thereby produc-
irritation, leading to cardiac irregularity or cardiac ing hypoxemia with resultant arousal and ventila-
ischemia. tory stimulation.
Assisted ventilation during sleep by means of Chronic lung disease, such as that seen in
either CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) CHRONIC OBSTRUCTIVE PULMONARY DISEASE, particu-
or artificial ventilation devices may be required for larly emphysema, is associated with impaired blood
patients who have hypoxemia. Oxygen therapy, gas transfer and hypoxemia. Patients with chronic
respiratory stimulant medications or relief of UPPER obstructive pulmonary disease can develop wors-
AIRWAY OBSTRUCTION by surgery are other means ening hypoxemia during sleep, especially during
employed to relieve hypoxemia in some patients. REM sleep.
As a result of hypoxia, sleep becomes frag-
mented, with an increased number of arousals and
hypoxia A reduction of oxygen supply to tissues awakenings related to the hypoxemia. The direct
below the level necessary to maintain normal cel- effects of hypoxemia can be detrimental on the
lular metabolism. Hypoxia can be produced either cardiovascular as well as other body systems. (See
by a reduction in the oxygen level of the inspired also CHEYNE-STOKES RESPIRATION.)
air, such as that seen at high altitudes or due to
UPPER AIRWAY OBSTRUCTION, or by means of an
abnormality of the lung whereby oxygen is unable Hz See HERTZ.
 I
idiopathic hypersomnia Disorder associated with insomnia is believed to be due to an inability to
EXCESSIVE SLEEPINESS; believed to be of central ner- achieve a sustained high quality of sleep. Idiopathic
vous system cause. This disorder has similarities to insomnia is typically characterized by a prolonged
narcolepsy but lacks the associated REM phenom- SLEEP LATENCY, frequent awakenings at night, and
ena. Features such as CATAPLEXY, SLEEP PARALYSIS, sometimes an EARLY MORNING AROUSAL. It is possible
and HYPNAGOGIC HALLUCINATIONS do not occur in that people with idiopathic insomnia are those who
patients with idiopathic hypersomnia. comprise the lower 5 percent of the normal dis-
Idiopathic hypersomnia has its onset during tribution of ability to have a normal quality sleep
adolescence and early adulthood and is character- period. Elements of ANXIETY and hyperarousal may
ized by gradually increasing daytime sleepiness. be present in such individuals, but there is no gross
Typically, patients with idiopathic hypersomnia will psychopathology warranting a diagnosis of ANXIETY
take frequent NAPS, usually of one to two hours in DISORDER nor any evidence to suggest a diagnosis
duration. The major sleep episode may be of nor- of DEPRESSION.
mal or longer than normal duration. Idiopathic insomnia needs to be differenti-
Polysomnographic studies (see POLYSOMNOG- ated from PSYCHOPHYSIOLOGICAL INSOMNIA, which
RAPHY) demonstrate a normal or prolonged total involves learned negative associations with sleep.
sleep time without evidence of sleep disruption. Idiopathic insomnia is more likely to be stable
Daytime MULTIPLE SLEEP LATENCY TESTING dem- over time, with poor quality sleep occurring in all
onstrates a mean sleep latency that is consistent sleep environments; the insomnia does not have
with pathological sleepiness but is characterized the intermittent exacerbations that are seen with
by the absence of naps with REM sleep. Typically, psychophysiological insomnia. Psychophysiological
patients with idiopathic hypersomnia will develop insomnia also rarely occurs from childhood. Indi-
deep sleep stages, such as stage three or four sleep viduals who are SHORT SLEEPERS typically awake
during nap opportunities. Central nervous system refreshed in the morning and lack a complaint of
tests, including brain imaging and encephalogra- poor quality sleep or of frequent awakenings as do
phy, are usually normal. those with idiopathic insomnia.
Treatment is similar to that for improving alert- INADEQUATE SLEEP HYGIENE may be confused with
ness in patients with narcolepsy. It involves the idiopathic insomnia, although the intermittent
use of STIMULANT MEDICATIONS, such as modafinil nature of inadequate sleep hygiene contrasts with
(Provigil), methylphenidate (Ritalin), or dextro- the more fixed complaint of idiopathic insomnia.
amphetamine (Dexedrine). Usually treatment is Polysomnographic studies of individuals with
lifelong; there is no evidence for remission of the idiopathic insomnia have demonstrated severe
underlying sleepiness. sleep disruption, which is characterized by a long
sleep latency and frequent arousals with early
morning awakening. Sleep efficiencies are usually
idiopathic insomnia A lifelong form of insomnia greatly reduced and there may be specific sleep
that is believed to have a neurochemical basis; stage abnormalities, such as reduction of spindle
originally termed childhood onset insomnia. This activity in stage two sleep or reduced rapid eye

105
106 imipramine

movements during REM sleep. As with psycho- ficult to attain. Sleep-related impaired erections
physiological insomnia, a reversed first night effect may occur following urogenital disorders such as
may be seen in which individuals sleep much bet- prostatic hypertrophy or Peyrone’s disease and fol-
ter in the sleep laboratory on the first night because lowing prostatic removal. Medications, particularly
of the change in their habitual environment. antihypertensives, ANTIDEPRESSANTS, narcotics, or
Idiopathic insomnia is typically lifelong and antipsychotic medications (see NEUROLEPTICS), may
could be genetically transmitted. Its prevalence be associated with impaired erectile ability.
is unknown. There is some evidence to suggest Impaired sleep-related erections may occur at
an alteration in serotonin metabolism with inad- any age; however, most commonly patients appear
equate production of serotonin. at a sleep disorders center with the problem after
Treatment of idiopathic insomnia is generally the age of 45.
unsatisfactory. Attention to SLEEP HYGIENE and The majority of patients with a complaint of
BEHAVIORAL TREATMENT OF INSOMNIA, such as STIMU- impotence have impaired sleep-related penile
LUS CONTROL THERAPY and SLEEP RESTRICTION THER- erections demonstrated during polysomnographic
APY, are useful. evaluation. It is estimated that approximately 10
percent of adult males suffer from IMPOTENCE, the
majority of whom have organic impotence.
imipramine (Tofranil) See ANTIDEPRESSANTS. Polysomnographic monitoring of erectile ability is
obtained by the use of strain gauges placed around
the penis and by the demonstration of adequate
impaired sleep-related penile erections The REM sleep. The absence of adequate penile erec-
inability to achieve a penile erection during sleep. tions either in rigidity or duration of erection is
(This term is preferred to sleep-related penile tumes- evidence for organic impotence. Typically erections
cence.) All males, from infancy to old age, have during REM sleep will last longer than five minutes
penile erections that occur during REM sleep. The and erections of shorter duration are inadequate.
inability to achieve an adequate erection during The rigidity of the penis can be determined by a
sleep at night may help differentiate an organic buckling pressure once the patient is awakened dur-
from a psychogenic cause of impotence. MEDICA- ing sleep. If a pressure of less than 500 grams causes
TIONS and sleep disorders that disrupt REM sleep a buckling of the penis then this is evidence of an
may also cause impaired sleep-related penile erec- insufficient degree of penile rigidity. In most healthy
tions. The measurement of penile circumference males, the buckling of the penis will not occur unless
and rigidity during sleep is an important test for the pressure exceeds 1,000 grams. Typically at least
differentiating organic impotence. two nights of polysomnographic recording, with
Diseases that affect the neurological or vascular measurement of penile tumescence, is necessary in
supply of the penis can produce impaired erectile order to determine a diagnosis of organic impotence.
ability during sleep. In addition, neurotransmitter However, many sleep laboratories require three
and endocrine disorders can also be contributing nights of recording for confirmation.
factors. Disorders such as diabetes mellitus and If impaired sleep-related penile erections are
HYPERTENSION are common causes of organic impo- present, other investigations, including penile blood
tence but other disorders, including renal failure, pressure, penile neurodiagnostic tests and hor-
spinal cord injury, alcoholism, back injury and monal tests may be indicated in order to determine
multiple sclerosis can also be common causes of the cause of the impaired erectile ability. Occasion-
impaired erections. Rarely, severe psychiatric dis- ally, sleep disorders, such as OBSTRUCTIVE SLEEP
ease, such as DEPRESSION, may be associated with APNEA SYNDROME, are associated with impaired
impaired sleep-related penile erections. However, sleep-related penile erections, which are improved
patients with PSYCHIATRIC DISORDERS are typically by treatment of the sleep apnea syndrome.
able to achieve several erections during REM sleep, In many patients with organic impotence, the
although erections during wakefulness may be dif- only means of treatment is by the surgical implan-
 incubus 107

tation of an artificial penile prosthesis. Patients involves enhancing factors that will allow sleep to
with normal erectile ability during sleep, but with become more organized. Substances such as CAF-
a complaint of impotence, may best be treated by FEINE, NICOTINE from cigarette SMOKING, and other
means of sex, marital or psychiatric therapy or stimulants are likely to cause sleep onset difficulties
drugs such as Viagra, Levitra or Cialis. (See also or the inability to sustain quality sleep. ALCOHOL
ALCOHOLISM, SLEEP-RELATED PAINFUL ERECTIONS.) can also cause AROUSAL, but more commonly pro-
duces sedation followed by an arousal during the
withdrawal phase.
impotence The inability to attain an adequate Vigorous exercise before bedtime, intense men-
penile erection for sexual intercourse. Impotence tal stimulation late at night or late night social
may be due to psychological or psychiatric dis- activities clearly increase arousal and reduce sleep
orders, such as DEPRESSION or ANXIETY DISORDERS. quality. Spending an excessive amount of time in
Physical causes of impaired erectile ability com- bed, irregular sleep onset and wake times or daily
monly include vascular disorders, such as peripheral NAPS can all disturb the normal circadian pattern of
vascular disease of HYPERTENSION, or neurological sleep and wakefulness, leading to a breakdown in
disorders, such as peripheral neuropathies or spi- the sleep organization.
nal cord lesions (such as those due to a spinal cord Inadequate sleep hygiene can lead to a persistent
injury). It is also a common manifestation of diabe- sleep disturbance, which develops into a PSYCHO-
tes, probably because of a combination of vascular PHYSIOLOGICAL INSOMNIA because of the learned
and neurological abnormalities associated with that negative associations due to the sleep disruption.
disorder. Impotence also can occur in the OBSTRUC- Inadequate sleep hygiene can also accompany sleep
TIVE SLEEP APNEA SYNDROME, where it appears to disorders of other types. For example, INSOMNIA due
have a higher prevalence than in the general popu- to DEPRESSION may be complicated by spending an
lation. Treatment of the obstructive sleep apnea excessive amount of time in bed and varying sleep
syndrome seems to improve erectile ability. onset and wake times. The start of the sleep distur-
The assessment of impotence involves an under- bance typically occurs between young adulthood
standing of the patient’s psychological and medical and old age; however, it can occur in adolescence.
condition. Marital problems are a primary cause Sleep studies document prolonged sleep latency,
of sexual difficulty and treatment by a marriage frequent nocturnal awakenings, early morning
guidance counselor may be indicated in such cases. arousal and reduced sleep efficiency.
If PSYCHIATRIC DISORDERS such as MOOD DISORDERS Treatment of inadequate sleep hygiene is to
are present, then psychiatric treatment is usually eliminate the negative behaviors, which usually
necessary. leads to rapid resolution of the sleep disturbance.
Patients with physical disorders, such as vascular
disorders or diabetes, may require the implanta-
tion of an artificial penile prosthesis if erectile dys- incubus Latin term that applies to a form of
function drugs are effective. Penile prostheses are nightmare that occurs in adults. The word comes
manufactured in two forms: an erect form, which from in and cubare, which signifies “to lie on.”
is continuously erect, and an inflatable prosthesis Incubus is an old term of SLEEP TERROR in adults.
that is made erect at the time of sexual activity. The term incubus refers to a demon lying on a
(See also IMPAIRED SLEEP-RELATED PENILE ERECTIONS, sleeper and therefore causing the sleeper discom-
NOCTURNAL PENILE TUMESCENCE TEST, SLEEP-RELATED fort and pain. This is most clearly demonstrated
PENILE ERECTION.) in the painting entitled The Nightmare, by Johann
Heinrich Fuseli (1741–1825), located in the Detroit
Institute of Art.
inadequate sleep hygiene Disturbance that Closely related to the term incubus is the term
results from practices that can have a negative inuus, which is the oldest of all Latin terms for
effect on the sleep pattern. Improved SLEEP HYGIENE “NIGHTMARE.” This term was first used in Virgil’s
108 indeterminate sleep

Aeneid (VI, 775) and may have led to the develop- infant sleep Infant sleep is first recognized at a
ment of the word incubus. conceptual age of about 32 weeks. At this time, the
While incubus generally refers to a male dream infant state can be differentiated into WAKEFULNESS,
demon, its female counterpart is known as the suc- QUIET SLEEP, and ACTIVE SLEEP.
cubus, which is derived from the Latin prefix sub, At the time of birth, the infant demonstrates a
meaning “below, underneath,” and the verb cubo, sleep pattern totaling 16 to 18 hours of sleep during
meaning “I lie.” So a succubus is someone who the 24 hours. Sleep is achieved in short episodes of
lies under another person, whereas an incubus lies three to four hours, with brief awakenings. Sleep is
on top of another person. They both cause night- evenly distributed over the day, and gradually the
mares. Succubus may also appear in castration amount of sleep at night compared to during the
nightmares. daytime increases, so that a clear night-day differ-
entiation is evident by three months of age.
The sleep episodes of the infant are character-
indeterminate sleep Term applied to INFANT SLEEP ized by approximately 50 percent of REM and 50
that cannot be clearly differentiated into ACTIVE percent of non-REM sleep. Infants will go from
SLEEP or QUIET SLEEP. Typically, indeterminate sleep wakefulness directly into REM sleep, a feature
consists of a short episode of sleep, usually occur- that is not seen in older children or adults unless
ring between sleep changes or during the transition some pathology is present. The NREM-REM SLEEP
from wakefulness to sleep. Sometimes the term CYCLE is slower than that seen in adults, occurring
intermediate sleep has been used as synonymous approximately every 60 minutes.
with indeterminate sleep. (See also NON-REM- The EEG pattern begins to resemble the sleep
STAGE SLEEP, WAKEFULNESS.) of adults by three months of age. SLEEP SPINDLE
activity begins at this time and within the next few
months K-COMPLEXES can be seen. The total amount
inductive plethysmography Noninvasive tech- of sleep gradually falls so that by six months the
nique that has been used for the evaluation of infant is sleeping approximately 15 hours per day.
ventilation during sleep. This device consists of As the sleep-wake pattern becomes more consoli-
a transducer of insulated wire placed around the dated at night, the latency into REM sleep becomes
chest to determine expansion of the lungs. A sec- biphasic so that the shortest REM latencies are usu-
ond loop of wire is placed around the abdomen; ally seen between 4 and 8 A.M. whereas the longer
by utilizing the changes in electrical current gener- latencies are typically seen between midday and
ated by the movements of the bands of wire, tidal 4 P.M. Longer REM latencies become more appar-
volume and evidence of UPPER AIRWAY OBSTRUC- ent following longer periods of wakefulness, and
TION can be determined. During apneic phases, the the prevalence of REM sleep during the daytime
excursions of the rib cage component in the abdo- gradually reduces over the first year of life.
men are equal and in opposite directions, thereby Because REM and non-REM sleep cannot be
causing a change in the measure that is typically distinguished at this stage, the terms active sleep and
called the sum. In a central apneic pause, all activ- quiet sleep are used. Active sleep is characterized by
ity at the rib cage and abdomen is absent, and body movement activity with occasional vocaliza-
hence the sum tracing is without change. tions, whereas quiet sleep consists of cessation of
Inductive plethysmography is most commonly body movements as well as the EEG features con-
used as a research procedure for the assessment of sistent with non-REM sleep. The characteristic EEG
VENTILATION during sleep; however, it can also be pattern of active sleep is a low voltage, irregular
used clinically in the evaluation of patients with pattern with 5 to 8 Hz theta and 1 to 5 Hz delta
SLEEP-RELATED BREATHING DISORDERS, not only of activity.
OBSTRUCTIVE SLEEP APNEA SYNDROME but also CEN- Quiet sleep is characterized by high voltage, slow
TRAL SLEEP APNEA SYNDROME and CENTRAL ALVEOLAR wave activity in the delta range. There is also the
HYPOVENTILATION SYNDROME. trace alternant pattern of high voltage slow waves
 infant sleep disorders 109

mixed with rapid low voltage activity that occurs in drome is characterized by UPPER AIRWAY OBSTRUC-
bursts alternating with periods of low voltage “flat” TION that occurs predominantly during sleep,
periods. The eye movement activity is increased particularly during REM sleep, and is associated
during active sleep and absent during slow wave with a reduction in oxygen levels in the blood as
sleep. The muscle tone activity is elevated during well as increases in carbon dioxide values. Apneic
quiet sleep and relatively low during active sleep. episodes of similar duration can occur in the cen-
Some sleep is not able to be differentiated into tral sleep apnea syndrome, but in this disorder
active and quiet and is often called INDETERMINATE upper airway obstruction is not the primary event,
SLEEP. This type of sleep decreases as the infant although there is a decrease in central nervous
develops. (See also ONTOGENY OF SLEEP, TRACE system respiratory drive. This form of apnea is
ALTERNANT.) more common in infants who have central ner-
vous system lesions. Some infants do not have
apneic pauses but will have prolonged episodes of
infant sleep apnea A variety of respiratory dis- reduced ventilation during sleep, with associated
turbances that can occur in infants, predominantly oxygen desaturation and increases in carbon diox-
during sleep. Infants who stop breathing during ide levels. This form of respiratory disturbance,
sleep often raise a fear of the SUDDEN INFANT DEATH termed central alveolar hypoventilation syndrome–con-
SYNDROME (SIDS), in which otherwise healthy genital type, may require assisted ventilation until
infants die suddenly during sleep. However, brief the infant is able to sustain ventilation spontane-
apneic pauses are common in infants; even for ously after maturation of the respiratory system.
infants who have longer respiratory pauses, there
is little evidence to substantiate that this is predic-
tive of SIDS. Children who have very prolonged infant sleep disorders INFANT SLEEP is very dif-
apneic pauses, greater than 20 seconds in duration, ferent from the sleep of young children or adults.
particularly premature infants, will have approxi- It has a high percentage of REM sleep that fills 50
mately a 5 percent greater risk of SIDS than oth- percent of the total sleep time, and sleep occurs
erwise healthy children. However, the observation in brief episodes throughout the 24-hour day.
of an infant who stops breathing and has some Approximately two-thirds of the day is spent in
change in color, either by cyanosis or pallor, and sleep.
who is often very limp at the time, is a frightening During the first three months of life, the child’s
occurrence for a mother or father. Although the sleep appears to occur with a cyclical pattern that is
majority of such witnessed episodes are not associ- slightly greater than 24 hours; therefore, the major
ated with any significant cardiorespiratory events sleep episode occurs slightly later on each successive
during infancy, there are a number of disorders day. This pattern, which is known as FREE RUNNING,
in which respiration may be greatly compromised is due to the underlying tendency of our biological
during sleep. circadian rhythms to have a PERIOD LENGTH slightly
Infants who suffer other medical illnesses at longer than 24 hours. This tendency in the infant
the time of birth, either infection, trauma or is usually not a concern so long as the typical ENVI-
hemorrhages, are more likely to develop respira- RONMENTAL TIME CUES are instituted to maintain
tory irregularity that will be most prominent dur- the major sleep episode over the nighttime hours.
ing sleep. In such circumstances, some children If these environmental time cues, such as quieter
may require aggressive intervention in order to nights and daytime stimulation, are not instituted,
maintain adequate VENTILATION. A number of a delayed sleep pattern will develop. As a result,
sleep-related respiratory disturbances can occur in the major sleep episode occurs at a slightly later
infants, such as the OBSTRUCTIVE SLEEP APNEA SYN- time and so the sleep episode will rotate around the
DROME, CENTRAL SLEEP APNEA SYNDROME, CENTRAL clock. This is called the NON-24-HOUR SLEEP-WAKE
ALVEOLAR HYPOVENTILATION SYNDROME, and APNEA SYNDROME and occurs in infants only if appropriate
OF PREMATURITY. The obstructive sleep apnea syn- environmental cues are not instituted.
110 infant sleep disorders

Colic is perhaps the most widely recognized A syndrome called APNEA OF PREMATURITY can exist
cause of awakenings and crying at night in infants where prolonged episodes may be associated with
within the first four months of age. Usually colic changes in oxygenation of the blood, and there-
occurs within the first three weeks of age and fore a child may briefly turn blue or pale in color.
reduces in frequency so that about 50 percent of Within the first few months of life, these episodes
infants with colic will not have attacks after two spontaneously decrease as a more healthy infant
months of age, and most infants will have out- pattern of ventilation develops. Healthy premature
grown colic by four months of age. The cause of infants with persistence of prolonged episodes of
colic is unknown and, although it is suspected of apnea may be predisposed to the SUDDEN INFANT
being due to stomach cramps, there is no scientific DEATH SYNDROME, a disorder that is of concern to
evidence to indicate that colic is of gastrointes- most parents because it is sudden, unexpected and
tinal cause. Current belief is that it is due to an occurs in otherwise healthy infants.
immature central nervous system. There are some At six months of age, the infant’s sleep pat-
irregularities of behavior with increased arousal tern becomes lighter and the number of awaken-
and sensitivity to environmental stimuli that cause ings can increase. It is at this time that the infant
the awakenings. Colic can lead to the development is becoming more aware of the world, and the
of more chronic sleep disturbances in the older frequent awakenings and difficulty in initiating
infant if it is not appropriately managed in the first sleep may cause the parents concern and anxiety.
few months of life. The institution of good SLEEP It is important during this time that positive sleep
HYGIENE and providing the appropriate sleep times hygiene practices are put into place, particularly
is essential to ensure that more persistent sleep the institution of limits on the time that the child
disturbances do not occur. is put down for sleep and the time that the child
A benign form of abnormal movements can is allowed to sleep undisturbed. An appropriate
occur in newborn infants and is called BENIGN NEO- amount of daytime stimulation is necessary so that
NATAL SLEEP MYOCLONUS. This disorder is associated the development of a full period of wakefulness
with jerking movements of limbs, and even of the can gradually occur. Physical illnesses, such as ear
face or trunk, but is not associated with underlying or other infections, can cause the sleep pattern to
epilepsy, and usually resolves within the first few be interrupted, but as long as the appropriate cues
weeks of life. and positive associations with sleep are instituted,
Usually the time between the second and sixth the disturbance is usually only temporary.
months of life is associated with a consolidated One form of insomnia, related to an allergy to
nighttime sleep episode and several daytime NAPS cow’s milk, is called FOOD ALLERGY INSOMNIA and
and is a relatively peaceful time for the parent. It can produce irritability in the infant, resulting in
is during this time that the major changes in the frequent arousals and crying. Very often there are
structure of the infant’s sleep are occurring and so other manifestations of the allergy, such as skin
it is a critical time for the infant. Patterns of cortisol difficulties and gastrointestinal upset. The close
and growth hormone production are developing association of the onset of the insomnia with the
and become established by six months of age. change from breast-feeding to cow’s milk is the first
During the first six months of life, the respira- indication that this form of sleep disturbance might
tory system undergoes development. It is one of be present. Elimination of cow’s milk in the diet
the most fragile body systems and is susceptible to brings about a resolution of the insomnia.
variations that can be noted by the parent. Most The main forms of pathological sleep distur-
healthy infants will have episodes of cessation of bance in the infant include ventilatory abnormali-
breathing that occur and last up to 20 seconds in ties, such as the obstructive sleep apnea syndrome,
duration. These episodes may concern a mother or neurological disorders, such as epilepsy. The
but may be a part of normal development and SLEEP-RELATED BREATHING DISORDERS are evidenced
decrease in frequency as the child develops. Prema- by difficulty in breathing during sleep or prolonged
ture infants are more likely to have these apneas. episodes of cessation of breathing. Apneic episodes
 insomnia 111

of greater than 20 seconds in duration are an It is applied to people who have a complaint
indication of pathology, and may be due either to of unrefreshing sleep, or difficulty in initiating or
upper airway obstruction or a central cause. Typi- maintaining sleep. Although the term has been
cal obstructive sleep apnea syndrome is less likely used to refer to a disorder in which sleep distur-
to occur in the infant than in the older child who bance can be objectively documented, it is more
has enlarged tonsils. When upper airway obstruc- generally used for any disorder associated with a
tion occurs, it usually occurs in both wakefulness complaint of disturbed or unrefreshing sleep.
and sleep. Excessive sleepiness is not evident in Most, but not all, patients with insomnia have
the infant, and the main features of upper airway daytime effects of the disturbed nighttime sleep,
obstruction are difficulty in breathing and the such as fatigue, tiredness, irritability or inability to
change in coloration or heart rate. Upper airway concentrate, that can impair the ability to work or
obstruction is more common in infants with cra- socialize. Insomnia has been used as a diagnosis in
niofacial abnormalities, such as those due to a the past, but in recent years, with the recognition
small jaw or an enlarged tongue. Central apnea of the many different causes of insomnia, the term
may be due to neurological disorders that may is now largely applied to the symptom complaint of
have occurred during the time of a difficult deliv- the patient and should not be viewed as a specific
ery, such as an intracerebral hemorrhage. Central disorder. With the development of SLEEP DISORDERS
nervous system lesions can affect the control of MEDICINE, many new disorders have been recog-
breathing and lead to frequent episodes of breath- nized that can produce a complaint of insomnia.
ing cessation during sleep, commonly called the The physician should determine the exact cause
CENTRAL SLEEP APNEA SYNDROME. of the symptom in order to initiate appropriate
Many illnesses of an infective, biochemical or treatment.
anatomical nature can predispose the infant to It is difficult to determine the prevalence of
central apnea. For most infants, treatment of the insomnia; however, it is clearly a widespread com-
underlying medical disorder will lead to resolution plaint. Everyone, at some point, has experienced
of the apneic episodes. However, some infants with insomnia, if only temporarily. National surveys
primary respiratory difficulty may need to have have reported that up to one-third of the popula-
artificial ventilation until the respiratory symptom tion has some degree of insomnia, and 50 percent
has improved so that spontaneous control is possi- of that third regard the insomnia as serious. Ten
ble. There has not been demonstrated a clear asso- percent of people reporting severe insomnia have
ciation between infants with apneic episodes of less been prescribed HYPNOTICS and 5 percent have used
than 20 seconds in duration and the subsequent OVER-THE-COUNTER MEDICATIONS.
development of sudden infant death syndrome. In general, insomnia has not been well treated
Central nervous system disorders, such as epi- in the past because clinicians lacked a good under-
lepsy, can cause abnormal movements in infants standing either of its causes or of the different
during sleep. These episodes are often the result of treatment options available. Although it was clear
central nervous system lesions, such as an intra- that PSYCHIATRIC DISORDERS were associated with
cerebral tumor. Metabolic abnormalities due to insomnia, particularly the MOOD DISORDERS, such
a change in the blood electrolytes are a common as DEPRESSION or the ANXIETY DISORDERS, there was
cause of seizures in the newborn infant, and with little understanding of the importance of physical
correction of the biochemical changes the seizure causes of insomnia.
manifestations resolve. Sometimes epilepsy can be Research studies have demonstrated that the
the cause of apneic episodes. total amount of sleep does not necessarily correlate
with the complaint of insomnia. Many patients
who complain of insomnia have an amount of
insomnia Term derived from the Latin words sleep that would be regarded as normal, and some
in, meaning “no,” and somnus, meaning “sleep.” patients very clearly have normal sleep without
Insomnia strictly means the inability to sleep. any interruptions or disruptions. Insomnia may
112 insomnia

also be related to impaired perception of sleep disorders, including PANIC DISORDERS, and ALCOHOL-
quality; for example, an infant may be brought to ISM. Specific treatment of the psychiatric state is
medical attention by a mother who complains that required; good sleep hygiene and behavioral treat-
the child has frequent awakenings at night, which ments of insomnia can assist the resolution of the
may be entirely normal in number and duration. sleep complaint.
Therefore, the assessment of insomnia is most
important, as treatment depends upon the cause of Environmental Factors
the insomnia and may vary from simple reassur- Particularly noise, temperature, or abnormal light
ance to behavioral, pharmacological or mechani- exposure may be important in the development of
cal means. The age of the patient will influence some forms of insomnia. The ingestion of some foods
the likelihood of certain sleep disorders being can produce a FOOD ALLERGY INSOMNIA, and toxins
responsible for the complaint of insomnia. A clear can produce a TOXIN-INDUCED SLEEP DISORDER.
understanding of the nature of the complaint and,
when indicated, further investigations, such as Medications and Insomnia
polysomnographic monitoring, may be required to Medications can be associated with the development
determine the exact cause of insomnia in order to of insomnia, with the chronic use of hypnotics lead-
develop a successful treatment plan. ing to HYPNOTIC-DEPENDENT SLEEP DISORDER, which
Although many different classifications of may exacerbate upon withdrawal of the hypnotic
insomnia have been developed, the differential agent. The chronic use of stimulants, such as CAF-
diagnosis developed in the International Classifica- FEINE, or weight-reduction medications, such as
tion of Sleep Disorders has been clinically very useful. amphetamines, can produce a STIMULANT-DEPENDENT
However, insomnia can be divided into slightly dif- SLEEP DISORDER. The chronic use of alcohol for sleep
ferent groups associated with the following causes: purposes can lead to an ALCOHOL-DEPENDENT SLEEP
behavioral or psychophysiological causes; psychiat- DISORDER. Gradual withdrawal of the offending
ric causes; environmental causes; drug-dependent agent under clinical supervision, with maintenance
factors; those associated with respiratory or move- of good sleep hygiene, is usually all that is required
ment disorders; those associated with alterations in for the treatment of these forms of insomnia.
the timing of the sleep-wake pattern or associated
with the parasomnias or neurological disorders; Sleep-related Breathing Disorders
those without any objective sleep disturbance; Can be associated with the complaint of insomnia,
idiopathic insomnia; and a miscellaneous group of particularly in the elderly. OBSTRUCTIVE SLEEP APNEA
other causes of insomnia. SYNDROME, CENTRAL SLEEP APNEA SYNDROME, and
CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME can
Insomnia Associated with Behavioral all produce awakenings at night, with little evidence
or Psychophysiological Causes of daytime impairment of respiratory function.
Insomnia associated with behavioral or psycho- Polysomnographic investigation is usually neces-
physiological causes includes ADJUSTMENT SLEEP DIS- sary to understand the severity and extent of these
ORDER, PSYCHOPHYSIOLOGICAL INSOMNIA, INADEQUATE disorders to determine appropriate treatment.
SLEEP HYGIENE, LIMIT-SETTING SLEEP DISORDER, SLEEP- Other respiratory disorders, such as CHRONIC
ONSET ASSOCIATION DISORDER, NOCTURNAL EATING OBSTRUCTIVE PULMONARY DISEASE and SLEEP-RELATED
(DRINKING) SYNDROME. ASTHMA, can have direct sleep effects. Insomnia
These disorders often respond to the institu- may also be exacerbated by the RESPIRATORY STIMU-
tion of SLEEP HYGIENE or BEHAVIORAL TREATMENT OF LANTS, such as the xanthines, that are used to treat
INSOMNIA. these disorders.

Insomnia Associated with Psychiatric Disorders Altitude Insomnia

Includes the mood disorders, such as depression Occurring at high altitudes and caused by the low
or manic-depressive disease, PSYCHOSES, anxiety level of inspired oxygen tension, which produces
 insomnia 113

a periodic pattern of breathing often associated frequently interrupted sleep episodes throughout
with insomnia. It usually resolves upon return to the 24-hour day—the IRREGULAR SLEEP-WAKE PAT-
a lower altitude. TERN. Rarely, the NON-24-HOUR SLEEP-WAKE SYN-
DROME can occur; here, the sleep pattern continues
Insomnia and Abnormal Movement Disorders to rotate around the clock, with a PERIOD LENGTH of
Insomnia may be associated with abnormal move- 25, and not 24, hours.
ment disorders during sleep. Typical SLEEP STARTS,
or hypnic jerks, can cause a sleep-onset insom- Neurological Disorders and Insomnia
nia, as can the RESTLESS LEGS SYNDROME, which Neurological disorders are common causes of the
is associated with disagreeable sensations in the inability to maintain sleep, and those most com-
legs. Rarely, nocturnal CRAMPS may cause sudden monly seen, particularly in the elderly, include
awakenings during sleep, leading to the complaint PARKINSONISM and DEMENTIA. Degenerative disor-
of insomnia. ders and epilepsy are two other neurological dis-
The PERIODIC LIMB MOVEMENT DISORDER is a orders that commonly present with the complaint
movement disorder that occurs solely during sleep. of disturbed sleep. Appropriate treatment of these
The patient may not be aware of it, but it is typi- neurological disorders includes attention to good
cally seen by a bed partner. It is associated with sleep hygiene, with or without the use of hypnotic
periodic movements of the limbs and disturbed agents. FATAL FAMILIAL INSOMNIA, a rare form of
quality of sleep, often leading to the complaint of insomnia, has a progressive deteriorating course
insomnia or unrestful sleep. that eventually leads to death. There is no known
The REM SLEEP BEHAVIOR DISORDER is associated treatment.
with excessive movement and abnormal behavior
during sleep. Insomnia also occurs in NOCTURNAL Insomnia Associated with Parasomnias
PAROXYSMAL DYSTONIA and RHYTHMIC MOVEMENT Insomnia can be caused by PARASOMNIAS that do
DISORDER, when it persists into adolescence or not typically produce complaints of insomnia or
adulthood. EXCESSIVE SLEEPINESS. CONFUSIONAL AROUSALS, SLEEP
TERRORS, NIGHTMARES, and SLEEP HYPERHIDROSIS
Insomnia Related to the Timing of Sleep (sweating) may cause awakenings that lead to
With the development of the science of CHRONOBI- insomnia.
OLOGY, there has been the recognition that disor-
ders of the timing of sleep are also associated with Insomnia with No Objective Sleep Disturbance
disturbed sleep quality. This is most evident to the A form of insomnia due to a misperception or mis-
general population through its awareness of TIME interpretation of sleep. SLEEP STATE MISPERCEPTION,
ZONE CHANGE (JET LAG) SYNDROME and SHIFT-WORK previously known as pseudoinsomnia, occurs when
SLEEP DISORDER. A delay in the onset of sleep can patients find sleep totally unrefreshing, when they
produce a sleep onset insomnia in adolescence deny having been asleep, despite having had a full
termed DELAYED SLEEP PHASE SYNDROME. In this night of good quality sleep. This unusual disorder is
disorder, the sleep pattern is delayed with regard poorly understood and is often resistant to attempts
to typical sleep times. Similarly, the opposite sleep at treatment.
pattern, the ADVANCED SLEEP PHASE SYNDROME, can Awakening at night with a sensation of an
cause an EARLY MORNING AROUSAL and a complaint inability to breathe, termed the SLEEP CHOKING
of insomnia. Sleep occurs at an earlier time than SYNDROME, can occur, yet polysomnographically
desired. This particular sleep pattern is more com- documented sleep is entirely normal. This disorder
mon in the elderly, who find it difficult to stay might be an unusual manifestation of an anxiety
awake late at night and yet awaken early in the or panic disorder.
morning, while it is still dark. Some people have a physiological requirement
Behavioral or neurological disorders can pro- for less sleep than most and can be classed as SHORT
duce an irregular sleep pattern characterized by SLEEPERS. However, the desire for longer sleep may
114 insomnia

lead to the complaint of insomnia. Reassurance INSOMNIA that occurs following stress usually lasts
that the short sleep is physiologically appropriate only a few days and then spontaneously resolves.
may be all that is required. However, the patient who suffers from continuing
insomnia may be reluctant to seek medical help for
Idiopathic Insomnia fear of being prescribed medications with poten-
Some patients appear to have a lifelong inability to tial adverse side effects. Many people suffer from
sustain good quality sleep, and the term IDIOPATHIC chronic insomnia in the hope that it will eventually
INSOMNIA (or childhood-onset insomnia) has been spontaneously resolve itself.
applied. This sleep disorder is believed to be due If the insomnia does not resolve, the patient
to a genetic or acquired abnormality in the sleep has several avenues to pursue for help. Popular
maintenance systems of the brain so that normal books and articles on insomnia are a source of
good quality sleep is never obtained. These patients information that is commonly used; for many
are particularly susceptible to minor stressful or patients, it provides successful treatment strategies.
environmental stimuli, which cause an exacerba- Over-the-counter medications for the treatment of
tion of the insomnia. Lifelong attention to good insomnia are plentiful and are widely publicized in
sleep hygiene is necessary for such patients. the media. Some patients will find these over-the-
counter medications helpful, although it is unclear
Other Causes of Insomnia whether the insomnia would have resolved sponta-
There are many other causes of insomnia, the neously despite their use. However, many patients
majority of which are related to underlying medical initially seek help from their physician, or turn
disorders, including SLEEP-RELATED GASTROESOPHA- to their physician after trying over-the-counter
GEAL REFLUX, FIBROSITIS SYNDROME, MENSTRUAL- medications. In the past, physicians tended to take
ASSOCIATED SLEEP DISORDER, PREGNANCY-RELATED a brief history and considered prescribing hypnotic
SLEEP DISORDER, TERRIFYING HYPNAGOGIC HALLUCINA- medications. But today, a more detailed history is
TIONS, SLEEP-RELATED ABNORMAL SWALLOWING SYN- usually taken to try to understand the source of the
DROME, and SLEEP-RELATED LARYNGOSPASM. insomnia. If necessary, the patient will be referred
All of the above-mentioned sleep disorders need to a specialist in sleep disorders medicine for fur-
to be considered in the differential diagnosis of ther investigation or treatment.
the patient presenting with insomnia. A detailed If the insomnia is clearly related to a situational
clinical and psychological history will often point stress, such as bereavement, hospitalization or
to the cause of the insomnia without the need travel that included a time zone change, specific
for objective polysomnographic evaluation (see treatment is usually unnecessary since patients
POLYSOMNO GRAPHY). However, many of the above know that the insomnia will be temporary, but
disorders need polysomnographic documentation. good sleep hygiene is still essential. However, if
When there is no evident cause for the insomnia, the condition is severe, treatment may be neces-
polysomnographic monitoring may be indicated. sary, particularly with a short course of hypnotic
Typically, the patient will be evaluated for the qual- medication. When insomnia lasts less than three
ity of sleep, as well as for abnormal physiological weeks, but more than a few days, the term SHORT-
events during sleep. One or two nights of recording TERM INSOMNIA is occasionally used, although it is
in a SLEEP DISORDER CENTER is usually necessary. This clear that there may be many different causes of
information, along with the historical information the onset of insomnia.
taken at the initial evaluation, usually leads to a If the insomnia lasts longer than three weeks,
precise diagnosis so an accurate treatment plan can then LONG-TERM INSOMNIA (or chronic insomnia)
be outlined. may develop, with specialist help and further
investigation often warranted. At this time, con-
Treatment sideration of the full differential diagnosis is nec-
Most patients with insomnia deal with it without essary, and polysomnographic investigation may
the need for professional help. The TRANSIENT be needed. Treatment is usually directed to one
 insomnia 115

or more of the above specific causes of insomnia an assessment of her SLEEP LOG demonstrated that
and very often also requires instituting good sleep she had much variety in both the time of going to
hygiene practices. Behavioral techniques that have bed and the time of awakening in the morning.
been found to be useful for patients with behav- She also had bronchitis, for which she occasionally
ioral or psychophysiological insomnia include STIM- took bronchodilators. As these medications have
ULUS CONTROL THERAPY, SLEEP RESTRICTION THERAPY, a stimulant effect, they tended to exacerbate her
COGNITIVE FOCUSING, SYSTEMIC DESENSITIZATION, sleep disturbance.
BIOFEEDBACK, AUTOGENIC TRAINING, PARADOXICAL She had a number of other somatic complaints,
TECHNIQUES, and PROGRESSIVE RELAXATION. The judi- which included mild generalized arthritis and gastro-
cious use of hypnotic medications can be helpful intestinal discomfort. She regarded herself as being
and consideration should be given to the use of a slightly tense and anxious person who was rather
appropriate psycho-pharmacological agents—such particular about things and a little compulsive.
as the BENZODIAZEPINES, zolpidem or other anti- Her examination revealed that she had normal
anxiety agents, or the tricyclic ANTIDEPRESSANTS—in blood pressure, and her breath sounds were rather
patients with anxiety and depression. Antianxiety harsh without any evidence of significant obstruc-
agents, or sedative antidepressants, can be use- tive airways disease. Examination of the orophar-
ful when given at night to improve the quality ynx revealed a long soft palate and the posterior
of sleep and lead to resolution of the underlying pharyngeal wall was slightly difficult to visualize.
psychiatric disorder. Occult sleep disorders, such The initial impression was one of difficulty in
as periodic limb movement disorder or obstructive initiating and maintaining sleep with mild daytime
sleep apnea syndrome, may require specific treat- sleepiness. This disturbance appeared to be related
ment by means of pharmacological or mechanical to a number of factors, including her psychological
means, such as the use of CONTINUOUS POSITIVE AIR- state that tended toward anxiety, and her physical
WAY PRESSURE (CPAP) devices. illnesses, arthritis and bronchitis. There was also
evidence to suggest she might have a mild degree
Case History of obstructive sleep apnea syndrome and periodic
A 50-year-old social worker had insomnia for most limb movements in sleep with the presence of rest-
of her life. Over the years, she had been treated by less legs syndrome.
medications, mainly hypnotics, and had undergone It was recommended that she should undergo
behavioral therapy and psychotherapy. There had polysomnography, which demonstrated 34 brief
been little improvement in her sleep disturbance awakenings during the night, one of which was
and in recent months she had been treated with longer than five minutes in duration. However, her
a benzodiazepine antianxiety agent, alprazolam SLEEP EFFICIENCY was quite good at 86 percent. She
(Xanax). However, although this produced some had a few shallow episodes of breathing and one
slight improvement, she still could sleep only central apnea with a slight fall in oxygen but not
one-and-one-half to two hours at night and was below 91 percent. She had 41 periodic leg move-
extremely fatigued and tired during the daytime. ments giving her an index of six episodes per hour
She was aware of loud snoring, which had been of sleep. She had some restlessness of her legs,
commented upon by her husband, and she won- indicative of the restless legs syndrome, which was
dered whether the breathing difficulty contributed present during the recording.
to her sleep disturbance. She had occasional feel- A MULTIPLE SLEEP LATENCY TEST demonstrated a
ings of restless leg syndrome. Although she had mean sleep latency of 7.3 minutes with one sleep
been effectively treated for this symptom in the onset REM period at 2 P.M., indicating a mild degree
past, she did not require treatment at the current of daytime sleepiness. A second night of polysom-
time. nography confirmed the initial findings but dem-
She typically would go to bed around 12:30 onstrated 177 periodic leg movements at a rate of
at night and awaken at 6:30 in the morning. She 25 episodes per hour, confirming the presence of
had numerous awakenings during the night, and significant periodic leg movement disorder.
116 insufficient sleep syndrome

Treatment consisted of avoiding the use of bron- This disorder needs to be differentiated from
chodilator medications for her bronchitis close to IDIOPATHIC HYPERSOMNIA, which is characterized by
the time of sleep onset. The Xanax was continued a normal or prolonged sleep episode at night, and
at 0.5 milligrams, taken one hour before sleep. from NARCOLEPSY, which is typically associated with
She was placed on a strict sleep restriction therapy REM sleep phenomena such as CATAPLEXY, SLEEP
schedule of going to bed at 1:30 A.M. and arising PARALYSIS, and HYPNAGOGIC HALLUCINATIONS.
at 6:30 A.M. Treatment rests upon a regular extension of
After two weeks, her sleep pattern considerably TOTAL SLEEP TIME to ensure that the individual’s
improved. There was less variability in the time of sleep duration meets his or her physiological needs.
going to bed and getting up, and the majority of The amount of sleep time required varies among
her sleep was occurring between the hours of 1 individuals; for some it may need to be as long as
and 6 A.M. Her sleep latencies, which consistently nine hours on a regular basis. (See also DISORDERS
were more than 30 minutes in duration, and some- OF EXCESSIVE SOMNOLENCE.)
times as long as four hours, gradually reduced so
that after a period of two months of adhering to
this regimen of sleep restriction, her sleep laten- interleukin-1 (IL-1) A substance produced by the
cies fell to less than 15 minutes. She consistently body in response to injury, inflammation and fever.
was getting about five hours of sleep and her sleep It appears to be a single polypeptide or a group of
time was extended from 1:30 A.M. to 7 A.M. After factors that are produced in response to the stress.
several weeks on the sleep program, she progressed The most prominent effect of interleukin-1 is to
to getting between five and five-and-a-half hours induce fever, but amongst its other effects is the
of sleep, a great increase over the one and a half induction of SLOW WAVE SLEEP. During the acute
or two hours she was getting previously. She was phase response of injury, there is an increased ten-
delighted with her improvement and regarded her dency for rest and sleep, possibly to allow affected
new sleep pattern as the best she could remember. cells to rest so repair is enhanced. Interleukin-1,
when infused into rabbits, will induce slow wave
sleep, along with fever. When interleukin-1 is
insufficient sleep syndrome Disorder character- administered, along with an antipyretic medica-
ized by EXCESSIVE SLEEPINESS during the day due to tion, the body TEMPERATURE does not rise, but slow
an inadequate amount of sleep at night; typically wave sleep increases, indicating that the tempera-
follows episodes of sleep deprivation that have ture effect is not the primary cause of the sleep-
reoccurred over weeks or months. Often the inad- inducing effect.
equate nocturnal sleep is unappreciated by the Blood levels of interleukin-1 have been shown
patient, who presents the complaint of excessive to increase shortly after sleep onset at a time that
sleepiness of unknown cause. Examination of a appears to coincide with the onset of natural slow
SLEEP LOG may demonstrate the characteristic fea-
wave sleep. When FACTOR S is injected into ani-
tures: a shorter than normal major sleep episode mals, it produces fever and slow wave sleep, a
with a short latency to sleep onset; and an early reaction that appears to be mediated by the pro-
morning awakening, usually by an alarm or other duction of interleukin-1. (See also SLEEP-INDUCING
disturbance. Polysomnographic monitoring may FACTORS.)
be necessary if the cause of daytime sleepiness is
unclear or if other disorders of excessive sleepiness
are considered.
Typically, insufficient sleep syndrome is a disor- “intermediary” sleep stage See NON-REM-STAGE
SLEEP.
der seen in adolescents or young adulthood; how-
ever, it can occur at any age. Usually it is associated
with nocturnal or daily commitments that require
an individual to go to bed or arise early. intermediate sleep See INDETERMINATE SLEEP.
 International Classification of Sleep Disorders 117

intermittent DOES (periodic) syndrome Term whereas the sleep-wake cycle may have a period
referring to a group of disorders characterized by length of 33 hours. In humans, the two main
RECURRENT HYPERSOMNIA. One form of this disorder, rhythms are determined by the so-called x and y
called the KLEINE-LEVIN SYNDROME, is distinguished oscillators, which are believed to be two indepen-
by recurrent hypersomnia, overeating, and hyper- dent sets of processors that determine the rhythm
sexuality. A form of the disorder exists in which of most physiological circadian rhythms. (See also
recurrent episodes only of hypersomnia occur at BIOLOGICAL CLOCKS, CHRONOBIOLOGY, SUPRACHIAS-
intervals of weeks or months. Each episode of MATIC NUCLEUS.)
hypersomnia lasts one to two weeks.
A form of recurrent hypersomnia occurs in asso-
ciation with the MENSTRUAL CYCLE and is called the International Classification of Sleep Disorders
MENSTRUAL-ASSOCIATED SLEEP DISORDER. This disor- In 1985, the Association of Sleep Disorder Cen-
der can also be characterized by recurrent episodes ters initiated the process of revising the original
of insomnia in association with the menses. DIAGNOSTIC CLASSIFICATION OF SLEEP AND AROUSAL
DISORDERS. The original classification was pub-
lished in 1979 in the journal Sleep. This classifica-
internal arousal Term occasionally used for the tion has been very widely used throughout the
effect of excessive mental activity inducing insom- world; however, with the recent advances in SLEEP
nia. This process is a typical feature of PSYCHO- DISORDERS MEDICINE it was believed that a revision
PHYSIOLOGICAL INSOMNIA and is often produced by was required.
apprehension over the inability to sleep and con- In 1997, a committee was headed by Michael
scious efforts to induce sleep. Thorpy, M.D., and consisted of 18 clinical sleep
disorder specialists who set about the process of
revising the classification.
internal arousal insomnia Term used for a state The classification scheme differs from that of
of heightened arousal that impairs the ability to fall 1979 in that it breaks the sleep disorders into four
asleep or to stay asleep. This form of heightened groups: the dyssomnias; the parasomnias; medical
arousal is typically seen in insomnia disorders such and psychiatric sleep disorders; and the proposed
as PSYCHOPHYSIOLOGICAL INSOMNIA, ANXIETY DISOR- sleep disorders. This classification system differed
DERS, or agitated DEPRESSION. At the desired sleep from the original system in order to bring the
time, patients become more alert with an increase classification more in line with the international
in mental activity, because a flood of thoughts pre- classification of diseases. The original classification
vents them from “turning off” their minds. (See was considered most useful as a differential diag-
also INSOMNIA, MOOD DISORDERS.) nostic listing for physicians but was not useful as an
international classificational schema because many
disorders were represented more than once. In the
internal desynchronization During normal new classification system, each disorder has only
entrainment to a 24-hour day, or during the initial one entry. In addition, the classification system dif-
part of a FREE RUNNING experiment in TEMPORAL ferentiates those disorders that are primarily sleep
ISOLATION, all of an individual’s biological rhythms disorders from those that are sleep disturbances
are internally synchronized. During this time the associated with other medical disorders.
rhythms have the same PERIOD LENGTH of approxi- The development of the international classifica-
mately 24 hours; however, during prolonged stud- tion of sleep disorders involved the cooperation
ies of an individual in time isolation, the biological of individuals in sleep societies from around the
rhythms may lose their synchrony and two or world and led to the recommendation that the
more rhythms will run at different period lengths. name “International Classification of Sleep Disor-
For example, the body temperature rhythm may ders” be applied to the new system. The new clas-
continue with a period length of about 24 hours, sification was published in 1990 by the American
118 international sleep societies

Sleep Disorders Association, a member society of seated, unfulfilled desires, particularly of a sexual
the Associate Professional Sleep Societies. The clas- nature.
sification was revised in 1997, 2001, and 2005. It is Although Freud’s interpretation of dreams is
available at libraries or for sale from the AMERICAN still widely held, modern science has added neu-
ACADEMY OF SLEEP MEDICINE (AASM). (See also rophysiological information that refutes some of
CIRCADIAN RHYTHM SLEEP DISORDERS, DYSSOMNIA, Freud’s hypotheses. (See also RAPID EYE MOVEMENT
PARASOMNIAS, PROPOSED SLEEP DISORDERS, REM SLEEP.)
PARASOMNIAS, SLEEP-WAKE TRANSITION DISORDERS.)

intrinsic sleep disorders Medical or psychologi-

international sleep societies A number of sleep cal sleep disorders that originate or develop from
societies have been developed around the world within the body, or arise from causes within the
for the purposes of fostering sleep research or for body. Examples of intrinsic sleep disorders include
promoting the development of clinical sleep disor- PSYCHOPHYSIOLOGICAL INSOMNIA, NARCOLEPSY, and
ders medicine. In the United States, the Association OBSTRUCTIVE SLEEP APNEA SYNDROME. EXTRINSIC
for the Psychophysiological Study of Sleep was SLEEP DISORDERS, originating from causes outside
founded in 1961, and it subsequently led to the of the body, the CIRCADIAN RHYTHM SLEEP DISOR-
Association of Professional Sleep Societies. The first DERS, and intrinsic sleep disorders are three groups
society to be founded outside of the United States within the category of the DYSSOMNIAS, disorders
was the European Sleep Research Society, in 1971, that produce difficulty in initiating or maintain-
followed by the Japanese Sleep Research Society ing sleep, excessive sleepiness, or both. (See also
in 1978, the Belgian Association for the Study of INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS,
Sleep in 1982, the Scandinavian Sleep Research PSYCHIATRIC DISORDERS.)
Society in 1985, the Latin American Sleep Research
Society in 1986, and the Sleep Society of Canada in
1986. The bimonthly journal Sleep, originally pub- irregular sleep-wake pattern A sleep pattern
lished by Raven Press, was sponsored jointly by the without the usual circadian cycle of sleep and
Association of Professional Sleep Societies, Euro- wakefulness. Episodes of sleep and wakefulness of
pean Sleep Research Society, Latin American Sleep variable duration occur throughout the 24-hour
Research Society, and the Japanese Sleep Research day, with sleep occurring unpredictably at any time
Society. The journal Sleep is now published by the of the day. However, in any 24-hour period, total
AMERICAN ACADEMY OF SLEEP MEDICINE (AASM) sleep duration is normal.
and the Sleep Research Society (SRC). This sleep pattern is commonly seen in indi-
viduals who are institutionalized, where there is
a loss of the normal ENVIRONMENTAL TIME CUES
interpretation of dreams The most significant to help maintain a regular sleep-wake cycle. In
advance in the interpretation of DREAMS occurred addition, such patients usually have neurologi-
with SIGMUND FREUD’s psychodynamic writings on cal disorders that predispose them to an inability
dreams in his initial publication The Interpretation of to maintain a normal sleep-wake cycle. But this
Dreams, published in 1900. Freud wrote: “The Inter- pattern can also occur in non-institutionalized
pretation of Dreams is the royal road to a knowledge of individuals who do not have strong environmen-
the part the unconscious plays in the mental life.” tal stimuli to ensure a regular sleep-wake cycle,
Dreams were regarded by Freud as protecting such as persons who work or sleep on irregular
mental health by allowing sleep to continue while schedules.
mental conflict was being expressed and managed This chronobiological sleep disturbance dif-
without producing sleep disruption. fers from the ADVANCED SLEEP PHASE SYNDROME,
Freud also regarded dreams as being symbols DELAYED SLEEP PHASE SYNDROME, and NON-24-HOUR
of internal conflicts and a representation of deep- SLEEP-WAKE SYNDROME in that these other disorders
 irregular sleep-wake pattern 119

have regular sleep-wake cycles, although they elderly. It does not appear to have any particular
may be temporarily displaced in relationship to a gender predominance.
24-hour clock time. Furthermore, patients with Polysomnographic studies have demonstrated
disorders producing EXCESSIVE SLEEPINESS during short (two-to-three-hour) episodes of sleep or wake-
the day may show a similar pattern of frequent fulness that occur at random throughout the 24-
sleep episodes, but most disorders of excessive hour day. Sleep cycle monitoring is usually required
daytime sleepiness occur in the presence of a for 48 hours or longer to substantiate this diagnosis.
relatively intact nocturnal sleep period. However, An alternative means of documenting this sleep-
NARCOLEPSY, which typically produces frequent wake pattern is by using ACTIVITY MONITORS, which
daytime sleep episodes, can be associated with are movement detectors sensitive to the presence of
a disrupted nocturnal sleep pattern, particularly sleep or wake episodes. Prolonged monitoring over
when the disorder is severe. Irregular sleep-wake days or weeks can be an effective way of document-
pattern also has to be differentiated from irregular ing this sleep disorder. Because of the disruption of
cycles due to either shift work (see SHIFT-WORK the sleep-wake cycle, the NREM-REM SLEEP CYCLE
SLEEP DISORDER) or time zone changes (see TIME is often disrupted, and the ELECTROENCEPHALOGRAM
ZONE CHANGE [JET LAG] SYNDROME). may show a reduction in SLEEP SPINDLES and K-COM-
In irregular sleep-wake pattern, daytime sleepi- PLEX activity, as well as reduced SLOW WAVE SLEEP.
ness and complaints of INSOMNIA are common. REM sleep may also be disrupted.
Full alertness is usually decreased, and memory Treatment of irregular sleep-wake pattern
and other cognitive functions are often impaired. involves trying to maintain a regular major sleep
Because of the unpredictability of sleep episodes episode at night and a full period of wakefulness
occurring throughout the 24-hour day, many indi- during the day. In the institutionalized elderly,
viduals with this pattern tend to remain in an envi- treatment includes providing stimulating activi-
ronment where they can be close to a bed. Elderly ties during the day and preventing daytime nap.
patients may become more housebound and less Appropriate environmental measures need to be in
likely to expose themselves to environmental stim- place to ensure a suitable nocturnal sleeping envi-
uli that, ironically, could help them to maintain a ronment. Assistance in maintaining a good sleep
more regular sleep-wake pattern. episode at night might be brought about by the use
This sleep pattern may be induced by the use of of HYPNOTICS or, conversely, in order to assist alert-
medications that provoke daytime sedation, such ness during the day, stimulant medications may be
as tranquilizers, or stimulants that can increase used. However, these medications are often of little
arousal at night. assistance, and attention to the sleep-wake sched-
This particular sleep disorder is relatively rare, uling is usually most effective. Patients who have a
although the prevalence in individuals with cen- central nervous system disease may lack the ability
tral nervous system dysfunction is thought to be to maintain both a regular sleep episode at night
greater than in other groups (although the exact and full awakeness during the daytime; therefore,
prevalence is unknown). The pattern may occur at attempts at correcting the irregular sleep-wake pat-
any age, although it is much more prevalent in the tern may be unsuccessful.
 J
Jacobsonian relaxation Term for relaxation meth- crossed and usually occurs with a change of more
ods proposed by Edmund Jacobson for promot- than one or two hours. The symptoms gradually
ing restful sleep. The relaxation methods involve abate as adaptation to the new time zone occurs
sequential relaxation of muscle groups of the limbs over the ensuing days. There is evidence to sug-
and trunk in order to reduce heightened arousal and gest that individuals may differ in their ability
muscle tension. This form of relaxation is commonly to adapt to the time zone changes. The ability to
recommended for patients who have INSOMNIA, adapt is also dependent on the direction of travel,
either of psychophysiological cause or insomnia due either eastward or westward: Studies of circadian
to ANXIETY DISORDERS. (See also SLEEP EXERCISES.) rhythmicity suggest that adaptation occurs at a
rate of 88 minutes per day after westbound travel,
and only 66 minutes per day after eastbound
jactatio capitis nocturna This term is synony- travel. (See also CIRCADIAN RHYTHM SLEEP DISOR-
mous with HEADBANGING or RHYTHMIC MOVEMENT DERS, PHASE RESPONSE CURVE, TIME ZONE CHANGE
DISORDER. The term was first proposed in 1905 [JET LAG] SYNDROME.)
by Julius Zappert who provided the first clinical
description of headbanging when he described six
children with the disorder. Jung, Carl Gustav The Swiss psychiatrist Jung
(1875–1961) studied medicine, specializing in
psychiatry. One of his key concepts was the col-
jet lag Term applied to symptoms experienced lective unconscious whereby someone seems to
following rapid travel across multiple time zones. know something instinctively just because they are
The term derives from jet air travel, which enables part of a culture, even if they have not personally
travelers to cross time zones much more quickly experienced it. In 1906, when he was 30, he sent
than by other, slower forms of transportation, SIGMUND FREUD a copy of his book, Studies in Word
such as by boat, where adaptation to the change Association, and a six-year close friendship ensued.
in time occurs. The symptoms of jet lag include But when Jung published his book, Psychology of
sleep disruption, gastrointestinal disturbances, the Unconscious, he and Freud had a falling out over
reduced vigilance and attention span, and a gen- their disparate ideas. Dream interpretation for Jung
eral feeling of malaise. The severity of the symp- was based on symbols rather than Freud’s approach
toms depends upon the number of time zones to dreams as a repressed wish.

120
 K
K-alpha A type of microarousal consisting of a EUGENE ASERINSKY and, later, WILLIAM DEMENT,
K-COMPLEX followed by several seconds of ALPHA Kleitman discovered the REM phase of sleep.
RHYTHM. Dr. Kleitman received his Ph.D. from the Uni-
versity of Chicago and was a National Research
Council Fellow in Utrecht, Paris, and Chicago.
K-complex A high-voltage ELECTROENCEPHALO- Kleitman’s 1939 work on sleep, in which he quoted
GRAM wave that consists of a sharp negative com- more than 1,400 references (more than 4,300 in
ponent followed by a slower positive component. the revised edition), was the first comprehensive
K-complexes typically have a duration exceeding book on the subject. Until 1960, he was a professor
.5 second, occur during non-REM sleep, and are of physiology at the University of Chicago.
required for the definition of STAGE TWO SLEEP (see Dr. Kleitman received the APSS Pioneer Award
SLEEP STAGES). They can be detected by electrodes for his work in sleep research, as well as the
placed over a wide area of the scalp, but they are 1966 Distinguished Service Award of the Thomas
most clearly detected in the fronto-central regions. W. Salmon Committee on Psychiatry and Men-
Frequently, K-complexes are associated with SLEEP tal Hygiene of the New York Academy of Medi-
SPINDLES. cine. The AMERICAN ACADEMY OF SLEEP MEDICINE’s
K-complexes need to be distinguished from ver- annual award for outstanding contributions to sleep
tex sharp waves, which are usually short in dura- medicine was named after Kleitman and is called
tion (less than 0.3 second), low in amplitude and the Kleitman Award. Dr. Kleitman died in 1999 at
usually restricted to the vertex area of the skull. the age of 104. (See also NATHANIEL KLEITMAN DIS-
K-complexes are thought to be manifestations of TINGUISHED SERVICE AWARD, SLEEP DEPRIVATION.)
central nervous system-evoked stimuli, and can be
elicited during sleep by external stimuli, such as a
loud noise. Kleitman, Nathaniel, Distinguished Service Award
See NATHANIEL KLEITMAN DISTINGUISHED SERVICE
AWARD.
Kleine-Levin syndrome Syndrome characterized
by RECURRENT HYPERSOMNIA, overeating, and hyper-
sexuality. This disorder was first described in part Klonopin (clonazepam) See BENZODIAZEPINES.
by Willi Kleine in 1925, and subsequently by Max
Levin in 1929. Michael Critchley, in 1942, coined
the term Kleine-Levin syndrome. (See also DIET AND kyphoscoliosis Curvature of the spine in the
SLEEP). thoracic region that causes a backward and lateral
curvature of the spinal column. The space available
for the lungs is reduced and patients therefore are
Kleitman, Nathaniel Dr. Kleitman (1895–1999) unable to adequately inflate the lungs, producing
is called “the father of modern sleep research”; a restrictive lung disorder. The breathing pattern
in 1952, at the University of Chicago, along with during sleep in patients with kyphoscoliosis may

121
122 kyphoscoliosis

resemble a CHEYNE-STOKES RESPIRATION pattern— exhibited as this may exacerbate apneic episodes
with or without central apneic episodes, solely with and lead to a dangerous rise in carbon dioxide.
central sleep apnea, or even with obstructive sleep Assisted ventilation may be required for some
apnea. The breathing disturbance is greatest in REM patients, either by a negative pressure ventila-
sleep and is usually associated with blood oxygen tion, such as a cuirass, or by means of a positive
desaturation. pressure ventilator applied to either a nasal mask
The impairment of VENTILATION may produce or through a TRACHEOSTOMY. If patients with
daytime ALVEOLAR HYPOVENTILATION with a reduc- kyphoscoliosis have an obstructive sleep apnea
tion in blood oxygen saturation and an eleva- component to their SLEEP-RELATED BREATHING DIS-
tion in carbon dioxide. More commonly, the ORDER, then treatment by means of a CONTINUOUS
ventilatory impairment may be restricted to POSITIVE AIRWAY PRESSURE (CPAP) device applied
sleep so that oxygen desaturation occurs solely through a nasal mask can be effective in improving
during REM sleep. Kyphoscoliosis produces an nocturnal oxygen saturation. Tracheostomy is usu-
increased number of awakenings and can lead to ally not helpful unless there is a severe degree of
a complaint of disturbed nocturnal sleep due to obstructive sleep apnea syndrome present. RESPI-
the sleep-related breathing abnormalities. If the RATORY STIMULANTS, such as medroxyprogesterone
HYPOXEMIA is severe and the number of awak- or acetazolamide, by themselves are not effective
enings frequent enough, symptoms of daytime in improving ventilation in patients with kypho-
sleepiness may develop. scoliosis. However, there is some evidence to sug-
Treatment in the initial stages may include noc- gest that a combination of both might be useful in
turnal oxygen therapy, although caution should be some patients.
 L
laboratory for sleep-related breathing disor- laryngospasm, sleep-related Term applied to
ders A medical facility providing diagnostic and acute and transient obstruction at the laryngeal
treatment services for patients with SLEEP-RELATED level of the respiratory tract, most commonly due
BREATHING DISORDERS. The laboratory is under the to vocal cord spasm. Laryngospasm is synonymous
directorship of a physician specializing in sleep- with the term glottic spasm. Laryngospasm can occur
related breathing disorders, such as a pulmonary during wakefulness or sleep and may be induced
physician, and provides overnight polysomno- by irritation of the vocal cords, anesthesia or psy-
graphic services. Some laboratories also perform chogenic mechanisms.
daytime MULTIPLE SLEEP LATENCY TESTS for EXCESSIVE Gastroesophageal reflux (see GASTROESOPHAGEAL
SLEEPINESS. REFLUX SLEEP-RELATED) can cause laryngospasm
Laboratories for sleep-related breathing disor- due to irritation of the vocal cords by gastric acid.
ders can be accredited by the AMERICAN ACADEMY Episodes of laryngospasm can be precipitated by
OF SLEEP MEDICINE if they fulfill the standards and gastroesophageal reflux in the OBSTRUCTIVE SLEEP
guidelines set by the association. However, these APNEA SYNDROME. However, episodes of laryngo-
facilities are not required to have an accredited spasm can occur during sleep independent of gas-
clinical polysomnographer on staff or the facilities troesophageal reflux or the obstructive sleep apnea
for the diagnosis of other sleep disorders, such as syndrome. In such patients, a psychogenic cause
INSOMNIA and excessive sleepiness. (SLEEP DISORDER is suspected. Some patients can produce laryngo-
CENTERS, comprehensive centers for patients with spasm voluntarily, sometimes even to the point of
all forms of sleep disorders, provide appropriate producing loss of consciousness.
services for such patients.) SLEEP-RELATED LARYNGOSPASM has some features
in common with other forms of sleep-related
ANXIETY DISORDERS, such as PANIC DISORDER. It is
lamboid See POSTS. associated with panic and fear, which occurs out of
sleep, and lasts only a few seconds before subsid-
ing. However, in sleep-related laryngospasm, the
lark An early-to-bed-and-early-to-rise person. stridor (high-pitched sound during inspiration of
This term is used as the opposite of the EVENING air) is a characteristic feature. Patients with this
PERSON or night owl, who is typically a person who disorder are abruptly awakened from sleep and
goes to bed late at night and arises late in the day. typically will jump out of bed in intense fear and
The tendency for being a lark appears to increase panic of dying. The patient will clutch his throat
with age as it is common for the elderly to fall and try to inspire and often produce a loud and
asleep relatively early in the evening and awaken rather frightening gasping sound. Bed partners are
early in the morning. Some larks may erroneously always awoken by the event, which is very dra-
think they have INSOMNIA due to the early hour matic, and the patient may be seen to be slightly
of awakening. However, the duration of the sleep cyanotic (blue in color). Typically the episode will
time is usually normal. (See also ADVANCED SLEEP subside within five minutes; sometimes the indi-
PHASE SYNDROME, OWL AND LARK QUESTIONNAIRE.) vidual requires a drink to speed the resolution of

123
124 laser uvulopalatoplasty

the episode. Following the episode of stridor, there does not assist in learning. However, there is some
may be hoarseness of the voice; the anxiety and evidence that learning during wakefulness imme-
panic gradually subside, and the individual returns diately before sleep is often associated with better
to sleep. Episodes usually occur only once a night memory retention of information after several
and are very rare, recurring only two to three times hours of sleep compared with learning following a
a year. In most patients, the cause of the episodes similar number of hours of wakefulness. But, the
is unknown. difference is relatively small and is not thought to
Laryngospasm due to gastroesophageal reflux be of great benefit.
is treated by the standard means of controlling Material exposed to an awakened sleeper will
gastroesophageal reflux, such as sleeping in a semi- be remembered more following awakenings from
upright position or taking medications. Surgery on REM sleep than from awakenings out of SLOW
the lower esophageal sphincter may be required WAVE SLEEP. However, there is no evidence to sug-
to prevent reflux. If obstructive sleep apnea is the gest that learning following an awakening from
cause of laryngospasm, then treatment is directed REM sleep poses any benefits over learning dur-
toward relief of the obstructive sleep apnea. ing usual wakefulness. Also, the element of sleep
deprivation conveyed by awakening out of REM
sleep may be detrimental to learning. EXCESSIVE
laser uvulopalatoplasty A surgical procedure that SLEEPINESS can produce memory difficulties that
involves the removal of the uvula and a change in may be due to the inability to retain information as
the shape of the soft palate. The procedure is per- a result of frequent microsleep episodes. (See also
formed for the relief of SNORING. It may also slightly COGNITIVE EFFECTS OF SLEEP STATES, MICROSLEEP.)
reduce mild OBSTRUCTIVE SLEEP APNEA SYNDROME.
The procedure is performed under local anesthesia
in the physician’s office and lasts about 20 minutes. leptin The appetite-suppressing counterpart of
It may need to be repeated several times until a GHRELIN. Leptin is a member of the cytokine fam-
satisfactory reduction in snoring is achieved. The ily of peptide hormones that is coded by the Ob
main complication of the procedure is pain, which gene on chromosome 7. It is produced by adipose
can be likened to a very bad sore throat that lasts tissue in amounts proportional to the amount of
for up to 10 days after the procedure. body fat and acts on receptors in neurons of the
ventromedial hypothalamus (“satiety center”) that
regulate energy intake and expenditure. Leptin
latency to sleep See SLEEP LATENCY. therefore acts as an adiposity signal that keeps the
brain informed of nutritional status. An animal
given leptin eats less and loses fat. Starvation low-
L-dopa An antiparkinsonian medication that has ers leptin levels, but overfeeding has less effect on
been demonstrated to be effective in reducing the leptin. Although leptin suppresses appetite, obese
severity of episodes of RESTLESS LEGS SYNDROME and people have high plasma levels of leptin and appear
PERIODIC LEG MOVEMENTS during sleep. (See also to be resistant to its effects. A population sample of
BENZODIAZEPINES, PERIODIC LIMB MOVEMENT DISOR- short sleepers had reduced leptin levels, elevated
DER, RESTLESSNESS.) ghrelin, and increased body mass index. Leptin
deficiency (ob/ob mice) disrupts the regulation of
sleep architecture and diurnal rhythmicity. Leptin
learning during sleep Some years ago, it was is also required for fertility; if the level of body fat
in vogue to try to develop ways of learning while decreases below a threshold level, as in anorexia
asleep. But playing tape recordings through ear- nervosa, menstruation ceases.
phones that were plugged into sleeping subjects
met with poor success. It is currently believed
that exposure to auditory stimuli during sleep light sleep See STAGE ONE SLEEP.
 limit-setting sleep disorder 125

light therapy Light has been shown to be effec- limit-setting sleep disorder A childhood sleep
tive in treating a number of psychiatric and sleep disorder characterized by inadequate limits on
disorders. The effect of light is most evident in the bedtime. A child who consistently refuses or
treatment of SEASONAL AFFECTIVE DISORDER (SAD), stalls going to bed will delay bedtime—leading to
which most commonly occurs in the mid- to late resultant, insufficient TOTAL SLEEP TIME. When par-
fall as the nights grow longer. The increased ten- ents or caregivers institute limits, sleep normally
dency for DEPRESSION is believed to be in part related occurs at the appropriate time. By adolescence,
to the reduced light exposure at that particular time children are able to institute their own limits and
of year. Those with SAD have other features of this disorder does not occur. This disorder may
depression, such as increased weight gain, fatigue, be present in individuals who, for neurological or
loss of concentration and greater time spent in bed. physiological reasons, are unable to institute their
Exposure to light of more than 2,000 lux for two or own bedtime.
more hours in the morning, from, say, 6 to 8 A.M., In childhood, limit-setting sleep disorder gener-
can improve mood and decrease the seasonal affec- ally begins once a child is at an age of being able
tive disorder. to climb out of the crib, or is placed in a bed. The
The individual with SAD may notice an improved stallings are frequently associated with the need
daytime mood; however, there may be a mid- to either get something to eat or drink, to watch
afternoon reduction in mood associated with the television or to play a game, or to have a story
circadian variation in daytime alertness. Another read. These behaviors may progress to reporting
exposure of light at that time, shorter than the first unfounded fears regarding sleep, such as monsters
treatment, may improve the symptoms and reduce in the bedroom.
the need for a mid-afternoon nap. The bedtime problem may be exacerbated by
Patients with DELAYED SLEEP PHASE SYNDROME can oversolicitous parents and is more likely to occur
benefit from exposure to bright light toward the when both parents are working. They readily give
end of the habitual major sleep episode. The light in to the child’s desire to spend extra time with the
exposure assists in producing a phase advance of parents. Children with physical or mental handi-
the sleep period. caps may induce feelings of parental guilt, promot-
Bright light exposure may also be useful for ing inadequate limit-setting.
treating sleep disorders due to shift work (see Parents may inadvertently contribute to limit-
SHIFT-WORK SLEEP DISORDER) or jet lag (see TIME setting sleep disorder by allowing their school-age
ZONE CHANGE [JET LAG] SYNDROME) as well as other children to take a nap at any time during the day,
causes of EXCESSIVE SLEEPINESS or INSOMNIA. which makes it more difficult to go to sleep at an
Although bright light systems are commercially appropriate hour at night. Furthermore, if parents
available, natural bright light can also be utilized. have inconsistent evening schedules, or a child
In the course of good SLEEP HYGIENE, those prone would miss seeing a working parent if he does go
to sleep disturbances should be exposed to natural to bed at the designated hour, the parents may be
light soon after awakening in the morning. Con- unwittingly contributing to limit-setting sleep dis-
versely, reduction of light exposure in the hours order. Allowing a drastically different bedtime on
prior to bedtime can be useful in improving sleep the weekends, versus weekday school nights, may
onset. also contribute to limit-setting sleep disorder.
The effect of light is believed to be mediated The course of this sleep disorder varies upon
through the retino-hypothalamic pathway to whether caregivers institute and adhere to appro-
the hypothalamus. In addition, light is known priate limits, or the child develops a sense of matu-
to affect the secretion of melatonin by the pineal rity related to school and other activities, which
gland, which may be important in the regula- reinforces the need to set one’s own limits. This
tion of circadian rhythmicity. (See also CIRCADIAN type of sleep disorder may be more common in
RHYTHMS, MELATONIN, MOOD DISORDERS, PINEAL children who have a natural tendency to be “owls,”
GLAND.) either because of a genetic tendency or through
126 lithium

learned behaviors due to parents tending to delay locus ceruleus was originally thought to be primar-
their own bedtime. ily responsible for the generation of REM sleep, but
Limit-setting sleep disorder leads to inadequate newer evidence has indicated that the area ventral
sleep at night, with resulting irritability, fatigue, to the locus ceruleus, the nucleus reticularis pontis
decreased attention, reduced school performances oralis (RPO), is the area primarily responsible for its
and tensions in interfamily social relationships. generation. However, the caudal third of the locus
Children with limit-setting sleep disorder gener- ceruleus is important in the maintenance of REM
ally show few abnormalities on polysomnography sleep atonia.
because appropriate limits are usually instituted in The cells of the locus ceruleus contain the
the course of performing sleep studies. neurotransmitter noradrenalin and their stimu-
Treatment of limit-setting sleep disorder involves lation induces wakefulness. The region around
instituting, adhering to and enforcing appropri- the locus ceruleus and the pons is important in
ate bedtimes and wake times. A regular routine the maintenance of the atonia of REM sleep, and
before sleep, as well as a consistent bedtime and destruction of this area leads to an increase in
wake time, will help to eliminate limit-setting sleep muscle tone. Experimental lesions in cats produce
disorder. a state in which cats move around during REM
This disorder needs to be differentiated from sleep. A similar state has been described in some
SLEEP ONSET ASSOCIATION DISORDER in which a humans who have brain stem lesions. The pontine
bedtime object becomes necessary for good qual- region around the locus ceruleus stimulates the
ity sleep and its withdrawal throws off the sleep medullary area of Magoun and Rhines, causing
pattern. Children who have the DELAYED SLEEP inhibition of the spinal motor neurons, resulting in
PHASE SYNDROME may have sleep onset difficulties. muscle atonia. (See also PGO SPIKES, RAPHE NUCLEI,
Limit-setting sleep disorder may develop into the SLEEP ATONIA.)
disorder of INADEQUATE SLEEP HYGIENE if a child
fails to assume responsibility for his own sleep
hygiene and sleep pattern when it is appropriate long sleeper Term for someone who has a habit-
to do so. ual sleep episode longer than the average for some-
one of the same age group. The quality of the sleep
episode and the timing of sleep is normal. A long
lithium Lightest of the alkali metals; in a form sleeper has a usual sleep duration of 10 hours or
such as lithium carbonate, it is used for the treat- greater. Someone with a physiological need for a
ment of mania in patients who have manic-depres- long sleep episode may regularly reduce the total
sive disease. Lithium has been shown to have sleep time by one or more hours, thereby leading
beneficial effects upon the sleep-wake pattern, to a state of chronic SLEEP DEPRIVATION, which may
particularly in individuals who have sleep distur- be compensated for on the weekends with longer
bances related to cyclical MOOD DISORDERS. Lithium sleep episodes.
increases the latency to REM sleep and enhances Long sleepers have EXCESSIVE SLEEPINESS during
the amount of SLOW WAVE SLEEP. Wakefulness and the day if they get less sleep than they require. Full
lighter stage one sleep is usually reduced. daytime alertness with a long sleep episode is nec-
Lithium has been used in the treatment of the essary to confirm the diagnosis.
RECURRENT HYPERSOMNIA due to the KLEINE-LEVIN The sleep pattern of the long sleeper has usu-
SYNDROME. ally been present since childhood and persists
throughout life. Polysomnographic studies have
demonstrated normal amounts of the deeper stages
locus ceruleus A region of darkly stained cells three and four sleep, but increased amounts of
that extends in two columns from the PONS to the REM sleep and stage two sleep. The MULTIPLE SLEEP
midbrain. The cells of the locus ceruleus contain LATENCY TESTING demonstrates normal daytime
melanin, which causes its dark pigmentation. The alertness without pathological sleepiness.
 lung disease 127

Long sleepers need to be differentiated from L-tryptophan See HYPNOTICS.

patients with other causes of excessive nocturnal
sleep that typically can be due to impaired sleep
quality. Disorders such as OBSTRUCTIVE SLEEP APNEA L-tyrosine See STIMULANT MEDICATIONS.
SYNDROME or PERIODIC LEG MOVEMENTS during sleep
may produce a long sleep episode. In addition, a
tendency to sleep later in the day may be due to lucid dreams DREAMS in which the dreamer is
DELAYED SLEEP PHASE SYNDROME, but those with actually aware of dreaming, as though the dreamer
delayed sleep phase syndrome fall asleep at a later is almost conscious, although he or she is in a state
hour than those who are long sleepers. Patients of REM sleep. Lucid dreams are more likely to hap-
with NARCOLEPSY generally lack a long sleep epi- pen in the later REM sleep episodes of the night, and
sode and have other features indicating the diagno- they happen only infrequently. Some individuals
sis, such as CATAPLEXY and sleep attacks. seem to be particularly susceptible to having lucid
A diagnosis of a long sleeper is determined by dreams. Attempts to increase lucid dreams have
the documentation of daily prolonged sleep epi- been partially successful by means of certain train-
sodes over a two- to four-week period. ing procedures, including posthypnotic suggestion
Treatment is usually not required and individu- and somatosensory stimulation. However, auditory
als need to be reassured that their long sleep epi- information, when presented to the dreamer, does
sode reflects one end of a continuum or pattern of not appear to induce lucid dreaming.
normal sleep durations. Long sleepers may need There is no evidence that there are differences
to be counseled to maintain a regular full sleep in personality features of lucid dreamers compared
episode at night to avoid sleep deprivation with with those who do not have lucid dreams; there are
resulting daytime sleepiness. Stimulant medica- differences in alpha activity of lucid dreamers.
tions should not be given.

Lunesta (eszopiclone) See HYPNOTICS.

long-term insomnia Term proposed by the con-
sensus development conference convened by the
National Institute of Mental Health and the Office lung disease Many medical disorders are associ-
of Medical Applications of Research of the National ated with impaired lung function. Disorders can
Institutes of Health in November of 1983. The be due to impaired respiration as a result of cen-
summary statement of the conference broke down tral nervous system, spinal cord, nerve or muscle
insomnia into TRANSIENT, SHORT TERM, and LONG diseases. Typically, these disorders are associated
TERM. Long-term insomnia was defined as insom- with hypoventilation during sleep (see ALVEOLAR
nia that lasted more than three weeks. The con- HYPOVENTILATION) which may take the form of
ference suggested that nondrug strategies, such CENTRAL SLEEP APNEA SYNDROME, OBSTRUCTIVE SLEEP
as SLEEP HYGIENE or BEHAVIORAL TREATMENT OF APNEA SYNDROME, or nonapneic hypoventilation.
INSOMNIA, be the initial approach to treating this KYPHOSCOLIOSIS due to thoracic spine curvature as
type of insomnia. In addition, a short trial of a a result of bone or neurological disease also results
sleep-promoting medication (see HYPNOTICS) could in sleep-related hypoventilation with HYPOXEMIA
also be indicated. Long-term insomnia is not a and HYPERCAPNIA. Restrictive lung disease can be
specific diagnostic entity but rather refers solely to produced by kyphoscoliosis as well as by other
duration. A large number of sleep disorders, such disorders that impair the ventilation of the lungs,
as PSYCHOPHYSIOLOGICAL INSOMNIA or insomnia due such as severe OBESITY. Obstruction to airflow may
to psychiatric disorders, can produce insomnia, be due to UPPER AIRWAY OBSTRUCTION as a result of
including long-term insomnia. (See also ADJUST- lesions that produce the obstructive sleep apnea
MENT SLEEP DISORDER, DISORDERS OF INITIATING AND syndrome. Small airways disease, such as that seen
MAINTAINING SLEEP, PSYCHIATRIC DISORDERS.) in patients with asthma or CHRONIC OBSTRUCTIVE
128 Luvox

PULMONARY DISEASE, or destruction of lung tissue, Treatment depends upon the cause of the respi-
such as seen in patients who have emphysema, can ratory disturbance and may involve the use of
also produce hypoventilation during sleep. Inter- MEDICATIONS or oxygen therapy, or artificial venti-
stitial lung disease is associated with the abnormal lation devices, such as CONTINUOUS POSITIVE AIRWAY
accumulation of cells, tissues or fluid in the lung, PRESSURE devices or negative pressure ventilators.
thereby impairing gas transfer. Many disorders, Surgery may relieve upper airway obstruction.
including idiopathic pulmonary fibrosis, sarcoid- (See also SLEEP-RELATED BREATHING DISORDERS.)
osis, malignancy, adverse effects of medications or
other toxic effects on the lung, can produce inter-
stitial lung disease. Luvox (fluvoxamine) See ANTIDEPRESSANTS.
 M
Maggie’s Law New Jersey passed Maggie’s Law P.M. The average sleep latency over the five naps is
in 2003. Now, if a driver is found guilty of driving recorded. Average latencies of 10 minutes or lon-
drowsy, prosecutors are able to charge the driver ger indicate normal daytime alertness, and laten-
with vehicular homicide, punishable by up to 10 cies of less than 10 minutes indicate pathological
years in prison and a $100,000 fine. The law got sleepiness.
its name from what happened to 20-year-old col- The maintenance of wakefulness test is most
lege student Maggie McDonnell. On July 20, 1997, useful in determining treatment response to STIMU-
at 11:30 A.M., Maggie was killed by a driver who LANT MEDICATIONS, such as Cylert or Ritalin, to
later admitted to have gone without sleep for 30 determine whether treatment of EXCESSIVE SLEEPI-
hours when his van crossed three lanes of traffic NESS has been effective.
and hit head-on the car she was driving. At that Although the maintenance of wakefulness test
time, because the jury was not allowed to take has less diagnostic usefulness than the multiple
his exhaustion into account, the driver was only sleep latency test, it is sometimes performed along
convicted of careless driving and given a $200 fine. with the MSLT in order to determine whether a
Representative Robert Andrews (D-NJ) introduced patient with a disorder of excessive sleepiness has
the first federal bill about drowsy driving in the the ability to remain awake. This assessment can
House of Representatives in October 2002. be useful for determining an individual’s ability to
drive a vehicle or operate dangerous machinery.

maintenance of wakefulness test (MWT) A test

of the ability to maintain alertness during the day- Mairan, Jean-Jacques d’Ortous de Astronomer
time. The maintenance of wakefulness test is car- (1678–1771) who conducted an experiment in
ried out in a manner similar to the MULTIPLE SLEEP 1729 that led to an improved understanding of the
LATENCY TESTING (MSLT) in that there are five nap internal control of CIRCADIAN RHYTHMS. De Mairan’s
opportunities, two hours apart, each 20 minutes in experiment was reported in a communication writ-
duration. However, the difference between these ten by M. Marchant to L’Academie Royale des
two tests is that in the MWT, the patient is encour- Sciences de Paris. De Mairan had studied the leaf
aged to try to stay awake, whereas in the MSLT, the movements of the heliotrope plant, which opens its
patient is encouraged to relax and fall asleep. leaves during the day and closes them at night. De
In the maintenance of wakefulness test, the Mairan removed the plant from daylight and placed
patient is seated in a semi-reclining position in it in a dark cabinet; he found that the plant contin-
a darkened room. The latency from lights out to ued to open its leaves during the day, even in the
sleep onset is recorded (see SLEEP LATENCY). Elec- absence of light in the cabinet, and to close them
trodes are placed on the head in order to electro- at night. This led de Mairan to conclude that there
physiologically determine sleep onset. was an internal biological circadian rhythmicity
For an individual who usually sleeps from 11 that occurred despite the absence of ENVIRONMEN-
P.M. to 7 A.M., the five nap opportunities are car- TAL TIME CUES, and he related these rhythms to the
ried out at 10 A.M., 12 noon, 2 P.M., 4 P.M. and 6 sleep patterns of bedridden patients.

129
130 malingerers

This experiment by de Mairan is heralded as mastoids Protuberances of the skull that are situ-
one of the earliest scientific experiments to demon- ated behind the ear canals. The mastoids form the
strate the persistence of BIOLOGICAL RHYTHMS in the standard placement for reference electrodes, particu-
absence of environmental time cues, in this case, larly in the monitoring of the ELECTROOCULOGRAM.
of light and dark.

maxillo-facial (maxillofacial) surgery In SLEEP

malingerers Persons pretending to have sleep DISORDERS MEDICINE, maxillo-facial surgery is per-
disturbances for such self-serving reasons as want- formed to prevent UPPER AIRWAY OBSTRUCTION dur-
ing medications that may be abused. A malingerer ing sleep in patients with the OBSTRUCTIVE SLEEP
may complain of INSOMNIA in order to to obtain APNEA SYNDROME. Surgery may involve moving the
prescriptions for HYPNOTICS, which will really jaw forward by means of a surgical procedure called
be used for recreational purposes. Alternatively, MANDIBULAR ADVANCEMENT SURGERY. This surgery
some individuals report EXCESSIVE SLEEPINESS and involves splitting of the mandible to produce a slid-
falsify the symptoms of NARCOLEPSY in an attempt ing osteotomy so that the anterior portion of the
to obtain STIMULANT MEDICATIONS. A patient may jaw can be advanced. Alternatively, a small portion
even go so far as to attempt to falsify the results of the tip of the jaw, which contains the attach-
of polysomnographic testing in order to convince ments of the tongue muscle, can be advanced to
a physician of the presence of a sleep disorder. bring the tongue muscle forward. Sometimes the
However, if someone is suspected of being a maxilla needs to be advanced to obtain appropri-
malingerer, careful analysis of POLYSOMNOGRAPHY, ate dental relationships in conjunction with the
which cannot be falsified, will confirm or refute mandibular advancement surgery. HYOID MYOTOMY
such suspicions. is sometimes performed in conjunction with the
anterior advancement of the tip of the jaw. This
procedure allows the muscles of the tongue to be
mandibular advancement surgery Surgery occa- advanced anteriorly to prevent obstruction at the
sionally performed for individuals with OBSTRUCTIVE base of the tongue during sleep. (See also SURGERY
SLEEP APNEA SYNDROME produced by a retroplaced AND SLEEP DISORDERS.)
lower jaw. This procedure consists of a sliding oste-
otomy that is a splitting of the mandible so that the
anterior half can be moved forward. It is primarily mazindol (Mazanor, Sanorex) See STIMULANT
performed on patients who have retrognathia (a MEDICATIONS.
jaw that is placed posteriorally), which produces
either facial abnormalities or severe obstructive
sleep apnea. medications Numerous medications can have an
This procedure usually requires long orthodon- effect on sleep either by disturbing the quality of
tic preparation, which may include temporarily nighttime sleep or by producing impaired alertness
advancing the jaw by means of rubber bands or drowsiness during the daytime. The HYPNOTICS,
attached to teeth clips. Repeated polysomno- including the BARBITURATES and BENZODIAZEPINES,
graphic evaluation is usually necessary, with the have a profound effect on inducing sleepiness and
jaw temporarily advanced to determine the likeli- therefore are given at night to improve the quality
hood of surgical success. Postoperatively, patients of nighttime sleep. If given during the daytime,
have the teeth wired together until the healing is these medications are less effective in inducing
complete. sleep, although they will allow underlying sleepi-
Mandibular advancement surgery has few acute ness to occur.
or long-term complications, and its main disadvan- In general, the effect of hypnotic medications
tage is the prolonged preoperative assessment and on nighttime sleep is short-lasting, and they are
postoperative recovery periods. not recommended for chronic INSOMNIA. There
 medications 131

may also be daytime side effects, such as impaired these medications can have an ability to impair the
alertness, a particular concern in the elderly, espe- quality of nighttime sleep because of a stimulating
cially with long-acting hypnotic medications. Some effect or reduce the tendency for daytime sleepi-
medications, such as the short-acting benzodiaz- ness. Medications such as mazindol and diethylpro-
epines, have been reported to increase the level of pion have been used for the treatment of excessive
alertness during the daytime but can also induce sleepiness due to disorders such as narcolepsy, even
feelings of ANXIETY and tension. though their primary use is for the treatment of
The other group of medications that have pro- obesity.
found effects upon the sleep-wake cycle are the Most other groups of medications have effects
STIMULANT MEDICATIONS, including the amphet- on the sleep-wake cycle that are predominantly
amines and their derivatives used for the treatment side effects or adverse reactions. ANTIHISTAMINES are
of disorders of EXCESSIVE SLEEPINESS. RESPIRATORY typically associated with the production of DROWSI-
STIMULANTS, such as the xanthines, are used for the NESS or sleepiness, and sometimes this side effect
treatment of CHRONIC OBSTRUCTIVE PULMONARY DIS- has been used for sleep-inducing purposes. One of
EASE. When administered at night, they can impair the most commonly used hypnotic medications in
the ability to fall asleep. childhood is chlorpheniramine. Promethazine, a
The stimulant medications, when given during phenothiazine derivative used for its antihistamine
the daytime, increase the level of arousal, causing effects in the treatment of upper respiratory tract
patients with disorders such as narcolepsy to be less infections, also has sedative effects.
likely to have undesired sleeping episodes. How- The use of antihistamines as hypnotics is not
ever, these medications have only a small effect on considered appropriate because more specific hyp-
preventing sleepiness, so that someone with a dis- notics are available, if necessary (though rarely
order of excessive sleepiness will find it relatively required in childhood).
easy to fall asleep if put in a situation conducive to Anticonvulsant and analgesic agents can have
sleep. When the stimulant medications are taken sedative properties that impair daytime alertness,
too close to nighttime sleep, they will impair the such as the benzodiazepines or barbiturates, which
ability to stay awake at night and lead to frequent can cause increased sedation at night or in the day-
interruptions and awakenings of nighttime sleep. A time. Similar effects can occur with the analgesics,
new medication, MODAFINIL, is called a “wake-pro- which can impair VENTILATION during sleep. The
moting agent” as it improves alertness by decreas- opioid analgesics, such as MORPHINE, and the seda-
ing sleepiness. It is not a stimulant and therefore tive anticonvulsives are therefore contraindicated
has little in the way of side effects. in patients with breathing disorders, such as the
Medications used for other medical disorders, obstructive sleep apnea syndrome.
such as the treatment of PSYCHIATRIC DISORDERS, Cardiac medications, particularly the beta-
also impair the ability to stay awake. The NEURO- blockers (drugs commonly used to treat hyperten-
LEPTICS, which include medications such as the sion or cardiac irregularities), can have detrimental
phenothiazines, and the minor tranquilizers, such effects upon the quality of nighttime sleep by
as the benzodiazepines, will enhance sleep onset increasing the number of arousals and awakenings.
in some people and may lead to impaired alertness Medications such as propranolol and metoprolol
during the daytime. Some of these medications are are particularly associated with disturbed sleep at
used for their hypnotic properties in the treatment night. Sometimes the beta-blocker medications will
of patients with abnormal behavior during sleep, increase dreaming at night and lead to more fre-
for example, haloperidol and chlorpromazine. As quent nightmares. Excessive sleepiness during the
with other medications with hypnotic properties, daytime may occur either because of the impaired
TOLERANCE to their beneficial effects may develop quality of sleep at night or as a direct effect of the
in time. medication during the daytime. The hypertensive
Medications used for weight reduction purposes medication clonidine, which has the effect of stim-
are often amphetamine derivatives, and therefore ulating adrenoreceptors, can produce sleepiness.
132 medroxyprogesterone

Another group of medications that can have a it appears to be able to synchronize the rest-activ-
profound effect on sleep and wakefulness are the ity cycle of animals. Attempts at manipulating the
ANTIDEPRESSANTS, particularly the tricyclic antide- sleep-wake cycle by the administration of melato-
pressant medications, such as amitriptyline. These nin in humans have produced variable results.
medications are commonly used for their sedating
effects in improving the nighttime sleep of patients
with depression. When administered during the day- MEMA See MIDDLE EAR MUSCLE ACTIVITY.
time, they can produce unwanted sedation. When
given at night, the tricyclic antidepressants suppress
REM sleep; their abrupt withdrawal can lead to a menopause Gradual reduction in ovarian func-
REM sleep rebound with associated NIGHTMARES. tion occurs in late to middle age in women asso-
Because many medications can disturb nighttime ciated with symptoms of emotional variability,
sleep and daytime alertness, the role of medication depression, and autonomic disturbances, such as
should be considered in any patient presenting hot flashes and night sweats. There is atrophy of
with symptoms related to sleep and alertness. SLEEP estrogen-dependent tissues, such as breast tis-
HYGIENE practices, along with alteration in the tim- sue and the vaginal lining. Sleep becomes more
ing or dosage of medications, may have a very fragmented, with awakenings often related to hot
beneficial effect on the sleep complaints. flashes or night sweats. (See also MENSTRUAL-ASSO-
CIATED SLEEP DISORDER, MENSTRUAL CYCLE.)

medroxyprogesterone (Provera) See RESPIRATORY

STIMULANTS. menstrual-associated sleep disorder A disor-
der of unknown cause characterized by INSOMNIA
or EXCESSIVE SLEEPINESS related to the menses or
melatonin A neurohormone that is found pri- menopause. This disorder exists in three main
marily in the PINEAL GLAND at the back of the brain. forms: insomnia or hypersomnia, related to the
The pineal gland releases melatonin at night, in MENSTRUAL CYCLE; and insomnia related to the
darkness, and its level in the blood reaches a peak MENOPAUSE. Insomnia, when it occurs in relation to
between 1 A.M. and 5 A.M. The secretion of mela- the menses, usually occurs during the week prior
tonin is inhibited by light through pathways that to the onset of the menses. The insomnia is charac-
extend from the retina through the SUPRACHIAS- terized by an inability to fall asleep, frequent awak-
MATIC NUCLEUS to the pineal gland. The secretion enings at night and the inability to maintain sleep.
of melatonin changes over life and appears to be Hypersomnia can also occur intermittently, but not
maximal around the time of puberty, at which time necessarily during the week prior to the onset of
it appears to be important in sexual maturation. the menses. There is no evidence of sleepiness at
The neurotransmitter serotonin is converted any other time of the menstrual cycle.
into melatonin in the pineal gland; therefore, med- Insomnia related to the menopause is charac-
ications that effect the synthesis of serotonin will terized by other features of the menopause, such
also effect melatonin synthesis. Beta-blocker medi- as hot flashes and night sweats. The insomnia is
cations used in the treatment of cardiac disorders primarily a maintenance insomnia with frequent
will suppress melatonin levels, whereas agents that awakenings rather than a sleep onset insomnia.
stimulate serotonin production, such as 5-hydroxy Polysomnographic monitoring has demonstrated
tryptophan (5-HT), will increase secretion. fragmented sleep with prolonged awakenings and
Melatonin appears to be important in giving reduced SLEEP EFFICIENCY in the premenstrual
seasonal time cues. In animals, its administration insomnia form. Polysomnography during premen-
can be used to affect the breeding season by induc- strual hypersomnia demonstrates a normal major
ing breeding behavior at an earlier time. Melatonin sleep episode. MULTIPLE SLEEP LATENCY TESTING
may also be able to alter circadian rhythmicity, as can demonstrate increased sleepiness during the
 migraine 133

symptomatic time. Spontaneous awakenings with the OBSTRUCTIVE SLEEP APNEA SYNDROME, and treat-
features of night sweats or temperature variation ment by means of surgery, such as MANDIBULAR
are seen in menopausal insomnia. ADVANCEMENT SURGERY, may be necessary to bring
Menstrual-associated sleep disorder needs to be the anterior attachment of the tongue forward.
differentiated from PSYCHIATRIC DISORDERS produc- Micrognathia should be differentiated from ret-
ing insomnia or hypersomnia. In particular, the rognathia, which refers to a normal-sized lower
premenstrual syndrome, which is associated with jaw that is situated posteriorly in relation to the
marked emotional liability, may produce an insom- maxilla or the base of the skull.
nia in addition to other symptoms, such as exces-
sive fluid gain, emotional symptoms of irritability,
ANXIETY or DEPRESSION. microsleep An episode of sleep lasting only a few
The menstrual-associated sleep disorder may seconds that occurs during wakefulness. Microsleep
be improved by the use of replacement hormone episodes are associated with disorders of EXCESSIVE
medications, such as progesterone or estrogen. SLEEPINESS during the day and may impair the abil-
Estrogen replacement also improves insomnia in ity to form new memory, and hence are a cause of
some menopausal women. Attention to good SLEEP AUTOMATIC BEHAVIOR. They most typically occur in
HYGIENE is helpful, and occasionally a short course patients with NARCOLEPSY; however, they can also
of a hypnotic medication given premenstrually be seen in patients with other disorders of exces-
may be useful. (See also DISORDERS OF EXCESSIVE sive sleepiness.
SOMNOLENCE, DISORDERS OF INITIATING AND MAIN-
TAINING SLEEP, HYPNOTICS.)
middle ear muscle activity (MEMA) Middle ear
muscle activity (MEMA) has been reported dur-
menstrual cycle Studies of sleep during the men- ing sleep and has been correlated with RAPID EYE
strual cycle have shown that during the premen- MOVEMENTS during REM sleep. This MEMA is
strual time, when progesterone and estrogen levels thought to reflect the phasic muscle activity that is
are high, there is a decrease in SLOW WAVE SLEEP. characteristic of REM sleep. However, middle ear
The amount of wake time during the major sleep muscle activity occurs simultaneously with rapid
episode is also increased during the premenstrual eye movements only 34 percent of the time. The
week. However, the change in healthy females is muscle activity can therefore also occur during the
relatively small. There are slight differences in the tonic phase of REM sleep. Skeletal muscle activity
amount of REM sleep throughout the menstrual that can occur during REM sleep includes the rapid
cycle. (See also MENOPAUSE, MENSTRUAL-ASSOCIATED eye movements, diaphragmatic activity and middle
SLEEP DISORDER.) ear muscle activity.

methylphenidate hydrochloride (Ritalin) See migraine Vascular headaches that are usually
STIMULANT MEDICATIONS. unilateral but can also be bilateral. These head-
aches can occur during sleep and, if so, are often
associated with REM sleep. Migraine headaches
methylxanthines See RESPIRATORY STIMULANTS. are often characterized by a throbbing sensation
that can awaken an individual from sleep—with
the usual migrainous prodrome of visual aura with
micrognathia A term used to describe a small flashes of light followed by the development of the
lower jaw. People with micrognathia are more lia- headache, most commonly in the fronto-temporal
ble to have UPPER AIRWAY OBSTRUCTION due to pos- region of the head. Anorexia (loss of appetite),
terior positioning of the tongue when the mouth is nausea, vomiting and photophobia (eyes sensitive
closed. The upper airway obstruction may induce to bright light) may develop in association with the
134 Mirapex

migraine headaches. There may also be other neu- Animal studies suggest that modafinil may act
rological features, such as paresthesiae or muscular in part through gamma-aminobutyric acidergic
weakness. (See also SLEEP-RELATED HEADACHES.) (GABA) systems and does not interact with central
alpha l-adrenergic, beta-adrenergic, serotonergic,
opioid or cholinergic systems. Recent research
Mirapex See PRAMIPEXOLE. has indicated that modafinil inhibits the tuber-
omammillary nucleus (TMN). The TMN is an
important nucleus that causes arousal by means of
mirtazapine (Remeron) See ANTIDEPRESSANTS. histamine.
Modafinil’s pharmacologic profile is distinctly
different from those of amphetamine and methyl-
Mitler, Merrill M. Born in Racine, Wisconsin, phenidate (see STIMULANT MEDICATIONS). The com-
Mitler (1945– ) received a Ph.D. in psychology pound has low abuse potential in humans. It is less
from Michigan State University. While a postdoc- effective at relieving sleepiness than amphetamine
toral fellow from 1973 to 1976 at the Sleep Research but has a better safety profile. It is well tolerated.
Center at Stanford University School of Medicine, The most frequent adverse event reported is head-
Dr. Mitler helped to found the first Sleep Disorders ache, which is usually mild and transient. Other
Center, under Dr. WILLIAM C. DEMENT, and served effects include dry mouth and nausea.
as administrative director from 1977 to 1978. In
1978, Dr. Mitler relocated his research activities to
the State University of New York at Stony Brook, Mogodon (nitrazepam) See BENZODIAZEPINES.
where he founded the SUNY-Stony Brook Sleep
Disorders Center. In 1983, Dr. Mitler moved to
Scripps Clinic and Research Foundation in La Jolla, Monday morning blues The feelings experienced
California. For 12 years, Dr. Mitler served as execu- at or soon after awakening on a Monday morning
tive secretary-treasurer of the Association of Sleep characterized by difficulty in awakening, tiredness,
Disorder Centers, later known as the American fatigue and grogginess. The symptoms are due to
Sleep Disorders Association and now the AMERICAN an insufficient amount of sleep that occurs because
ACADEMY OF SLEEP MEDICINE. Dr. Mitler is currently the sleep pattern has been shifted to a later phase
a professor in the Department of Neuropharmacol- over the prior Friday and Saturday nights. (Many
ogy at the Scripps Research Institute as well as a people prefer to go to bed later on a Friday and
clinical professor of psychiatry in the Department Saturday night compared to their usual time of
of Psychiatry, University of California, San Diego. going to bed during the work or school days during
Dr. Mitler’s sleep research contributions include the week.) The sleep pattern shift on the weekend
new methods of daytime testing for excessive som- causes difficulty in initiating sleep at an earlier time
nolence, efficacy studies of drug treatments for a on Sunday night, resulting in a later-than-desired
variety of sleep disorders, and, along with Dr. Wil- sleep-onset time. This is compounded by the fact
liam Dement, the discovery of narcolepsy in dogs. that the time of arising on Monday is typically ear-
Dr. Mitler has been actively involved with public lier than that which occurred on the prior weekend
policy and sleep, and he authored the often-cited mornings. As a result, the total sleep duration prior
committee report on the relationship between to awakening on Monday morning is less than is
sleep and health risk. required for full alertness.
Ensuring regular sleep hours seven days a week
will prevent the Monday morning blues. Other-
modafinil (Provigil) A unique compound for the wise, a brief Monday afternoon nap will lessen
treatment of NARCOLEPSY. It has become the first- some of the sleepiness.
line treatment for narcolepsy in the United States The natural tendency to delay the timing of the
since being made available early in 1999. sleep pattern, and the difficulty in making an ade-
 mood disorders 135

quate advancement, is due to the chronobiologi- montage The manner in which a variety of phys-
cal PHASE DELAY of the sleep pattern. There is less iological variables are displayed on the polysom-
physiological capability to make phase advances nograph paper. The montage defines not only the
of the sleep episode. (See also DELAYED SLEEP PHASE number of physiological variables measured but
SYNDROME, FREE RUNNING, PHASE RESPONSE CURVE, also the sequence in which they are displayed. For
SUNDAY NIGHT INSOMNIA.) example, in epilepsy recordings the electrodes may
be connected to each other in varied sequences.

monoamine oxidase inhibitors A group of drugs

that have the ability to block the breakdown of the mood disorders PSYCHIATRIC DISORDERS charac-
metabolism of naturally occurring monoamines. terized by a partial or a full manic or hypomanic
These medications are primarily used when the episode, or by one or more episodes of DEPRES-
tricyclic ANTIDEPRESSANTS are ineffective in treat- SION. A common feature of mood disorders is sleep
ing depression. However, the monoamine oxidase disturbance characterized primarily by INSOMNIA
inhibitors are limited in their usefulness because but also by EXCESSIVE SLEEPINESS. Mood disorders
there are often severe and unpredictable interac- comprise a variety of disorders, including bipolar
tions between the monoamine oxidase inhibitors disorder, cyclothymia, major depressive disorders
and many drugs and foods. In particular, foods or dysthymia.
containing tyramine, such as cheese, are liable to Patients with bipolar disorder have episodes of
produce a hypertension crisis. The monoamine mania or hypomania. The patient has a degree
oxidase inhibitors can also produce excessive cen- of inflated self-esteem, is more talkative than
tral nervous system stimulation, with the produc- usual, has a flight of ideas, is more distractible,
tion of INSOMNIA or excessive sweating. Severe has an increase in goal-directed activity, and has
hypotension can occur. Other side effects, such as a heightened involvement in pleasure activities.
dizziness, headache, difficulty in urination, weak- In addition to episodes of mania, there are often
ness, dry mouth, constipation and skin rashes, are episodes of depression. During the manic episode,
common. the sleep disturbance is characterized by a reduced
The monoamine oxidase inhibitors have been sleep duration, often requiring only three or four
shown to be very powerful REM sleep suppressant hours of sleep, and at times going without sleep
medications. Nocturnal use of monoamine oxidase for several days in a row. In contrast, at times of
inhibitors can induce total suppression of REM depression, excessive time may be spent in bed,
sleep at night. The REM sleep suppressant effect with feelings of fatigue, tiredness and sleepiness
of the monoamine oxidase inhibitors is thought to that occur throughout the daytime.
be related to their effectiveness as antidepressants. Patients with cyclothymia have numerous epi-
The withdrawal of monoamine oxidase inhibitors sodes of mania that are less intense (hypomania)
can be associated with exacerbation of REM sleep and alternate with many episodes of depressive
phenomena, such as NIGHTMARES, SLEEP PARALYSIS, symptoms. The sleep pattern of those with cyclo-
and HYPNAGOGIC HALLUCINATIONS. In NARCOLEPSY thymia may fluctuate between a night with one
there can be an exacerbation of CATAPLEXY. short sleep duration and one with much longer
The monoamine oxidase inhibitors exist in two sleep durations.
forms, types A and B, that affect the two isoen- Those with major depression have one or more
zymes. The type A inhibitors, such as phenelzine episodes of depressed mood, with loss of interest in
(Nardil), have been shown to be more effective pleasurable activities, that lasts at least two weeks.
in the treatment of narcolepsy than the type B During this time, sleep is commonly disturbed,
inhibitors, such as selegiline (Deprenyl). However, with insomnia as the typical complaint. There
because of their potential for side effect, the mono- is difficulty in initiating and maintaining sleep,
amine oxidase inhibitors have a very limited role in with a characteristic EARLY MORNING AROUSAL.
the treatment of narcolepsy. Sometimes patients with major depression also
136 morning person

complain of excessive sleepiness or tiredness dur- tors and the MONOAMINE OXIDASE INHIBITORS. In
ing the daytime and may spend prolonged periods addition, electroconvulsive therapy and psycho-
in bed. Excessively long sleep durations are more therapy may be helpful in some patients. Patients
commonly seen in adolescents with major depres- with bipolar disorder may be helped with the use
sion. This severe depression is seen in individu- of mood stabilizing medications such as lithium
als who have dysthymia in whom the depressed carbonate. In addition to medication directed to
mood is constantly present, with features of poor the underlying mood disorder, the sleep distur-
appetite, low energy, low self-esteem, feelings bance can be helped by means of attention to
of hopelessness and poor concentration. Sleep SLEEP HYGIENE and behavioral treatments, such as
disturbance in such dysthymic patients is similar STIMULUS CONTROL THERAPY and SLEEP RESTRICTION
to that seen in individuals with major depressive THERAPY.
disorders and is characterized by insomnia but Other sleep disorders that produce a complaint
occasionally by the complaint of excessive day- of insomnia or excessive sleepiness must be con
time sleepiness. sidered in any patient with a mood disorder
Polysomnographic features of patients with who complains of sleep disturbance. SLEEP-RELATED
major depressive disorder particularly show BREATHING DISORDERS and PERIODIC LIMB MOVEMENT
changes in REM sleep. Typically, sleep latency is DISORDER may produce tiredness and fatigue, which
increased and there may be frequent awakenings may be confused with depression. The effects of
and an early morning awakening; however, there medications and drugs such as ALCOHOL should also
is often reduced slow wave sleep and an increased be considered to be a complicating factor in the
amount of REM sleep. The first REM period of sleep disturbance. Patients who have NARCOLEPSY
the major sleep episode often occurs earlier than not uncommonly will have depression secondary
normal, with a short first non-REM sleep period. to the excessive sleepiness. If not recognized as due
The density of rapid eye movements, particularly to the narcolepsy, excessive sleepiness may erro-
in the first REM period, is increased. Patients with neously be ascribed solely to depression. Patients
depression may show a sleep onset REM period, with other disorders of excessive sleepiness, such
and there may be more sleep disruption with as IDIOPATHIC HYPERSOMNIA, can easily be misdiag-
low REM sleep percentages, particularly in older nosed as having depression as the cause of their
patients. daytime sleepiness. Other sleep disorders are com-
Patients with bipolar depression may have an mon causes of sleep symptoms similar to that seen
improved sleep efficiency, with a longer total in depression and, when appropriate, polysomno-
sleep time than that seen in patients with a more graphic monitoring may be indicated to help arrive
typical major depression. However, bipolar patients at an accurate diagnosis.
typically will complain of feeling unrefreshed upon
awakening. There may also be complaints of
excessive daytime sleepiness, especially during the morning person Term applied to persons who
depression phases. During the manic phases, REM go to bed early and awaken earlier than what is
sleep, as well as stage three/four sleep, may be typical for the general population. Morning per-
greatly reduced, as may the total sleep time. sons awaken early because their sleep pattern is
Polysomnographic features, particularly those of advanced—the pattern of body temperature and
REM sleep, may be useful in confirming a diagnosis other circadian rhythms are ahead of most other
of depressive disorder and may be helpful in differ- people’s. A morning person conforms to the “early
entiating a diagnosis of depression from DEMENTIA to bed, early to rise” maxim.
in elderly patients.
The treatment of the mood disorder is primarily
by the use of psychoactive medications, particu- Morpheus The Greek god of dreams. The word
larly the ANTIDEPRESSANTS, including the tricyclic MORPHINE was derived from Morpheus. (See also
antidepressants, the serotonin reuptake inhibi- HYPNOS, SOMNUS.)
 muramyl dipeptide 137

morphine A derivative of the opium poppy, papa- stages. Movement time must last at least 15 sec-
ver somniferum, which in 1806 was one of the first onds to be scored as movement time. Movement
substances to be isolated from opium. It was named time is usually not counted with either sleep or
after MORPHEUS, the Greek god of dreams. Mor- wake time but is scored as a separate state, unless
phine has been used in medicine primarily as an sleep can be scored for more than half of the epoch.
analgesic to relieve PAIN but also as a treatment for In that case, the record is scored according to the
acute congestive heart failure. It has sedative and prevailing sleep stage. If wake time precedes or fol-
respiratory depressant effects that limit its use in lows the movement activity, then movement time
medicine. Morphine is also a drug that is abused for is scored as wake time.
its euphoric properties, often being administered by
intravenous injection by drug addicts.
Morphine has sedative effects that are associ- multiple sleep latency testing (MSLT) First
ated with increasing SLOW WAVE SLEEP, often at developed in 1978 by MARY CARSKADON as a
the expense of REM sleep. Following morphine’s means of determining levels of daytime sleepi-
administration, mental impairment commonly ness. This test measures an individual’s ability
occurs and is characterized by learning and mem- to fall asleep when given five nap opportunities
ory difficulties, as well as impaired psychomotor throughout an average day. Naps would typically
function and mood changes. occur at 10 A.M., 12 noon, 2 P.M., 4 P.M. and 6
Morphine may be dangerous to patients with P.M. for an individual on an average 11 P.M. to
impaired ventilation. The combination of morphine 7 A.M. sleep schedule. Electrodes are attached to
with other sedative medications is particularly dan- the head for the measurement of the ELECTROEN-
gerous and can lead to respiratory arrest. (See also CEPHALOGRAM, ELECTROOCULOGRAM and ELECTRO-
SLEEP-RELATED BREATHING DISORDERS.) MYOGRAM in order to determine the onset and
type of sleep. The patient is asked to lie down in
a darkened room and the time from lights out to
morphology The shape of a particular wave form the start of stage one sleep is the sleep latency on
or tracing recorded during POLYSOMNOGRAPHY. The a particular nap. The patient is usually given a
morphology of ALPHA ACTIVITY is a sinusoidal wave 20-minute opportunity to fall asleep. If sleep does
form, whereas that of a K-COMPLEX is a biphasic not occur during this time, the test is terminated
slow wave. The morphology of abnormal EEG until the next nap opportunity. If sleep occurs,
waves can help in determining the type of seizure the individual is given a 10-minute opportunity
and its location. to continue sleeping in order to determine the
type of sleep that occurs. If sleep does not occur,
then the latency is scored as lasting 20 minutes,
mountain sickness See ALTITUDE INSOMNIA. and at the end of the five nap opportunities, the
mean SLEEP LATENCY is determined. A mean sleep
latency of greater than 10 minutes over the five
movement arousal A lightening of sleep associ- naps is regarded as being normal. Values of less
ated with a body movement; typically defined as than 10 minutes indicate pathological sleepiness,
an increase in EMG (ELECTROMYOGRAM) activity and those less than five minutes indicate severe
in association with a change in pattern seen in daytime sleepiness. The presence of two or more
another recorded channel of either the EEG (ELEC- sleep-onset REM periods on a multiple sleep
TROENCEPHALOGRAM) or ELECTROOCULOGRAM. latency test following a night of documented nor-
mal sleep is indicative of NARCOLEPSY.

movement time When a subject moves during

a polysomnographic recording, the tracing pen muramyl dipeptide (MDP) A compound found
will move widely, obscuring the recording of sleep primarily in bacterial cell walls. This substance
138 muscle tone

came to attention when FACTOR S was found to be to circadian changes in biochemical, platelet and
similar to muramyl dipeptide. Muramyl dipeptide, fibrinolytic factors.
when infused into the brains of rats, has been Following myocardial infarction, patients typi-
shown to increase non-REM sleep and, in addition, cally have poor quality sleep, which is characterized
appears to increase body temperature. Muramyl by an increased number of awakenings, reduced
dipeptide appears to increase serotonin turnover REM sleep and reduced sleep efficiency. Daytime
in the brain, and may therefore have its effect on sleep episodes are also more common in such
sleep primarily by means of a serotonergic mech- patients. SLEEP-RELATED BREATHING DISORDERS have
anism. (See also DELTA SLEEP-INDUCING PEPTIDE, been implicated as a cause of myocardial infarction
SLEEP-INDUCING FACTORS.) during sleep due to the associated HYPOXEMIA. CAR-
DIAC ARRHYTHMIAS are known to be more common
in patients with sleep-related breathing disorders.
muscle tone Term applies to resting muscle activ- (See also DEATHS DURING SLEEP, OBSTRUCTIVE SLEEP
ity that is measured by means of the ELECTRO- APNEA SYNDROME, VENTRICULAR ARRHYTHMIAS.)
MYOGRAM. Muscle tone is usually present during
wakefulness but decreases during non-REM sleep
stages. During REM sleep, muscle tone activity is myoclonus Term that refers to brief muscle con-
almost absent. Muscle tone may be assessed by tractions detectable by electromyographic record-
manual muscle testing as part of the neurological ing. The term is used to denote muscle activity that
examination. ELECTROMYOGRAPHY may also provide lasts less than one second in duration. However,
a measure of tone. in sleep-related NOCTURNAL MYOCLONUS or PERI-
ODIC LIMB MOVEMENT DISORDER, the muscle activity
exceeds one second in duration and has a recurring
myocardial infarction Commonly known as a pattern of characteristic frequency (20 to 40 sec-
heart attack; occurs when the blood supply to a onds). (See also PERIODIC LEG MOVEMENTS.)
portion of the heart muscle is impaired, leading
to necrosis of the heart muscle. Acute myocardial
infarction is associated with 35 percent mortal- myxedema A severe form of HYPOTHYROIDISM
ity. There is a circadian pattern of myocardial that is characterized by generalized accumulation
infarction with an increase in episodes occurring of mucopolysaccharide. A patient with myxedema
between 6 A.M. and 12 noon. The cause of this cir- will have a bland, expressionless face, doughy indu-
cadian variability is unknown but may be related ration of the skin, and hypothermia. Myxedema
to factors set in process by sleep mechanisms or coma may result in a hypothermic, stuporous state
may be related to the sudden increase in activ- that is often fatal. SLEEP-RELATED BREATHING DISOR-
ity upon awakening following a relatively quiet DERS and EXCESSIVE SLEEPINESS are typical features
state during sleep. Infarction may also be related of patients with myxedema.
 N
nadir The lowest point of a biological rhythm. that time, they often feel very lethargic, confused,
The nadir may be applied to a CIRCADIAN RHYTHM, and unrefreshed.
such as body TEMPERATURE, which has its nadir dur- Naps are to be discouraged in individuals who
ing the major sleep episode, typically two to three have a primary complaint of INSOMNIA, particu-
hours before awakening. (See also ACROPHASE, larly PSYCHOPHYSIOLOGICAL INSOMNIA or insomnia
CHRONOBIOLOGY.) related to psychiatric disorders. Any daytime sleep
will take away sleep from the nighttime sleep epi-
sode, thereby leading to greater nighttime sleep
naps Brief sleep episodes taken outside of the disturbance.
major sleep episode. Naps vary in duration, from Naps commonly occur in children from infancy
five minutes to four or more hours. The time that and gradually reduce in number and in duration
naps are most likely to occur is in the midafter- as the child develops. Young children who have
noon, when there is a reduced degree of alert- disturbed nighttime sleep often benefit from a
ness because of the biphasic circadian pattern of daytime nap, and the elimination of the nap may
alertness. Some cultures will take a SIESTA in the contribute to sleep difficulties at night. However, in
mid-afternoon; consequently, nighttime sleep is some children excessive sleeping during the day-
reduced in duration. time contributes to nighttime sleep disturbances.
Frequent daytime naps are seen in sleep disor- Napping in children has been shown largely to be
ders, particularly those associated with EXCESSIVE culturally determined, particularly in older chil-
SLEEPINESS. The naps that occur in NARCOLEPSY are dren. For example, in a study of children in Zurich,
typically short in duration—often five minutes of 21 percent at age five had daytime naps com-
sleep will be refreshing—and are characterized by pared with 5 percent of five-year-olds surveyed in
the presence of REM sleep. Naps taken by persons Stockholm.
with disorders that cause fragmentation and dis- As multiple daily naps are indicative of a sleep
ruption of nighttime sleep, such as the OBSTRUCTIVE disturbance, one should consider disorders of
SLEEP APNEA SYNDROME, are commonly of longer excessive sleepiness as being the cause. Naps that
duration, lasting 30 minutes or more, and are are taken at times when maximal alertness is to
largely composed of non-REM sleep. The refresh- be expected, for example about two hours after
ing quality of naps varies from individual to indi- awakening and about four hours before the time of
vidual, but typically naps in narcoleptics are found usual sleep onset at night, are particularly impor-
to be very refreshing, whereas the naps in patients tant in considering whether napping behavior is
with obstructive sleep apnea syndrome are often reflective of an underlying sleep disorder. Mid-
perceived as inducing even greater sleepiness and afternoon naps are of less significance.
sometimes are associated with headaches upon
awakening.
Persons who go into deep SLOW WAVE SLEEP dur- narcolepsy A disorder of excessive sleep that is
ing naps are often difficult to awaken until their associated with CATAPLEXY and other REM sleep phe-
time of spontaneous awakening. If aroused prior to nomena, such as SLEEP PARALYSIS and HYPNAGOGIC

139
140 narcolepsy

HALLUCINATIONS. This disorder was first described ness may occur in one or more groups of muscles,
by JEAN GELINEAU in 1880. Since that time it has so that the jaw may droop or the head may sag or
been recognized as an important cause of excessive the wrist may go limp. Sometimes the weakness
sleepiness. The sleepiness is characterized by brief is not evident to observers, but is perceived as an
episodes of lapses into sleep that occur throughout unusual sensation by the sufferer. The symptoms
the day, usually lasting less than an hour. Some- of cataplexy can be dramatically eliminated by the
times only five or 10 minutes of sleep is sufficient use of tricyclic ANTIDEPRESSANTS, including pro-
to refresh the patient with narcolepsy. triptyline, clomipramine, and imipramine. Other
The daytime episodes of sleep are often accom- medications that have been shown to be helpful
panied by DREAMS and a sensation of inability to in the treatment of cataplexy are gamma-hydroxy-
move the body (sleep paralysis) upon awaken- butyrate (GHB) and L-tyrosine. (See STIMULANT
ing, which are typically associated with RAPID MEDICATIONS.) Episodes of cataplexy may be rare
EYE MOVEMENT (REM sleep). The sleepiness in or infrequent, or may occur on a daily basis, caus-
narcolepsy usually becomes manifest when the ing severe incapacity.
individual is in a quiet situation, such as relaxing, In addition to excessive sleepiness and cata-
reading or watching television, as well as in situ- plexy, patients with narcolepsy often have other
ations with minimal participation, such as while features indicative of an abnormality of REM
attending meetings, movies, theater or concerts. sleep, such as sleep paralysis and hypnagogic hal-
Sleep is also liable to be induced when the patient lucinations. Sleep paralysis is an inability to move
with narcolepsy travels in a moving vehicle, such upon awakening from sleep and is often perceived
as an automobile, train, bus or airplane. Due to as a frightening sensation of being unable to
the induction of sleepiness while driving, motor breathe. Episodes usually last only a few seconds
vehicle accidents are more common in individuals following which the individual comes to full
who have narcolepsy. wakefulness and is able to move. These episodes
Sometimes the episodes of sleep that occur are thought to be partial manifestations of REM
during the daytime occur quite suddenly and the sleep that occur in the transition from REM sleep
individual is unable to prevent them, in which to wakefulness.
case they are often termed “sleep attacks.” When In addition, when REM sleep occurs at the onset
the sleepiness is severe, it can occur while the of sleep, vivid, dreamlike images are often per-
individual is talking, eating, walking or actively ceived. Termed hypnagogic hallucinations, these
conversing. images may be frightening. The sufferer may
In addition to the excessive sleepiness, the imagine that someone is in the bedroom or the
characteristic and unique feature of narcolepsy is house is on fire, yet have difficulty in being able
the presence of cataplexy, the onset of muscular to respond to these images. These images occur in
weakness that occurs with emotional stimuli. the transition from wakefulness to sleep, usually
A sudden, intense emotional response, such as during nocturnal sleep, but they also occur during
laughter, anger, surprise, elation or pride, can sleep episodes in the daytime. Less frequently the
induce a loss of muscle tone manifested by a episodes will occur upon awakening from a sleep
weakness in the legs, with an occasional fall to episode, at which time the episodes are termed
the ground. If the precipitating stimulus contin- hypnopompic hallucinations.
ues, the sufferer may have a continuing state of An additional feature of narcolepsy is AUTOMATIC
paralysis that affects all skeletal muscles, and the BEHAVIOR, which is characterized by a seemingly
individual will be completely paralyzed, in a state normal behavior that occurs when an individual
sometimes called “status cataplecticus.” During is tired or sleepy. These episodes of behavior are
episodes of cataplexy, consciousness, memory not recalled afterward. An example: When driving
and the ability to breathe and move the eyes are a car and arriving at a destination the individual
retained. In milder forms of cataplexy, the weak- may not recall the trip. Sometimes rather unusual
 narcolepsy 141

behavior can occur during such states, so that a Narcolepsy is of unknown origin but is believed
narcoleptic patient may erroneously put clothing to be due to a CENTRAL NERVOUS SYSTEM abnormal-
in a refrigerator or stove and afterward not recall ity. Some alterations in neurotransmitter levels,
having done so. These episodes of inappropriate such as for dopamine, have been found to be in
behavior are less common than normal behavior the fluid that bathes the brain (cerebrospinal fluid);
for which the individual is amnesiac. however, an exact site of neuroanatomical abnor-
Patients with narcolepsy will note disruption of malities has not been determined.
nocturnal sleep that is characterized by frequent Narcolepsy greatly affects an individual in
awakenings and the inability to continuously sus- almost every situation. Children with narcolepsy
tain normal sleep. The treatment of the nocturnal may have great difficulty in concentration, with
sleep disruption can lead to some improvement in memory difficulties that lead to impaired educa-
the daytime sleepiness but does not eliminate day- tion. Adults will have frequent job changes and are
time sleepiness, even if nocturnal sleep is returned prone to accidents due to sleepiness while driving
to an entirely normal pattern. Some patients with a car or operating dangerous equipment.
narcolepsy may require treatment of severe noc- The diagnosis of narcolepsy is made by a clinical
turnal sleep disruption. history of excessive sleepiness or the presence of
Narcolepsy generally develops around the time cataplexy. In the absence of a clear history of cata-
of puberty (usually just after puberty, but occa- plexy, objective confirmation of the diagnosis by
sionally before). Initially, excessive sleepiness is polysomnographic testing (see POLYSOMNOGRAPHY)
the presenting complaint and cataplexy occurs is essential. Polysomnographic testing typically will
either concurrently or a period of months or years show a reduced SLEEP LATENCY at night, often with
afterward. Due to the gradual onset of symptoms the appearance of a sleep-onset REM period. Noc-
and the difficulty of diagnosis in the early years, turnal sleep is also characterized by an increased
most patients present in early adulthood, at which amount of the lighter stage one sleep but normal
time the diagnosis is made. The disorder is lifelong amounts of deep sleep and REM sleep. There may
and reaches a peak in middle age; however, there be a disruption of the sleep-wake cycle, with fre-
is considerable individual variability, and occa- quent intermittent awakenings. Daytime sleepi-
sionally patients have maximal symptoms around ness is demonstrated by the MULTIPLE SLEEP LATENCY
the time of onset, with a gradual decrease over a TESTING (MSLT), which usually shows a mean sleep
lifetime. latency of less than 10 minutes (typically below
The complete disappearance of daytime sleepi- five minutes), indicating severe sleepiness. Also,
ness is not, however, thought to occur. Much of the presence of two or more sleep-onset REM peri-
the improvement in symptoms is the individual’s ods during a five-nap multiple sleep latency test is
learning to cope with the disability and the devel- diagnostic and characteristic. Poly somnographic
opment of either denial for symptoms or subcon- testing must be performed while the patient is on
scious unawareness of symptoms that may be seen the usual sleep-wake pattern and free of medica-
by others. tions that influence sleep and wakefulness.
Narcolepsy is thought to occur in approxi- Disorders such as PERIODIC LIMB MOVEMENT DIS-
mately 40 per 100,000 of the general population, a ORDER and CENTRAL SLEEP APNEA SYNDROME are more
prevalence rate similar to multiple sclerosis. Some liable to occur in patients with narcolepsy but are
ethnic groups appear to have a lower incidence not the primary cause of the daytime sleepiness.
of narcolepsy, such as Israeli Jews. The disorder Recent evidence has demonstrated the presence
affects both males and females equally, and there of a specific genetic marker in patients with narco-
does seem to be a familial tendency, with a narco- lepsy. Histocompatibility typing (see HLA-DR2) has
leptic patient’s child having an eight-times-greater demonstrated the presence of the DR2 and DQ1
risk of developing the disorder than the child of a groupings in nearly every patient with narcolepsy.
non-narcoleptic. But since these histocompatibility characteristics
142 narcolepsy

are also present in 25 percent to 30 percent of the sleep. In other words, these medications improve
general population, some additional factor must the ability to remain awake but do not impair the
also be present to cause narcolepsy. It is believed ability to fall asleep.
that the presence of this genetic marker suggests Even with adequate dosages of medications,
that certain individuals are predisposed to devel- individuals with narcolepsy are still often handi-
oping narcolepsy; and the addition of another capped by the tendency to fall asleep easily.
factor, possibly another viral or genetic factor, may However, the medications can greatly improve
be responsible for the expression of the disease. functional performance and allow an individual to
The presence of DR2 positivity varies with ethnic maintain regular employment and social contacts.
groups, being approximately 100 percent associ- As well as the treatment of excessive sleepiness,
ated in the Japanese population, approximately other medications are required for the treatment
96 percent in the Caucasian population and about of cataplexy. Tricyclic ANTIDEPRESSANTS are the
85 percent associated with the African-American most effective, with protriptyline, clomipramine
population. The HLA testing may be useful in aid- and imipramine being the most commonly used
ing the diagnosis of individuals where there is some medications. Recently the amino acid L-tyrosine
uncertainty as to the nature of the disorder produc- has been reported to be effective in relieving cata-
ing excessive daytime sleepiness, or can be useful plexy and improving daytime alertness in some
in determining if children of narcoleptic patients patients with narcolepsy. Other effective medica-
are predisposed to developing the disorder. A DR2 tions include GAMMA-HYDROXYBUTYRATE, which can
negative child is unlikely to ever develop narco- also improve cataplexy. Viloxazine has been shown
lepsy. The allele HLA DQB1-0602 is the genetic to be effective in the treatment of cataplexy in
factor most highly associated with narcolepsy. patients with narcolepsy. Viloxazine hydrochloride
In 2000 it was discovered that most narcoleptic is a derivative of propranolol, the beta-adrenergic-
patients are deficient in HYPOCRETIN, and pathologi- blocking cardiovascular drug used for the treat-
cal studies have demonstrated the loss of hypocre- ment of hypertension. The medication is available
tin cells in the hypothalamus. in Europe but not in the United States.
The presence of cataplexy is a major factor in In addition to the treatment by medications,
differentiating this disorder from other disorders of attention has to be given to intentional scheduled
excessive sleepiness. In the absence of cataplexy, naps and SLEEP HYGIENE, with the maintenance of
other disorders, such as idiopathic hypersomnia, regular sleep onset and wake times, as well as an
subwakefulness syndrome, obstructive sleep apnea appropriate nocturnal sleep duration.
syndrome, periodic limb movement disorder, insuf-
ficient sleep syndrome, psychiatric disorders, recur- Case History
rent hypersomnia and menstrual-associated sleep A 35-year-old fireman presented with a his-
disorder must be considered as possible causes. tory of excessive sleepiness that had been pres-
Treatment of narcolepsy is mainly symptom- ent since his teenage years. This sleepiness had
atic and consists of the use of STIMULANT MEDICA- become more severe during the three years prior
TIONS for daytime sleepiness. The amphetamines to presentation at the SLEEP DISORDER CENTER. The
MODAFINIL and methylphenidate hydrochloride pattern of sleepiness was somewhat complicated
(Ritalin) are often used. Dextroamphetamine is by the irregular shift work that was necessary as
used less commonly now than in the past. These a fireman. However, it was clear to himself and
medications appear to have the ability to improve others around him that he would fall asleep more
arousal during the daytime so the individual can readily than other firemen who were on similar
prevent himself from falling into sleep episodes; shift work. On several occasions, he had been
however, these medications appear to have less erroneously accused of taking drugs or having
effect in preventing sleep episodes when the indi- alcohol, as he appeared to be extremely drowsy
vidual is relaxed and in a situation conducive to and lethargic. His work was in jeopardy; his sleepi-
 narcotics 143

ness was clearly excessive and he was not allowed He gave up his job as a fireman and trained as a
to drive the fire truck. However, when he was mechanical engineer serving home electric equip-
aroused he was fully alert and could actively and ment, a position more appropriate for someone
accurately perform his duties. with narcolepsy as it kept him active during the
The sleepiness affected his social life in that he day and also enabled him to have a more regular
would fall asleep very easily when sitting and talk- sleep-wake pattern. (See also HISTOCOMPATIBILITY
ing, watching television or reading. When he went ANTIGEN TESTING, NARCOLEPSY PROJECT, SLEEP ONSET
to the movies, he would always fall asleep within REM PERIOD.)
the first 20 minutes of the picture. When he went
out for a drive with friends, he would let them
drive because he was too sleepy to do so. narcolepsy-cataplexy syndrome See NARCOLEPSY.
He also noticed the onset of a weakness that
would come on when he became emotional, par-
ticularly with anger and to a lesser extent with Narcolepsy Institute A state-funded program
laughter. He felt a very strange sensation that was developed in 1985 by Michael J. Thorpy, M.D., at
unpleasant and he would try to fight it internally the Sleep-Wake Disorders Center of Montefiore
by suppressing his emotions; however, he would Medical Center in New York City; it provides sup-
eventually have to sit or lie down. Although he was port services to individuals who have NARCOLEPSY
close to falling on many occasions, he never did so. as well as to their families. Originally called the
These episodes were extremely embarrassing. Narcolepsy Project, it was renamed the Narcolepsy
He had very excessive dreams and regarded Institute in 1997. Meeta Goswami, Ph.D., has been
himself as being the world’s greatest dreamer. Usu- director of the Narcolepsy Institute since it was
ally the dreams were of pleasant events; however, founded.
many were characterized by a perception of flying The project serves all five boroughs of New York
through the air while viewing himself lying in bed. City, with counseling and crisis intervention pro-
(This perception has been called an “out-of-body” grams for individuals or groups who are diagnosed
experience.) At times he also would see hallucina- as having, or suspected of having, narcolepsy. It
tions of people or events just before falling asleep provides basic information and helps individuals
at night. and their families to develop skills necessary to
The patient underwent polysomnographic test- cope with the social and physical impact that this
ing that showed a rapid onset of REM sleep on condition has on their lives.
the nighttime test, with a high amount of stage The project is directed and run by professionals
one sleep—features that were consistent with the in counseling; it also offers training in counseling
diagnosis of narcolepsy. His sleep otherwise was as well as research opportunities in the area of the
normal; however, during a daytime multiple sleep psychosocial factors of narcolepsy. The program
latency test he fell asleep in less than two minutes produces educational materials for patients that
on average of the five naps, and during four of the include videotapes, patient handbooks and a regu-
naps he went into REM sleep. These features on lar newsletter called Perspectives.
both the polysomnographic tests were diagnostic
for narcolepsy.
He was initially treated with pemoline (Cylert), Narcolepsy Project See NARCOLEPSY INSTITUTE.
which in his particular case was only partially
effective, and at times he needed the extra help
of a short-acting stimulant. Ritalin was occasion- narcotics The word “narcotic” is derived from
ally used in conjunction with a background, stable the Greek word narkosis, meaning a benumbing.
dosage of Cylert. His cataplexy episodes were com- Narcosis is a nonspecific and reversible form of
pletely controlled by the use of Vivactil. depression of the central nervous system, marked
144 nasal congestion

by stupor that is produced by drugs. The term nasal positive pressure ventilation (NPPV) A new
“narcotics” primarily refers to the opioid deriva- treatment modality that can be useful for patients
tives of opium. The opioids include MORPHINE, who have BREATHING DISORDERS, SLEEP-RELATED that
pentazocine, oxycodone, heroin and CODEINE. The are not responsive to CONTINUOUS POSITIVE AIRWAY
narcotic derivatives have been used in sleep medi- PRESSURE devices (CPAP). Nasal positive pressure
cine for the treatment of RESTLESS LEGS SYNDROME, ventilation (NPPV) consists of the application of
particularly the medication oxycodone. Codeine intermittent positive pressure ventilation through
has been shown to be helpful in improving sleepi- a nasal mask. Because of the increased ventila-
ness in some patients with NARCOLEPSY; however, tory pressure, compared with continuous positive
because of its potential for addiction it is rarely airway pressure devices, the lungs can be inflated
used. in patients who otherwise have difficulty inspiring.
The narcotic derivatives mainly affect the cen- This method is particularly useful for the treatment
tral nervous system and can induce analgesia, of CENTRAL SLEEP APNEA SYNDROME, especially in
sleepiness, mood changes, respiratory depression, those with NEUROMUSCULAR DISEASES that prevent
constipation, nausea and vomiting. These medica- adequate VENTILATION during sleep, as well as for
tions affect specific receptors in the central nervous patients with KYPHOSCOLIOSIS.
system that can be blocked by agents such as nal-
oxone. (See also MORPHEUS.)
nasal surgery Occasionally performed to relieve
SNORING or the OBSTRUCTIVE SLEEP APNEA SYNDROME.
nasal congestion Normally breathing occurs Surgery to reduce the bulk of the nasal mucosa,
through the nose during sleep, unless there is submucuous resection, produces initial improve-
upper airway obstruction—when mouth breath- ment in the severity of obstructive sleep apnea.
ing is necessary. Nasal congestion produces However, it is unusual for the syndrome to be com-
impaired nasal breathing during sleep, whether pletely relieved by this procedure. As a result, sub-
the congestion is due to acute nasal stuffiness or mucous resection has infrequently been performed
allergic rhinitis. It can also exacerbate preexist- for the obstructive sleep apnea syndrome.
ing OBSTRUCTIVE SLEEP APNEA SYNDROME or can Some patients who are prescribed the nasal
induce apneas in a person who otherwise does CPAP (CONTINUOUS POSITIVE AIRWAY PRESSURE)
not have apnea during sleep. Nasal infection system find that the nasal congestion prevents
and congestion need to be treated in any patient the routine use of CPAP. Surgical management of
with obstructive sleep apnea syndrome to avoid a mucous congestion can improve airflow, thereby
worsening apnea. allowing the patient to tolerate CPAP more
Nasal congestion can be treated surgically by easily.
submucous resection, the removal of polyps or Submucous resection is required for severe devi-
treatment with mucosal medications. Medications ation of the nasal septum. A major improvement in
used to treat allergic rhinitis include ANTIHISTA- nasal breathing can result from the surgery. Mild
MINES, topical steroids, and related medications. septal deviation does not require corrective surgery
Patients with the obstructive sleep apnea syn- because little beneficial effect on the sleep apnea is
drome who are treated by CPAP (CONTINUOUS POSI- likely to be seen.
TIVE AIRWAY PRESSURE) may have an exacerbation Nasal obstruction may occur at the nares, par-
or a new onset of allergic rhinitis. Initial treatment ticularly in patients who have previous submucous
by nasal decongestants often will settle the nasal resection with a subsequent nose droop. Choanal
congestion; however, medications such as the obstruction at the posterior nasopharynx may also
antihistamines, anticholinergics or steroids may be treated and is more likely to occur in patients
be required to allow the patients to continue the who have cranial facial abnormalities contributing
CPAP. (See also NASAL SURGERY.) to the obstructive sleep apnea syndrome. (See also
 National Sleep Foundation 145

AIRWAY OBSTRUCTION, PHARYNX, SURGERY AND SLEEP fer from sleep disorders and to the prevention of
DISORDERS.) catastrophic accidents related to sleep deprivation
or sleep disorders. The NSF was founded in 1990
with a grant from the American Sleep Disorders
Nathaniel Kleitman Distinguished Service Association (now called the AMERICAN ACADEMY
Award “. . . created in 1981 to honor service OF SLEEP MEDICINE). The first executive director
to the field of sleep research and sleep disorders was Carol Westbrook. The first president was Tom
medicine, especially generous and altruistic efforts Roth, followed by John Hoag (1994), Alan Pack
in the areas of administration, public relations, (1995) and Lorraine Wearley (1996). In 2009, the
and legislation. Whereas research and academic chief executive officer of NSF was David M. Cloud,
contributions produce their own rewards in pub- M.B.A., and the chairman of the board of directors
lications, tenure, and recognition, the achieve- was Meir H. Kryger, M.D., director of research and
ments of those who toil in the above areas may education, Gaylord Hospital. Originally established
go unnoticed.” in Los Angeles, the NSF moved to Washington,
The award, presented by the Association of Pro- D.C., in October 1994.
fessional Sleep Societies, was named for NATHANIEL The foundation seeks public and private funding
KLEITMAN, Ph.D., one of the founders of modern to support research, education, training and infor-
sleep research, who at the University of Chicago, mation programs. Programs have included: the
along with EUGENE ASERINSKY and WILLIAM C. “Drive Alert—Arrive Alive” campaign to reduce
DEMENT, discovered the REM phase of sleep. the high incidence of sleep-related auto crashes;
Recipients of the Nathaniel Kleitman Award publications designed to inform and educate pri-
have included: Conrad Iber, M.D. (2008); Andrew mary care physicians on the diagnosis and treat-
L. Chesson, M.D. (2007); John Shepard, Jr., M.D. ment of sleep disorders; educational symposia for
(2006); Stuart Quan, M.D. (2005); Daniel Buysse, physicians; public education; research grants; and
M.D. (2004); Wolfgang Schmidt-Nowara, M.D. partnerships with business and government to
(2003); Thomas Hobson, M.D. (2002); J. Chris- extend educational reach.
tian Gillin, M.D. (2001); David P. White, M.D. In 1996 the NSF sponsored the development
(2000); John Sassin, M.D. (1999); Mark Mahow- of a national narcolepsy registry at Montefiore
ald, M.D. (1998); Paul Fredrickson, M.D. (1997); Medical Center in New York, to help determine
Alan Pack, M.B., Ch.B., Ph.D. (1996); James the genetic cause of narcolepsy. The NSF estab-
Walsh, Ph.D. (1995); Richard Ferber, M.D. (1994); lished the Pickwick Club for physicians and other
Michael Thorpy, M.D. (1993); Phillip Westbrook, health care workers to assist in providing funds for
M.D. (1992); MARY CARSKADON, Ph.D. (1991); research and other foundation activities.
Thomas Roth, Ph.D. (1990); Peter Hauri, Ph.D. In November 2007, the NSF established Drowsy
(1989); Helmut Schmidt, M.D. and Helio Lemmi, Driving Prevention Week, a weeklong campaign
M.D. (1988); William C. Dement, M.D., Ph.D. to educate Americans about the hazards of driv-
(1987); Christian Guilleminault, M.D. (1986); Alan ing when sleep deprived, which is now an annual
Rechtschaffen, Ph.D. (1985); Mitchel B. Balter, public awareness effort. NSF also sponsors National
Ph.D. and MERRILL M. MITLER, Ph.D. (1984); ELLIOT Sleep Awareness Week, which is held each March.
D. WEITZMAN, M.D. (1983); William C. Dement, One of the highlights of the week is the release of
M.D., Ph.D. (1982); Ismet Karacan, M.D. and How- the statistical data that was compiled the previous
ard P. Roffwarg, M.D. (1981). fall in the NSF annual sleep surveys based on a
telephone sampling of approximately 1,000 men
and women. Previous years’ themes have included
National Sleep Foundation (NSF) A nonprofit “America’s Sleepy Teens” (2006), “Sleep in Amer-
organization dedicated to improving the quality ica Poll” (2008, 2007, 2005), “Sleep and Children”
of life for the millions of Americans who suf- (2004), and “Sleep and Aging” (2003).
146 nefazodone

nefazodone (Serzone) See ANTIDEPRESSANTS. medications such as haloperidol. These medica-

tions can have pronounced sedative effects and
are often used for patients with psychiatric dis-
neurogenic tachypnea, sleep-related Disorder orders to control the underlying psychiatric state
characterized by a sustained increase in respiratory and also to improve sedation at night. The halo-
rate that occurs during sleep as compared with peridol and thioridazine are also commonly used
wakefulness. The respiratory rate increase is not for patients with DEMENTIA in order to produce
due to alterations in blood gases that might result nocturnal sedation.
from cardiac or respiratory factors; it appears to be Schizophrenia is now being treated with new
of central nervous system origin. Some patients medications called ATYPICAL ANTIPSYCHOTICS that
with sleep-related neurogenic tachypnea have tend to have less severe side effects than the pre-
been reported to have EXCESSIVE SLEEPINESS during vious generation of drugs. Antipsychotics help
the day that appears to be related, at least in part, correct an imbalance in the chemicals that enable
to the underlying tachypnea. brain cells to communicate with each other. As
Neurological disorders have been associated with drug treatments for physical illnesses, many
with sleep-related neurogenic tachypnea, particu- patients with severe mental illnesses may need to
larly lesions of the brain stem, such as the lateral try several antipsychotic medications before they
medullary syndrome and multiple sclerosis. An find the one, or the combination of medications,
idiopathic (without a known cause) form of the that works best for them.
disorder can occur. The atypical antipsychotics include clozapine (Clo-
There have been only a few reports of this dis- zaril), risperidone (Risperdal), olanzepine (Zyprexa),
order and its exact cause is not understood. Poly- quetiapine (Seroquel), ziprasidone (Geodon), aripip-
somnographic monitoring has demonstrated sleep razole (Abilify), paliperidone (Invega), and olanzap-
fragmentation, which appears to be related to the ine and fluoexetine (Symbyax).
respiratory rhythm. Although excessive sleepiness In June 2004, the U.S. Food and Drug Adminis-
would be expected, sleep latency testing has not tration (FDA) asked the manufacturers of atypical
been reported in this disorder. antipsychotics drugs to add a warning to the drug
Sleep-related neurogenic tachypnea must be labels indicating the possibility of an increased risk
differentiated from other SLEEP-RELATED BREATH- of hyperglycemia (low blood sugar) and diabetes
ING DISORDERS, such as OBSTRUCTIVE SLEEP APNEA (high levels of blood glucose or blood sugar).
SYNDROME, CENTRAL SLEEP APNEA SYNDROME, and In June 2008, the FDA issued an alert to health
CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME. care professionals that both conventional and
These disorders can all produce an increase of atypical antipsychotics are associated with “an
respiratory rate during sleep. Left-sided heart increased risk of mortality in elderly patients for
failure and PAROXYSMAL NOCTURNAL DYSPNEA can dementia-related psychotics.” The FDA also notes
result in an increase of respiratory rate during “there is no approved drug for treatment of demen-
sleep. tia-related psychosis. Health care professionals
No specific treatment is known for this disorder. should consider other management options.” (See
also CEREBRAL DEGENERATIVE DISORDERS, MOOD DIS-
ORDERS, NOCTURNAL CONFUSION.)
neuroleptics Medications that have beneficial
effects upon mood and thought and are used pri-
marily to treat severe PSYCHIATRIC DISORDERS. This neuromuscular diseases Term applied to those
group of drugs, also known as the antipsychotic disorders that are due to an abnormality of the
medications, has side effects that are characterized muscle or its nerve supply. Typically these disor-
by abnormal neurological function. The neurolep- ders will lead to muscle weakness and feelings of
tic medications include the phenothiazines and fatigue. Many neuromuscular disorders affect the
 night fears 147

muscles of VENTILATION, and SLEEP-RELATED BREATH- TOLERANCE develops to some of the effects of
ING DISORDERS occur. nicotine with chronic use. Withdrawal syndromes
Neuromuscular disorders that affect ventilation may occur in individuals who are chronic smok-
in sleep include: lesions that affect the peripheral ers and are characterized by daytime DROWSI-
nerves, viral infections, such as Landry-Guillain- NESS, headaches, increased appetite and sleep
Barre syndrome, and spinal cord lesions, such as disturbances.
myelopathies, trauma, and vascular diseases of the Help for quitting the cigarette habit is available
spinal cord. from a variety of programs or organizations, such
Muscle disorders, such as the dystrophies, dysto- as SmokEnders, the American Lung Association,
nia myotonica and acid maltase deficiency, can all be ASH (Action on Smoking and Health), based in
associated with sleep-related breathing disorders. Washington, D.C., the American Cancer Society’s
Typically the neuromuscular diseases will pro- FreshStart Program, and local or state affiliates of
duce a decrease of ventilation during REM sleep, GASP (Group Against Smoking Pollution). (See
with the development of HYPOXEMIA and some- also INSOMNIA, SMOKING.)
times HYPERCAPNIA. Depending upon the course
of the neuromuscular disorder, treatment can
be by oxygen, RESPIRATORY STIMULANTS, assisted night fears Fears common in children, particularly
ventilation devices, or diaphragmatic pacemakers. around the time of nursery school. The fears usually
(See also ALVEOLAR HYPOVENTILATION, CENTRAL SLEEP represent insecurity about some aspect of growing
APNEA SYNDROME, PULMONARY HYPERTENSION.) up, whether it is the beginning school or being left
with a baby-sitter, which leads to the development
of fears at bedtime. Anxiety may not be apparent
nicotine Stimulant that can interfere with the during the daytime; however, when the child goes
quality of sleep. It may produce a SLEEP ONSET to bed and is alone in the dark, mental images may
INSOMNIA if taken immediately prior to the sleep begin and turn into fantasies. Commonly, a child
episode, or it may prevent sleep from recurring may say there is a monster under the bed or hiding
if a cigarette is smoked during the night. People behind the curtains. In such situations, the parent
who have disorders of EXCESSIVE SLEEPINESS, such should reassure the child that there is nothing to be
as OBSTRUCTIVE SLEEP APNEA SYNDROME, are liable to afraid of; however, exhaustive searches in the bed-
fall asleep while smoking in bed. A fire may result room are unnecessary and will not aid in relaxing
and can be a major cause of accidental death dur- the child. The best way to manage these concerns
ing sleep. is for the parents to demonstrate love and concern
Nicotine is contained in cigarette tobacco. The for the child, and look for the daytime anxieties that
content of nicotine in tobacco varies between 1 are the cause of the nighttime fears.
percent and 2 percent and the average cigarette Fear of the dark is also common in older chil-
delivers approximately 1 milligram of nicotine dren and the fear can be exacerbated by some
(range 0.05 to 2.0 milligrams). Nicotine is also event during the daytime, such as watching a
present in chewing tobacco and can be obtained in scary movie. The parents should not insist that the
a gum form (Nicorette). Nicorette has 2 milligrams child sleep in the dark but should accommodate
of nicotine contained in small pieces of gum and is the child by leaving a door partly open or using a
often used by smokers in an attempt to prevent or night-light in the bedroom or hall. The sounds of
decrease some of the withdrawal effects when try- other family members moving around the house
ing to stop smoking. can reassure the child that he or she is protected by
Nicotine produces an alerting pattern in the the parents, which will help to reduce some of the
ELECTROENCEPHALOGRAM. In addition, it can pro- fears of the dark.
duce hand tremor, decreased skeletal muscle tone NIGHTMARES commonly occur in children, and
and reduction in deep tendon reflexes. bad DREAMS are associated with the REM state of
148 nightmare

sleep. Nightmares may be a reflection of daytime occur in adulthood they may be associated with
concerns. Because nightmares are so common, underlying PSYCHIATRIC DISORDERS, particularly bor-
reassurance at the time is all that is required to derline personality disorders, schizophrenia or
settle the child. The child may come into the schizoid personality disorder. However, 50 percent
parent’s bedroom and wish to remain for the night, of adults with nightmares have no psychiatric
particularly if the dream was especially frightening diagnosis. Emotional stress is clearly associated
(see FAMILY BED). with an increased frequency of nightmares, as well
Sometimes night fears are a technique used as traumatic event stress. The use of medications,
to stall going to bed at night, and parents should especially L-DOPA and the beta adrenergic blockers,
be aware if their children are using these fears to used for the treatment of hypertension or cardiac
manipulate their bedtime hours. It is important disease, are often precipitants of nightmares.
for the parents to establish limits, and if parents There does not appear to be any gender dif-
suspect this is the cause of the night fears, then ference in the incidence of nightmares in child-
appropriate management may be necessary or a hood. But in adulthood, nightmares appear to be
form of LIMIT-SETTING SLEEP DISORDER may develop. frequent in women. There is little evidence of any
A child with recurrent or frequent fears or familial predisposition.
nightmares may require intervention with psy- Polysomnographic monitoring of nightmares
chological counseling, but this is unnecessary for demonstrates an abrupt arousal occurring out of
the majority of healthy children. (See also CONFU- REM sleep. Episodes will usually occur after a
SIONAL AROUSALS, SLEEP ONSET ASSOCIATION DISOR- prolonged period of REM sleep, and there may
DER, SLEEP TERRORS.) be an increased number of rapid eye movements
and a variation in the heart and respiratory rates.
Nightmares can also occur from REM sleep that is
nightmare A frightening dream that usually pro- present in daytime NAPS.
duces an awakening from the dreaming stage of Nightmares should be differentiated from SLEEP
sleep. It often consists of having been chased or TERRORS, which are abrupt awakenings from the
of personal injury. The nightmare sufferer will sit deep stage three or four sleep, usually heralded by
upright in bed in an intensely scared state. Dream a loud, piercing cry. The features that differentiate
recall is immediate, and the person is fully awake, nightmares include the full awakening that is pres-
often with a petrified look, breathing rapidly and ent in nightmares, whereas arousal is difficult in
with a rapid heart rate. Sometimes the nightmares someone suffering from sleep terrors. Frightening
may not cause awakenings, and the frightening dream content is always present in nightmares,
content of the dream will be recalled upon awak- whereas no dream content is typical for sleep ter-
ening the next morning. rors. Very often an individual with a sleep terror
Nightmares are very common in childhood, par- will go back to sleep and not recall the episode the
ticularly between the ages of three and six years. next morning, whereas this is extremely unusual
However, it is not uncommon for nightmares to following nightmares.
be reported from the age of two years. Nightmares Episodes of REM SLEEP BEHAVIOR DISORDER may
appear to be a common phenomenon, occurring have features similar to a nightmare; however, in
in 10 percent to 50 percent of children between REM sleep behavior disorder there is more “acting
the ages of three and five years; treatment is usu- out” of the dream content, with less fear and panic.
ally unnecessary. The child should be reassured Usually sufferers of REM sleep behavior disorder
and usually can return to sleep without great do not fully awaken during the behavior.
difficulty. Treatment for nightmares is not necessary
The tendency for nightmares appears to decrease in childhood, whereas adults can benefit from
with increasing age; however, episodes commonly attempts to reduce emotional stress or withdrawal
occur after the age of 60 years. When episodes of precipitating medications. In some instances,
 nocturnal 149

suppression of episodes can occur with medications nitrazepam (Mogadon) See BENZODIAZEPINES.
such as the tricyclic ANTIDEPRESSANTS. However,
their abrupt withdrawal may lead to an increase in
the nightmare frequency. (See also STRESS.) Noctec (chloralhydrate) See HYPNOTICS.

night owl See EVENING PERSON. noctiphobia Term synonymous with nyctopho-
bia; refers to an irrational fear of night and darkness
that may be a manifestation of ANXIETY DISORDERS.
night person See EVENING PERSON. Some children may experience noctiphobia during
their early childhood, but they outgrow it. (See
also ANXIETY, NIGHTMARE.)
night shift Work during the nocturnal hours,
typically from 11 P.M. through to 7 A.M. (Work
from 3 P.M. till 11 P.M. is usually called an EVENING nocturia Term referring to frequent urination
SHIFT.) Night shift workers typically have disturbed at night, compared with the daytime; synony-
chronobiological rhythms because of the altered mous with nycturia. Patients with nocturia will
sleeping pattern. A night worker will usually have a full bladder, causing them to arise several
attempt to sleep upon returning home from the times from sleep to go to the bathroom. Urinary
night work but often has a short sleep period of frequency may be due to a variety of urological
four hours (from about 8 A.M. to 12 noon). A nap problems, including infections, local tumors, such
in the late afternoon or evening is usually required as bladder or prostate tumors, bladder prolapse, or
before going to work. other disorders affecting sphincter control. Patients
Typically, night shift workers will revert to a with sleep disturbance typically will have an
normal time of sleeping, from 11 P.M. to 7 A.M., increase in the number of episodes of nocturia at
on the days off from work. However, because of times of the sleep disturbance. Some patients with
the fluctuating time for sleep, the sleep pattern is insomnia may arise five or six times at night to go
usually disrupted on the days off, and brief sleep to the bathroom, and each time will typically void
episodes can occur at other times of the day. Most only a small amount of urine.
shift workers find it very difficult to maintain full There is a strong association between the devel-
alertness during the night shift, particularly if the opment of OBSTRUCTIVE SLEEP APNEA SYNDROME and
work being performed is monotonous and bor- the need for nocturia. Relief of the obstructive
ing. However, if the shift worker has a circadian sleep apnea syndrome relieves the nocturia, as
drop of body temperature that occurs during the does the treatment of insomnia in patients who
shift work hours, it may be extremely difficult to have nocturia related to insomnia. If urinating
maintain full alertness, particularly between 4 occurs during sleep, then the term SLEEP ENURESIS
A.M. and 7 A.M. Studies of night shift work have is used.
failed to show complete adaptation to the shift Many other medical disorders can produce noc-
work, even after 10 years of shift-work experi- turia, such as diabetes and bladder disorders, as
ence. (See also CHRONOBIOLOGY, SHIFT-WORK SLEEP well as medications, particularly diuretics. Nocturia
DISORDER.) becomes almost universal with age, probably as a
result of alterations in circadian control.

night sweats See SLEEP HYPERHIDROSIS.

nocturnal Pertaining to night, night-related. It
does not necessarily imply a sleep-related phe-
night terrors See SLEEP TERRORS. nomenon. Although many nocturnal disorders are
150 nocturnal angina

sleep-related, some occur during the night hours, of cardiac disease, and an elevated cholesterol
when the person is either awake or asleep, such as level.
nocturnal epilepsy. The term is used to differenti- Electrocardiographic monitoring during sleep
ate night from day, and is the opposite of the word may demonstrate cardiac ischemia, which is evi-
“diurnal.” denced by ST wave changes of 1 millimeter or
greater, either elevation or depression. Polysom-
nographic monitoring may demonstrate either the
nocturnal angina See NOCTURNAL CARDIAC cardiac ischemia or predisposing disorders, such as
ISCHEMIA. SLEEP-RELATED BREATHING DISORDERS.
Patients demonstrating cardiac ischemia require
further cardiac investigations, which may include
nocturnal cardiac ischemia Ischemia (lack of cardiac exercise testing with echocardiography or
oxygen that causes damage to the tissue) of the coronary angiography.
myocardium (heart muscle) that occurs during Nocturnal cardiac ischemia needs to be dif-
the major sleep episode. Cardiac ischemia may be ferentiated from other causes of chest pain that
symptomatic, in which case it is often termed noc- occur during sleep, such as left ventricular failure
turnal angina, or the ischemia may be asymptom- producing PAROXYSMAL NOCTURNAL DYSPNEA, gastro-
atic. It may be detected by electrocardiographic esophageal reflux, or peptic ulcer disease.
monitoring during sleep, either by Holter moni- Treatment of nocturnal cardiac ischemia rests
toring (a 24-hour electrocardiograph) or during on treatment of the underlying cardiac disease.
nocturnal polysomnographic monitoring. When Anti-anginal agents, such as long acting nitroglyc-
symptomatic, cardiac ischemia produces a chest erine, may need to be given before bedtime. Other
pain that is described as a tightness within the medications and surgical management of coronary
chest, often like a vise. The pain may be felt in the artery disease need to be considered. If underly-
jaw, left arm or the back. The pain may be mild, ing sleep-related disorders induce cardiac isch-
in which case the person may not believe it is of emia, such as the CENTRAL SLEEP APNEA SYNDROME,
cardiac origin, or it may be severe, requiring acute OBSTRUCTIVE SLEEP APNEA SYNDROME, or CENTRAL
medical attention. ALVEOLAR HYPOVENTILATION SYNDROME, then treat-
Patients who have nocturnal cardiac ischemia ment of these disorders is necessary.
will also usually have daytime ischemic episodes.
However, nocturnal cardiac ischemia may be
independent of any prior or current daytime nocturnal confusion A typical occurrence in
ischemic features, and it may be related solely to patients who have DEMENTIA. Patients will arise
underlying pathological disorders that occur dur- from sleep at night in a confused state, not knowing
ing sleep, such as the OBSTRUCTIVE SLEEP APNEA where they are, and start to behave as if it is daytime
SYNDROME. Episodes of nocturnal cardiac ischemia rather than nighttime. The activity of such patients
are more common in the later half of the night, may pose some major problems for caretakers and
particularly during REM sleep. Severe CARDIAC often can lead to institutionalization of the patient.
ARRHYTHMIAS and even sudden DEATH DURING The nocturnal confusion can be worsened by some
SLEEP may result. HYPNOTICS or acute underlying medical illnesses.
Cardiac ischemia is usually a feature of coronary Attention to good SLEEP HYGIENE and the judicious
artery disease—either intrinsic disease, such as ath- use of sedative medications may be helpful.
erosclerosis or coronary artery spasms, or valvular
disease, such as aortic stenosis.
Patients at most risk for coronary artery disease nocturnal dyspnea Respiratory difficulty that
are overweight males. Other risk factors include occurs during sleep at night. This commonly occurs
HYPERTENSION, cigarette smoking, a family history in association with lung or cardiac disease. Noctur-
 nocturnal emission 151

nal dyspnea (also known as paroxysmal nocturnal The need for food or drink in infants gener-
dyspnea) is typically seen in patients who have ally persists until the child is weaned completely,
leftsided heart failure that causes fluid to accumu- typically by age three to four months. However,
late in the lungs, thereby producing discomfort and if bottle feeding or drinks are allowed to be given
difficulty in breathing and leading to an awakening throughout the night until an older age, then the
with a sensation of respiratory distress. It may also sleep disturbance may occur.
be due to other disorders that produce difficulty in Caregiver factors are very important in the
breathing at night, for example, CENTRAL ALVEOLAR development of this sleep disorder. In infants and
HYPOVENTILATION SYNDROME, CHRONIC OBSTRUCTIVE children, the caregiver needs to recognize appropri-
PULMONARY DISEASE, or OBSTRUCTIVE SLEEP APNEA ate hunger signals; repeated demands without true
SYNDROME. need should not be complied with.
Marked OBESITY can cause compression of the The increased weight gain may be a source of
lower lung fields, thereby leading to impaired VEN- concern, anxiety and depression.
TILATION during sleep and a sensation of dyspnea. Approximately 5 percent of the population from
Most often, individuals with nocturnal dyspnea six months to three years of age may exhibit the
will use several pillows in order to sleep in a nocturnal eating (drinking) syndrome; the preva-
semi-reclining position, which assists in improving lence in adults is unknown.
ventilation during sleep. Sometimes nocturnal dys- Adults who ingest more than 50 percent of
pnea may be so severe that a person needs to sleep their caloric intake during the sleeping hours are
upright in a chair for the entire night. regarded as having the nocturnal eating (drinking)
Treatment of many sleep-related respiratory syndrome. This condition is frequently associated
disorders will relieve nocturnal dyspnea and allow with increasing weight gain and concern over fre-
improved quality of nocturnal sleep. quent nocturnal awakenings.
Treatment of this disorder involves weaning
the young child from the breast or bottle, the rec-
nocturnal eating (drinking) syndrome Disorder ognition of any true need for sustenance during
characterized by one or more awakenings that sleep, the elimination of compliance with the false
occur during the night with a desire for food or demands of children, behavior modification with
drink. Sleep cannot be reinitiated until the intake sleep consolidation, and eliminating the need in
has been completed, after which sleep occurs adults to awake and eat or drink. There have been
easily. This sleep disorder usually occurs in chil- reports that there may be benefits from reduc-
dren, although it can occur in adults. Typically, ing carbohydrate intake, and increasing protein
an infant would require nursing at the breast, or intake, before sleep. In the adult, hypoglycemia
bottle feeding, after which the baby will return can occur during sleep and, if indicated, a glucose
to sleep. The older child may request something tolerance test may be necessary to explore this
to eat or drink and is unable to sleep until the possibility. (Hypoglycemia is a disorder that is asso-
requested food or drink has been taken. This dis- ciated with intermittent low blood sugar levels.
order is also seen in adults who occasionally will Treatment may require an adult to eat small por-
awaken with a strong desire to eat. Again, sleep tions of food at frequent intervals to stabilize the
cannot be initiated until the desired food or drink blood sugar level.)
has been ingested.
An infant’s ability to sleep through the night
without the need for food or drink is usually nocturnal emission Ejaculation of sperm that
attained by the age of six months. Frequent awak- occurs during sleep in relationship to a dream that
enings may lead to the production of a disturbed is sexually motivated. (A common term for this
sleep-wake pattern, with the need for sustenance phenomenon is “wet dream.”) According to the
at frequent intervals. Kinsey study of American males, approximately 85
152 nocturnal enuresis

percent of the male population will experience one 2006, it received 665 reports of adverse effects
or more “wet dreams” during their lifetime. The with dramatic outcomes, including 93 deaths,
highest incidence of nocturnal emissions occurs associated with quinine use. CARDIAC ARRHYTH-
during the late teens and diminishes with age. MIAS, severe hypersensitivity, and thrombocyto-
Nocturnal emissions occur in association with the penia (a lowering of the blood platelets that could
SLEEP-RELATED PENILE ERECTIONS that occur during lead to hemorrhage or clotting problems) were
REM sleep. cited as reasons for this. As Dr. Steven Galson,
director of the FDA’s Center for Drug Evaluation
and Research, stated in the FDA press release: “We
nocturnal enuresis See SLEEP ENURESIS. believe unapproved quinine products represent a
serious health risk because of the widespread use
of this product for treating leg cramps. Quinine
nocturnal leg cramps A painful feeling associ- needs to be dosed carefully, and FDA-approved
ated with muscle tightness or tension in the calves labeling reflects the fact that the risks associated
of the legs, but occasionally in the feet. The tight- with the use of this drug for treatment of leg
ening of the muscle lasts a few seconds and usu- cramps outweigh the benefits.”
ally stops spontaneously, but the discomfort may The disorder needs to be distinguished from
persist for up to about 30 minutes. When the noc- other forms of muscle disorder that can occur dur-
turnal cramps occur during sleep, they will cause ing sleep, such as PERIODIC LIMB MOVEMENT DISOR-
an awakening. Episodes may also occur during the DER, sleep-related seizures, NOCTURNAL PAROXYSMAL
daytime; however, patients with daytime cramps DYSTONIA, and sleep-related tonic spasms, which all
rarely have episodes during sleep. Some patients have differing clinical features and history.
have a predisposition for having only sleep-related
cramps.
Nocturnal cramps have also been called by the nocturnal myoclonus Term applied by Charles
term “charley horse,” derived from the old term Symonds in 1953 for repetitive leg jerks that occur
for a horse that was lame due to the stiffness of its during sleep. The movements are 0.5 to 5 seconds
muscles. in duration and occur at an interval of 20 to 40
The cause of the muscle cramps is poorly under- seconds. The movements can occur simultaneously
stood, but metabolic disturbances, such as diabe- or asynchronously in either leg or both, or simul-
tes or calcium abnormalities, can contribute. The taneously in the upper limbs. As the movements
cramps also appear to be more common during are of longer duration than typical myoclonic jerks,
pregnancy. the term PERIODIC LEG MOVEMENTS is preferred.
The peak age of onset of nocturnal cramps When the movements reach sufficient frequency
appears to be in adulthood, but they can occur in to disrupt sleep, the resulting disorder is called the
children. However, this type of cramping has never PERIODIC LIMB MOVEMENT DISORDER. (See also REST-
been reported in infants or very young children. LESS LEGS SYNDROME.)
This discomfort can be relieved by stretching
the involved muscle, by movement and massage
of the muscle, or by local heat to the affected nocturnal paroxysmal dystonia (NPD) A neu-
area. rological disorder that produces abnormal move-
Although quinine was previously considered ment activity during sleep, particularly non-REM
an effective treatment for nocturnal leg cramps, in sleep. This disorder produces dystonic or dyskinetic
December 2006, the FDA issued a warning against movements that are characterized by a twisting or
the off-label use of quinine to treat leg cramps. writhing type of movement. Nocturnal paroxysmal
(Quinine is a drug used to treat malaria.) This was dystonia appears to be of central nervous system
due to the FDA noting that between 1969 and origin (caused by mechanisms inside the brain)
 nocturnal penile tumescence (NPT) test 153

and seems to have a long course lasting many years diately prior to the onset of the abnormal motor
without spontaneous resolution. movement activity the ELECTROENCEPHALOGRAM
There are two forms of nocturnal paroxysmal shows evidence of an arousal or a brief awaken-
dystonia that are differentiated by the duration of ing. Other forms of investigation, including brain
the abnormal movement activity. One form, with imaging, have failed to reveal any specific central
short-lasting episodes, generally has movements nervous system pathology to account for the disor-
that last only one minute or less, and episodes can der. Patients with generalized tonic-clonic seizures
occur up to 15 times every night. They are usually may have abnormal epileptiform activity seen on
preceded by evidence of an arousal or an awaken- routine daytime electroencephalograms.
ing that occurs immediately prior to the onset of The abnormal movement needs to be differ-
the abnormal movements. Typically the patient entiated from other forms of sleep-related move-
will open his eyes during the arousal and then ment disorders, such as the REM SLEEP BEHAVIOR
the movements will occur. They usually consist DISORDER, which occurs predominantly during
of writhing or twisting movements of the arms or REM sleep and can be easily discerned by poly-
legs. Following an episode, the patient is able to somnography. Other forms of parasomnia activ-
go back to sleep without difficulty. These brief epi- ity, including SLEEP TERRORS and SLEEPWALKING,
sodes are believed to be manifestations of frontal are easily differentiated by their characteristic
lobe epilepsy. features. There may be difficulty in differentiat-
Another form of nocturnal paroxysmal dystonia ing from SLEEP-RELATED EPILEPSY, particularly that
has long episodes that are more than two minutes of frontal lobe origin. Electroencephalographic
in duration. These long episodes tend to occur less patterns consistent with epilepsy are rarely seen
frequently and there may be only two or three in paroxysmal dystonia and suggest that noc-
episodes in a night. They are also characterized by turnal paroxysmal dystonia is not an epileptic
the writhing and twisting movements of the limbs. phenomenon. Polysomnographic documentation
This type of dystonia has been known to occur of episodes has failed to show any preceding or
before the onset of other degenerative neurological following epileptic features.
disorders, such as Huntington’s chorea. Nocturnal paroxysmal dystonia is responsive
Episodes of nocturnal paroxysmal dystonia can to the anticonvulsive medication CARBAMAZEPINE
lead to severe sleep disruption and therefore a (Tegretol).
complaint of INSOMNIA. The patient will feel tired
and not rested upon awakening in the morning.
Also, because of the movements, the sleep of the nocturnal penile tumescence (NPT) The sponta-
bed partner can be disturbed and injuries can neous occurrence of a penile erection during sleep
occur, either to the patient or the bed partner. in the absence of any sexual stimulation. This occurs
Short-lasting episodes rarely occur during the in most men who are physically able to achieve an
daytime, and generalized tonic-clonic seizures have erection, typically several times a night. It usually
also been reported. happens during REM sleep, and it is not uncommon
Episodes of nocturnal paroxysmal dystonia have for an erection to be present when a man wakes up.
occurred in infancy or can occur for the first time This term is usually applied to a test to determine
as late as the fifth decade. It appears to have an the ability of a man to obtain an adequate erection
equal prevalence in men and women, and epi- or the ability to maintain an erection of sufficient
sodes do not subside spontaneously but have been rigidity to perform sexual intercourse.
known to occur for at least 20 years.
Polysomnographic investigation has demon-
strated that the episodes occur during stage two nocturnal penile tumescence (NPT) test A test
sleep and rarely can occur in stages three and four of the ability to attain an adequate erection dur-
sleep; they do not occur during REM sleep. Imme- ing sleep. This test involves monitoring the erectile
154 nocturnal sleep episode

ability during an all-night polysomnogram (see around the time of puberty and increases in middle
POLYSOMNOGRAPHY). Usually two or three nights age to old age.
of recording are required to adequately determine The nocturnal sleep episode may be reduced in
whether normal erections occur during sleep. All duration in some ethnic groups or in some indi-
healthy males from infancy to old age have erec- viduals who prefer to take prolonged daytime NAPS
tions during REM sleep. If there is an inadequate (SIESTA) that can last two to four hours. Then the
amount or reduced quality of REM sleep, normal nocturnal sleep episode is reduced by the amount
erections will not occur. The NPT test is used to help of time of the siesta. In such individuals, the typi-
differentiate organic causes of erectile dysfunction cal nocturnal sleep episode duration is only four
from psychological causes. Impaired sleep-related to six hours. (See also ONTOGENY OF SLEEP, SLEEP
erections during normal REM sleep are indicative DURATION.)
of an organic cause of impotence.

NoDoz See OVER-THE-COUNTER MEDICATIONS.

nocturnal sleep episode The typical nighttime or
major sleep episode that is determined by the daily
rhythm of sleep and wakefulness. The nocturnal noise A common cause of sleep disturbance.
sleep episode is the conventional or habitual time Environmental noise, due to traffic, aircraft or
for sleeping. For the majority of individuals, the neighbors, can cause a person to have difficulty in
nocturnal sleep episode lasts eight hours and com- initiating or maintaining sleep and can contribute
monly occurs between the hours of 11 P.M. and 7 to an EARLY MORNING AROUSAL. It is one of many
A.M. The nocturnal sleep period usually consists of environmental effects that can produce an envi-
alternating cycles of REM and non-REM sleep and ronmental sleep disorder. In addition to its more
typically is comprised of about 5 percent stage one obvious effect of causing awakenings and insom-
sleep, 45 percent stage two sleep, 5 percent stage nia, noise can also disturb the quality of sleep by
three sleep, 15 percent stage four sleep and 30 inducing brief arousals, which do not lead to full
percent REM sleep. There are usually four to six awakenings. This disturbance may lead to EXCES-
cycles of non-REM/REM sleep (see SLEEP STAGES). SIVE SLEEPINESS that can be documented by a MUL-
The percentages of each sleep stage and the dura- TIPLE SLEEP LATENCY TESTING.
tion of the nocturnal sleep episode vary according Environmental noise can be eliminated from the
to age; in addition, there are individual differences bedroom by ensuring tight seals around windows
at any one age. and doors and the use of heavy curtains. Earplugs
An infant’s sleep duration can be a total of 16 or the use of a white noise machine can be help-
hours; however, the sleep is spread throughout the ful for some patients. (Overuse or improper use of
24-hour period and consists of a higher percentage ear plugs, however, can lead to a buildup of wax,
(about 50 percent) of REM sleep. In young adoles- which might necessitate removal by a physician.)
cents, the percentage of REM sleep falls to about Alternatively, HYPNOTICS, which prevent the arous-
20 percent of the total sleep time and remains at als and the awakenings, can be useful, particularly
that level throughout adulthood and into old age. in the short term.
The amount of stage three and four sleep increases The subjective assessment of noise can vary
in percentage, to 30 percent of total sleep time in among individuals. Some good sleepers may be
the pre-puberty age groups, diminishes through totally oblivious to loud sounds during the night
adulthood to old age and is typically not present and sleep is undisturbed. However, others find
after 60 years. The total sleep time decreases from even the quietest sounds especially disturbing. It
16 hours per day in infancy to between 6.5 and 8.5 is well-recognized that the mother of the newborn
hours in adolescence and through adulthood to infant is able to sleep yet responds to the softest
old age. The number of awakenings and arousals whimper of her baby, which may not be heard
during the sleep period is typically at a minimum by her sleeping spouse. Patients who, for other
 non-24-hour sleep-wake syndrome 155

reasons, have impaired sleep quality at night char- can produce unrestful sleep. But in SLEEP STATE
acterized by a complaint of insomnia are usually MISPERCEPTION sleep may be normal and full, yet
especially sensitive to environmental sounds. the patient may awaken with the complaint of not
SNORING, which can reach very loud levels, as feeling fully refreshed.
high as 80 or 90 decibels, is a common cause of
disturbance to a sleeping spouse. Although many
bed partners are able to sleep beside a snorer with- non-24-hour sleep-wake syndrome Character-
out being bothered, loud snoring is usually very ized by a regular pattern of one-to-two-hour delays
disruptive. Often there will be complaints not only in the sleep onset and wake times; also known
from the bed partner but also from other people as the hypernycthemeral syndrome. (Hyper, over,
sleeping in the house, either children or relatives. above; nychthemeron, a full period of a night and
Snoring may be of concern even to strangers, par- a day.) This rare disorder is one of the CIRCADIAN
ticularly when the snorer sleeps in a hotel or motel RHYTHM SLEEP DISORDERS. The non-24-hour sleep-
room. Loud snoring is commonly associated with wake syndrome is a sleep pattern that is similar
the OBSTRUCTIVE SLEEP APNEA SYNDROME. Snoring to that seen in human subjects who live in a time
not associated with the syndrome is often termed isolation facility, free of ENVIRONMENTAL TIME CUES.
PRIMARY SNORING. Such subjects have a sleep-wake 25-hour pattern
induced by the time period of the ENDOGENOUS
CIRCADIAN PACEMAKER. Such patients complain of
nonfocal activity See DIFFUSE ACTIVITY. difficulty in falling asleep at night, or difficulty in
awakening in the morning. Typically, this pattern
is most disruptive when the major sleep episode
non-REM intrusion Imposition of non-REM occurs during the daytime and is least disruptive
sleep during the REM sleep stage. Typically, a when the sleep episode occurs during the noctur-
component of non-REM sleep, such as the SLEEP nal periods. Attempts to control the sleep pattern
SPINDLE, SLOW WAVE SLEEP, or K-COMPLEX, may by the use of HYPNOTICS are usually unsuccessful.
intrude during REM sleep. Non-REM intrusion is Because the sleep pattern severely interferes
generally associated with sleep disruption and is with daytime activities, individuals with this pat-
due to non-REM sleep occurring at a time of the tern are either self-employed or have flexible work
sleep-wake cycle when it would otherwise not patterns.
normally occur. Some individuals with this sleep pattern have
psychopathology characterized by being schizoidal
or having an avoidant personality disorder. The
non-REM-REM sleep cycle See NREM-REM syndrome is also present in blind adults and has
SLEEP CYCLE. been described as occurring congenitally in blind
infants.
Polysomnographic studies have rarely been
non-REM-stage sleep Sleep is composed of two reported but would be expected to show normal
main sleep stages: non-REM and REM sleep. Non- sleep duration and quality that occurs with a pro-
REM is further divided into stages one, two, three gressive daily delay in sleep onset time.
and four sleep. (See also SLEEP STAGES.) The differential diagnosis of non-24-hour sleep-
wake pattern includes DELAYED SLEEP PHASE SYN-
DROME, which is characterized by a stable sleep
nonrestorative sleep Sleep regarded as nonre- onset and awake time. The IRREGULAR SLEEP-WAKE
freshing or insufficient to produce full daytime PATTERN has a variable sleep onset time, with occa-
alertness. Many disorders that produce sleep inter- sional sleep episode advances.
ruption, such as the OBSTRUCTIVE SLEEP APNEA There are few reports of treatment attempts in
SYNDROME and PERIODIC LIMB MOVEMENT DISORDER, patients with the non-24-hour sleep-wake syn-
156 noradrenaline

drome, but recent evidence about LIGHT THERAPY have been developed over the years for the sleep
being able to advance or delay sleep-onset time disorders; however, the system most commonly
holds promise of enabling maintenance of a stable used was developed in 1979 by the Association of
sleep-wake pattern. (See also FREE RUNNING, TEM- Sleep Disorder Centers and was published in the
PORAL ISOLATION.) journal Sleep. The DIAGNOSTIC CLASSIFICATION OF
SLEEP AND AROUSAL DISORDERS has been widely
used as the main classification for sleep disorders,
noradrenaline See NOREPINEPHRINE. not only in the United States but also internation-
ally. In 1985, the process of redefining the names
and classification of sleep disorders was under-
norepinephrine A neurotransmitter, also known taken by the American Sleep Disorders Associa-
as noradrenaline, that is widely found within the tion (now called the AMERICAN ACADEMY OF SLEEP
central and peripheral nervous system. Although MEDICINE). In 1990, the INTERNATIONAL CLASSIFI-
norepinephrine was originally believed to enhance CATION OF SLEEP DISORDERS was published by the
sleep, it is now believed to be an important agent American Sleep Disorders Association. The most
in the activation of WAKEFULNESS. It is probable recent revision was published in 2005. It contains
that norepinephrine works in conjunction with an extensive listing of all sleep disorders.
ACETYLCHOLINE in order to produce wakefulness.
Studies with agents that inhibit the synthesis of
norepinephrine have shown an initial increase in NPD See NOCTURNAL PAROXYSMAL DYSTONIA.
REM sleep, but then REM sleep appears to be sup-
pressed. It is possible that the norepinephrine in the
LOCUS CERULEUS is important in the maintenance of NPPV See NASAL POSITIVE PRESSURE VENTILATION.
wakefulness and the production of REM sleep. The
receptors known as the alpha 2 adreno-receptors
appear to be most important in the regulation of NPT See NOCTURNAL PENILE TUMESCENCE.
sleep and wakefulness.
Studies of pharmaceutical agents have dem-
onstrated that the role of norepinephrine in the NREM-REM sleep cycle This term denotes a
control of sleep and wakefulness is very complex recurrent cycle of non-REM alternating with REM
and poorly understood; further research is needed sleep that occurs throughout the major sleep epi-
to define its exact role. sode. This term is synonymous with the terms sleep
Medications that have an effect on norepineph- cycle and sleep-wake cycle. Any non-REM sleep
rine synthesis, such as the MONOAMINE OXIDASE stage may alternate with REM sleep to form the
INHIBITORS, can markedly suppress REM sleep. How- NREM portion of the NREM-REM sleep cycle. In a
ever, these inhibitors have effects other than their typical adult sleep period of 6.5 to 8.5 hours, there
effects upon norepinephrine synthesis. Clonidine, are five non-REM-REM sleep cycles. The duration
an antihypertensive agent, stimulates the adreno- of the cycle increases from about 60 minutes in
receptors, and yet REM sleep is inhibited by very infancy to 90 minutes in young adulthood.
small doses of clonidine. However, clonidine also
has an effect on wakefulness in that wakefulness
can be increased with relatively small doses of cloni- NREM sleep See NON-REM-STAGE SLEEP and SLEEP
dine, but high doses seem to inhibit wakefulness. STAGES.

nosology The science of the classification of NREM sleep period Usually applies to the NREM
disease. The term is derived from the Greek word sleep portion of the NREM-REM SLEEP CYCLE. The
nosos, meaning disease. Many classification systems non-REM period usually consists mainly of stages
 Nytol 157

two, three and four sleep. (See also NON-REM- Nuvigil (Armodafanil) For the treatment of
STAGE SLEEP.) NARCOLEPSY.

nutrition and sleep See DIET AND SLEEP. Nytol See OVER-THE-COUNTER MEDICATIONS.
 O
obesity Defined as a body weight that is greater been shown to produce a profound weight loss
than the ideal body weight. The Metropolitan Life with a major degree of clinical improvement in
Insurance Co. weight tables are a commonly used obstructive sleep apnea syndrome.
source of determining ideal weight; these tables The theory that effective treatment of obstruc-
determine weight according to the patient’s age, tive sleep apnea syndrome would increase activity,
weight, sex and height. Morbid obesity is regarded and thereby lead to improved weight reduction,
as 100 pounds of weight over the ideal body weight has not been demonstrated in research studies.
as expressed on the Life tables. Even five and 10 years after treatment, a significant
Obesity is a common feature of OBSTRUCTIVE loss of weight is not seen. Some patients, despite
SLEEP APNEA SYNDROME and is most graphically optimum treatment of their sleep apnea syndrome,
portrayed in the story of Joe the fat boy in The Pick- will put on more weight.
wick Papers by Charles Dickens. The PICKWICKIAN Obesity appears to affect obstructive sleep apnea
SYNDROME, which applies to persons with obesity, in three ways: it may contribute to the narrow-
sleepiness, and evidence of right-sided heart fail- ing of the upper airway by increasing the bulk
ure, was reported in the medical literature in 1954; of tissues in the pharyngeal and neck region; the
since that time the relationship between obesity increased bulk of tissues may cause the tongue to
and sleepiness has been increasingly recognized. prolapse back, thereby contributing to the block-
Up to 80 percent of patients with obstructive age (occlusion) of the upper airway during sleep.
sleep apnea syndrome are overweight, and the Second, the excessive weight on the chest wall
syndrome itself is exacerbated by obesity. Reduc- may contribute to impaired VENTILATION during
tion of body weight sometimes reduces the sever- sleep; this appears to be a more significant factor in
ity of obstructive sleep apnea syndrome, although females with large, pendulous breasts. Third, the
this is not a universal finding. Many patients find large abdominal size affects diaphragm function.
that there is a critical weight at which symptoms For most patients with obstructive sleep apnea
of obstructive sleep apnea become evident, and syndrome, obesity impairs diaphragmatic func-
there may be little improvement in the symptoms tion during sleep, thereby impairing the function
until that weight is reached. For some people, of the lungs (perfusion of the basal lung fields).
reduction of body weight by as little as five or 10 The resulting right-to-left shunt allows unoxygen-
pounds causes a major degree of improvement in ated blood to pass through the heart, which in
symptoms, whereas in other patients even 100 turn causes arterial oxygen desaturation. Many
pounds of weight loss may not produce any useful extremely obese patients find they are unable to
improvement. breathe adequately when lying on their backs
In general, because there is a possibility that the because of this effect and therefore sleep in a semi-
obstructive sleep apnea syndrome can be improved, reclining or even in a sitting position.
it is recommended to all patients that they achieve In addition to surgical management of the obe-
an ideal body weight. For some morbidly obese sity, which is typically reserved for patients over
patients, weight reduction by surgical means has 300 pounds in weight, dietary programs, such as

158
 obstructive sleep apnea syndrome 159

liquid diets, can be very effective in producing a that reduces appetite, leading to an increased need
rapid weight reduction. However, the long-term to eat.
effects of the liquid diet programs have not been In 2004, Columbia University professor of medi-
demonstrated, and initial results tend to suggest an cine Steven Hymsfield and James Gangwisch, Ph.D.,
early recurrence of the lost weight. Some patients reported the results of a study conducted on 9,000
find the more well-known dietary programs to be people from 1982 to 1984 and then followed up in
very effective, such as Weight Watchers or Over- 1987. A key finding was that those who slept fewer
eaters Anonymous. Dietary suppressant medica- than five hours a night were 73 percent more likely
tions, such as the amphetamine derivatives, are not to become obese than those who got seven to nine
only ineffective but are also potentially dangerous, hours of sleep nightly. (See also BARIATRIC SURGERY;
as their cardiac stimulant properties may lead to DIET AND SLEEP; SURGERY AND SLEEP DISORDERS.)
serious CARDIAC ARRHYTHMIAS.
Although weight reduction is important for all
overweight patients with obstructive sleep apnea obesity hypoventilation syndrome Applied to the
syndrome, it cannot be relied upon as a primary condition of obese individuals who suffer severe
form of treatment except in the mildest cases. As hypoventilation during sleep and wakefulness. The
a primary treatment strategy weight reduction is hypoventilation causes a lowering of the oxygen
poorly achieved by patients, and during the weight level and an elevation of carbon dioxide, usually
reduction attempts the patient’s life may be at risk above 60 millimeters of mercury. The term describes
because of the effects of obstructive sleep apnea any number of disorders characterized by hypoven-
syndrome. Therefore, any recommendations for tilation during sleep, including OBSTRUCTIVE SLEEP
weight reduction must be pursued concurrently APNEA SYNDROME, CENTRAL SLEEP APNEA SYNDROME,
with effective treatment of the obstructive sleep and CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME.
apnea syndrome, which is most commonly carried
out by either a CONTINUOUS POSITIVE AIRWAY PRES-
SURE device or upper airway surgery. obstructive sleep apnea syndrome A disorder
Research over the last five years confirms the characterized by repetitive episodes of UPPER AIR-
theory that the number of hours you sleep each WAY OBSTRUCTION that occur during sleep and are
night may affect whether or not you are over- usually associated with a reduction in the blood
weight or obese. A study published in the January oxygen saturation. It is synonymous with upper
10, 2005, issue of the Archives of Internal Medicine airway sleep apnea. The clinical features of this
reported on how sleep related to body mass index disorder were clearly described by Charles Dickens
(BMI) is linked to being overweight or obese. in his novel The Pickwick Papers. It was only in the
(BMI is considered an indication of whether or 1960s that its pathophysiological basis could be
not someone is within a healthy weight range. A understood.
BMI of 18.5 to 25 is considered a healthy weight Several hundred apneic episodes can occur dur-
range; if the BMI range is over 30, the person is ing a night of sleep, thereby leading to severe sleep
considered obese.) In the study of 1,001 men and disruption and fragmentation, with the develop-
women between the ages of 18 and 91, findings ment of EXCESSIVE SLEEPINESS during the daytime.
confirmed that those with a normal BMI slept, on The apneic episodes are most severe during the
average, 16 minutes longer each day. It is suggested REM stage of sleep, in part due to the associated
that a reason for this is that the hormone GHRELIN, loss of muscle tone, but also because of the change
which increases appetite, is associated with lack of in metabolic control of VENTILATION.
sleep. The hormone LEPTIN, which reduces appetite, The disorder is associated with loud SNORING,
is decreased by lack of sleep. Therefore, getting too which is indicative of intermittent upper airway
little sleep increases the hormone that leads to a obstruction that at times can be complete and cause
bigger appetite and it also decreases the hormone a cessation of airflow and obstructive apnea. The
160 obstructive sleep apnea syndrome

loud snoring is disturbing to bed partners or others, hour of sleep are features that indicate severe
which often leads to the presentation of the patient obstructive sleep apnea syndrome.
to a SLEEP DISORDERS CENTER. Electrocardiographic changes typically occur in
A typical feature of obstructive sleep apnea association with apneas and oxygen desaturation.
syndrome is excessive sleepiness. Sleepiness A slowing of the heart rate during the apneic pause
occurs whenever the patient is in a relaxed situ- followed by reflex tachycardia (ARRHYTHMIA char-
ation, varies from mild to severe and can lead acterized by speeding of the heart rate) during the
to automobile ACCIDENTS. Typically patients with few breaths of hyperventilation commonly occurs
the obstructive sleep apnea syndrome fall asleep and is termed the brady-tachycardia (arrhythmia
while reading, watching TV or even while attend- characterized by slowing and speeding of the heart
ing business or social meetings. The patient may rate) syndrome. This electrocardiographic pattern,
purposefully take a daytime nap, but the NAPS when it occurs solely during sleep, is diagnostic of
are usually not sufficiently refreshing. Awaken- obstructive sleep apnea syndrome. Occasionally,
ings are associated with a dull, groggy feeling and sinus pauses lasting 10 or more seconds, episodes
sometimes a headache. of atrial tachycardia or VENTRICULAR ARRHYTHMIAS
Obstructive sleep apnea syndrome is also asso- can occur.
ciated with very restless sleep, particularly in Other investigations include documentation of
children who have varied positions in bed, often the degree of severity of daytime sleepiness by
sleeping on their hands and knees. Occasionally means of MULTIPLE SLEEP LATENCY TESTING (MSLT).
the restlessness can result in a fall out of bed, but Mean sleep latencies of less than five minutes are
more typically movements of the arms and legs commonly seen in patients with severe sleep apnea
greatly disturb the sleep of a bed partner. syndrome. Studies of the upper airway, including
Primary or secondary enuresis can occur during FIBEROPTIC ENDOSCOPY, can determine both the
sleep, particularly in children. (See SLEEP ENURESIS.) site of upper airway obstruction and the potential
Gastroesophageal reflux may also be produced by for success of operative procedures such as UVU-
obstructive sleep apnea syndrome. LOPALATOPHARYNGOPLASTY or TONSILLECTOMY AND
The apneic events occur during NREM or ADENOIDECTOMY.
REM sleep, but they are usually more severe in In addition, CEPHALOMETRIC RADIOGRAPHS of the
REM sleep. Repetitive episodes of upper airway upper airway will help demonstrate skeletal abnor-
obstruction last from 20 to 40 seconds. Apneic malities and also the soft tissue changes of the
episodes as long as several minutes in duration upper airway.
can occur and are associated with a severe drop in Consequences of the obstructive sleep apnea
blood oxygen and an increase in carbon dioxide. syndrome include social difficulties related to
The apneic episode is terminated by an arousal, the snoring and excessive daytime sleepiness;
which leads to an awakening with return of increased risk of motor vehicle accidents because
increased muscle tone and several large breaths. of the sleepiness; cardiovascular consequences,
After several breaths, sleep returns and another which can include a MYOCARDIAL INFARCTION during
apneic event will occur. sleep or sudden death during sleep; severe oxygen
Obstructive sleep apnea syndrome can be inves- desaturation during sleep, which can be associated
tigated by means of all-night POLYSOMNOGRAPHY, with development of pulmonary hypertension and
with appropriate measurement of breathing, oxy- right-sided heart failure; and risk of a stroke, which
gen saturation and heart rate. All-night polysom- has been found to be doubled in obstructive sleep
nography confirms the diagnosis and also allows apnea.
determination of its severity. Apneic episodes of Treatments of obstructive sleep apnea syndrome
more than 60 seconds in duration, oxygen desatu- include behavioral as well as medical or surgical
ration that falls below 70 percent and an APNEA- measures. Weight reduction is recommended for
HYPOPNEA INDEX of greater than 30 episodes per any overweight patient (see OBESITY) with obstruc-
 obstructive sleep apnea syndrome 161

tive sleep apnea syndrome. Bariatric surgery can PSYCHOPHYSIOLOGICAL INSOMNIA or insomnia associ-
succeed and may be effective, but is reserved for ated with psychiatric disorders.
cases of morbid obesity. SMOKING may cause irri- Effective treatment of obstructive sleep apnea
tation and swelling of the upper airway, thereby syndrome can lead to a dramatic resolution of the
exacerbating the upper airway obstruction as well clinical symptoms and features. Respiration during
as impairing pulmonary function, leading to dete- sleep will return to normal without apneic epi-
rioration of blood-gas exchange. sodes or oxygen desaturation. Electrocardiographic
ALCOHOL exacerbates obstructive sleep apnea changes can be improved.
syndrome by causing central nervous system
depression resulting in the increasing severity of Case History
apneic events. A 45-year-old tour guide noticed the gradual onset
The most effective medical treatment for obstruc- of excessive sleepiness over a five-year period. He
tive sleep apnea syndrome is by use of a nasal CON- was also a very loud snorer and the snoring, as well
TINUOUS POSITIVE AIRWAY PRESSURE (CPAP) device. as the excessive sleepiness, were major concerns.
CPAP provides an air splint of the upper airway The snoring bothered his wife, who had to sleep
preventing collapse of the soft tissues and thereby in another room because the snoring disturbed her
eliminating the apneic events. Unfortunately, up sleep. As he was a tour guide, and often slept in
to 40 percent of the patients are unable to use the hotels, he was unable to share a room with oth-
CPAP device, either for psychological reasons or ers because of the loudness of his snoring. Dur-
because of medical complications of the treatment. ing a trip to eastern Europe, the hotel maid had
Chronic rhinitis is an uncommon cause of inability awoken him in the middle of the night because of
to use nasal CPAP and may result from irritation of complaints about his snoring from people in other
the nasal tissues by the airflow. A variation of CPAP rooms. He recalled that 25 years earlier, during a
allows the air pressure to be reduced during expira- ski trip, he had to be separated from the rest of the
tion. These devices offer bilevel control of positive group because of his snoring.
pressure. One device is called a BiPAP. His daytime sleepiness would occur whenever
Surgical management of obstructive sleep apnea he was in a quiet situation. He would fall asleep
syndrome includes adeno-tonsillectomy—surgery when sitting and watching TV in the evening or
in which the soft tissue at the level of the soft pal- while reading. He was a smoker and, as a result
ate is removed. Other surgical procedures involve of dropping cigarettes beside his favorite chair,
enlarging the air space at the back of the tongue had burnt holes in the carpet. He had fallen asleep
by jaw surgery; this may be indicated in some while driving on at least two occasions and fre-
patients who have severe obstructive sleep apnea quently would find himself veering to the side of
syndrome. the road because of sleepiness while driving. His
Excessive daytime sleepiness due to obstructive wife was particularly concerned about his driving
sleep apnea syndrome needs to be distinguished and therefore did most of it herself when they were
from other disorders of excessive sleepiness. NAR- together in the car.
COLEPSY and PERIODIC LIMB MOVEMENT DISORDER can He was a very restless sleeper and this con-
produce excessive sleepiness and can occur concur- tributed to his wife seeking refuge in another bed
rently with the obstructive sleep apnea syndrome. in another room. He also had a dry mouth upon
Other breathing disorders, such as CENTRAL SLEEP awakening and occasionally would have severe
APNEA SYNDROME or CENTRAL ALVEOLAR HYPOVEN- morning headaches that would last for one to two
TILATION SYNDROME, can be differentiated from hours. He was 5 feet 10 inches tall and weighed
obstructive sleep apnea syndrome by polysomnog- 210 pounds, which was the heaviest that he had
raphy. Patients who present with the primary com- ever been. Five years previously he had weighed
plaint of INSOMNIA need to be differentiated from 185 pounds and had tried to lose weight but found
patients with other insomnia disorders, such as it very difficult to do so.
162 obtundation

A physical examination showed an elevated acterized by drowsiness and a tendency for excessive
blood pressure with diastolic level of 95. He sleepiness. This altered state of consciousness may
had a very compromised posterior oropharynx, be due to metabolic, pharmacologic or intracerebral
which appeared to be the site of his upper airway lesions. (See also COMA, DELIRIUM, STUPOR.)
obstruction. He had bilateral conjunctivitis that
was probably due to the chronic and constant sleep
disturbance. Ondine’s curse From Act III of Ondine by Jean
He underwent polysomnographic evaluation and Giraudoux; means the inability to breathe during
had 222 obstructive sleep apneas, the longest being sleep.
66 seconds, and he had 161 episodes of shallow
Ondine: Hans, you too will forget.
breathing (HYPOPNEAS). The oxygen saturation value
fell from a baseline level of 93 percent while awake, Hans: Live! It’s easy to say. If at least I could work
to a low of 77 percent during the most severe up a little interest in living, but I’m too tired to
make the effort. Since you left me, Ondine, all
apneas. He underwent a daytime multiple sleep
the things my body once did by itself it does now
latency test, which confirmed severe sleepiness with only by special order . . . It’s an exhausting piece of
a mean sleep latency of 5.3 minutes. However, he management I’ve undertaken. I have to supervise
did not have any REM sleep during the naps. five senses, two hundred bones, a thousand mus-
He underwent a repeat night of polysomno- cles. A single moment of inattention and I forget
graphic monitoring while using a nasal continuous to breathe. He died, they will say, because it was a
positive airway pressure (CPAP) device. During the nuisance to breathe . . .
recording he had only 10 obstructive sleep apneas
It was first described by John Severinghaus
during the adjustment phase. When the CPAP sys-
and Robert Mitchell in 1962 in three patients who
tem was adjusted to a pressure of 10 centimeters of
had long episodes of cessation of breathing that
water, he was entirely free of apnea episodes. His
occurred particularly while asleep. They needed
oxygen level did not fall below 90 percent at that
assisted ventilation during sleep, but the patients
pressure. The study demonstrated a great improve-
were able to breathe voluntarily during the day.
ment in the quality of sleep, with a REM sleep
The term CENTRAL SLEEP APNEA SYNDROME is now
rebound as well as a great increase in the amount
most commonly used to refer to similar forms of
of slow wave sleep. Upon awakening in the morn-
sleep-induced apnea.
ing he felt much more alert and was energetic for
A number of neurological disorders have been
the rest of the day.
associated with Ondine’s curse, such as brain stem
He was prescribed a CPAP system to use on a
lesions affecting the respiratory centers or spinal
regular basis at night and with this treatment his
cord lesions. Patients with Ondine’s curse require
sleepiness was eliminated. He was able to drive
assisted VENTILATION at night, usually by means of a
without getting sleepy and stay up and watch his
positive pressure ventilator.
favorite TV programs without falling asleep. In addi-
tion to the improvement in his breathing at night
and his sleepiness, the CPAP system also eliminated oneiric Derived from the Greek oneirus, which
his snoring and restlessness, and his wife was able means a dream; an event or activity pertaining to
to return to sleeping in the same bed. dreaming. Oneirism refers to an abnormal dream-
like state of consciousness and is occasionally used
to describe the unusual behavior that occurs in
obtundation Term applied to a reduced level of REM sleep in disorders such as REM SLEEP BEHAV-
mental acuity often associated with decreased psy- IOR DISORDER and FATAL FAMILIAL INSOMNIA.
chomotor activity. The alertness and awareness of
the environment are reduced, although the patient
may act in an appropriate manner to various inter- ontogeny of sleep There are major changes in
nal needs and stimuli. The quiet state is often char- sleep from infancy to old age. It is uncertain when
 oral appliances 163

sleep first occurs in infants; however, differentia- Oral appliances are indicated for patients with
tion of an infant’s state into WAKEFULNESS, ACTIVE moderate to severe OSAS who are intolerant of
SLEEP, or QUIET SLEEP cannot be made until around or refuse treatment with nasal CPAP. Oral appli-
32 to 35 weeks of age. Because sleep in the infant ances are also indicated for patients who refuse
is immature, it cannot be clearly differentiated into treatment or are not candidates for TONSILLECTOMY
REM and non-REM and therefore the terms active AND ADENOIDECTOMY, craniofacial operations, or
and quiet sleep reflect the state of EEG and body TRACHEOSTOMY.
activity. These terms are believed to be synony- At least 37 different oral appliances have been
mous with REM and non-REM sleep, respectively. developed to maintain airway patency during
(See INFANT SLEEP.) sleep. They can be categorized into two groups:
The total amount of sleep gradually decreases devices that hold the mandible anteriorly in rela-
over the first decade and the percentage of non- tion to the maxilla, and devices that hold the
REM sleep reaches a peak around the middle of tongue in an anterior position. Commercially avail-
the first decade. Normal developmental behavioral able oral appliances include the following: Herbst
phenomena that occur from SLOW WAVE SLEEP, such Appliance, Mandibular Repositioner, Nocturnal
as SLEEPWALKING and SLEEP TERROR episodes, are Airway Patency Appliance, Snore Guard, TONGUE
commonly seen at this time. RETAINING DEVICE, Klearway, PM Positioner, and
The total duration of sleep by around the time Therasnore.
of puberty is seven to nine hours, with the onset of
the teenage years often associated with a tendency Herbst Appliance
to go to bed later, which may lead to SLEEP DEPRIVA- An oral appliance developed from an orthodontic
TION. The amount of REM sleep reaches 20 percent appliance that has been used for many years. It
and 25 percent around the time of puberty and holds the jaw forward in both the open and closed
stays at that level in adulthood. positions. It has the advantage of allowing jaw
Throughout adulthood, sleep remains relatively opening during sleep. The Herbst Appliance usu-
stable, with the exception of a gradual reduction in ally holds the jaw open 75 percent of the patient’s
the total amount of stages three and four sleep and maximal protrusion and can be adjusted to allow
an increase in the number of arousals and awaken- further protrusion if it initially is ineffective. Poly-
ings during sleep. By age 60, less than 10 percent somnographic studies have shown improvement
of nocturnal sleep is slow wave sleep, and there are in obstructive sleep apnea indices in patients using
greater amounts of wakefulness and an increas- this appliance.
ing tendency for daytime sleepiness after this age.
Pathological disturbances in sleep become more Mandibular Repositioner
common, such as obstructive or central apneas and A device that primarily moves the mandible for-
periodic limb movements. (See also ELDERLY AND ward to prevent tongue occlusion of the posterior
SLEEP.) airway. A rigid mandibular positioner moves the
jaw forward 3 to 12 millimeters and has been
shown to be effective in improving obstructive
oral appliances Appliances that are indicated sleep apnea syndrome in several studies.
for use in patients with primary snoring or mild
OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS) who Nocturnal Airway Patency Appliance (NAPA)
do not respond to or are not candidates for treat- A device that advances the mandible 6 millimeters
ment with behavioral measures such as weight loss anteriorly and 9 millimeters inferiorly. It has an
or sleep-position change. Patients with moderate to oral breathing beak to prevent the lips from clos-
severe OSAS should have an initial trial of nasal CON- ing, and it stabilizes the mandible in both the hori-
TINUOUS POSITIVE AIRWAY PRESSURE (CPAP) because zontal and vertical directions. The NAPA has been
greater effectiveness has been shown with this inter- shown to be effective in obstructive sleep apnea
vention than with the use of oral appliances. syndrome in a small number of studies and was
164 orexin

granted marketing clearance by the U.S. Food and and is effective in many patients both for snoring
Drug Administration (FDA) for snoring and OSAS. and obstructive sleep apnea syndrome. It has been
granted FDA marketing clearance for snoring.
Snore Guard
An appliance that positions the mandible 3 mil- Klearway
limeters behind maximal protrusion and opens An appliance with a unique mechanical protru-
the jaw 7 millimeters. It is easy to fit, covers the sive mechanism that permits the lower jaw to be
anterior teeth only and is soft and comfortable. moved forward in small steps of 0.25 millimeter
Studies have shown improvement in snoring and until symptoms abate. It permits 1 to 3 millimeters
obstructive sleep apnea syndrome in most patients. of vertical and lateral movement, which allows
It is FDA-approved for snoring only. patients to yawn, swallow or drink water while the
device is in place. Published studies have shown
Therasnore significant reduction in APNEA-HYPOPNEA INDEX
A mandibular repositioner. It is one of the few (AHI), an improvement in sleep quality and fewer
appliances that requires no laboratory construction awakenings and arousals for obstructive sleep
and is easily fitted chairside from a boil-and-bite apnea syndrome. FDA approval has been obtained
blank. This appliance retains the mandible in a pro- for snoring and OSAS.
trusive position with pliable thermoplastic material
and affords the wearer limited jaw movement. Pro-
trusive adjustability is possible to a small degree. orexin See HYPOCRETIN.
Data supporting the effectiveness of the Therasnore
is not yet published. FDA marketing clearance for
snoring has been granted. orthopnea Term used for shortness of breath that
occurs in the recumbent position, not necessarily
PM Positioner associated with nocturnal sleep. (See also NOCTUR-
A mandibular repositioner that may be laboratory- NAL DYSPNEA, OBESITY.)
constructed from thermoplastic material allowing
for easy insertion and removal when warmed. It
is tooth-retained via friction grip and may be con- OTC See OVER-THE-COUNTER MEDICATIONS.
structed with unique acrylic projections located
in the cervical areas of the posterior teeth to aid
retention. Protrusive adjustability is made quick, overlap syndrome Term used for patients who
easy and accurate by movement of two expan- have a combination of OBSTRUCTIVE SLEEP APNEA
sion screws located bilaterally in the buccal region. SYNDROME and CHRONIC OBSTRUCTIVE PULMONARY
When indicated, patients may self-adjust the appli- DISEASE. This combination of disorders produces a
ance at home. Its unique positioning of the expan- more sustained degree of HYPOXEMIA during sleep
sion screws affords lateral and vertical movement and increases the risk of developing PULMONARY
to the mandible. Data demonstrating effectiveness HYPERTENSION and right-sided cardiac failure. Most
of the PM Positioner has not yet been published. patients with this syndrome present with typical
FDA marketing clearance is pending. features of obstructive sleep apnea, including EXCES-
SIVE SLEEPINESS during the day and SNORING. Patients
Tongue Retaining Device (TRD) with the overlap syndrome may be more susceptible
An appliance that holds the tongue forward in sleep to developing elevations of carbon dioxide levels fol-
by means of a suction effect on the tongue. The lowing the administration of OXYGEN during sleep.
tongue fits into a bulge anteriorly. Lateral airway Following relief of the obstructive sleep apnea
tubes can be added if necessary. The device has syndrome, REM sleep-related oxygen desaturation
been extensively studied with and without addi- typical of chronic obstructive pulmonary disease can
tional behavioral measures such as position training require treatment by the administration of oxygen.
 owl and lark questionnaire 165

over-the-counter medications Medications that chloride that has antihistamine and anticholinergic
are available without a prescription. In sleep medi- effects. Sominex is not recommended for children
cine, the medications commonly available include under 12, and there may be drug interactions
the sleep aids and the stimulants. with alcohol and other CENTRAL NERVOUS SYSTEM
Sleep aids for those with INSOMNIA include medications.
Goody’s PM Powder (Block), Sleepinal (Thompson
Medical), Sominex (Beecham Products), and Uni- Tylenol PM
som (Leeming). Sold in caplet, geltab, or gelcap form, each dose
contains 500 milligrams acetaminophen plus 25
Goody’s PM Powder milligrams diphenhydramine. It is useful as a rem-
Each dose contains 500 milligrams acetaminophen edy for sleep onset difficulties, especially when
and 38 milligrams diphenhydramine citrate. This pain is a problem.
medicine is for temporary relief of occasional head-
aches and minor aches and pains with accompany- Unisom
ing sleeplessness. Unisom is a 25-milligram tablet of doxylamine suc-
cinate, which is an antihistamine with a sedative
Nytol effect. Because of the possible anticholinergic side
Nytol is composed of the antihistamine diphenhydr- effects of this antihistamine it should not be used
amine hydrochloride in a 25-milligram tablet. This by persons with asthma, glaucoma or prostatic
medicine can induce drowsiness and may interact enlargement.
with other depressant drugs, including alcohol. It The stimulants most commonly used for those
should not be given to children under 12 years of with EXCESSIVE SLEEPINESS include NoDoz (Bristol
age. It has anticholinergic properties and is contrain- Myers) and Vivarin (Beecham Products).
dicated if someone has asthma, glaucoma or prostatic
enlargement. Other possible side effects include dry NoDoz Maximum Strength Caplets
mouth, loss of appetite, nausea, and hypotension. A tablet with 200 milligrams of CAFFEINE, used to
counteract tiredness and sleepiness; often used by
Nytol Natural Tablets long-distance drivers. It can interact with such caf-
Each tablet contains equal parts ignatia amara 3X feine-containing beverages as coffee, tea, or sodas
(St. Ignatius bean) and aconitum radix 6X (aconite and produce a greater level of stimulation. Caf-
root). It is indicated for occasional treatment of feine may induce tachycardia, elevation of blood
sleeplessness. pressure, and insomnia and may produce a drug
dependency sleep disorder.
Sleepinal
Contains 50 milligrams of diphenhydramine hydro- Vivarin Alertness Aid Tablets
chloride in a tablet form. This medication is a help A tablet with 200 milligrams of caffeine, used to
for difficulty in falling asleep. The diphenhydr- improve daytime alertness and wakefulness. It may
amine is an antihistamine with anticholinergic interact with such caffeine-containing beverages
effects and should not be given to children under as coffee, tea, or sodas and may produce a greater
the age of 12 years. level of stimulation.
The anticholinergic effects can produce dry Caffeine may induce tachycardia, elevation of
mouth, dilated pupils, and constipation, and the blood pressure, insomnia, and drug dependency
medication is contraindicated in patients who have sleep disorders.
asthma, glaucoma or prostatic enlargement.

Sominex Original Formula Nighttime Sleep Aid owl and lark questionnaire Survey developed in
The pharmaceutical (Beecham Products) name for 1977 by James Horne and Olov Ostberg to deter-
a 25-milligram tablet of diphenhydramine hydro- mine morning or evening activity preference. This
166 oximetry

questionnaire determines the time of day that indi- oximeter can give a pulse to pulse determination
viduals are most active, least active or sleeping. Indi- of oxygen saturation according to each heartbeat,
viduals who are alert until late evening, and do not whereas the transcutaneous oximeter can give
arise early in the morning, are termed owls, whereas only a trend of oxygen change, which requires
those who are early to bed and awaken early in several minutes for equilibration.
the morning are termed larks. There is a range of
preference for morning or evening tendency, and
the most extreme forms of evening tendency are oxycodone (OxyContin) See NARCOTICS.
seen in patients who have the DELAYED SLEEP PHASE
SYNDROME. Conversely, the most extreme form of a
tendency to being a morning person is seen in some- oxygen Oxygen is an effective treatment for some
one who has the ADVANCED SLEEP PHASE SYNDROME. SLEEP-RELATED BREATHING DISORDERS associated with
(See also CIRCADIAN RHYTHM SLEEP DISORDERS, PHASE HYPOXEMIA. CHRONIC OBSTRUCTIVE PULMONARY DIS-
RESPONSE CURVE.) EASE, OBSTRUCTIVE SLEEP APNEA SYNDROME, CENTRAL
SLEEP APNEA SYNDROME, and CENTRAL ALVEOLAR
HYPOVENTILATION SYNDROME are disorders where the
oximetry The measurement of oxygen levels nocturnal use of oxygen may be indicated.
that reflects the oxygen presence in the blood. Studies of patients with chronic obstructive pul-
Two forms of oximetry are commonly used, the monary disease have demonstrated that 15 hours
predominant form being an infrared oximeter that of oxygen therapy at 3 liters per minute adminis-
measures the oxygen saturation of the capillar- tered by nasal prongs is associated with improved
ies by infrared light waves. Typically, an infrared survival. However, similar levels of oxygen given to
oximeter has a probe that attaches to a patient’s patients with the obstructive sleep apnea syndrome
ear and the infrared light shines through the tis- have produced prolonged apneic episodes during
sues and gives an estimation of the oxygen satura- sleep with elevations of carbon dioxide. Low-flow
tion. Such oximeters are most accurate for oxygen oxygen at approximately 0.5 or 1 liter per minute,
saturation levels greater than 50 percent. They are however, can be useful for some patients with sleep
routinely used during POLYSOMNOGRAPHY to deter- apnea. But the reports are variable, and in some
mine oxygen saturation values in patients who studies oxygen has not been beneficial; therefore it
have respiratory disturbance, such as patients with should initially be administered under polysomno-
OBSTRUCTIVE SLEEP APNEA SYNDROME or CENTRAL graphic control.
SLEEP APNEA SYNDROME. Some patients with obstructive sleep apnea
In infants, a transcutaneous partial pressure of treated by CONTINUOUS POSITIVE AIRWAY PRESSURE
oxygen oximeter is used that gives a more stable (CPAP) may still have sleep-related hypoventila-
assessment of the blood oxygen level. These oxim- tion that is not caused by UPPER AIRWAY OBSTRUC-
eters are less liable to damage the sensitive skin of TION. The administration of oxygen through the
infants compared with the probe of the infrared CPAP mask may be an effective way of dealing with
oximeters, which can get quite hot. The infrared this residual hypoxemia. (See also HYPOXIA.)
 P
pacemaker In sleep medicine, this term is often Acute pain is associated with sleep disturbance, but
used to denote a group of neurons responsible psychological and environmental factors, such as
for maintaining a biological rhythm. Most often it hospitalization, probably add to the sleep distur-
is used for the circadian pacemaker, a term used bance for this group. In a study of patients with
to refer to the SUPRACHIASMATIC NUCLEUS, which chronic pain compared with a group of patients
determines the rhythms of sleep and wakefulness, with insomnia of psychiatric cause, the insom-
or rest and activity in animals. Many pacemakers nia patients had more sleep disturbance than the
are present in the body for the timing of different patients with chronic pain.
rhythms, such as cardiac rhythm or the control Several disorders have sleep complaints that
of the MENSTRUAL CYCLE. Some pacemakers are may have a basis in pain. Patients with rheumatoid
believed to be a subtle network of cells, such as the arthritis have frequent awakenings and disturbed
system that may be responsible for the circadian sleep; however, sleep is usually not greatly dis-
rhythm of body TEMPERATURE. turbed unless there is an acute exacerbation of
The term pacemaker is used in cardiology for the arthritis. Patients with FIBROSITIS SYNDROME
an artificial device that maintains cardiac rhythm. complain of NONRESTORATIVE SLEEP, which is pre-
A cardiac pacemaker may be required for certain dominantly a complaint upon awakening. Poly-
sleep disorders, such as REM SLEEP-RELATED SINUS somnographic studies show the presence of ALPHA
ARREST, which may induce a fatal episode of sinus ACTIVITY throughout the sleep recording of these
arrest. Sometimes patients with bradycardia occur- patients.
ring during sleep, due to the OBSTRUCTIVE SLEEP Tricyclic ANTIDEPRESSANTS can be useful for treat-
APNEA SYNDROME, have a pacemaker inserted as a ing pain and also for the sleep disruption and alpha
temporary measure. Treatment of the obstructive sleep seen in patients with fibrositis syndrome.
sleep apnea syndrome will reverse the bradycardia HYPNOTICS can be useful in improving the quality
and episodes of sinus arrest associated with the of sleep of the patient in acute pain, such as is seen
syndrome. However, when investigative facilities postoperatively.
for obstructive apnea are unavailable or where
treatment cannot be immediately initiated, a tem-
porary pacemaker may be necessary. A permanent painful erections, sleep-related Condition where
pacemaker usually is not required for CARDIAC penile erections occurring at night are very painful.
ARRHYTHMIAS due to obstructive sleep apnea syn- All males, from infancy to old age, have erections
drome. (See also CIRCADIAN RHYTHMS, CIRCADIAN during REM sleep, and the occurrence of a partial
TIMING SYSTEM, NREM-REM SLEEP CYCLE.) or full erection may be associated with intense pain
that awakens the person during sleep. The frequent
interruptions of sleep can cause the sufferer to
pain Pain is commonly thought to be a major have daytime tiredness and fatigue.
cause of sleep disturbance; however, research stud- Typically erections during wakefulness are not
ies have shown that most patients with chronic painful. Some disorders, such as Peyrone’s disease
pain do not have complaints regarding sleep. and phymosis, can be present concurrently with

167
168 panic disorder

painful erections, but these disorders are not the Panic disorder needs to be differentiated from
cause of the discomfort. anxiety disorder, in which anxiety is generalized
This disorder is rare and typically will occur in and less focused on a specific situation or place.
the age group over 40, although it can occur at an Panic disorder also has to be distinguished from
earlier age. It tends to become more severe with SLEEP TERRORS, which typically occur from stage
increasing age. No clear penile pathology has been three/four sleep and are heralded by a loud scream.
shown to explain this disorder. Patients with sleep terror episodes are confused
Polysomnographic studies will demonstrate an or disoriented compared with patients with panic
awakening during an episode of sleep-related disorders, who are more typically aware of their
penile tumescence accompanied by the complaint surroundings. Agoraphobia is also not a feature of
of penile pain. patients who have sleep terror episodes. The SLEEP
Treatment of the disorder is usually symptom- CHOKING SYNDROME has some features that are
atic, although medications such as tricyclic ANTI- similar to panic disorder; however, the focus of the
DEPRESSANTS, which impair sleep-related erections, anxiety is on the symptom of choking that occurs
may be effective. (See also IMPAIRED SLEEP-RELATED during sleep, and agoraphobia is not present, nor
PENILE ERECTIONS.) are daytime panic attacks.
In addition to discrete episodes of panic occur-
ring during sleep, patients with panic disorders
panic disorder A psychiatric condition charac- may have other features of difficulty in initiating
terized by discrete episodes of intense fear that and maintaining sleep, and they demonstrate a
occur unexpectedly and without any specific prolonged sleep latency and frequent awakenings
precipitation. Panic disorder can occur during with reduced total sleep time on polysomnographic
sleep and is associated with a sudden awakening investigation. The sleep disturbance appears to par-
with intense fear. A number of somatic symptoms allel the course of the underlying panic disorder.
occur with panic disorder, including shortness of Treatment of panic disorder is mainly pharma-
breath, dizziness, palpitations, trembling, sweat- cological. Alprazolam (see BENZODIAZEPINES) has
ing, choking, chest discomfort, numbness and a been demonstrated to be effective in suppressing
fear of dying. Panic attacks can be associated with episodes. Tricyclic ANTIDEPRESSANTS and beta-block-
the symptoms of agoraphobia, in which there ers have also been reported as being effective.
is a fear of being in certain places or situations.
For example, an individual may have the feeling
of needing to escape when outside of the home paradoxical sleep See RAPID EYE MOVEMENT
alone, in wide open spaces, in a crowd or travel- SLEEP.
ing in a vehicle. Most panic attacks occur during
the daytime and only rarely do panic attacks occur
during sleep. paradoxical techniques Procedures commonly
A panic episode that occurs during sleep is used for the treatment of INSOMNIA. These tech-
characterized by a sudden awakening during NON- niques involve instituting wakeful activity, such as
REM-STAGE SLEEP, particularly stage two sleep (see reading, writing or watching television, whenever
SLEEP STAGES), with a feeling of intense fear of the patient is unable to sleep. The premise is that by
dying. Other somatic symptoms may be present. trying to remain awake sleep will occur naturally.
The panic disorders are most commonly seen in (Very often sleep disturbance may be due to the
young adults. There may be a prior history of child- strong attempts made to fall asleep.) The patient
hood separation anxiety, and the disorder tends to undergoing a paradoxical technique of trying to
run in families; it is more common in females. remain awake, by diverting the attention away
The cause of panic disorder is unknown; how- from sleep, allows sleep to occur more rapidly. (See
ever, infusions of lactate can precipitate episodes in also AUTOGENIC TRAINING, BEHAVIORAL TREATMENT OF
susceptible individuals. INSOMNIA, BIOFEEDBACK, COGNITIVE FOCUSING, SLEEP
 Parkinsonism 169

RESTRICTION THERAPY, STIMULUS CONTROL THERAPY, ing the daytime. In addition, there may be specific
SYSTEMIC DESENSITIZATION.) complaints related to the lack of body movement
that occurs during sleep, such as the inability to
arise to go to the bathroom or the inability to
parasomnia Term used for the disorders of turn over in bed. Muscular disorders, such as leg
arousal, partial arousal and sleep stage transition. A cramping or jerking of the limbs, can also occur
parasomnia represents an episodic disorder in sleep, during sleep. Vivid dreams and NIGHTMARES and
such as SLEEPWALKING, rather than a disorder of REM sleep behaviors may occur in patients with
sleep or wakefulness per se. The parasomnias may Parkinsonism.
be induced or exacerbated by sleep but do not pro- Parkinson’s disease affects up to 20 percent of
duce a primary complaint of INSOMNIA or EXCESSIVE the population over 60 years of age. The disorder
SLEEPINESS. According to the INTERNATIONAL CLAS- is associated with loss of the dopamine cells of the
SIFICATION OF SLEEP DISORDERS, the parasomnias are brain, particularly of the substantia nigra. Neu-
divided into four groups: the first, the disorders of rotransmitter abnormalities are present, particu-
arousal, comprises sleepwalking, SLEEP TERRORS and larly of dopamine, serotonin, and norepinephrine,
CONFUSIONAL AROUSALS; the second, the sleep-wake which may contribute to the sleep disturbance.
transition disorders, comprises SLEEP STARTS, SLEEP The disruption of nighttime sleep can often
TALKING, NOCTURNAL LEG CRAMPS and RHYTHMIC lead to increased sleepiness during the daytime.
MOVEMENT DISORDERS; the third, a group usually It is unclear whether the daytime sleepiness is
associated with REM sleep, consists of NIGHTMARES; primarily the result of impaired nighttime sleep or
SLEEP PARALYSIS; PENILE ERECTIONS, SLEEP-RELATED; whether it is an effect of degenerative neurologi-
PAINFUL ERECTIONS, SLEEP-RELATED; REM SLEEP- cal systems responsible for maintaining a regular
RELATED SINUS ARREST; and REM SLEEP BEHAVIOR sleep-wake pattern.
DISORDER; and the fourth group of other parasom- Patients with Parkinsonism, particularly those
nias includes SLEEP BRUXISM; PRIMARY SNORING; with the Shy-Drager syndrome, can have respira-
SLEEP ENURESIS; ABNORMAL SWALLOWING SYNDROME, tory disorders during sleep to the extent that the
SLEEP-RELATED; NOCTURNAL PAROXYSMAL DYSTONIA; OBSTRUCTIVE SLEEP APNEA SYNDROME or CENTRAL
SUDDEN UNEXPLAINED NOCTURNAL DEATH SYNDROME; SLEEP APNEA SYNDROME is present.
and BENIGN NEONATAL SLEEP MYOCLONUS. The medications used to treat Parkinson’s dis-
The parasomnias comprise those disorders that ease can also play a part in disturbing sleep-wake
are regarded as primary or major sleep disorders patterns. Medications primarily involve the use of
and do not comprise the occurrence of medical levodopa, which can decrease nighttime sleep and
or psychiatric events during sleep that otherwise exacerbate abnormal movement activity during
might not cause a complaint of insomnia or exces- sleep. However, treatment of Parkinson’s disease
sive sleepiness. Such disorders, for example, the is essential to maintain mobility, full alertness and
tremor of Parkinson’s disease, are not included in activity during the daytime and restfulness at night.
the section entitled “parasomnias.” SLEEP HYGIENE measures are essential to reinforce a
good sleep-wake cycle.
Polysomnographic monitoring may demonstrate
Parkinsonism Group of neurological disorders many features of disrupted sleep, including sleep
characterized by muscular rigidity, slowness of fragmentation with increased numbers of awaken-
movements, and tremulousness. The term is ings and arousals, and prolonged wakefulness dur-
derived from the most well-known neurological ing the night with a reduced amount of REM sleep.
disorder that produces these symptoms, Parkinson’s Sometimes there is a reduced amount of stage
disease. Associated with the neurological disorders three/four sleep (see SLEEP STAGES). Tremulousness
are sleep complaints, typically INSOMNIA. Patients occurs during wakefulness but usually disappears
often have difficulty in maintaining both a regular during sleep; however, it can reappear during
sleep pattern and a full period of wakefulness dur- brief arousals and episodes of awakening during
170 paroxetine

the night. Sometimes patients can have abnormal ing position during sleep. In such a position, the
movements such as myoclonic jerks or PERIODIC accumulation of fluid in the lungs is reduced and
LEG MOVEMENTS that occur during sleep, and there sleep may occur with fewer disturbances. The term
can also be tonic contractions of the muscles. ORTHOPNEA is also used for shortness of breath that
Disruption of REM sleep with frequent arousals, occurs in the recumbent position but is not neces-
and features of REM sleep occurring during other sarily associated with nocturnal sleep. (See also
sleep stages, is commonly seen. The presence of NOCTURNAL CARDIAC ISCHEMIA.)
excessive dreaming and nightmares may lead to
abnormal movement activities and behaviors dur-
ing REM sleep. SLEEP SPINDLE activity is generally paroxysmal nocturnal dystonia See NOCTURNAL
reduced in patients with Parkinsonism. PAROXYSMAL DYSTONIA.
Episodes of hypoventilation with central or
obstructive apneas are occasionally seen in patients
with Parkinsonism but are more common in paroxysmal nocturnal hemoglobinuria (PNH) An
patients who have the Shy-Drager form. acquired chronic hemolytic anemia that is charac-
Treatment of Parkinsonism is primarily through terized by intravascular hemolysis, which is exac-
the use of levodopa or dopaminergic medications erbated during sleep and results in hemoglobinuria
such as pramipexole or ropinerole. Other medi- (blood in the urine).
cations include anticholinergics, amantadine and The primary abnormality is an abnormal sensi-
bromocriptine. The treatment of the sleep distur- tivity of the red blood cells to complement (a medi-
bance involves good sleep hygiene and appropri- cal term for a substance produced by a certain type
ate usage of the anti-Parkinsonism medications. of cell that is involved in the breakdown of other
Sometimes daytime STIMULANT MEDICATIONS, such blood cells). The red cells undergo lysis (a medical
as methylphenidate or dextroamphetamine can be term for the destruction of cells), thereby releasing
useful; however, the benefits are often only tempo- hemoglobin into the blood and predisposing the
rary. The nighttime sleep may be helped by short- individual to venous thrombosis (blood clot). The
acting benzodiazepine hypnotics, and sometimes thrombosis is a common cause of death in patients
low doses of the sedative tricyclic antidepressant who are severely affected by paroxysmal nocturnal
amitriptyline. hemoglobinuria.
The disorder is diagnosed by either the acid
hemolysis test or the sucrose lysis test. The pres-
paroxetine (Paxil) See ANTIDEPRESSANTS. ence of low leucocyte alkaline phosphatase and
low red blood cell counts are other features of
diagnostic significance.
paroxysmal nocturnal dyspnea Term referring to The association between hemolysis and sleep
recurrent episodes of shortness of breath that occur is somewhat tenuous. The increased hemoly-
when an individual lies in the recumbent position, sis is often first noticed when awakening in the
typically during nocturnal sleep. This condition morning.
occurs in individuals with heart failure in whom Sometimes referred to as sleep-related hemo-
the ventricular dysfunction causes an increase in lysis, paroxysmal nocturnal hemoglobinuria is the
the pulmonary venous pressure, thereby allowing preferred term.
fluid to pass from the blood vessels into the alveoli
of the lung, impairing respiratory gas exchange.
Upon assuming the sitting or standing position, the pavor nocturnus Term derived from the Latin
fluid is cleared from the lungs, and the shortness pavor, for terror, and nocturnus, meaning at night;
of breath diminishes. Individuals who suffer from refers to night terrors. The term SLEEP TERRORS is
paroxysmal nocturnal dyspnea require several pil- now commonly used because it specifies that epi-
lows in order to be able to assume a semi-reclin- sodes occur out of sleep.
 periodic breathing 171

Paxil (paroxetine) See ANTIDEPRESSANTS. onset. The pain can produce arousals and awak-
enings during sleep that lead to a complaint of
INSOMNIA.
pemoline (Cylert) Is no longer available in the Peptic ulcer disease can be associated with
United States due to safety concerns regarding liver SLEEP-RELATED GASTROESOPHAGEAL REFLUX with acid
toxicity. indigestion, HEARTBURN, and a sour, acid taste in
the mouth. The pain of peptic ulcer disease often
radiates to the chest or back. There is typically
penile erections, sleep-related All healthy males a hunger-like sensation, often with nausea, and
from infancy to old age have penile erections there may be a cramping discomfort. The pain
during sleep. The erections occur with each REM becomes intense and constant if perforation of the
sleep episode, that is, approximately five times in ulcer occurs.
a night, each erection lasting about 30 minutes in There are hereditary factors involved in the
duration. The total amount of time that the penis cause of peptic ulceration. Individuals whose rela-
is erect decreases slightly with age to a total of tives have peptic ulcers have an increased likeli-
approximately 100 minutes in the elderly. hood of developing peptic ulcers; cigarette smoking
Erections during sleep have their onset in is associated with a greater risk of developing duo-
infants between three and four months of age. denal ulceration. Drug ingestion of antiinflamma-
They are usually not produced by sexual excite- tory agents is also associated with a greater chance
ment, but are an automatic response generated by of developing peptic ulceration.
the nervous system. However, some erections dur- Duodenal ulceration is most common at about
ing sleep occur in association with sexual dreams, 20 years of age whereas gastric ulcer peaks between
and NOCTURNAL EMISSIONS (“wet dreams”) during 50 and 60 years of age. There is an increased male
sleep are always associated with sexual dreaming. predominance of peptic ulceration, with a male to
An assessment of normal penile erectile ability female ratio of 2.5 to 1.
during sleep can be used to determine whether a Polysomnography demonstrates an awakening
complaint of IMPOTENCE has an organic or psycho- that occurs just prior to the sensation of abdomi-
logical cause. Patients with an organic cause of the nal discomfort. Confirmation of the peptic ulcer
impotence have an inability to obtain adequate disease is usually made by the demonstration of an
erections during sleep. This form of testing, termed ulcer by radiological or endoscopic studies.
NOCTURNAL PENILE TUMESCENCE TESTING, is often Treatment of peptic ulcer disease is by reduction
used to determine the cause of the impotence of gastric acid secretion and by such medications
before the patient is referred either for implanta- as rantidine (Zantac) or cimetidine (Tagamet). (See
tion of an artificial penile prosthesis or for psychi- also ESOPHAGEAL PH MONITORING.)
atric or sex therapy. (See also PENILE ERECTIONS,
IMPAIRED SLEEP-RELATED, IMPOTENCE, PAINFUL EREC-
TIONS, SLEEP-RELATED.) periodic breathing A breathing pattern that
consists of shallow episodes alternating with an
increased depth of breathing. This can be seen
penile tumescence, sleep-related See PENILE at any age and commonly is seen in infants with
ERECTIONS, SLEEP-RELATED. breathing disorders (see INFANT SLEEP DISORDERS). It
is also a typical pattern of the SLEEP-RELATED BREATH-
ING DISORDERS, such as the OBSTRUCTIVE SLEEP APNEA
peptic ulcer disease This disease can awaken SYNDROME or CENTRAL SLEEP APNEA SYNDROME. The
individuals at night because of a pain or discom- periodicity of the breathing may induce a slight
fort present in the abdomen. Spontaneous pain reduction in central respiratory drive that allows
occurs during sleep that is typically a dull, steady the upper airway to collapse, thereby exacerbating
ache, usually within one to four hours after sleep or inducing an obstructive apneic event.
172 periodic hypersomnia

Periodic breathing is seen in normal, healthy The leg movements are of short duration, lasting
individuals at high altitudes due to the low level 0.5 to 5 seconds, and recur repetitively at intervals
of inspired oxygen. This pattern of breathing is of approximately 20 to 40 seconds. The movements
usually relieved by the administration of oxy- can occur in either leg or both simultaneously or
gen or by treatment with medications such as asynchronously. The episodes typically occur in
acetazolamide. non-REM sleep and are usually absent during REM
A periodic pattern of breathing was first described sleep. Often they cluster throughout the night so
by Cheyne and Stokes in patients with cardiac dis- that there may be a run of 50 movements followed
ease. It is a pattern of breathing that commonly by uninterrupted sleep before a second or even a
occurs during non-REM sleep; it is believed to be third cluster of movements.
produced by either an increased circulation time or Patients with periodic limb movement disorder
intracerebral disease. present with the complaint of being unrested upon
Periodic breathing is produced by alteration in awakening in the morning. There may be tiredness
the blood carbon dioxide and oxygen levels, which and fatigue during the day and there may be fre-
causes a cessation of breathing, thereby allowing quent awakenings during the major sleep episode.
a low carbon dioxide level to return to normal. Typically this disorder has been present for many
HYPOXEMIA or HYPERCAPNIA produces respiratory years, often having been present since childhood. If
stimulation with an increased depth and rate of the frequency of the episodes is sufficient to cause
breathing, which causes a lowering of the carbon severe disruption of the nocturnal sleep episode
dioxide level and an elevation of the blood oxygen then daytime sleepiness may result. Usually this
level. These changes lead to a reduction of respira- sleepiness is somewhat vague and nonspecific at
tory drive, thereby producing the oscillations of the onset but may become more severe with the
ventilation. (See also ALTITUDE INSOMNIA, CHEYNE- increasing duration of the disorder.
STOKES RESPIRATION, INFANT SLEEP APNEA.) People with the RESTLESS LEGS SYNDROME will typ-
ically have periodic limb movement disorder dur-
ing sleep. The episodes of limb movements can be
periodic hypersomnia See RECURRENT HYPER- exacerbated by metabolic disorders, such as chronic
SOMNIA. uremia or hepatic disease. Medications, such as the
tricyclic ANTIDEPRESSANTS, can aggravate this disor-
der and the withdrawal of CENTRAL NERVOUS SYSTEM
periodic leg movements This term is synony- depressants, such as the HYPNOTICS, BENZODIAZEPINES,
mous with periodic limb movements, nocturnal and BARBITURATES, can also exacerbate it.
myoclonus and periodic movements of sleep. It Typically the patient is unaware of the leg
refers to periodic leg movements that occur with movements, because they occur only during sleep;
a stereotyped pattern of 0.5 to 5 seconds duration polysomnographic documentation may be required
in one or both legs. The movement is typically a to establish the presence of the disorder. The leg
rapid partial flexion of the foot at the ankle, exten- movements are often associated with upper limb
sion of the big toe and partial flexion of the knee movements and hence the term periodic limb
and hip. movement disorder is preferred over such terms as
periodic leg movements in sleep.
Treatment may be by means of medications that
periodic limb movement disorder A disorder of suppress the arousals related to the movements or
recurrent episodes of leg movements that occur the use of the newer dopaminergic agents such as
during sleep that can be associated with a com- pramipexole.
plaint of either INSOMNIA or EXCESSIVE SLEEPINESS.
Episodes of leg movements may be infrequent
during sleep or may occur up to several thousand periodic movements of sleep See PERIODIC LEG
times during a typical sleep episode. MOVEMENTS.
 phase response curve 173

period length The interval between recurrences of palate caused by an elongated soft palate and nar-
a particular phase of a biological rhythm. It can be rowing of the air passage at that level. Patients with
measured from peak to peak, or trough (low point) obstruction of the pharynx at the soft palate level
to trough, or at some other recurring point of the may be suitable for the UVULOPALATOPHARYNGO-
rhythm. The period length of the sleep-wake cycle PLASTY procedure for the relief of SNORING and the
is typically 24 hours. (See also CHRONOBIOLOGY, CIR- obstructive sleep apnea syndrome. Commonly the
CADIAN RHYTHMS, NREM-REM SLEEP CYCLE.) obstruction in the airway is at the oropharyngeal or
hypopharyngeal level, in which case procedures to
bring the tongue forward, such as hyoid myotomy
PGO spikes PGO is an acronym for pontogenicu- (Hyoid myotomy is a surgical procedure to correct
looccipital spikes, which are generated from the obstructive sleep apnea syndrome.) or mandibular
pons immediately prior to the onset of REM sleep. advancement surgery, may be helpful. Mechanical
They are rapidly conducted through the lateral devices, including the TONGUE RETAINING DEVICE,
geniculate body to the occipital cortex. PGO spikes or other dental appliances, such as the EQUALIZER,
appear to be produced by cells in the pons that can be useful in maintaining a patent posterior
have been called PGO “on” neurons. The spikes are pharyngeal airway in some patients. A more effec-
associated with the development of phasic activity tive means is by the use of a CONTINUOUS POSITIVE
during REM sleep, such as rapid eye movements, AIRWAY PRESSURE DEVICE, which applies a positive
and may be elicited by sensory stimulation, such as air pressure to the posterior pharynx, thereby pre-
sound or touch. venting the collapse of the pharyngeal tissue.
Various explanations have been offered for the
function of PGO spikes. It has been suggested that
PGO spikes may be involved in alertness during phase advance A chronobiological term applied
REM sleep, general brain stimulation during REM to an advancement of a rhythm in relationship to
sleep to enhance learning and memory, and may another variable, most commonly clock time. (See
be important in the production of dream imagery also PHASE DELAY, PHASE SHIFT.)
during sleep. (See also DREAMS.)

phase delay The delay of a rhythm in relation

pharynx Derived from the Greek for “the throat”; to another variable, usually clock time. (See also
refers to the musculo-membranous passage among PHASE RESPONSE CURVE, PHASE SHIFT.)
the mouth, posterior nares and the larynx and the
esophagus. The pharynx is often divided into the
portion above the level of the soft palate, which is phase response curve A plot of the change in
called the nasopharynx, a lower portion between the phase shift as a response to a stimulus given
the soft palate and the epiglottis, called the oro- at different points of a biological cycle. The phase
pharynx, and the hypopharynx, which lies below response curve demonstrates an animal’s ability to
the tip of the epiglottis and opens into the larynx advance or delay a particular rhythm, most com-
and esophagus. It has been suggested that the por- monly the rest activity or the sleep-wake cycle.
tion of the pharynx that lies behind the soft palate (Although a phase response curve has not yet
be called the velopharynx. been documented in humans, there is evidence
The oropharynx is the prime site of obstruc- that a phase change of the sleep-wake cycle can be
tion in patients who have the OBSTRUCTIVE SLEEP accomplished by altering the timing of exposure to
APNEA SYNDROME. Evaluation of the pharynx may bright light.)
involve FIBEROPTIC ENDOSCOPY of the upper airway The phase response curve demonstrates that
or CEPHALOMETRIC RADIOGRAPHS. phase delays occur when the light stimulus is pre-
Most patients with obstructive sleep apnea sented early in the night, whereas phase advance
syndrome have obstruction at the level of the soft shifts occur when the stimulus is presented late
174 phase shift

in the night; and little or no phase response shift photoperiod The duration of light in a light-dark
occurs when the stimulus is presented during the cycle. In environments where darkness does not
day portion of the light-dark cycle. (See also LIGHT occur until 10 P.M. and sunrise occurs at 4 A.M.,
THERAPY, PHASE SHIFT.) the photoperiod will be 18 hours in duration. In
the extreme polar regions, the photoperiod may
last 24 hours when there is continuous light.
phase shift A displacement of a rhythm in rela- The photoperiod is often varied during experi-
tionship to some other variable, usually clock mental studies of the effects of light upon animals,
time. and so the portion of light to dark is varied.
An abnormal photoperiod may be a factor in
producing sleep disturbance, and some CIRCADIAN
phase transition This term is used to specify one RHYTHM SLEEP DISORDERS, such as DELAYED SLEEP
of the two junctures between the major sleep epi- PHASE SYNDROME, may be induced by an abnormal
sode and the major portion of wakefulness in the photoperiod in the Arctic or Antarctic regions.
24-hour sleep-wake cycle.

phylogeny The evolution or development of a

phasic event A brain muscle or autonomic event plant or animal. The phylogeny of sleep is based on
of an episodic or fluctuating nature that occurs studies of the evolutionary physiology of vertebrate
during a sleep episode. Such a phasic event is sleep, which have revealed three distinct phyloge-
seen during REM sleep and can comprise muscle netic stages. The first type of sleep, which is found
twitches or the rapid eye movements. Usually, in fish and amphibians, is termed “primary sleep”
phasic events have a duration that is measured and comprises different sleep-like forms of rest.
in terms of milliseconds, and they last one to two This type of sleep appears to be a non-differenti-
seconds at the most. ated form compared to the sleep patterns found in
higher vertebrates. An “intermediate sleep” form
is found in reptiles and is characterized by acti-
pH monitoring Technique used to evaluate the vated and nonactivated stages, which divide sleep
acidity of esophageal contents in order to deter- into two distinct phases. Nonactivated sleep has a
mine if gastroesophageal reflux has occurred. more pronounced, synchronized, electrical cerebral
A pH probe is usually placed through the nose activity, with features that are indicative of SLOW
approximately 5 centimeters above the esophageal WAVE SLEEP.
sphincter. Esophageal pH is generally 7.0 and the The third type of sleep, a “paradoxical phase of
reflux is associated with drop in the pH of the distal sleep” seen in birds, is characterized by desynchro-
esophagus below the level of 4.0. Following a drop nization of the electroencephalogram and a reduc-
in the pH, clearance of the acid in the esophageal tion in muscle tone. Suggestive of REM sleep, this
sphincter is associated with a rise to a pH of 5 or type of sleep is differentiated from the slow activity
greater. that is more pronounced in mammals.
PH monitoring is usually performed over a 24- On the evolutionary scale, slow wave sleep
hour period or over the sleep episode to determine appears to have arisen about 200 million years ago,
whether gastroesophageal reflux occurs in asso- and paradoxical sleep approximately 50 million
ciation with sleep or daytime activities. Esophageal years later.
reflux can be the cause of esophageal disorders, This evolution of sleep correlates with the
such as esophagitis, or sleep-related disorders, degree of development of overall cerebral electri-
such as respiratory distress during sleep. (See also cal activity and the level of development of the
LARYNGOSPASM, SLEEP-RELATED, GASTROESOPHAGEAL higher regions of the brain. The evolution of the
REFLUX, SLEEP-RELATED, OBSTRUCTIVE SLEEP APNEA thalamo-cortical system is of particular impor-
SYNDROME.) tance in the development of sleep. This system
 plethysmograph 175

first began in amphibians, became more special- suppressed during the day. The circadian pattern of
ized in reptiles, and is most clearly developed melatonin levels peaks between 1 A.M. and 5 A.M.
in mammals. The development of mammalian and is maximal around the time of puberty. Mela-
sleep is clearly related to the development of the tonin is an important hormone in the regulation of
thalamo-cortical pathways. The development of circadian rhythms. It also appears to be important
REM sleep appears to arise from the early forms in the control of reproduction and in normal sexual
of activated sleep. development.
The pineal gland is innervated (nerve fibers go
to the gland) by sympathetic fibers that arise in
Pickwickian syndrome Term applied to individu- the superior cervical ganglion of the neck. Light
als who are overweight, with ALVEOLAR HYPOVEN- impulses from the retina pass through the SUPRA-
TILATION, an elevated carbon dioxide level and CHIASMATIC NUCLEUS of the hypothalamus. Path-
abnormally low oxygen level in the blood, and, ways extend from the suprachiasmatic nucleus to
most commonly, to patients who have severe the spinal cord and innervate the superior cervical
OBSTRUCTIVE SLEEP APNEA SYNDROME, who are sleepy ganglion and from there pass to the pineal gland.
during the daytime, are loud snorers, obese and (See also CIRCADIAN RHYTHMS.)
have impairment of daytime blood gases. The term
was derived from the description of Joe the fat
boy in The Posthumous Papers of the Pickwick Club, placebo A sham or false treatment that most
published in 1836. Charles Dickens modeled his commonly is in the form of a tablet with no effec-
description of the sleepy boy upon someone who tive ingredient, used for either the psychological
very clearly had all the typical features of obstruc- effects or for control purposes in research studies.
tive sleep apnea syndrome. The term is derived from the Latin, meaning “I will
Although the term Pickwickian syndrome had please.”
been used prior to the 1950s, according to Simon A placebo is also known as a “dummy medi-
Williams, writing in Sleep and Society, it was brought cation.” The placebo response depends upon the
to more general attention in a paper published in patient-physician relationship, with the sense of
1956 by Burwell, et al. The term may apply to dis- being helped by the physician an essential element
orders of impaired respiration during sleep other to its effectiveness. The effects of a placebo are
than obstructive sleep apnea, and it frequently most commonly experienced as changes in mood
is used to describe people who have right-sided or other subjective feelings. The response can be
heart failure in association with the other typical either positive or negative, depending upon the
features. desired effect. Usually the response to a placebo
It is preferable to use more specific terms than cannot be taken to mean that the patient has
Pickwickian syndrome to describe patients who either a “psychogenic” or “real” symptom. (See also
have sleep disorders characterized by OBESITY, MEDICATIONS.)
hypersomnolence, snoring and alveolar hypoven-
tilation, such as the obstructive sleep apnea
syndrome or CENTRAL ALVEOLAR HYPOVENTILATION Placidyl (ethchlorvynol) See HYPNOTICS.
SYNDROME.

plethysmograph A biomedical instrument used

pineal gland A small, pea-sized protuberance for measuring changes in the volume of an organ
situated at the back of the brain above the brain or a part of the body. Plethysmography is used in
stem. Rene Descartes in the 17th century regarded SLEEP DISORDERS MEDICINE for determining changes
the pineal as the seat of the soul. The pineal gland in chest and abdominal volume and in the mea-
is markedly influenced by light because its primary surement of changes in TUMESCENCE (swelling) of
hormone, MELATONIN, is released at night and is the penis during sleep.
176 poliomyelitis

Plethysmography is most commonly performed can present with increasing daytime sleepiness due
for the determination of SLEEP-RELATED BREATH- to impairment of respiration during sleep, which
ING DISORDERS by means of an inductive plethys leads to fragmented sleep with blood gas changes
mograph. Loops of insulated wire are placed around characterized by oxygen desaturation at night. In
the rib cage and abdomen and connected to a trans- such cases, assisted ventilation during sleep may be
ducer so that changes in impedance of the wire necessary, and if daytime ventilation is impaired,
bands reflect changes in the volume of the chest or assisted ventilation 24 hours a day may be indi-
abdomen. Typically, an increasing lung volume is cated. (See also CENTRAL SLEEP APNEA SYNDROME,
associated with a reduction in abdominal volume. SLEEP-RELATED BREATHING DISORDERS.)
However, if UPPER AIRWAY OBSTRUCTION occurs, there
is a reduction of lung volume, with an increase in
abdominal volume due to the diaphragm action. polycythemia An increase in the size of the red
This paradoxical pattern of respiration is indica- blood cell mass of the blood. Polycythemia is occa-
tive of obstructive sleep apneic episodes, whereas a sionally seen in patients with the OBSTRUCTIVE SLEEP
reduction of activity of both bands is representative APNEA SYNDROME, particularly when associated
of central apneic episodes. with chronic obstructive lung disease (the OVERLAP
Mercury-filled STRAIN GAUGES are placed around SYNDROME), which produces a more constant level
the penis in order to detect changes in the volume of HYPOXEMIA. Approximately 7 percent of patients
of the penis during sleep. Usually a strain gauge is presenting with obstructive sleep apnea syndrome
placed around the base of the penis and another are found to have polycythemia. The chronic
at the tip. During REM sleep all healthy males will hypoxemia stimulates the red blood cell marrow
have penile erections and the measurement of the to increase the number of red cells so that the
size of the penile erection by plethysmography oxygen-carrying capacity of the blood is increased.
gives an indication as to whether the patient has Treatment of the sleep-related hypoxemia leads to
the physiological capability of attaining normal improvement of the polycythemia.
erections in sleep (which helps to assess if impo-
tence is of a physiological or psychiatric cause).
Respitrace is the trade name for an inductive ple- polysomnogram The continuous and simultane-
thysmograph that is capable of measuring changes ous recording of physiological variables during
in volume of the chest and abdomen to determine sleep; includes the ELECTROENCEPHALOGRAM (EEG),
ventilation. (See also CENTRAL SLEEP APNEA SYN- the ELECTROOCULOGRAM (EOG), and the ELECTRO-
DROME, OBSTRUCTIVE SLEEP APNEA SYNDROME, PENILE MYOGRAM (EMG). In addition, the electrocardio-
ERECTIONS, SLEEP-RELATED.) gram (ECG) (a graph of the electrical activity of
the heart) records respiratory airflow, respiratory
movements, blood oxygen saturation and lower
poliomyelitis A viral infection that affects the limb movement activity. Other commonly taken
nerves that innervate skeletal muscles. This dis- measures include intraesophageal pressure, intra
order can affect the nerves within the brain stem esophageal pH changes, end-tidal carbon dioxide
or spinal cord, and as a result there can be wast- values and penile tumescence.
ing and atrophy of the muscles, leading to severe The polysomnogram is the recording upon
weakness or paralysis. Patients with severe polio- which sleep disorder specialists rely in order to
myelitis may have the inability to sustain respi- obtain objective documentation of a patient’s phys-
ratory movements on their own and therefore iological status during sleep. It typically consists of
require assisted VENTILATION, particularly during a paper tracing, approximately 1,000 pages long.
sleep. The late effect of poliomyelitis may produce However, it may be recorded on magnetic tape or
worsening of the muscle strength many years after on a computer disc.
the initial infective insult, and a picture of progres- The polysomnogram is scored in a standard
sive ventilatory deterioration may be seen. Patients manner according to epochs of 20 or 30 sec-
 polysomnography 177

onds in duration, and sleep is scored by the Alan other physiological variables during sleep, such as
Rechtschaffen and Anthony Kales method. (See respiratory movements, airflow, electrocardiogram,
also POLYSOMNOGRAPHY, SLEEP DISORDER CENTERS.) blood-oxygen saturation, carbon dioxide levels,
urometry, skeletal muscle activity, pH monitoring
and penile tumescence (erections of the penis) to
polysomnography Studies of sleep require the help in analyzing the cause of impotence.
measurement of several physiological variables, The electrical signals go in just one direction—
including activity of the brain, the eyes and the from the patient to the polygraph—so there is
muscles. Sleep is typically recorded on an electro- little possibility of the patient receiving an electrical
encephalograph machine, which has the ability of shock. The tracings for each sensor are recorded on
measuring not only the ELECTROENCEPHALOGRAM a continuous roll of moving paper, which becomes
(EEG), but also the electromyographic (EMG) (see the record of a night’s sleep, and that record is
ELECTROMYOGRAM) activity and electrooculography known as a POLYSOMNOGRAM. Typically, a patient
(EOG) (see ELECTROOCULOGRAM). The EEG records will be asked to come to the sleep laboratory an
the brain activity, the EMG records the muscle hour or two before the patient’s usual bedtime. The
activity, and the EOG monitors eye movements. electrodes are attached at the appropriate place to
The electroencephalogram electrodes are placed enable recording of each desired measure. An entire
on the scalp in the routine manner; however, only a night of sleep will be recorded on the polygraph,
few electrodes are required. For reporting sleep, an creating almost a thousand pages of chart paper
electrode is centrally placed on the head (in the C3 or monitoring of EEG waves, eye movements, muscle
C4 position), and this electrode is referred to an elec- activity and the other physiological variables.
trically neutral lead usually placed on the mastoid For clinical or research studies, the different
bone behind the ear (at either A1 or A2 position). parameters can be measured according to differ-
This produces a unipolar recording, which measures ent arrays called a MONTAGE, depending upon the
the difference in the electrical activity between the clinician’s preference and the particular variables
C3 position and the A1 electrode. The electrodes are under investigation. A standard recording for a
usually attached to the head by means of collodion, patient with the disorder of OBSTRUCTIVE SLEEP
a temporary glue, in order to prevent their dislodg- APNEA SYNDROME might be as follows: two electro-
ment during a whole night’s recording. (Electrodes encephalogram measures, one at the C3 position
may be attached to the face with surgical tape, but and one at the O2 position, as well as electroocu-
collodion is used to attach electrodes to the scalp.) logram and chin electromyogram recordings. Leg
The electromyogram is usually recorded from movement activity can be recorded by means of
chin-muscle activity. Two electrodes are placed electromyographic measures of the right and left
just beneath the tip of the chin and the difference anterior tibialis muscles in order to help confirm
between recorded potentials is measured, giving a body movements associated with arousals that
bipolar recording. may occur because of apnea episodes. In order to
With the electrooculogram, the electrodes are determine airflow, THERMISTORS that determine
attached to the outer canthus of each eye to record temperature changes of inspired and expired air
eye movements. Usually two eye channels are may be placed at both left and right nasal passages
measured, so when the eyes move conjugately, the and another at the mouth. A small microphone
tracings appear as mirror images of each other. The may be utilized in order to determine sounds of
electro-oculogram electrodes are referred to a ref- SNORING. Respiratory movements are detected by
erence electrode. Because the retina is negatively means of bellows pneumographs placed around the
charged with respect to the surface of the eye, abdomen and chest or, alternatively, mercury strain
movements of the eye induce a potential differ- gauges can be placed on the chest and abdomen.
ence, which is recorded by the electrodes. An electrocardiogram is recorded by chest leads.
In addition to measuring sleep activity, poly- An infrared, transcutaneous sensor may be used for
somnography often involves the measurement of recording oxygen saturation values, and end-tidal
178 pons

carbon dioxide levels may be recorded by means of potential that is commonly seen during stages two
a small tube placed in one of the nostrils attached and three sleep in adolescents and young adults.
to a capnograph. There is no known cause or association of POSTS.
Patients undergoing polysomnography for sus- (See also ELECTROENCEPHALOGRAM, NON-REM-STAGE
pected seizure disorders may have additional elec- SLEEP, SLEEP STAGES.)
troencephalogram channels recorded, whereas a
patient undergoing studies for PENILE ERECTIONS,
SLEEP-RELATED would have sleep measured along posttraumatic hypersomnia A disorder of EXCES-
with measurements of penile tumescence during SIVE SLEEPINESS that occurs within 18 months of a
sleep. traumatic event involving the central nervous sys-
Although patients typically undergo polysom- tem. This disorder may consist of a changed sleep
nography over their habitual sleep period for a pattern, such as a long sleep duration at night, as
minimum of eight hours of recording, in many well as frequent sleep episodes during the day on
clinical situations it may be necessary for the a background of excessive sleepiness. The sleep
patient to undergo more than one night of record- disturbance typically occurs within months of the
ing in order to obtain adequate information. (See trauma and may resolve spontaneously within a
also ACCREDITED CLINICAL POLYSOMNOGRAPHER, SLEEP period of weeks to months. However, sometimes
DISORDER CENTERS.) the sleep disturbance may be long-lasting and may
never resolve. This disorder is diagnosed in the
presence of severe excessive daytime sleepiness if
pons Region of the brain stem that lies between there are no other features of neurological deficit.
the medulla and the midbrain; important in the Certain parts of the CENTRAL NERVOUS SYSTEM
maintenance of sleep and wakefulness because are more likely to induce this sleep disturbance if
it contains the LOCUS CERULEUS, RAPHE NUCLEI, involved in the trauma, such as injury involving
and reticular nuclei. Although the pons is clearly the hypothalamic or brain stem regions. Pathologi-
defined by the external anatomical landmarks, cal studies have usually demonstrated widespread
the nuclei extend across boundaries. Various and lesions throughout the central nervous system at
incompatible terms have been used to describe the autopsy so that the specific site causing posttrau-
reticular regions of nuclei. matic hypersomnia is unknown.
The raphe nuclei, which are likely to be impor- Polysomnographic studies of this disorder have
tant in the regulation of phasic events of REM sleep, shown a slightly prolonged nocturnal sleep period
contain serotonin. Although the raphe nuclei of the or relatively normal nocturnal sleep with exces-
pons were thought to be important in the mainte- sive sleepiness, evident on MULTIPLE SLEEP LATENCY
nance of slow wave sleep, the region around the TESTING. The daytime sleep episodes are generally
nuclei appears to be more important. of non-REM sleep. It is possible that some patients
The pons is also the site of the pontogeniculooc- with this disorder have microsleep episodes that
cipital (PGO) waves (see PGO SPIKES), which are impair daytime functioning and may be detectable
large phasic potentials generated from the pons only by 24-hour polysomnographic monitoring.
immediately prior to the onset of REM sleep. (See Diagnosis of this disorder is made in part upon
also SLEEP ATONIA.) the temporal association with the head trauma.
Other disorders of excessive sleepiness contribute
to motor vehicle accidents, which may lead to head
pontogeniculooccipital spikes (PGO) See PGO trauma. Patients suspected of having posttraumatic
SPIKES. hypersomnia should have other disorders of sleepi-
ness ruled out by appropriate polysomnographic
investigation.
Positive Occipital Sharp Transients of Sleep Treatment of posttraumatic hypersomnia is
(POSTS) A transient electroencephalographic largely symptomatic and rests on the use of day-
 pregnancy-related sleep disorder 179

time STIMULANT MEDICATIONS, such as methylpheni- predormital myoclonus See SLEEP STARTS.
date to alleviate the sleepiness.

pregnancy-related sleep disorder Sleep disor-

post-traumatic stress disorder (PTSD) A disorder der characterized by either EXCESSIVE SLEEPINESS
brought about by exposure to an extreme trau- or INSOMNIA occurring during the course of preg-
matic event, such as an accident, violence, or natu- nancy. Typically the disorder is a biphasic one,
ral disaster. PTSD is a common reaction to military with the onset of sleepiness during the first trimes-
service in a war zone. Sleep disorders, including ter and insomnia in the third trimester. In some
frequent nightmares, are symptoms of PTSD. Other women, parasomnia activity, such as NIGHTMARES
symptoms include flashbacks, anxiety, sadness, or and SLEEP TERRORS, can occur in association with
uncontrollable anger. Help from a trained profes- the pregnancy.
sional may be useful or necessary. Complaints of tiredness, fatigue and sleepiness
are common during the first trimester, sometimes
even before the pregnancy has been diagnosed.
pramipexole (Mirapex) A clinically effective The TOTAL SLEEP TIME can be increased and a preg-
nonergot dopamine agonist used in the treatment nant woman will frequently have the need to take
of RESTLESS LEGS SYNDROME (RLS). Pramipexole has a nap.
preferential affinity to the D3 receptor subtype; the Normal pregnancy is associated with changes
D3 receptor subtype seems to be the most impor- in the quality of nighttime sleep and an alteration
tant in suppressing the features of RLS. Pramipexole in daytime alertness. Typically in the first trimester
also interacts with D2 and D4 receptors. However, there is an increased sleepiness with a heightened
it has seven times greater affinity for the D3 recep- desire to take a daytime nap. For some women who
tor than it does for the D2 or D4 receptor. It has experience ANXIETY related to the pregnancy, insom-
some affinity for norepinephrine receptors but little nia may occur, related to the emotional components
affinity for 5HT (SEROTONIN) receptors. Pramipexole of the pregnancy and not due to any pregnancy-
may also provide neuroprotective effects through related physical condition. CAFFEINE or NICOTINE
depression of dopamine metabolism, antioxidant withdrawal may add to the sleep disruption.
effects and stimulation of trophic activity. During the second trimester, the tendency for
The limited studies available suggest that it is daytime napping disappears; however, the quality
effective in treating restless legs syndrome and sup- of the nocturnal sleep episode starts to deteriorate.
presses periodic limb movements. Its profile and SLEEP LATENCY, the number of awakenings and the
side effect profile appear to be better than those SLEEP EFFICIENCY tend to increase at this time.
of L-DOPA or pergolide: It causes less daytime aug- Some of the sleep disturbances in the later
mentation of RLS than L-dopa and less nausea than months of the pregnancy may be related to the
does pergolide. The pharmacologic profile includes increase in the physical complaints at this time,
an elimination half-life of 12.9 hours. Pramipexole such as an uncomfortable sleep position due to
does not interact with cytochrome P450 enzymes back discomfort, increased urinary frequency and
and is not expected to alter responses to concomi- fetal movements.
tant medications by interfering with their metabo- Because of increased abdominal pressure, it
lism. It is an effective antiparkinsonian medication. might be expected that sleep-related breathing
Doses are from 0.125 milligram to 4.5 milli abnormalities would increase. However, respiratory
grams. Side effects that have been encountered disturbance has not been described in pregnancy,
include nausea, constipation, and insomnia. Sleep- and this may be due to the increased progesterone
iness and visual hallucinations occur more com- levels at this time that act as a respiratory stimu-
monly than with placebo. The brand name for lant. TIDAL VOLUME is increased by PROGESTERONE.
pramipexole is Mirapex. (See also PERIODIC LEG Polysomnographic studies have demonstrated a
MOVEMENTS.) gradual reduction of deeper stages three/four sleep
180 premature infant

during the pregnancy (see SLEEP STAGES), with its is at risk, sedative hypnotics may be indicated in
absence in the later stage of pregnancy in some the third trimester, but only under the guidance
women. The sleepiness may be clinically evident of an obstetrician. (See also INFANT SLEEP DISOR-
and documented by MULTIPLE SLEEP LATENCY TESTING. DERS, INSUFFICIENT SLEEP SYNDROME, SLEEP-RELATED
The polysomnographic features of the nocturnal BREATHING DISORDERS.)
sleep disturbance are typically those of an increased
sleep latency, frequent awakenings, increased stage
one sleep and reduced sleep efficiency. premature infant Infant born after the 27th week
There is some evidence to suggest that post- of pregnancy and before full term, who weighs
partum psychoses may be related to the sleep state between 1,000 grams (2.2 pounds) and 2,500
changes that occur in late pregnancy. Following grams (5.5 pounds). Premature infants are more
delivery, REM sleep decreases markedly and nor- likely to have SLEEP-RELATED BREATHING DISORDERS
malizes over the subsequent two weeks, and there characterized by APNEA. Apneic episodes occur pre-
is a gradual recovery of stage four sleep after de dominantly during sleep but can also occur during
livery. wakefulness. This disorder, APNEA OF PREMATURITY,
Following delivery, the disturbed quality of sleep often spontaneously resolves as the infant ages.
generally resolves itself unless other factors inter- Premature infants have a greater risk of suffering
vene, such as postpartum depression, in which case from SUDDEN INFANT DEATH SYNDROME than full-
insomnia or hypersomnia due to MOOD DISORDERS term infants. (See also INFANT SLEEP, INFANT SLEEP
may occur. There may now be sleep-related prob- APNEA, INFANT SLEEP DISORDERS.)
lems because of the frequent awakening of the
newborn, but those problems are environmentally
caused rather than a physical complaint associated premature morning awakening See EARLY MORN-
with the post-pregnancy period. The new mother ING AROUSAL.
can minimize the effects of sleep deprivation that
often occur because she interrupts her sleep to
respond to the newborn, by taking turns with her premature ventricular contraction See VENTRIC-
spouse to respond to the newborn if the cries are ULAR PREMATURE COMPLEXES.
not food-related, or, if she is bottle-feeding, by
keeping the baby nearby so it is easier to go back
to sleep after attending to the newborn, or by primary insomnia See PSYCHOPHYSIOLOGICAL
taking naps during the day at the same time that INSOMNIA or IDIOPATHIC INSOMNIA.
the newborn naps so that she does not try to get
through the next night of interrupted sleep com-
pletely exhausted. primary snoring A disorder characterized by loud
The onset of fatigue, tiredness, and exces- sounds that come from the back of the mouth
sive sleepiness (of relatively short duration) in a during breathing in sleep and in the absence of
woman of childbearing age should suggest the pos- impaired breathing. This disorder is differentiated
sibility of pregnancy-related sleep disorder. Other from the OBSTRUCTIVE SLEEP APNEA SYNDROME, in
disorders contributing to sleep disruption, such as which loud snoring is associated with impaired
NARCOLEPSY or PERIODIC LIMB MOVEMENT DISORDER, VENTILATION during sleep, sleep disruption and
should be considered in the differential diagnosis. abnormal cardiovascular features. Usually, primary
Treatment of pregnancy-related sleep disorder snoring is noted by a disturbed bed partner. The
is purely supportive mainly by SLEEP HYGIENE mea- snorer is typically unaware of the loud snoring;
sures. Pregnant women should not take hypnotic however, there may be a brief gasp or choking sen-
medications. However, if the sleep disturbance is sation at the termination of a loud snore.
associated with the development of severe anxiety The snoring is usually rhythmical, with a con-
or DEPRESSION, and the maternal or fetal well-being tinuous sound made during inspiration and expira-
 prolactin 181

tion that can be worsened by body position, such or redundant nasal mucosa. Treatment of upper
as sleeping on the back. (Sometimes this form of respiratory tract infections, or the use of nasal
snoring is eliminated when the snorer lies on the decongestants or antihistamines, may be help-
side.) ful. Specialized operative procedures, such as the
Any disorder that produces narrowing of the UVULOPALATOPHARYNGOPLASTY operation, may be
upper airway, such as enlarged tonsils, acute rhi- effective in reducing the snoring in many patients;
nitis or upper respiratory tract infections, may however, careful selection is necessary as not all
exacerbate or bring out the tendency for primary patients will respond to this procedure.
snoring. Medications that impair arousal, such as
HYPNOTICS or ALCOHOL, may also exacerbate the
tendency for snoring. Often the development of progesterone A female sex hormone, used in
snoring is associated with increasing weight gain sleep medicine in the form of medroxyprogester-
and can be relieved in many patients by loss of one (see RESPIRATORY STIMULANTS), for stimulation
body weight (see OBESITY). of respiration to treat some SLEEP-RELATED BREATH-
Snoring is more common in males than in ING DISORDERS.
females and is most common for both groups in
the elderly population over the age of 65 years.
However, snoring may occur at any age and may progressive relaxation The sequential relaxation
be seen in infancy, but it is more commonly seen of muscle groups to assist in sleep onset for those
in children associated with tonsillar or ADENOIDAL with INSOMNIA. This method of relaxation was first
enlargement before or around the time of puberty. proposed by Edmund Jacobson and is occasion-
Polysomnographic monitoring helps to distin- ally referred to as JACOBSONIAN RELAXATION or
guish primary snoring from the obstructive sleep SLEEP EXERCISES. (See also DISORDERS OF INITIAT-
apnea syndrome. UPPER AIRWAY OBSTRUCTION is not ING AND MAINTAINING SLEEP, PSYCHOPHYSIOLOGICAL
present during sleep, and the sleep episode is nor- INSOMNIA.)
mal without arousals or awakenings, nor is there
evidence of oxygen desaturation or associated CAR-
DIAC ARRHYTHMIAS. Very often the snoring is more Project Sleep A program developed in 1979
pronounced during REM sleep. by the United States Surgeon General’s office to
Snoring can produce social consequences, such create materials and educate physicians and the
as embarrassment and even marital discord. The general public about sleep and arousal disorders.
sleep of a bed partner is liable to be disrupted, This project was created in coordination with the
particularly if the bed partner is a light sleeper or Association of Sleep Disorder Centers, the Ameri-
has INSOMNIA. Primary snoring may be treated by can Medical Association, and members from the
means of behavioral measures, such as the avoid- pharmaceutical industry, including the Upjohn
ance of smoking, alcohol or large meals before Company.
sleep. Sleeping on the side rather than on the In addition to disseminating printed informa-
back often lessens the severity of snoring. It may tion on sleep and arousal disorders, one of the
be necessary for a bed partner to use earplugs program’s major contributions was the production
or use a noise machine to muffle the sound of of a comprehensive series of slides with audio cas-
snoring. Sometimes a bed partner may try to fall sette tapes on sleep and sleep disorders. It was dis-
asleep earlier in the night than the snorer so that seminated to medical schools and other interested
the sounds of snoring do not interfere with sleep parties throughout the United States.
onset.
If the above behavioral means are ineffective
in removing the snoring, consideration can be prolactin A hormone released from the pituitary
given to surgical relief of the upper airway obstruc- gland that accompanies GROWTH HORMONE release.
tive lesions, such as removal of enlarged tonsils This hormone is under the close control of the
182 proposed sleep disorders

neurotransmitter DOPAMINE, which inhibits prolac- protriptyline (Vivactil) See ANTIDEPRESSANTS.

tin secretion. Prolactin is secreted during sleep and
has a CIRCADIAN RHYTHM that is tied to the sleep-
wake cycle but is not related to specific sleep stage Provera (medroxyprogesterone) See RESPIRATORY
activity. STIMULANTS.
Prolactin is secreted in higher amounts during
pregnancy and lactation and also appears to be
important in the maintenance of the reproductive Provigil (Modafinil) See STIMULANT MEDICATIONS.
system in both males and females.
Medications that affect dopamine levels will
influence the secretion of prolactin. Phenothiazines Prozac (fluoxetine) See ANTIDEPRESSANTS.
(antipsychotic drugs) that inhibit dopamine action
can produce elevated levels of prolactin whereas
bromocriptine, a dopamine agonist (a drug that pseudoinsomnia See SLEEP STATE MISPERCEPTION.
acts in the same manner as dopamine), will sup-
press the release of prolactin. (See also ADRENOCOR-
TICOTROPHIN HORMONE, CORTISOL.) psychiatric disorders A psychiatric diagnosis is
the most frequent diagnosis given to patients with
the complaint of INSOMNIA who are seeking help
proposed sleep disorders A category of the INTER- at SLEEP DISORDER CENTERS; almost all patients with
NATIONAL CLASSIFICATION OF SLEEP DISORDERS that DEPRESSION have some sleep complaint. (Insomnia
lists various disorders for which there is insufficient due to acute situational stress is more common in
information available to substantiate the presence the general population.)
of a particular disorder. This category also contains The MOOD DISORDERS, typically disorders due to
newly described disorders not yet substantiated mania, hypermania or depression, are common
by replicated data in the medical literature—for causes of the complaint of insomnia, especially
example, the SLEEP CHOKING SYNDROME. In addition, EARLY MORNING AROUSAL. Patients with bipolar
disorders representing one end of the spectrum of disorder, such as manic-depressive disorder, will
normality are included here—for example, SHORT often show periods of short sleep duration during
SLEEPER and LONG SLEEPER. the manic episodes, alternating with episodes of
EXCESSIVE SLEEPINESS during the depressive phase.
Typically, patients with depression do not have true
prostaglandins Chemicals (autocoid) derived hypersomnia, that is, the total sleep time during a
from arachidonic acid (acid present in the body) 24-hour period is not increased above normal lev-
that are widely distributed in almost every tissue els. However, an excessive amount of time spent in
and fluid in the body. The lipid-soluble acid was first bed is a common feature of depressed patients.
identified in seminal fluid, which led to the name ANXIETY DISORDERS cause sleep disruption, char-
“prostaglandin.” In addition to their widespread acterized by prolonged sleep latency with frequent
actions throughout the body, the prostaglandins awakenings and poor sleep efficiency. These fea-
are found in areas of the brain concerned with tures are most commonly seen in patients who
sleep mechanisms. The presence of prostaglandin have general anxiety disorders; however, poor
D (PGD2) in the preoptic nuclei is associated with sleep quality is also seen in patients who have
sleep induction and maintenance, whereas PGE2, PANIC DISORDERS. More typically, panic disorder
which is found in the posterior thalamic nuclei, is causes an acute event during sleep, with an awak-
believed to be responsible for wakefulness. These ening and feelings of fear and intense anxiety.
newly discovered neurotransmitters are major fac- These abrupt and infrequent episodes during sleep
tors in the control of sleep and wakefulness. (See at night are usually accompanied by similar panic
also SLEEP-INDUCING FACTORS.) attacks during wakefulness. Patients with panic
 psychophysiological insomnia 183

disorders may also suffer from agoraphobia, which that negatively impact on sleep. Typically, indi-
is characterized by a fear of being in certain situ- viduals with psychophysiological insomnia tend to
ations where escape may be difficult, such as in react to stress with an increased level of agitation
a crowded environment or a moving vehicle. The and tension that is often evident by physiological
features of agoraphobia and daytime panic epi- arousal with increased muscle tension and vaso-
sodes are important in order to differentiate panic constriction. With psychophysiological insomnia,
disorder from awakenings with panic due to other there is an overconcern about the inability to fall
disorders, such as SLEEP TERRORS, which may have asleep, which makes it harder to fall asleep. This
a similar presentation. apprehension may exist throughout the daytime
Patients with the PSYCHOSES, such as schizo- when thinking about the likelihood of little sleep
phrenia or schizoaffective disorder, may have that night.
very severe sleep disturbance. This disturbance is Sometimes individuals with psychophysiological
characterized by sleep onset difficulties, with small insomnia can fall asleep at times when it is unex-
amounts of nocturnal sleep that can alternate with pected, such as relaxing in a chair in the early eve-
prolonged episodes of sleep. This pattern of sleep ning. This reflects their ability to fall asleep when
may lead to a complete sleep reversal, with no unconcerned about sleep, but when in situations of
sleep at night and the major sleep episode during wanting to fall asleep, the harder the person tries,
the day. Patients with a psychosis can have REM the less likely it is that sleep will occur. Condition-
sleep disorders characterized by a reduced REM ing factors that contribute to this insomnia include
sleep latency and increased REM density, which lying in bed awake. The usual sleep environment
is similar to that seen in patients with depression. becomes negatively associated with good sleep.
However, these polysomnographic features are not Therefore many individuals with this type of insom-
invariably present, as they are in the depressive nia find that when sleeping in bedrooms other than
disorders. their own, sleep can occur relatively easily.
ALCOHOLISM is associated with severe sleep Psychophysiological insomnia may be precipi-
disturbance due to the acute ingestion of alcohol; tated by a stressful event and may develop sub-
it is initially associated with an increase in SLOW sequent to an ADJUSTMENT SLEEP DISORDER so that
WAVE SLEEP, but is followed by a withdrawal effect after the precipitating event has resolved, the nega-
of sleep disruption, which is seen as the alcohol is tively learned associations with sleep continue, and
metabolized. The chronic alcoholic who abstains the insomnia becomes chronic. This type of insom-
from drinking alcohol will have severe sleep dis- nia often becomes fixed over a period of time as
ruption. This may be characterized by disrupted intermittent life stress may exacerbate or produce
REM sleep, hallucinations and NIGHTMARES, as well recurrence of psychophysiological insomnia.
as disturbed sleep related to autonomic hyperactiv- Although elements of anxiety and depression
ity as a result of the alcohol withdrawal. Drinking are present, particularly in relation to the sleep
alcohol during the day will cause impaired daytime period, there is little evidence of overt psychopa-
functioning because of increased lethargy and thology. Patients with this form of insomnia do not
sleepiness; that effect is often exacerbated if there meet standard psychiatric criteria for the diagnosis
was too little sleep the night before. of a general anxiety disorder or depression.
Other psychiatric disorders, such as substance Psychophysiological insomnia is uncommon in
abuse, adjustment disorder, dissociative and childhood or adolescence. It will usually present
somatoform disorder, can also be associated with for the first time in the twenties or thirties. More
either difficulty in initiating and maintaining sleep typically, individuals will seek help in middle age. It
or excessive sleepiness. appears to be more common in females, and there
may be a familial tendency.
Polysomnographic monitoring of sleep usually
psychophysiological insomnia A form of INSOM- demonstrates a prolonged sleep latency, mul-
NIA that develops because of learned associations tiple awakenings, early morning awakening and a
184 psychoses

reduced sleep efficiency. There may be an increase behavior, which lead to impaired social and work
in the lighter stage one sleep and reduction in a functioning. Sleep disturbance, either INSOMNIA or
deeper slow wave sleep. Increased muscle ten- EXCESSIVE SLEEPINESS, is a common feature of these
sion during sleep can be demonstrated by muscle disorders.
activity monitoring. Not infrequently, individuals Psychoses can be produced by organic neurolog-
with psychophysiological insomnia will show a ical disorders, as well as by DEMENTIA, ALCOHOLISM,
reversed “first night effect” in which they sleep drug effects, schizophrenia, AFFECTIVE DISORDERS,
much better in the lab on the first night because paranoid states, and autism.
of the change in their habitual environment; how- The sleep disturbances associated with psycho-
ever, the learned negative associations with sleep ses are typically sleep disruption, with a severe
return by the second night, which demonstrates difficulty in initiating sleep. There may be an inad-
the reduced quality of sleep. equate amount of sleep because of hyperactivity
Psychophysiological insomnia needs to be dif- associated with the psychotic disorder, which leads
ferentiated from a number of other insomnia to a partial or complete reversal of the sleep-wake
disorders. INADEQUATE SLEEP HYGIENE can produce cycle. Daytime sleepiness may result due to the dis-
a chronic form of insomnia due to alterations in turbed sleep at night or the disrupted sleep-wake
the timing of sleep, excessive CAFFEINE intake, pattern.
altered meal times, or the ingestion of dietary Polysomnographic studies of patients with psy-
factors that can adversely affect sleep (see DIET choses have shown varied sleep patterns; some
AND SLEEP). An environmental sleep disorder patients will even show normal sleep. Typically
can develop because of such factors as light, there is an increased SLEEP LATENCY, decreased total
noise, abnormal temperature or an uncomfort- sleep time, reduced SLEEP EFFICIENCY with frequent
able or adverse sleeping environment. If anxiety awakenings, and reduced SLOW WAVE SLEEP. There
or depression are major factors and warrant a may be features of disturbed REM sleep, such as
psychiatric diagnosis of either anxiety or mood shortened REM latency, increased REM density
disorder, the appropriate psychiatric treatment and varied percentages of REM sleep.
is indicated. If the sleep disturbance is the result Treatment of the psychoses is by pharma-
of an acute stressful situation, and lasts less than cological means and typically involves the use
three weeks, then a diagnosis of adjustment sleep of phenothiazine medications. The drug therapy
disorder is made. may produce sedation, insomnia or withdrawal
Treatment of psychophysiological insomnia syndromes. Institutionalization may be required
involves redeveloping positive associations with for patients with psychoses who have a severe
the sleeping environment. Attention to good sleep impairment of their ability to adequately function
hygiene is essential, and behavioral management in society.
is the most appropriate form of treatment. Relax-
ation therapy, such as JACOBSONIAN RELAXATION,
specific behavioral treatments that may involve pulmonary hypertension An increased pressure
STIMULUS CONTROL THERAPY, or SLEEP RESTRICTION in the pulmonary arteries that leads to hypertro-
THERAPY can be helpful. A short or intermittent phy and dilation of the right side of the heart.
course of HYPNOTICS may be useful; however, The most potent stimulus for pulmonary con-
chronic and long-term use of hypnotics is to be striction leading to pulmonary hypertension is
discouraged. alveolar HYPOXIA. Hypoxia may be produced by
SLEEP-RELATED BREATHING DISORDERS that impair
ventilation of the lungs. Pulmonary hypertension
psychoses PSYCHIATRIC DISORDERS character- can be a consequence of severe OBSTRUCTIVE SLEEP
ized by the presence of delusions, hallucinations, APNEA SYNDROME or CENTRAL ALVEOLAR HYPOVENTI-
inappropriate effect, incoherence, and catatonic LATION SYNDROME.
 pupillometry 185

pupillometry The measurement of pupil diameter and fluctuations in pupil size can be measured by a
and activity. Large, stable pupils are associated with pupillometer. The pupillometry test is mainly used
alertness, and small, unstable pupils are associated as a research procedure to determine sleepiness
with decreased alertness and sleepiness. Variations and has little diagnostic usefulness.
 Q
quiet sleep Term used to describe NON-REM- ings or muscle tone recording. The term “non-
STAGE SLEEP that is seen in infants and animals REM” is preferred when specific SLEEP STAGES are
when the specific sleep phases from one through able to be determined. Quiet sleep is distinguished
four are unable to be clearly determined. Quiet from ACTIVE SLEEP, in which there is an increase
sleep usually refers to an encephalographic pattern in body movement and faster electroencephalo-
of sleep in the absence of eye movement record- graphic patterns.

186
 R
ramelteon (Rozerem) See HYPNOTICS. Rapid eye movements are seen during wake-
fulness but are also characteristic of the rapid eye
movement stage of sleep (REM sleep). The EEG
raphe nuclei Serotonin-containing neurons in pattern and muscle tone distinguish the presence
two columns that extend from the medulla to the of REM sleep from wakefulness, although the pat-
upper border of the PONS. This region was consid- tern of the rapid eye movements usually differs
ered to be important in the maintenance of NON- and is characteristic in REM sleep. The movements
REM-STAGE SLEEP and SLOW WAVE SLEEP because often occur in discrete bursts in REM sleep. In
lesions in the area of the raphe nuclei produced addition, the presence of the sawtooth EEG pat-
INSOMNIA in cats. If the cells of the raphe nuclei are tern in association with the rapid eye movements
exposed to an anti-serotonergic agent that inhibits assists in the determination of REM sleep. The eye
the production of SEROTONIN, such as parachoro- movements are conjugate (move together) and can
phenylalanine (PCPA), insomnia will result. How- occur in a vertical, horizontal or diagonal direction.
ever, more recent evidence has suggested that the The rapid eye movements can be seen under the
serotonin-containing cells are not essential for the closed eyelids.
production of non-REM sleep. But the serotonin- With the discovery of the association of dream-
containing neurons may facilitate the onset of slow ing and rapid eye movement sleep it was initially
wave sleep, possibly through a mechanism that thought that the rapid eye movements reflected
stimulates synthesis of sleep factors. The seroto- visual scanning of the content of dreams. (See
nergic raphe neurons project to the hypothalamus, also REM DENSITY, REM-OFF CELLS, REM-ON CELLS,
which is thought to be the primary site of the pro- REM PARASOMNIAS, REM SLEEP LATENCY, REM
duction of sleep factors. SLEEP ONSET, REM SLEEP PERCENT, REM SLEEP
Destruction of the raphe nuclei is associated PERIOD.)
with an increase in PGO waves, whereas stimula-
tion of the raphe nuclei causes a reduction of PGO
activity. It has been suggested that the role of the rapid eye movement sleep (REM sleep) One of
raphe nuclei is to inhibit the production of PGO the five stages of sleep that are scored according to
waves during wakefulness and limit their activity the method of Allan Rechtschaffen and Anthony
to REM sleep. (See also LOCUS CERULEUS.) Kales. REM sleep is defined by the appearance of a
relatively low voltage, mixed frequency EEG activ-
ity and episodic, rapid eye movements that occur
rapid eye movements The presence of rapid eye simultaneously. The EEG pattern resembles stage
movements during sleep was first discovered by one sleep (see SLEEP STAGES), with the exception
EUGENE ASERINSKY and NATHANIEL KLEITMAN in that there are fewer vertex sharp transients and,
1953. This historic discovery of REM sleep led to sometimes, distinctive “saw tooth” waves. The
the recognition that sleep was not a homogeneous muscle activity is usually at its lowest degree of
state but consisted of two major divisions, REM tone as the skeletal muscles become paralyzed in
sleep and non-REM sleep. this sleep stage (see REM ATONIA).

187
188 rebound insomnia

The loss of muscle tone is due to a hyperpolariz- Rebound insomnia is characterized by increased
ing inhibitory activation of the alpha motor neuron. sleep disruption with a greater number of awak-
The REM phasic activity is due to excitatory input enings and sleep stage changes that occur upon
on the motor-neurone, which is superimposed on a cessation of the medication. It can be reduced by
background of inhibitory input. All striated muscle a gradual decrease in dosage prior to withdrawal.
is affected by the phasic jerks and twitches that All patients withdrawing from hypnotic medication
occur during REM sleep. Rapid eye movements, should be reassured that some sleep disruption is
contractions of the middle ear musculature and the likely for the first few days following cessation of
irregular contractions of the respiratory muscles drug treatment. But as long as good SLEEP HYGIENE
are all components of this phasic muscle activity. is instituted, and other causes of insomnia are not
REM sleep typically comprises about 20 percent present, sleep should return to normal within a
to 25 percent of normal adult sleep. However, the few days. (See also BARBITURATES, BENZODIAZEPINES,
percentage in childhood is greater, with up to 50 HYPNOTIC-DEPENDENT SLEEP DISORDER.)
percent of sleep being REM sleep in infancy.
Usually there are five NREM-REM SLEEP CYCLES
in a full night of sleep, with REM sleep occurring reciprocal interaction model of sleep First pro-
in episodes of increasing duration from 10 to 30 posed by J. Allan Hobson, Robert McCarley, and
minutes. Peter W. Wyzinski in 1975 to explain the cellular
REM sleep is also associated with other physi- interactions in the regulation of REM sleep. They
ological changes, such as an increased oxygen con- suggested that there are two sets of cells, the REM-
sumption of the brain compared with that during OFF CELLS and REM-ON CELLS, that are located in
non-REM sleep, variability of blood pressure and the pontine region of the brain stem. The REM-on
heart rhythm, variable respiratory rate and altered cells cause the initiation of REM sleep, and the
blood gas control. Body TEMPERATURE control also REM-off cells cause the termination of REM sleep.
differs during REM sleep compared with non-REM The REM-on cells are situated near the REM-on
sleep. cells in a similar region of the brain stem and
Certain pathological events are more likely to include the serotonergic cells of the RAPHE NUCLEI.
occur during REM sleep, such as obstructive sleep Since the original proposal, the model has been
apneas (see OBSTRUCTIVE SLEEP APNEA SYNDROME) modified to include both explanations of non-REM
and blood oxygen desaturation. Some disorders sleep and waking. (See also ASCENDING RETICULAR
occur solely during REM sleep, such as the REM ACTIVATING SYSTEM, GIGANTOCELLULAR TEGMENTAL
SLEEP BEHAVIOR DISORDER, NIGHTMARES, and PAINFUL FIELD, SEROTONIN.)
ERECTIONS, SLEEP-RELATED. The presence of penile
erections during REM sleep is an important finding
in the differentiation of IMPOTENCE due to organic recurrent hypersomnia A group of disorders
versus psychogenic causes. Normal erections dur- characterized by recurrent episodes of EXCESSIVE
ing REM sleep in a patient complaining of impo- SLEEPINESS that occur weeks or months apart. These
tence generally reflect a psychogenic cause of the disorders may be associated with other symptoms,
impotence. such as obesity or hypersexuality. The combination
of recurrent hypersomnia, gluttony and hypersex-
uality is also known as the KLEINE-LEVIN SYNDROME,
rebound insomnia INSOMNIA that occurs upon which was first described by Willi Kleine in 1925
acute withdrawal of hypnotic medication. This and Max Levin in 1929. However, a form of recur-
form of insomnia more commonly occurs in per- rent hypersomnia can exist without features of
sons who are on high dosages of HYPNOTICS, par- gluttony or hypersexuality; it is then called recur-
ticularly short-acting hypnotics. It is less likely to rent hypersomnia monosymptomatic type.
occur in persons who take hypnotic agents for a Recurrent hypersomnia more commonly occurs
brief period of time. in adolescents or young adults. Typically an episode
 REM-beta activity 189

of excessive sleepiness will occur over a one-to- (See also DISORDERS OF EXCESSIVE SOMNOLENCE,
two-week period followed by weeks or months of MOOD DISORDERS.)
normal daytime alertness. There often are person-
ality disturbances, such as withdrawal, irritability
and lethargy. Persons with this disorder may eat relaxation exercises A variety of techniques to
excessively and start to eat any food in sight. The enhance muscle relaxation in order to reduce
hypersexuality is characterized by excessive discus- muscle tension and help sleep onset. Various forms
sion or display of sexual behavior along with public of relaxation exercises are utilized; however, one
masturbation. of the most commonly used is the JACOBSONIAN
Episodes occur very infrequently and, on aver- RELAXATION method. BIOFEEDBACK exercises can also
age, occur twice a year. Some patients may go enhance relaxation. (See also SLEEP EXERCISES.)
many years without an episode or may have as
many as one episode each month.
During the period of hypersomnolence, there REM atonia The atonia (loss of muscle tone) of
can be great impairment of social and occupa- REM sleep causes the skeletal muscles to become
tional functioning. The behavior changes can be so flaccid so that the arms and legs are paralyzed.
intense that the patient requires hospitalization. REM sleep cannot be scored if the ELECTROMYO-
Polysomnographic investigation has tended to GRAM (EMG) muscle activity is increased. Only a
show excessive sleepiness with high sleep efficien- few muscles have the ability to move during REM
cies and reduced awake time during sleep. A loss sleep, such as the eye muscles, the auditory mus-
of the deeper stage three and four sleep has been cles, and the diaphragm for respiration. Occasional
demonstrated; however, MULTIPLE SLEEP LATENCY phasic (short burst) muscle activity is seen during
TESTING during the daytime has shown the pres- the atonia of REM sleep.
ence of sleep onset REM periods on one or more Some disorders, such as the REM SLEEP BEHAVIOR
naps. DISORDER, are associated with a variable degree of
The disorder is believed to be in part due to a muscle activity that episodically occurs during REM
hypothalamic dysfunction. There have been some sleep and leads to the behavior that is characteristic
reports of abnormal hormone secretory patterns of the disorder. The polygraphic features of REM
during sleep. GROWTH HORMONE and PROLACTIN sleep behavior disorder indicate a disrupted and
secretion may be abnormal. dissociated form of REM sleep. The REM behavior
A recurrent form of hypersomnia, MENSTRUAL- disorder is not too dissimilar to an experimental
ASSOCIATED SLEEP DISORDER, also occurs in relation- condition seen in cats with neurological lesions
ship to the MENSTRUAL CYCLE and is characterized placed in the pontine region of the brain stem. Cats
by insomnia and hypersomnia. with such lesions have the absence of the REM ato-
Recurrent hypersomnia needs to be differenti- nia and are able to move around during REM sleep.
ated from hypersomnias due to central nervous It has been proposed that there are two systems in
system tumors and other causes of excessive the nervous system that control muscle tone and
sleepiness, such as IDIOPATHIC HYPERSOMNIA, NARCO- movement during REM sleep: a locomotor system
LEPSY, and INSUFFICIENT SLEEP SYNDROME. Excessive and a system that determines atonia. Usually the
sleepiness due to PSYCHIATRIC DISORDERS, such as locomotor system is inhibited by REM sleep simul-
major DEPRESSION or bipolar depression, may pres- taneously with activation of the system producing
ent similarly, with the exception of obesity and the muscle atonia during REM sleep. (See also
hypersexuality. RAPID EYE MOVEMENT SLEEP.)
Treatment of recurrent hypersomnia is largely
supportive. Lithium carbonate has been reported
to stabilize the behavior in some patients but not REM-beta activity Beta rhythm that occurs dur-
in others. The effect of STIMULANT MEDICATIONS in ing REM sleep. This particular electroencephalo-
improving alertness is usually only very temporary. graphic pattern can be seen in patients who have
190 REM density

ingested medications, particularly the BENZODI- REM rebound An increase in the amount, dura-
AZEPINE hypnotics (see also HYPNOTICS), such as tion and density of REM sleep that occurs following
flurazepam. The presence of increased beta activity the curtailment of a variety of techniques that have
during REM sleep and other sleep stages may per- suppressed REM sleep. For example, REM rebound
sist for as long as two weeks after the last ingestion can occur following medication suppression of REM
of the hypnotic agent. (See also BETA RHYTHM, RAPID sleep by such drugs as the tricyclic ANTIDEPRESSANTS
EYE MOVEMENT SLEEP.) or MONOAMINE OXIDASE INHIBITORS, commonly used
for the treatment of DEPRESSION.
Another means of producing REM sleep depri-
REM density The frequency of eye movements vation is by mechanically arousing an individual
that occur during REM sleep; usually expressed as whenever REM sleep is detected during a poly-
the number of eye movements per minute of REM somnographic recording. This procedure not only
sleep. REM density may be increased in patients reduces REM sleep but also causes frequent arous-
with DEPRESSION; treatment with tricyclic ANTIDE- als during the major sleep episode. Following
PRESSANTS can reduce REM density. Although REM this method of REM sleep deprivation there is a
density can be an indicator of depression, it is less rebound of REM sleep.
useful than the presence of a shortened REM SLEEP Some disorders, such as OBSTRUCTIVE SLEEP
LATENCY in aiding the diagnosis of such patients. APNEA SYNDROME, can markedly interfere with
the ability of the subject to maintain REM sleep;
its relief by either TRACHEOSTOMY or CONTINUOUS
Remeron (mirtazapine) See ANTIDEPRESSANTS. POSITIVE AIRWAY PRESSURE devices can lead to an
initial REM rebound. REM sleep episodes lasting
several hours can sometimes be seen in these
REM-off cells Cells believed to inhibit the REM-ON situations.
CELLS and, by so doing, stop the occurrence of REM A REM rebound is often accompanied by an
sleep. These cells are believed to be located in the increase in awareness of having had long and com-
pontine region of the brain stem and include the plex DREAMS. Occasionally NIGHTMARE activity may
RAPHE NUCLEI. (See also GIGANTOCELLULAR TEGMENTAL be exacerbated by the REM rebound. ALCOHOL is
FIELD, RECIPROCAL INTERACTION MODEL OF SLEEP.) also a REM suppressant drug and its withdrawal,
particularly in the chronic alcoholic, can lead to a
REM rebound, with an increase in nightmares.
REM-on cells Cells believed to be responsible for
the initiation of REM sleep; located in the GIGAN-
TOCELLULAR TEGMENTAL FIELD of the pons. (See also REM sleep See RAPID EYE MOVEMENT SLEEP.
RECIPROCAL INTERACTION MODEL OF SLEEP, REM-OFF
CELLS.)
REM sleep and dreaming In 1953, EUGENE ASE-
RINSKY and NATHANIEL KLEITMAN at the University
REM parasomnias Abnormalities that occur dur- of Chicago made a major scientific development
ing sleep that are not associated with excessive in the study of dreams when they recognized
sleepiness or insomnia but are usually associated physiological changes during dreaming and rapid
with REM sleep; a subdivision of the parasomnias eye movements (REM). Over the next few years,
and the INTERNATIONAL CLASSIFICATION OF SLEEP joined by WILLIAM C. DEMENT, the researchers com-
DISORDERS. The parasomnias in this section include pared dream recall during REM versus NREM SLEEP
NIGHTMARES, SLEEP PARALYSIS, IMPAIRED SLEEP- PERIODS. By 1957, the results of these experiments
RELATED PENILE ERECTIONS, SLEEP-RELATED PAINFUL were published: Subjects awakened 191 times dur-
ERECTIONS, REM SLEEP-RELATED SINUS ARREST, and ing REM periods had dream recall 80 percent of
REM SLEEP BEHAVIOR DISORDER. the time, or in 152 of the awakenings. By contrast,
 REM sleep behavior disorder 191

subjects were awoken 160 times during NREM may antedate the development of the more physi-
periods, with only 6.9 percent or 11 dream recalls. cally active behavior.
Dement writes in Some Must Watch While Some Must The most common age of presentation is after
Dream: “When compared to the overall NREM age 60; however, episodes have been reported to
results, the REM period was unquestionably estab- occur in childhood and in individuals of any age
lished as the time when the probability of being with neurological disorders such as cerebral vas-
able to recall a dream is maximal.” cular disease, degeneration or tumors of the brain
Dement further notes that persons who keep stem, and DEMENTIA. It has also been described in
dream diaries at home will recall only one dream association with multiple sclerosis. Recent evidence
when interviewed the next morning about their indicates that REM sleep behavior disorder can
dreams. By contrast, subjects in a laboratory, be a precursor to the development of Parkinson’s
when awakened throughout the REM periods, will disease.
remember four out of the five dreams that occur The majority of persons with REM sleep behav-
during the REM period, forgetting only 20 percent ior disorder appear to be male, and there is some
of their dreams. (See also RAPID EYE MOVEMENT evidence to suggest a familial pattern.
SLEEP.) An identical disorder has been described in ani-
mals who have suffered lesions in the brain stem.
Cats with lesions affecting the locomotor inhibi-
REM sleep behavior disorder (RBD) Disorder tory region of the brain stem often will have motor
characterized by the acting out of dream content activity during REM sleep.
during the dreaming stage (REM sleep) of sleep. Polysomnographic monitoring of persons with
Typically, affected persons will have a predomi- this disorder has shown an intermittent absence
nance of violent activity that occurs during sleep of muscle tone. Concurrent rapid eye movements
and involves punching, kicking, running, or other indicative of REM sleep alternate with high muscle
movements of the limbs. These movements may activity lasting a few seconds prior to the immedi-
injure a bed partner, which precipitates the dis- ate resumption of REM sleep. There may be an
order being brought to medical attention. The increase in the density of the rapid eye movements
episodes usually occur about 90 minutes after the and also in the total amount of SLOW WAVE SLEEP.
onset of sleep when the person goes into REM REM sleep behavior disorder needs to be dif-
sleep; however, they can occur throughout the ferentiated from SLEEP-RELATED EPILEPSY or other
major sleep episode. Very often episodes may be disorders of arousal, such as SLEEPWALKING or SLEEP
precipitated by withdrawal from ALCOHOL or other TERRORS. Nightmares may be somewhat similar but
HYPNOTICS. In his book Sleep, Carlos H. Schenck, are characterized by less motor activity and lack
M.D., senior staff psychiatrist at the Henne- of the typical polysomnographic features of REM
pin County Medical Center and the Minnesota sleep behavior disorder.
Regional Sleep Disorders Center, describes how Treatment of REM sleep behavior disorder
in 1982 the second patient he saw in his career involves securing the bedroom—such as removing
as a sleep doctor, Don, turned out to be his first sharp objects from nightstands—so the individual
case of RBD. Don, a 67-year-old retiree, was act- does not suffer injury. Clonazepam (see BENZODIAZ-
ing out “violent moving nightmares” of playing EPINES) in a dose of 0.5 to 1 milligram, given before
football. Over a five-year period, after treating 10 sleep at night, has been shown to be very effective
patients with the same perplexing parasomnia as in suppressing the behavior. Occasionally tricyclic
Don’s, Dr. Schenck named it rapid-eye-movement antidepressants have been shown to be effective
(REM) sleep behavior disorder. as well.
The disorder has also been described as occur-
ring in association with NARCOLEPSY. There may be Case History
partial manifestations of the disorder, evidenced by A 58-year-old real estate executive had episodes of
episodes of SLEEP TALKING or limb movements that excessive body activity in association with dreams
192 REM sleep deprivation

at night. On occasion, he would hit the nightstand cations, including antidepressant medications such
or his wife while moving about excessively dur- as tricyclic ANTIDEPRESSANTS or MONOAMINE OXIDASE
ing sleep. These episodes had occurred over the INHIBITORS, as well as BENZODIAZEPINES, STIMULANTS,
previous five years. He did have a history of sleep- and ALCOHOL, can usually inhibit REM sleep.
walking as a child; however, this went away in The initial effects of REM sleep deprivation are
adolescence and had never reoccurred. The current an increase in brain activity; aggressive and sexual
activity during sleep was characterized by a lot of behavior may be increased. Psychological difficul-
violent activity, particularly boxing or fighting an ties have been reported as the result of REM depri-
individual, and was very different from his child- vation; however, recent evidence tends to suggest
hood sleepwalking episodes. At times, his wife, that this is an unlikely effect.
who was lying quietly beside him, would become Positive effects of REM deprivation can include
the focus of his dream activity and occasionally improvement of DEPRESSION, and several studies
would get in the way of some of his more violent have shown this to be clinically useful.
movements. On one occasion, his activity caused The most pronounced effect of REM sleep depri-
him to fall out of bed and he cut his head on the vation is REM REBOUND, with a dramatic increase
nightstand. All of the activity was associated with in the amount and duration of REM sleep episodes.
dream content, and he appeared to be actually (See also DREAMS.)
trying to act out dreams during sleep. He was on
no medication at this time, and had sought help
from several physicians. His baseline blood work REM sleep intrusion A brief episode of REM
and brain scan were normal. There was no evi- sleep that occurs during non-REM sleep. The
dence of any underlying neurological disorder. He term may also be applied to the occurrence of a
underwent an all-night POLYSOMNOGRAM, which single, disassociated component of REM sleep,
demonstrated much restlessness during REM sleep such as eye movements or loss of muscle tone,
with an abnormal amount of muscle activity; REM that occurs in the absence of all typical features
sleep was very fragmented. of REM sleep. It may also apply to a brief episode
A diagnosis of REM sleep behavior disorder was of REM sleep that occurs out of sequence with
made on the clinical history and the polysomno- the normal NREM-REM SLEEP CYCLE. REM sleep
graphic data. He was prescribed clonazepam (0.5 intrusion may be seen in severe sleep disruption
milligram) to take before sleep at night. With this due to an INSOMNIA of many causes or in distur-
medication, the activity abruptly subsided and he bances of REM sleep, such as fragmentation seen
had a quiet night’s sleep. The patient noticed con- as a result of medication or other sleep disorders,
siderable improvement over the subsequent two such as NARCOLEPSY.
months; however, some activity reoccurred and the
dosage was increased to 1 milligram, whereupon
the episodes subsided and remained absent over REM sleep latency The interval from sleep onset
the subsequent months. to the first appearance of REM sleep during a sleep
episode. In normal, healthy adults, REM sleep
usually occurs approximately 90 minutes after the
REM sleep deprivation REM sleep deprivation onset of non-REM sleep. A short REM latency is
can be produced by mechanically preventing REM seen in patients who have DEPRESSION and may
sleep from occurring, or by the use of REM suppres- be a biological marker of depression. Treatment of
sant medications. A patient may be mechanically depression in such patients often leads to a nor-
aroused whenever a polygraph shows that he is malization of the REM latency. REM latencies of
entering REM sleep; however, this tends to produce less than 65 minutes are regarded as being shorter
frequent arousals and therefore the effects of REM than normal. A short REM latency may also be
deprivation may be masked by the effects of the seen in patients who acutely withdraw from a
frequent arousals or awakenings. A variety of medi- REM suppressant medication, such as tricyclic
 respiratory disturbance index 193

ANTIDEPRESSANTS, ALCOHOL, or MONOAMINE OXIDASE therefore, REM sleep period may be confused with
INHIBITORS. the NREM-REM SLEEP CYCLE.
In NARCOLEPSY, the REM sleep latency is usu-
ally reduced. Patients may sometimes go directly
into REM sleep. However, this is not always pres- REM sleep–related sinus arrest A disorder of
ent. The presence of REM sleep during a daytime cardiac rhythm that produces episodes of sinus
MULTIPLE SLEEP LATENCY TESTING (MSLT) has more arrest during REM sleep in otherwise healthy indi-
diagnostic usefulness. The occurrence of REM viduals. This disorder has been described in young
sleep within 10 minutes of initiating a daytime adults and appears to be associated with symptoms
nap is regarded as supportive evidence of narco- that include acute discomfort, sudden palpitations,
lepsy. Two or more sleep onset REM periods dur- light-headedness, feeling of faintness, and blurred
ing a multiple sleep latency test that is performed vision. Some individuals with this disorder have
following a night of normal sleep is diagnostic of reported episodes of syncope (fainting) that have
narcolepsy. occurred during the nocturnal hours.
Infants (see INFANT SLEEP) have a much greater The diagnosis is based entirely upon the pres-
percentage of REM sleep (in contrast to adults) and ence of episodes of sinus arrest of at least 2.5
will frequently initiate their short sleep episodes by seconds in duration, which suddenly occur during
an immediate occurrence of REM sleep; therefore, REM sleep. Episodes as long as nine seconds have
a short REM sleep latency is commonly seen. been reported. Additional investigations, including
coronary angiography and electrical conduction
studies, are normal.
REM sleep-locked This term has been used for The episodes of CARDIAC ARRHYTHMIA are not
the close association between CHRONIC PAROXYSMAL associated with sleep-related respiratory distur-
HEMICRANIA (a type of headache) and REM sleep.
bance or oxygen desaturation. They occur in clus-
Episodes of chronic paroxysmal hemicrania during ters and do not induce arousals or awakenings.
sleep always occur in association with REM sleep. This disorder must be differentiated from the
(See also HEADACHES, SLEEP-RELATED.) cardiac irregularity characterized by brady-tachy-
cardia that is typically seen in the OBSTRUCTIVE
SLEEP APNEA SYNDROME.

REM sleep onset The occurrence of REM sleep at If the episodes are frequent in occurrence and
sleep onset; occasionally used instead of the longer long in duration, consideration should be given to
SLEEP ONSET REM PERIOD, which is the preferred
implantation of a ventricular inhibited pacemaker
in order to prevent episodes of cardiac arrest.
term.

RERA See RESPIRATORY EFFORT-RELATED AROUSAL.

REM sleep percent The proportion of total sleep
time that is filled by REM sleep. For adults, a typi-
cal night of sleep is comprised of 20 percent to 25 respiratory disturbance index (RDI) Also known
percent REM sleep; in an infant, REM sleep equals as APNEA-HYPOPNEA INDEX. RDI is a measure of the
50 percent of the total sleep time. The percentage number of apneas, both central and obstructive,
of REM sleep falls slightly from young adulthood to plus the number of hypopneas, expressed per hour
old age. (See also RAPID EYE MOVEMENT SLEEP.) of sleep. A respiratory disturbance index of greater
than five is regarded as an abnormal frequency of
respiratory events during sleep. This index is com-
REM sleep period Occasionally used for an epi- monly used as a measure of the severity of the
sode of REM sleep that occurs during the major sleep apnea syndromes. (See also APNEA, CENTRAL
sleep episode. The term is discouraged from use SLEEP APNEA SYNDROME, OBSTRUCTIVE SLEEP APNEA
because the word “period” implies a cyclical event; SYNDROME.)
194 respiratory effort

respiratory effort Applies to respiratory muscle This drug affects carbonic anhydrase activity,
activity; typically measured during sleep to deter- leading to a rise in the carbon dioxide tension in
mine the degree of respiratory impairment. Patients the tissues that stimulates the chemoreceptors,
who have cessation of respiratory movements dur- resulting in increased respiratory stimulation.
ing sleep, as is seen during an apneic episode, Acetazolamide has diuretic properties and can
will have no respiratory effort, whereas patients cause an increase in NOCTURIA. Other side effects
with the OBSTRUCTIVE SLEEP APNEA SYNDROME may include paresthesia (abnormal sensory symptoms,
have an increased degree of respiratory effort, such as numbness and tingling) and daytime
particularly immediately prior to the termination DROWSINESS.
of the obstructive event. Respiratory effort does
not imply that there is a transfer of air between Medroxyprogesterone (Provera)
the atmosphere and the lung because complete Medroxyprogesterone acetate is a derivative of the
airway obstruction may occur despite the presence naturally-produced hormone progesterone, which
of respiratory effort. is used in sleep disorders medicine as a respira-
Respiratory effort can be measured by means tory stimulant for the promotion of ventilation.
of a mercury-filled strain gauge, a bellows pneu- Medroxyprogesterone has been demonstrated to
mograph or INDUCTIVE PLETHYSMOGRAPHY. (See also be effective in some patients with the obstructive
APNEA, CENTRAL SLEEP APNEA SYNDROME.) sleep apnea syndrome, although it may be more
useful for patients who have central sleep apnea
syndrome or CENTRAL ALVEOLAR HYPOVENTILATION
respiratory effort-related arousal (RERA) An SYNDROME. However, optimal therapy still does not
arousal associated with increasing negative esoph- completely eliminate the respiratory disturbance
ageal pressure which is terminated by a sudden during sleep, and therefore other treatments for
change in pressure to a less negative level with an the sleep-related breathing disorders are prefer-
arousal. The event lasts 10 seconds or longer. able, such as assisted ventilation devices.
Five or more RERAs per hour are regarded as The effect of medroxyprogesterone appears to
abnormal and in association with other symptoms be by means of increasing respiratory center che-
are sufficient to produce a diagnosis of OBSTRUCTIVE mosensitivity to alterations in the blood gases.
SLEEP APNEA SYNDROME. (See also CENTRAL SLEEP Adverse side effects of medroxyprogesterone
APNEA SYNDROME.) include reduced libido, fluid retention and an
increased likelihood of thrombosis; therefore its
usefulness is limited. Provera is the trade or phar-
respiratory stimulants Drugs used in SLEEP DIS- maceutical name for medroxyprogesterone.
ORDERS MEDICINE for the stimulation of VENTILATION
in SLEEP-RELATED BREATHING DISORDERS such as CEN- Methylxanthines
TRAL SLEEP APNEA SYNDROME or OBSTRUCTIVE SLEEP A group of stimulant medications that includes
APNEA SYNDROME. CAFFEINE, theophylline, and theobromine. These
alkaloids occur in plants that are widely found in
Acetazolamide (Diamox) nature, and the leaves are often used to create bev-
A carbonic anhydrase inhibitor used as a respiratory erages such as tea, cocoa and coffee.
stimulant for the treatment of breathing disorders The methylxanthines are used to stimulate
such as central sleep apnea syndrome. This agent the central nervous system in order to improve
is primarily used for central sleep apnea syndrome alertness but also to relax muscles, such as the
due to central nervous system lesions or impaired muscle of the lung airways. Theophylline is par-
circulation time. It is also an effective agent for the ticularly useful for the treatment of asthma and
treatment of ALTITUDE INSOMNIA (acute mountain CHRONIC OBSTRUCTIVE PULMONARY DISEASE because
sickness) and may be partially beneficial in the treat- of its effect of relaxing bronchial muscle. However,
ment of the obstructive sleep apnea syndrome. theophylline is an even stronger central nervous
 restlessness 195

system stimulant than caffeine. It can stimulate the jerks that occur only at sleep onset. The restless
medullary respiratory center and can be useful for movements that occur during REM SLEEP BEHAVIOR
treating sleep-related breathing disorders of infants DISORDER typically occur during REM sleep at night
and also Cheyne-Stokes breathing. The methylxan- and are associated with more violent movements,
thines also cause cardiac stimulation and theophyl- reflecting the acting out of DREAMS. NOCTURNAL
line can produce an increase in heart rate, even PAROXYSMAL DYSTONIA is a disorder associated with
precipitating cardiac irregularity in some sensitive abnormal posturing of the limbs; it typically occurs
people. Theophylline, if taken for breathing disor- during non-REM sleep and not at sleep onset.
ders during sleep, can cause so much stimulation Although the cause of this disorder is unknown,
that INSOMNIA may result. (See also CHEYNE-STOKES relief of the discomfort is available by using a vari-
RESPIRATION, INFANT SLEEP DISORDERS.) ety of medications including the anticonvulsants
as well as the HYPNOTICS. Carbamazepine (see
ANTIDEPRESSANTS) may be helpful in some patients;
restless legs syndrome (RLS) A disorder associ- however, many patients do not respond to this
ated with discomfort experienced in one or both medication. The most effective BENZODIAZEPINE is
legs as well as the uncontrollable urge to keep clonazepam, which is also effective against the
moving the legs. This discomfort is described as a periodic leg movements that can occur in associa-
crawling, tickling, itching sensation in the legs and tion with restless legs syndrome. However, other
is usually found in the calf, feet and sometimes in benzodiazepines, such as trizolam, and narcotic
the thigh. It is rarely experienced as a pain. This derivatives, such as oxycodone, have also been
syndrome was first described by K.A. Ekbom in shown to be useful in some patients.
1945, and it is recognized as a cause of difficulty in I-DOPA has been shown to be effective in reduc-
falling asleep at night. The legs are moved around ing the number of episodes of both restless legs
in bed to find a comfortable position, and often the syndrome and periodic leg movement during sleep.
patient has to get out of bed to walk around. Rub- Other dopaminergic agents such as PRAMIPEXOLE
bing the calves and exercising the muscles often and ropinirole have also proved to be very effec-
produces a temporary relief. tive. However, in May 2005, the FDA issued a
The discomfort is typically present at SLEEP report requesting labeling changes to clearly indi-
ONSET, although it often can occur during wakeful cate warnings, precautions, and possible adverse
episodes during the night. Sometimes the sensation reactions to ropinirole, a class of drugs known as
is also experienced during the daytime when lying dopamine agonists. The warnings included the pos-
down or sitting. sibility that the drug could cause someone to fall
The discomfort may be very intense and has asleep while performing daily activities especially
been said to have driven sufferers, on rare occa- if someone who is taking the drug also has Parkin-
sion, to commit suicide. son’s disease. Warnings for hallucinations, syncope
Since restless legs syndrome is typically associ- (fainting or passing out), or symptomatic hypoten-
ated with PERIODIC LEG MOVEMENTS, treatment may sion (low blood pressure) were also included.
be required for both conditions. Polysomnographic
evaluation of restless legs syndrome demonstrates
movement of the legs that occurs at sleep onset restlessness Term applied to increased body
and a prolonged SLEEP LATENCY. There may be fur- movements occurring during sleep. Restlessness (a
ther episodes of leg movements occurring during restless sleep) is often an indication of an under-
wakeful episodes throughout the night. Intermit- lying sleep disorder, and therefore investigation
tent periodic leg movements can be seen in sleep by appropriate polysomnographic studies may be
throughout the polysomnographic recording. indicated. Although occasional awakenings are
Restless legs syndrome needs to be differentiated not uncommon in normal, healthy sleepers, in
from other disorders that produce abnormal move- ge neral sleep should be relatively quiet for most
ments during sleep. SLEEP STARTS are whole body individuals.
196 Restoril

Restlessness predominantly occurs during disor- Restlessness may be the primary complaint of a
ders that produce INSOMNIA, such as PSYCHOPHYSI- spouse.
OLOGICAL INSOMNIA, or insomnia due to psychiatric The restless legs syndrome is characterized by
disorders. However, it can also occur in other dis- a discomfort experienced in the legs in which the
orders that disrupt sleep, such as the OBSTRUCTIVE legs have to be moved to relieve the discomfort.
SLEEP APNEA SYNDROME, the REM SLEEP BEHAVIOR Typically, patients will get out of bed in order to
DISORDER, and the RESTLESS LEGS SYNDROME. walk around thereby easing the pain. Once sleep
Individuals who complain of insomnia will onset has occurred, generally the legs are still;
often describe how they stay motionless during however, brief interruptions or awakenings of
sleep with the hope it will enhance sleep onset and sleep will often be associated with an increase in
reduce the amount of times they awaken during the leg movements.
sleep. However, lying in bed awake often makes Although a number of parasomnias, such as
the individual aware of discomfort related to body SLEEPWALKING, can be associated with abnormal
position. Restlessness occurs because of the need movement activity, restlessness is usually not a com-
to keep changing position. Some disorders may be mon feature, in part due to the episodic nature of the
directly associated with discomfort of body posi- movements. SLEEP-RELATED EPILEPSY generally pro-
tion, such as PREGNANCY-RELATED SLEEP DISORDER duces infrequent episodes during sleep, and there-
or the restless legs syndrome. However, in the fore a complaint of restless sleep is uncommon.
majority of individuals who suffer from insomnia
due to psychophysiological or psychiatric causes,
the discomfort experienced is a result of being in a Restoril (temazepam) See BENZODIAZEPINES.
single position for a prolonged period of time while
awake. Very often the discomfort is exacerbated by
the increased muscular tension and ANXIETY that reticular activating system See ASCENDING RETIC-
accompany insomnia. The generalized restless- ULAR ACTIVATING SYSTEM.
ness that accompanies insomnia often leads to the
individual getting out of bed and going to another
room or walking about for a period of time before reversal of sleep A 12-hour shift in the onset of
returning to bed. Although the SLEEP SURFACE is the major sleep episode. Reversal of sleep has been
sometimes responsible for the discomfort, in most performed experimentally to determine the effect
cases it is not the primary cause unless there was a on circadian rhythmicity. Sleep itself is less efficient
recent change in the sleep surface. when acutely moved, and there is usually a decrease
Patients with the obstructive sleep apnea syn- in deep stages three/four sleep and REM sleep (see
drome can be particularly restless. The termination SLEEP STAGES). Total sleep time is shorter than before
of the apneic events is associated with an increase the shift, and the REM SLEEP LATENCY is reduced.
in body movements, and not uncommonly there Following an acute reversal of the sleep pattern
are reports of an arm being raised from the bed or there are changes in underlying circadian rhythms
the legs changing position. The movements may in that some will shift with the change in the sleep
become excessive and lead the individual to fall pattern, but others will remain fixed at the previ-
out of bed. Not uncommonly, children will adopt ous phase. For example, the pattern of cortisol
a hands/knees position in order to improve their secretion and body temperature adjusts very slowly
breathing at night. over a period of one to two weeks to the new time
In the elderly population, in addition to the of sleep. Some body rhythms, such as urine vol-
increased number of causes of insomnia, the REM ume and electrolyte excretions, shift to the new
sleep behavior disorder is associated with increased pattern of sleep within a few days, as does growth
motor activity during sleep. In this disorder, the hormone secretion.
individual will tend to act out DREAMS and so there Reversal of sleep is also applied to individuals
may be quite violent arm and leg movements. who are on a stable pattern of sleeping during the
 Rozerem 197

day and awakening at night. In such individuals, sleep-wake rhythm. Rhythms that occur within
the pattern of circadian rhythmicity has adjusted to a 24-hour cycle are called CIRCADIAN RHYTHMS.
the new time of sleep and therefore there is no dis- Rhythms during a period of less than 24 hours are
sociation between circadian rhythms. This pattern called ultradian (see ULTRADIAN RHYTHM), and those
is sometimes seen in individuals who have a severe greater than 24 hours are called infradian.
form of the DELAYED SLEEP PHASE SYNDROME. An acute The most frequently studied rhythms in human
reversal of the sleep pattern also occurs in shift work- physiology are the circadian rhythms, of which the
ers and individuals who cross many time zones. (See sleep-wake cycle, body TEMPERATURE, and cortisol
also CIRCADIAN RHYTHMS, SHIFT-WORK SLEEP DISORDER, pattern are examples.
TIME ZONE CHANGE (JET LAG) SYNDROME.) The term “biological rhythm” applies to the
rhythmicity of biological variables; however, this is
not to be confused with BIORHYTHM, a term that is
reversed first night effect Typically, sleep is of not used in CHRONOBIOLOGY. Biorhythms are pat-
better quality on the first night of polysomno- terns of human behavior that are determined by
graphic recording in the laboratory, and of much astrological signs and have no scientific validity.
reduced quality during the second night. This pat-
tern can be seen in patients with IDIOPATHIC INSOM-
NIA or PSYCHOPHYSIOLOGICAL INSOMNIA. (See also Rigiscan An ambulatory rigidity and tumescence
FIRST NIGHT EFFECT.) monitor that is worn by the patient overnight to
determine whether normal erections occur. This
monitoring device is used to differentiate between
rheumatic pain modulation disorder See FIBRO-
IMPOTENCE of an organic or psychogenic cause. If
SITIS SYNDROME.
full erections occur at night, then the problem is
often considered to be due to psychogenic causes.
rhythmic movement disorder A disorder charac- The Rigiscan consists of two loops: one is
terized by repetitive abnormal movements during placed around the base of the penis, and the other
sleep such as HEADBANGING, BODYROCKING, or leg around the tip of the penis. The loops are pulled
rolling. These movements usually occur during the at intermittent intervals to detect tumescence and
lighter stages of sleep or immediately prior to sleep rigidity. Some patients find the loops to be uncom-
onset; however, rarely they can occur during deep fortable; however, most patients are able to sleep
sleep stages or RAPID EYE MOVEMENT (REM) SLEEP. without difficulty while wearing the device. In
Usually treatment is limited to securing the envi- some sleep laboratories, the Rigiscan has replaced
ronment so that banging into solid objects does not the use of STRAIN GAUGES in the determination of
NOCTURNAL PENILE TUMESCENCE. (See also IMPAIRED
harm the individual. For example, a child in a crib
SLEEP-RELATED PENILE ERECTIONS, NOCTURNAL PENILE
may need to have padding affixed to crib bars to
TUMESCENCE TEST, POLYSOMNOGRAPHY.)
prevent injury. Medication treatment is usually not
effective although the BENZODIAZEPINES have been
helpful in some patients. (See also HEAD ROLLING.)
Ritalin See STIMULANT MEDICATIONS.

rhythms This term applies to a cyclical pro-

cess and in sleep medicine mainly applies to the Rozerem (ramelteon) See HYPNOTICS.
 S
SAD See SEASONAL AFFECTIVE DISORDER. mon in schizophrenic patients and are character-
ized by INSOMNIA or alterations in the sleep-wake
cycle.
sandman A personification of sleep or sleepiness During acute schizophrenia, there may be a
that refers to someone who goes around sprinkling reduction in the TOTAL SLEEP TIME, and an alteration
sand in the eyes as a way of inducing sleep. The in the timing of REM sleep, with a short REM SLEEP
term developed from the gritty sensation that often LATENCY, similar to that seen in DEPRESSION. The
occurs in the eyes upon awakening in the morning. amount of SLOW WAVE SLEEP may be reduced, but
The term “dustman” was first reported in P. Egan’s the amount of REM sleep is usually normal.
Tom and Jerry in 1821: “till the dustman made his The sleep symptoms often parallel the course
appearance and gave the hint to Tom and Jerry that of the underlying schizophrenia, which usually
it was time to visit their beds.” The term referred requires psychiatric management.
to getting sleepy and the sensation of dust being
in the eyes. Over the years, “dustman” became
associated with garbage and refuse, and therefore SCN See SUPRACHIASMATIC NUCLEUS.
the term was changed from “dustman” to “sand-
man.” The term “sandman” is still commonly used
in children’s fairy tales. seasonal affective disorder (SAD) A disorder
that most often occurs in the mid-to-late fall as
the nights grow longer. The increased tendency
Sanorex (mazindol) See STIMULANT MEDICATIONS. for DEPRESSION is believed to be in part related to
the reduced light exposure at that particular time
of year. A clinical diagnosis of SAD is made if, for
sawtooth waves A form of THETA ACTIVITY that at least two consecutive winters, someone experi-
occurs during REM sleep and is characterized by ences being depressed, sleeping too much, overeat-
a notched appearance on the wave form. This ing, craving carbohydrates, a diminished sex drive
notched appearance looks like the teeth of a saw, and working less productively. Such individuals
hence the term sawtooth waves. These episodes of are relatively depression-free during the rest of
EEG activity occur in bursts that last up to 10 sec- the year, when there is more light. Exposure to
onds and are a characteristic of REM sleep. light of more than 2,000 lux (a unit of illumina-
tion) for two or more hours in the morning from
6 A.M. to 8 A.M. can improve mood and decrease
schizophrenia Group of psychiatric disorders the seasonal affective disorder. But there may be a
(see PSYCHOSES) characterized by disturbances of mid-afternoon reduction in mood associated with
thought process, with delusions and hallucina- the circadian variation in daytime alertness. A
tions. Specifically there is a low level of intellec- shorter exposure of light at that time may improve
tual and social functioning that typically occurs the symptoms and reduce the need for a mid-after-
before middle age. Sleep disturbances are com- noon nap.
198
 seizures 199

Although SAD is uncommon—an estimated half behavioral abnormalities, such as temporal lobe
a million people are affected in the United States— (psychomotor) seizures. Manifestations include
a related seasonal condition has been found in walking movements that can occur out of sleep and
25 percent of the general population whereby appear similar to sleepwalking episodes. Frontal
clinically depression is absent, but there are mood lobe seizures are typically associated with behav-
swings related to the winter and diminished light. ioral disorders or abnormal mentation. Autonomic
In the northern United States, light deprivation seizures are characterized by changes in autonomic
and related mood swings seem to begin in October, functions such as heart rate, respiratory rate, gas-
achieve their most severe form in January and go trointestinal function, sweating or pupil diameter.
into remission by the end of February. Bright light Some seizure disorders, such as tonic seizures, may
systems are commercially available. (See also CIR- produce a stiffening of the muscles that results in
CADIAN RHYTHMS, LIGHT THERAPY, MOOD DISORDERS.) generalized increased muscle tone, and others,
such as akinetic seizures, are often associated with
loss of muscle tone producing falls to the ground.
sedative-hypnotic medications See HYPNOTICS. Seizures often occur during sleep and are typi-
cally characterized by abnormal motor activity,
sometimes producing SLEEPWALKING episodes or
sedative medications See HYPNOTICS. enuresis (bed-wetting, see SLEEP ENURESIS). Epilepsy
is a major cause in children of secondary enuresis.
Rarely SLEEP TERROR episodes may be due to epi-
seizures Term commonly used to denote a clini- lepsy. Some abnormal movement disorders, such as
cal manifestation of an epileptic discharge. (The NOCTURNAL PAROXYSMAL DYSTONIA, can occur during
term “epilepsy” applies to a disorder of abnormal sleep and have features similar to those of seizures.
brain electrical activity, whereas the term “seizure” These disorders can be differentiated from seizures
applies to the clinical manifestation.) Patients may by appropriate encephalographic monitoring dur-
have epilepsy but may not have seizures if their ing sleep.
disorder is under good control with anticonvulsant Seizure disorders can affect an individual of any
medications. Rarely some forms of epilepsy do not age; however, some seizures are more commonly
have seizure manifestations, such as ELECTRICAL seen in childhood. Infantile spasms associated with
STATUS EPILEPTICUS OF SLEEP. hypsarrhythmia (abnormal EEG pattern) or the
Seizures may take many forms and may be asso- tonic seizures of Lennox-Gastaut syndrome (atonic
ciated with cognitive, motor or sensory symptoms. seizures) are seen in young children. Petit mal
The most commonly recognized seizure manifesta- epilepsy and generalized tonic-clonic (grand mal)
tion is that of a tonic-clonic seizure disorder, which seizure disorder are common in prepubertal and
produces jerking movements of the arms and legs, postpubertal children.
often in association with loss of consciousness. In adults, including the elderly, partial complex
However, focal forms of movement disorders are seizures (temporal lobe or psychomotor) are more
also seen in which only one limb or a portion of a commonly seen. Generalized seizures can also
limb may be involved in abnormal movement. occur as a result of central nervous system lesions,
Sometimes the seizure manifestation is very such as a stroke. A stroke typically produces a focal
subtle and may produce only blinking or a slight motor seizure that may become generalized, with
twitching of the mouth. This form of presentation whole body tonic-clonic movements similar to that
of a seizure disorder is typically seen in patients seen in grand mal epilepsy.
with absence or petit mal disorder, which is asso- Most seizure disorders can be adequately con-
ciated with impaired cognition; its only outward trolled by anticonvulsant medications such as
manifestation may be blinking, lip smacking or phenytion, phenobarbital, or carbamazepine (see
repetitive hand movements. Other forms of dis- ANTIDEPRESSANTS). (See also BARBITURATES, BENIGN
orders may be associated with more pronounced EPILEPSY WITH ROLANDIC SPIKES.)
200 selective serotonin reuptake inhibitors

selective serotonin reuptake inhibitors (SSRIs) See serotonin reuptake inhibitors See ANTIDEPRES-
ANTIDEPRESSANTS. SANTS.

serotonin A neurotransmitter that is found in SESE See ELECTRICAL STATUS EPILEPTICUS OF SLEEP.
cells of the central nervous system, particularly
within the brain stem. Serotonin is a naturally-
occurring agent in the blood that has the effect settling Popular term that is often used to describe
of producing vasoconstriction. It is believed to be an infant who sleeps through the night and does
involved in the regulation of sleep because inhibi- not awaken for feedings during the night. Settling
tion of the synthesis of serotonin in animals has typically occurs within the first three months of life.
led to very profound INSOMNIA. Michel Jouvet in (See also INFANT SLEEP, INFANT SLEEP DISORDERS.)
1969 first proposed that serotonin is involved in
the maintenance of sleep, particularly SLOW WAVE
SLEEP. The RAPHE NUCLEI of the brain stem are the shift-work sleep disorder Disorder that affects
primary site of the serotonin-containing neurons workers who work the night shift and who typi-
that are involved in sleep regulation. cally have a disturbed sleep-wake pattern. Since
Precursors of serotonin, such as tryptophan, most nighttime shift work is performed between
have been shown to induce drowsiness in animals; 11 P.M. and 7 A.M., sleep is typically delayed until
however, the effects in man are unclear. Research after the shift. SLEEP ONSET would begin anywhere
studies on L-tryptophan (see HYPNOTICS) have sug- between 6 A.M. and 12 noon. In addition, on days
gested a beneficial effect on reducing SLEEP LATENCY off the shift worker may attempt to return to a
and improving the depth of sleep. L-TRYPTOPHAN is more normal sleep-wake pattern, with sleep occur-
a commonly used OVER-THE-COUNTER MEDICATION in ring during the night hours when he would usu-
patients who have sleep disturbance; however, it ally be working. As a consequence of the delayed
has a relatively weak hypnotic effect. L-tryptophan sleep pattern when working the NIGHT SHIFT and
was withdrawn from the market in the United the alteration and timing in sleep on days off,
States because of an association with potentially complaints of INSOMNIA, or EXCESSIVE SLEEPINESS
fatal eosinophilia-myalgia syndrome. However, are common.
it is still available as a dietary supplement. It is The duration of sleep after the night shift is
recommended that you check with your health reduced to between one and four hours, often at
care professional before taking L-tryptophan if you the expense of the lighter stages one and two sleep
have kidney disease, liver disease, other serious or REM sleep (see SLEEP STAGES). This sleep length
health conditions, certain allergies, or are a woman is often found to be unrefreshing; a second sleep
who is pregnant or breastfeeding. There are those episode is often taken prior to commencing the
who claim that L-tryptophan helps treat insomnia, next night of shift work. The second sleep episode
among other conditions. may commence at approximately 8 P.M. and last
Several ANTIDEPRESSANTS that inhibit the reup- for two hours. Despite these attempts to maintain
take of serotonin—the so-called serotonin block- a normal amount of sleep in a 24-hour period, a
ers—tend to decrease REM sleep. Serotonin tendency to sleepiness exists throughout all periods
reuptake blockers, such as fluvoxamine, zimelidine, of wakefulness, often impairing the mental ability
femoxitine, and fluoxetine, have been reported to of the night shift worker while working. Reduced
be effective in suppressing the CATAPLEXY of NAR- ALERTNESS and errors are commonly reported as
COLEPSY. The tricyclic antidepressants that inhibit consequences of shift work.
the uptake of serotonin have pronounced effects In addition to disturbed sleep-wake patterns and
in decreasing REM sleep. It has been proposed that reduced work capacity, there are medical and social
the antidepressant effect of these medications is consequences of shift work. Gastrointestinal disor-
due to this suppression effect on REM sleep. ders are reported as are drug and alcohol depen-
 shift-work sleep disorder 201

dency induced by attempts to correct the disturbed and wakefulness and the onset of shift work is an
sleep-wake pattern. The social consequences may important variable in excluding other causes of
include marital discord and impairment of other insomnia or excessive daytime sleepiness. A sec-
social relationships. ondary drug-dependent sleep disorder, or STIMU-
The disturbance of the sleep-wake pattern fol- LANT-DEPENDENT SLEEP DISORDER, may result from
lows the shift work change. Rotating shifts will the disrupted sleep-wake patterns.
divide the day into three work periods: a night Treatment for shift-work sleep disorder requires
shift, day shift and EVENING SHIFT. A shift worker attention to the sleep-wake pattern and also to the
may rotate between one shift and another and nature of the shift work. The daytime sleep episode
typically will have less sleep-wake difficulties when should occur in an environment that is conducive
on the day shift. After resuming the night shift, to good sleep (see SLEEP HYGIENE). Elimination of
the first few days are associated with the most daytime noise and light as well as attention to
pronounced disturbance of the sleep-wake cycle, appropriate temperature control is important in
and after a few days there is a partial adaptation. order to assure a good sleep period during the
This adaptation, however, is typically disturbed by daytime. In addition, if an adequate sleep period
the altered sleep-wake pattern that occurs on days cannot be obtained following a night of shift work,
off from work. it may be preferable to break the sleep period into
There is evidence to suggest that an individual two portions, with an initial four-hour sleep epi-
who has been described as a NIGHT OWL or EVENING sode after the shift, in the morning, and another
PERSON is more able to adapt to shift work than an two-hour period, at night, prior to going to the
individual described as a LARK or MORNING PERSON. shift. This particular sleeping pattern seems to be
With increasing age, shift workers find it more dif- associated with improved alertness on the shift
ficult to sustain an adequate sleep episode during work. Also, the work performed on the night shift
the daytime after a night of shift work. must be stimulating and not monotonous or bor-
The prevalence of this sleep disorder is related ing in order to maintain full alertness. If the sleep
to the number of shift workers in the community. pattern that is established can be maintained seven
Between 5 percent and 8 percent of the total popu- days a week, rather than five days a week, the shift
lation work the night shift. worker is more likely to adapt to the altered sleep-
Polysomnographic monitoring of the 24-hour wake pattern.
day confirms the difficulty of maintaining an The direction of the rotation of shift work has
appropriate sleep duration during the morning been reported to influence a worker’s adaptation
after the shift work, and the tendency to sleepiness to shift work. Rotations that occur in a clockwise
during the waking portion of the 24-hour cycle. direction are said to be preferable to those rota-
Continuous monitoring of polysomnographic vari- tions that occur in an anticlockwise direction. (For
ables, or the use of an ACTIVITY MONITOR, can be example, a rotation from day to evening to night
helpful in documenting the tendency to sleepiness, shift is clockwise.) In addition, there is a contro-
and the pattern of sleep and wake episodes. versy over the duration of the shift rotation. Some
Other disorders of sleep and wakefulness must specialists consider that a short and rapidly rotating
be considered as causes of sleep disturbance in shift shift period of only a few days on each night or day
workers. Patients with insomnia may adopt night shift is preferable to one in which the night shift
work in order to help deal with their excessive worker will work for several weeks on a particular
wakefulness at night. Sometimes patients on shift shift. The tendency for sleepiness also increases
work may present with a complaint of excessive with the length of the night shift so that 12-hour
sleepiness and be mistaken for having a disorder shifts are associated with a greater sleepiness in the
such as NARCOLEPSY. Very often, patients with final few hours of the shift than in shorter, six- or
narcolepsy may adopt shift work in an attempt to eight-hour shifts.
rationalize their excessive sleepiness. The temporal HYPNOTICS have been reported to be beneficial
(time) association between the disturbance of sleep for the shift worker. A short course of a short-
202 short sleeper

acting hypnotic can enhance a shift worker’s day- mania, an increase in activity, with an elevated,
time sleep episode and lead to improved alertness expansive mood.
during the waking portion of the sleep-wake cycle. A survey by Daniel Kripke, R. Simons, L. Gar-
New treatments that are being explored include finkel, and E. Hammond that involved over one
the use of MELATONIN to shift sleep and MODAFINIL million individuals indicated that people with a
to improve alertness. (See also CIRCADIAN RHYTHM nocturnal sleep period of less than five hours had a
SLEEP DISORDERS.) shorter life expectancy than those with more usual
sleep durations.
Objective documentation of the sleep patterns
short sleeper An individual who consistently of short sleepers is relatively sparse. It is difficult
sleeps less than someone of the same age. Typically, to confirm the habitual tendency to short sleeping
the total sleep time is less than 75 percent of the because of the difficulty in monitoring someone for
lowest normal sleep time for someone of that age. 24 hours a day for many consecutive days. Studies
Although exact limits for the total sleep times of a that have been performed have tended to show
particular individual are unknown, a sleep episode normal amounts of stages three and four sleep,
of less than five hours in any 24-hour day, before with reduced lighter sleep stages and REM sleep.
the age of 60 years, is regarded as an unusually There is no evidence for any sleep disorder caus-
short sleep episode. ing disrupted nighttime sleep or for a tendency to
Sleep lengths in short sleepers may vary from daytime sleepiness.
two hours to five hours in duration; however, most Short sleepers need to be differentiated from
short sleepers sleep for only three to five hours, individuals who have psychopathology that may
without any tendency for daytime sleepiness. cause a short-term reduction in total sleep time,
Monitoring of sleep-wake patterns by means of such as is seen during the manic phase of manic-
an activity monitor may be useful in documenting depressive disease.
the sleep length of short sleepers over a period of Short sleepers also have to be differentiated
weeks or months. from those who have short sleep but then make up
Short sleepers, because of a complaint of INSOM- for it by an excessively long sleep episode, such as
NIA at night, often have the expectation that they on the weekends. Those individuals are classified
should sleep for eight hours. Excessive time spent as having insufficient sleep and may be chronically
in bed awake is considered an inability to fall asleep sleep deprived.
and, hence, induces a complaint of insomnia. No treatment is indicated or necessary for a
Although the pattern of short sleep has its onset short sleeper other than the reassurance that the
in early adolescence, when the more typical adult sleep length is normal for that individual and that
sleep pattern is being established, it is not usually an appropriate time spent in bed will allay con-
regarded as a problem until adulthood, when a full cerns regarding insomnia. Many short sleepers,
eight-hour sleep period is desired. An adolescent particularly in middle or old age, are concerned
short sleeper very often has fewer complaints about about being awake at night when others are sleep-
the sleep period and usually enjoys the luxury of ing; it should be suggested that they find activities
being able to stay up late at night. to occupy them during their period of wakefulness.
Studies have indicated that most short sleepers (See also ACTIVITY MONITOR, INSUFFICIENT SLEEP SYN-
are males and the prevalence of this disorder is DROME, MOOD DISORDERS.)
rare. There is some evidence to suggest it is more
common in families.
A psychological profile of short sleepers by Ernest short-term insomnia Term proposed by the con-
Hartmann, Frederick Baekeland, and George Zwill- sensus development conference that was held in
ing indicated that they generally are not psychiatri- November 1983 by the National Institute of Mental
cally disturbed but tend to be high achievers who Health and the Office of Medical Applications of
are efficient and who have a tendency to hypo- the National Institutes of Health. The conference
 sigma rhythm 203

summary suggested the terms TRANSIENT INSOM- the tendency for tiredness. Many cultures that
NIA, short-term insomnia, and long-term insom- take a siesta will purposely have a large midday
nia. Short-term insomnia was defined as lasting meal, which is an additional stimulus to taking
up to three weeks, usually in association with a a midafternoon nap. Consequently, the evening
situational stress—such as an acute loss, work or meal is often taken at a later hour, approximately
marital stress—or due to a serious medical illness. 9 to 10 P.M.
SLEEP HYGIENE and nondrug procedures are primar- It is believed by many that the sleep pattern seen
ily recommended for the treatment of this type in prepubertal children of eight or nine hours of
of sleep disturbance. However, sleep-promoting nocturnal sleep along with a daytime of maximal
medications, such as the BENZODIAZEPINES, could alertness is preferable. Therefore in many societies
be considered. This form of insomnia is equivalent the tendency for a daytime nap or siesta is dis-
to ADJUSTMENT SLEEP DISORDER; however, other couraged. The avoidance of a midafternoon nap is
causes of insomnia, such as jet lag or shift work, especially important for persons who suffer from
when seen within three weeks of their onset, could sleep disorders such as INSOMNIA, as it may lead to
also be regarded as short-term insomnia. (See also a further breakdown and disruption of nighttime
HYPNOTICS.) sleep. (See also CIRCADIAN RHYTHMS, NAPS.)

SIDS See SUDDEN INFANT DEATH SYNDROME. Siffre, Michel A speleologist (cave expert) who
began an experiment on July 16, 1962, of living in
an underground cavern in the Alps between France
siesta A voluntary nap usually taken in the mid- and Italy. The underground cavern contained an
afternoon by certain cultural and ethnic groups, ice glacier at a depth of 375 feet below the sur-
such as the Latin Americans and the Spanish. face. At the age of 23, Siffre stayed in a tent on the
Many societies adopt the midafternoon siesta to underground ice shelf for 59 days and recorded his
avoid the hottest part of the day, particularly in sleep-wake pattern while isolated from ENVIRON-
tropical environments. A siesta usually lasts two MENTAL TIME CUES. The sleep-wake pattern showed
hours and is taken at a point in the biphasic cir- a rhythm of 24 hours and 30 minutes over the
cadian ALERTNESS cycle when there is an increased course of the experiment. This study was one of
amount of sleepiness, typically between 2 P.M. and the first demonstrations of man’s FREE RUNNING pat-
4 P.M. Prolonged siestas are taken at the expense tern of sleep and wakefulness in an environment
of nighttime sleep so that total sleep time within isolated from time cues. His time orientation was
any 24-hour period is still one-third of the day, so disoriented because of the lack of external time
or about eight hours. Longer siestas of four hours cues that when he left the cave Siffre thought it was
may be accompanied by a short nocturnal sleep August 20th but it was actually September 17th.
episode of a similar duration. Most persons in He used himself as the subject for two more tem-
cultures where siestas are typical tend to stay up poral-isolation experiments. The second time was
later at night because the NAP necessitates shorter in 1972 when he spent 205 days at the bottom of
nocturnal sleep. Midnight Cave in Del Rio, Texas. The third time,
There is some debate as to whether a pattern of in 1999, when he was 60 years old. He remained
daytime and nighttime sleep is preferable to a pat- underground without any time cues for 73 days in
tern of a single longer nocturnal sleep episode. The the Clamousse cave in southern France. (See TEM-
natural tendency for increased sleepiness twice PORAL ISOLATION.)
during a 24-hour period tends to imply that a day-
time siesta may be preferable. In addition, lunch
has a soporific effect and although the tendency sigma rhythm Previously used term for SLEEP
for sleepiness in the midafternoon is not entirely SPINDLES. Sigma rhythm is derived from the shape
due to food intake at midday, it will exacerbate of the Greek sigma character.
204 situational insomnia

situational insomnia See ADJUSTMENT SLEEP How Much Sleep Do We Need?

DISORDER. The National Sleep Foundation (NSF) recommends
that you get between seven and nine hours of sleep
every night. However, according to a recent NSF
sleep A behavioral state characterized by rest, poll, the average American gets fewer than seven
immobility and reduced perception of environ- hours, or just 6.9 hours, of sleep a night.
mental stimuli in which cognition and conscious- We know about the varying sleep needs of dif-
ness are suspended. Sleep occurs when the brain ferent populations because of experiments that
waves slow, and the erratic activity of many parts have been conducted. One, for example, had 30
of the brain starts to coalesce into a coordinated men and 30 women (18 subjects aged 20 to 35 and
synchronized background rhythm. The heart rate 12 subjects aged 70 to 79) confined to individual
slows, the muscles relax, and the wakeful brain apartments from which information regarding the
mentation calms to the point that a satisfying sense time of day and any time cues had been excluded.
of contentment occurs as we mentally drift away There were no windows, clocks, or broadcast
from our environment into peaceful unconscious- media, and the members of coauthor Dr. Charles
ness. You are asleep for, on average, between six Pollak’s staff, who served their meals and collected
and nine hours every day. data, were trained to avoid any references to time
We have learned that sleep, no matter how of day. Sleep-wake patterns were recorded from
many hours you manage to get each night, is the subjects continuously, using scalp and facial
not one long episode. Instead there are two types electrodes, for seven 24-hour days. The team was
of sleep—NON-RAPID EYE MOVEMENT (NREM) and thereby able to measure a subject’s sleep need as
RAPID EYE MOVEMENT (REM)—and within those two the fraction of time spent sleeping (hours of sleep
types of sleep, there are five stages: NREM has four per 24-hour day), which was sufficient to maintain
stages and REM has one stage. The combined five alert WAKEFULNESS. Subjects were allowed to sleep
stages to the period of time we call sleep are: as much as they needed and indeed had no control
over the number of hours they slept because they
NREM (non-rapid eye movement) had no means of measuring the passage of time.
1. Stage one is when theta waves characterize your The findings of this experiment are instruc-
brain activity. This stage, which is a lighter type tive. The young 20- to 35-year-old subjects slept
of sleep, lasts approximately five minutes and is 8.6 hours per 24-hour day, while the older 70- to
the period between wakefulness and sleep. 79-year-old subjects slept 6.5 hours per day. Also,
2. Stage two is still moderately light sleep—which younger subjects spent 10.2 hours/day at bed rest,
consists of sleep spindles and K-complexes—a while the older subjects spent 9.6 hours/day. Not
stage that comprises 45 to 50 percent of total only did the older subjects require less sleep, but
sleep time. their sleep time relative to time in bed was much
3. Stage three, known as slow wave sleep or delta less than that of the young subjects. The older sub-
sleep, comprises 4 to 6 percent of total sleep jects were therefore inefficient sleepers, even in a
time. Eye movement is usually absent during normal temporal environment. It has been known
stage three. for years that reducing the amount of time spent
4. Stage four, or deepest sleep, what is similar to in bed by otherwise healthy insomniacs improves
slow wave sleep, usually makes up 12 to 15 per- sleep efficiency and continuity without inducing
cent of total sleep time. Sleepwalking or sleep ter- sleep deprivation. This safe, nondrug measure
rors will most likely occur during stage 4 NREM. should become a universal practice in persons over
the age of 70.
REM sleep Humans typically respond to circadian time
During this rapid eye movement stage, dreaming cues, from which they deviate at their peril, for
occurs. REM stage takes up about 20 to 25 per- example, if they engage in night shift work, but
cent of the total sleep time for an adult. they also have expectations about sleep itself. Cli-
 sleep 205

nicians know that their insomniac patients expect tion sleep aids, such as melatonin pills or herbal
to sleep eight hours a night. This is true even of remedies containing lavender, valerian root, or
the elderly, whose sleep needs actually amount to chamomile, to soaps, body washes, and candles
fewer than seven hours a night. promoting aromatherapy as a sleep enhancement.
Does it follow, then, that insomnia is simply a There have also been some surprising improve-
common human affliction that results from unre- ments in hypnotic drug safety, though not to the
alistic expectations of how long we should sleep, point that it is clearly preferable to behavioral
especially as we grow older? Should we simply methods. In fact, on March 14, 2007, the U.S. Food
jettison our sleeping pills and live by nature’s own and Drug Administration (FDA) issued a press
day-night signals? It probably would not be that release, “FDA Requests Label Change for All Sleep
difficult to convince most readers of the benefits of Disorder Drug Products,” asking the manufactur-
getting along without hypnotic drugs, but eradicat- ers of sedative-hypnotic drug products, “to include
ing these from American, European, or Asian soci- stronger language concerning potential risks.” The
eties hardly seems feasible. Many situations exist FDA listed these risks to include “severe allergic
for which hypnotics seem indispensable, particu- reactions and complex sleep-related behaviors,
larly post-operative pain, along with other sleep- which may include sleep-driving. Sleep driving
disrupting medical conditions such as dyspnea, jet is defined as driving while not fully awake after
lag, some cases of shift work, as well as temporary ingestion of a sedative-hypnotic product, with no
stressors such as bereavement, an upcoming wed- memory of the event.”
ding, or imminent school examinations. Second, In April 2006, the Institute of Medicine (IOM) of
before cutting down or eliminating sleeping pill use the National Academy of Sciences issued a report
altogether, it is essential to get a handle on sleep entitled, “Sleep Disorders and Sleep Deprivation:
habits by estimating an individual’s sleep need and An Unmet Public Health Problem.” Among many
scheduling sleep accordingly. other conclusions, the IOM report recognizes that
The best rule is to schedule sleep hours to be “sleep disorders and sleep deprivation are signifi-
both regular and rational. Rational means that cant public health problems that have a wide range
the scheduled hours should be consistent with the of deleterious health and safety consequences.”
individual’s sleep need, which can be estimated
by keeping a two-week sleep log. After sleep has Why Do We Need Sleep?
become more regular and continuous, sleeping Although scientists are still trying to figure out why
pills may be tapered off and cut down. Should we sleep, the consequences of either failing to sleep
sleeping difficulty recur after hypnotics have been at night, what is referred to as insomnia, or getting
cut out, drug dependency or concomitant depres- too little sleep, what is known as sleep deprivation
sion and/or anxiety disorder should be considered. (and the related fatigue that it causes), are clear
In that case, taper the hypnotics more slowly or and include:
evaluate and treat the emotional disorder. Perhaps
we will see a movement to try to encourage more • an increased likelihood of falling asleep at the
natural cures for the most typical sleep challenge, wheel, at work, or at school
insomnia, just as the Lamaze method of natural
childbirth has been an alternative way for some to • a greater possibility of having a car or work-
deal with the pain of childbirth. related accident
Currently, however, the increase in expendi- • depression
tures on prescription sleep aids is notable. In 2006, • moodiness
in the United States alone, it is estimated that $3.6
• poorer concentration
billion was spent on prescription sleep medications,
an increase of 29 percent from 2005, according to • reduced memory retention
IMS Health, a health care research firm. That does • too little sleep has been linked to a greater chance
not include all the money spent on nonprescrip- of obesity or a higher body mass index (BMI)
206 sleep

According to the National Center on Sleep Now it remains up to sleep professionals to detect
Disorders Research of the National Institutes of and treat sleep apnea on a widespread scale.
Health, 70 million American adults, or one out A January 2, 2007, New York Times op-ed piece
of every three, have some kind of sleep problem. by Drs. H. Gilbert Welch, Lisa Schwartz, and Ste-
Insomnia, whether an occasional night of inter- ven Woloshin complained about the escalating
rupted sleep or hours of sleep deprivation, has been number of medical diagnoses citing such “everyday
linked to an increase in daytime sleepiness and to a experiences like insomnia . . . [and] twitchy legs”
greater likelihood of mistakes or accidents at work, as examples of diagnoses of questionable legiti-
as well as to drowsy driving. macy—sleep disorder and restless leg syndrome,
respectively.
Sleep as a Medical Subspecialty and an Industry Although insomnia and restless leg syndrome in
According to an article in the New York Times themselves may not be as life-threatening as can-
entitled, “The Sleep-Industrial Complex” by Jon cer or heart disease, the authors are picking on the
Mooallem on November 18, 2007, Business 2.0 esti- wrong conditions to label as part of a larger threat
mated in 2007 that Americans spent an estimated posed by “an epidemic of diagnoses.” Chronic insom-
$20 billion on products or services to help them nia is indeed a condition to be considered. Research
sleep, such as special mattresses, adjustable beds, conducted by Dr. Pollak and his associates Deborah
hypoallergenic pillows, white-noise machines, Perlick, Jerome P. Linsner, John Wenston, and Frank
music to help induce sleep, and visits to more than Hsieh from 1984 to 1985 with the elderly revealed
1,000 accredited sleep clinics. that “in males insomnia was the strongest predictor
Since the second edition of this encyclopedia was of both mortality and nursing home placement.”
published in 2001, the number of sleep disorder More recent research on sleep and the elderly con-
practitioners has grown substantially as evidenced ducted by Sonia Ancoli-Israel, Ph.D., and reported on
by the burgeoning attendance at annual meet- at the American Geriatrics Society meeting as quoted
ings of the Associated Professional Sleep Societies on February 11, 2008, in www.vision.org, that sleep
(APSS), a joint venture of the AMERICAN ACADEMY problems and aging do not have to go together. Says
OF SLEEP MEDICINE and the Sleep Research Society, Ancoli-Israel: “Don’t think it’s normal because they
held each June. In July 2006 accredited programs are older . . .” A study by Wilfred R. Pigeon, Ph.D.,
to train physician sleep specialists began with the of 1,801 elderly patients ages 60 or older, reported in
American Board of Medical Specialties’ recognition the April 2008 issue of the journal Sleep found that
of sleep medicine as a subspecialty. According to chronic insomnia can cause the elderly who have
the American Board of Sleep Medicine, there were depression to remain depressed.
3,445 certified sleep specialists in the United States
as of 2006. Sleep Concerns and Sleep Trends
In the last seven years, there have been some There is a debate over whether or not daytime
stunning scientific advances in the causes of NAR- naps should be encouraged. In recent years there
COLEPSY, a condition marked by EXCESSIVE DAYTIME are some sleep experts such as Dr. WILLIAM C.
SLEEPINESS whereby someone could fall asleep at DEMENT, founder of the Stanford University sleep
any time. It appears likely that narcolepsy arises research center, who favor naps as a way to treat
from a deficiency of orexin neurons in the lateral sleep deprivation. On the other hand, Dr. Gerard
hypothalamus, although the exact manner in T. Lombardo, the director of the sleep center at
which this causes the sleep abnormalities of narco- New York Methodist Hospital in Brooklyn, argues
lepsy is far from clear. against napping, saying it could disrupt the normal
Perhaps the biggest step taken by the sleep nighttime sleep cycle. Instead of naps, Dr. Lom-
research and treatment field is the appreciation of bardo recommends daytime exercise as a better
nasal CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) way to improve sleep.
as virtually a cure for sleep apnea (although it is A trend developing in metropolitan areas is the
not truly a cure since it must be applied nightly). “sleep” salon or spa. These salons provide people
 sleep 207

with a safe, comfortable place to take a nap. Unlike levels of calcium actually caused them to have
restrooms, however, sleep chambers are not free. insomnia.”
One such salon receiving a lot of media attention, In summary: avoid self-medicating for chronic
including a brief article in the New York Times, is insomnia especially combining over-the-counter
Yelo in New York City, which calls itself a corporate and prescription medications. If behavioral modi-
wellness center. Yelo charges $12 to $24 for 20- to fication cures for the insomnia do not work,
40-minute naps, available in 5-minute increments. see a reliable sleep professional for treatment
Each private cabin, called a YeloCab, contains a recommendations.
leather recliner, dimmed lighting, soothing music
or sounds, and a cashmere blanket. Educating the Public about Sleep
One key area of concern in regard to sleep and Based in Washington, D.C., the National Sleep
sleep-related problems, such as insomnia, is the Foundation, founded in 1990, is an independent
issue of self-medicating through a combination nonprofit organization that conducts surveys, funds
of over-the-counter treatments and prescription sleep research, and spearheads public awareness
drugs, combinations that can be dangerous. For campaigns about sleep. Their persistent and con-
starters, there may be side effects to prescription certed efforts have put a spotlight on the hazards
sleep aids, such as dry mouth or drowsiness upon of sleep deprivation especially among car and truck
awakening. There could be unpleasant or danger- drivers (drowsy driving) and even airline crews
ous interactions if someone is taking two or more and its relationship to accidents and fatalities.
medications in addition to the prescription or over- In 2006, the NSF also focused on the sleep-
the-counter medications. The American Academy related consequences to students whose schools
of Sleep Medicine also cautions against the off- have extremely early start times, and in 2007 they
label use (or misuse) of antihistamines, usually released the findings of their study of women and
used for treating allergies, as a sleep aid. There sleep. NSF’s sponsorship of the National Sleep
are side effects to using antihistamines for treating Awareness Week each March highlights the find-
insomnia, such as next-day drowsiness. ings of its annual nationwide sleep polls as well as
Other nonprescription treatments for insomnia, reinforces steps that the public may consider taking
such as herbs like St. John’s wort and Valerian root, to achieve more effective sleep habits.
have been used with varying degrees of success Complementing these efforts was the 2006
as well as possible side effects. According to the release of cinematographer Haskell Wexler’s docu-
2005 American Academy of Sleep Medicine Clini- mentary entitled Who Needs Sleep, which was moti-
cal Practice Review Committee report of January vated by the death of a coworker and friend whose
2005, Valerian root, which patients say improves long hours at work and resulting sleep deprivation
“the quality of their sleep,” is the only herb to be had deadly consequences. Drowsy Driving Preven-
studied in any detail with and “there do not appear tion Week is an annual November initiative that
to be any major side effects.” (But that does not started in 2007. There are numerous educational
mean that it might not have a side effect for a spe- materials as well as TV advertising campaigns
cific individual.) St. John’s wort, however, has not helping to educate the public about the lives that
been studied for the treatment of insomnia but it are lost on the road or at work because of drowsy
has been studied for the treatment of depression. driving tragedies as well as preventable accidents
Reported side effects include headache, fatigue, caused by driving, being a passenger in a vehicle
anxiety, dizziness, possible dangerous drug interac- driven by a drowsy driver, or being the pedestrian
tions, and stomach complaints. Certain vitamins or passenger in a car or vehicle hit by a drowsy
and minerals have been said to help cure insomnia; driver. On June 23, 2008, as reported in the New
according to the AASM report, “no careful stud- York Sun, a truck slammed into a bus in Chinatown;
ies have shown that they help you sleep better in a 57-year-old waiting to cross the street was killed
any way.” The report states “Patients with kidney by flying debris and four additional pedestrians had
failure were studied after they took calcium. High to be hospitalized. A witness said this about the
208 sleep apnea

truck’s driver: “I think he might have been asleep.” tone. The most pronounced reduction of muscle
(See also BEDTIME, DREAM CONTENT, DREAMS, DREAMS tone is during REM sleep. A similar situation exists
AND CREATIVITY, SLEEP DEPRIVATION, SLEEP DURATION, in humans in whom muscle activity persists during
SLEEP NEED, SLEEP ONSET, SLEEP STAGES.) REM sleep and the patient also “acts out” dreams.
This disorder, which has been called the REM SLEEP
BEHAVIOR DISORDER (RBD), is most commonly seen
sleep apnea Cessation of breathing that occurs in persons over the age of 60 years, although it
during sleep. APNEA in association with complete has been described in younger individuals, usually
cessation of respiratory movements is termed “cen- in association with neurological lesions of varied
tral sleep apnea” whereas apnea that occurs in types. The majority of cases of REM sleep behavior
association with upper airway obstruction is called disorder have no known neurological cause. (See
“obstructive sleep apnea.” A mixed form of apnea also PONS.)
may occur if there is an initial central apnea that
is continuous with an obstructive apnea. Sleep
apnea is differentiated from episodes of partial sleep bruxism Stereotyped movement disorder
obstruction, which are termed HYPOPNEAS, in which that involves clenching or grinding the teeth dur-
there is an incomplete reduction of airflow (but a ing sleep. Some individuals have bruxism when
reduction of 50 percent or more) associated with a awake during the day; others have bruxism pre-
reduction in blood oxygen saturation. dominantly while asleep. When bruxism occurs
Some people have frequent episodes of sleep during sleep, it commonly produces an unpleasant
apnea and may develop a sleep apnea syndrome. grinding sound that may be disturbing to a bed
CENTRAL SLEEP APNEA SYNDROME or OBSTRUCTIVE partner; it can also interfere with the sufferer’s
SLEEP APNEA SYNDROME are the two apnea syn- quality of sleep by causing brief arousals. When the
dromes seen in infancy, childhood or adulthood. grinding occurs over many years, the cusps of the
A physiological form of central sleep apnea may teeth can be worn down, and this may be detected
occur in premature infants and is called APNEA OF during a routine dental examination. The constant
PREMATURITY. (See also INFANT SLEEP APNEA, SLEEP- grinding during sleep often leads to discomfort in
RELATED BREATHING DISORDERS.) the muscles of the jaw and there may also be gum
damage. Bruxism is a cause of an atypical headache
and may also produce a temporomandibular joint
sleep architecture The organization of the NREM- discomfort.
REM SLEEP CYCLE and wakefulness as it occurs dur- Bruxism typically occurs in healthy adults or
ing a sleep episode. The duration of SLEEP STAGES children, but it is more common in children who
and the relationship to preceding and following have a central nervous system disorder such as
wakefulness is recorded so that the structure of the cerebral palsy. Exacerbation of the bruxism may
sleep episode can be demonstrated, often as plotted occur with psychological stress.
in the form of a histogram. Although the majority of the population will at
The sleep architecture is often described as being some time grind their teeth, if only infrequently, up
disrupted if there are frequent sleep stage changes to 5 percent of the population have more persistent
and a greater number than normal of arousals or teeth grinding. The onset of teeth grinding among
awakenings. A sleep episode that is normal may be healthy infants occurs at a mean age of 10 months,
described as having a normal sleep architecture. affecting male and female children equally.
Studies of bruxism during sleep have shown that
it can occur during all stages but is most common
sleep atonia Term denoting the decrease of mus- during stage two sleep (see SLEEP STAGES). Rarely
cle activity during sleep. As sleep gets deeper, from will it occur predominantly in REM sleep.
the early stages of NON-REM STAGE SLEEP through Bruxism may be helped by the use of a dental
to SLOW WAVE SLEEP, muscles reduce in activity and appliance, the mouth guard, which is worn during
 sleep deprivation 209

sleep. Attention to underlying psychological stress ICS, may be required for some patients. The cause
by using appropriate psychological or psychiatric of the disorder is thought to be psychological.
treatment may also be helpful. For many individu-
als, the disorder does not require a specific treat-
ment. Particularly in children, it appears to be a sleep cure See SLEEP THERAPY.
transient phenomenon.

sleep cycle See NREM-REM SLEEP CYCLE.

sleep choking syndrome Disorder characterized
by choking episodes that occur during sleep and do
not have an apparent organic or psychiatric cause. sleep deprivation One of the most intriguing
The patient awakens with a sudden and intense questions in sleep research is, “Why do we need
feeling of being unable to breathe associated with to sleep?” As this is a difficult question to answer,
a choking sensation. The episodes occur typically experimenters have studied the opposite phenom-
in the early part of the night. Once awake, there enon of what happens if you do not sleep. Sleep
is a sensation of fear, ANXIETY, and the feeling of deprivation has been studied extensively to deter-
impending death. Within a few seconds, the anxi- mine the effect of sleep loss, as well as the loss of
ety abates as the awareness develops that breath- specific components of sleep, such as REM sleep.
ing is unimpaired. This disorder commonly occurs Although it is clear that most people who are
either nightly or almost every night. deprived of sleep become sleepy, this became
The sleep choking syndrome is not associated clear in 1959, when PETER TRIPP, a New York
with any objective evidence of difficulty in breath- disc jockey, stayed awake for some 200 hours
ing. There is no stridor, hoarseness or change in as a fund-raising publicity stunt. Toward the
color noted in these patients. Bed partners are end of Tripp’s 200-hour vigil, psychotic features
usually not aware of the episodes until reported to became evident, with hallucinations. As a result
them the next morning. of this unscientific experiment of sleep depriva-
The episodes most commonly occur in females tion, it was erroneously believed that the loss of
in early to middle adulthood. sleep would be accompanied by severe mental
Polysomnographically, patients demonstrate no deterioration.
abnormalities and do not have choking episodes The first opportunity to scientifically study
during the monitoring. Polysomnographic monitor- someone who had been deprived of sleep occurred
ing is usually necessary to exclude an organic cause in 1964 when RANDY GARDNER, a San Diego
and to have sufficient information to reassure the resident, remained awake for 260 hours. Dur-
patient of the benign nature of the syndrome. ing the later part of his stint of wakefulness, he
Episodes of awakening with a choking sensa- was observed by the sleep researcher WILLIAM C.
tion need to be differentiated from several breath- DEMENT, and subsequently studied by Dr. Laverne
ing disorders, including the OBSTRUCTIVE SLEEP Johnson in the sleep laboratory at the San Diego
APNEA SYNDROME, CENTRAL SLEEP APNEA SYNDROME, Naval Hospital. Toward the end of the attempt at
and CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME. keeping awake, it was clear that Gardner was in
Other disorders that can produce a sensation of a state of partial sleep and wakefulness that could
difficulty in breathing and fear include PANIC DIS- not be separated. One of the intriguing questions
ORDERS, which are usually associated with agora- that arose was whether he would have a prolonged
phobia and the presence of daytime panic episodes. sleep episode following the wakefulness. After the
SLEEP-RELATED LARYNGOSPASM can be differentiated 11 days, Gardner slept for 14 hours and 40 minutes
by the absence of stridor, hoarseness, cyanosis or and appeared entirely refreshed upon awakening.
pallor in association with the episodes. He subsequently remained awake for 24 hours
Treatment of the disorder is primarily by reas- before having a second sleep episode of normal
surance. However, antianxiety agents, or HYPNOT- duration of approximately eight hours. Gardner
210 sleep deprivation

did not have any psychiatric disturbance related Polysomnographic monitoring after a brief
to the sleep deprivation; subsequent sleep episodes episode of sleep deprivation demonstrates a short
demonstrated that the accumulated lost sleep was SLEEP LATENCY with an increased amount of SLOW
not made up by the body, as a short sleep episode WAVE SLEEP that often occurs at the expense of
appeared to be fully refreshing. REM sleep. On subsequent nights, there may be
Subsequent research studies have given conflict- an increase in REM sleep until the pattern returns
ing results, with some brief psychiatric disturbances to normal sleep stage percentages (see SLEEP
following sleep deprivation of up to 10 days. How- STAGES).
ever, prolonged and complete sleep deprivation Studies of selective sleep deprivation are largely
is usually not possible because of the intrusion of limited to suppression of slow wave sleep or REM
brief sleep episodes, even though the subject is sleep. It is almost impossible to suppress non-
active and conversant. REM sleep due to its universal occurrence at sleep
There are major changes in mood and perfor- onset.
mance, with fatigue, irritability, impaired percep- REM sleep deprivation is typically produced by
tion and orientation, and inattentiveness due to an auditory or physical stimulus that mechanically
sleep deprivation. These features begin after about awakens the subject whenever entering into the
36 hours of sleep deprivation and are most notable particular sleep stage as determined by polysom-
during the time that would usually be the time nographic monitoring. REM sleep deprivation is
of the habitual sleep period. Even during the first associated with an increased pressure for REM
night of sleep deprivation, subjects have great dif- sleep that is evident during the subsequent sleep
ficulty in maintaining full alertness at the time that episode. The amount and percentage of REM sleep
correlates with the low point in body TEMPERATURE, is increased, and there often is a short REM SLEEP
typically between 4 A.M. and 6 A.M. This particular LATENCY. These are features indicative of REM
time is most crucial in studies of sleep deprivation REBOUND.
because a few minutes of inattention will allow a REM sleep deprivation has been used as a treat-
nonactive subject to fall asleep. ment means for patients who have depression and
Activity and mood following one night of sleep has been found to be effective. The association
deprivation do not show a linear decrease from the between improved mood and reduction in REM
time of the last sleep episode but rather there is a sleep has led to the hypothesis that the tricyclic
cyclical fluctuation in the relation to the circadian ANTIDEPRESSANTS work because they are effec-
pattern of alertness and sleepiness. The mid-after- tive REM sleep suppressants. MONOAMINE OXIDASE
noon following a night of sleep deprivation is a INHIBITORS, which are particularly powerful REM
time of increased sleepiness and decreased alert- sleep medications, are also strong improvers of
ness, which is related to the physiological, biphasic mood and depression and are usually associated
pattern of alertness. However, there is increasing with severe reduction and almost total elimination
alertness in activity a few hours later although the of REM sleep during their administration.
level of activity may be much reduced. Animal studies with REM sleep deprivation in
There are some neurological features of sleep controlled experiments have recently suggested
deprivation, such as weakness of the muscles and that deprivation of REM sleep may be associated
tremulousness of the limbs, as well as incoordina- with early death in animals, which may have rel-
tion and unsteadiness. evance for humans as well.
Short episodes of sleep deprivation have been Sleep deprivation as a clinical feature is common
beneficial in some situations. It is often used as an in disorders that affect the quality of nighttime
activating procedure for the diagnostic monitor- sleep, leading to disruption of sleep stages. Disor-
ing of patients with suspected seizure disorders. ders such as OBSTRUCTIVE SLEEP APNEA SYNDROME
Total sleep deprivation has also been demon- or PERIODIC LIMB MOVEMENT DISORDER produce
strated to improve mood in patients suffering from EXCESSIVE SLEEPINESS due to the frequent disrup-
DEPRESSION. tion of sleep stages. However, patients with INSOM-
 sleep-disordered breathing 211

NIA typically do not have an increased amount of A typical sleep disorder center comprises a
daytime sleepiness despite complaints of very little specialist in SLEEP DISORDERS MEDICINE, usually a
sleep. Research studies have demonstrated that the physician, and consultants from a variety of differ-
duration of sleep in patients with insomnia is only ent medical specialties, including otolaryngology,
slightly shorter than that of the normal population, pulmonary medicine, cardiology, neurology and
whereas the subjective assessment of sleep reduc- psychiatry. Patients typically undergo a full clinical
tion is much greater. evaluation that may involve seeing a psychologist
Chronic sleep deprivation is a common feature and, if necessary, patients will undergo polysomno-
of adolescents who go to bed late and have to rise graphic testing.
early for school. Adolescents who get less sleep A sleep disorder center will have at least one
than is required develop sleepiness during the recording room for POLYSOMNOGRAPHY, and typi-
daytime, which may become manifest as daytime cally will have two or three rooms. These rooms
NAPS. People who live in tropical countries often consist of a hotel-like bedroom with specialized
take a mid-afternoon SIESTA, but subsequently monitoring equipment housed in an adjacent
have a shorter nighttime sleep episode with a later control room. Patients will undergo all-night poly-
bedtime and an early time of arising. Such people somnographic monitoring as needed, which may
have a total sleep time in a 24-hour period that is be followed by an assessment of excessive daytime
normal. Some people who do not allow themselves sleepiness by MULTIPLE SLEEP LATENCY TESTING. Some
to take a daytime sleep episode can become chroni- patients require several nights of polysomnographic
cally sleep-deprived by the limited amount of time monitoring to determine an accurate diagnosis, or
they sleep at night. Sleep of five or less hours may to provide for treatment under polysomnographic
produce severe chronic sleepiness in a person who monitoring. Bathroom and kitchen facilities are
usually requires seven hours of sleep. Chronic usually available for the patient’s comfort.
sleep deprivation needs to be differentiated from In addition to clinicians’ offices and the polysom-
NARCOLEPSY or other disorders of excessive sleepi- nographic recording areas, a sleep disorders center
ness. The INSUFFICIENT SLEEP SYNDROME is the term usually will have a conference room where multi-
used for the disorder characterized by chronic sleep disciplinary clinical case conferences are held.
loss and excessive sleepiness. The development of quality standards for sleep
disorder centers throughout the United States is
provided through the AMERICAN ACADEMY OF SLEEP
sleep diary See SLEEP LOG. MEDICINE. Sleep disorder centers are accredited if
they meet the standards and guidelines of the Amer-
ican Academy of Sleep Medicine. (See also ACCREDI-
sleep disorder centers Facilities designed for the TATION STANDARDS FOR SLEEP DISORDER CENTERS, FIRST
diagnosis, evaluation and treatment of patients with NIGHT EFFECT, REVERSED FIRST NIGHT EFFECT.)
sleep disorders. A comprehensive sleep disorder
center has the expertise and facilities for diagnosing
and evaluating disorders that occur during sleep sleep disorder centers, accreditation standards
as well as disorders of EXCESSIVE SLEEPINESS during for See ACCREDITATION STANDARDS FOR SLEEP DIS-
the day. The disorders that are able to be evaluated ORDER CENTERS.
cover all medical specialties and age groups from
infancy to old age. The first sleep disorder center in
the United States was developed in the early 1970s sleep disorder clinics See SLEEP DISORDER
at the Stanford University Medical Center. By the CENTERS.
end of 1988, 110 sleep disorder centers had been
accredited in the United States. Similar centers are
being developed in many other countries, includ- sleep-disordered breathing Term applied to a
ing Japan, England and Germany. variety of breathing disorders that can occur during
212 sleep disorders

sleep, such as the OBSTRUCTIVE SLEEP APNEA SYN- tion is nearly always the oropharynx. In addition
DROME, CENTRAL SLEEP APNEA SYNDROME, or CEN- to being the most common type of sleep disor-
TRAL ALVEOLAR HYPOVENTILATION SYNDROME. Chronic der, obstructive sleep apnea is the one that most
respiratory diseases including nocturnal asthma threatens health by doubling or tripling the risk
can also produce sleep-related breathing abnormal- of heart attack (myocardial infarction) and stroke.
ities, characterized by reduction in blood oxygen Fortunately OSA is easy to recognize, diagnose,
saturation during sleep as well as disrupted sleep. and treat.
Sleep-disordered breathing may consist of a pat- OSA is usually recognized by the presence of
tern of hyperventilation or hypoventilation with or toad snoring. Indeed, snoring may constitute an
without apneic episodes. The term sleep-disordered important nuisance or a serious marital problem,
breathing has also been applied to the APNEAS and even if it is not associated with obstructive apneas.
HYPOPNEAS that occur during sleep and is often Another symptom of OSA is daytime sleepiness,
expressed as the RESPIRATORY DISTURBANCE INDEX. which may expose a patient to the risk of a driving
(See also CHRONIC OBSTRUCTIVE PULMONARY DISEASE, accident or interference with performance of occu-
SLEEP-RELATED ASTHMA, SLEEP-RELATED BREATHING pational responsibilities.
DISORDERS.) Treatment of OSA usually rests on the use of
nasal CPAP (CONTINUOUS POSITIVE AIRWAY PRES-
SURE) by which air entering the airway is placed
sleep disorders The past few decades have wit- under pressure, thereby preventing the tissues of
nessed the expansion and deepening of our knowl- the oropharynx from obstructing airflow. This is
edge regarding what might go wrong with sleep or both safe and highly effective, avoiding the usual
during sleep. In fact, the pace of discovery has been tradeoff between safety and efficacy required by
so rapid as to constitute an entirely new branch of most other forms of medical treatment. Treatment
medicine. Only a few years ago, it was possible to success is apparent within a few days of nightly use
classify most disorders as instances of the classical of CPAP, when daytime sleepiness disappears and
medical specialties (neurology, psychiatry, cardiol- sleep becomes sounder and nocturia, for example,
ogy, etc.), but with the burgeoning field of sleep may lessen.
medicine, it has become obvious that these classi- In contrast to the risks and susceptibility to
cal categories no longer suffice. Instead, the new treatment of OSA, apneas may also be of a nonob-
field of sleep medicine spans multiple disciplines, structive (“central”) type (i.e., breath holds). These
including neurology, psychiatry, internal medicine usually occur less often during sleep but, when
(including pulmonary medicine, and cardiology), they do, can be difficult to treat. Fortunately, a new,
and otolaryngology. At last count, there were 77 effective type of CPAP known as assisted servoven-
separate sleep disorders. Of these, only a few are tilation (ASV) has been developed and is being used
encountered frequently by sleep medicine practi- in the treatment of central sleep apnea.
tioners: SLEEP APNEA, INSOMNIA, RESTLESS LEGS SYN- Insomnia is not a disorder per se; instead, it refers
DROME, and NARCOLEPSY. to difficulty either initiating or maintaining sleep.
Sleep apnea is usually of the obstructive type, There are several reasons for insomnia, including
also known as OSA or obstructive sleep apnea, constitutional disorders resulting in hyperarousal
because the cessation of airflow—apnea—is the as well as affective disorders such as depression and
result mainly of functional obstruction of the upper anxiety. Depression is especially likely to be present
airway by the tongue and other local tissues. This when insomnia is severe and prolonged. Recogni-
obstruction is functional, not structural, because it tion of depression can be difficult, as depression
takes place only during sleep. During wakefulness, may be “masked” and sometimes takes the form of
no signs of obstruction can be found, whether by alcohol abuse or sleeping pill abuse; it is especially
sleep laboratory testing or by examination of the likely to masquerade as insomnia with a physical
airway. We know from endoscopic examination cause. Thus, insomnia may be both a proxy for
of the airway during sleep that the site of obstruc- depression as well as a symptom of depression.
 sleep disorders 213

Treating depression in the usual way (medication The movements, termed PERIODIC LIMB MOVEMENTS
with or without psychotherapy) may also be effec- OF SLEEP (PLMS), may briefly arouse the sleeper,
tive for the associated insomnia. especially if they are frequent, but small periodic
A special instance of insomnia is mania or hypo- movements of the toes and ankles are usually not
mania in people with bipolar disorder, which may disturbing to sleep. RLS is commonly associated
be associated with sleeplessness lasting over 24 with PLMS, but PLMS is less often associated with
hours. Additional causes of insomnia are substance RLS. Both conditions are responsive to dopamine
abuse (CAFFEINE, COCAINE, AMPHETAMINE) as well as receptor agonists, such as PRAMIPEXOLE (Mirapex)
hypnotic drug dependency and withdrawal. Sleep- or, less successfully in our experience, ropinirole
ing pill use may also cause or prolong insomnia. (Requip).
PSYCHO PHYSIOLOGICAL INSOMNIA is said to be pres- Narcolepsy is a neurological disorder that
ent when the effort to sleep, at bedtime or during becomes problematic in the late teens or a little
the night, results in a frustrating inability to relax. later. Rarely, it may follow a head injury. Once
Patients often complain that they are unable to established, narcolepsy remains as a lifelong con-
stop thinking and conclude that their thoughts dition. There are no known cases of spontaneous
are responsible for keeping them awake. This may remission. The onset of narcolepsy is sometimes
indeed be the case, especially if the nocturnal evident when a high school student begins to fall
thoughts reflect frustration and anger. In addition asleep during class without explanation.
to frustration during efforts to fall asleep, patients A child may also begin to experience CATAPLEXY
may develop anticipatory anxiety as bedtime and within a few years. This is weakness that is usu-
its related frustrations draw closer. Relaxation ther- ally triggered by an emotion such as laughter or
apies such as progressive relaxation or visualization anger. Typically a child loses the strength to stand
can be useful, as can hypnotic agents including while being made to laugh by being tickled or
BENZODIAZEPINE, zolpidem, or esozopiclone taken being embarrassed. Episodes of cataplexy usually
at bedtime. However, patients should be aware of do not last for more than a minute during which
cautionary notes about temporary or prolonged a neurological examination reveals arreflexia and
use of these drugs for treatment of insomnia. atonia. If the child’s limb is raised, for example, it
When it is present on a nightly basis, insomnia falls without resistance when released. An identical
of the onset type (difficulty initiating sleep) often state may occur upon awakening or falling asleep
results from a displacement of sleep with respect (sleep paralysis).
to the circadian sleep-wake cycle. The same dis- The possibility that a child may have narcolepsy
placement of sleep results in difficulty arising should be entertained whenever episodes of unex-
until late in the day. This disorder, delayed sleep plained sleep develop. Typically, daytime naps last
phase syndrome, is most common in teenagers and less than 20 to 30 minutes and are followed by a
results in frequent lateness. It may be best treated state of alertness that may last several hours. There
by strict adherence to a regular, sufficiently early is also a remarkable ability to fall asleep whenever
sleep schedule, plus MELATONIN taken several hours requested. These characteristics may be tested
before bedtime and either sunlight or artificial by the MULTIPLE SLEEP LATENCY TESTING (MSLT) in
bright light exposure in the morning. which a narcolepsy suspect is asked to go to sleep
Restless legs syndrome (RLS) is an intolerable four or five times during the day. The MSLT is con-
feeling of restlessness or the need to move the legs ducted in a sleep laboratory so the effect of each
that develops in the afternoon or evenings and attempt to sleep may be recorded on a polygraph.
reaches its peak at bedtime. It is often incompatible The mean latency to sleep onset is less than five
with sleep and may require the sufferer to get out minutes in narcolepsy. In addition to the short
of bed to walk around. However, relief may be only latency to sleep onset, naps may begin with REM
temporary. Once SLEEP ONSET is achieved, sponta- sleep instead of the usual NREM sleep. Narcoleptic
neous, automatic movements often develop in the patients often corroborate the occurrence of REM
legs with a frequency of every 20 to 40 seconds. sleep by reporting a vivid dream soon after falling
214 sleep disorders

asleep, and such sleep-onset REM periods may also in their efforts to advance the hours of sleep can
be observed during a nocturnal sleep recording. be effective. However, the sleep schedule achieved
There are two treatment strategies in narcolepsy: in this way must be strictly enforced to avoid
intentional napping and enhancement of alertness. re-delay of the hours of sleep. The tendency to
The utility of intentional napping is based on the delay the hours of sleep may last for many years,
refractory period that follows naps. Subjects are though the condition has never been described in
instructed to plan naps that last up to 20 minutes. advanced age. Efforts to reverse the bias toward
This may depend on the forbearance of others, delay of the sleep phase have included taking
including employers. The payoff is renewed alert- melatonin before bedtime and using bright light in
ness and improved productivity. Usually no more the morning, but these efforts have usually been
than one to three naps a day is needed. Attempts disappointing.
to postpone naps are often useless or even harmful. PARASOMNIAS are disorders in which behaviors
For example, patients who avoid naps are at risk of normal during WAKEFULNESS occur during sleep,
inappropriate behaviors such as blurting out non- sleep-wake transitions, or during the night. An
sensical utterances or, when driving, slamming on example is SLEEPWALKING, which usually begins
the brakes (automatic behavior), exactly as patients during childhood. Behaviors range from simply
with psychomotor seizures may do. sitting up in bed to opening locked doors or dress-
CIRCADIAN RHYTHM SLEEP DISORDERS represent ing, which may require a complicated series of
disruptions of the normal circadian sleep-wake actions, and last more than 30 minutes, yet are
rhythm, which has a period of about 24 hours. A only partially recalled or are not recalled at all the
common cause of these disorders is travel across next morning. Sleepwalking may be triggered in
time zones so that the biological clock no longer susceptible children by forcibly sitting the child up
tells the correct time according to daylight and in bed. It usually takes place during SLOW-WAVE
nighttime hours, mealtimes, etc., at the new loca- SLEEP (SWS). Sudden, unprovoked arousals found
tion. Such temporal dislocation is only notice- in a sleep recording during SWS may be the only
able when travel is rapid, hence the term jet lag. evidence of sleepwalking. This behavior must be
There exists as yet no effective and reliable means distinguished from partial complex seizures. In
of rapidly resetting the biological clock, though the latter, the child does not return to his or her
melatonin taken several hours before bedtime may own bed, and there are also daytime seizures with
have some effect in resetting the timing of sleep. automatisms and EEG abnormality. Sleepwalk-
A related problem is that of shift work, which is ing must also be distinguished from sleep apnea,
likely to be an even greater challenge than that of Tourette’s syndrome, and fugue states.
jet lag, because the ability to sleep in the daytime SLEEP TERRORS are another childhood para-
and wake at night are not reinforced by shifted somnia associated with SWS. Typically, the child
local time cues such as light/dark patterns and emits a piercing scream, is found sitting up, and
social rhythms. seemingly intensely anxious but unresponsive and
DELAYED SLEEP PHASE SYNDROME is a sleep dis- inconsolable for five to 10 minutes. There is partial
order that, like narcolepsy, manifests itself dur- or complete amnesia; no dream is reported. Sleep
ing the teen years. As is well known, teenagers terrors should be differentiated from nightmares,
often go to bed late at night and, especially on the which typically occur during the middle or last
weekends or days off from school, arise late, but third of the night and are associated with dream
the tendency to delay sleep may be so extreme it recall as well as from partial complex seizure,
becomes a disability. Children may, for example, associated with automatisms, waking seizures, and
require home tutoring because they are unable to EEG abnormalities. In addition sleep terrors must
attend classes early in the morning. At the same be distinguished from sleep panic attacks, which
time, they may be unable to fall asleep before 1 are often associated with school phobia or school
to 3 A.M. The expediency of delaying the hours of refusal, separation anxiety, depression, and unex-
sleep by several hours a night instead of persisting plained somatic complaints.
 sleep disorders medicine 215

NOCTURNAL ENURESIS or bedwetting occurs most Sleep disorders medicine in the United States
often in boys and may be secondary to urinary tract has evolved from basic and clinical research of
infections (especially in girls), as well as diabetes sleep disorders. Research programs were devel-
(mellitus and insipidus), seizures, and sleep apnea. oped to understand the anatomy and physiology
Adult parasomnias include REM BEHAVIOR DIS- of normal sleep. In 1961, the first sleep research
ORDER (RBD), restless legs syndrome, and PERIODIC society, the Association for the Psychophysiologi-
MOVEMENTS OF SLEEP. REM BEHAVIOR DISORDER is the cal Study of Sleep, was developed; its name was
enactment of a dream (laughing, yelling, swearing, subsequently changed to the Sleep Research Soci-
gesturing, reaching, grabbing, punching, kicking, ety, out of which sleep disorders medicine arose.
jumping out of bed, running) during REM sleep, Sleep disorder centers were developed in the early
as verified by a sleep recording. The patient is most 1970s and standards and guidelines for such facili-
often a man in his 50s or older with a history of ties were established in 1975 by the Association of
dementia, Parkinson’s disease, narcolepsy, stroke, Sleep Disorder Centers. This led to the development
or abstinence from alcohol. In many cases, RBD of the Clinical Sleep Society, a society of clinicians
is a forerunner of Parkinson’s disease, which may from all medical specialties with a specific interest
develop several years later. in sleep and sleep disorders medicine. The Associa-
tion of Sleep Disorder Centers and the Clinical Sleep
Society merged to form the American Academy of
sleep disorders medicine A clinical specialty con- Sleep Medicine (formerly called the American Sleep
cerned with the diagnosis and treatment of disor- Disorders Association), which currently oversees
ders of sleep and wakefulness. In the last 25 years, the standards and guidelines for the accreditation of
there has been a rapid development of this subspe- sleep disorder centers and provides information and
cialty area due to the recognition of the importance professional education in all aspects of patient care.
of sleep in health and disease. It is estimated that The AMERICAN BOARD OF SLEEP MEDICINE has devel-
approximately 100 million people in all age groups oped examinations for the certification of physicians
in the United States have a disturbance of sleep and in sleep medicine. In addition, the technologists
wakefulness, which can manifest itself in many trained in performing polysomnographic studies
different ways. SUDDEN INFANT DEATH SYNDROME have formed the Association of Polysomnographic
affects some 7,000 normal infants every year. Technologists, which provides training courses and
Approximately 250,000 people have a disorder of certification examinations for sleep technicians. In
EXCESSIVE SLEEPINESS termed NARCOLEPSY, which 1987, the three main sleep societies formed the
causes them to have impaired ALERTNESS during the Association of Professional Sleep Societies, which
day—a lifelong and incurable disorder. comprised the Sleep Research Society, the American
Approximately 18 million shift workers have Sleep Disorders Association and the Association of
disturbed sleep-wake patterns due to the altered Polysomnographic Technologists. In 1995, the Asso-
relationship of sleep and their underlying circa- ciation of Polysomnographic Technologists left the
dian rhythms (see SHIFT-WORK SLEEP DISORDER). In group to organize its own annual meeting.
recent years, it has become known that breathing Major events that impacted on the development
disturbances during sleep can produce daytime of sleep disorders medicine included the discovery
sleepiness and are associated with sudden death of REM SLEEP in the early 1950s, the recognition
during sleep; the OBSTRUCTIVE SLEEP APNEA SYN- of the obstructive sleep apnea syndrome in the late
DROME is believed to occur in up to two million 1960s, the development of the first diagnostic clas-
Americans. About 30 million people have INSOMNIA sification of sleep disorders in 1979 (see DIAGNOSTIC
at some time of their lives that causes significant CLASSIFICATION OF SLEEP AND AROUSAL DISORDERS)
concern and stress. The recognition that these and and the development of physical facilities (see
other disorders are associated with the pathophysi- SLEEP DISORDER CENTERS) for the practice of sleep
ology of sleep has led to the development of sleep disorders medicine, with the capability of perform-
disorders medicine. ing polysomnographic evaluations during sleep
216 sleep drunkenness

(see POLYSOMNOGRAPHY) and for assessing daytime seven episodes of sleep occur throughout the
sleepiness (see MULTIPLE SLEEP LATENCY TESTING). In 24-hour day. The number of episodes decreases,
1989, the first comprehensive teaching text was and the duration of the nocturnal sleep episode
developed, The Principles and Practices of Sleep Disor- increases, so that by one year of age a child may be
ders Medicine, edited by Drs. Meir Kryger, Thomas sleeping nine hours at night with two short naps
Roth, and William C. Dement. of about two hours each during the rest of the 24-
Sleep disorders medicine has clarified the many hour day. By age four years, the major sleep episode
disturbances of sleep and wakefulness that not only comprises about 10 hours in duration and there
threaten physical and emotional health and lives may or may not be one nap. Most prepubertal chil-
but also greatly impair the ability to adequately dren have a nocturnal sleep duration of approxi-
perform during the working part of the day. mately 10 hours without a tendency for daytime
naps, and this length of nocturnal sleep gradually
reduces to six hours after 60 years of age.
sleep drunkenness Term applied to the condition Most young adults sleep 7.5 hours each night,
of people who have difficulty awakening in the with a slight increase in sleep duration on week-
morning and who often awaken in a confused and ends by approximately one hour. However, there
disoriented state. Although originally proposed as is a normal distribution of sleep length across each
a distinct disorder, sleep drunkenness is no longer age group, with some individuals having less than
thought to be a specific diagnostic entity. Instead, five hours of sleep a night and others having more
sleep drunkenness, or confusion and disorientation than nine hours. Recent research has indicated that
upon awakening, is a feature of many DISORDERS adults who receive less than five hours of sleep on
OF EXCESSIVE SOMNOLENCE, such as the OBSTRUCTIVE a regular basis, or more than nine hours of sleep,
SLEEP APNEA SYNDROME, IDIOPATHIC HYPERSOMNIA, have an increased mortality (see DEATHS DURING
CONFUSIONAL AROUSALS, or the SUBWAKEFULNESS SLEEP).
SYNDROME. In addition to a reduction of total sleep duration
as one gets older, there is also a change in the ratio
of REM to non-REM sleep. In infancy, about 50 per-
sleep duration The time one spends sleeping var- cent of all sleep is REM SLEEP, and this percentage
ies according to age, and there are individual dif- decreases as one gets older so that by age two years,
ferences at any particular age. A number of factors about 25 percent of the sleep period is REM sleep
can influence sleep duration, such as an individu- and at age 60 years, about 20 percent is REM sleep.
al’s voluntary control of sleep duration (by going to In addition, the frequency and number of awaken-
bed earlier or later, or waking up earlier or later) ings during the major sleep episode increases from
and genetic determinants. Variation in sleep time childhood through adulthood to old age.
may be determined by nighttime or daytime social In some societies, the nocturnal sleep episode
or work commitments. When a short sleep episode is of shorter duration because a daytime SIESTA is
persists on a regular basis it may impair daytime taken. Siestas that last four hours may be accompa-
alertness and EXCESSIVE SLEEPINESS may occur. In nied by a nocturnal sleep episode that is only four
such circumstances, the individual will have a ten- to six hours long. The total amount of sleep within
dency to fall asleep at inappropriate times and may a 24-hour period is usually normal, and is equiva-
take frequent daytime NAPS. lent to that seen in societies without a siesta.
Sleep duration varies from approximately 16 Research has demonstrated that sleep duration
hours in infancy (see INFANT SLEEP) to six hours may be reduced voluntarily if one gradually cuts
in the elderly (see ELDERLY AND SLEEP). In general, back on the amount of sleep at night. This sleep
there is a gradual decline in the sleep duration as reduction is done at the expense of the lighter stages
one ages. Sleep in infancy is characterized by short of sleep and REM sleep, which become reduced. If
episodes of REM and non-REM sleep that alternate sleep duration is reduced below the physiological
with short episodes of wakefulness. Approximately need for an individual then excessive sleepiness
 sleep enuresis 217

will result. Many people who report a long sleep and PERIODIC LIMB MOVEMENT DISORDER are two
duration often spend an excessive amount of time disorders commonly associated with an increased
in bed awake at night. Reduction in hours spent nocturnal sleep duration. In addition, patients with
sleeping will eliminate this wake time and lead to the disorder IDIOPATHIC HYPERSOMNIA typically have
more consolidated and efficient nocturnal sleep. a rather prolonged nocturnal sleep episode.
Although individuals have been reported to sleep
as little as two hours per night, this is very rare.
(Individuals who have a genetic predisposition to sleep efficiency The amount of sleep that occurs
less sleep are termed SHORT SLEEPERS.) In order to during a sleep episode in relation to the amount
confirm a short sleep duration, an individual must of time available for sleep. During POLYSOMNOG-
be studied in an environment free of time cues RAPHY it is usually expressed as a percentage of
(see ENVIRONMENTAL TIME CUES) for at least seven TOTAL SLEEP TIME according to the TOTAL RECORDING
days so that both nocturnal and daytime sleep can TIME. The sleep efficiency is an indication of how
be recorded. Some individuals report the complete much wakefulness occurred during the time avail-
absence of sleep for months and even years. Such able for sleep. Usually a sleep efficiency of greater
people, when studied in the sleep laboratory, are than 80 percent is regarded as normal in the sleep
seen to be sleeping, yet upon awakening do not laboratory. Efficiencies greater than 95 percent are
perceive that they slept. This disorder is called SLEEP indicative of an abnormally high sleep efficiency
STATE MISPERCEPTION or pseudosomnia. and are typically seen in patients with NARCOLEPSY
Some persons have a genetic tendency for a or IDIOPATHIC HYPERSOMNIA. Sleep efficiencies of
prolonged nocturnal sleep episode (greater than less than 80 percent are typical of disorders that
nine hours of sleep per day). For others, very often produce a complaint of INSOMNIA.
prolonged nocturnal sleep episodes occur at the
expense of consolidated sleep so that frequent or
lighter stages of sleep occur throughout the sleep sleep enuresis Also known as bed-wetting, this
episode. Long sleep episodes may alternate with is a disorder that is characterized by urinating dur-
short sleep episodes; this is particularly seen with ing sleep. This disorder can occur in both children
people who have mental disease characterized by and adults, although it is much more common in
manic-depressive stages. Rarely, some people can children. Usually sleep enuresis is not considered
extend their nocturnal sleep for one or two nights to be a diagnosis before the age of five; up to that
for periods as long as 15 hours in total duration. time frequent bed-wetting may be a normal devel-
When an episode of prolonged sleep occurs, there is opmental behavior. Primary enuresis indicates that
usually a return of stage three or four sleep toward control of urination at night has never occurred and
the end of the sleep episode. Awakening from this therefore bed-wetting has occurred since infancy.
sleep can lead to a complaint of fatigue, tiredness Secondary enuresis indicates that there has been a
and DROWSINESS for the remainder of the day. Such period of time when complete urinary control has
prolonged sleep durations in healthy people rarely occurred during sleep but then some factor caused
occur for more than two nights at a time. However, the control of urination to become disturbed, and
a genetic predisposition to long sleep rarely occurs bed-wetting occurred. At least three to six months
and those individuals are termed LONG SLEEPERS. of dryness is considered necessary before the term
Many sleep disorders can affect sleep duration. secondary enuresis is used.
Patients with insomnia typically report a short sleep Polysomnographic studies of bed-wetting have
duration at night, although recent studies have indicated that it occurs in any stage of sleep, most
shown that sleep duration in insomnia patients commonly at the end of the first third of the night.
is very similar to people without a complaint of As children between the ages of five and eight
insomnia. Disorders that affect the quality of noc- years of age have a larger percentage of stage
turnal sleep may lead to a change in sleep duration; three/four sleep at night than adults, it is more
for example, OBSTRUCTIVE SLEEP APNEA SYNDROME likely that an episode of enuresis will occur during
218 sleep exercises

stage three/four sleep (see SLEEP STAGES). Originally approximately 10 times for each voiding of the
it was thought that there might be a specific sleep bladder—have also been reported to be helpful. A
stage association with enuresis; however, this has variety of conditioning processes have been uti-
not been proven. Bed-wetting episodes appear to lized, such as using an alarm system. These means
occur in relation to the amount of time that has are often successful but require motivation on the
passed since the last episode of voiding urine and part of the enuretic. Reinforcement of positive uri-
are not due to a particular sleep stage. nary control during sleep by means of a star chart
It is estimated that approximately 10 percent or other reward system is helpful.
of all six-year-old children are enuretic and this Along with any management of enuresis it is
percentage decreases with age to 3 percent of 12- very important that the individual is supported by
year-olds. In early adulthood, approximately 1 per- other members of the family. A loss of the support
cent to 3 percent continue to be enuretic. Primary will often lead to the relapse of urinary control.
enuresis comprises the majority of all enuretic Other positive reinforcement processes, such as
patients—up to 90 percent—the remainder being removing the child from diapers or transferring
secondary enuretics. The male to female ratio is from a crib to a bed, can often be positive steps in
three to two. encouraging emotional maturation.
The cause of primary enuresis is unknown. Cur- Medication can be useful for patients who have
rent theories suggest it is due to a central nervous not responded to behavioral techniques. The tricy-
system maturational defect, as it spontaneously clic ANTIDEPRESSANTS, such as imipramine, may be
resolves with age. Rarely enuresis may be due to useful in some patients, as also an anticholinergic
bladder abnormalities, such as a small bladder or medication, such as oxybutynin chloride (Ditro-
urinary sphincter abnormalities. In the adult, sec- pan). Antidiuretic hormones have also been shown
ondary enuresis may be caused by a variety of disor- to be useful, such as the intranasal desmopressin
ders, including urinary tract infections, and lesions (DDAUP). Although medications are not the com-
that affect the urinary sphincter mechanism, such plete answer to treatment of enuresis, they can be
as local bladder or prostatic tumors. Sleep disorders useful, particularly for a child who may be stay-
may increase the frequency of NOCTURIA, although ing over at a friend’s place or staying at overnight
enuresis during sleep does not occur. However, camp. Other causes of enuresis must be excluded.
OBSTRUCTIVE SLEEP APNEA SYNDROME is a common Urinary tract infections must be treated, and if
cause of secondary enuresis in both children and obstructive sleep apnea is present, treatment of this
adults. Rarely enuresis may be related to emotional disorder can lead to resolution of the enuresis.
immaturity. It may be seen in the child who dem-
onstrates regression or passive-aggressive behavior
due to family or social stresses. sleep exercises Exercises prior to sleep at night
Treatment is not required before age five, and are often recommended for patients who have
if there is evidence that the frequency of urina- an increase in muscle tension and a difficulty in
tion is decreasing, treatment may be unnecessary relaxing that impairs the ability to fall asleep. The
even after age five. Studies have demonstrated exercises are composed of relaxation techniques
that patients who undergo treatment by a variety that lower arousal so that natural sleep can occur.
of different means can usually be helped. However, They can be performed during the daytime (wake-
approximately 15 percent of all patients will have a fulness) to assist in recognizing when muscle ten-
spontaneous remission of the enuresis. sion is high, and prior to the sleep episode to relax
Bladder training exercises such as controlling the tension and facilitate sleep onset. BIOFEEDBACK
urination by preventing frequent daytime urina- techniques have also been developed to aid in rec-
tion may be helpful. It is reported that up to 30 ognizing when muscle tension is high.
percent of children are helped by such exercises. Typical relaxation exercises involve tensing and
Sphincter training exercises—where the child is tightening up one or more muscles and then per-
asked to interrupt the urinary stream repeatedly, ceiving the sensation that occurs when they relax.
 sleep hyperhidrosis 219

Relaxation exercises can be performed while lying Practices that are associated with a normal sleep-
on the back with the eyes closed and the legs wake pattern are: avoidance of napping during the
uncrossed. They should last at least 30 minutes; daytime; regular wake and sleep onset times; ensur-
however, up to 60 minutes may be necessary if a ing that an appropriate length of time is spent in
great deal of muscle tension is present. Exercises bed, which is neither too short nor too excessive;
of the legs involve bending both feet downward at avoidance of stimulants such as CAFFEINE, NICOTINE
the ankles and clawing the toes at the same time. and ALCOHOL in the period immediately preceding
The knees are straight and should not bend. The bedtime; avoidance of stimulating exercise before
feet and toes are then allowed to go limp suddenly. bedtime; an adequate relaxation period before bed-
Several minutes of relaxation should then occur time; avoidance of emotionally-upsetting activi-
before repeating the tension and relaxation phase ties or conversations immediately before bedtime;
of the feet. Following relaxation of the legs, the rest avoidance of activities associated with wakefulness
of the body, including the arms, should be relaxed. in bed, for example, watching television or listening
Similar exercises can be used for other muscles in to the radio; a pleasant sleep environment, which
the legs, arms, trunk, head and neck. includes sleeping on a comfortable mattress with
The muscle exercises proposed by Edmund adequate bed covers, and ensuring that the bedroom
Jacobson in 1983 have been found useful by many environment is not too cold, too hot or too bright;
patients with increased muscle tension (see JACOB- avoidance of dwelling on mental problems in bed.
SONIAN RELAXATION). (See also INADEQUATE SLEEP HYGIENE.)

sleep fragmentation The term for when someone sleep hyperhidrosis Term for profuse sweating
wakes up repeatedly during the night. It is one that occurs during sleep; also known as night
of the key causes of excessive daytime sleepiness sweats. The patient may have an excessive amount
(EDS). It has been shown experimentally that of sweating during daytime hours as well. This
daytime sleepiness does not result only from time disorder can produce discomfort due to the exces-
spent being awake instead of asleep during the sive wetness of the bed clothes, which may need to
night. It also occurs as a result of being repeat- be changed several times throughout the night. In
edly awakened regardless of the duration of the some patients, the disorder can be relatively brief
awakenings. in duration, but in others it is a lifelong tendency.
Excessive sweating can be exacerbated by chronic
febrile (feverish) illness and a variety of other dis-
sleep hygiene A variety of different practices that orders, including diabetes insipidus, hyperthyroid-
are necessary in order to have normal, good quality ism, pheochromocytoma, hypothalamic lesions,
nocturnal sleep and full daytime alertness. These epilepsy, cerebral and brain stem strokes, cerebral
practices ensure that a regular pattern of sleep palsy, CHRONIC PAROXYSMAL HEMICRANIA, spinal cord
and wakefulness will occur in association with a infarction, head injury and spontaneous periodic
pattern of underlying circadian rhythms. ENVIRON- hypothermia. Sleep hyperhidrosis can also be a
MENTAL TIME CUES are an important component of feature of pregnancy and can be induced by the
ensuring that the sleep-wake cycle maintains a use of antipyretic medications. The most important
normal rhythm and timing; disturbances of these principles are maintenance of regular and rational
cues will lead to a weakening of the circadian bedtime schedules (e.g., regular times of retiring
rhythmicity with consequent disturbances of the and arising) and an age-appropriate period spent in
sleep-wake pattern. bed (if the length of time in bed is too short, sleep
The strongest environmental time cues are those deprivation may result; if it is too long, sleep effi-
that occur around the time of awakening and ciency may suffer). Menopause is another common
involve the maintenance of a regular wake time cause of hyperhidrosis and may be relieved with
with adequate exposure to light. hormone replacement therapy.
220 sleep hypochrondriasis

There does not appear to be any gender differ- acute phase response to injury and has marked
ence in the presence of this disorder, and it can be slow wave sleep–inducing properties.
seen at any age but most commonly is seen in early Other natural compounds that may have a
adulthood. Sleep hyperhidrosis can occur in older sleep-inducing effect include CHOLECYSTOKININ
age groups in association with the development of (CCK), which is a peptide that is found in both
the OBSTRUCTIVE SLEEP APNEA SYNDROME. the gastrointestinal tract and the brain. Injection of
Treatment is dependent on the cause of the CCK into animals has produced a reduction in the
sweating. Some patients may respond to amitrip- SLEEP LATENCY. However, it may be associated more
tyline or clonidine given before sleep. However, with behavioral sedation rather than the induction
for many patients no cause can be determined; for of true sleepiness.
most patients, treatment is not required. (See also Somatostatin is another agent that has been
PREGNANCY-RELATED SLEEP DISORDER.) localized to the cells in the brain stem that are
associated with the induction and maintenance of
sleep. It may well have a direct effect on the regula-
sleep hypochrondriasis See SLEEP STATE MISPER- tion of sleep.
CEPTION. Various neurotransmitter agents, including
SEROTONIN, NOREPINEPHRINE, and ACETYLCHOLINE,
are known to be agents that have a pronounced
sleep-inducing factors Various natural factors effect on inducing alertness or sleep; agents such as
that are produced by the body are thought to have prostaglandin-D2 and uridine also have been dem-
the effect of inducing sleep. The presence of these onstrated to have some sleep-inducing properties.
factors was first suggested by Henri Pieron in 1913 Thus a variety of agents are believed to be
when the cerebrospinal fluid of a sleep-deprived involved in the regulation of sleep and wakeful-
dog had induced sleep in another dog after being ness, and the exact role of each has yet to be eluci-
injected into the ventricles of the brain. Since dated. However, it is clear that the control of sleep
that time, studies have confirmed the presence and wakefulness is a complex system that involves
of sleep-inducing properties of natural fluids, and numerous neurochemical agents.
various substances have been isolated that appear
to have a sleep-inducing property. In 1967, Pap-
penheimer took spinal fluid from sleep-deprived sleepiness Difficulty in maintaining the alert
goats and injected it into the ventricles of other state so that, if an individual is not kept active and
animals and found that sleep could be induced. aroused, he will readily fall into sleep. Sleepiness
The compound that was known as FACTOR S was is not just a form of tiredness and fatigue, but a
eventually isolated from the urine of healthy reflection of a true need for sleep. When sleepi-
males and this compound, when injected into rab- ness occurs in situations where sleep would be
bits, produced SLOW WAVE SLEEP. Since that time, inappropriate, such as during the day, it is termed
a variety of other sleep-promoting peptides have EXCESSIVE SLEEPINESS. A variety of disorders that
been discovered, including delta-sleep-inducing affect the quantity or quality of nocturnal sleep
peptide (DSIP) and SLEEP-PROMOTING SUBSTANCE can lead to excessive sleepiness; however, nor-
(SPS). Factor S appears to be very similar to a mal sleepiness occurs in relation to the major
substance, which is found in bacterial cell walls, sleep episode at night. Although sleepiness may
called MURAMYL DIPEPTIDE (MDP). This compound, be predominant, the arousal system can allow
when infused into animals, has been shown to the individual to maintain full alertness, despite
increase NON-REM-STAGE SLEEP. However, it also there being a strong physiological need for sleep.
affects increasing body TEMPERATURE. Further work For example, this occurs in individuals working
with MDP suggested a relationship between the the night shift or in individuals staying up late
immune system and sleep because the compound at night because of work commitments or social
INTERLEUKIN-1, a polypeptide, is produced in the interactions.
 sleep medicine and clinical polysomnography examination 221

sleeping pills See HYPNOTICS. of wakefulness. Sleep interruption occurs in per-

sons who have disorders during sleep that lead
to an arousal or an awakening, such as INSOMNIA,
sleeping sickness Also known as trypanosomia- OBSTRUCTIVE SLEEP APNEA SYNDROME, or PERIODIC
sis (brucei), sleeping sickness is an acute infection LIMB MOVEMENT DISORDER.
caused by a protozoan that induces sleepiness asso-
ciated with a chronic meningoencephalomyelitis.
This protozoan is transmitted to humans by the tse- sleep latency The amount of time from lights
tse fly. There are two main forms of the disease: the out, or bedtime, to the commencement of the first
Gambian, or West African type; and the Rhodesian, stage of sleep, either non-REM or REM sleep. The
or East African type. Trypanosomiasis differs in its sleep latency is usually within 20 minutes in nor-
sensitivity to medication, and the Rhodesian form mal sleepers and is typically 30 minutes or longer
is often more severe, and more often fatal, than the in persons suffering from INSOMNIA. Short sleep
Gambian form. latencies of less than 10 minutes are usually seen
The infection usually presents in the acute in disorders of EXCESSIVE SLEEPINESS, such as NARCO-
phase with high fever and lymphadenopathy, often LEPSY or OBSTRUCTIVE SLEEP APNEA SYNDROME. This
accompanied by severe headaches. Gradually the term is preferred over the term “latency to sleep.”
major sleep episode becomes disrupted and EXCES-
SIVE SLEEPINESS develops. The central nervous system
features may develop several years after the onset sleep log A written record for 24 hours or lon-
of the acute infection. Seizures, coma and eventu- ger of a person’s sleep-wake pattern. Sleep logs
ally death can occur if the disorder is untreated. typically comprise information on sleep for at least
Sleeping sickness can be diagnosed by demonstrat- two weeks. The information recorded includes the
ing the presence of the trypanosome in the blood, BEDTIME, SLEEP ONSET time, SLEEP DURATION, awake
lymph nodes or spinal fluid. Serum abnormalities times, final wake-up, ARISE TIME, and the timing
include increases in the IgM, and there is an increase and length of daytime NAPS. Other information can
of cerebrospinal fluid protein with central nervous also be recorded, such as the use of sleep-induc-
system involvement. The disease is easily recognized ing or STIMULANT MEDICATIONS, and the nature of
if there has been exposure in endemic areas. wakeful activities. Sleep log is synonymous with
Polysomnographic studies demonstrate that the the term “sleep diary.”
non-REM sleep loses its characteristic features
of spindle activity (see SLEEP SPINDLES) and K-
complexes, and the SLEEP STAGES become unrec- sleep maintenance insomnia (DIMS) This term
ognizable. However, REM sleep maintains its applies to people who complain of INSOMNIA and
polysomnographic features, but sleep onset REM have difficulty in maintaining sleep once it has
periods may be present during daytime episodes of been initiated. Sleep maintenance insomnia can
sleepiness. comprise either awakenings during the sleep epi-
Early in the disease, suramin is the most effective sode or an early final awakening. It is a common
medication; however, melarsoprol is recommended feature of most forms of insomnia with the excep-
once there is central nervous system involvement. tion of the DELAYED SLEEP PHASE SYNDROME, which is
An alternative medication is alpha-difluorometh- characterized by a prolonged SLEEP ONSET without
ylornithine (DFMO), which has recently been any sleep maintenance difficulty.
shown to be more effective and less toxic than
melarsoprol.
sleep medicine and clinical polysomnography
examination This examination was held for the
sleep interruption A break in the SLEEP ARCHI- first time in 1990 for applicants with a degree
TECTURE that results in an arousal or an episode in the health field. Applicants can be either a
222 sleep mentation

Ph.D., M.D. or D.O. This examination replaces the ity or even a skill that has to be learned. About a
pre vious accredited CLINICAL POLYSOMNOGRAPHER third of our lives is spent sleeping. It is possible for
EXAMINATION. Physicians can receive certification a short while to get by on less sleep, or to put off
in both sleep medicine and clinical polysomnogra- sleeping, but the need to sleep will eventually force
phy, and Ph.D.s can receive certification in clinical anyone to succumb (see SLEEP DEPRIVATION).
polysomnography. The question “Why do we need to sleep?” is one
Physician applicants for the examination are that has intrigued scientists over the centuries, ever
required to hold an M.D. or D.O. and be licensed since Aristotle, in the fourth century B.C., noted
to practice medicine in a state, commonwealth that afternoon sleepiness appeared to follow mid-
or territory of the United States or Canada. They day meals. Lucretius in 55 B.C. perceived a connec-
must have undergone a one-year training in SLEEP tion between sleep and wakefulness.
DISORDERS MEDICINE or POLYSOMNOGRAPHY under We know that all animals, and fish, sleep for
the supervision of a board-certified sleep specialist part of the 24-hour day, yet there is little under-
and at least two years of an accredited residency standing about why sleep is necessary.
program. There are currently three main theories about
Both part one and part two of the examina- why we need to sleep. The first, the Restorative
tion were reorganized to be more specific to the Theory, hypothesizes that sleep restores some com-
applicant’s background training. Part one is entirely ponent of our physiology that is used up during
multiple-choice questions; however, the questions wakefulness. This restoration may be of a physical,
focus on medical, diagnostic and treatment deci- chemical or mental nature. However, no one has
sions for the physician. yet been able to determine exactly what might
Applicants for the Ph.D. examination need a be lost during wakefulness that is restored during
Ph.D. degree with doctoral specialization in the sleep.
health field and two years of clinical experience. Studies have centered around trying to deter-
They must have one year of training in clinical mine if there is any direct association between
polysomnography under the supervision of an daytime physical activity and nighttime sleep. But
accredited clinical polysomnographer. (See also investigations into athletes who are well-trained
ACCREDITATION STANDARDS FOR SLEEP DISORDER CEN- have failed to show any association between
TERS, AMERICAN ACADEMY OF SLEEP MEDICINE, CLINI- increased daytime activity and improved quality
CAL POLYSOMNOGRAPHER.) or duration of nighttime sleep. Some studies, how-
ever, have tended to show that there is an increase
in stage three/four sleep, particularly if the exer-
sleep mentation The imagery and thinking expe- cise is performed in the late afternoon. However,
rienced during sleep. Sleep mentation usually other studies have tended to show different results
consists of a combination of thoughts and images with delay and decrease in REM sleep. The means
that can occur during REM sleep. The imagery is of analyzing electroencephalographic sleep may
most vividly expressed in DREAMS, which are clear affect these results because more specialized forms
representations of waking activity. This form of of analysis (by means of spectral analysis, EEG fre-
imagery is usually expressed during REM sleep, but quency analysis) have given different information
it may occur less vividly during NON-REM-STAGE than studies that have been scored by more tradi-
SLEEP, particularly during stage two sleep (see SLEEP tional methods. The spectral analysis studies have
STAGES). Sometimes mentation and dream imagery tended to give support to the restorative theory of
can occur at SLEEP ONSET and may be termed HYP- exercise and SLOW WAVE SLEEP by demonstrating
NAGOGIC REVERIE. improved slow wave sleep.
A second theory, called the Cleansing Theory,
was first proposed by Hughlings Jackson, a neu-
sleep need Like the need for air and water, sleep rologist. The Cleansing Theory suggests that sleep
is a necessity for humans, not an optional activ- affects memory, it cleans away unwanted memo-
 sleep onset association disorder 223

ries and allows consolidation of memories that are characterized by EXCESSIVE SLEEPINESS during the
important and need to be retained. The theory has day or by hypersomnia, such as OBSTRUCTIVE SLEEP
been extended by others, including Francis Crick APNEA SYNDROME or narcolepsy. (See also SLEEP
in 1983, who has proposed that it is the REM LATENCY, SLEEP STAGES.)
sleep that is particularly valuable in cleaning out
unwanted memories, perhaps by a mechanism that
involves dreaming. sleep onset association disorder Primarily a dis-
The third theory of sleep need is the Circadian order of childhood where a child typically needs to
Theory developed in the 1970s. This theory hypoth- have a favorite object (teddy bear, stuffed toy, blan-
esizes that sleep is necessary in order to maintain ket, or bottle) or behavior (rocking in a parent’s
CIRCADIAN RHYTHMS. It has been proposed that the arms, hearing lullabies) for SLEEP ONSET to occur. In
interaction of the circadian rhythms is the most adults, the associated behavior may be the use of a
effective and efficient means of maintaining physi- television or a radio. When the object or behavior
ology in a state so that it can adequately adapt to is not present, sleep onset becomes more difficult,
changes in environmental or internal factors. A nor- and awakenings may occur throughout the night.
mal sleep-wake cycle has been shown to promote The sleep onset association is often reinforced
the maximal and ideal rhythm amplitude and phase by a caregiver. A child may be put to bed with a
relationships. Body temperature has its nadir during pacifier or a bottle, and the pattern or association
sleep and rises to a maximum amplitude 12 hours with sleep becomes fixed until the child reaches
later. The strength of the cyclical pattern is dimin- a level of independence when it can maintain its
ished by a disrupted sleep pattern. (See also AGE.) own sleep pattern without the use of the object. If
the behavior is not spontaneously eliminated with
in creasing maturity, it may be necessary to actively
sleep onset The transition from wakefulness to limit the introduction of the object.
sleep that usually comprises stage one sleep. In cer- This form of sleep disorder can be present from
tain situations, particularly in infancy (see INFANT the first few days of life, but most commonly it
SLEEP) and in NARCOLEPSY, sleep onset may occur becomes set between six months and three years
with REM sleep. Sleep onset is usually character- of age. The disorder can occur for the first time at
ized by: a slowing of the ELECTROENCEPHALOGRAM any age, and it is frequently seen in adulthood to
(EEG); the reduction and eventual disappearance old age, when falling asleep to a television or radio
of ALPHA ACTIVITY; the presence of EEG vertex is typical.
sharp transients; and slow rolling eye movements. This sleep disturbance can also occur at any age
Although an EPOCH (one page of a POLYSOMNO- in response to a household disturbance, such as a
GRAM) of stage one sleep is usually required as move to a new home, marital difficulties, sibling
documentation for sleep onset, some researchers rivalries or other forms of emotional stress that
prefer to take the first epoch of any stage of sleep necessitate getting a comforting object in order to
other than stage one as being the criterion for sleep initiate sleep.
onset. The reason is that stage two sleep is more Polysomnographic monitoring demonstrates
associated with subjective recall of sleep onset. essentially normal sleep patterns, particularly if the
Sometimes the sleep onset will be regarded as the sleep onset association object is present. However,
onset of continuous sleep, which may comprise the sleep onset difficulties and an increase in the fre-
beginning of three or more continuous epochs of quency and duration of awakenings at night may
stage one or other stages of sleep. occur if the object is unavailable.
Sleep onset usually occurs within 20 minutes This form of sleep disturbance needs to be
of the bedtime; however, people who complain differentiated from LIMIT-SETTING SLEEP DISORDER
of INSOMNIA may have a sleep onset that occurs where inadequate limits on bedtimes and wake
30 minutes or longer from the attempt to initiate times are the primary cause of the sleep distur-
sleep. Sleep onset may occur rapidly in disorders bance. It also needs to be distinguished from
224 sleep onset insomnia

PSYCHOPHYSIOLOGICAL INSOMNIA in the adult, in disorders of disrupted REM sleep, such as in severe
which negative associations to sleep are developed OBSTRUCTIVE SLEEP APNEA SYNDROME.
rather than the positive associations seen in sleep Most patients with narcolepsy will have three
onset association disorder. sleep onset REM periods during a five-nap multiple
Treatment involves a gradual withdrawal of the sleep latency test; however, not uncommonly five
object so that positive associations are developed sleep onset REM periods will occur. A single sleep
to sleep, in the sleeping environment, without the onset REM period, particularly on the first or sec-
need for a specific object. During the time of with- ond nap of the multiple sleep latency test, may be
drawal of the object, good SLEEP HYGIENE measures seen in normal individuals who otherwise do not
are essential in order to prevent a breakdown of have a sleep disorder. However, two or more sleep
the sleep pattern or the development of psycho- onset REM periods are regarded as being distinctly
physiological insomnia. abnormal for people without a sleep disorder.

sleep onset insomnia A form of insomnia char- sleep palsy A muscle weakness, present upon
acterized by difficulty in initiating sleep; there is an awakening, that is associated with pressure over
increased SLEEP LATENCY, but once sleep is initiated, nerves supplying a particular muscle or group of
little, if any, sleep disruption occurs. Sleep onset muscles. Some nerves in the limbs, such as the
insomnia is typically seen in patients with the ulnar, radial and peroneal, are superficially placed
DELAYED SLEEP PHASE SYNDROME, where the timing in the limbs and therefore are liable to compres-
of sleep is altered in relationship to the 24-hour sion interfering with their conductive properties. A
day. There may be a prolonged sleep latency but, sleep palsy is commonly experienced if the limb is
once sleep is initiated, sleep is normal in quality. not moved and pressure is sustained over the nerve
Rarely, a sleep onset insomnia may be produced as for half an hour or longer.
a result of a PSYCHOPHYSIOLOGICAL INSOMNIA or an Sleep palsies generally resolve within a few min-
ANXIETY DISORDER; a pure sleep onset insomnia is utes after resuming a more comfortable position;
also a rare feature of DEPRESSION. Some disorders, however, if an individual sleeps deeply and does
such as the RESTLESS LEGS SYNDROME or excessive not awaken because of the discomfort, the muscle
SLEEP STARTS, may also be associated with a sleep weakness that results may last hours, days or even
onset insomnia. weeks. A typical form of sleep palsy occurs in indi-
viduals who have their arousal threshold increased
because of drinking ALCOHOL. The so-called Satur-
sleep onset nightmares See TERRIFYING HYPNAGO- day night palsy is related to excessive alcohol con-
GIC HALLUCINATIONS. sumption, causing sleep to occur with the person
in an unusual position, often with the radial nerve
of the arm being compressed, leading to paralysis
sleep onset REM period (SOREMP) Typically the of the muscles supplied by that nerve. Typically a
onset of REM sleep is 90 minutes after sleep onset. wrist drop will result after sleep has occurred in a
But a sleep onset REM period is characterized by chair and the arm is draped over the hard chair-
the initiation of REM sleep within 20 minutes of back. (See also CARPAL TUNNEL SYNDROME.)
sleep onset. Sleep onset REM periods are a char-
acteristic feature of NARCOLEPSY during the major
sleep episode as well as during daytime NAPS. Two sleep paralysis A condition of whole body muscle
or more sleep onset REM periods seen during a paralysis that occasionally may be present at the
daytime MULTIPLE SLEEP LATENCY TEST, in an indi- onset of sleep, or upon awakening during the night
vidual who otherwise has a normal preceding night or in the morning. It is a manifestation of the muscle
of sleep, may be diagnostic of narcolepsy. However, atonia (loss of muscle activity) that occurs in asso-
sleep onset REM periods may also be seen in other ciation with the dreaming (REM) stage of sleep (see
 sleep restriction therapy 225

DREAMS). Dream activity can accompany the limb sleep-regulating center Term proposed by
paralysis; however, the patient is usually awake and Constantin Von Economo following his careful
fully conscious during the phenomenon. Typically anatomic studies of patients with ENCEPHALITIS
an individual will attempt to move a limb and, find- LETHARGICA. He believed that a sleep-regulating
ing an inability to do so, will feel fear, panic and at center was present in the upper brain stem in the
times the sensation of impending death. Respiratory posterior hypothalamus.
movements are usually unimpaired, but the sensa-
tion of an inability to breathe is common.
The episodes last from seconds to several min- sleep restriction therapy A treatment for patients
utes and usually terminate spontaneously. The with INSOMNIA based upon the recognition that
individual may make some moaning sounds during excessive time spent in bed often perpetuates
the episode, which may attract the attention of the insomnia. Typically, patients with insomnia go to
bed partner; being touched or some other stimulus bed on some nights earlier than usual in order
will assist in terminating the episode. to obtain more sleep, or to counteract feelings of
The condition, when seen frequently in any daytime tiredness and fatigue. In addition, patients
individual, raises the possibility of the diagnosis of may stay in bed longer in the morning to make
NARCOLEPSY and typically is associated with EXCES- up for lost sleep at night, or because of feelings of
SIVE SLEEPINESS during the day and CATAPLEXY. tiredness or fatigue. Because sleep is often spread
Unless the condition is associated with narcolepsy, out over a longer portion of the 24-hour day, often
it usually does not warrant therapeutic interven- as much as 12 hours, sleep becomes fragmented,
tion. Reassurance is often required, and the initial with frequent intervals of wakefulness. Maintain-
episodes are often those of most concern, since in ing a consolidated nighttime sleep and a full epi-
time recognizing the benign nature of the episodes sode of wakefulness for the rest of the day is most
reduces the concern. helpful in promoting normal and strong circadian
A familial form of the condition has been rec- rhythms.
ognized that is unaccompanied by other abnormal Sleep restriction therapy involves reducing the
neurological features. amount of time spent in bed by one or more
Sleep paralysis can sometimes be seen where hours and ensuring that sleep occurs only dur-
there has been insufficient or poor-quality noc- ing the set BEDTIME and awake times. In that way,
turnal sleep, such as with patients who have been sleep becomes more consolidated after one or two
sleep deprived (see SLEEP DEPRIVATION) or who have days on the new pattern. In some cases, the total
OBSTRUCTIVE SLEEP APNEA SYNDROME. time recommended for sleep may be as little as
If the treatment is indicated, a REM suppressant 4.5 hours, but typically it is on the order of 6 to
medication, such as one of the tricyclic ANTIDEPRES- 7.5 hours. Once the sleep restriction produces an
SANTS, may be useful. increased consolidation of sleep with less wakeful-
ness and more continuous and longer durations
of sleep, the total time available for sleep may be
sleep pattern A person’s routine of sleep and increased slightly by 15 or 30 minutes. In this man-
waking behavior that includes the clock hour of ner, an initial restricted pattern of 4.5 hours may be
BEDTIME and ARISE TIME, as well as NAPS and time increased to 5 hours after one week, and then to
and duration of sleep interruptions. A typical 24- 5.5 hours one week later, with sequential increases
hour sleep pattern comprises eight hours of sleep until a point is reached where allowing additional
at night, followed by 16 hours of wakefulness. time contributes only to increased wakefulness at
A biphasic sleep pattern is seen in individuals night.
who have a prolonged sleep episode in the late People who undergo sleep restriction therapy
afternoon, such as a SIESTA, in association with a may notice an increased tendency for sleepiness
major sleep episode at night. (See also CIRCADIAN in the first few days, often because the reported
RHYTHMS, SLEEP DURATION, SLEEP INTERRUPTION.) TOTAL SLEEP TIME is less than the actual sleep and
226 sleep restriction therapy

therefore there may be an element of SLEEP DEPRI- usual. She regarded herself as slightly tense and
VATION. However, as sleep fills the available time for anxious, although she denied any evidence of
sleeping, and the time for sleeping is extended, the depression. She had undergone relaxation exer-
tendency for daytime sleepiness reduces. cises in the past and occasionally would play a
This therapy improves sleep by consolidating relaxation tape, which would somewhat help her
sleep and also by reducing the number of disrupt- to sleep.
ing factors associated with sleep disturbance. Main- She had visited a number of physicians, and had
taining regular SLEEP ONSET and wake times and the undergone a number of unorthodox treatments for
occurrence of sleep at the time of the maximum her sleep disturbance. She had seen a nutritionist,
circadian phase for sleep are some of the features an acupuncturist, a chiropractor and a homeo-
that make sleep restriction therapy effective. In path. All these treatments had produced slight
addition, because the patient knows that sleep improvement but none had produced any consis-
onset will occur rapidly as a result of the sleep tent benefit. She received a number of diagnoses
restriction, there is less concern and worry over that included hypoglycemia (low blood sugar),
being able to fall asleep at night. As the amount of hypothyroidism (low blood thyroid hormone) and
sleep is predictable from night to night, the indi- infectious mononucleosis, although there was no
vidual has less concern over having a night with strong evidence for the presence of any of those
no sleep. As the sleep restriction pattern is contin- disorders.
ued, the patient becomes conditioned to improved The initial impression was one of a psycho-
sleep, and the heightened anxiety and arousal physiological insomnia exacerbated by elements
related to sleep dissipates, allowing the individual of underlying anxiety and depression. However, a
to sleep peacefully. psychiatric diagnosis of anxiety disorder or depres-
Sleep restriction therapy has been shown to be sion could not be established.
useful for young and middle-aged adults; however, It was recommended that she be placed on a
recent studies have shown that this form of treat- strict pattern of sleep restriction with a bedtime of
ment may be less effective in geriatric patients. 11 at night and an awake time of 6 in the morn-
Sleep restriction therapy has some similarities with ing. She was advised to restrict her use of hypnotic
STIMULUS CONTROL THERAPY, which has a similar medication and to complete a sleep log, which
basis of encouraging the reduction of the amount would assist in determining any change in her
of wakefulness spent in bed. sleeping pattern.
The strict adherence to the regular pattern of
Case History going to bed later and awakening at a fixed time
A 48-year-old research scientist at a medical school in the morning produced a major benefit in her
had a lifelong history of sleeping difficulties, which overall sleep. From having sleep times that could
had deteriorated even further several years prior vary between 3 hours and 7.5 hours, she devel-
to her presentation at the sleep disorders center. oped a consistent pattern of sleeping 6.5 to 7 hours
The presentation was related to a recent increase on a regular basis. During this treatment program,
in anxiety that accompanied changing her employ- she took a trip across time zones and although her
ment. She occasionally would take a benzodiaz- stay in the new time zone was only a few days and
epine hypnotic to help her sleep, although she she tried to keep to her new schedule, she found
preferred to avoid taking medications. She would that her sleep deteriorated. Upon returning to her
awaken several times at night and would go to the original environment, she reduced her total time in
bathroom each time but generally would stay in bed by half an hour so she would awaken at 5:30 in
bed between the hours of 10 P.M. and 7 A.M. Sleep the morning. This brought about a resolution of the
onset times were variable and she often would exacerbation produced by the time-zone travel.
not go to bed until she was very tired and sleepy. After several weeks, she was able to return to
On other occasions, following a night of very poor her more usual pattern of going to bed at 11 P.M.
sleep, she would go to sleep a little earlier than and arising at 6 A.M., and her sleep pattern was sig-
 sleep stages 227

nificantly improved. (See also CIRCADIAN RHYTHMS, spindle consists of a spindle-shaped burst of 11
FATIGUE, SLEEP PATTERN.) to 15 Hz waves that lasts for 0.5 to 1.5 seconds.
Spindles can occur diffusely over the head and are
of highest voltage over the central regions, with an
sleep schedule The pattern of sleep that occurs amplitude that is usually less than 50 microvolts
within a 24-hour day. Typically, the sleep sched- in adults. Sleep spindles, although characteristic
ule involves the sleep onset and awake times in of stage two sleep, may persist into deeper stages
relationship to the 24-hour clock time. The sleep three and four sleep but usually are not seen in
schedule may vary if the times for sleep change, in REM sleep. Reduction of spindle activity may be
which case an irregular sleep schedule may occur. seen in the elderly, and an increase can be seen in
However, a typical sleep schedule is one that has association with disorders of the basal ganglia of
a regular sleep onset time at night and a regular the brain, such as dystonia, or as a result of medi-
awake time in the morning. (See also CIRCADIAN cations, such as the BENZODIAZEPINES. Sleep disrup-
RHYTHMS, IRREGULAR SLEEP-WAKE PATTERN, NREM- tion, if severe, can cause spindle activity to occur in
REM SLEEP CYCLE, TOTAL SLEEP TIME.) other sleep stages, including REM sleep. (See also
ELECTROENCEPHALOGRAM, HYPNOTICS, SIGMA RHYTHM,
SLEEP STAGES.)
sleep specialist A physician (M.D.) who is trained
and knowledgeable in the practice of SLEEP DISOR-
DERS MEDICINE. In the United States, the majority
sleep stage demarcation Term that refers to the
of sleep specialists have undergone appropriate specific changes that mark the boundary between
certification by passing the examination in sleep one sleep stage and another, or a sleep stage and
medicine that is given by the AMERICAN ACADEMY
wakefulness. Typically the boundary between one
OF SLEEP MEDICINE. Most sleep specialists have
sleep stage and another is very clearly defined;
polysomnographic monitoring equipment avail-
however, in some sleep disorders sleep may become
able to assist in the diagnosis and management of
very fragmented and features of one sleep stage may
sleep disorders. Sleep specialists usually practice in
occur with another and therefore the demarcations
a SLEEP DISORDER CENTER, which is a comprehensive
may become very blurred. A similar situation can
diagnostic and treatment facility capable of diag-
occur in individuals who are taking MEDICATIONS,
nosing and treating all types of sleep disorders.
such as HYPNOTICS. (See also SLEEP STAGES.)
According to the American Academy of Sleep
Medicine (AASM) a sleep specialist is

A physician who is a sleep specialist is certified sleep stage episode An interval of sleep that rep-
in the subspecialty of sleep medicine and special- resents a specific sleep stage in the non-REM/REM
izes in the clinical assessment, physiologic testing, cycle. For example, the first REM sleep episode is
diagnosis, management and prevention of sleep the first interval of REM sleep that occurs in the
and circadian rhythm disorders. Sleep specialists major sleep episode and will comprise a part of the
treat patients of any age and use multidisciplinary NREM-REM SLEEP CYCLE. Typically, four to six recur-
approaches. Disorders managed by sleep special-
ists include, but are not limited to, sleep related
ring cycles of non-REM-REM sleep occur, therefore
breathing disorders, insomnia, hypersomnia, cir- four to six discrete stage episodes of non-REM and
cadian rhythm sleep disorders, parasomnias and REM sleep will occur. (See also SLEEP STAGES.)
sleep movement disorders.

sleep stage period See SLEEP STAGE EPISODE.

sleep spindles A pattern of electrical activity
occurring during sleep that appears in an elec-
troencephalographic recording. Sleep spindles are sleep stages Following the development of the
an identifying feature of stage two sleep. A sleep ELECTROENCEPHALOGRAM (or EEG) in 1930 by Hans
228 sleep stages

Berger, sleep was recognized to consist of changes Stage Two Sleep

in the electroencephalographic activity of the Stage two sleep is characterized by sleep spindles and
brain. Based on these electroencephalographic K-complexes; it accounts for 45 percent to 50 percent
patterns, sleep was originally classified into four of total sleep time. The sleep spindles are 11 to 15 Hz
stages, sometimes characterized by letters of the activity occurring in episodes greater than .5 second
alphabet, excluding REM sleep, which was not in duration and reaching 25 microvolts in amplitude.
discovered for another two decades. With the dis- K-complexes consists of a negative vertex, sharp
covery of REM sleep in 1953 by EUGENE ASERINSKY, wave followed by a positive slow wave and are fre-
NATHANIEL KLEITMAN, and WILLIAM DEMENT, sleep quently seen accompanied by sleep spindles.
was recognized to be a continuous state of alter- Electrode EEG studies, in which the electrodes
nating rhythm with very pronounced physiological are inserted directly through the scalp into the
changes. REM sleep was occasionally termed stage brain, performed concurrently with scalp electrode
five sleep, or D sleep. The electroencephalographic recordings suggest that spindle activity appears first
pattern of REM sleep was also termed desynchro- in the thalamic nucleic of the brain and undergoes
nized sleep, compared with the synchronized EEG a certain degree of synchronization before it is
activity of non-REM or SLOW WAVE SLEEP. detectable at the scalp EEG electrodes. Superior
In 1968 a group of researchers headed by Allan frontal regions appear to be the starting point for
Rechtschaffen and Anthony Kales developed a the spindle activity.
standardized method of sleep scoring, and sleep
was divided into four stages, plus REM sleep. The Stage Three Sleep
four stages of sleep came to be called NREM or A deep level of sleep that comprises 4 percent to 6
non-REM sleep. In order to standardize the scor- percent of total sleep time. This stage is sometimes
ing of sleep, the record was divided into epochs of combined with stage four into NREM stages three
20 or 30 seconds in duration. The electroencepha- and four because of the physiological similarities
logram is performed at a slower rate of 10 or 15 between the two stages, and called slow wave
millimeters per second than the more typical EEG sleep. Stage three is present when between 20
speed of 30 millimeters per second. In addition to percent and 50 percent of the epoch contains delta
the electroencephalogram, electrodes placed to re waves of .5 to 2.5 Hz, which are 75 microvolts
cord eye movements and muscle tone are required or greater in amplitude. Typically eye movement
to more adequately determine sleep stages. activity is absent during this stage.
The electroencephalogram electrode placement
is at either C3 or C4 position. Eye movements are Stage Four Sleep
detected by electrodes placed at the outer CANTHUS Stage four sleep is scored when over 50 percent
of each eye and referred to a reference electrode, of the epoch contains delta waves of the same fre-
and the ELECTROMYOGRAM is typically recorded by quency and amplitude as those seen in stage three
electrodes placed over the muscles at the tip of the sleep. Although rarely, sleep spindles may occur in
chin. stage four sleep. This stage, the deepest sleep of the
four non-REM stages, is synonymous with slow
Stage One Sleep wave sleep and usually comprises 12 percent to 15
Stage one sleep occurs right after the awake stage percent of total sleep time. It is during this stage
and comprises 4 percent to 5 percent of TOTAL SLEEP that SLEEP TERRORS or SLEEPWALKING may occur.
TIME. It is characterized by medium amplitude, Sometimes stage four is combined with stage three
mixed frequency activity that is mainly theta and into NREM stages three and four because the stages
comprises more than 20 percent of an epoch. Dur- are so similar.
ing this stage there may be SLOW ROLLING EYE MOVE-
MENTS in contrast to the RAPID EYE MOVEMENTS seen Rapid Eye Movement Sleep (REM)
during wakefulness. There are no SLEEP SPINDLES, REM sleep is characterized by rapid eye movement
K-COMPLEXES, or REMs. (hence its name, REM), loss of muscle tone (or
 sleep state misperception 229

REM ATONIA) and a mixed frequency, low voltage activity can help differentiate that disorder. REST-
EEG pattern with occasional bursts of sawtooth LESS LEGS SYNDROME is not likely to be confused
theta waves of 5 to 7 Hz. Dreaming occurs during because the leg movements are slower and not
REM sleep. (See also DREAMS, POLYSOMNOGRAPHY.) associated with a whole body jerk. PERIODIC LEG
MOVEMENTS, as with restless legs syndrome, gen-
erally have more prolonged muscle episodes and
sleep starts Also known as hypnagogic jerks, pre- do not have the shocklike, brief character of the
dormital myoclonus, or hypnic jerks. Sleep starts sleep start. Periodic movements occur in a repeti-
are sudden, shocklike sensations that involve most tive manner during sleep and do not usually occur
of the body, particularly the lower limbs. They usu- solely at sleep onset.
ally consist of a solitary, generalized contraction that Treatment of sleep starts is usually unnecessary
occurs spontaneously or is caused by a stimulus. as they are an infrequent occurrence and usually
Sleep starts bring the individual to wakefulness, and are not associated with any great concern. How-
a sensation of falling or a visual flash, dream or hal- ever, in some individuals sleep starts may be a cause
lucination may be experienced at this time. Rarely of sleep onset insomnia, in which case benzodiaz-
the individual may call out with the acuteness of epine muscle relaxants (see BENZODIAZEPINES), such
the episode. Multiple episodes can occur at SLEEP as triazolam, may be useful in suppressing episodes
ONSET, and SLEEP ONSET INSOMNIA may develop. and in allowing sleep onset to be initiated.
Not infrequently, individuals will have multiple
episodes that do not induce a full awakening. Such
episodes may not be remembered by the individual sleep state misperception A disorder where there
but will be reported by a bed partner. is a complaint of insomnia, yet the major sleep epi-
It is thought that most people experience sleep sode is objectively normal. This disorder has also
starts at some time in their life, and only a few been called “subjective DIMS complaint without
have frequent episodes. There is some evidence to objective findings,” “pseudoinsomnia” or “sleep
suggest that the ingestion of stimulant agents, such hypochondriasis,” but sleep state misperception is
as CAFFEINE, or the use of NICOTINE may exacerbate the preferred term. Patients with this disorder pres-
the occurrence of sleep starts. Physical exercise and ent a very convincing history of sleep disturbance
emotional STRESS have also been reported to be and insomnia and typically will awaken feeling
associated with such episodes. unrefreshed. When studied poly somnographically
Sleep starts may occur at any age, although in the sleep laboratory, sleep is normal in duration,
most typically they are reported in adulthood. sleep stages and sleep efficiency, yet the patient will
There does not appear to be any gender or familial awaken and report having had no sleep at all.
tendency. The cause of the misperception of sleep is
Polysomnographic monitoring of sleep starts unknown; however, it does appear to be an
demonstrates a brief (generally 75–250 millisec- exaggeration of a normal phenomenon. Healthy
ond), high amplitude muscle potential that can individuals who have been asleep for only a few
be associated with an arousal pattern seen on the minutes often will report not having slept at all. As
EEG. There may be accompanying increased heart the duration of sleep increases, the awareness of
rate following an episode, but usually the heart having slept also increases. However, patients with
rate returns to normal and sleep resumes rapidly. sleep state misperception, despite having prolonged
Sleep starts must be distinguished from hyper- periods of good quality sleep, misperceive sleep as
explexia syndrome in which a generalized body being a time of no sleep.
jerk can occur during wakefulness or during sleep. This disorder must be differentiated from indi-
The association of hyperexplexia with full wakeful- viduals who report a lack of sleep in order to obtain
ness differentiates that disorder from sleep starts. MEDICATIONS. Such patients are often drug abusers,
An epileptic form of myoclonus can produce simi- and the report of no sleep is usually not a con-
lar generalized body jerks; however, abnormal EEG vincing or honest report (see MALINGERERS.) This
230 sleep surface

disorder also needs to be differentiated from other who suffer from SLEEP TERRORS or somnambulism
causes of insomnia, such as PSYCHOPHYSIOLOGICAL (see SLEEPWALKING). It also is seen in individuals
INSOMNIA or insomnia related to a mental disor- who have significant psychopathology, emotional
der. Sleep fragmentation, reduced total sleep time stress or medical illness, such as febrile (feverish)
and reduced sleep efficiency are characteristically illness, in which case it is related to that illness. It
seen in patients with insomnia due to these other appears to be more common in males than females
causes. (See also DISORDERS OF INITIATING AND MAIN- and a slight familial tendency is reported.
TAINING SLEEP, PSYCHIATRIC DISORDERS.) Sleep talking has been demonstrated to occur
during all stages of sleep, including REM sleep. The
majority of episodes, in fact, have been reported
sleep surface The sleep surface has been subject out of REM sleep, with the next most common
to investigation over the years to determine its role being sleep stage two, followed by slow wave sleep.
in the maintenance of good quality sleep. Most of Individuals who have somnambulism or sleep ter-
the research has tended to demonstrate that the rors are more likely to have sleep talking out of
quality of sleep is independent of the surface on slow wave sleep, whereas individuals who have
which a person sleeps; however, a change in the the REM SLEEP BEHAVIOR DISORDER are more likely
sleeping surface can disrupt sleep. The inhabitants to have episodes out of REM sleep. (See also CON-
of some countries typically sleep on a hard surface FUSIONAL AROUSALS, SLEEP STAGES.)
yet appear to sleep as well as people who sleep on
soft, innerspring mattresses. Adaptation to the new
surface needs to occur if someone changes from a sleep terrors Considered one of the disorders
hard to a soft surface, or vice versa. Many different of arousal as described by Roger J. Broughton
sleeping surfaces have been produced; hard mat- in 1968. These episodes also go under the name
tresses have been marketed particularly for people of night terrors and they have occasionally been
who have back complaints, whereas softer surfaces called pavor nocturnus (derived from the Latin
appear to have more appeal to young adults. pavor, for “terror,” and nocturnus, for “at night”) in
Whether to change the sleeping surface should children and INCUBUS in adults.
depend solely on comfort. If a mattress is too soft or Sleep terror episodes are characterized by an
too hard, a change may be beneficial to sleep. For arousal during the first third of the night from
most people, however, the sleeping surface plays deep stage three/four sleep (see SLEEP STAGES), and
a small role in the cause or maintenance of sleep are heralded by a loud, piercing scream along with
disturbance. (See also INSOMNIA.) intense fear and panic. An individual experiencing
a sleep terror will typically sit up abruptly in bed
with an agitated and confused expression. Fol-
sleep talking Also known as somniloquy. Sleep lowing the intense and loud scream, there may
talking is the production of utterances of speech or be other features of panic and fear, such as rapid
other sounds during a sleep episode. Typically, indi- breathing, rapid heart rate, dilation of the pupils
viduals suffering from sleep talking are unaware of and profuse sweating. The individual will usually
the content of their speech, which is reported after- flee from the bedroom in an intense panic and is
ward. The utterances may take the form of compre- often inconsolable until the episode subsides. Most
hensible speech, isolated words, parts of sentences, episodes last less than 15 minutes; sleep usually
moans or other nonverbal sounds. Typically sleep follows very rapidly, and the individual is unable
talking is devoid of emotional content; however, it to recall the episode the next morning.
can be associated with intense emotional stress, at The cause of the episodes is unknown, but it
which time calling out, crying, screaming or curs- appears to be a benign and maturational behavior
ing may occur. frequently seen in children. Up to 6 percent of
Sleep talking is often a temporary phenomenon, prepubescent children will have recurrent episodes
although it may be a repetitive occurrence in those of sleep terrors, with the peak frequency of the
 sleep terrors 231

behavior being around six years of age. Episodes such as imipramine. However, these agents are best
then decrease in frequency and generally cease in reserved for children or adults with the most severe
early adolescence. form of the disorder.
The frequency in adults is typically less than 1 Since injuries might occur during the intense
percent and episodes usually persist from child- fleeing from the bedroom, objects liable to cause
hood, although episodes may occur for the first injury should be removed and appropriate steps
time in adulthood. Episodes occur equally in males made to secure the bedroom.
and females, and there are no racial or cultural
differences in the prevalence. However, there is a Case History
marked familial incidence of the disorder, with up A 28-year-old woman came to a SLEEP DISORDER
to 96 percent of individuals having a family history CENTER with the primary complaint of episodes of
of the disorder. suddenly awakening and screaming. These epi-
Episodes may be precipitated in susceptible sodes had occurred about once every month over
individuals by fatigue, emotional stress and febrile the prior five years and had begun when she was
illness. Adults with the disorder may also have in college, causing her considerable distress and
evidence of psychopathology characterized by psy- embarrassment. The screaming would be frighten-
choasthenia (weakness and reduced motivation), ing to those who slept around her as she would
DEPRESSION and schizophrenia. suddenly jump out of bed and rush to the door
Children with sleep terror episodes either con- or window. The rapid attempt to flee the bed and
currently have SLEEPWALKING episodes or develop bedroom resulted in her knocking into furniture
sleepwalking episodes subsequently. Sleep terror and injuring herself on several occasions. Typically,
episodes rarely occur in adulthood after the fifth during the episodes she would not remember any
decade. dream content, but was aware of being intensely
Because of the intense fear and anxiety, sleep frightened and panicky, as if she were about to
terror episodes are differentiated from more typical die. The immediate reaction was to flee from the
NIGHTMARES or DREAM ANXIETY ATTACKS. Nightmares bed, although there was no clear comprehension
usually occur in the later half of the night, more of where she was going. Very often, her room-
typically during REM sleep. Nightmares also have a mates were unable to console her during these
less intense scream at their onset than sleep terrors, episodes. However, eventually she would gradually
and usually the individual comes to full alertness, settle down and when taken back to bed would fall
whereas the sufferer of night terrors does not usu- asleep easily. Occasionally she would have abrupt
ally become fully awake during an episode. Rarely episodes with screaming and immediately go back
does an epileptic seizure produce an episode similar to sleep, only to be told about the episodes the next
to sleep terror; other features of epilepsy would morning.
typically be present in such individuals. Polysomnographic monitoring failed to reveal a
Some features of sleep terrors and sleepwalking clinical episode; however, she did show frequent
overlap, and it appears that there is a spectrum of and abrupt arousals from SLOW WAVE SLEEP with a
disorders of which CONFUSIONAL AROUSAL appears to rapid change in heart rate. The arousals were con-
be the most mild form, with sleepwalking episodes sidered to be minor and subclinical manifestations
being a more severe form of AROUSAL DISORDERS, of the sleep terror episodes.
and sleep terrors being the most extreme form. A psychological evaluation failed to reveal any
Treatment of sleep terrors is usually not neces- evidence of psychopathology and psychotherapeu-
sary in the young child, but the child should be tic intervention was not considered to be useful.
reassured. In older children, a psychological cause The patient was prescribed triazolam, initially
should be explored, and appropriate psychiatric 0.125 milligram, which improved the episodes
treatment instituted, if warranted. Medications, but did not terminate them. This dosage was
such as the BENZODIAZEPINES, have been shown increased to 0.25 milligram and the episodes did
to be useful, as well as tricyclic ANTIDEPRESSANTS, not reoccur.
232 sleep therapy

Five years later, the patient continued to remain emphasize the importance of disorders of both sleep
free of episodes so long as she took the medication. and wakefulness, such as the disorders that pro-
However, attempts at reducing the medication duce EXCESSIVE SLEEPINESS. The shorter term, SLEEP
led to the return of the sleep terror episodes. It is DISORDER CENTERS, is more commonly used. (See
expected that in time, probably before her mid-30s, also ACCREDITATION STANDARDS FOR SLEEP DISORDER
the episodes will spontaneously subside. CENTERS, AMERICAN ACADEMY OF SLEEP MEDICINE.)

sleep therapy Term related to a treatment that sleep-wake schedule disorders See CIRCADIAN
employs the inducement of sleep in order to treat RHYTHM SLEEP DISORDERS.
various medical disorders. In its simplest form,
sleep therapy can be viewed as treatment by
rest—required by situations that promote fatigue. sleep-wake transition disorders A subgroup of
Sleep therapy may also involve the inducement of the PARASOMNIAS, as listed in the INTERNATIONAL
sleep by MEDICATIONS and drugs, the use of HYPNO- CLASSIFICATION OF SLEEP DISORDERS, consisting of
SIS to induce prolonged sleep, or the application of RHYTHMIC MOVEMENT DISORDER, SLEEP STARTS, SLEEP
electrical current, which has been termed ELECTRO- TALKING, and NOCTURNAL LEG CRAMPS. These dis-
SLEEP, ELECTRONARCOSIS or electroanesthesia. orders occur mainly during the transition from
Sleep therapy has been used to treat a variety wakefulness to sleep, or during the transition from
of disorders, most commonly the mental disorders, one SLEEP STAGE to another. Some of these disorders
but also cardiovascular, gastrointestinal, central may occur during sleep, but the predominant activ-
nervous system and infective disorders. ity occurs in the transition to and from sleep.
The majority of studies on sleep therapy occurred
around the turn of the century, and little objective
documentation of their effectiveness has been sleepwalking Episodes characterized by move-
presented. Electrosleep is still performed in some ment that occurs while the subject is still asleep
European countries and is administered in a variety and in a partially aroused state. This disorder,
of different manners. Electrodes may be applied which is also known as somnambulism, typically
to the forehead and a limb, and then the electri- occurs during deep SLOW WAVE SLEEP in the first
cal current gradually increased to the amount of third of the night. The behavior is often seen in
approximately three-quarters of a milliamp, at prepubescent children, although it can persist or
which time the patient can feel a tingling sensa- start anew in adulthood.
tion through his head, which is believed to induce A typical sleepwalking episode is characterized
sleep. The majority of publications on electrosleep by the individual sitting up in bed, usually with a
come from the Russian literature. vacant and unresponsive look. Repetitive move-
The usefulness of sleep therapy is believed to be ments, such as picking at the bedclothes, may
limited at best. There is a need for more research occur prior to the individual rising from the bed
and documentation of its effectiveness before it can and walking around the room. Episodes last min-
be widely recommended. utes or hours at most. Frequently the individual
will open doors and walk out of the bedroom,
or sometimes walk out of the house. During the
sleep-wake cycle See NREM-REM SLEEP CYCLE. sleepwalking episode, there is a limited capacity
to appreciate environmental stimuli, and there is
an impaired ability to fully awaken. Occasional
sleep-wake disorders center This term is occa- utterances may occur during sleepwalking, but
sionally used to describe a facility that evaluates verbalizations usually do not occur, and rarely
patients who have disorders of sleep and wakeful- is any cognitive or mental content expressed.
ness. The hyphenated term was used initially to Although unresponsive to environmental stimuli,
 sleepwalking 233

the individual is able to negotiate objects without Polysomnographically, the episodes are charac-
difficulty, although occasional stumbling or bang- terized by an abrupt arousal that occurs during the
ing into walls or furniture may occur. Attempts deep stage three/four sleep (see SLEEP STAGES). The
at restraining a sleepwalker are usually met slow wave activity appears to persist throughout
with some resistance. Sleepwalking episodes may the walking episode with some faster rhythms,
involve dangerous activities, such as opening such as theta and alpha activity. Individuals who
windows and climbing onto fire escapes, and seri- sleepwalk may demonstrate abrupt arousals from
ous falls have been reported. There are occasional deep sleep in the absence of full sleepwalking
reports of violent behavior during sleepwalking episodes.
being directed toward a specific individual. Fol- Sleepwalking in children is not associated with
lowing a period of ambulation, the sleepwalker any psychopathology, but Anthony Kales has
usually returns to bed and rapidly returns to sleep. reported a clear association between psychopa-
The next morning, the individual is typically thology and sleepwalking episodes in adults. Such
unable to recall the episode and is often surprised individuals are reported to be more aggressive,
by the accounts of others. hypomanic and have a tendency for acting out.
Sleepwalking episodes usually occur in chil- Sleepwalking episodes may be very similar to
dren in the prepubescent age group, and the peak episodes of psychomotor epilepsy with ambulation.
frequency is around 10 years of age. According to However, repetitive automatisms are more com-
Anthony Kales, et al., up to 30 percent of healthy mon during epileptic seizures and there is more
children are said to have sleepwalked at least once confusion upon awakening.
in their lives, and up to 5 percent of healthy chil- Recently a form of episodic nocturnal wander-
dren are reported to have frequent episodes. ing has been reported to occur in young adults in
Following puberty, episodes decrease in fre- association with abnormal electroencephalographic
quency, and usually children have outgrown them activity on a daytime, awake ELECTROENCEPHALO-
by the age of 15. It is estimated that approximately GRAM. Such patients respond to anticonvulsant ther-
1 percent of adults sleepwalk, the majority having apy, which may suggest that these individuals have
done so since childhood. Usually, episodes in adult- a form of epilepsy and not true sleepwalking.
hood resolve by the fifth decade. Sleepwalking episodes can be differentiated from
Elderly persons who walk around a house at psychogenetic fugues, which usually occur in indi-
night may be mistaken for sleepwalkers. They viduals with severe psychopathology. Fugues consist
may be suffering from a brain dysfunction, such as of episodes of wandering that usually last for hours
DEMENTIA, and are typically awake when they walk and days and are often associated with complex
about, although confused about their behavior. behaviors that are more typically seen during wake-
Sleepwalking occurs equally in males and fulness. REM SLEEP BEHAVIOR DISORDER has similari-
females, and there is little evidence for any cultural ties to sleepwalking in that motor activity can occur
or racial differences in the tendency to sleepwalk. during sleep, but such individuals are usually elderly
However, there is a strong pattern of inheritance, and the activity more clearly represents acting out of
with a high rate of sleepwalking activity seen in dream content. In addition, in REM sleep behavior
relatives of sleepwalkers. disorder the abnormal features are seen during REM
The cause of sleepwalking is unknown; how- sleep and not slow wave sleep. OBSTRUCTIVE SLEEP
ever, sleepwalking can be provoked by arousing APNEA SYNDROME can produce nocturnal wanderings
sleepwalking-prone individuals and standing them that may simulate sleepwalking, although other
on their feet when they are in a deep sleep. Exces- typical features of obstructive sleep apnea, such as
sive fatigue can precipitate episodes as can febrile snoring and episodes of cessation of breathing, usu-
(feverish) illness. Episodes of sleepwalking behav- ally allow an easy differentiation from more typical
ior have been reported in association with medi sleepwalking episodes.
ations such as LITHIUM and triazolam (see BENZODI- The child who infrequently sleepwalks requires
AZEPINES), or other HYPNOTICS. no specific treatment other than making sure that
234 slow rolling eye movements

the bedroom is secure to prevent the child from several years prior to her presentation at the sleep
injury. It may be necessary to place locks on win- disorder center. She would see a psychologist inter-
dows or doors for the child who walks excessively mittently in order to help her cope with everyday
at night. The older individual and adult should be stress, but not because of any psychiatric distur-
evaluated for underlying psychopathology, and the bance. She was successful in her occupation as a
appropriate psychiatric treatment should be insti- clerical administrator and outwardly was a bright
tuted. There have been good reports of response and energetic woman who was involved in many
to psychotherapy and psychiatric management. social activities.
In many situations sedatives, including imipra- Polysomnographic evaluation during sleep did
mine, diazepam or flurazepam, can be helpful in not reveal any sleepwalking episodes, and there
suppressing episodes, particularly if an individual was no evidence of any epileptic activity. However,
sleeps away from home. she had frequent, abrupt awakenings from stage
four sleep.
Case History She was commenced on triazolam, 0.25 milli-
A 26-year-old woman sought help at a SLEEP DISOR- gram taken on a nightly basis, and this completely
DER CENTER because of sleepwalking episodes that suppressed the episodes. After six months, she
had been occurring since she was 10 years of age. attempted to gradually withdraw from the medica-
When the episodes began, they were infrequent tion in the hope that the episodes would no longer
and were regarded as being typical for childhood occur. However, as the dose was reduced she had
sleepwalking in that she would be found by her a return of the sleepwalking episodes and then
parents walking in the corridor and returned to her recommenced the medication for a longer period
bedroom where she would go back to sleep with- of time. Five years after being placed on medica-
out any difficulty. During the walking episodes, she tion, she was free of sleepwalking episodes so long
was unaware of the environment although she did as she continued to take the medication. However,
not walk into objects or injure herself. several additional attempts to withdraw from the
At age 13, the episodes became less frequent medication were associated with a recurrence of
until age 16, when they again increased in fre- episodes. She no longer had embarrassment or fear
quency. Over the following years, she would have at staying over at other people’s homes, and she
episodes of sleepwalking that caused her consider- felt more secure and confident of having a sound
able embarrassment, particularly when staying at night of sleep.
the homes of friends. She would often have some If she ever decides to raise a family, she will
DREAM CONTENT along with the episodes and get need to consider coming off the medication prior
up and start to walk around the house. On one to and during pregnancy. The decision to continue
occasion she picked up some keys, put them in medication in the pregnancy will need to be bal-
her pocket and walked out the front door. She was anced against her potential for harm from the
found by a friend sleepwalking outside the house. sleepwalking episodes at that time. It is likely that
With some of the episodes, she would awaken her tendency for sleepwalking will gradually lessen
and become aware of having been sleepwalking. in time.
On other occasions, she would be returned to her
bedroom by friends or family only to be told about
the episodes the next morning. slow rolling eye movements Movements that occur
The sleepwalking episodes appeared to occur with the entrance into stage one non-REM sleep
less often when she was not in her usual environ- (see SLEEP STAGES). The eye movements begin a
ment. There was an increase in the frequency of slow sinusoidal (cyclical) pattern of movement on a
the episodes if she became very tired, fatigued horizontal plane while other EEG (ELECTROENCEPH-
or was ill with a fever. There was no evidence of ALOGRAM) and EMG (ELECTROMYOGRAM) features
underlying psychopathology except for one short- of stage one sleep are present. As the individual
lasting episode of DEPRESSION that had occurred passes from stage one into deeper stage two and
 snoring 235

three sleep, the eye movements become less active. Smoking can also exacerbate the obstructive
The presence of slow eye movements marks the sleep apnea syndrome by irritating the pharyngeal
onset of sleep from the rapid eye movements that tissues, thereby contributing to increasing erythema
are typically seen during wakefulness and helps and swelling. The carbon monoxide in smoke can
distinguish stage one sleep from REM sleep, which contribute to impaired blood gas exchange, and
is also characterized by rapid eye movements. Chin the smoke can irritate the large pulmonary air-
muscle activity is usually lower in stage one sleep ways with production of mucus, thereby leading
than in wakefulness but is much higher than the to chronic bronchitis that can further worsen the
muscle activity seen during REM sleep. obstructive sleep apnea syndrome.
Smoking in bed at night is a major cause of
fires, many of which are fatal. People with sleep
slow wave sleep (SWS) Sleep that is characterized disorders, or those who have ingested ALCOHOL or
by electroencephalographic waves of a frequency drugs, may have difficulty in remaining alert while
less than 8 Hz; typically comprises stages three smoking. If sleep occurs, cigarettes will be dropped
and four sleep combined. Slow wave sleep usually and can set fire to bedclothes or other materials.
comprises approximately 20 percent of the sleep of Patients with obstructive sleep apnea syndrome
the young adult; however, greater percentages are are at particular risk, because of their severe leth-
seen in prepubertal children. Gradual reduction in argy, of accidentally starting a fire if they smoke in
the total amount of slow wave sleep is seen with bed at night. (See also SLEEP HYGIENE, STIMULANT
aging so that after the age of 60 years, there is little MEDICATIONS.)
slow wave sleep. Slowing of the EEG (see ELECTRO-
ENCEPHALOGRAM), with increased amounts of slow
wave sleep, can be seen in several situations. snoring A noise produced by vibration of the
During partial SLEEP DEPRIVATION, the amount of soft tissue of the back of the mouth. Most typically
stage three/four sleep (see SLEEP STAGES) is usually the soft palate and the anterior and posterior pil-
reduced. Following the sleep deprivation, slow wave lar of fauces, which surround the tonsil, vibrate,
sleep rebounds so that a greater percentage of slow causing the sounds. Snoring is associated with
wave sleep can be seen on the subsequent sleep epi- obstruction of the upper airway that occurs during
sode. In addition, disorders that affect the cerebral sleep. Some snorers have only a very slight degree
hemispheres, such as a cerebral vascular accident, of UPPER AIRWAY OBSTRUCTION, and snoring will
can be associated with an increased amount of be rhythmical and regular on a breath to breath
slowing and therefore an increased amount of slow basis; lung ventilation is not compromised. Alter-
wave sleep. Drug effects, such as the use of HYPNOT- natively, if the upper airway obstruction is more
ICS or other central nervous system depressants, severe, there may be a complete inability to inspire
can also increase EEG slowing and lead to a greater air, and consequently the oxygen in the lung will
amount of slow wave sleep. Lithium is a known decrease, causing blood HYPOXEMIA. When snoring
cause of increased slow wave sleep. is severe, with associated hypoxemia, the disorder
of OBSTRUCTIVE SLEEP APNEA SYNDROME most likely is
present. This disorder is characterized by repetitive
smoking Smoking cigarettes can have an impor- episodes of upper airway obstruction, loud snoring
tant effect upon INSOMNIA and the OBSTRUCTIVE and EXCESSIVE SLEEPINESS during the day. Individu-
SLEEP APNEA SYNDROME. Cigarettes contain NICOTINE, als with obstructive sleep apnea syndrome are at
a stimulant that causes central nervous system risk of developing cardiac irregularity during sleep
arousal and therefore can contribute to difficulty and sudden death.
in initiating sleep. People who suffer from insom- There is some evidence to suggest that snoring
nia are advised not to smoke prior to bedtime, and may be associated with elevated blood pressure,
it is counterproductive to smoke cigarettes during even in the absence of obstructive sleep apnea syn-
nighttime awakenings. drome. Other epidemiological studies, which have
236 socially or environmentally induced disorders of the sleep-wake schedule

not differentiated simple snoring from that associ- TONSILLECTOMY AND ADENOIDECTOMY). However,
ated with the obstructive sleep apnea syndrome, enlarged tonsils or adenoids are rarely the cause
have shown a correlation of snoring with ischemic of snoring in adults, who more typically have an
heart disease and stroke. increase in the soft tissues of the pharynx, such
In addition to the direct cardiorespiratory con- as an elongated soft palate and excessive pillars of
sequences of snoring, the noise of snoring may be fauces. An operative procedure termed UVULOPALA-
a social annoyance and handicap. A spouse’s snor- TOPHARYNGOPLASTY (UPP) is usually very effective
ing may be the cause of marital discord that leads in reducing the sound of snoring. UPP consists of
to the snorer having to sleep in a separate bed, or the removal of the uvula and the lower portion of
even in another room. Not only can snoring affect the soft palate as well as the removal of the tissue
a spouse, it can also affect other people who are associated with the pillar of fauces. In general, this
sleeping nearby. Snoring can be particularly dis- operation is not indicated for people who have
turbing to roommates who have to share rooms, snoring in the absence of obstructive sleep apnea
such as on business trips, in the armed forces or at syndrome because of the very slight risk that gen-
summer camp. Snoring has been measured at up to eral anesthesia presents. However, this procedure
80 decibels, a level that can be potentially harmful may be performed on some snorers, but more
to hearing. commonly is performed on patients with obstruc-
Some 300 mechanical devices have been pat- tive sleep apnea syndrome in whom the snoring is
ented in the United States to reduce or eliminate associated with medically important upper airway
snoring. However, the majority are ineffective. Very obstruction. Two new forms of uvulopalatoplasty
few effective treatments are available for snoring, have been developed: LASER UVULOPALATOPLASTY
and, because most loud snorers will tend to have and radiofrequency uvulopalatoplasty (see SOMNO-
some degree of obstructive sleep apnea syndrome, PLASTY). Laser uvulopalatoplasty is a procedure that
a medical evaluation may be ne cessary. can be performed within 20 minutes in a physi-
Snoring may be affected by a number of factors, cian’s office. It is primarily done to eliminate snor-
such as increased body weight, alcohol consumption, ing. Radiofrequency uvulopalatoplasty involves
body position, respiratory tract infections and central inserting a needle into the tissues of the soft palate
nervous depressant medications, such as HYPNOTICS. and exposing the tissues to high-frequency radio
Sleeping on the back is liable to induce snoring in a waves. It is a less painful procedure than laser uvu-
person who otherwise does not snore when sleeping lopalatoplasty. Careful polysomnographic docu-
on the side or stomach. However, most loud snorers mentation of the presence and severity of the sleep
will tend to snore in any position. apnea is essential before surgery is undertaken.
Treatment of snoring, if required, may encom- Alternative treatments of snoring can involve
pass weight reduction, avoidance of alcohol, avoid- the use of mechanical devices, such as CONTINU-
ance of depressant medications and training to OUS POSITIVE AIRWAY PRESSURE (CPAP) devices or
sleep on the side rather than on the back. When airway patency devices such as the TONGUE RETAIN-
these measures are ineffective, or if obstructive ING DEVICE (TRD) or other ORAL APPLIANCES. These
sleep apnea syndrome is present, then other forms appliances may be useful in treating some patients
of treatment may be necessary, such as surgical who have snoring; however, with the exception
or mechanical treatment (see SURGERY AND SLEEP of the CPAP, these other mechanical devices have
DISORDERS). generally not been effective for the treatment of
The most effective surgical treatment for loud obstructive sleep apnea syndrome.
snoring is removal of the upper airway obstruc-
tive lesion. Children who can be loud snorers
with severe obstructive sleep apnea syndrome socially or environmentally induced disorders
most typically will have upper airway obstruction of the sleep-wake schedule This term has been
due to enlarged tonsils or adenoids, which, when applied to the CIRCADIAN RHYTHM SLEEP DISORDERS,
surgically removed will eliminate the snoring (see which are induced by external or behavioral fac-
 somnoplasty 237

tors such as TIME ZONE CHANGE (JET LAG) SYNDROME rarely performed in patients with the OBSTRUCTIVE
and SHIFT-WORK SLEEP DISORDER. It can be applied SLEEP APNEA SYNDROME due to patients’ difficulty in
to DELAYED SLEEP PHASE SYNDROME, ADVANCED SLEEP falling asleep during the radiological procedure. An
PHASE SYNDROME, and NON-24-HOUR SLEEP-WAKE SYN- alternative means of evaluating the upper airway
DROME when the cause of the disorder is induced by is by SOMNOENDOSCOPY or by the use of FIBEROPTIC
social or environmental factors. Examples of social ENDOSCOPY during wakefulness. (See also UPPER
or environmental factors include social isolation, AIRWAY OBSTRUCTION.)
extremes of light exposure such as that seen in the
polar regions, or excessive activity late at night.
somnolence See EXCESSIVE SLEEPINESS.

Sominex See OVER-THE-COUNTER MEDICATIONS.

somnologist Term applied to sleep specialists. The
word is derived from the Latin somnus, for “sleep.”
somniferous Term meaning “causing or inducing The term SLEEP DISORDER SPECIALIST is preferred.
sleep.” The word is derived from the Latin word (See also ACCREDITED CLINICAL POLYSOMNOGRAPHER,
somnus, for “sleep.” SLEEP DISORDERS MEDICINE.)

somniloquy See SLEEP TALKING. somnology Word meaning the study of sleep,
derived from the Latin somnus, for “sleep,” and
ology, meaning “the study of.”
somnoendoscopy Procedure performed during
sleep so the upper airway can be observed; involves
placing a fiberoptic endoscope (see FIBER-OPTIC somnoplasty A surgical method that uses radio-
ENDOSCOPY) through the nose into the upper air- frequency heating to create targeted tissue ablation
way and observing the changes that occur in a to reduce tissue volume; also known as radiofre-
sleeping patient. Somnoendoscopy is most com- quency thermal ablation. The procedure uses very
monly performed on patients with the OBSTRUCTIVE low levels of radiofrequency energy to create small,
SLEEP APNEA SYNDROME to determine the exact site finely necrotic lesions in soft tissue structures. The
of UPPER AIRWAY OBSTRUCTION during sleep. necrosis leads to scar formation and retraction of
Somnoendoscopy is a difficult procedure because tissue. This method has been applied to the soft
the presence of the fiberoptiscope can be uncom- palate of snorers to reduce soft palate tissue and
fortable and disruptive to sleep; it is hard for thereby reduce SNORING. The procedure has been
someone to sleep through the procedure, and even used successfully in clinical trials; patients expe-
harder for patients with the obstructive sleep apnea rience a minimal amount of pain, mainly from
syndrome because of the frequent arousals associ- the insertion of the needle into the soft palate to
ated with the apneic events. (See also ENDOSCOPY.) administer the local anesthesia. The procedure uses
temperatures of less than 100 degrees centigrade,
much less than those used in laser surgery (over
somnofluoroscopy Term that refers to a fluoro- 600 degrees centigrade).
scopic evaluation of the upper airway during sleep. The effectiveness of radiofrequency ablation has
This radiological procedure typically involves place- not been reported in patients with OBSTRUCTIVE
ment of barium in the upper airway to outline the SLEEP APNEA SYNDROME; however, the procedure
upper airway cavity. When the patient falls asleep, appears to be effective in reducing tongue-based
the barium outlines the upper airway so the radio- soft tissue in animal studies and therefore could
graphic images enable the dynamic changes of the be an effective treatment for human obstruc-
upper airway to be visualized. Somnofluoroscopy is tive sleep apnea syndrome. Further research is
238 Somnus

required. (See also LASER UVULOPALATOPLASTY, SUR- the annual meeting of the Associated Professional
GERY AND SLEEP DISORDERS, UPPER AIRWAY OBSTRUC- Sleep Societies (APSS) are given to an author
TION, UVULOPALATOPHARYNGOPLASTY.) whose paper or abstract in the field of basic sleep
research is recognized for its scientific excellence.
The awardee must be younger than 36 years of age,
Somnus The ancient Roman god of sleep, who have received a doctoral degree within five years
was the son of night and the brother of death. before the award and be the first or sole author
The words “somnambulism” (SLEEPWALKING) and of the paper or abstract; abstracts submitted to the
“somnolent” (sleepy) were derived from the Latin annual meeting of the Association of Professional
somnus. (See also HYPNOS.) sleep societies are eligible. Applicants must be
members of the Sleep Research Society or include
a membership application and fee with the award
Sonata See HYPNOTICS. application.

soporific Term derived from Latin sopor, mean- stage A sleep One of five sleep stages (A to E) that
ing “a deep sleep,” and ferre, “to bring,” that refers were first classified in the 1930s by E. Newton Har-
to the induction of a deep sleep, typically by the vey, Alfred L. Loomis, and Garret Hobart, according
use of drugs. MEDICATIONS that can induce a deep to their electroencephalographic pattern (see ELEC-
sleep-like state are the HYPNOTICS and anesthetic TROENCEPHALOGRAM). This sleep stage classification
agents, which include the BENZODIAZEPINES, BAR- was replaced by the method of Allan Rechtschaffen
BITURATES, and opiate derivatives. These agents in and Anthony Kales in 1968 following the discovery
high doses will produce a slowing of the ELECTRO- of REM SLEEP. Stage A sleep is equivalent to pre-
ENCEPHALOGRAM and the patient will be difficult to sleep drowsiness and has no exact correlation with
arouse. (See also COMA, NARCOTICS.) the new sleep stage classification system.
Stage A sleep consists of an interrupted alpha
EEG, which is typically found in relaxed wakeful-
SOREMP See SLEEP ONSET REM PERIOD. ness or drowsiness. (See also SLEEP STAGES.)

spindle See SLEEP SPINDLES. stage B–E sleep The second through fifth stages of
the original sleep classification devised by E. New-
ton Harvey, Alfred L. Loomis, and Garret Hobart in
SRS Distinguished Scientist Award An award the 1930s. It consists of a low-voltage EEG pattern
presented by the Sleep Research Society (SRS) without alpha activity. This pattern represents the
to “recognize work of the highest distinction in onset of sleep and is reflective of stage one sleep of
the field of basic sleep research.” The recipient is the Alan Rechtschaffen and Anthony Kales scoring
selected by the SRS Distinguished Scientist Award method, which replaced the Harvey and Loomis
Committee, and the award is presented by the method. (See also SLEEP STAGES.)
committee chairperson at the annual meeting. A
plaque and cash prize are given by the SRS in the
awardee’s name to subsidize the attendance of a stage four sleep See SLEEP STAGES.
trainee at the annual meeting. Deadline for appli-
cations is March 1st of the year of the award.
stage one sleep See SLEEP STAGES.

SRS Young Investigator Award A plaque and a

travel honorarium of $750 to be used to attend stage three sleep See SLEEP STAGES.
 stimulant-dependent sleep disorder 239

stage two sleep See SLEEP STAGES. cataplexy the individual generally is paralyzed and,
at most, can make moaning sounds. The episode
may last several minutes and rarely can last up to
stage two sleep spindles Spindles are fast brain one hour. The condition can also be precipitated
wave rhythms that last up to 1 1/2 seconds, have a by a sudden withdrawal of anticataplectic medica-
specific spindle shape, and can be detected using an tions, such as the tricyclic ANTIDEPRESSANTS, in an
electroencephalograph (EEG). These spindles occur individual with a diagnosis of narcolepsy.
during stage two sleep, which follows stage one
sleep. Stage two sleep accounts for 25 percent to 50
percent of the total sleep time. According to a study stimulant-dependent sleep disorder Disorder
conducted by Stuart M. Fogel and Carl T. Smith, and characterized by a reduction in the ability to
reported in the August 2006 Journal of Sleep Research fall asleep at night, produced by the use of cen-
under the title, “Learning-dependent changes in tral nervous system stimulants, or an increase in
sleep spindles and Stage 2 sleep,” “sleep spindles are drowsiness or excessive sleepiness during the day,
involved in the off-line reprocessing of simple motor following drug abstinence. The central nervous
procedural memory during Stage 2 sleep.” system stimulants encompass a wide variety of
medications that include amphetamines (see STIMU-
LANT MEDICATIONS), COCAINE, thyroid hormones,
Stanford Sleepiness Scale (SSS) A subjective CAFFEINE, methylxanthines (see RESPIRATORY STIM-
measure of alertness developed at Stanford Uni- ULANTS), bronchodilators, and antihypertensives.
versity in 1973. Individuals rate themselves accord- Many OVER-THE-COUNTER MEDICATIONS also contain
ing to one of several statements that most closely stimulants such as decongestants, cough mixtures,
describes their level of ALERTNESS or SLEEPINESS. In or diet suppression medications. Typically these
order to achieve a spectrum of sleepiness across a medications are associated with difficulty in the
day, the Stanford Sleepiness Scale is administered ability to fall asleep, especially when treatment with
at two-hour intervals, most commonly across the the medications is first started. After a period of
waking part of the day. It is often completed imme- time, TOLERANCE to this effect develops so that sleep
diately before and after the NAPS during a MULTIPLE initiation difficulties are less frequent. However,
SLEEP LATENCY TEST. upon withdrawal of the medication, symptoms of
The Stanford Sleepiness Scale is as follows: sleepiness, irritability, tiredness, and fatigue are
common. The recurrence of daytime symptoms
1. Feeling active, vital, alert, wide awake. on withdrawal of the stimulant medications often
2. Functioning at a high level but not at peak. Able leads to a cyclical pattern of administration. This
to concentrate. can lead the individual to believe that the medica-
3. Relaxed, awake, but not fully alert, responsive. tion is required in order to maintain full daytime
4. A little foggy, let down. ALERTNESS.
5. Foggy, beginning to lose track. Difficulty in stay- Individuals can be oblivious to the pattern of
ing awake. medication use because it is not regarded as a prob-
6. Sleepy, prefer to lie down, woozy. lem. However, others may become aware of the
7. Almost in reverie, cannot stay awake, sleep relationship of the stimulant medication to changes
onset appears imminent. in behavior that include periods of excessive acting
out with high activity, sometimes with paranoid
ideas and repetitive behaviors. In the case of high
status cataplecticus Continuous state of CATA- doses of cocaine, for example, generalized convul-
PLEXY that occurs in a patient with NARCOLEPSY. The sions can occur; with the amphetamines, a severe
continuous cataplectic state can be induced by a psychiatric state of psychosis may develop. Abnor-
persistence of the stimulus causing cataplexy, such mal movement disorders can also occur with toxic
as laughter, elation or anger. During the state of levels of amphetamines. Addiction to stimulant
240 stimulant medications

medications can develop, with severe DEPRESSION the RESPIRATORY STIMULANTS, such as doxypram and
and often suicidal ideation and hallucinations. nikethimide, as well as other miscellaneous medi-
The pattern of behavior associated with exces- cations, such as pemoline and methylphenidate
sive stimulant ingestion often leads to denial of hydrochloride.
drug use, which may be detected only by means of In sleep disorders medicine, the stimulant medi-
urinary and screening tests. cations are primarily used for the improvement
Severe addiction to stimulants may lead to intra- and relief of EXCESSIVE SLEEPINESS, and the most
venous administration, which increases the pos- commonly used medications are the amphet-
sibility of contacting infectious hepatitis, acquired amines, methylphenidate, and pemoline.
immune deficiency syndrome (AIDS) or a systemic The major disadvantage of the stimulant medi-
arteritis. Infection with the AIDS virus is a real cations is that they produce general body stimula-
possibility for intravenous stimulant abusers. Acute tion and therefore can induce ANXIETY and cardiac
severe toxicity of the medications may result in stimulation, leading to HYPERTENSION or tachycardia
death from CARDIAC ARRHYTHMIAS, brain hemor- (abnormally rapid heartbeat). There may also be
rhages, convulsions and respiratory arrest. gastrointestinal stimulation with resulting diarrhea.
Stimulant abuse is most common in adolescents
and young adults, and it appears to be equal among Amphetamines
the sexes. The effects of stimulant abuse may be Stimulant medications that are derived from
seen on polysomnographic testing as a prolonged the sympathomimetic amines and consist of a
SLEEP LATENCY, reduced TOTAL SLEEP TIME and an benzene and an ethylamine group. The amphet-
increased number of awakenings. REM sleep is amines have powerful central nervous system
often reduced and fragmented. Upon withdrawal stimulant effects, and therefore are used to pro-
of the stimulants, there may be a REM REBOUND, duce ALERTNESS in disorders associated with exces-
with an increased amount of REM sleep. The sive sleepiness during the day. Most often, they
chronic use of stimulants may give a picture on the are used for the treatment of NARCOLEPSY and
MULTIPLE SLEEP LATENCY TEST suggestive of NARCO- related conditions. Due to their stimulant effects,
LEPSY. A one- to two-week withdrawal period from these drugs can also be abused and illegally used
all medications may need to be documented before for recreational purposes to provoke central ner-
an accurate diagnosis of EXCESSIVE SLEEPINESS can vous system excitement.
be given. Amphetamines were first used for the treatment
Stimulant abusers may attempt to obtain stimu- of narcolepsy in the 1930s and were found to be
lant medications from physicians by falsely giving an effective agent for improving daytime sleepi-
a history of another sleep disorder (see MALINGER- ness. However, the powerful side effects were also
ERS), such as narcolepsy. Polysomnographic moni- recognized, such as elevated blood pressure and
toring of patients to confirm a bona fide diagnosis greater incidence of CARDIAC ARRHYTHMIAS. The
of a sleep disorder is necessary prior to the long- central nervous system effects can also provoke
term administration of stimulant medications. agitation, confusion, anxiety, irritability, DELIRIUM,
Patients who have stimulant dependency should and DEPRESSION. However, in appropriate doses,
embark upon a program of drug withdrawal under amphetamines are very helpful in the treatment of
medical supervision and, if necessary, appropriate narcolepsy, improving patients’ functioning during
psychiatric therapy. Individuals who suffer from the daytime.
severe drug dependency may require treatment in Other forms and derivatives of amphetamines
a specialized drug detoxification clinic. have been used more recently in the treatment of nar-
colepsy because they have less tendency for adverse
reactions. Methamphetamine (Desoxyn) was also
stimulant medications This term applies to used to improve alertness but, like amphetamine,
drugs that stimulate the central nervous system. It caused side effects and has largely been replaced by
includes methylxanthines, the amphetamines and dextroamphetamine sulfate (Dexedrine).
 stimulant medications 241

Dextroamphetamine is available in 5-, 10- and SLEEP ONSET and sleep maintenance difficulties are
15-milligram tablets, a 5 milligram per 5 milliliter common. A STIMULANT-DEPENDENT SLEEP DISORDER
Elixir, and in 5-, 10- and 15-milligram slow-release may result from their chronic ingestion. They can
spansules. Initial doses are typically 5 milligrams, also produce a feeling of fatigue or sleepiness when
three times a day, but may need to be increased not taken, thereby leading to repeated ingestion to
to as much as 100 milligrams per day. The tablets maintain full alertness.
have a duration of action of three to four hours, Some non-amphetamine anorectic agents are
whereas the spansules have a duration of action up available, such as phentermine, mazindol or dieth-
to 12 hours. Some patients find that a background ylpropion. These agents are generally less effective
dose of the longer-acting form of the medication, than the amphetamines in producing weight reduc-
such as a 15-milligram Dexedrine spansule, can be tion. Mazindol (see below) can be helpful in improv-
used with the extra stimulant effect of the shorter- ing alertness in some patients with narcolepsy.
acting tablets.
The adverse effects of dextroamphetamine are L-tyrosine
similar to those of the other amphetamines except A naturally occurring stimulant agent, this amino
there is less peripheral stimulant effect. But because acid has been shown to be effective in the treat-
of the potential for cardiac and mental stimulation, ment of narcolepsy. It is given in the dose of 100
disorders of daytime sleepiness, such as narcolepsy, milligrams per kilogram, and the beneficial effect
are now more frequently treated with methylphe- upon cataplexy is seen within the first few days
nidate hydrochloride (Ritalin). of use. The beneficial effects upon sleepiness take
Amphetamine users develop a TOLERANCE to somewhat longer to occur. L-tyrosine is currently
the drug; consequently, prescribed dosages are recommended only as a dietary supplement; in
increased in order to maintain improved alertness. high doses it can cause alteration of blood pressure,
Sudden cessation of medication will induce a level nausea, vomiting and headaches.
of sleepiness that is greater than baseline levels, The initial reports of the beneficial effects of
thereby promoting the continued use of the medi- L-tyrosine need to be confirmed before this medi-
cation. An amphetamine psychosis and abnormal cation can be recommended for the routine treat-
movements have been reported to be associated ment of narcolepsy.
with toxic doses of amphetamines.
Mazindol
Anorectics This is an imidazoline chemical produced mainly as
Anorectics are the appetite suppressant medications. a weight reduction medication. It has similar phar-
Anorectics typically are comprised of two groups, macological effects to the amphetamines, but has
amphetamines and the non-amphetamines. As the less central nervous system stimulation and also
amphetamines have stimulant effects, they are also less peripheral stimulant effects, such as tachycar-
used for the treatment of excessive sleepiness. When dia, tremor or gastrointestinal stimulation. But side
prescribed in appropriate dosages, they can be use- effects, such as dry mouth, transient irritability and
ful for the treatment of narcolepsy or IDIOPATHIC headaches, may occur. Mazindol is sometimes used
HYPERSOMNIA. However, some disorders that can in the treatment of disorders of excessive sleepiness,
produce daytime sleepiness, such as the OBSTRUCTIVE including narcolepsy. It has some similar effects to
SLEEP APNEA SYNDROME, may be adversely affected the tricyclic ANTIDEPRESSANTS, in that it blocks the
by the use of amphetamines. These medications can uptake (ability to absorb) of the catecholamines,
be dangerous in the sleep apnea syndromes due norepinephrine and dopamine.
to their cardiac stimulant effect. Also, the amphet- Sanorex, the trade name for mazindol, is avail-
amine anorectic medications are liable for abuse able in 1- and 2-milligram tablets, and the usual
because of their general stimulant properties. dosage is 1 milligram, three times a day. Usually
Anorectics, because of their stimulant effects, doses of 2 to 12 milligrams per day are required for
can produce an impaired ability to sleep at night. the treatment of sleepiness in narcolepsy. Unlike
242 stimulus control therapy

the amphetamine stimulants, mazindol has also negative conditioning in someone who lies in bed
been shown to be effective in the treatment of awake at night, allowing the insomnia to persist.
cataplexy. (Lying in bed awake at night heightens the ANXIETY
Mazindol is less effective in treating excessive for insomnia patients and further disrupts sleep
daytime sleepiness than pemoline or methylphe- and prevents its onset.)
nidate. Stimulus control instructions, ensuring that
wakeful activities are kept away from the bedroom,
Methylphenidate Hydrochloride are as follows: 1) go to bed only when sleepy; 2) if
This agent, a piperidine derivative, was first intro- not asleep within 10 minutes of getting into bed,
duced by Dan Daly and Robert Yoss in 1956 as the get out of bed and, after returning to bed, if sleep
treatment of choice for narcolepsy. The reduced ten- does not occur within 10 minutes, again leave the
dency for central nervous system stimulation and bed; 3) an alarm should be set so that awakening
peripheral stimulation, compared to amphetamines, occurs at the same time every morning and the
was considered advantageous for the treatment of taking of NAPS should be avoided; 4) the bed should
sleepiness in narcolepsy. Methylphenidate is still the not be used for wakeful activities other than sexual
treatment of choice for patients with severe narco- activity. (See also SLEEP RESTRICTION THERAPY.)
lepsy, although patients with mild cases of narco-
lepsy are more typically treated with pemoline.
Methylphenidate is usually given in divided strain gauge A mercury-filled tube that acts as a
doses, two to three times a day. It has a relatively transducer for movement; most commonly used
short duration of action, from four to six hours. for the measurement of respiratory movements or
Although most patients can be controlled with a penile tumescence (erection) during sleep. Strain
dose of about 20 milligrams per day, doses of up gauges may be applied to the chest or abdomen
to 60 milligrams may be required in some patients. in several places in order to detect respiratory
Due to its poor absorption when taken with food, movement.
patients are instructed to take the medication on an The main disadvantage of strain gauges is that
empty stomach. they need to be taped to the skin and may break,
This drug is available in 5-, 10- and 20-milligram with resulting leakage of mercury. Many sleep
tablets and is also available in a sustained-release disorder centers therefore utilize chest electromy-
form of 20 milligrams (Ritalin-SR). Ritalin is the ography, bellows, pneumobelts or respitrace for the
trade name for methylphenidate. Although some detection of abdominal or chest movement.
patients find the sustained-release form effective, Strain gauges are commonly used for deter-
others prefer the intermittent use of the shorter- mining penile tumescence, with one strain gauge
acting form of the medication. being applied to the base of the penis and the other
to the tip. A commercially-produced device, the
Over-the-Counter Medications RIGISCAN, has supplanted the use of strain gauges
A number of nonprescription OVER-THE-COUNTER in the determination of nocturnal penile tumes-
MEDICATIONS are available for weight reduction or cence in some sleep laboratories. However, the
stimulant purposes. These include phenylpropa- Rigiscan may be uncomfortable for some patients
nolamine, which is sometimes given in combina- due to its method of action, which involves an
tion with CAFFEINE. The use of these medications intermittent constriction of bands around the
is controversial as they may be ineffective yet penis. (See also NOCTURNAL PENILE TUMESCENCE
dangerous to individuals, particularly those with TEST, POLYSOMNOGRAPHY.)
hypertension or cardiac disease.

stress Term applied to the body’s physical or psy-

stimulus control therapy BEHAVIORAL TREATMENT chological response to an unexpected or unpleas-
of INSOMNIA that counteracts the development of ant environmental or emotional stimulus, such
 sudden infant death syndrome 243

as marital problems, pressure at work, upcoming There appear to be some predisposing factors,
examinations, or even changes in everyday pat- derived from epidemiological studies, that indi-
terns, such as spending the night away from home cate that premature infants, infants with low birth
or having to make a public speech. The term is weight, infants that are twins or of a multiple birth,
most commonly used in SLEEP DISORDERS MEDI- and siblings of another child who has died of SIDS
CINE for the cause of a disturbed sleep pattern that are at greater risk. Sleeping on the stomach is also
occurs due to a marital, financial or employment a major factor. In addition, there are a number of
situation. Typically, the sleep disorder, termed maternal factors that appear to predispose some
ADJUSTMENT SLEEP DISORDER, is a result of the psy- children to the development of SIDS: for example,
chological stress produced by such events. When infants born to mothers who are substance abusers
the event produces a greater degree of stress, of agents such as COCAINE or heroin. It does appear
an overt ANXIETY DISORDER may result. (See also that SIDS is more common in lower socioeconomic
INSOMNIA, SHORT-TERM INSOMNIA.) and minority groups, such as American blacks and
American Indians. Sudden infant death syndrome
has a prevalence of between one and two per
stupor A state of altered consciousness character- 1,000 live births, with the peak onset around three
ized by unresponsiveness to strong stimuli. Such months of age, and up to 90 percent of cases occur
patients are usually perceived as being in a deep before the sixth month of age. There is a slightly
sleep, and electroencephalographic studies may increased male to female ratio.
indicate slow wave activity. However, unlike in After death, autopsy examinations have dem-
COMA, individuals can be awakened and become onstrated a number of features that suggest that
aware of the environment, but they usually return the infant may have suffered from an acute
rapidly to the unresponsive state. upper respiratory tract obstruction. There are pete-
Stupor may be produced by metabolic or phar- chiae and evidence of pulmonary congestion and
macologic insults to the central nervous system. edema. Also, pathological abnormalities have been
However, this condition can also be seen in severe reported in the brain stem, suggesting a prior cen-
psychiatric illness, such as that seen with catatonic tral nervous system insult, such as HYPOXIA.
schizophrenia or severe DEPRESSION. (See also Polysomnographic investigations are rarely use-
DELIRIUM, OBTUNDATION.) ful. Although originally there was some sugges-
tion that short apneic episodes may be predictive
of SIDS, subsequent research has not confirmed
subjective DIMS complaint without objective this finding. Infants who have significant apneic
findings See SLEEP STATE MISPERCEPTION. events, such as those with APNEA OF PREMATURITY,
or infants requiring assisted ventilation following
an apneic event, do have a higher risk for sudden
sudden infant death syndrome (SIDS) The term infant death syndrome, although this risk is less
used for the death of an otherwise healthy infant than 5 percent.
who dies suddenly and in whom a postmortem Having an infant sleep on its back is the most
examination fails to reveal a cause of death. The effective preventative measure a parent or caregiver
majority (over 80 percent) of SIDS infants die dur- can take. There is evidence that some infants may
ing sleep. have a cardiac abnormality that can be detected
Less than 5 percent of children who die of sud- by an electrocardiograph. The Q-T interval on the
den infant death syndrome have been known to electrocardiograph is prolonged in infants with
have some respiratory disturbance during sleep. greater risk of SIDS. Other than the electrocardio-
However, the cause of the sudden infant death graphic changes, there are no features that readily
syndrome is unknown. Evidence suggests that identify the child who is at risk of sudden infant
it is not directly related to any prior respiratory death syndrome. A policy statement on reducing
irregularity. the risk of SIDS was released by the American
244 sudden unexplained nocturnal death syndrome

Academy of Pediatrics (AAP) in 2005. The Eunice Most of the reported cases in the United States
Kennedy Shriver National Institute of Child Health have been in the ethnic subgroup called the
and Human Development (NICHD) incorporated Hmong, from the highlands of northern Laos. The
the AAP recommendation in its Back to Sleep incidence of the disorder in the Hmong refugees in
campaign. Since the Back of Sleep campaign the United States is reported at 92 per 100,000. It
advising parents and caregivers of the benefits of is slightly less common in Laotian refugees at 82
placing infants on their backs to sleep, the rate of per 100,000; it is 59 per 100,000 in Kampuchean
SIDS has been reduced by more than 50 percent. (Cambodian) refugees.
(See also AGE, CENTRAL ALVEOLAR HYPOVENTILATION Although SUND cannot be predicted, healthy
SYNDROME, CENTRAL SLEEP APNEA SYNDROME, INFANT young adults with cardiorespiratory arrest dur-
SLEEP APNEA, INFANT SLEEP DISORDERS, OBSTRUCTIVE ing sleep need to be examined for any underlying
SLEEP APNEA SYNDROME.) cardiorespiratory disorder. A sleep-related disorder,
such as OBSTRUCTIVE SLEEP APNEA SYNDROME or REM
SLEEP-RELATED SINUS ARREST, may be the cause of
sudden unexplained nocturnal death syndrome the arrest.
(SUND) Syndrome primarily recognized in peo-
ple of Southeast Asian descent who die unexpect-
edly during sleep. It occurs in healthy young adults SUND See SUDDEN UNEXPLAINED NOCTURNAL DEATH
without any prior history of cardiac or respiratory SYNDROME.
disease. Typically there will be a sudden awakening
with a choking or gasping sensation and difficulty
in breathing. Cardiorespiratory arrest occurs with Sunday night insomnia Difficulty in initiating
a fatal outcome. In very rare situations, patients and maintaining sleep that commonly is seen
have been successfully resuscitated and found on Sunday nights. This form of insomnia occurs
to have cardiac irregularity called VENTRICULAR due to the tendency to go to bed later on Fri-
ARRHYTHMIAS. day and Saturday nights than during the week
This rare and unusual syndrome primarily affects (because of social events). Typically the awake
persons between the ages of 25 and 45 who are of time on Saturday and Sunday mornings is later
Laotian, Kampuchean (Cambodian), or Vietnamese than usual, thereby causing the sleep pattern to
origin. It is primarily a male disorder, although rare be slightly delayed on the weekends compared to
cases have been reported in females, and most of the that of weekdays. Consequently, many people will
reported cases have been described in refugees who attempt to fall asleep at an early time on Sunday
have immigrated to the United States. However, night in order to achieve an adequate amount of
the disorder has been recognized for a long time, sleep for work or school on Monday. Because the
and the Laotian term for the disease is non-laita, in time of going to bed on Sunday night is much
Tagalog, bangungut, and in Japanese, pokkuri. earlier than that of the previous two nights, there
Investigations have failed to reveal any spe- often can be difficulty in falling asleep, which is
cific cause for the disorder either clinically or by characterized by a long period of time spent in
autopsy. There has been no evidence of exposure bed awake. If the time of falling asleep on Sunday
to either biological or chemical toxins, or the use of night is similar to the later time of initiating sleep
drugs or alcohol. that occurs on the Friday and Saturday nights,
Many of the victims of SUND have been reported then individuals may find that they are sleep
to have had prior SLEEP TERROR episodes with a deprived upon awakening for work or school on
sudden awakening and screaming. It has been Monday morning. This will lead to a degree of
suggested that the sudden death during sleep may SLEEP DEPRIVATION that is often termed MONDAY
be due to a severe form of terror episode in which MORNING BLUES.
the heart is so stimulated that it goes into a fatal In order to prevent Sunday night insomnia, an
arrhythmia. individual should maintain a regular time of going
 surgery and sleep disorders 245

to bed seven days a week and not allow the time to this disorder are now treated by means of CONTINU-
be significantly later on Friday or Saturday nights. OUS POSITIVE AIRWAY PRESSURE (CPAP) devices, a
treatment that has very few complications. The
CPAP device provides a low pressure of air to the
sundown syndrome See DEMENTIA. back of the throat, thereby preventing its collapse
during sleep. However, some patients do not find
this device suitable for use, and surgery may be the
suprachiasmatic nucleus (SCN) Cells that are only effective treatment available.
located at the bottom of the third ventricle in the The most common form of surgery used in chil-
hypothalamus. This is believed to be the prime cen- dren with obstructive sleep apnea syndrome is ton-
tral nervous system site that determines endoge- sillectomy with or without an adenoidectomy (see
nous circadian rhythms, the so-called ENDOGENOUS TONSILLECTOMY AND ADENOIDECTOMY). Enlarged ton-
CIRCADIAN PACEMAKER. The suprachiasmatic nucleus sils are a common cause of obstructive sleep apnea
(SCN) has connections with the eye by means of in prepubertal children. Children with enlarged
the retino-hypothalamic pathway, which is com- tonsils may also have craniofacial abnormalities
posed of fibers that pass from the optic nerves to that contribute to the upper airway obstruction,
the hypothalamus. By means of the retino-hypo- such as an altered mandibular relationship to the
thalamic tract (RHT), light and dark influence the skull with or without retrognathia. In such patients,
circadian pacemaker and act as entraining (main- MANDIBULAR ADVANCEMENT SURGERY can allow the
taining a regular 24-hour) stimuli for our circadian tissues of the tongue to come forward, thereby pre-
rhythms. Other connections pass to local areas of venting pharyngeal obstruction. An experimental
the central nervous system, as well as through the surgical procedure involves the release of the hyoid
brain stem and up to the pineal gland, causing the muscles (see HYOID MYOTOMY). These muscles fasten
release of the hormone MELATONIN in darkness. the base of the tongue to the skull and their release
Destruction of the suprachiasmatic nucleus has allows the tongue to be moved forward to open up
produced loss of the circadian rhythmicity of vari- the posterior pharyngeal air space.
ous CIRCADIAN RHYTHMS. Patients who have a long soft palate, an enlarged
uvula and narrow pillar or fauces may be suitable
for the UVULOPALATOPHARYNGOPLASTY (UPP) opera-
surgery and sleep disorders Surgery is a primary tion, which is a soft tissue surgical procedure per-
treatment form considered for patients who have formed at the back of the mouth. This procedure
the OBSTRUCTIVE SLEEP APNEA SYNDROME. Patients is effective for patients with either the obstructive
with this syndrome have UPPER AIRWAY OBSTRUCTION sleep apnea syndrome or simple SNORING; how-
that occurs at the back of the mouth in the region ever, only 40 percent to 50 percent of patients
from the nose to the larynx. Surgical procedures have a successful result by means of this surgery.
that remove excessive tissue or localized lesions in Two new forms of palatoplasty are LASER UVULO-
the upper airway have been shown to be effective in PALATOPLASTY and radiofrequency palatoplasty (see
the treatment of some patients with this syndrome. SOMNOPLASTY). CEPHALOMETRIC RADIOGRAPHS and
Obstructive sleep apnea may be due to enlarged FIBEROPTIC ENDOSCOPY aid in selecting patients for
tonsils or adenoids, craniofacial abnormalities the uvulopalatopharyngoplasty procedure, thereby
including retrognathia (posterior-positioned lower leading to improved surgical results.
jaw) or micrognathia (small lower jaw), or general- TRACHEOSTOMY is a procedure that was the pri-
ized soft tissue enlargement, particularly at the level mary form of treatment for obstructive sleep apnea
of the soft palate. Various forms of surgery have in the past, but it has largely been replaced by the
been devised in order to improve the upper airway use of mechanical treatments or the UPP operation.
so that obstruction during sleep does not occur. However, it is still an effective procedure. A hole is
Surgical treatment of obstructive sleep apnea is created in the trachea (windpipe) so that breathing
still widely performed; however, most patients with occurs through the hole and the upper airway is
246 sweating

bypassed during sleep. This procedure is very effec- non-REM sleep, and it reflects the slowing of the
tive; however, the social problems associated with EEG. The term is best avoided if other features of
tracheostomy prevent it from being commonly non-REM sleep can be determined. A more specific
performed today. (Patients are unable to swim with statement of the stage of sleep (see SLEEP STAGES),
a tracheostomy and its appearance can be undesir- such as stage two or three sleep, should be given,
able.) In some patients, tracheostomy can produce if possible.
dramatic improvement in symptoms and features
of the obstructive sleep apnea syndrome and can
be lifesaving. systemic desensitization Behavioral technique
occasionally used to treat INSOMNIA, particularly
in patients who have insomnia due to anxiety or
sweating There can be an increase of sweating negatively-conditioned associations. The patient is
during sleep; if it is a regular occurrence it is called required to make a list of various situations that are
SLEEP HYPERHIDROSIS. An increase in sweating can likely to contribute to the sleep disturbance, and
be due to febrile illness, specific neurological disor- then concentrate upon those items while coupling
ders, such as stroke, or pregnancy. (See also PREG- them with more restful thoughts. The aim of the
NANCY-RELATED SLEEP DISORDERS.) treatment is to try to turn the unpleasant associa-
tions into pleasant ones so they no longer contrib-
ute to the disturbed sleep. Systemic desensitization
synchronized sleep Term used to denote NON- is sometimes used in conjunction with RELAX-
REM-STAGE SLEEP, particularly in ontogenetic or ATION EXERCISES procedures. (See also AUTOGENIC
phylogenetic sleep research. It is derived from the TRAINING, BEHAVIORAL TREATMENT OF INSOMNIA, BIO-
synchronized patterns of EEG (see ELECTROEN- FEEDBACK, COGNITIVE FOCUSING, PARADOXICAL TECH-
CEPHALOGRAM) activity that are commonly seen in NIQUES, PROGRESSIVE RELAXATION.)
 T
tachycardia A heartbeat that is beyond the nor- cent of the time during the rising phase of the body
mal range of 60 to 100 times a minute. The dis- temperature cycle.
order sleep apnea is one of many conditions that There is some evidence to suggest that exercise
increases the possibility of developing tachycardia. and WARM BATHS may be beneficial to nighttime
Others include high blood pressure (hyperten- sleep by raising the body temperature prior to sleep
sion), an overactive thyroid, a family history of onset. However, elevation of the temperature of
heart disease or arrhythmia disorders including the sleeping environment is generally not helpful
atrial fibrillation, atrial flutter, or SVT (super- to good sleep and can be an environmental stimu-
ventricular tachycardia), damaged heart valves, lus that contributes to INSOMNIA. Persons who sleep
coronary artery disease, and aging. Symptoms of in hot tropical areas can sleep well as long as the
tachycardia include, a fast heartbeat, missed heart- environmental temperature is constant and the
beats, dizziness, palpitations, chest pain, blackouts, person has adapted to it. A sudden change in the
and shortness of breath. Drinking alcohol, caf- environmental temperature during the sleeping
feine, smoking tobacco, and taking over-the-coun- hours can lead to a disturbed night of sleep. (See
ter medications are some of the potential causes of also CHRONOBIOLOGY, CIRCADIAN RHYTHMS, EXERCISE
tachycardia. AND SLEEP, THERMOREGULATION.)

Tegretol See CARBAMAZEPINE.

temporal isolation In 1962, MICHEL SIFFRE spent
59 days in an underground cavern in the French-
Italian Alps and discovered that his sleep-wake
cycle had a period length of just over 24 hours as
temazepam (Restoril) See BENZODIAZEPINES.
a result of being isolated from ENVIRONMENTAL TIME
CUES. In 1962, Jürgen Aschoff developed a research
facility in a German bunker and demonstrated that
temperature Body temperature decreases dur- with isolation from social and temporal cues, many
ing sleep and reaches its minimum level before biological rhythms with a 24-hour cycle would free
awakening. It reaches its maximum level during run (see FREE RUNNING) with a PERIOD LENGTH of just
the middle of the period of wakefulness that typi- over 24 hours. Internally generated rhythms were
cally occurs during the daytime. A fluctuation of termed CIRCADIAN RHYTHMS by FRANZ HALBERG in
1.5 degrees Fahrenheit is usually seen between the 1959. Additional studies on humans were per-
low point and the highest point during any 24- formed by ELLIOT WEITZMAN at Montefiore Hospital
hour period. The lowest point of body temperature in New York where healthy subjects were studied
is about three hours before awakening, typically in an environment free of time cues for periods of
between 3 A.M. and 5 A.M., and then rapidly rises up to six months. From such experiments much
during the time of awakening. Chronobiological was learned about the human circadian timing sys-
studies have demonstrated that normal-sleeping tem and the effect of environmental and time cues
individuals in time isolation will awaken 85 per- in influencing circadian rhythms.

247
248 terminal insomnia

terminal insomnia See EARLY MORNING AROUSAL. changing its resistance when connected to an
electrical current. The signal that is produced is
amplified by the polysomnograph (see POLYSOM-
terrifying hypnagogic hallucinations Terrifying NOGRAPHY) and a record of airflow is obtained on
HYPNAGOGIC HALLUCINATIONS, also known as sleep the POLYSOMNOGRAM.
onset nightmares, are terrifying DREAMS that occur Thermistors are used in polysomnographic
at the beginning of sleep. These dreams are simi- monitoring to detect whether airflow occurs dur-
lar to NIGHTMARES; however, nightmares usually ing sleep, so that differentiation may be made
occur during REM sleep, well after sleep onset. The between obstructive (see OBSTRUCTIVE SLEEP APNEA
affected person will become drowsy, start to fall SYNDROME) and central apneas (see CENTRAL SLEEP
asleep, and then see images that become very terri- APNEA SYNDROME). Thermistors are used in con-
fying. The images cause a sudden awakening, with junction with measures of respiratory effort that
anxiety and fear; the content of the nightmare can are placed at both the chest and abdominal levels.
be recalled. Sometimes the associated movement (See also SLEEP-RELATED BREATHING DISORDERS.)
activity in sleep can be very excessive, with calling
out and screaming.
Terrifying hypnagogic hallucinations occur in thermoregulation The body’s ability to control
disorders of disturbed REM sleep, such as in body TEMPERATURE within a narrow range. Changes
NARCOLEPSY, where a SLEEP ONSET REM PERIOD in body temperature and environmental tempera-
can occur, or following the acute withdrawal of ture can have important effects upon sleep. The
REM-suppressant medications, such as the tricyclic body maintains body temperature within a close
ANTIDEPRESSANTS. range and usually varies it by no more than 1.5
Terrifying hypnagogic hallucinations need to be degrees throughout the day. Body temperature
differentiated from other forms of hallucinatory falls during sleep, reaching a low point approxi-
behavior, such as that seen in more typical hyp- mately three hours before the time of awakening.
nagogic hallucinations where the dream content Even sleep during the daytime can cause body
is not terrifying. SLEEP TERRORS occur during SLOW temperature to fall slightly. Therefore, sleep and
WAVE SLEEP, well after sleep onset, and the terror circadian factors are important in the control of
episodes are associated with fear and anxiety but body temperature.
little dream recall. Rarely, a mental disorder can During sleep, there are specific effects of the
produce nocturnal hallucinatory behavior; how- sleep state upon the control of body temperature,
ever, the occurrence only at sleep onset would be which is under the control of the preoptic and
atypical. anterior hypothalamic nuclei (POAH). Thermo-
Treatment of terrifying hypnagogic hallucina- regulation changes reduce body temperature dur-
tions involves treatment of the underlying disorder, ing NON-REM-STAGE SLEEP in association with the
either narcolepsy or other causes of sleep onset reduction in the metabolic rate. During REM sleep,
REM episodes, and may involve the use of REM- body temperature in humans increases slightly;
suppressant medications, such as the tricyclic anti- however, studies in animals have tended to show
depressant medications. that the metabolic rate and body temperature typi-
cally are reduced in REM sleep. The slight increase
in humans may be related to the increased central
theophylline (Bronkodyl, Slo-bid) See RESPIRA- nervous system activity. Reduced muscle activ-
TORY STIMULANTS. ity is likely to be responsible for the reduction of
metabolic rate and body temperature that is seen
in animals.
thermistor Heat-sensitive device used to mea- The control of body temperature varies between
sure airflow at the nostrils or mouth. The therm- sleep states so that the control mechanisms are
istor responds to variations in temperature by intact during non-REM sleep and are inhibited
 time zone change (jet lag) syndrome 249

during REM sleep. Sweating does not occur dur- tidal volume The amount of air usually taken
ing REM sleep, and usual body responses to cold, into the lungs during a normal breath at rest. It is
such as shivering, are not seen during REM sleep. typically 500 cubic centimeters of air.
The body’s temperature is largely under the control
of the environment temperature during the REM
sleep state. time zone change (jet lag) syndrome Syndrome
Changes in the environmental temperature associated with complaints of difficulty in main-
also have an effect on sleep itself. The amount of taining sleep and EXCESSIVE SLEEPINESS; typically
SLOW WAVE SLEEP and REM sleep is maximal at an associated with rapid travel across multiple time
environmental temperature of 29 degrees Celsius zones. The sleep-wake pattern has to be temporar-
(84.2 degrees Fahrenheit); as the body temperature ily shifted to another time, the difference in time
changes, the amount of each sleep stage reduces. In depending upon the number of time zones crossed.
addition, there are changes in the quality of sleep In addition to disturbance of the sleep-wake pat-
with increased arousals and number of awaken- tern, there are changes in alertness and perfor-
ings, and an increased sleep latency. However, a mance and general feelings of malaise. The severity
person’s adaptation to the environmental tempera- and duration of these symptoms is dependent
ture influences the effects on sleep that are seen. upon not only the number of time zones crossed
Artificial changes in body temperature can have but also the direction of travel. Adaptation to time
an effect on the quality of sleep. An increase in zone change is usually quicker following westward
body temperature prior to the major sleep episode travel, where the onset of a new sleep episode is
will lead to an increase in non-REM sleep (see delayed in relation to the prior sleep episode. The
WARM BATHS). tendency for improved adaptation after westward
The control of body temperature may have travel is thought to be due to the natural tendency
important effects upon the infant during its devel- to delay the onset of the sleep episode, the same
opment. Because of the prevalence of SUDDEN tendency seen if one is placed in an environment
INFANT DEATH SYNDROME, the possibility has been free of time cues.
raised that an abnormality in the control of ther- Once the individual is in the new time zone,
moregulation during sleep stages may predispose adaptation occurs rapidly, with the symptoms of
an infant to apneic episodes. Hypothermia has sleep disturbance diminishing with each day in the
been shown to cause laryngeal hyperexcitability, new environment. Typically, the sleep episode in
which can lead to UPPER AIRWAY OBSTRUCTION. Body the new time zone is of shorter duration and may
temperature changes are also useful for the deter- be of lesser quality than that prior to the travel,
mination of circadian rhythmicity, as they are a and this produces a tendency to SLEEP DEPRIVATION
marker of the phase of the circadian rhythm. Body and consequent excessive sleepiness. As there is
temperature changes are commonly recorded in a greater ability to delay our sleep onset than to
the investigation of shift work and jet-lag effects. advance the sleep onset, travel to the east, where
(See also CIRCADIAN RHYTHMS, EXERCISE AND SLEEP, sleep is scheduled to occur at a time earlier than
SHIFT-WORK SLEEP DISORDER, SLEEP LATENCY, TIME the prior sleep onset time, is associated with a
ZONE CHANGE (JET LAG) SYNDROME.) greater SLEEP ONSET difficulty.
The disruption in the sleep episode and exces-
sive sleepiness produced by time zone change may
theta activity EEG (ELECTROENCEPHALOGRAM) induce reduced work performance and interfere
activity with a frequency of 4 to 8 Hz that is gener- with social and occupational activities, but the sleep
ally maximal over the central and temporal areas. disturbance usually rapidly abates upon adaptation
Theta activity is commonly seen in lighter stages of in the new environment. However, for business
NON-REM-STAGE SLEEP but also is present in REM persons who frequently travel and have limited
sleep. A specific form of theta activity called SAW- time to adapt to the time zone changes, chronic
TOOTH WAVES is characteristic of REM sleep. sleep disturbance and impaired work performance
250 Tofranil

may be of particular concern. Airline crews are effect. Certain MEDICATIONS, such as the amphet-
particularly susceptible to the effects of time zone amines (see STIMULANT MEDICATIONS), induce a
change. resistance to the drug so that greater dosages are
Polysomnographic studies following time zone necessary to achieve the initial results. In that way,
change have shown a greater number of arousals tolerance to a drug necessitates the escalation of
and increased stages of lighter sleep with a conse- the dose in order to maintain the drug’s effect, such
quent reduction in SLEEP EFFICIENCY. SLOW WAVE as improved ALERTNESS in the case of the amphet-
SLEEP generally occurs in normal amounts but amines. Since sudden cessation of the medication
there may be reduced REM sleep. will often worsen the original problem that was
Time zone change sleep disorder can occur in being corrected, such as sleepiness, continued (and
individuals of any age; however, the elderly are escalated) use of the medication is often inadver-
believed to be more likely to suffer from symptoms tently promoted.
due to their difficulty in maintaining a regular and
highly efficient sleep-wake cycle.
JET LAG may be exacerbated by the use of HYP- tongue retaining device (TRD) Dental appli-
NOTICS. Treatment is directed toward maintaining ance designed to hold the tongue forward to pre-
a regular pattern of sleep in the new environ- vent SNORING. The mouthpiece, which is inserted
ment. A regular sleep onset time and wake time into the mouth and fitted over the upper and
is recommended, with an appropriate sleep dura- lower teeth, contains a compartment that holds
tion. An attempt to adapt to the new environ- the tongue in a forward position by suction. The
mental time is preferable for individuals who plan tongue retaining device works on the principle that
to be in the new time zone for episodes of one the position of the tongue contributes to UPPER AIR-
or more weeks. However, if staying in the new WAY OBSTRUCTION, thereby adding to snoring. It is
time zone for only a few days, maintenance of the particularly effective for patients who snore while
prior sleep-wake pattern, even though it is not lying in a supine position.
coordinated with the new environmental time, is Polysomnographic studies have demonstrated
preferable. that the TRD can be useful for treating mild
If a delay in the sleep episode is to be expected OBSTRUCTIVE SLEEP APNEA SYNDROME, especially in
in the new environment, attempts to adapt may patients who are unable either to use a nasal CON-
involve initiating a gradual delay in the original TINUOUS POSITIVE AIRWAY PRESSURE (CPAP) device or
environment prior to travel so the sleep episode is undergo UVULOPALATOPHARYNGOPLASTY. However,
partially adapted. many patients find the device uncomfortable and
Daytime flights are said to be preferable to are unable to tolerate it for more than 50 percent
nighttime flights, so the night sleep can occur of the night. In addition, the device appears to be
in a more acceptable environment. Studies have less successful in patients who are more than 50
shown that hypnotics use can be beneficial for percent overweight. (See also ORAL APPLIANCES.)
the first one or two nights in the new time zone
in order to enhance the efficiency of the sleep
episode. (See also CIRCADIAN RHYTHM SLEEP DISOR- tonsillectomy and adenoidectomy Tonsillectomy,
DERS, ENVIRONMENTAL TIME CUES, PHASE ADVANCE, with or without an adenoidectomy, is a surgical
PHASE DELAY, PHASE RESPONSE CURVE.) procedure that is performed for the relief of the
OBSTRUCTIVE SLEEP APNEA SYNDROME. This procedure
is most commonly performed in children because
Tofranil (imipramine) See ANTIDEPRESSANTS. tonsil enlargement is common in the prepubertal
age group. However, some adults can also have
very enlarged tonsils, or enlarged adenoids, which
tolerance Term used when greater dosages of contribute to UPPER AIRWAY OBSTRUCTION and there-
medication are required to obtain the original fore may need to undergo this surgery. Many
 tracheostomy 251

patients treated by a UVULOPALATOPHARYNGOPLASTY total sleep time (TST) The amount of actual sleep
(UPP) operation also have removal of tonsils or that occurs during a sleep episode; consists of the
adenoids if they are enlarged at the time of the sum of the total amount of non-REM plus REM
UPP surgery. sleep. The total sleep time varies according to age,
Tonsillectomy involves removal of the enlarged being greatest in infancy with a gradual reduction
lymphoid tissue situated between the anterior and as one gets older. (See also SLEEP DURATION, TOTAL
posterior pillar of fauces. This tissue is involved in RECORDING TIME, TOTAL SLEEP EPISODE.)
the immune response to infections in childhood
but gradually regresses and is of little functional
importance in adulthood. Removal of the tonsils toxin-induced sleep disorder A sleep disorder
is a simple procedure in children, but it assumes characterized by either INSOMNIA or EXCESSIVE
greater likelihood of complications, such as exces- SLEEPINESS; produced by the ingestion of toxic
sive bleeding, in adults. agents such as heavy metals or organic toxins. The
In the majority of children with enlarged tonsils poisoning due to the repeated ingestion of these
and obstructive sleep apnea, tonsillectomy entirely agents produces central nervous system effects,
relieves the obstructive sleep apnea. However, some such as stimulation and agitation, and can also pro-
patients who have craniofacial abnormalities may duce depression-causing sleepiness and even COMA.
continue to have obstructive sleep apnea following Other symptoms such as cardiac stimulation, respi-
removal of the tonsils or adenoids. Post-operative ratory depression, and gastrointestinal upset can
polysomnographic monitoring for obstructive sleep occur with the ingestion of the toxic agents. Liver,
apnea is required for patients with severe obstruc- renal and cardiac poisoning can occur.
tive sleep apnea who appear to be symptomatic This type of sleep disorder is most commonly
following surgery. Other surgical procedures, for seen in industrial workers who are exposed to toxic
example, MANDIBULAR ADVANCEMENT SURGERY, may chemicals. It can also be seen in children, who may
be required, or the use of a CONTINUOUS POSITIVE ingest lead in paint or be excessively exposed to the
AIRWAY PRESSURE (CPAP) device. (See also CRANIO- exhaust fumes of leaded gasoline.
FACIAL DISORDERS, HYOID MYOTOMY, SURGERY AND The treatment of the sleep disturbance involves
SLEEP DISORDERS, TRACHEOSTOMY.) removal of exposure to the offending agent as well
as providing good SLEEP HYGIENE measures in order
to prevent continuation of the sleep disturbance.
total recording time (TRT) The duration of time
from sleep onset (lights out) to the end of the final
awakening. The total recording time comprises the trace alternant An encephalographic pattern that
TOTAL SLEEP TIME, including stages non-REM and is characterized by bursts of slow waves inter-
REM sleep, and episodes of wakefulness and move- mixed with sharp waves alternating with periods
ment time that occur until the lights are on; arousal of relative low amplitude activity. This particular
time; or ARISE TIME. EEG pattern is characteristically seen in the sleep
of newborns. (See also INFANT SLEEP.)

total sleep episode The duration of the major

sleep episode, which usually occurs at night. This tracheostomy Regarded as the most effective
is the total amount of time available for sleep, and surgical treatment for OBSTRUCTIVE SLEEP APNEA
typically it is approximately eight hours in dura- SYNDROME; involves placing a hole in the trachea
tion. The total sleep episode includes REM sleep and inserting a tube so that the upper airway is
and NON-REM-STAGE SLEEP, as well as periods of bypassed when the individual breathes. The tra-
WAKEFULNESS that occur during the time available cheostomy typically is closed during the daytime
for sleep. (See also TOTAL RECORDING TIME, TOTAL and open at night so that sleep-related UPPER AIR-
SLEEP TIME.) WAY OBSTRUCTION does not occur.
252 tranquilizers

Tracheostomy is reserved for patients with severe apply to agents with very mild effects, the term is
sleep apnea syndrome who are unable to be treated best avoided. The terms antipsychotic and antianxiety
effectively by medical and nonsurgical means. The mediations are preferred. (See also ANXIETY DISOR-
most effective alternative nonsurgical treatment is DERS, HYPNOTICS, PSYCHIATRIC DISORDERS.)
by means of a CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP) device. Some patients, for varying reasons,
are unable to use such a system, and tracheostomy transient insomnia Insomnia that is differenti-
may be considered if their obstructive sleep apnea ated from SHORT-TERM and LONG-TERM INSOMNIA.
is severe enough. These terms were generally publicized as a result
Immediately following the placement of the tra- of a National Institutes of Health consensus devel-
cheostomy, patients with severe obstructive sleep opment conference that was convened by the
apnea notice a dramatic improvement in terms of National Institute of Mental Health and the Office
the quality of sleep at night and relief of daytime of Medical Applications of Research in November
sleepiness. There are improved objective clinical of 1983. The summary statement of the conference
features, such as improved oxygen saturation dur- suggested that the term “transient insomnia” be
ing sleep, reduced CARDIAC ARRHYTHMIAS, improved applied to normal sleepers who experience acute
quality of sleep and objective evidence of improved stress or situational changes that lead to sleep dis-
daytime alertness. turbance that is temporary, lasting only a few days.
The complications of tracheostomy are primar- The term is synonymous with ADJUSTMENT SLEEP
ily the social difficulties of having a hole at the DISORDER and situational insomnia.
base of the neck. (Patients are unable to swim or
go into small boats where they might fall into the
water.) The complications of tracheostomy include transient psychophysiological insomnia See AD-
recurrent infections, development of granulation JUSTMENT SLEEP DISORDER.
tissue at the site of the tracheostomy, and recur-
rent irritation or cough. More severe problems,
such as tracheomalacia (a weakness of the tracheal treatment of sleep disorders Treatments for sleep
cartilage) may rarely occur. However, despite the disorders vary widely, just as the nature of the
potential complications, tracheostomy can be a disorders also vary. The most spectacular success is
dramatically effective and lifesaving treatment. in treating what is potentially the most dangerous
(See also HYOID MYOTOMY, MANDIBULAR ADVANCE- sleep disorder, the sleep apneas. It is common for
MENT SURGERY, SURGERY AND SLEEP DISORDERS, cases of sleep apnea to be so severe that a patient
UVULOPALATOPHARYNGOPLASTY.) is unable to sleep and breathe at the same time.
Airflow in such cases may become completely
obstructed as soon as the person falls asleep, and
tranquilizers Term introduced in the early it remains obstructed while the person sleeps. As a
1950s to characterize the calming effect of the result, a person may have to awaken every minute
medication reserpine. The tranquilizers are often or so in order to breathe. This means having over
divided into two groups, the major and the minor 60 obstructions per hour of sleep. Because each
tranquilizers. obstruction interrupts sleep, it is impossible to sleep
The major tranquilizers include medications, continuously, and severe daytime sleepiness results.
such as phenothiazines, that are often used to treat Even in such severe cases, however, the simple
the major psychiatric disorders. The minor tran- expedient of imposing mildly increased pressure on
quilizers are those that have lesser mind-altering the air that is being breathed (CONTINUOUS POSITIVE
effects and are primarily used for reducing anxiety, AIRWAY PRESSURE or CPAP) almost always results in
such as the BENZODIAZEPINE antianxiety agents. the disappearance of the obstructions and the nor-
As the term tranquilizer can apply to agents with malization of sleep. The pressure is developed by a
very marked effects on mood and thought, or can small blower, and the pressure is transferred to the
 treatment of sleep disorders 253

airway by an airtight mask that must be worn dur- and completed each morning. The log should also
ing sleep. Not only is airflow restored but also all provide information regarding bedtime and time of
of the physiological consequences of discontinuous arising, their regularity and their appropriateness.
breathing return to normal. These include elevated It is not appropriate, for example, for a 65-year-old
blood pressure and such life-threatening outcomes woman to spend eight hours trying to sleep, as
as heart attack and stroke. Of more immediate most older patients require less than seven hours.
benefit, snoring disappears along with daytime The excess time will inevitably be spent awake,
somnolence. Judging by the number and impor- probably frustrated and angry. A hypnotic medica-
tance of these benefits, CPAP is easily one of the tion cannot be expected to treat this problem or,
most beneficial treatments in medicine. Remark- for that matter, to increase the time spent sleeping
ably, the risks of CPAP are practically nonexistent. beyond the time needed. Difficult though it may
Lately, the benefits of CPAP or related techniques be, the regularity of sleep hours can usually be
have been extended even to nonobstructive sleep increased, even on weekends.
apneas (“central apneas”), which had been notori- Myriad varieties of insomnia may exist, but
ously resistant to treatment. all ultimately result from excessive arousal. The
Obstructive sleep apnea (OSA) is clearly a dis- physiological principles involved are those gov-
order for which there can be little opportunity erned by the ascending reticular arousal system.
for patient-directed treatment. The diagnosis may An arousing stimulus is generally one that has not
be suggested by such factors as age (mid-50s or previously been experienced—it is novel or threat-
over), obesity or neck circumference, gender (men ening in some way. In both cases, its salience lies
are more severely affected), history of snoring, in its significance as a harbinger of the need for an
and daytime sleepiness. Once suspected, however, imminent response by the organism. Thus, anxiety
definitive diagnosis of OSA rests on an accurate is a protracted state of need for action manifested,
assessment of sleep continuity and breathing pat- not only by disturbed sleep, but also other signs
tern. This requires instruments available only in of hyperarousal: easy startle, autonomic activa-
sleep laboratories, although devices for home use tion (vasoconstriction, elevated blood pressure and
are increasingly used. pulse, muscle tension), sensory (visual, auditory)
Once a diagnosis of sleep apnea is confirmed, hyper acuity, as if fight or flight might be required
the success of CPAP treatment depends on accu- at any minute. This state of preparedness is of
rate assessment of CPAP pressure. CPAP pressure course ill suited to states requiring relaxation, such
is adjusted while apneas are observed to disappear as falling asleep.
in the laboratory. Self-adjusting CPAP machines Converting a state of preparedness and tension
have become available, but are often less success- to a state conducive to sleep can be challenging,
ful than a correctly adjusted CPAP machine. Here especially in personalities predisposed to tension
again, there is limited scope for patient-directed and anxiety. Anxiolytic drugs may be helpful.
treatment. These include BENZODIAZEPINES such as lorazepam
Turning to INSOMNIA, difficulty initiating sleep (Ativan). Many sleep aides are benzodiazepines,
(DIS), and/or difficulty maintaining sleep (DMS), such as flurazepam (Dalmane), and they may work
both diagnostic tools and treatment methods offer mainly as an anxiolytics, but it is not clear whether
considerably more leeway to the nonspecialized newer hypnotic agents (zolpidem or Ambien) also
medical practitioner and the patient. For example, work this way. Besides anxiolytic drugs, behavioral
the development of increasingly effective and methods (progressive relaxation, yoga) have also
safe hypnotic drugs makes possible their indis- been developed. They require training and diligent
criminate use in what is sometimes a caricature practice to be effective. The required techniques
of the diagnosis-treatment process. Good medical are applied by practitioners of behavioral sleep
practice requires at least some effort at diagnosis. medicine who are usually psychologists.
The complaint, whether sleep DIS or DMS, should A particularly interesting form of sleep-onset
be quantified with a SLEEP LOG kept by the patient insomnia is the DELAYED SLEEP PHASE SYNDROME
254 triazolam

(DSPS). This condition afflicts school-age children are examples of treatments requiring exact medi-
who are habitually tardy in the morning owing to cal diagnosis in a sleep laboratory and prescription
extreme difficulty terminating sleep. At the same of medications that cannot be obtained other-
time, they have difficulty falling asleep before wise. Not all sleep disorders require this level of
midnight and often much later. Hence the entire expertise, however. The management of insomnia
period of sleep—onset at night and offset in the depends on patient effort and knowledge, both in
morning—is delayed probably as the result of an diagnosing such as sleep log, which may be essen-
anomaly of the circadian timing system for sleep tial to recognizing DSPS, and treating insomnia,
and wakefulness. The disorder is often disabling. for which behavioral treatment methods are often
Tardiness may be disruptive to schooling, and later successful and usually necessary. Sleep disorders
in life certain occupations may be effectively closed centers can therefore play a variety of roles. They
(construction trades, surgery). Treatment of DSPS are most important in the early stage of diagnosis
rests on resetting the biological clock backward. and management, when laboratory diagnosis may
MELATONIN can be helpful as long as it is adminis- be essential. Thus, for example, there is no sub-
tered several hours before the scheduled (desired) stitute for accurate recording of sleep and breath-
bedtime. Goggles that exclude blue light should be ing in cases of suspected sleep apnea. Even here,
worn at bedtime while exposure is encouraged to however, home recording techniques are being
full-spectrum sunlight immediately upon arising developed that may be most helpful in cases of
in the morning. Incidentally, the delayed hour of mild sleep apnea.
sleep onset and sleep offset can be corrected by Can sleep laboratories be avoided altogether, at
delaying both by approximately three hours each least in some cases? Yes, but the risks of missing a
day until sleep is occurring so late that it is earlier, severe case of sleep apnea must be weighed against
so to speak. Unfortunately this is only a short- the expense or inconvenience of spending a night
term correction. The new, earlier schedule must in the lab. Exact knowledge of the diagnosis and its
be rigorously enforced. The first late-night party severity may save a patient from unnecessary treat-
attended, for example, restores the delayed phase ment or cardiovascular disease that can sometimes
of sleep. Truly effective treatment of DSPS will be prevented with CPAP treatment. A sleep disor-
only be possible when its underlying mechanism ders center should at least be consulted. In doubtful
is understood. cases, a patient’s physician might be encouraged to
RESTLESS LEGS SYNDROME can now be treated suc- consult with a sleep expert.
cessfully in most cases with a medication termed a
dopamine receptor agonist. In our experience the
most effective drug of this class is pramipexole triazolam (Halcion) See BENZODIAZEPINES.
(Mirapex), probably because it binds most strongly
to the D3 receptor. A related drug, ropinirole
(Requip), binds to D2, D3, and opioid receptors. triclofos See HYPNOTICS.
REM BEHAVIOR DISORDER is a sleep disorder in
which REM-sleep related dreams are acted out
and can be observed and recorded. RBD may be tricyclic antidepressants See ANTIDEPRESSANTS.
explained by the activation of a pathway in the
brain stem. Fortunately, the nocturnal behaviors
can in most cases be inhibited with administration Tripp, Peter A 32-year-old New York City radio
of a benzodiazepine such as clonazepam. The same disc jockey who stayed awake for eight consecutive
is true for such abnormal nighttime behaviors as days as a fund-raising event for the March of Dimes
SLEEPWALKING. birth defects organization. Each day he performed
The last few disorders mentioned are examples his regular three-hour broadcasts, but he went
of successful treatment of sleep disorders that had without any sleep. By the fifth day, Tripp began
to remain untreated only a few years ago. They hallucinating and became increasingly paranoid. At
 type-1 oscillator 255

the end of his ordeal, Tripp slept for 13 consecutive is used for a better understanding of the cause of
hours. Although his psychotic-like thinking cleared IMPOTENCE. (See also IMPAIRED SLEEP-RELATED PENILE
up after he slept, Tripp was slightly depressed for ERECTIONS, NOCTURNAL PENILE TUMESCENCE TEST,
several months, possibly linked to his SLEEP DEPRI- SLEEP-RELATED PAINFUL ERECTIONS, SLEEP-RELATED
VATION ordeal. (See also SLEEP NEED.) PENILE ERECTIONS.)

TRT See TOTAL RECORDING TIME. twitch A very small body movement such as
a foot or finger jerk. A body twitch during sleep
is not usually associated with an arousal but is
trypanosomiasis See SLEEPING SICKNESS. consistently detected either visually or by electro-
myographic recordings. Body twitches are common
during normal sleep, particularly of infants. These
tryptophan See HYPNOTICS. movements are often myoclonic jerks, and when
they occur in great frequency in neonates the dis-
order BENIGN NEONATAL SLEEP MYOCLONUS may be
TST See TOTAL SLEEP TIME. present. In adults, twitches can occur at sleep onset
and are then termed SLEEP STARTS, particularly if
they are associated with a whole body movement.
tumescence Term used for the engorgement of
the penis that occurs in relationship to sexual
excitement or REM sleep at night. A measure of the type-1 oscillator See ENDOGENOUS CIRCADIAN
ability of the penis to obtain adequate tumescence PACEMAKER.
 U
ulcer See PEPTIC ULCER DISEASE. vidual has some reduction in level of alertness,
with decreased awareness of the environment.
Such patients may have EXCESSIVE SLEEPINESS or
ultradian rhythm Rhythms that have a cycle DROWSINESS.
length of fewer than 24 hours’ duration. The term The term STUPOR is often applied to a loss of
is used for biological rhythms that occur with a responsiveness in which the individual can be
higher frequency than the 24-hour sleep-wake aroused only by very strong and vigorous stimuli.
cycle, such as respiratory or cardiac rhythms. Bio- The patient may be in deep sleep with slow wave
logical rhythms that have a period length greater activity from which it is difficult to be aroused.
than 24 hours (such as the MENSTRUAL CYCLE) are After arousal, such subjects typically will lapse back
known as infradian rhythms. (See also CHRONOBIOL- into the unresponsive state. This condition is often
OGY, CIRCADIAN RHYTHMS.) associated with organic cerebral dysfunction; how-
ever, severe schizophrenia or DEPRESSION can lead
to a similar state. (See also DEMENTIA, PSYCHIATRIC
unconsciousness A mental state in which there DISORDERS.)
is loss of responsiveness to sensory stimuli. States
of unconsciousness can be produced by metabolic,
pharmacologic or intracerebral lesions. Patients Unisom (doxylamine) See OVER-THE-COUNTER
who are unconscious are usually in COMA; how- MEDICATIONS.
ever, impaired levels of consciousness may be pres-
ent with intact sleep-wake cycling and retention of
some responses to stimuli. upper airway obstruction Term applied to
The term “clouding of consciousness” is often obstruction that typically occurs during sleep and
applied to reduced states of wakefulness and is associated with the OBSTRUCTIVE SLEEP APNEA SYN-
awareness in which the patient may be responsive DROME. Obstruction can occur anywhere from the
to external stimuli but has a variation in the level nose to the larynx and may not be evident during
of attention, with hyperexcitability and irritability, wakefulness. Causes of such obstruction include
that alternates with episodes of drowsiness. More a very narrow nasal airway, enlarged adenoids or
advanced degrees of clouding of consciousness can tonsils, an elongated soft palate, and obstruction at
produce a confusional state in which there is dif- the base of the tongue by tongue tissues, includ-
ficulty in following commands. A state of DELIRIUM ing the lingual tonsil (tonsil sometimes found
is characterized by disorientation, fear, irritabil- at the base of the tongue). Predisposing condi-
ity and a misperception of stimuli. Such patients tions to upper airway obstruction include skeletal
frequently will have visual hallucinations that abnormalities such as a posterior-placed lower jaw
can alternate with periods when the mental state (retrognathia).
appears intact. Surgery or appliances, such as a CONTINUOUS
The term OBTUNDATION often applies to an POSITIVE AIRWAY PRESSURE (CPAP) device, can
impairment of full consciousness where the indi- relieve the upper airway obstruction during sleep

256
 uvulopalatopharyngoplasty 257

and resolve the clinical features associated with the was introduced into the United States by Shiro
obstructive sleep apnea syndrome. (See also HYOID Fujita in 1979 as an alternative to TRACHEOSTOMY
MYOTOMY, MANDIBULAR ADVANCEMENT SURGERY, for the treatment of the OBSTRUCTIVE SLEEP APNEA
ORAL APPLIANCES, SURGERY AND SLEEP DISORDERS, SYNDROME. The surgical procedure for uvulopala-
TONSILLECTOMY AND ADENOIDECTOMY, TRACHEOS- topharyngoplasty involves the removal of redun-
TOMY, UVULOPALATOPHARYNGOPLASTY.) dant and excessive tissue from the pharynx in
order to prevent UPPER AIRWAY OBSTRUCTION during
sleep. This surgical procedure shortens the soft
upper airway resistance syndrome (UARS) A dis- palate and removes the uvula and the anterior
order consisting of an increased effort of breathing and posterior pillars of the fauces that attach to
during sleep which produces an arousal that results the soft palate. The tonsils, if present, are usually
in sleep fragmentation and subsequent daytime removed.
sleepiness. These arousals occur in the absence of UPP is a widely used procedure for the treat-
APNEAS, HYPOPNEAS, and oxygen desaturation. The ment of snoring and the obstructive sleep apnea
presence of frequent arousals in a patient com- syndrome. However, studies have demonstrated
plaining of EXCESSIVE SLEEPINESS who does not have that only 40 percent to 50 percent of an unselected
apneas and hypopneas should raise suspicion that group of patients with obstructive sleep apnea
upper airway resistance syndrome is present. syndrome will respond to this procedure. Patients
The best way to document the pressure change who have been screened by means of upper airway
is by esophageal pressure monitoring. However, in studies have an increased operative success; how-
the absence of pressure monitoring an increased ever, the procedure is ideal for only 20 percent to
number of arousals (more than 10 per hour) dur- 30 percent of all patients who are evaluated for the
ing sleep is typically associated with this syndrome. obstructive sleep apnea syndrome.
Approximately 10 percent of all breaths have nega- Potential complications of the surgical procedure
tive intrathoracic pressures (less than -10 centime- include insufficiency of the palate closure so that
ters of water). Ten percent of all breaths involve an fluids being swallowed may be regurgitated into
increased effort that is greater than two standard the nose. (But this complication rarely occurs if the
deviations of the value monitored during quiet patient is well screened beforehand and an exces-
relaxed breathing. (See also OBSTRUCTIVE SLEEP sive amount of tissue is not removed.) Other com-
APNEA SYNDROME.) plications of uvulopalatopharyngoplasty are those
related to anesthesia and other nonspecific surgical
complications. Two new forms of palatoplasty have
upper airway sleep apnea See OBSTRUCTIVE SLEEP been developed: LASER UVULOPALATOPLASTY and
APNEA SYNDROME. radiofrequency palatoplasty (see SOMNOPLASTY).
These procedures have the advantage of being able
to be performed in a physician’s office without the
uvulopalatopharyngoplasty (UPP) A surgical need for general anesthesia. (See also HYOID MYOT-
procedure that was developed by Tanenosuke Ike- OMY, MANDIBULAR ADVANCEMENT SURGERY, SURGERY
matsu in 1964. This surgical procedure was first AND SLEEP DISORDERS, TONSILLECTOMY AND ADENOID-
used in Japan for the treatment of SNORING and ECTOMY, TRACHEOSTOMY.)
 V
Valium (diazepam) See BENZODIAZEPINES. blood gas impairments. Other disorders, such as
KYPHOSCOLIOSIS and intrinsic lung disease, can also
have impaired ventilation during sleep.
VAS See VISUAL ANALOGUE SCALE. Treatment of sleep-related breathing disor-
ders may involve weight reduction (see OBESITY),
assisted ventilatory devices, such as a positive pres-
vasointestinal polypeptide (VIP) A peptide iso- sure ventilator or CONTINUOUS POSITIVE AIRWAY PRES-
lated in 1972 that contains 28 amino acid residues. SURE (CPAP) device, or upper airway surgery, such
It is a naturally occurring peptide that is released as TRACHEOSTOMY or UVULOPALATOPHARYNGOPLASTY.
into the cerebrospinal fluid. Studies have shown (See also SURGERY AND SLEEP DISORDERS.)
VIP to be associated with an increase in wakeful-
ness; however, in high doses it appears to be able
to induce REM sleep. ventricular arrhythmias Also known as ventricu-
VIP is present in several regions in the central lar premature contractions, ventricular tachycar-
nervous system and is located with the neurons dia, ventricular flutter and ventricular fibrillation.
that contain ACETYLCHOLINE. The effects of vasoin- Ventricular arrhythmias are commonly seen in
testinal polypeptide are similar to the effects of ace- association with SLEEP-RELATED BREATHING DISOR-
tylcholine in inducing wakefulness and REM sleep. DERS, particularly at the end of an apneic episode
(See also SLEEP-INDUCING FACTORS.) when tachycardia (abnormally rapid heartbeat) is
seen. The ventricular arrhythmias can reduce in
frequency or be eliminated following the treatment
venlafaxine (Effexor) See ANTIDEPRESSANTS. of the sleep-related breathing disorder. Studies
have demonstrated that the frequency of ventricu-
lar arrhythmias in sleep can vary; some reports
ventilation Movement of air in and out of the show a decrease of ventricular arrhythmias during
lungs. Ventilation can be impaired by a number of sleep, and others an increase in frequency of such
disorders that affect the central nervous system, episodes.
and the nerves and muscles involved in the chest Studies on patients with chronic obstructive
mechanics. Several SLEEP-RELATED BREATHING DISOR- respiratory disease have demonstrated that ventric-
DERS, such as OBSTRUCTIVE SLEEP APNEA SYNDROME, ular arrhythmias seen during sleep can be reduced
CENTRAL SLEEP APNEA SYNDROME, CENTRAL ALVEOLAR by the administration of supplemental oxygen,
HYPOVENTILATION SYNDROME, and CHRONIC OBSTRUC- suggesting that HYPOXEMIA is directly related to
TIVE PULMONARY DISEASE, can affect ventilation. these arrhythmias. The effect of hypoxemia in
Ventilation abnormalities during sleep can lead to inducing cardiac arrhythmias may be by a direct
ALVEOLAR HYPOVENTILATION (abnormal arterial blood mechanism of ischemia upon the cardiovascular
gases during the daytime, with HYPOXEMIA and system, or may be indirect, through the stimula-
HYPERCAPNIA). Relief of the sleep-related breathing tion of catecholamines such as adrenaline. Also,
disorder can lead to resolution of these daytime RESPIRATORY STIMULANTS may exacerbate the CAR-

258
 ventrolateral preoptic nucleus 259

DIAC ARRHYTHMIAS seen in patients with CHRONIC tricular premature contractions that are associ-
OBSTRUCTIVE PULMONARY DISEASE. ated with sleep-related breathing disorders resolve
Ventricular arrhythmias of the ventricular once the breathing disorder has been treated, and
tachycardia, flutter or fibrillation type are medical therefore additional treatment is not required.
emergencies that require active intervention. Anti- However, the presence of frequent ventricular pre-
arrhythmic medications, such as beta-blockers, mature contractions, or the inability to completely
verapamil, or quinidine-like medications, may be resolve the sleep-related breathing disorder, may
useful in suppressing or preventing such arrhyth- make treatment with antiarrhythmic medications
mias. Because of the increased incidence of ven- necessary. Medications used in this setting could
tricular arrhythmias in patients with sleep-related include the beta-adrenergic blockers. Other medi-
breathing disorders, stimulant medications should cations that may be required include quinidine
not be given to treat the excessive sleepiness. (See or quinidine-like medications. (See also CENTRAL
also DEATHS DURING SLEEP, EXCESSIVE SLEEPINESS, SLEEP APNEA SYNDROME, DEATHS DURING SLEEP, MYO-
OBSTRUCTIVE SLEEP APNEA SYNDROME, SLEEP-RELATED CARDIAL INFARCTION, SLEEP-RELATED CARDIOVASCU-
CARDIOVASCULAR SYMPTOMS, VENTRICULAR PREMA- LAR SYMPTOMS.)
TURE COMPLEXES.)

ventricular premature contractions See VEN-

ventricular fibrillation See VENTRICULAR ARRHYTH- TRICULAR ARRHYTHMIAS.
MIAS.

ventricular tachycardia See VENTRICULAR

ventricular flutter See VENTRICULAR ARRHYTHMIAS. ARRHYTHMIAS.

ventricular premature complexes Also known as ventrolateral preoptic nucleus A nucleus

premature ventricular contractions; very common believed to be important in the control of CIR-
arrhythmias that occur in patients with or without CADIAN RHYTHMS. There are two groups of neu-
heart disease. These complexes are commonly seen rons responsible: the intergeniculate leaflet (IGL)
during polysomnographic monitoring of patients. and the dorsal SUPRACHIASMATIC NUCLEUS (SCN);
In those patients without cardiorespiratory disease, and the cells in the ventrolateral preoptic area
the premature ventricular contractions are usually (VLPO).
benign and not associated with any increased inci- It appears that sleep-activated VLPO neurons
dence in mortality or morbidity. innervate the tuberomammillary nucleus of the
However, ventricular premature complexes can posterior hypothalamus to modulate arousal. The
commonly occur in association with SLEEP-RELATED neurons of the VLPO innervate cell bodies and
BREATHING DISORDERS, such as OBSTRUCTIVE SLEEP proximal dendrites of histaminergic cells in the
APNEA SYNDROME. Typically, a pattern of brady- ipsilateral tuberomammillary nucleus (TMN).
cardia (slow heart rate), followed by tachycardia These histaminergic neurons are involved in the
(fast heart rate), is seen in these disorders. The posterolateral hypothalamic arousal system. They
tachycardia phase occurs at the end of the apneic are tonically active during waking, become less
episode, during the hyperventilation portion of the active during SLOW WAVE SLEEP, and cease firing
apnea. The ventricular premature complexes seen in REM sleep. It is believed that the histaminergic
at this time can also be associated with the tachy system is inhibited during sleep by GABA-ergic
arrhythmias of ventricular tachycardia, which is input from the VLPO. Recent research has sug-
defined as three or more consecutive ventricular gested that the medication MODAFINIL, which is
contractions. Ventricular tachycardia imposes an used for the treatment of NARCOLEPSY, may act by
increased risk of sudden death. Usually the ven- means of VLPO.
260 vertex sharp transients

vertex sharp transients Rapid ELECTROENCEPHALO- flashes) studies and letter sorting tasks. These tests
GRAM (EEG) waves that occur either spontaneously determine the ability to concentrate and adequately
during sleep or in response to a sensory stimulus. perform the task at hand.
They are characterized by a sharp negative poten- Other electrophysical means of determining
tial, which is maximal at the vertex of the head. alertness include MULTIPLE SLEEP LATENCY TESTING
The amplitude of these negative potentials varies (MSLT) and MAINTENANCE OF WAKEFULNESS TESTING
but rarely exceeds 250 microvolts. Vertex sharp tran- (MWT), which involve five nap opportunities and
sient is preferred to vertex sharp wave. measure SLEEP LATENCY on each nap. Evoked poten-
tial (an electroencephalographic wave response)
measurements by means of an auditory stimulus
vertex sharp wave See VERTEX SHARP TRANSIENTS. show changes consistent with alterations in levels
of alertness. Computerized electroencephalography
with analysis by power spectra can determine the
vigilance Term first proposed by Henry Head in presence of electroencephalographic slowing con-
1923 to refer to the physiological state of the cen- sistent with a change in the level of alertness.
tral nervous system. With the development of an
understanding of the reticular activating system,
the term became indicative of the level of arousal. viloxazine See NARCOLEPSY.
Vigilance is now used synonymously with ALERT-
NESS and is the opposite of SLEEPINESS.
Impaired vigilance may be due to reduced VIP See VASOINTESTINAL POLYPEPTIDE (VIP).
central nervous system functioning as a result of
increased sleepiness brought about by reduced
visual analogue scale (VAS) Scale that gives a
quality or quantity of nighttime sleep. Disorders
quick subjective assessment of ALERTNESS or SLEEPI-
of unknown cause, such as NARCOLEPSY and IDIO-
NESS. The visual analogue technique has been used
PATHIC HYPERSOMNIA, are associated with impaired
in research since the 1920s and is frequently admin-
vigilance and EXCESSIVE SLEEPINESS.
istered for rating sleepiness or alertness in sleep
Tests of vigilance can be made either by perfor-
research. The analogue scale consists of a straight
mance measures, such as the WILKINSON AUDITORY
line that represents the range of alertness from very
VIGILANCE TEST, or by means of electroencephalo-
sleepy, at one end, to very alert, at the other. Sub-
graphic testing for patterns consistent with sleepiness
jects mark on the line the position that adequately
or DROWSINESS, such as the MULTIPLE SLEEP LATENCY
represents their status at a particular time. The dis-
TEST. (See also AROUSAL, ASCENDING RETICULAR ACTI-
tance from the left end of the line is measured and
VATING SYSTEM, SUBWAKEFULNESS SYNDROME.)
recorded in arbitrary units for comparison with the
patients’ state at another point in time.
The VAS scale of alertness is frequently used
vigilance testing Tests of vigilance to assess the
in studies of shift work, time of day effects, sleep
level of alertness during the period of wakefulness
loss and in chronobiological research. (See also
as applied in clinical or research settings. Tests may
CHRONOBIOLOGY.)
be subjective, by rating scales such as the STANFORD
SLEEPINESS SCALE or the VISUAL ANALOGUE SCALE.
However, most vigilance testing involves some Vivactil (protriptyline) See ANTIDEPRESSANTS.
physiological measure, such as the determination
of pupil diameter by PUPILLOMETRY. (The pupil is
very sensitive to changes in ALERTNESS and becomes Vivarin See OVER-THE-COUNTER MEDICATIONS.
smaller as the level of alertness decreases.)
Other tests involve reaction time tests, such as
flicker fusion (rapid alternating pattern of light VPCs See VENTRICULAR PREMATURE COMPLEXES.
 W
wakefulness A brain state that occurs in the studies. The beneficial effect of a warm bath is
absence of sleep in an otherwise healthy individual. attributed to raising both the core body TEMPERA-
It is the state of being awake that is characterized by TURE and the more peripheral skin temperature.
EEG wave patterns dominated by ALPHA RHYTHM, or
electrocortical activity, between 8 Hz and 13 Hz. This
weight Weight plays an important part in exac-
alpha activity is most pronounced when the eyes are
erbating some sleep disorders. OBSTRUCTIVE SLEEP
closed and the subject is relaxed. Infants tend to have
APNEA SYNDROME more commonly occurs in persons
a slower rhythm of about 4 Hz at four months of age,
who are overweight, and weight reduction can be
and this increases in frequency with age. The wake-
associated with an improvement in the symptoms
fulness rhythm is about 6 Hz at about 12 months of
of the syndrome. However, the amount of weight
age, 8 Hz at three years of age, and reaches 10 Hz to
loss required for improvement varies greatly. Some
13 Hz at 10 years of age. The alpha rhythm remains
individuals may lose 100 pounds without there
stable in adults; however, there is often a decline in
being any significant effect, whereas in others, five
the elderly, particularly in those with some degree of
or 10 pounds of weight loss may produce improve-
cerebral pathology. The amplitude varies from per-
ment. Most of the sleep-related breathing disorders
son to person, but most often amplitudes of 20 to 60
are worsened by weight gain.
microvolts are found (rarely, amplitudes above 100
The NOCTURNAL EATING (DRINKING) SYNDROME is a
microvolts can be seen). This wakefulness rhythm is
sleep disorder often associated with increasing body
thought to be of cortical origin.
weight. People with this disorder will awaken during
In addition to the characteristic alpha activity of
the night with a compulsion to eat or drink; most
wakefulness, there are also BETA RHYTHMS, which
of the day’s caloric intake may be taken during the
occur particularly with increased ALERTNESS, motor
hours of sleep. Those with the disorder often seek
activity and in response to environmental stimuli.
help in preventing the awakenings to eat in the hope
Wakefulness is often subdivided into quiet wake-
that this will lead to a reduction of body weight. (See
fulness, where an individual is resting in a relaxed
also CENTRAL ALVEOLAR HYPOVENTILATION SYNDROME,
condition, compared with a period of active wake-
DIET AND SLEEP, OBESITY, OBESITY HYPOVENTILATION
fulness, when the individual is more alert and may
SYNDROME, SLEEP-RELATED BREATHING DISORDERS.)
be engaged in talking or other motor activities.

Weitzman, Elliot D. One of the founders of

wake time The total time that is scored as wake-
the Association of Sleep Disorder Centers, Dr.
fulness during a polysomnographic recording. This
Weitzman (1929–83) was largely responsible for
period of wakefulness usually occurs between
writing its first policy guideline, the Certification
SLEEP ONSET and the final wake-up time, or final
Standards and Guidelines.
awakening.
Dr. Weitzman was chairman of the Department of
Neurology and director of the Sleep/Wake Disorders
warm baths Taking a warm bath just before sleep Center at Montefiore Medical Center. He founded its
may improve sleep, according to some scientific sleep disorders center, the first to be accredited, in

261
262 wet dream

1977, by the Association of Sleep Disorder Centers. documenting ALERTNESS and EXCESSIVE SLEEPINESS
He also founded and directed the Institute of Chro- during the day. In this test, the subject listens
nobiology at New York Hospital-Cornell Medical through headphones to a recording of a repetitive
Center and was professor of neurology in psychiatry, series of timed pips. These pips of sound are 500
Cornell University Medical College. milliseconds in duration, have a regular stimulus
He was editor of the eight-volume series of books interval of 1.5 seconds, and occur on a background
entitled Advances in Sleep Research, published by SP of “gray” noise. Occasionally, at unpredictable
Medical and Scientific Books. Weitzman is credited intervals, one of the tone pips is slightly shorter
with being an outspoken advocate for the disciplines in duration than the rest (approximately 400 mil-
of SLEEP DISORDERS MEDICINE and CHRONOBIOLOGY. liseconds). The subject has the task of detecting
An annual award is given in his name by the Asso- the shorter signals and indicating their presence
ciation of Polysomnographic Technologists (APT). by pressing a button. The test continues for 30
minutes and is analyzed in terms of the signals cor-
rectly detected, the number of erroneously pushed
wet dream See NOCTURNAL EMISSION. buttons, and the reaction time from the presenta-
tion of the stimulus to the response.
This test is mainly used for research purposes to
Wilkinson auditory vigilance testing Proven to determine levels of alertness and has little clinical
be one of the most sensitive performance tests in applicability.
 X–Z
Xanax (alprazolam) See ALPRAZOLAM; BENZO- zaleplon (Sonata) See HYPNOTICS.
DIAZEPINES.

zeitgeber See ENVIRONMENTAL TIME CUES.

xanthines See RESPIRATORY STIMULANTS.

zimelidine (Normud, Zelmid) See ANTIDEPRES-

X-oscillator See ENDOGENOUS CIRCADIAN SANTS.
PACEMAKER.

zolpidem (Ambien) See HYPNOTICS.

yawning An involuntary movement of the mouth
that occurs in humans as well as in such animals
as dogs, cats, crocodiles, snakes, birds, and even zopiclone (Lunesta) See HYPNOTICS.
some fish. A yawn begins with a slow inhalation
of air followed by a quicker expiration. Yawns may
signify sleepiness as well as stress or boredom.

263
 APPENDIX I
SOURCES OF INFORMATION

Since addresses, Web sites, and even names of asso- The Better Sleep Council (BSC)
ciations, organizations, or information resources 501 Wythe Street
may change at any time, accuracy of these listings Alexandria, VA 22314
cannot be guaranteed. Furthermore, a listing does http://www.bettersleep.org
not imply an endorsement of that information
resource nor should omission from this listing have British Sleep Society
any implications. P.O. Box 247
Colner, Huntingdon PE28 3UZ
American Academy of Sleep Medicine United Kingdom
(AASM) http://www.sleeping.org.uk
1 Westbrook Corporate Center
Suite 920 Center for Sleep Research
Westchester, IL 60154 Level 7
www.aasmnet.org Playford Building
University of South Australia
American Automobile Association (AAA)
City East Campus
Foundation for Traffic Safety
Frome Road
607 14th Street NW
Adelaide SA 500
Suite 201
Australia
Washington, DC 20005
www.unisa.edu.au/sleep
http://www.aaafoundation.org

American Insomnia Association Circadian™ Learning Center

1 Westbrook Corporate Center Circadian™ Technologies, Inc.
Suite 920 2 Main Street
Westchester, IL 60154 Suite 310
http://www.americaninsomniaassociation.org Stoneham, MA 02180
http://www.circadian.com
American Sleep Apnea Association
6856 Eastern Avenue NW Narcolepsy Institute
Suite 203 Sleep-Wake Disorders Center
Washington, DC 20012 Montefiore Medical Center
http://www.sleepapnea.org 111 East 210th Street
Bronx, NY 10467
Association for the Study of Dreams (ASD) http://www.narcolepsyinstitute.org
1672 University Avenue
Berkeley, CA 94703 Narcolepsy Network
http://www.asdreams.org 110 Ripple Lane

264
 Appendix I 265

N. Kingstown, RI 02852 Sleep Net

www.narcolepsynetwork.org http://www.sleepnet.com
National Center for Sleep Disorders Research Sleep Quest
National Institutes of Health 985 Industrial Road
NHLB1, Building 31, Room 4A11 Suite 200
9000 Rockville Pike San Carlos, CA 94070
Bethesda, MD 20892 http://www.SleepQuest.com
http://www.nhlbi.nih.gov/about/ncsdr/index.htm
Sleep Research Online
National Sleep Foundation
c/o WebSciences
1522 K Street NW
10911 Weyburn Avenue
Suite #500
Suite 348
Washington, DC 20005
Los Angeles, CA 90024
http://www.sleepfoundation.org
http://www.sro.org
Restless Legs Syndrome Foundation, Inc.
1610 14th Street NW Sleep Research Society (SRS)
Suite 300 1 Westbrook Corporate Center
Rochester, MN 55901 Suite 920
http://www.rls.org Westbrook, IL 60154
http://www.srssleep.org
SleepEducation.com
c/o American Academy of Sleep Medicine Society for Light Treatment and Biological
(AASM) Rhythms
http://www.sleepeducation.com http://www.sltbr.org
Sleep Home Pages World Federation of Sleep Research Societies
http://sleephomepages.com (WFSRSMS)
Sleep Medicine Home Page http://www.wfsrsms.org/
http://www.cloud9.net/~thorpy/
 APPENDIX II
RESEARCH ORGANIZATIONS

Since addresses, Web sites, and even names of asso- of Sleep Medicine. APSS organizes and implements
ciations, organizations, or information resources an annual national scientific and clinical meeting.
may change at any time, accuracy of these listings The association was specifically created to represent
cannot be guaranteed. Furthermore, a listing does the common interests of sleep researchers and sleep
not imply an endorsement of that information disorders medicine and to provide a single body
resource nor should omission from this listing have for representation to the general public and the
any implications. government. Dr. William C. Dement of Stanford
University was the first chairman of APSS.
American Narcolepsy Association (ANA)
P.O. Box 26230 Association of Polysomnographic
San Francisco, CA 94126 Technologists (APT)
(800) 222-6085 1 Westbrook Corporate Center
Suite 290
An independent, not-for-profit organization
Westchester, IL 60154
established in 1975 in the San Francisco Bay Area
http://www.aptweb.org
by nine people who suffered from narcolepsy.
Its purpose was to “improve the quality of living Founded in 1978 by Peter A. McGregor, chief
of persons who have narcolepsy.” By 1989 the polysomnographic technologist at the Sleep-
association member/donor base numbered more Wake Disorders Center of Montefiore Medical
than 4,000 persons, and ANA maintained contact Center in New York. An organizational meeting of
with more than 10,000 persons suffering from polysomnographic technologists was held in April
narcolepsy. ANA provided information and referral 1978 at the annual convention of the Association
services nationwide and provided funds for for the Psychophysiological Study of Sleep and the
narcolepsy-related sleep research. Volunteers were Association of Sleep Disorder Centers.
recruited for research projects; it provided direct The main aims of APT are to develop standards of
mail assistance for narcolepsy survey research. Its professional competence within the area of polysom-
governing board consisted of patients, scientists, nographic technology, to provide and administer a
and industry representatives. The executive director registration process for polysomnographic technolo-
of ANA was William Baird. The ANA ceased to gists, to help technologists develop the finest possible
function in the early 1990s and no longer exists. patient care and safety and produce the highest qual-
ity of polysomnographic data, to provide a means
Associated Professional Sleep Societies, LLC
of communication among technicians and others
(APSS)
working in the field of sleep disorders medicine and
1 Westbrook Corporate Center
sleep research, to support and advance the profes-
Suite 920
sional identities of technologists in health care, and
Westchester, IL 60154
to standardize polysomnographic procedures.
http://www.apss.org/
The Association of Polysomnographic Technolo-
Founded in 1985, a joint venture of the Sleep gists started with about 50 members in 1978 and by
Research Society (SRS) and the American Academy 1999 had increased its membership to almost 2,000.
266
 Appendix II 267

Nearly 3,000 technicians have passed the associa- Founded in 1971, the European Sleep Research
tion’s registration examination and are registered Society is the first international sleep society to
polysomnographic technologists (R.P.S.G.T.). be formed outside of the United States. Like the
Association for the Psychophysiological Study of
Belgian Association for the Study of Sleep
Sleep, founded in 1961 in the United States, the
(BASS)
European Sleep Research Society is devoted to
Sleep Disorders Centre
promoting sleep research and the development of
UZ Antwerpen
clinical sleep disorders medicine. The European
Wilrijkstraat 10
Sleep Research Society was one of four international
B-2650 Edegem
www.belsleep.org/pageview.aspx societies that jointly sponsored the bimonthly
journal Sleep, published by Raven Press. The
Founded in 1982, the Belgian Association for European Sleep Research Society now has its own
the Study of Sleep is one of a number of sleep journal, The Journal of Sleep Research, published by
societies that has been founded around the world Blackwell Press in the United Kingdom.
to promote sleep research and the development of
clinical sleep disorders medicine. The first society Federation of Latin American Sleep Research
to be founded outside the United States was the Societies (FLASS)
European Sleep Research Society in 1971. http://www.flass.icb.usp.br/index2.html

British Sleep Society (BSS) Founded in 1986, the Latin American Sleep Research
P.O. Box 247 Society is one of several sleep societies around the
Colne, Huntingdon world founded to foster sleep research and the growth
PE28 3UZ of clinical sleep disorders medicine. In the United
England, UK States, the Association for the Psychophysiological
www.sleeping.org.uk/ Study of Sleep was founded in 1961, and it
subsequently led to the Association of Professional
Founded in 1989, the British Sleep Society is one Sleep Societies. The Latin American Sleep Research
of the numerous international sleep associations Society is one of the four international societies that
founded to aid the growth of clinical sleep disorders originally sponsored the bimonthly journal Sleep.
medicine.
Japanese Sleep Research Society
Canadian Sleep Society Tatsuro Ohta, M.D., Ph.D.
Felicissimo, Rossie & Associates Professor and Director, Asian Sleep Research
C/O Canadian Sleep Society Society
1111 St. Urbain Department of Psychiatry, Child and Adolescent
Suite 116 Psychiatry and Psychobiology
Montreal, Quebec, Canada Nagoya University Graduate School of Medicine
H2Z 1Y6 65 Tsuruma-Cho, Showa-ku, Nagoya 466-8550
www.css.to/ Japan
Founded in 1986, the sleep society is one of several http://jssr.jp/
sleep societies around the world founded to promote Founded in 1978, one of a number of sleep societies
sleep research and clinical sleep disorders medicine.
developed around the world to assist sleep research
European Sleep Research Society and promote the growth of clinical sleep disorders
Neuropsychology and Functional Neuroimaging medicine. In the United States, the Association
Research Unit for the Psychophysiological Study of Sleep was
Université Libre de Bruxelles founded in 1961, and it subsequently led to the
Avenue F.D. Roosevelt 50 Association of Professional Sleep Societies. The first
B-1050 Bruxelles, Belgium society to be founded outside the United States was
www.esrs.eu/cms/front_content.php the European Sleep Research Society in 1978.
268 The Encyclopedia of Sleep and Sleep Disorders

Narcolepsy Institute work, as well as numerous other printed and taped

Montefiore Medical Center educational materials.
111 East 210th Street
Scandinavian Sleep Research Society
Bronx, NY 10467
http://www.narcolepsyinstitute.org Founded in 1985, the Scandinavian Sleep Research
Society is one of many sleep societies founded
A state-funded program developed in 1985 by
around the world to stimulate sleep research and
Michael Thorpy, M.D., at the Sleep-Wake Disorders
Center of Montefiore Medical Center in New York the growth of clinical sleep disorders medidne.
City; it provides support services to individuals In the United States, the Association for the
who have narcolepsy as well as to their families. Psychophysiological Study of Sleep was founded
Originally called the Narcolepsy Project, it was in 1961 and subsequently led to the Association of
renamed the Narcolepsy Institute in 1997. Professional Sleep Societies. The first society to be
The project serves all five boroughs of New York founded outside the United States was the European
City, with counseling and crisis intervention pro- Sleep Research Society in 1971.
grams for individuals or groups who are diagnosed Sleep Research Society (SRS)
as having, or suspected of having, narcolepsy. It 1 Westbrook Corporate Center
provides basic information and helps individuals Suite 920
and their families to develop skills necessary to Westchester, IL 60154
cope with the social and physical impact that this http://www.sleepresearchsociety.org/
condition has on their lives.
The project is directed and run by professionals Originally founded in Chicago in 1961 as the
in counseling; it also offers training in counseling Association for the Psychophysiological Study of
as well as research opportunities in the area of the Sleep. In 1983, the association changed its name
psychosocial factors of narcolepsy. The program to the Sleep Research Society, in part because the
produces educational materials for patients that society no longer primarily concerned itself with
include videotapes, patient handbooks, and a regu- the psychophysiological aspects of sleep research.
lar newsletter called Perspectives. The Sleep Research Society joined with the
American Sleep Disorders Association to form the
Narcolepsy Network federation called the Association of Professional
110 Ripple Lane Sleep Societies, which holds a combined annual
North Kingstown, RI 02852 meeting of sleep research.
http://www.narcolepsynetwork.org/
World Federation of Sleep Research and
Incorporated as a not-for-profit organization in 1986 Sleep Medicine Societies
and organized on a local, state, and national basis.
http://www.wfsrsms.org/index.aspx
Its motto, “CARE” (Communication, Advocacy,
Research and Education), embodies its goals of Founded in 1989 by the European Sleep Research
sharing information about narcolepsy, advocating Society, the Japanese Sleep Research Society, the
for needs at all levels, supporting and encouraging Latin American Sleep Research Society, and the
narcolepsy research, and helping to make the general Sleep Research Society (of the United States).
public aware of narcolepsy and its consequences. International meetings are held every two years.
Persons having narcolepsy, their families, The first congress was held in 1991.
friends, and those interested in narcolepsy and Programs include a sleep training workshop, a
related daytime sleepiness disorders are welcome training fellowship program, and an equipment
to attend meetings and to become active members. and general exchange program. The first president
The organization publishes a newsletter, The Net- was Michael H. Chase, Ph.D., of the United States.
 APPENDIX III
SELECTED SLEEP CENTERS

ALABAMA 3rd Floor

Stamford, CT 06902
Sleep Disorders Center
Children’s Hospital Yale Center for Sleep Medicine
1600 Seventh Avenue South Temple Medical Center
Birmingham, AL 35233 40 Temple Street, Suite 3C
www.chsys.org New Haven, CT 06510

ARIZONA
FLORIDA
Banner Sleep Disorder Center
Banner Baywood Medical Center Florida Sleep Disorder Center on Oakfield
6644 E. Baywood Avenue 910 Oakfield Drive
Mesa, AZ 85206 Suite 101
Brandon, FL 33511
Banner Thunderbird Medical Center www.floridasleep.com
5605 W. Eugie Avenue
Suite 215 Florida Sleep Disorder Center on Swann
Glendale, AZ 85306 2111 West Swann Avenue
Suite 101
CALIFORNIA Tampa, FL 33602
www.floridasleep.com
Mercy Sleep Laboratory
6601 Coyle Avenue
Carmichael, CA 95606 ILLINOIS
Sleep Disorders Center Center for Narcolepsy, Sleep and Health
Scripps Clinic and Research Foundation Research
10666 North Torrey Pines Road University of Illinois at Chicago
La Jolla, CA 92037-1093 College of Nursing M/C802
845 South Damen Avenue
Sleep Disorders Center
Chicago, IL 60612
2340 Clay Street Suite 237
San Francisco, CA 94115
INDIANA
CONNECTICUT Methodist Hospital Sleep Center
Connecticut Center for Sleep Medicine Rehab Centers
Stamford Hospital 303 East 89th Avenue
30 Shelburne Road Merrillville, Indiana 46410

269
270 The Encyclopedia of Sleep and Sleep Disorders

MASSACHUSETTS 520 East 70th Street

Suite 607
The Center for Sleep Diagnostics New York, NY 10021
1400 Centre Street, #101 http://www.cornellphysicians.com/sleepctr/
Newton Centre, MA 02159
Sleep Medicine Program, Massachusetts Sleep Disorders Center
General Hospital (MGH) NYU Medical Center and School of Medicine
MGH Sleep Clinic 550 First Avenue
Wang Ambulatory Care Center, 835 New York, NY 10016
55 Fruit Street http://www.med.nyu.edu/sleep/
Boston, MA 02114
Sleep-Wake Disorders Center
Montefiore Medical Center
MINNESOTA 111 East 210th Street
Minnesota Sleep Institute (MSI) Bronx, NY 10467
Burnsville Sleep Disorders Center
501 Nichollet Boulevard East
Suite 250
PENNSYLVANIA
Burnsville, MN 55337 Sleep Disorders Center
http://www.minnsleep.com/ Thomas Jefferson University
1025 Walnut Street
Minnesota Sleep Institute (MSI)
Philadelphia, PA 19107
Edina Sleep Disorders Center
7450 France Avenue South
Suite 210 WISCONSIN
Edina, MN 55435
http://www.minnsleep.com/ Sleep Disorders Center of Wisconsin
2603 West Rawson Avenue
Suite 137
MISSOURI Oak Creek, WI 53154
Midwest Sleep Diagnostics
13975 Manchester Road Sleep Disorders Center of Wisconsin
Suite 9 Fairview Building
Manchester, MO 63011-4500 10425 W. North Avenue
Suite 147
Wauwatosa, WI 53226
NEW YORK
Center for Sleep Medicine
New York Presbyterian Hospital—Weill-Cornell
Medical Center
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 INDEX

Note: Boldface page numbers indicate extensive treatment of a topic.

A adenoids 5 sleep onset association disorder in

AAP. See American Academy of Pediatrics adenosine 5 223–224
AASM. See American Academy of Sleep ADHD 58 sleep terrors in 230–232
Medicine Adie, William John xxxvi sleepwalking in 232, 233
AAST. See American Association of Sleep adjustment sleep disorder 5 sudden unexplained nocturnal death
Technologists anxiety in 5, 24, 25 syndrome in 43, 44, 244
abnormal swallowing syndrome 1 and excessive sleepiness 82 advanced sleep phase syndrome 6
accidents 1–2. See also drowsy driving as extrinsic disorder 83 causes of 113
DUI-related xlv, 2 and hypnotic-dependent sleep chronotherapy for 6, 51
narcolepsy and 140, 141 disorder 99 early morning arousal in 6, 74
sleep deprivation in xl, xlv psychophysiological insomnia and v. irregular sleep-wake pattern
sleepiness in 1–2 183 118–119
sleep terrors and 2, 231 as short-term insomnia 203 as persistent circadian rhythm sleep
sleepwalking and 2, 233–234 stress in 243 disorder 52
smoking and 147, 235 as transient insomnia 5, 252 as socially or environmentally
accreditation standards xxxviii, 2–3, adolescents 10–11 induced disorder 237
211 delayed sleep phase syndrome in 10, affective disorders 6, 21
accredited clinical polysomnographers 60–61, 213, 214 African Americans 95, 96, 142, 243
(ACPs) 3, 20, 52, 53 dreams in 70 age 6–13. See also adolescents; adults;
acetaminophen 165 drowsy driving by 71 children; elderly; infant(s)
acetazolamide 122, 194 erections during sleep in 70 agoraphobia 168, 183
acetylcholine 3, 156, 220, 258 in family residence xlii–xliii AIDS 240
acetylcholinesterase 3 growth hormone in 10, 92 airway obstruction 13–14. See also upper
achondroplasia 57 idiopathic hypersomnia in 105 airway obstruction
acid hemolysis test 170 narcolepsy in 10–11, 141, 213 akinetic mutism 54
aconitum radix 165 nocturnal emissions in 152 akinetic seizures 199
ACPs. See accredited clinical nocturnal sleep episodes of 154 alarm clocks xlvi
polysomnographers obstructive sleep apnea syndrome Alcmaeon xxi, xxii, xxviii
acquired immune deficiency syndrome in 10 alcohol 14
(AIDS) 240 recurrent hypersomnia in 188 in accidents xlv, 2
acromegaly 3–4, 41 as short sleepers 202 in ancient Egypt xix
acrophase 4 sleep deprivation in 211 as hypnotic 100
ACTH. See adrenocorticotrophin sleep disorders in 10–11 in inadequate sleep hygiene 107
hormone sleep patterns of 10–11, 163 for insomnia xix
actigraphy 4 stimulant abuse by 240 and obstructive sleep apnea
acting out dreams 191–192, 196, 208 adrenocorticotrophin hormone (ACTH) syndrome 2, 14, 161
action potentials xxxiii 5–6, 56 and REM rebound 190
activated sleep 174 Adrian, Lord 39 and sleep palsies 224
active sleep 4, 108–109, 163, 186 adults 11–12. See also elderly withdrawal from 14, 15
active wakefulness 261 food allergy insomnia in 88 alcohol-dependent sleep disorder 14–15,
activity monitors 4, 119 growth hormone in 12, 92 112
activity-rest cycle 4 nightmares in 148 alcoholism 14, 15, 61, 183
acupuncture xx nocturnal eating syndrome in 151 Aldrich, Thomas xxviii
acute mountain sickness. See altitude nocturnal sleep episodes of 154 alertness 15–16. See also wakefulness
insomnia parasomnias in 215 alcohol and 14
adaptive servo-ventilation (ASV) 4–5 REM sleep in 188 caffeine and 16, 73
Adderal. See amphetamines REM sleep percent in 193 drugs’ effects on 16, 73, 130–132
adenoidectomy 5, 245, 250–251 sleep duration in 216 nonrestorative sleep and 155

285
286 The Encyclopedia of Sleep and Sleep Disorders

in pregnancy 179 anatomy, history of field xxiii, xxv anxiety attacks, dream 67, 70
shift-work and 200 ancient era xvii–xxiii, 68 anxiety disorders 24–26, 182–183
as vigilance 260 Ancoli-Israel, Sonia 12–13, 206 affective disorders as 6
Alexander of Tralles xxiv Andrews, Robert 129 and insomnia l
allergies 24. See also food allergy anemia 170 v. laryngospasms 123
insomnia anemia theory of sleep xxix noctiphobia in 149
alpha activity 16 anesthesia xxxi v. panic disorders 24, 168
antidepressants’ effects on 22 angina, nocturnal 43–44, 150 v. psychophysiological insomnia 25
as background activity 32 angina decubitus. See nocturnal cardiac and sleep onset insomnia 224
in coma 54 ischemia stress in 243
discovery of 39 animal(s) 21 symptoms of 24–25, 44
in drowsiness 70–71 basic rest-activity cycle in 33 treatment of 17, 24, 25–26, 36, 38
in electroencephalogram 16–17, disease in xviii types of 24
32, 75 dreams of 69 AOP. See apnea of prematurity
in fibrositis syndrome 16, 17, 86 electronarcosis of 77 apallic syndrome 54
morphology of 137 evolution of xvii–xviii apnea 26, 208, 212. See also central sleep
in wakefulness 261 Factor S in 84 apnea syndrome; obstructive sleep
alpha coma 54 hibernation in 95 apnea syndrome
alpha-delta activity 16, 86 quiet sleep in 186 in altitude insomnia 17
alpha-difluoromethylornithine (DFMO) REM sleep deprivation in 210 apoptosis and 27
221 sleep in xvii–xviii, xxviii, xxix, 21, central alveolar hypoventilation
alpha intrusion 16 174 syndrome and 45
alpha rhythm 16–17, 39, 121, 261 yawning in 263 first descriptions of xxxii
alprazolam (Xanax) 17, 38, 115, 168 animal magnetism xxvii v. hypopnea 208
altitude insomnia 17, 83, 112–113, 194 animal spirits xxv, xxvi, xxxiii indexes of 26, 193
alveolar hypoventilation 17, 122, 175 anorectics 241 in infants 7, 26–27, 47, 109, 243
Alzheimer’s disease 62, 85 antianxiety agents 115, 209, 252 mixed form of 26, 208
Ambien (zolpidem) 17, 102 anticholinergic effects 3, 21, 22–23 monitoring of 26–27
ambulatory monitoring 18 anticonvulsants 80, 131, 199 of prematurity (AOP) 27, 110, 180,
American Academy of Pediatrics (AAP) antidepressants 21–24. See also specific 208
8, 243–244 types and SIDS 27, 47, 109, 243
American Academy of Sleep Medicine for cataplexy 21–24, 45, 140, 142 as sleep-disordered breathing 212
(AASM) 18–19 for depression 21–24, 63 snoring in xli
accreditation standards of 2–3, 123 for fibromyalgia 86 tachycardia in 247
in American Board of Sleep Medicine for mood disorders 136 treatment of, success in 206,
20 REM sleep deprivation caused by 252–253
awards of 19, 121 192 apnea-hypopnea index 26, 193
emblem of xx sedative effects of 132 apnea index 26
establishment of 18, 215 and serotonin 200 apnea monitors 26–27
examinations given by 52–53 side effects of 21–24 apnea of prematurity (AOP) 27, 110,
on self-medication 207 for sleep induction 72 180, 208
sleep center and lab listings of vii, ix types of 21–24 apoptosis 27
on sleep specialists 227 antidiuretics 10, 218 appetite
American Association of Sleep antihistamines 24 regulation of 91, 124, 159
Technologists (AAST) 19 as hypnotics 24, 102, 131 suppressants for 159, 241
American Board of Sleep Medicine 3, mechanism of 95 APSS. See Association of Professional
19–20, 206, 215 for nasal congestion 144 Sleep Societies
American Indians xxxii, 243 for sleep induction 72, 207 APT. See Association of
American Sleep Disorders Association sleepiness caused by 131 Polysomnographic Technologists
(ASDA). See American Academy of antipsychotics. See neuroleptics arachidonic acid 182
Sleep Medicine anxiety 24 ARAS. See Ascending Reticular
amitriptyline 22, 87, 132, 220 in adjustment sleep disorder 5, 24, Activating System
amphetamines 240–241 25 Arber, Sara xl–xli, xliii
alertness affected by 16, 240 and headaches 93 arginine vasotocin (AVT) 27–28
analeptic 21 in hyperarousal 96 Argonne anti-jet-lag diet 28
dependence on 239 hypnotics for 102 arise time
sleepiness affected by 131 in idiopathic insomnia 105 in delayed sleep phase syndrome 60
tolerance to 250 in insomnia l, li, liv, 253 erratic hours of 81
for weight loss 159 in pregnancy 179 in sleep patterns 225
amphibians 174, 175 in psychophysiological insomnia 24, in sleep restriction therapy 225
Anafranil. See clomipramine 25, 183 in sleep schedules 227
analeptics 20–21 and restlessness 196 Aristotle xxi, xxii, xxv, xxx, 68, 222
analgesics 86, 131 in sleep choking syndrome 209 armodafinil 28
 Index 287

arousal(s) 28 attention deficit disorder 11 bedroom(s)

in central alveolar hypoventilation attention deficit hyperactivity disorder children’s xliii
syndrome 45 (ADHD) 58 history of xvii, 33
in Cheyne-Stokes respiration 49 atypical antipsychotics 30, 146 master xliii, xliv
early morning 6, 63, 74 Aubert, Vilhelm xlii noise in 154–155
hyperarousal 96, 105 auditory vigilance testing, Wilkinson bedtime 34–35
internal 117 262 for adolescents 10
movement 137 autoCPAP 30–31 in advanced sleep phase syndrome
respiratory effort-related 194 autogenic training 31 6
in upper airway resistance syndrome automatic behavior 31, 98, 140–141 for children 8, 34–35
257 autonomic seizures 199 in limit-setting sleep disorder 34,
arousal disorders 28–29, 169. See also Avicenna xxiv 125–126
specific types AVT. See arginine vasotocin in sleep patterns 225
arrhythmias. See cardiac arrhythmias awakening(s) 31. See also wakefulness in sleep restriction therapy 225
art, dreams and 70 in advanced sleep phase syndrome in Sunday night insomnia 244–245
Artemidorus of Daldis xix 6 bed-wetting. See sleep enuresis
arthritis, rheumatoid 167 alcohol and 14, 15 behavior, automatic 31, 98, 140–141
artifact 29 alpha activity before 16 behavioral theories of sleep xxx, xxxii–
Ascending Reticular Activating System in anxiety disorders 24–25 xxxiii
(ARAS) xxxv, 29, 55, 96 in central alveolar hypoventilation behavioral treatments. See also insomnia
Aschoff, Jules xxxv–xxxvi syndrome 45 treatments; specific types
Aschoff, Jürgen xxxv, 247 in chronic obstructive pulmonary for mood disorders 1131
Asclepiades of Bithynia xxii disease 50 for snoring 181, 236
Asclepios xxi, xxiv in delayed sleep phase syndrome 60 Bekhterev, Vladimir Michailovitch
ASDA. See American Academy of Sleep dream recall after 190–191 xxxii–xxxiii
Medicine early morning. See early morning Belgian Association for the Study of
ASDC. See Association of Sleep Disorder arousal Sleep (BASS) xxxviii, 118
Centers in exploding head syndrome 83 belladonna xix
Aserinsky, Eugene xxxiii–xxxiv, xxxix, in infants 7–8 bellows pneumograph 194
29 from nightmares 70, 148 Benadryl. See diphenhydramine
on dreams 68, 190 in sleep fragmentation 219 Bendelow, Gillian xlii
on REM sleep 62, 121, 187, 228 in sleep maintenance insomnia 221 Benedict of Nursia xxiv
Asoka (Indian ruler) xix awakening epilepsies 31 benign epilepsy with Rolandic spikes
Association for the Psychophysiological awards 19, 45, 62, 121, 145, 238 (BERS) 35, 75
Study of Sleep xxxviii, 118, 215 benign epileptiform transients of sleep
Association of Polysomnographic B (BETS) 35, 71
Technologists (APT) xxxviii, 19, 215. babies. See infant(s) benign neonatal sleep myoclonus 7,
See also American Association of Sleep background activity 32 35–36, 110
Technologists back sleeping 8, 236, 243–244 benzodiazepine receptors 36, 101
Association of Professional Sleep Bacon, Francis xxv benzodiazepines 36–38. See also specific
Societies (APSS) xxxviii, 118, 145, Baekeland, Frederick 202 types
206, 215, 238 barbiturates 32 alertness affected by 131
Association of Sleep Disorder Centers v. benzodiazepines 32, 36, 37, 72 v. antihistamines 24
(ASDC) xxxvi, xxxviii, 2, 19, 64. disadvantages of 32, 72, 100 v. barbiturates 32, 36, 37, 72
See also American Academy of Sleep effectiveness of 72, 100 common uses for 36
Medicine GABA and 90 for confusional arousals 55
astasia 91 history of xxxvi, 100 effectiveness of 72
asthma 29–30, 57, 59, 194, 212 in hypnotic-dependent sleep disorder for fibromyalgia 86
astrology xxv 99 for fragmentary myoclonus 88
astronauts 58 recreational use of 72 GABA and 90
ASV. See adaptive servo-ventilation side effects of 32, 100 in hypnotic-dependent sleep disorder
asymptomatic polysomnographic sleepiness caused by 130 99
findings 30 soporific effects of 238 for insomnia 37–38, 253
athletes 83 bariatric surgery 32–33, 91, 161 introduction of xxxvi, 36, 100
atomism xxii, xxvi baseline 33 and REM-beta activity 190
atonia 30, 208 basic rest-activity cycle (BRAC) 4, 33 for restless legs syndrome 195
functions of 69–70 BASS. See Belgian Association for the for rhythmic movement disorder
in narcolepsy. See cataplexy Study of Sleep 197
in REM sleep xxxv, 30, 69–70, 189, baths, warm 247, 261 for short-term insomnia 203
208 bed(s) xvii, 33–34 side effects of 37, 100, 131
in REM sleep behavior disorder 189, family xliv, 84 sleepiness caused by 130
208 sleep surface of 230 for sleep starts 229
REM sleep without 69 smoking in 235 for sleep terrors 231
288 The Encyclopedia of Sleep and Sleep Disorders

soporific effects of 238 Braid, James xxxi and insomnia 65

as tranquilizers 252 brain. See also neurology as methylxanthine 194
types of 36–38 in central nervous system 46 in over-the-counter medications 165
bereavement xli, 39 in theories of sleep xxi, xxviii–xxxiiii and sleep starts 229
Berger, Hans xxxiii, 39, 227–228 brain stem CAHS. See central alveolar
Berger rhythm. See alpha rhythm in central apnea 46 hypoventilation syndrome
BERS. See benign epilepsy with Rolandic in central nervous system 29 Calkins, Mary 68
spikes in coma 54 Candolle, Augustin-Pyramus de xxxi
beta-blockers 97, 131, 132, 148, 168 in dreams 69 canthus 42, 77, 228
beta rhythm 36, 39, 75, 189–190, 261 pons of 69, 178 Cappie, James xxix
BETS. See benign epileptiform transients in theories of sleep xxx–xxxi, xxxv Cappuccio, Francesco xli
of sleep brain-wave rhythms 40 car accidents. See accidents
Bible xxiii–xxiv, 68 breath, shortness of. See dyspnea; carbamazepine 42, 153, 195, 199
biofeedback liv, 39, 189, 218 hypopnea; orthopnea carbimazol 97
biological clocks xxxv–xxxvi, 40 breathing. See ventilation carbohydrates 65
biological rhythms 51, 197. See also breathing disorders 40–41, 211–212, carbon dioxide 42–43
circadian rhythms 258. See also specific types in central alveolar hypoventilation
acrophase in 4 in adolescents 10 syndrome 45
v. biorhythms 40, 197 and alveolar hypoventilation 17 in central apnea 47
discovery of 129–130 carbon dioxide in 43 in Cheyne-Stokes respiration 49
free running 88, 109 cardiac arrhythmias and 44, 138 in chronic obstructive pulmonary
internal desynchronization of 117 cardiovascular symptoms and 43–44 disease 50
nadir of 139 in chronic obstructive pulmonary end-tidal 79
period lengths of 51, 173 disease 50 in hypercapnia 96
phase shifts in 173–174 coughing in 57 in periodic breathing 172
ultradian 256 and deaths during sleep 59 in theories of sleep xxx
biorhythms 40, 197 in elderly 12, 74 carbonic anhydrase 194
BiPAP 161 hypoxemia in 104 cardiac arrhythmias 43
biphasic sleep-wake pattern xviii, 225 in infants 7, 110–111, 180 bradycardia 40, 47, 167
bipolar disorder 135, 136, 182, 213 insomnia associated with 112 brady-tachycardia 43, 193
birds 174 in kyphoscoliosis 121–122 and breathing disorders 44, 138
bladder training exercises 218 laboratories for 123 in central alveolar hypoventilation
Blake, William 70 v. mood disorders 136 syndrome 45
blindness 69, 155 and myocardial infarction 138 in central apnea 47
blood in neuromuscular diseases 147 in chronic obstructive pulmonary
in central alveolar hypoventilation periodic breathing in 171 disease 50
syndrome 45, 46 plethysmography of 176 and deaths during sleep 59
movement of, discovery of xxvi treatment of 4–5, 41, 144, 181, in obstructive sleep apnea syndrome
in theories of sleep xxi, xxii, xxvii, 194–195 43, 167
xxviii–xxix types of 41 in REM sleep–related sinus arrest
blood cells, red 170, 176 ventricular arrhythmias and 258, 43, 193
bloodletting xviii, xix, xxiii, xxv 259 in sudden unexplained nocturnal
blood pressure, high. See hypertension Bremer, Frederic xxxiv death syndrome 244
blood sugar 96, 151 British Sleep Society (BSS) xxxviii, xli tachycardia 45, 165, 247
blue bloaters 50, 51 Broadbent, William Henry xxxii ventricular 43, 244, 258–259
blue light 40, 254 bromides xxxi, 100 ventricular premature complexes
Blumenbach, Johann Friedrich xxviii, bromocriptine 41, 182 259
xxix Broughton, Roger J. 28, 29, 54, 230 cardiac ischemia, nocturnal 43–44, 150
BMI. See body mass index Brown, Megan xliv cardiac medications 131
body clocks 40. See also biological clocks Brown-Sequard, Charles-Edouard xxx cardiac pacemakers 43, 167, 193
body fluids xix, xxi bruxism 41, 77, 208–209 cardiovascular disease 49
body mass index (BMI) 32–33, 159 BSS. See British Sleep Society cardiovascular symptoms 43–44
body movements. See movement(s) Bunning, Erwin xxxv carpal tunnel syndrome 44
bodyrocking 40, 94, 197 Carskadon, Mary A. xxxiv, liv, 44–45,
body temperature. See temperature C 137
body weight. See weight caffeine 42 cat(s) 21, 33, 69, 189
Boerhaave, Hermann xxviii adenosine receptors and 5 cataplexy 45, 140
Bootzin, Richard xxxvii, liii and alertness 16, 73 in adolescents 11
botany xxvi as analeptic drug 20–21 in children 213
Bouchard, Abel xxx dependence on 73 continuous state of 45, 140, 239
Boyle, Robert xxvi for drowsy driving 71 definition of xxxi, 45
bradycardia 40, 47, 167 drugs with 73 in diagnosis of narcolepsy 142
brady-tachycardia 43, 193 food and drinks with 42, 65, 73 emotional stimuli in 45, 140
 Index 289

origins of term xxxi Cheyne, John 49, 172 chronic insomnia. See long-term
symptoms of 140 Cheyne-Stokes respiration 4–5, 46–47, insomnia
treatment of 142 49, 55, 122 chronic obstructive pulmonary disease
antidepressants in 21–24, 45, childhood onset insomnia. See idiopathic 50–51
140, 142 insomnia coughing in 57
gamma-hydroxybutyrate in 72, children 8–10. See also adolescents; and hypoxia 104
90, 140, 142 infant(s) in overlap syndrome 164
serotonin reuptake inhibitors antidepressants for 23 polycythemia in 176
in 200 apnea monitors for 26–27 treatment of 166, 194
catatonia 45 asthma in 29 chronic paroxysmal hemicrania (CPH)
Catlin, George xxxii bedrooms of xliii 51, 93, 193
catnaps 21 bedtime for 8, 34–35 chronobiology xxvi–xxvii, xxxi, xxxv–
Caton, Richard xxxiii benign epilepsy with Rolandic spikes xxxvi, 51. See also circadian rhythms
CAT scan xxxii in 35 chronotherapy xxxvii, 6, 51, 58, 61
cave gout xviii bodyrocking in 40 Chuang Tzu xx
CBT. See cognitive behavioral therapy bruxism in 208, 209 cigarettes. See smoking
CCHS. See congenital central alveolar cataplexy in 213 cimetidine 171
hypoventilation syndrome central alveolar hypoventilation circadian pacemaker, endogenous 78, 167
CCK. See cholecystokinin syndrome in 45–46 in advanced sleep phase syndrome 6
CDC. See Centers for Disease Control and central apnea in 46 in circadian rhythm sleep disorders 52
Prevention confusional arousals in 9, 55 constant routine test of 55–56
Celsus, Cornelius xxii–xxiii delayed sleep phase syndrome in in delayed sleep phase syndrome 61
Centers for Disease Control and 60–61 discovery of role of 58
Prevention (CDC) 49, 65, 101 dreams of 69 as suprachiasmatic nuclei 78, 167,
central alveolar hypoventilation electrical status epilepticus of sleep 245
syndrome (CAHS) 45–46, 51, 109 in 75 circadian rhythms liv–lv, 51–52
central nervous system (CNS) 46 enuresis in 9–10, 217–218 in asthma 29–30
cerebral degenerative disorders in in family bed 84 of body temperature lv, 139
48–49 in family residence xlii–xliii cortisol and xxxvi, 30, 56–57
cholecystokinin in 49 food allergy insomnia in 88 definition of lv, 197
dopamine in 67 headbanging in 9, 94, 120 desynchronization of 63, 117
dreams and 68–69 head rolling in 94 discovery of xxvi–xxvii, xxxi, xxxv–
gamma-aminobutyric acid in 90 limit-setting sleep disorder in 8, 34, xxxvi, 51, 129–130
in narcolepsy 141 125–126, 148 in insomnia lv
in posttraumatic hypersomnia 178 naps in 139 melatonin in 132
serotonin in 200 night fears in 8, 147–148 of myocardial infarction 138
vasointestinal polypeptide in 258 nightmares in 8, 148 nadir of 139
vigilance of 260 noctiphobia in 149 origins of term 93
central nervous system depressants. See nocturnal eating syndrome in 151 period lengths of 51, 58
barbiturates obstructive sleep apnea syndrome in in reasons for sleep 223
central nervous system stimulants. See 9, 160, 245, 250–251 reversal of sleep and 196–197
stimulant(s) REM sleep in 8–9, 188 ventrolateral preoptic nucleus in 259
central sleep apnea syndrome 26, 46– seizures in 199 circadian rhythm sleep disorders 52,
47, 208, 212 sleep duration in 216 214. See also specific types
as breathing disorder 41 sleep onset association disorder in ambulatory monitoring of 18
in elderly 12, 47 8, 223 classification of 64
index of 26 sleep patterns of, development of discovery of xxxvii
in infants 47, 109, 111 8–9, 163 early morning arousal in 74
v. obstructive apnea 47 sleep terrors in 9, 214, 230–231 photoperiod in 174
as Ondine’s curse 162 sleepwalking in 9, 214, 232–234 as socially or environmentally
treatment of 47, 212 snoring in 181, 236 induced disorders 236–237
assisted ventilation in 4, 47, 144, tonsillectomy in 250–251 transient v. persistent 52, 64
162 toxin-induced sleep disorder in 251 treatment of 214
respiratory stimulants in 194 chimpanzees xviii types of 52, 64
cephalometric radiographs 48, 86, 160 China, ancient xx Circadian Theory of sleep 223
cerebral degenerative disorders 48–49 chloral hydrate 100, 101 circadian timing system 52
cerebrospinal fluid 28, 84, 102, 220 chlordiazepoxide 36 circasmedian rhythms 52
CFS. See chronic fatigue syndrome chlorpheniramine 131 Claparede, Edouard xxxiii
charley horse 152 choking 1, 44, 113, 168, 209 Cleansing Theory of sleep 222–223
Chase, Michael H. 49 cholecystokinin (CCK) 49, 65, 220 clinical polysomnographers 52
chemical theories of sleep xxx, xxxii choroid plexus xxx accredited 3, 20, 52, 53
Chester Beatty papyrus xix Christianity xxiv examinations taken by 52–53,
chest pain. See angina chronic fatigue syndrome (CFS) 49–50 221–222
290 The Encyclopedia of Sleep and Sleep Disorders

Clinical Sleep Society (CSS) xxxviii, 18, oxygen therapy with 166 v. non-24-hour sleep-wake syndrome
215 and pharynx 173 61, 155
clomipramine 22, 142 for snoring 236 as persistent circadian rhythm sleep
clonazepam 38, 191, 195 convulsions 56 disorder 52
clonidine 97, 131, 156, 220 coronary artery disease 150 photoperiod in 174
Cloud, David M. 145 Corpus Hippocraticum xxii reversal of sleep and 197
clouding of consciousness 256 cortisol xxxvi, 5, 30, 56–57, 92, 196 sleep onset insomnia in 224
club drugs 72 co-sleeping 8 as socially or environmentally
cluster headaches 53, 93 cot death 57 induced disorder 237
CNS. See central nervous system coughing 1, 50, 57 treatment of 61, 213, 253–254
cocaine 53, 239 CPAP. See continuous positive airway chronotherapy in 51, 58, 61
codeine 53, 57, 144 pressure light therapy in 10, 125
coffee 42 CPH. See chronic paroxysmal hemicrania delirium 61
cognitive behavioral therapy (CBT) “C” process. See circadian pacemaker delta sleep 61, 62
lii–liv, 101 cramps 57, 152, 232 delta sleep inducing peptide (DSIP)
cognitive effects of sleep states 53 craniofacial disorders 57–58 61–62
cognitive focusing 53–54 creativity, dreams and 69, 70 delta waves 61, 62, 75–77
cognitive theory of dreaming 93 Creutzfeldt-Jakob disease 85 Dement, William C. 62
Coleridge, Samuel Taylor 70 crib death 58 in American Board of Sleep Medicine
colic 7, 88, 110 Crick, Francis 223 20
collective unconscious 120 Critchley, Michael 121 on dream recall 190–191
color, in dreams 69, 93 CSS. See Clinical Sleep Society on naps 206
coma 54, 103, 138, 243, 251, 256 cuirass. See negative pressure ventilators on pathology of sleep xxxvi
complex partial seizures 79–80 Cushing’s syndrome 5–6 on REM sleep xxxiv, xxxix, 62, 121,
computerized axial tomography (CAT) cyclothymia 135 228
scan xxxii Cylert (pemoline) 58, 143, 171 on sleep deprivation 90, 209
conditioned insomnia xxxvii, 54 Czeisler, Charles A. xxxvi, 51, 58, 60 on sleep disorders medicine xxxviii,
conditioning xxxii–xxxiii, liii 216
confusion, nocturnal. See nocturnal D dementia 13, 62–63
confusion Dalmane. See flurazepam in elderly 74–75
confusional arousals 9, 29, 54–55, 231 Daly, Dan 242 nocturnal confusion in 62, 75, 150
congenital central alveolar dark, fear of 147, 149 v. sleepwalking 233
hypoventilation syndrome (CCHS) 45, Dark Ages xxiv–xxv treatment of 63, 146
109 Darwin, Charles 33 Democritus of Abdera xxii, xxvi
congestion theory of sleep xxvii, date rape drug 72, 90 dental appliances. See oral appliances
xxviii–xxix Davy, James George xxxi Deprenyl. See selegiline
congestive heart failure 55 daydreaming 59 depression 63
constant routine 55–56 daylight. See environmental time cues; in adolescents 11
continuous positive airway pressure light in delayed sleep phase syndrome 60
(CPAP) 56 day shift 201 dysthymia 73, 136
v. adaptive servo-ventilation 4–5 daytime sleepiness. See excessive early morning arousal in 63, 74
alcohol and 14 sleepiness in elderly 13
alternatives to 56 DDAVP 10 excessive sleepiness in 63, 136
nasal positive pressure ventilation deafferentation theory xxxiv–xxxv and impotence 106, 107
as 144 death(s) and insomnia xlix–l, 63, 182,
oral appliances as 163, 250 during sleep 13, 43, 59 212–213
surgery as 245 sleep associated with, in Bible xxiii major 135–136
tracheostomy as 252 sleepwalking and 2 and narcolepsy 136
autoCPAP 30–31 deep sleep 54, 59–60, 83. See also non- postpartum 180
for central alveolar hypoventilation REM-stage sleep; stage four sleep; stage v. recurrent hypersomnia 189
syndrome 46 three sleep REM density in 190
for central apnea 47 Dejerine, Joseph-Jules xxxiv REM sleep latency in 63, 192
for chronic obstructive pulmonary delayed sleep phase 60 in seasonal affective disorder 63,
disease 51 delayed sleep phase syndrome 60–61, 125, 198–199
development of xxxvii, 56 214 sleep deprivation and 192, 210
effectiveness of 206, 252–253 in adolescents 10, 60–61, 213, 214 symptoms of 63, 135–136
in elderly 13 causes of 61, 113 treatment of 63, 192, 210. See also
for hypoxemia 104 discovery of xxxvii, 60 antidepressants
for kyphoscoliosis 122 v. irregular sleep-wake pattern deprivation. See sleep deprivation
nasal congestion and 144 118–119 depth encephalography 63
for obstructive sleep apnea syndrome v. limit-setting sleep disorder 126 Descartes, René xxv, 175
xxxvii, 56, 161, 163, 166, 212 v. long sleepers 127 desensitization, systemic 246
 Index 291

desmopressin 218 Donders, Frans Cornelius xxix and disorders of excessive

Desoxyn. See methamphetamine dopamine 67, 182 somnolence 66
desynchronization dopamine agonists 67, 182, 195, 254 drowsiness caused by 71
of circadian rhythms 63, 117 doxylamine succinate 165 and drowsy driving 71
internal 117 dream(s) 68–70. See also nightmare(s); for elderly 74–75
desynchronized sleep 63–64, 228. See sleep terrors and growth hormone 92
also REM sleep acting out 191–192, 196, 208 and impaired erections 106
Dewan, Edmond M. 68 ancient views of xix, xx, xxii, 68 insomnia associated with 112
Dexedrine. See dextroamphetamine anxiety attacks in 67, 70 malingerers in search of 130, 229
dextroamphetamine 142, 240–241 in Bible xxiii–xxiv, 68 and nightmares 148
DFMO. See alpha- cognitive theory of 93 pharmaceutical. See medications
difluoromethylornithine color in 69, 93 placebo 175
diabetes mellitus 106, 107 content of 68, 69, 93 and prolactin 92
Diagnostic and Statistical Manual of Mental and creativity 69, 70 recreational use of 72, 130
Disorders xlix, 73 v. daydreaming 59 self-medication with 207
Diagnostic Classification of Sleep and diaries of 191 sleep disturbance caused by 12, 13
Arousal Disorders 64 in fatal familial insomnia 85 sleepiness caused by 72, 130–132
on circadian rhythm sleep disorders functions of 68–69, 70, 118 in sleep therapy 232
52 interpretation of 118 and sleepwalking 233
development of xxxvi, 156 Freud on 88–89, 118 soporific 238
on dream anxiety attacks 67 history of xix, xxxii, 68 tolerance to 250
major categories of 64, 66 Jung on 120 drunkenness, sleep 216
on psychophysiological insomnia lucid 70, 127 DSIP. See delta sleep inducing peptide
xxxvii manifest v. latent 89 D sleep 59, 228. See also REM sleep
revision of 64, 117, 156 mentation in 222 Du Bois-Reymond, Emil xxx
Diamox. See acetazolamide in narcolepsy 70, 140, 143 DUI-related accidents xlv, 2
diaries, dream 191. See also sleep logs and nocturnal emissions 151–152, Dürer, Albrecht xxv
diazepam 38 171 Durham, Arthur Edward xxix
Dickens, Charles physiological changes in xxxiii, 68, dustman 198
on apnea xxxi–xxxii, xxxvii, 158, 190 Duval, Marie Mathias xxix
159, 175 recall of 53, 68, 70, 190–191 dwarfism 57, 92
bed of 33 in REM rebound 190 Dynes, John Burton xxxvi
diet 65. See also food in REM sleep 68–70, 187, 190–191 dyspnea, nocturnal 43, 55, 150–151,
Argonne anti-jet-lag 28 in REM sleep behavior disorder 191– 170
weight loss through 158–159 192, 196, 208 dyssomnias 73, 83, 118
diethylpropion 241 sexual 70, 171 dysthymia 73, 136
diffuse activity 65 work-related stress in xlii dystonia. See nocturnal paroxysmal
Digitalis purpurea xxvii dream deprivation studies 62 dystonia
DIMS. See disorders of initiating and drinks
maintaining sleep; sleep maintenance with caffeine 42, 65, 73 E
insomnia in nocturnal eating syndrome 65, early morning arousal 6, 63, 74
dinosaurs xviii 91, 151 earplugs 154
diphenhydramine 24, 72, 165 driving, sleep 205. See also accidents; ECG. See electrocardiograph
disease drowsy driving echidnas xviii
classification of 156 dropsy xxvii ECoG. See electrocorticogram
evolution of xviii drowsiness 70–71 Economo, Constantin Von xxxiv, 78,
history of treatment of xviii–xx drowsy driving 71–72 103, 225
disorders of excessive somnolence accidents caused by xlv, 1–2, 71–72, ECT. See electroconvulsive therapy
(DOES) 64, 66, 216. See also excessive 145 Edison, Thomas A. xvii, xxxvii
sleepiness changes in attitudes toward xlv EDS. See excessive sleepiness
disorders of initiating and maintaining education of public about 72, education
sleep (DIMS) 64, 66–67, 221. See also 207–208 of patients with narcolepsy 143
insomnia Maggie’s Law on 71, 129 of public 207–208
disorders of the sleep-wake schedule. See by men v. women xli, 71 about drowsy driving 72,
circadian rhythm sleep disorders drug(s) 72–73, 130–132. See also specific 207–208
diurnal 67, 150 drugs and types of drugs by National Sleep Foundation ix,
divination xviii–xix alcohol combined with 14 72, 145, 207
DOES. See disorders of excessive alertness affected by 16, 73, 130– in Project Sleep 181
somnolence 132 EEG. See electroencephalogram
dog(s) xxxii, xxxiii, xxxvi, 21, 84 and confusional arousals 55 Effexor. See venlafaxine
dogmatism xxii for delayed sleep phase syndrome 60 Egan, P. 198
Doll, Erich xxxvii and dementia 62 Egas Moniz, Antônio xxxiv
292 The Encyclopedia of Sleep and Sleep Disorders

Egypt, ancient xviii, xix electronarcosis 77, 232 epochs 80

Ehret, Charles 28 electrooculogram (EOG) 77, 177 Epworth Sleepiness Scale (ESS) 16,
Eichler, Victor B. xxxv electrophysiology xxvii, xxxiii–xxxiv 80–81, 82
ejaculation during sleep. See nocturnal electrosleep 77–78, 232 Equalizer 81
emissions elements, four xxi erections during sleep 81, 171
Ekbom, K. A. 195 EMG. See electromyogram dreams and 70
Elavil. See amitriptyline emotional stimuli, in cataplexy 45, 140 in elderly 12
elderly 12–13, 74–75. See also adults Empedocles xxi impaired 106–107
advanced sleep phase syndrome in 6 EMS. See eosinophilia-myalgia syndrome nocturnal penile tumescence test of
amount of sleep needed by 204, 205 encephalitis, viral xxxiv 153–154, 171, 242
breathing disorders in 12, 74 encephalitis lethargica 78, 103, 225 painful 167–168
central apnea in 12, 47 encephalography, depth 63 plethysmography of 176
exploding head syndrome in 83 Endep. See amitriptyline in REM sleep 81, 106, 154, 171, 188
hypnotics for 74, 75, 99 endogenous circadian pacemaker. See Rigiscan and 197, 242
insomnia in 206 circadian pacemaker spontaneous 153
irregular sleep-wake pattern in 119 endogenous rhythm. See circadian erratic hours 81
as larks 123 pacemaker Errera, Leo xxx
naps in 13, 74 endoscopy 78, 85–86, 160, 237 ESES. See electrical status epilepticus of
restlessness in 196 end-tidal carbon dioxide 79 sleep
sleep restriction therapy for 226 enuresis. See sleep enuresis esophageal pH monitoring 81, 174
sleepwalking in 233 environmental sleep disorder 79, 83, esophageal reflux 81–82. See also
snoring in 181 154–155, 184 gastroesophageal reflux
time zone change syndrome in 250 environmental time cues 79 ESRS. See European Sleep Research
electrical status epilepticus of sleep absence of, effects of xxxv–xxxvi, Society
(ESES) 75, 199 51–52, 79, 129–130, 203, 247 ESS. See Epworth Sleepiness Scale
electroanesthesia 232 v. body clocks 40 estrogen 133
electrocardiograph (ECG) 8, 150, 160, in circadian rhythms 51–52, 63 eszopiclone 100–102
176 in circadian rhythm sleep disorders ethchlorvynol 101
electroconvulsive therapy (ECT) 77, 136 52 ethnicity
electrocorticogram (ECoG) 75 in delayed sleep phase syndrome 61 and narcolepsy 95, 96, 141, 142
electroencephalogram (EEG) 75–77 for infants 109 and nocturnal sleep episodes 154
alpha activity in 16–17, 32, 75 in irregular sleep-wake pattern 118 and siestas 203
alpha-delta activity in 16 in sleep hygiene 219 and sudden infant death syndrome
ambulatory monitoring in 18 temporal isolation from 247 243
background activity in 32 EOG. See electrooculogram and sudden unexplained nocturnal
beta activity in 39, 75 eosinophilia-myalgia syndrome (EMS) death syndrome 244
v. brain-wave rhythms 40 65, 72, 87, 101, 200 European Sleep Research Society (ESRS)
of coma 54 ephedra xx xxxviii, 118
delta waves in 61, 62, 75–77 Epicurus xxii, xxvi evening person (night owl) 82, 125–
depth 63 epidemics xxvi, xxviii 126, 165–166, 201
development of xxxiii, 39, 227–228 epilepsy(ies) 79–80 evening shift 82, 201
diffuse activity in 65 alcohol and 14 evolution xvii–xviii, 174–175
of drowsiness 70–71 awakening 31 excessive daytime sleepiness (EDS). See
of epilepsy 79, 80 benign, with Rolandic spikes 35, 75 excessive sleepiness
ESES pattern in 75 v. benign neonatal sleep myoclonus excessive sleep inertia 54
of fragmentary myoclonus 88 36 excessive sleepiness 82. See also
of hibernation 95 convulsions in 56 hypersomnia
hypnagogic hypersynchrony in 98 depth encephalography and 63 in accidents 1–2
of infant sleep 108–109 v. electrical status epilepticus of sleep in adults 11
K-complexes in 121 75 alcohol and 14, 15
morphology of 137 in infants 7, 36, 111 armodafinil and 28
in polysomnography 177 v. nocturnal paroxysmal dystonia caffeine and 42
rapid eye movements in 187 153 in central alveolar hypoventilation
REM-beta activity in 189–190 v. REM sleep behavior disorder 191 syndrome 46
of REM sleep 187 v. restlessness 196 central apnea and 46
of sleep onset 223 seizures in 79–80, 199 codeine and 53
sleep spindles in 227 sleep enuresis in 199 in delayed sleep phase syndrome 60
of slow wave sleep 235 v. sleep terrors 80, 199, 231 in depression 63, 136
theta activity in 75, 249 v. sleepwalking 79–80, 233 in disorders of excessive somnolence
trace alternant in 251 treatment of 38, 42, 80 66
vertex sharp transients in 260 types of 79–80 in encephalitis lethargica 78
of wakefulness 261 epinephrine 30 Epworth Scale of 16, 80–81, 82
electromyogram (EMG) 39, 77, 138, 177 episodes. See sleep episodes v. exhaustion 83
 Index 293

v. fatigue 85 fears. See night fears Freud, Sigmund xvii, 88–89

fragmentary myoclonus and 88 feeding intervals, infant 7, 33 The Interpretation of Dreams xxxii,
in idiopathic hypersomnia 105 females. See women xxxvi, xxxix, 68, 88, 118
in insufficient sleep syndrome 116 femoxetine 23 Jung and 120
irregular sleep-wake pattern and 119 Ferber, Richard 84, 85 on physiological changes during
in long sleepers 126 fiber-optic endoscopy 78, 85–86, 160 dreams xxxiii
and memory 124 fibromyalgia (FM) 86, 87 and psychoanalysis xxxvi, 89
in menstrual cycle 66, 132–133 fibromyositis syndrome. See fibrositis frontal lobe seizures 199
microsleep in 133 syndrome fugues, psychogenetic 233
multiple sleep latency test of 82, 137 fibrositis syndrome 16, 17, 22, 86–87, Fu Hsi xx
in narcolepsy 139–141 167 Fujita, Shiro xxxvii, 257
in obstructive sleep apnea syndrome Findley, Knox H. xxxvi Fuseli, Johann Heinrich 107
159–160, 212 fires, caused by cigarettes 147, 235
in Parkinsonism 169 first night effect 87, 106 G
in periodic limb movement disorder reversed 184, 197 GABA. See gamma-aminobutyric acid
172 Fischer, Franz xxxi Galbraith, J. J. xxxvi
in pregnancy 179 fish 174 Galen xxiii, xxiv
in recurrent hypersomnia 188–189 Fisher, Charles 62 Galson, Steven 152
in shift-work sleep disorder 200, 201 5-hydroxytryptamine (5HT) 87. See also Galvani, Luigi xxvii, xxxiii
sleep fragmentation and 219 serotonin gamma-aminobutyric acid (GABA) 36,
in sleeping sickness 221 5-hydroxytryptophan 87 37, 90, 134
excessive somnolence, disorders of Fleming, Alexander xxix gamma-aminobutyric acid (GABA)
(DOES) 64, 66 flicker fusion studies 260 receptors 36, 90, 101
exercise(s) 82–83 Flourens, Marie-Jean-Pierre xxviii, xxx gamma-hydroxybutyrate (GHB) 72, 90,
and body temperature l, 83, 247 flower-clock xxvi 140, 142
by elderly 13 fluoroscopy 237 Gangwisch, James 159
in inadequate sleep hygiene 107 fluoxetine 23 Gardner, Randy 90, 209–210
influence on sleep l, 82–83, 222 flurazepam 36, 37, 190 Garfield, Patricia 70
v. naps 206 fluvoxamine 24 Garfinkel, L. 202
relaxation. See relaxation FM. See fibromyalgia Gastaut, Henri xxxvii
exhaustion 83, 85 focal seizures. See partial seizures gastric bypass surgery 33
exorcism xxv Fogel, Stuart M. 239 gastroesophageal reflux (GERD) 90–91
exploding head syndrome 83 food 65. See also appetite; diet v. abnormal swallowing syndrome 1
extrinsic sleep disorders 83, 118 with caffeine 42, 65, 73 cardiovascular symptoms of 44
eye in Kleine-Levin syndrome 65, 121, diet and 65
canthus of 42, 77, 228 188 heartburn in 94
pupillometry of 16, 82, 185 and MAO inhibitors 135 laryngospasms caused by 123–124
eye movement(s) 83. See also rapid eye in nocturnal eating syndrome 65, in obstructive sleep apnea syndrome
movements 91, 151, 261 90–91, 160
in cerebral degenerative disorders 48 in recurrent hypersomnia 65, peptic ulcer disease and 171
during dreams 68, 69 188–189 pH monitoring of 81, 174
electrooculogram of 77, 177 and siestas 203 Gayet, Maurice-Edouard-Marie xxx
in encephalitis lethargica 78 in theories of sleep xxii, xxx Gelineau, J. B. E. (Jean-Baptiste-
measurement of 42 food allergy insomnia xxxvii, 7, 87–88, Edouard) xxxi, xxxvi, 91, 140
in REM sleep 77, 83 110 Genesis, book of xxiii–xxiv
slow rolling 234–235 Food and Drug Administration (FDA) genetics 91
eye movement disorders xxx, 48 on atypical antipsychotics 146 in histocompatability antigen testing
on dopamine agonists 67, 195 95
F on fibromyalgia treatments 86 of narcolepsy 91, 95–96, 141–142
Factor S xxxiii, 84, 116, 138, 220 on hypnotics 100, 101, 205 of peptic ulcer disease 171
family bed 84 on oral appliances 164 of sleep duration 217
family residence xlii–xliii on quinine 152 of sleep terrors 91, 231
fast sleep. See REM sleep on ropinirole 195 of sleepwalking 91, 233
fatal familial insomnia xxxvii, 84–85, Forel, Auguste-Henri xxxv Georg Ebers papyrus xix
113 forgetting, interference theory of 53. See GERD. See gastroesophageal reflux
fatigue 85 also memory GHB. See gamma-hydroxybutyrate
in chronic fatigue syndrome 49–50 fragmentary myoclonus 36, 48, 88 ghrelin 91, 124, 159
driver. See drowsy driving fragmentation, sleep 15, 219. See also gigantism 4, 92
in exhaustion 83, 85 NREM-REM sleep cycles gigantocellular tegmental field 91, 190
in neuromuscular diseases 146 Franklin, Benjamin 33 ginseng xx
v. sleepiness 85, 220 free running 88, 109, 203 giraffes 21
in sleep terrors 231 frequently changing sleep-wake schedule Giraudoux, Jean xxxvii, 162
FDA. See Food and Drug Administration 52 Glenn, John 58
294 The Encyclopedia of Sleep and Sleep Disorders

glottic spasms. See laryngospasms Helmont, Jan Baptista Van xxvi pulmonary 184
glucose 96 hemoglobinuria, paroxysmal nocturnal sleep deprivation and xlv
gluttony 188 170 snoring and 235
gods, ancient xviii–xxi Henneberg, Richard xxxi hyperthyroidism 97
Goldenhars syndrome 58 Herbst Appliance 163 hypnagogic hallucinations 70, 97–98,
Golgi, Camillo xxix hernia, hiatal 90 139–140, 248
gonadotrophin 10, 12, 28 Herodotus xix hypnagogic hypersynchrony 98
Goody’s PM Powder 165 hertz (Hz) 95 hypnagogic reverie 98, 222
Goswami, Meeta 143 Hesiod xx hypnalgias 98
grand mal seizures 79 Hess, Walter Rudolph xxxiv hypnograms 98. See also
Graves’ disease 97 hiatal hernia 90 polysomnograms
Greece, ancient xx–xxiii hibernation 95 hypnopompic events 98
Greenberg, Ramon 68 Hill, Sir Leonard Erskine xxix hypnopompic hallucinations 98, 140
grief xli, 39 Hill, William xxxii Hypnos (god) xx, 98
Griesinger, Wilhelm xxxiii Hilprecht, Hermann V. 70 hypnosis xxxi, 31, 98, 232
Grosscup, Ethel A. xliv Hippocrates xvii, xxii, xxv, xxviii hypnotic-dependent sleep disorder 37,
growth hormone 92 Hislop, Jenny xl–xli, xliii 98–99, 112, 213
in acromegaly 3–4, 41 histamine 24, 95 hypnotics 99–102. See also specific types
in adolescents 10, 92 histocompatability antigen testing for adjustment sleep disorder 5
in adults 12, 92 xxxvii, 95, 96, 141–142 alcohol as 100
age and 6 HLA. See human leukocyte antigen for alcohol-dependent sleep disorder
prolactin and 181 HLA-DR2 xxxvii, 95–96, 141–142 15
in recurrent hypersomnia 189 Hmong 244 antihistamines used as 24, 102, 131
Guilleminault, Christian 1, 62 Hoag, John 145 v. cognitive behavioral therapy 101
Hobart, Garret xxxiii, 238 and deaths during sleep 59
H Hobson, J. Allan xxxv, 91, 188 for dementia 63
Halberg, Franz 51, 93, 247 homeostatis 96 dependence on 37, 72, 73, 98–99,
Halcion 100. See also triazolam Homer xvii, xx–xxi, xxiii 100, 102
Hall, Calvin S. 69, 93 homicide, vehicular 71, 129 effectiveness of 72
Haller, Albrecht Von xxvii, xxviii Honda, Yutaka xxxvii for elderly 74, 75, 99
hallucinations H1 receptors 95 electrosleep combined with 78
hypnagogic 70, 97–98, 139–140, hormonal therapy 12, 133 ending use of 205
248, 248 hormones. See specific types for environmental sleep disorder 154
hypnopompic 98, 140 Horne, James 165 in epilepsy diagnosis 79
from sleep deprivation 209 hotels xli history of xxxi, xxxvi, 100
haloperidol 146 hot flashes 12, 132 in hypnotic-dependent sleep disorder
Hammond, E. 202 Howell, William Henry xxix 37, 98–99, 112, 213
Hammond, William Alexander xxix, xxxi Hsieh, Frank 206 for insomnia 35, 100–102, 114, 184,
hands, carpal tunnel syndrome in 44 H2 receptors 95 253
Hartmann, Ernest 202 Huang Ti xx insomnia caused by 99, 213
Harvey, E. Newton xxxiii, 238 human leukocyte antigen (HLA) xxxvii, need for 205
Harvey, William xxvi 95–96, 141–142 new, development of 72
Hayaishi, Osamu xxxiii humoralism xxi, xxvi, xxvii over-the-counter 102
Head, Henry 260 hunger. See appetite for pain 167
headaches 93 hygiene. See sleep hygiene during pregnancy 180
biofeedback and 39 Hymsfield, Steven 159 prevalence of use 205
in bruxism 208 hyoid myotomy 96, 130, 173, 245 in rebound insomnia 188
in central alveolar hypoventilation hyoscyamine xix recreational use of 130
syndrome 45 hyperarousal 96, 105 risks of 205
chronic paroxysmal hemicrania 51, hypercapnia 96 for shift-work sleep disorder 201–
93, 193 hyperexplexia syndrome 229 202
cluster 53, 93 hyperhidrosis (night sweats) 132, side effects of 99–102, 130–131, 205
migraine 93, 133–134 219–220 for sleep choking syndrome 209
muscle contraction 93 hypernycthemeral sleep-wake syndrome sleepiness caused by 72, 130–131
tension 93 96–97, 155–156 soporific effects of 238
headbanging (jactatio capitis nocturna) hypersexuality 121, 188, 189 and time zone change syndrome
9, 94, 120, 197 hypersomnia. See also excessive 102, 250
head rolling 94 sleepiness; recurrent hypersomnia types of 100–102
heart attack. See myocardial infarction idiopathic 105, 116, 136 withdrawal from 72, 98–99, 188
heartburn 94, 171 posttraumatic 178–179 hypnotoxins xxxiii, 102
heart failure 43, 50, 55 hypertension 97 hypocretin 102, 142
heavy metals 251 and headaches 93 hypoglycemia 151
heliotrope plant 129 and impotence 106, 107 hypomania 213
 Index 295

hypopharynx 173 dreams of 69 in encephalitis lethargica 78

hypopnea 26, 102–103, 193, 208, 212 epilepsy in 7, 36, 111 erratic hours in 81
hypothalamus xxxv, 103, 189, 245 erections in 171 history of xvii, xxxvii
hypothyroidism 97, 103, 138 in family bed 84 hyperarousal and 96
hypoventilation. See also central alveolar feeding intervals for 7, 33 in hypnotic-dependent sleep disorder
hypoventilation syndrome food allergy insomnia in 7, 87–88, 99, 213
alveolar 17, 122, 175 110 hypothalamus and 103
lung disease and 127–128 indeterminate sleep in 108 inadequate sleep hygiene and 107
in obesity hypoventilation syndrome naps in 7, 139 in irregular sleep-wake pattern 119
159 nocturnal eating syndrome in 151 in menopause 132, 133
in Parkinsonism 170 nocturnal sleep episodes of 154 in menstrual-associated sleep
hypoxemia 104 non-REM-stage sleep in 108 disorder 132–133
in altitude insomnia 17 oximetry for 166 in mood disorders 182
in chronic obstructive pulmonary premature 27, 47, 180 naps and 139
disease 50 quiet sleep in 108–109, 163, 186 nocturia in 149
in overlap syndrome 164 REM sleep in 108, 188, 193 in nocturnal paroxysmal dystonia
snoring and 235 REM sleep latency in 193 153
in theories of sleep xxx REM sleep percent in 193 in pregnancy 179
ventricular arrhythmias and 258 settling in 200 prevalence of 111, 206
hypoxia 104, 184 SIDS in. See sudden infant death psychiatric disorders associated with
hypsarrhythmia 36 syndrome xlix–lxl, 112, 182
hysteria 45 sleep disorders in 7–8, 109–111 psychology of l–lv
Hz. See hertz sleep duration in 6–7, 108, 216 raphe nuclei in 187
sleeping position of 8, 243–244 restlessness in 196
I sleep patterns of, development of serotonin and 87, 187, 200
ICSD. See International Classification of 6–8, 108–110, 163 in shift-work sleep disorder 200,
Sleep Disorders trace alternant in 251 201
idiopathic hypersomnia 105, 116, 136 wakefulness in 108, 163 in short sleepers 113–114, 202
idiopathic insomnia 105–106, 114 infantile spasms 36, 199 v. sleep deprivation 210–211
IGL. See intergeniculate leaflet infradian rhythms 197, 256 sleep duration in 217
ignatia amara 165 infrared oximetry 166 sleep onset in 223
Ikematsu, Tanenosuke xxxvii, 257 inhibition theory of sleep xxx, xxxii– v. sleep state misperception 229–230
IL-1. See interleukin-1 xxxiii, xxxiv–xxxv smoking and 235
Iliad (Homer) xvii, xx, xxiii insomnia 111–116, 212–213. See also sociological research on xlvi–xlvii
Imhotep (god) xix specific types as symptom v. diagnosis 102, 111,
imipramine 23, 142, 218, 231 abnormal swallowing and 1 212
Imorane. See zopiclone in adolescents 11 treatment of. See insomnia treatments
impaired sleep-related penile erections in adults 11, 12 types of 112–114, 127
106–107 alcoholism and 15 insomnia treatments 114–115, 213,
impotence 12, 81, 106, 107, 154, 171, alpha-delta activity in 16 253–254
188 ambulatory monitoring of 18 alcohol as xix
inadequate sleep hygiene 34, 61, 107, amount of sleep needed and 204– ancient xix
126, 184 205 behavioral 35, 115, 253
incubation ceremony xxi in animals 21 autogenic training 31
incubus 107–108, 230 anxiety in l, li, liv, 253 cognitive lii–liv
indeterminate sleep 108 bereavement and 39 cognitive focusing 53–54
India, ancient xix caffeine and 65 psychoanalysis in xxxvi
inductive plethysmography 108, 176, 194 causes of lii, 111–114, 212–213 for psychophysiological insomnia
Industrial Revolution xxviii central apnea and 46, 47 35, 184, 213
infant(s) 6–8, 108–109 in Cheyne-Stokes respiration 49 relaxation 120, 184, 213
active sleep in 108–109, 163 in chronic obstructive pulmonary sleep restriction therapy liv,
apnea in 7, 26–27, 109, 243 disease 50–51 225–227
central 47, 111 circadian rhythms in lv stimulus control therapy 242
monitors for 26–27 classifications of 112 systemic desensitization 246
obstructive 109, 110–111 cocaine and 53 benzodiazepines in 37–38, 253
of prematurity 27, 110, 180, 208 in delayed sleep phase syndrome 60 delta sleep inducing peptide in 62
benign neonatal sleep myoclonus in depression and xlix–l, 63, 182, effectiveness of 253–254
7, 35–36, 110 212–213 history of xix, xxxvi, xxxvii, 111
bodyrocking in 40 diagnoses of, increase in 206 hypnotics in 35, 100–102, 114, 184,
breathing disorders in 7, 110–111 v. disorders of initiating and 253
congenital central alveolar maintaining sleep 64, 66 limitations of xlvi
hypoventilation syndrome in 45, effects of l–lii, 205–206 over-the-counter drugs in 114, 165,
109 in elderly 206 207
296 The Encyclopedia of Sleep and Sleep Disorders

paradoxical techniques of 168–169 jet lag xxxvii, 120, 249–250. See also Lavoisier, Antoine-Laurent xxvii
side effects of xlvi time zone change syndrome Lawrence of Arabia 33
tricyclic antidepressants in 22 Jews 141 L-dopa 124, 148, 169, 170, 179, 195
Institute of Dream Research 93 Johns, Murray W. 81 lead paint 251
Institute of Medicine (IOM) 205 Johnson, Laverne 209 learning during sleep 53, 124
insufficient sleep syndrome 6, 116, 202, Jouvet, Michel xxxv, 62, 200 Leduc, Stephane Armand Nicolas 77
211 JSSR. See Japanese Sleep Research leg cramps 57, 152, 232
insulin 96 Society Legendre, René xxxii, xxxiii
interference theory of forgetting (ITF) 53 Judaism xxiv leg movements. See periodic leg
intergeniculate leaflet (IGL) 259 Jung, Carl Gustav 68, 120 movements; restless legs syndrome
interleukin-1 (IL-1) xxxiii, 116, 220 leg rolling 197
“intermediary” sleep stage. See non- K Lennox-Gastaut syndrome 75, 199
REM-stage sleep Kahn, Andre xxxvii Lepine, Raphael-Jacques xxix
intermediate sleep 108, 174. See also Kales, Anthony xxxiv, xxxvii, 187, 228, leptin 124, 159
indeterminate sleep 233, 238 letter sorting tasks 260
intermittent DOES (periodic) syndrome K-alpha 121 Leucippus of Miletus xxii, xxvi
117 K-complexes 121, 137, 228 leucomaines xxx
internal arousal(s) 117 Kekule, Friedrich A. 70 Levin, Max 121, 188
internal arousal insomnia 117 Klearway 164 Lhermitte, Jacques-Jean xxxiv
internal desynchronization 117 Kleine, Willi 121, 188 life expectancy, of short sleepers 202
International Classification of Sleep Kleine-Levin syndrome 65, 66, 117, light, blue 40, 254
Disorders (ICSD) 117–118 121, 188 light-dark cycle xxxvi, 40, 79, 174,
development of 64, 117–118, 156 Kleitman, Nathaniel 121 198–199
on dyssomnias 73 as AASM fellow 19 light sleep. See stage one sleep
on insomnia lii, 112 award named for 145 light therapy 125
major categories of 73, 83, 117 on basic rest-activity cycle 33 for advanced sleep phase syndrome
on parasomnias 169 and deafferentation theory xxxiv 6
proposed sleep disorders in 182 on dream recall 190 for delayed sleep phase syndrome
international sleep societies 118 on dyssomnia 73 10, 125
interpretation of dreams 118 on physiological changes during for depression 63
Freud on 88–89, 118 dreams 68, 190 for elderly 13
history of xix, xxxii, 68 on REM sleep xxxiii–xxxiv, xxxix, for non-24-hour sleep-wake
Jung on 120 62, 121, 187, 228 syndrome 156
Interpretation of Dreams, The (Freud) writings of xxxvi, 121 for seasonal affective disorder 125,
xxxii, xxxvi, xxxix, 68, 88, 118 Kleitman Distinguished Service Award. 198–199
intracerebral disease 49 See Nathaniel Kleitman Distinguished limb movement disorders. See periodic
intrinsic sleep disorders 118 Service Award leg movements; periodic limb
intrusion Klonopin. See clonazepam movement disorder
alpha 16 Kolata, Gina 12–13 limit-setting sleep disorder 7, 8, 34,
non-REM 155 Kripke, Daniel F. liii, 202 125–126, 148, 223
REM 192 Kroll-Smith, Steve xliv Linné, Karl von (Linnaeus) xxvi, xxxv
inuus 107–108 Kryger, Meir H. xxxvi, 145, 216 Linsner, Jerome P. 206
iodine, radioactive 97 Kuhlo, Wolfgang xxxvii liquid diets 159
IOM. See Institute of Medicine kyphoscoliosis 121–122, 127 lithium 126, 136, 189, 235
ipratropium 57 locomotor system 189
irregular sleep-wake pattern 34, 52, L locus ceruleus 126
118–119, 155 laboratories vii, ix, 123 Lombardo, Gerard T. 206
Islam xxiv lactate 168 long sleepers 126–127, 217
Israeli Jews 141 lactic acid xxx long-term (chronic) insomnia 127
Italians 84 Landau-Kleffner syndrome 75 congestive heart failure and 55
ITF. See interference theory of forgetting Landry-Guillain-Barre syndrome 147 hyperarousal and 96
Laotians 244 perpetuating factors in lii
J larks 123 v. transient insomnia 252
Jackson, John Hughlings xxix, xxxv, laryngospasms 1, 123–124, 209 treatment of 102, 114–115, 127
222 laser uvulopalatoplasty 124, 236, 257 Loomis, Alfred L. xxxiii, 238
Jacobson, Edmund 82, 120, 181, 219 LASS. See Latin American Sleep Research Louis XIV (king of France) 33
Jacobsonian relaxation 120, 181, 184, Society L-tryptophan 65, 72, 87, 101, 200
219 latency to sleep. See sleep latency L-tyrosine 67, 140, 142, 241
jactatio capitis nocturna. See headbanging lateral tegmental field 91 lucid dreams 70, 127
Janota, Otakar xxxvi Latin America 203 Lucretius Carus, Titus xxii, 222
Japan 95, 96, 142 Latin American Sleep Research Society Lugaresi, Elio xxxvii, 19
Japanese Sleep Research Society (JSSR) (LASS) xxxviii, 118 Lugaro, Ernesto xxix–xxx
xxxviii, 118 laudanum xxvi Lunesta. See eszopiclone
 Index 297

lung(s). See also breathing disorders drowsy driving by xli, 71 mood disorders 135–136. See also
in kyphoscoliosis 121–122 excessive sleepiness in 11 depression
tidal volume of 45, 50, 249 middle-aged 12 v. advanced sleep phase syndrome
lung disease 104, 127–128. See also nocturnal emissions in 70, 151–152, 6
chronic obstructive pulmonary disease 171 and insomnia 182
Luvox. See fluvoxamine obstructive sleep apnea syndrome treatment of 126, 136. See also
Lyrica. See Pregabalin in 12 antidepressants
lysis 170 peptic ulcer disease in 171 Moore, Robert Y. xxxv
REM sleep behavior disorder in 191 morbid obesity 32–33, 158
M as short sleepers 202 morning person (lark) 136, 165–166,
Machanon xxi snoring in xli, 181 201
MacNish, Robert xxviii sudden unexplained nocturnal death Morpheus (god) 136, 137
Maggie’s Law (National Drowsy Driving syndrome in 244 morphine 136, 137
Act) 71, 129 menopause 12, 132, 133, 219 morphology 137
magnocellular tegmental field 91 menstrual-associated sleep disorder 117, Moruzzi, Guiseppe xxxv, 29
Magoun, Horace W. xxxv, 29 132–133, 189 Moses ben Maimon xxiv
Maimonides xxiv menstrual cycle 66, 117, 132, 133, 189 Mosso, Angelo xxix
maintenance of wakefulness test (MWT) mental retardation 94 mountain sickness. See altitude insomnia
16, 82, 129, 260 mentation, sleep 222 movement(s)
Mairan, Jean-Jacques d’Ortous de xxvii, Mesmer, Franz Anton xxvii abnormal
xxxi, 40, 129–130 mesmerism xxvii, xxxi in cerebral degenerative disorders
major histocompatability complex Mesopotamia xviii–xix 48–49
(MHC) 95 methamphetamine 240 in epilepsy 79
male. See men methscopolamine 92 and insomnia 113
malingerers 130, 229 methylphenidate hydrochloride 16, 142, monitoring of 4
mammals xvii–xviii, 175 241, 242 in restlessness 195–196
Manceine, Marie de xxx methylxanthines 194–195 movement arousal 137
mandibular advancement surgery 130, metoprolol 131 movement time 137
245 MHC. See major histocompatability moxibustion xx
Mandibular Repositioner 163 complex MSLT. See multiple sleep latency test
mania 135, 213 Michelangelo xxv mucopolysaccharide 138
manic-depressive disorder 182 Mickey Finn 100 muller maneuver 86
MAO. See monoamine oxidase micrognathia 133 multiple cerebral infarction 62
marriage counseling 107 microsleep 133 multiple sclerosis 191
mastoids 130 middle-aged adults 12 multiple sleep latency test (MSLT) 137
mattresses 33–34, 230 Middle Ages xxiv–xxv, 33 in adjustment sleep disorder 5
Mauthner, Ludwig xxx–xxxi, xxxiv middle ear muscle activity (MEMA) alertness measured by 16
maxillo-facial (maxillofacial) surgery 133 development of xxxiv, 44, 137
130 migraine headaches 93, 133–134 for excessive sleepiness 82, 137
Mazanor. See mazindol military beds 34 v. maintenance of wakefulness test
mazindol 241–242 milk, cow’s 7, 65, 88, 110 129
McCarley, Robert William xxxv, 91, 188 mind-body therapy 39 for narcolepsy xxxvi–xxxvii, 137,
McDonnell, Maggie 71, 129 Minoans xx 141, 213
McGregor, Peter Anderson xxxviii, 19 Mirapex. See pramipexole in obstructive sleep apnea syndrome
MDP. See muramyl dipeptide mirtazapine 24 160
Meadows, Robert xliii Mitchell, Robert A. xxxvii, 162 in vigilance testing 260
meals, large 65 Mitchell, Silas Weir xxxi muramyl dipeptide (MDP) 137–138,
medications 130–132. See also drug(s); Mitler, Merrill M. 134 220
specific medications modafinil ix, 28, 131, 134, 142, 202 muramylpeptides 84
medicine, history of xviii–xxxviii. See Mogodon. See nitrazepam muscle(s)
also sleep disorders medicine monasteries xxiv in fibrositis syndrome 86–87
medieval period xxiv–xxv, 33 Monday morning blues 34, 134–135, neuromuscular diseases of 146–147
medroxyprogesterone 122, 181, 194 244 in poliomyelitis 176
melanin 126 monitoring. See specific types in sleep palsies 224
melarsoprol 221 monoamine oxidase (MAO) inhibitors muscle activity
melatonin 10, 125, 132, 132, 175, 202, 135, 136, 156, 210 in fragmentary myoclonus 88
245, 254 monophasic sleep-wake pattern xviii measurement of. See electromyogram
MEMA. See middle ear muscle activity montage 135, 177 middle ear 133
memory 53, 124, 133, 222–223 Montefiore Medical Center xxxviii, 19 during REM sleep 133
men. See also erections Mooallem, Jon 206 muscle contraction headaches 93
anxiety disorders in 25 mood muscle cramps 57, 152, 232
deaths during sleep 59 interaction between sleep and li muscle paralysis 139–140, 224–225
dreams of 68, 69 in sleep deprivation 210 muscle relaxation. See relaxation
298 The Encyclopedia of Sleep and Sleep Disorders

muscle tone 138 v. idiopathic hypersomnia 105 Nei Ching (Yu Hsiung) xx
acetylcholine and 3 v. insufficient sleep syndrome 116 Neolithic period xviii
alcoholism and 15 irregular sleep-wake pattern and 119 Nergel (god) xviii
loss of. See atonia v. long sleepers 127 nervous system. See central nervous
in REM sleep 138, 187–188 microsleep in 133 system
MWT. See maintenance of wakefulness multiple sleep latency test of xxxvi– NESS. See Northeastern Sleep Society
test xxxvii, 137, 141, 213 neural theories of sleep xxix–xxx
Mycenaeans xx naps in 139, 140, 213–214 neuroanatomy xxviii
myocardial infarction 138 National Sleep Foundation on 145 neurochemistry xxxiii
myoclonus 138 obstructive sleep apnea syndrome neurogenic tachypnea 146
benign neonatal sleep 7, 35–36, 110 and 161 neuroglia xxix
fragmentary 36, 48, 88 origins of term xxxi, 91 neurohistology xxix–xxx
nocturnal 138, 152, 172 prevalence of 141, 215 neuroleptics 146
v. sleep starts 229 REM sleep behavior disorder and atypical 30, 146
mysticism xxiv, xxv 191 for cerebral degenerative disorders
myxedema 103, 138 REM sleep latency in 193 49
shift-work sleep disorder and 201 for dementia 63, 146
N sleep onset in 223 for schizophrenia 30, 146
nadir 139 sleep onset REM periods in 224 side effects of 131, 146
NAPA. See Nocturnal Airway Patency sleep paralysis in 139–140, 225 sleepiness affected by 131
Appliance symptoms of 139–141, 213 neurological disorders 113, 146, 169–
naps 139 treatment of 142–143, 214 170
in animals xviii antidepressants in 21–24 neurology, history of xxvi, xxviii–xxxv
and drowsy driving 71 armodafinil in 28 neuromuscular diseases 146–147
in elderly 13, 74 codeine in 53 neurons xxix–xxx, 46, 167
in idiopathic hypersomnia 105 delta sleep inducing peptide in neurophysiology xxxiv–xxxv
in infants 7, 139 62 neurospongium xxix
in maintenance of wakefulness test history of xxxvi neurotransmitters xxx. See also specific
129 MAO inhibitors in 135 types
in multiple sleep latency test 137 modafinil in 134 newborns. See infant(s)
in narcolepsy 139, 140, 213–214 naps in 214 New York Sun, The 207
and nocturnal sleep episodes 154 narcotics in 144 New York Times, The 206, 207
in obstructive sleep apnea syndrome stimulants in 142, 240–242 NICHD. See National Institute of Child
139, 160 Narcolepsy Institute 143 Health and Human Development
in pregnancy 179 narcosis 143–144 Nicorette 147
recommendations on 206 narcotics 143–144 nicotine 147, 229, 235. See also smoking
siestas 16, 139, 203, 211 Nardil. See phenelzine night, fear of 149
in sleep patterns 225 nasal congestion 144 night fears 8, 147–148
at sleep salons 206–207 nasal positive pressure ventilation nightmare(s) 70, 148–149
timing of 139, 203 (NPPV) 144 in alcoholism 15
narcolepsy 139–143, 213–214 nasal surgery 144–145 as arousal disorder 28–29
in adolescents 10–11, 141, 213 nasopharynx 173 awakening from 70, 148
advances in research on 206 Nathaniel Kleitman Distinguished in children 8, 148
ambulatory monitoring of 18 Service Award 45, 62, 121, 145 as dream anxiety attacks 67, 70
automatic behavior in 140–141 National Drowsy Driving Act (2002) 71, incubus 107–108
cataplexy in. See cataplexy 129 inuus 107–108
cause of 141–142, 206 National Fibromyalgia Association 86 in narcolepsy 70
central apnea in 47 National Institute of Child Health and night fears and 147–148
depression and 136 Human Development (NICHD) 8, 244 recall of 70, 148
diagnosis of 95–96, 141–142, 213 National Institutes of Health liii in REM rebound 190
as disorder of excessive somnolence National Sleep Foundation (NSF) 145 v. REM sleep behavior disorder 148,
66 on amount of sleep needed 204 191
dopamine in 67 on drowsy driving 71–72 v. sleep terrors 70, 148, 214, 231
dreams in 70, 140, 143 polls by xl, xli v. terrifying hypnagogic
encephalitis lethargica and 78 public education by ix, 72, 145, 207 hallucinations 248
ethnicity and 95, 96, 141, 142 sleep center listings of vii treatment of 148–149
first descriptions of xxxi, 91, 140 on sleep deprivation xl, xli night owl. See evening person
genetics of 91, 95–96, 141–142 Native Americans xxxii, 243 nightshade xix
hallucinations in Nauta, Walle Jetz Harinx xxxv night shift 149, 200–201
hypnagogic 70, 98, 139–140, 248 nebulizers 57 night sweats 132, 219–220, 246
hypnopompic 98, 140 nefazodone 24 night terrors. See sleep terrors
history of xxxi, xxxvi–xxxvii negative feedback 96 nighttime snacks 65
hypocretin in 102, 142 negative pressure ventilators 47 nitrazepam 38
 Index 299

nitroglycerine 150 non-24-hour sleep-wake syndrome in adolescents 10

NMR scan xxxii 155–156 in adults 11, 12
Nobel Prize xxix, xxxiv v. delayed sleep phase syndrome 61, alcohol and 2, 14, 161
Noctec. See chloral hydrate 155 alcoholism and 15
noctiphobia 149 as hypernycthemeral sleep-wake as breathing disorder 41
nocturia 149 syndrome 96–97, 155 carbon dioxide in 43
nocturnal 149–150 in infants 109 cardiac arrhythmias in 43, 167
Nocturnal Airway Patency Appliance v. irregular sleep-wake pattern 118– cause of 13, 159, 212
(NAPA) 163–164 119, 155 v. central apnea 47
nocturnal angina 43–44, 150 as persistent circadian rhythm sleep cephalometric radiographs in 48,
nocturnal cardiac ischemia 43–44, 150 disorder 52 86, 160
nocturnal confusion 62, 75, 150 as socially or environmentally in children 9, 160, 245, 250–251
nocturnal dyspnea 43, 55, 150–151, induced disorder 237 and chronic obstructive pulmonary
170 norepinephrine (noradrenaline) 126, disease 164
nocturnal eating (drinking) syndrome 156, 220 cocaine and 53
65, 91, 151, 261 Northeastern Sleep Society (NESS) 44 in congestive heart failure 55
nocturnal emissions 70, 151–152, 171 nosology 156 craniofacial disorders and 57–58
nocturnal enuresis. See sleep enuresis NPD. See nocturnal paroxysmal dystonia and deaths during sleep 59
nocturnal leg cramps 152, 232 NPPV. See nasal positive pressure diagnosis of 160, 161, 212
nocturnal myoclonus 138, 152, 172 ventilation diet and 65
nocturnal paroxysmal dystonia (NPD) NPT. See nocturnal penile tumescence as disorder of excessive somnolence
152–153 NREM. See non-REM 66
in children 9 NREM-REM sleep cycles (sleep-wake in elderly 12, 13
discovery of xxxvii cycles) 156 endoscopy in 78, 86, 237
forms of 153 architecture of 208 and enuresis 160, 218
v. restless legs syndrome 195 environmental time cues and 79 esophageal reflux in 81–82
v. seizures 199 growth hormone in 92 excessive sleepiness in 159–160, 212
treatment of 42 in infants 108 first descriptions of xxxi–xxxii,
nocturnal penile tumescence (NPT) log of 221 xxxvii, 158, 159, 175
153–154 NREM sleep period in 156–157 gastroesophageal reflux in 90–91,
nocturnal penile tumescence (NPT) test number per night 188 160
153–154, 171, 242 v. REM sleep period 193 headaches in 93
nocturnal sleep episodes 154 sleep stage episodes in 227 heartburn in 94
NoDoz 165 NREM sleep period 156–157 history of xxxvii
noise 79, 154–155 NSF. See National Sleep Foundation hypertension in 97
nonactivated sleep 174 nuclear magnetic resonance (NMR) scan hypothyroidism and 103
nonfocal activity 65 xxxii hypoxemia in 104
non-REM intrusion 155 nutrition. See diet; food impotence in 106, 107
non-REM-REM sleep cycles. See NREM- Nuvigil. See armodafinil index of 26
REM sleep cycles nyctophobia. See noctiphobia in infants 109, 110–111
non-REM sleep period 156–157 nycturia. See nocturia laryngospasms and 123, 124
non-REM-stage sleep 155, 204. See also Nytol 165 v. long sleepers 127
quiet sleep; stage four sleep; stage one Nytol Natural Tablets 165 micrognathia and 133
sleep; stage three sleep; stage two sleep naps in 139, 160
in benign epilepsy with Rolandic O nasal congestion and 144
spikes 35 obesity 158–159 nocturia and 149
Cheyne-Stokes respiration in 49 bariatric surgery for 32–33 obesity and 158–159
in coma 54 and central apnea 47 in overlap syndrome 164
dream recall in 190–191 ghrelin and 91, 159 pharynx in 173
electrical status epilepticus of sleep and hypoventilation 45, 46, 159 as Pickwickian syndrome xxxvii, 175
in 75 morbid 32–33, 158 polycythemia in 176
electromyogram of 77 and nocturnal dyspnea 151 polysomnography in 177–178
in infants 108 in recurrent hypersomnia 188, 189 prevalence of 215
intrusion of, in REM sleep 155 sleep duration and 159 REM rebound in 190
K-complexes in 121 obesity hypoventilation syndrome 159 v. REM sleep-related sinus arrest 193
muscle tone in 138 obstructive pulmonary disease. See respiratory effort in 194
neurophysiology of xxxv chronic obstructive pulmonary disease restlessness in 196
quiet sleep as 186 obstructive sleep apnea syndrome (OSA v. SIDS 8
raphe nuclei in 187 or OSAS) 26, 159–162, 208, 212. See v. sleepwalking 233
REM sleep intrusion in 192 also upper airway obstruction smoking and 161, 235
stages of 155, 204 v. abnormal swallowing syndrome 1 snoring in 155, 159–160, 180, 181,
as synchronized sleep 246 accidents related to 2 212, 235–236
nonrestorative sleep 155 adenoids in 5 somnofluoroscopy in 237
300 The Encyclopedia of Sleep and Sleep Disorders

symptoms of 44, 159–160, 212 owl and lark questionnaire 165–166 paroxysmal nocturnal hemoglobinuria
treatment of. See obstructive sleep oximetry 104, 166 (PNH) 170
apnea syndrome treatment oxybutynin chloride 218 Parsons, Talcott xliii–xliv
weight in 261 oxycodone 195 partial (focal) seizures 79, 80, 199
obstructive sleep apnea syndrome oxygen 166. See also hypoxemia; hypoxia Pasteur, Louis xxxi
treatment 160–162, 212 in altitude insomnia 17 Pavlov, Ivan Petrovitch xxx, xxxii–
amphetamines in 241 and carbon dioxide 43 xxxiii, liii
cardiac pacemaker in 167 in central alveolar hypoventilation pavor nocturnus 170. See also sleep
CPAP in xxxvii, 56, 161, 163, 166, syndrome 45 terrors
212 in central apnea 47 Paxil. See paroxetine
effectiveness of 206, 252–253 in Cheyne-Stokes respiration 49 PCPA. See parachlorphenylamine;
history of xxii, xxxvii in chronic obstructive pulmonary parachorophenylalanine
hyoid myotomy in 96, 173 disease 50 pemoline (Cylert) 58, 143, 171
laser uvulopalatoplasty in 124 discovery of xxvii penile erections. See erections
mandibular advancement surgery measurement of 104, 166 penile prostheses 107
in 130 in overlap syndrome 164 penile tumescence 153–154, 255. See
maxillo-facial surgery in 130 in periodic breathing 172 also erections
nasal surgery in 144 in theories of sleep xxx peptic ulcer disease 171
oral appliances in 163–164, 250 oxygen therapy 104, 122, 166 pergolide 179
oxygen therapy in 166 periodic breathing 171–172
respiratory stimulants in 194 P periodic hypersomnia. See recurrent
somnoplasty in 237–238 pacemakers 43, 167, 193. See also hypersomnia
surgical 245–246 circadian pacemaker periodic leg movements 172
tonsillectomy in 250–251 Pack, Alan 145 asymptomatic 30
tracheostomy in xxii, xxxvii, pain 167. See also headaches cerebral degenerative disorders and
251–252 in fibromyalgia 86 48
uvulopalatopharyngoplasty in in fibrositis syndrome 86–87, 167 in elderly 74
xxxvii, 257 in hypnalgias 98 electromyogram in diagnosis of 77
weight loss in 158–161, 261 in nocturnal angina 43–44, 150 v. fragmentary myoclonus 88
obtundation 162, 256 in peptic ulcer disease 171 L-dopa for 124
oculoauriculo-vertebral dysplasia 58 painful erections 167–168 v. long sleepers 127
Odyssey (Homer) xx palsies, sleep 224 as nocturnal myoclonus 152, 172
Ogle, William xxxi panic disorders 168, 182–183 restless legs syndrome and 172, 195,
Ondine’s curse xxxvii, 46, 162 v. anxiety disorder 24, 168 213
oneiric 162 cardiovascular symptoms of 44 v. sleep starts 229
ontogeny of sleep 162–163 and hyperarousal 96 periodic limb movement disorder
opium xix, xx, xxvii, 137, 144 v. laryngospasms 123 (PLMD) 172
oral appliances 81, 163–164, 173, 208– v. sleep choking syndrome 168, 209 v. benign neonatal sleep myoclonus
209, 236, 250 v. sleep terrors 168, 214 36
orexin. See hypocretin treatment of 17, 168 in elderly 12, 13
Origin of Species (Darwin) 33 Papaver somniferum xix, 137 and insomnia 113
oropharynx 173 Pappenheimer, John xxxiii, 220 v. mood disorders 136
orthopnea 43, 55, 164, 170 Paracelsus xxv myoclonus in 138, 152
OSA. See obstructive sleep apnea parachlorphenylamine (PCPA) 87 obstructive sleep apnea syndrome
syndrome parachorophenylalanine (PCPA) 187 and 161
OSAS. See obstructive sleep apnea paradoxical phase of sleep 174 periodic limb movements of sleep
syndrome paradoxical sleep. See REM sleep (PLMS) 213
Osborne, Jonathon xxx paradoxical techniques 168–169 period lengths 51, 52, 58, 173
Osler, Sir William xxxvii paraldehyde xxxi peripheral nervous system (PNS) 46
Ostberg, Olov 165 paralysis, sleep 139–140, 224–225 Perlick, Deborah 206
OTC. See over-the-counter medications parasomnias 169, 214–215. See also petit mal seizures 199
out-of-body experience 143 specific types Pettenkofer, Max xxx
Overeaters Anonymous 159 classification of 64, 169 Peyrone’s disease 167–168
overlap syndrome 164 v. dyssomnias 73 Pfeffer, Wilhelm Friedrich Phillip xxxi
over-the-counter (OTC) medications insomnia associated with 113 Pfluger, Eduard Friedrich Wilhelm xxx
165. See also specific types types of 64, 169, 190, 214–215 PGO spikes 69, 173, 178, 187
hypnotics as 102 Parkinsonism 169–170 pharmacology, history of xxxi
for insomnia 114, 165, 207 Parkinson’s disease 67, 169, 191, 215 pharynx 173
self-medication with 207 paroxetine 24 phase advance 173
stimulants as 165, 239, 242 paroxysmal nocturnal dyspnea 43, 55, phase delay 173
L-tryptophan in 200 150–151, 170 phase response curve 61, 173–174
Ovid xxiii paroxysmal nocturnal dystonia. See phase shift 173, 174
owl. See evening person nocturnal paroxysmal dystonia phase transition 174
 Index 301

phasic events 174 of advanced sleep phase syndrome 6 primary sleep 174
phenelzine 135 v. apnea monitors 27 primary snoring 155, 180–181
phenobarbital 32, 199 asymptomatic findings in 30 primates xviii, 21
phenothiazines xxxvi, 146, 181, 184, 252 baseline in 33 progesterone 133, 179, 181, 194
phentermine 241 board certification in 19–20 progressive relaxation 181
phenylpropanolamine 242 epochs in 80 Project Sleep 181
phenytoin 24, 75, 199 of erectile ability 106 prolactin 12, 92, 181–182, 189
pH monitoring 81, 174 examinations given in 52–53, promethazine 131
photoperiod 174 221–222 propensity, sleep liii–liv
phylogeny xvii–xviii, 174–175 eye movements in 83 proposed sleep disorders 182
phymosis 167–168 first night effect in 87 propranol 97
physical activity. See exercise history of xxxvii propranolol 131
physical exhaustion 83 of insomnia 114 prostaglandins xxxiii, 182
physiology of malingerers 130 proteins 65
of dreams xxxiii, 68, 190 montage in 135, 177 protriptyline 23, 47, 142
history of views on xix, xx, xxvii morphology in 137 Provera. See medroxyprogesterone
of REM sleep 188 movement time in 137 Provigil. See modafinil
Pickwickian syndrome xxxvii, 175. See of narcolepsy 141 Prozac. See fluoxetine
also obstructive sleep apnea syndrome of obstructive sleep apnea syndrome pseudoinsomnia. See sleep state
Pieron, Henri xxxii, xxxiii, xxxvi, 84, 160 misperception
102, 220 in sleep disorder centers 211 psychiatric disorders 182–183. See also
Pierre-Robin syndrome 57 thermistors in 248 specific types
Pigeon, Wilfred R. 206 pons 69, 178, 190 v. cerebral degenerative disorders 48
pillows 34 pontogeniculateoccipital spikes. See PGO and dreams 69
pineal gland 27, 132, 175 spikes history of xxvii, xxxvii
Pinel, Phillipe xxvii positive airway pressure. See continuous and impotence 106, 107
pink puffers 50 positive airway pressure influence on sleep xlix–l, 182–183
pituitary adenoma 3 Positive Occipital Sharp Transients of insomnia associated with xlix–lxl,
pituitary gigantism 4 Sleep (POSTS) 71, 178 112, 182
pituitary gland 5–6, 92, 181–182 positive pressure ventilation, nasal 144 v. menstrual-associated sleep disorder
placebos 175 postpartum depression 180 133
Placidyl. See ethchlorvynol postpartum psychoses 180 neuroleptics for 146
plants POSTS. See Positive Occipital Sharp nightmares in 148
circadian rhythms of xxvi–xxvii, Transients of Sleep v. recurrent hypersomnia 189
xxxi, xxxv, 40, 129–130 posttraumatic hypersomnia 178–179 tranquilizers for 252
medicinal xviii, xix, xxvii post-traumatic stress disorder (PTSD) psychoanalysis xxxvi, 89
methylxanthines in 194 xlii, 179 psychogenetic fugues 233
Plato xxii pramipexole 67, 179, 195 psychological effects
plethysmography 108, 175–176, 194 predormital myoclonus. See sleep starts of insomnia l–lii
Pliny the elder xxii–xxiii Pregabalin 86 of sleep deprivation l–li, 209–210
PLMD. See periodic limb movement pregnancy psychological well-being l–li
disorder night sweats in 219 psychology of sleep xlix–lv
PLMS. See periodic limb movements of prolactin in 182 psychophysiological insomnia 183–184,
sleep restlessness in 196 213. See also adjustment sleep disorder
PM Positioner 164 sleep disturbance in 12, 179–180 anxiety in 24, 25, 183
PNH. See paroxysmal nocturnal sleeping position in 34, 179 bereavement and 39
hemoglobinuria pregnancy-related sleep disorder 179– conditioned insomnia in 54
PNS. See peripheral nervous system 180, 196 after extrinsic sleep disorders 83
POAH. See preoptic and anterior prehistoric era xvii–xviii v. idiopathic insomnia 105
hypothalamic nuclei premature infants 27, 47, 110, 180, 208 v. inadequate sleep hygiene 107, 184
Podalirios xxi premature morning awakening. See early internal arousals in 117
poliomyelitis 176 morning arousal naps and 139
Pollak, Charles 204 premature ventricular contraction. See restlessness in 196
polycythemia 176 ventricular premature complexes v. sleep onset association disorder
polyphasic sleep-wake pattern xviii premenstrual syndrome 132–133 224
polysomnograms xxxvii, 176–177. preoptic and anterior hypothalamic and sleep onset insomnia 224
See also electroencephalogram; nuclei (POAH) 248 v. sleep state misperception 230
electromyogram; electrooculogram Preyer, Thierry Wilhelm xxx treatment of 35, 184, 213
polysomnographers. See clinical Priestley, Joseph xxvii psychoses 183, 184
polysomnographers primary enuresis 217, 218 postpartum 180
polysomnography 177–178 primary insomnia. See idiopathic in sleep deprivation 209, 210
of abnormal swallowing syndrome 1 insomnia; psychophysiological PTSD. See post-traumatic stress disorder
of adjustment sleep disorder 5 insomnia public education. See education
302 The Encyclopedia of Sleep and Sleep Disorders

pulmonary disease. See chronic REM-on cells 91, 188, 190 percent of 193
obstructive pulmonary disease REM parasomnias 190 period of 193
pulmonary hypertension 184 REM rebound 190, 192 physiological changes in 188
pupillometry 16, 82, 185, 260 REM sleep 187–188, 204, 228–229 in psychiatric disorders l
Purkinje, Johannes Evangelistica xxix, age and 216 rebound of 190, 192
xxxiv alcohol and 14, 15 reciprocal interaction model of 188,
Pythagoras xxi angina during 43 190
arginine vasotocin in 28 recurring patterns of xxxiv
Q in arousal disorders 29 REM-off cells in 190
quiet sleep 108–109, 163, 186 atonia in 30, 69–70, 189, 208 REM-on cells in 190
quiet wakefulness 261 awakening from in schizophrenia 198
quinine 57, 152 cognitive effects of 53 sinus arrest in 43, 44, 193
dream recall after 190–191 at sleep onset 193, 224
R learning after 124 sleep talking in 230
rabbits 61–62 barbiturates and 32 stimulants and 240
radiofrequency thermal ablation. See benzodiazepines and 36 thermoregulation in 248–249
somnoplasty beta activity in 189–190 tricyclic antidepressants and 22
radiofrequency uvulopalatoplasty 236, bruxism in 208 REM sleep behavior disorder (RBD)
257 in cataplexy 45 191–192, 215
radiographs, cephalometric 48, 86, 160 central alveolar hypoventilation atonia in 189, 208
ramelteon 72, 101 syndrome in 46 cerebral degenerative disorders and
Ramon y Cajal, Santiago xxix in children 8–9, 188 48
Ranson, Steven Walter xxxiv, xxxv in chronic obstructive pulmonary discovery of xxxvii
rantidine 171 disease 50 v. fatal familial insomnia 85
raphe nuclei xxxv, 178, 187, 190, 200 in coma 54 v. nightmares 148, 191
rapid eye movements 133, 187, 235 density of 190 v. restless legs syndrome 195
rapid eye movement sleep. See REM depression and 136 restlessness in 196
sleep deprivation of 62, 190, 192, 210 sleep talking in 191, 230
rational sleep hours 205 as desynchronized sleep 63–64, 228 v. sleepwalking 233
Rauwolfia serpentina xix discovery of xxxiv, xxxix, 29, 62, treatment of 191–192, 254
Razi xxiv 121, 187, 228 REM sleep deprivation 62, 190, 192,
RBD. See REM sleep behavior disorder dopamine in 67 210
RDI. See respiratory disturbance index dreams in 68–70, 127, 187, 190–191 REM sleep intrusion 192
reaction time tests 260 as D sleep 59, 228 REM sleep latency 63, 192–193
rebound insomnia 37, 188 electromyogram of 77 REM sleep-locked 193
Rechtschaffen, Allan xxxiv, 187, 228, episodes of 227 REM sleep myoclonus 88
238 erections during 81, 106, 154, 171, REM sleep onset 193
reciprocal interaction model of sleep 188 REM sleep percent 193
188, 190 evolution of xviii, 175 REM sleep period 193
recurrent hypersomnia 188–189 eye movements in 77, 83 REM sleep–related sinus arrest 43, 167,
as disorder of excessive somnolence in fatal familial insomnia 85 193
66 functions of 223 Renaissance xxv
food in 65, 188–189 hallucinations in 97 reptiles xvii–xviii, 174, 175
in intermittent DOES syndrome headaches in 53, 93, 193 RERA. See respiratory effort-related
117 headbanging in 94 arousal
in Kleine-Levin syndrome 121, 188 in infants 108, 188, 193 reserpine xix, 252
lithium for 126, 189 intrusion of, in NREM sleep 192 residence, family xlii–xliii
red blood cells 170, 176 kyphoscoliosis in 122 respiratory disorders. See breathing
reflexology xxxii–xxxiii lithium and 126 disorders
refugees 244 locus ceruleus in 126 respiratory disturbance index (RDI) 26,
relaxation 82, 189 maintenance of xxxv 193, 212
as insomnia treatment liv, 35, 184, MAO inhibitors and 135 respiratory effort 194
213 and memory 223 respiratory effort-related arousal (RERA)
Jacobsonian 120, 181, 184, 219 in menstrual cycle 133 194
progressive 181 muscle activity in 133 respiratory stimulants 194–195. See also
sleep exercises 218–219 muscle tone in 138, 187–188 specific types
systemic desensitization combined neurophysiology of xxxv for altitude insomnia 17
with 246 non-REM intrusion in 155 analeptic 21
REM atonia xxxv, 30, 69–70, 189, 208 norepinephrine in 156 for central alveolar hypoventilation
REM-beta activity 189–190 obstructive sleep apnea syndrome syndrome 46
REM density 190 in 160 for central apnea 47
Remeron. See mirtazapine parasomnias associated with 190 for Cheyne-Stokes respiration 49
REM-off cells 188, 190 in Parkinsonism 170 for kyphoscoliosis 122
 Index 303

sleepiness affected by 131 Rozhon, Tracie xliv sexuality. See hypersexuality

types of 194–195 RPO. See reticularis pontis oralis Shakespeare, William xxv
and ventricular arrhythmias 258– Ruckhardt, Rabl xxix Shen Nung xx
259 shift-work 200–202
Respitrace 176 S evening shift in 82, 201
restless legs syndrome (RLS) xxvi, 195, SAD. See seasonal affective disorder night shift in 149, 200–201
213 St. John’s wort 207 reversal of sleep and 197
and fibromyalgia 86 Salerno xxiv shift-work sleep disorder 200–202, 214
periodic leg movements in 172, 195, saliva 1 discovery of xxxvii
213 Sanctorious xxvi–xxvii and drowsy driving 71
restlessness in 196 sandman 198 prevalence of 215
v. sleep starts 195, 229 Sanorex. See mazindol as short-term insomnia 203
treatment of 195, 254 Saturday night palsy 224 as socially or environmentally
carbamazepine in 42, 195 sawtooth waves 187, 198, 249 induced disorder 237
dopamine agonists in 67, 254 Scandinavian Sleep Research Society as transient circadian rhythm sleep
effectiveness of 254 (SSRS) xxxviii, 118 disorder 52
L-dopa in 124, 195 Scheele, Karl xxvii treatment of 58, 201–202
narcotics in 144 Schenk, Carlos xxxvii, 191 short sleepers 202
pramipexole in 179, 195 schizophrenia 30, 45, 77, 146, 183, 198 v. advanced sleep phase syndrome 6
restlessness 195–196 Schmidt, Helmut S. 19 v. idiopathic insomnia 105
Restorative Theory of sleep 222 Schwartz, Barry xlii insomnia in 113–114, 202
Restoril. See temazepam Schwartz, Lisa 206 leptin in 124
reticular activating system. See Ascending scientific revolution xxv sleep duration of 202, 217
Reticular Activating System SCN. See suprachiasmatic nuclei short-term insomnia 39, 102, 114,
reticular formation xxxv, 29, 91 scopolamine xix 202–203, 252
reticularis pontis oralis (RPO) 126 seasonal affective disorder (SAD) 63, Shprintzen’s syndrome 58
reticular nuclei 178 125, 198–199 Shy-Drager syndrome 169
retino-hypothalamic tract (RHT) 245 secondary enuresis 217, 218 SIDS. See sudden infant death syndrome
retrognathia 133 sedatives 14, 24, 72, 94. See also siestas 16, 139, 203, 211, 216
Rett syndrome 48 hypnotics Siffre, Michel xxxvi, 203, 247
reverie, hypnagogic 98, 222 seizures 199 sigma rhythms 203
reversal of sleep 196–197 in benign epilepsy with Rolandic Simons, R. 202
reversed first night effect 184, 197 spikes 35 Simpson, Sutherland xxxvi
rheumatic disorders 86–87 in electrical status epilepticus of sleep sinus arrest 43, 44, 193
rheumatic pain modulation disorder. See 75, 199 situational insomnia 5, 252. See also
fibrositis syndrome in epilepsy 79–80, 199 adjustment sleep disorder
rheumatoid arthritis 167 hypnopompic 98 sleep 204–208. See also specific types
Rhines, Ruth xxxv in nocturnal paroxysmal dystonia attitudes toward, changes in xliv–
rhinitis 144, 161 153 xlvi
RHT. See retino-hypothalamic tract v. sleepwalking 214 behavioral theories of xxx, xxxii–
rhythmic movement disorder 40, 94, selective serotonin reuptake inhibitors xxxiii
120, 197, 232 (SSRIs) 21–22 chemical theories of xxx, xxxii
rhythms 197. See also biological selegiline 135 v. coma 54
rhythms; circadian rhythms self-hypnosis 31 drive to liii–liv
infradian 197, 256 self-medication 207 evolution of xvii–xviii, 174–175
ultradian 197, 256 serotonin 200 functions of 205–206, 209, 222–223
Richardson, Gary xxxiv, xxxvii antidepressants’ effects on 21–22 history of xvii–xxxviii
Richter, Curt P. xxxv biochemical name for 87 in 17th and 18th centuries
right to sleep xliv functions of xxxv, 200 xxv–xxvii
Rigiscan 197, 242 and insomnia 87, 187, 200 in 19th century xxvii–xxxii
Ritalin. See methylphenidate and melatonin 132 in 20th century xxxii–xxxviii
hydrochloride muramyl dipeptide and 138 ancient xvii–xxiii
RLS. See restless legs syndrome in raphe nuclei 187, 200 biblical xxiii–xxiv
Roentgen, Wilhelm Konrad xxxii L-tryptophan and 65, 87, 101, 200 medieval xxiv–xxv
Roffwarg, Howard Philip xxxvi, 64, 68, serotonin reuptake inhibitors 21–22, prehistoric xvii–xviii
69 23–24, 87, 136, 200 Renaissance xxv
Rolando, Luigi xxviii, xxx sertraline 24 interdependence of wakefulness and
Rome, ancient xxii–xxiii Serzone. See nefazodone xlix–lv
Rophypnol 72 SESE. See subclinical electrical status modern concerns about 206–207
ropinirole 67, 195 epilepticus of sleep need for 204–205, 222–223
Rosenblatt, Paul xliv settling 200 neural theories of xxix–xxx
Roth, Thomas xxxvi, 216 Severinghaus, John W. xxxvii, 162 ontogeny of 162–163
Rozerem. See ramelteon sexual dreams 70, 171 pathology of xxxvi–xxxviii
304 The Encyclopedia of Sleep and Sleep Disorders

psychology of xlix–lv number of 212 causes of 9, 215, 218

reasons for 205–206, 209, 222–223 prevalence of 206, 215 obstructive sleep apnea syndrome
reversal of 196–197 proposed 182 and 160, 218
rhythm of liv–lv treatment of. See treatment of sleep primary v. secondary 217, 218
right to xliv disorders seizures and 199
sociology of vii, xxxix–xlvii sleep disorder centers 211. See also treatment of 9–10, 23, 218
types of 204 laboratories sleep episodes 227
vascular theories of xxviii–xxix accreditation of xxxviii, 2–3, 211 duration of. See sleep duration
Sleep (journal) xxxviii, 118 cephalometric radiographs at 48 efficiency in 217
sleep aid medications 72–73, 165. See establishment of xxxviii, 211, 215, nocturnal 154
also hypnotics; specific types 261–262 NREM-REM sleep cycle in 156
sleep apnea 208. See also apnea first night effect in 87, 106 siestas 203
sleep architecture 208, 221 reversed 184, 197 total 251
sleep atonia 208. See also atonia lists of vii, ix, 269–270 total sleep time in 251
sleep attacks 140 role of 254 sleepers. See also short sleepers
sleep bruxism 208–209. See also bruxism sleep specialists in 227 long 126–127, 217
sleep choking syndrome 113, 168, 209 as sleep-wake disorders center 232 rights of xliv
sleep cure. See sleep therapy sleep-disordered breathing 211–212. See role of xliii–xliv
sleep cycles. See NREM-REM sleep cycles also breathing disorders sleep exercises 218–219. See also
sleep deprivation 209–211 sleep disorders medicine 215–216 relaxation
accidents caused by xl, xlv. See also advances in 206, 212, 215–216 sleep fragmentation 15, 219
drowsy driving board certification in 19–20 sleep hygiene 219. See also inadequate
changes in attitudes toward xliv–xlvi examination in 221–222 sleep hygiene
and confusional arousals 55 growth of field 206, 212, 215 alcohol and 15
for depression 192, 210 history of xxxviii and anxiety disorders 25
in drowsy driving 71 sleep specialists in 52, 206, 227 beds in 34
effects of xl, xli, xlv, l–li, 205, sleep disturbance. See also sleep and cerebral degenerative disorders
209–210 interruption 49
v. insomnia 210–211 in anxiety disorders 24–25 and dementia 63
in insufficient sleep syndrome 116 in cerebral degenerative disorders 48 in elderly 75
in long sleepers 126 in chronic obstructive pulmonary erratic hours in 81
prevalence of xl disease 50–51 exercise in 82
record for longest 90 in dementia 62–63 in fibrositis syndrome 87
of REM sleep 62, 190, 192, 210 in depression 63 in hypnotic-dependent sleep disorder
v. short sleepers 202 in elderly 12–13, 74–75 99
and slow wave sleep 235 in fibrositis syndrome 86–87 in infants 7
studies on 62, 209–210, 254–255 in infants 7 as insomnia treatment 35
time management and xl in pregnancy 12, 179–180 and shift-work sleep disorder 201
in time zone change syndrome 249 in psychiatric disorders 182–183 sleep hyperhidrosis (night sweats) 132,
in women xli in psychoses 184 219–220, 246
sleep diaries. See sleep logs in women xl–xli, 12 sleep hypochrondriasis. See sleep state
sleep disorder(s) 212–215. See also specific sleep drive liii–liv misperception
types sleep driving 205 Sleepinal 165
in adolescents 10–11 sleep drunkenness 54, 216 sleep-inducing factors xxxiii, 49, 65, 84,
in adults 11–12 sleep duration 216–217. See also total 90, 220
age and 6 sleep time sleepiness 220. See also excessive
in children 9 in adolescents 10 sleepiness
classification of 212 amount needed 204–205 in accidents 1–2
common, overview of 212–215 and deaths during sleep 59 in adolescents 10–11
in elderly 12–13, 74–75 in delayed sleep phase syndrome 60 cycle of 16
history of in infants 6–7, 108, 216 v. daydreaming 59
in 17th and 18th centuries in insomnia 217 drugs’ effects on 72, 130–132
xxv–xxvii in long sleepers 126–127, 217 in elderly 74
in 19th century xxvii–xxxii of naps 139 v. fatigue 85
in 20th century xxxii–xxxviii of nocturnal sleep episodes 154 history of understanding of xvii, xxviii
ancient xvii–xxiii and obesity 159 in hypothyroidism 103
medieval xxiv–xxv ontogeny of 163 measurement of. See also multiple
prehistoric xvii–xviii in shift-work sleep disorder 200, 201 sleep latency test
Renaissance xxv in short sleepers 202, 217 Epworth Scale 16, 80–81, 82
history of understanding of xvii– sleep efficiency 217 Stanford Scale 16, 82, 239
xxxviii sleep enuresis (bed-wetting) 9–10, visual analogue scale 260
in infants 7–8, 109–111 217–218 nonrestorative sleep and 155
new types of xvii, xxxvii as arousal disorder 28 pupillometry and 185
 Index 305

sleeping pills. See hypnotics evolution of xviii, 174–175 sleep-wake disorders center 232. See also
sleeping position 34 of infants 6–8, 108–110, 163 sleep disorder centers
of infants 8, 243–244 of long sleepers 126 sleep-wake schedule disorders. See
in pregnancy 34, 179 ontogeny of 162–163 circadian rhythm sleep disorders
and sleep palsies 224 reversal of 196–197 sleep-wake transition disorders 169,
and snoring 181, 236 schedule of 227 232. See also specific types
sleeping sickness 221 of shift workers 200–201 sleepwalking 214, 232–234
sleep interruption 221. See also sleep period, NREM 156–157 accidents in 2, 233–234
awakening(s); sleep disturbance sleep promoting substance (SPS) 102 Ambien and 17
sleep laboratories. See laboratories sleep-regulating center xxxiii, xxxiv, 225 as arousal disorder 28–29
sleep latency 221 Sleep Research Society (SRS) xxxviii, in children 9, 214, 232–234
alcohol and 14 44, 238 and confusional arousals 55
barbiturates and 32 sleep restriction therapy xxxvii, liv, v. epilepsy 79–80, 233
benzodiazepines and 36 225–227 gamma-hydroxybutyrate and 90
in chronic obstructive pulmonary sleep salons and spas 206–207 genetics of 91, 233
disease 50 sleep schedules 227 hypnosis and 98
evaluation of. See multiple sleep sleep societies v. restlessness 196
latency test history of 118, 215 v. seizures 214
in maintenance of wakefulness test international 118 sleep talking and 230, 232
129 list of 264–268 and sleep terrors 2, 231
REM sleep latency 63, 192–193 Sleep Society of Canada (SSC) xxxviii, slow rolling eye movements 234–235
in sleep onset insomnia 224 118 slow wave sleep (SWS) 235. See also
sleep logs 61, 221, 253 sleep specialists 52, 206, 227, 237 stage four sleep
sleep maintenance insomnia (DIMS) sleep spindles 48, 54, 121, 203, 227, in alcoholics 15
221 228, 239 angina during 44
sleep medicine. See sleep disorders sleep stage(s) 204, 227–229. See also arginine vasotocin and 28
medicine REM sleep; stage four sleep; stage one in arousal disorders 29
sleep medicine and clinical sleep; stage three sleep; stage two sleep awakening from
polysomnography examination 221– A–E classification of 238 cognitive effects of 53
222 age and 6 learning after 124
sleep mentation 222 demarcation of 227 barbiturates and 32
sleep need 222–223 discovery of xxxiii, 227–228 benign neonatal sleep myoclonus
sleep onset 223 electroencephalogram of 76 during 35
in advanced sleep phase syndrome 6 episodes of 227 in children 9
alcohol and 14 evolution of xviii, 174–175 as delta sleep 61
in anxiety disorders 24–25 sleep starts 80, 195, 229, 232, 255 in elderly 12
conditioning of liii sleep state(s), cognitive effects of 53 evolution of xviii, 174
in delayed sleep phase syndrome 60 sleep state misperception 113–114, 155, exercise and 83
dopamine and 67 217, 229–230 eye movements in 83
erratic hours of 81 sleep surface 196, 230 Factor S and 84
exercise and 82 sleep talking 191, 230, 232 in fatal familial insomnia 85
REM sleep at 193, 224 sleep terrors 214, 230–232 gamma-hydroxybutyrate and 90
in sleep schedules 227 and accidents 2, 231 headbanging in 94
sleep starts at 229 alcoholism and 15 in hibernation 95
in time zone change syndrome 249, as arousal disorder 28–29, 230, 231 interleukin-1 in 116
250 cardiovascular symptoms of 44 lithium and 126
sleep onset association disorder 8, 35, in children 9, 214, 230–231 in menstrual cycle 133
126, 223–224 and confusional arousals 55, 231 in naps 139
sleep onset insomnia 21, 37–38, 113, v. epilepsy 80, 199, 231 raphe nuclei in 187
224, 229 genetics of 91, 231 serotonin in 200
sleep onset nightmares. See terrifying hypnosis and 98 sleepwalking in 214, 232, 233
hypnagogic hallucinations v. incubus 107, 230 Smith, Carl T. 239
sleep onset REM period (SOREMP) 193, v. nightmares 70, 148, 214, 231 smoking 235
224 v. panic disorders 168, 214 in chronic obstructive pulmonary
sleep palsies 224 as pavor nocturnus 170, 230 disease 50
sleep paralysis 139–140, 224–225 sleepwalking and 2, 231 fires caused by 147, 235
sleep patterns 225. See also irregular in sudden unexplained nocturnal nicotine in 147, 235
sleep-wake pattern death syndrome 244 and obstructive sleep apnea
of adolescents 10–11, 163 v. terrifying hypnagogic syndrome 161, 235
of animals xviii, 21 hallucinations 248 and peptic ulcer disease 171
of children 8–9, 163 sleep therapy 77–78, 232 and sleep starts 229
in coma 54 sleep-wake cycles. See NREM-REM sleep snacks, nighttime 65
of elderly 74 cycles Snore Guard 164
306 The Encyclopedia of Sleep and Sleep Disorders

snoring 235–236 spine, kyphoscoliosis of 121–122 in post-traumatic stress disorder xlii,

accidents related to 2 SPS. See sleep promoting substance 179
in adolescents 11 SRS. See Sleep Research Society in psychophysiological insomnia
alcohol and 14 SRS Distinguished Scientist Award 238 183, 184
in children 181, 236 SRS Young Investigator Award 238 in short-term insomnia 203
in men xli, 181 SSC. See Sleep Society of Canada in sleep talking 230
noise of 155, 236 SSRIs 21–22 in sleep terrors 231
in obstructive sleep apnea syndrome SSRS. See Scandinavian Sleep Research work-related xlii
155, 159–160, 180, 181, 212, Society stridor 123–124
235–236 SSS. See Stanford Sleepiness Scale stroke 199
primary 155, 180–181 stage(s), sleep. See sleep stage(s); specific stupor 243, 256
treatment of 236 stages subclinical electrical status epilepticus of
behavioral 181, 236 stage A sleep 238 sleep (SESE) 75
laser uvulopalatoplasty in 124, stage B sleep 238 subjective DIMS complaint without
236 stage C sleep 238 objective findings. See sleep state
oral appliances in 81, 163–164, stage D sleep 59, 238 misperception
236 stage E sleep 238 succubus 108
somnoplasty in 237 stage five sleep. See REM sleep sucrose lysis test 170
uvulopalatopharyngoplasty in stage four sleep 61, 62, 204, 217–218, sudden infant death syndrome (SIDS) 8,
181, 236, 257 228. See also slow wave sleep 243–244
in women 12 stage one sleep 71, 83, 204, 223, 228, apnea and 27, 47, 109, 243
Snyder, Frederick xxxvii 234–235 as cot death 57
socially or environmentally induced stage three sleep 61, 62, 204, 217–218, as crib death 58
disorders of the sleep-wake schedule 228 in premature infants 110, 180
236–237. See also circadian rhythm stage two sleep 62, 98, 121, 204, 208, prevalence of 215, 243
sleep disorders 228, 239 thermoregulation and 249
societies. See sleep societies Stahl, George xxvi sudden unexplained nocturnal death
Sociology (journal) xl Stanford Sleepiness Scale (SSS) 16, 82, syndrome (SUND) 43, 44, 244
sociology of sleep xxxix–xlvii 239, 260 sulfonal xxxi
attitudes toward sleep deprivation in status cataplecticus 45, 140, 239 Sullivan, Colin xxxvii, 56
xliv–xlvi Stephan, F. K. xxxv SUND. See sudden unexplained
change and grief in xli Stevenson, Robert Louis 70 nocturnal death syndrome
future of xlvii stimulant(s) 240–242. See also specific Sunday night insomnia 34, 244–245
insomnia in xlvi–xlvii types sundown syndrome 62, 75. See also
rise of field xliii alertness affected by 16, 131 dementia
scope of field vii, xxxix, xliii v. codeine 53 suprachiasmatic nuclei (SCN) 245
time management in xl common uses for 240 biological clock in 40
in women v. men xl–xli dependence on 73, 239–240 circadian pacemaker as 78, 167, 245
somatostatin 220 dopamine as 67 discovery of xxxv
Sominex 165 drinks and foods as 42, 65 of hypothalamus 103, 245
Sommer, Wilhelm xxx for idiopathic hypersomnia 105 and melatonin 132, 245
somnambulism. See sleepwalking for narcolepsy 142, 240–242 and pineal gland 175
somniferous 237 nicotine as 147 and ventrolateral preoptic nucleus
somniloquy. See sleep talking over-the-counter 165, 239, 242 259
somnoendoscopy 78, 237 for Parkinsonism 170 suramin 221
somnofluoroscopy 237 for posttraumatic hypersomnia 179 surgery, for sleep disorders 245–246. See
somnolence 82. See also excessive for recurrent hypersomnia 189 also specific types
sleepiness side effects of 240–242 swallowing, abnormal 1
somnologists 237 sleepiness affected by 131 sweating during sleep 132, 219–220,
somnology 237 and sleep starts 229 246
somnoplasty 237–238 in stimulant-dependent sleep SWS. See slow wave sleep
Somnus (god) 238 disorder 112, 201, 239–240, 241 Sydenham, Thomas xxvi
Sonata. See zaleplon tolerance to 239, 241, 250 Symonds, Charles 152
soporific 238 types of 240–242 synchronized sleep 246
SOREMP. See sleep onset REM period stimulant-dependent sleep disorder 112, systemic desensitization 246
Southeast Asia 244 201, 239–240, 241
Spain 203 stimulus control therapy xxxvii, 226, T
spicy foods 65 242 tachyarrhythmias 43
Spielman, Arthur xxxvii Stokes, William 49, 172 tachycardia 45, 165, 247
spinal cord 46 strain gauges 176, 194, 197, 242 tachypnea, neurogenic 146
spinal fluid. See cerebrospinal fluid stress 242–243 Tagamet. See cimetidine
spindle coma 54 biofeedback and 39 Tartini, Guiseppe 70
spindles. See sleep spindles and nightmares 148 Taylor, Brian xlii
 Index 307

technologists, sleep xxxviii, 19 tonic-conic seizures 80, 153, 199 for sleep paralysis 225
teenagers. See adolescents tonsillectomy 161, 245, 250–251 for sleep terrors 231
teeth grinding 41, 77, 208–209 tonsils 9, 10, 11 v. SSRIs 22
Tegretol. See carbamazepine total recording time (TRT) 251 types of 22–23
temazepam 36, 37–38 total sleep episode 251 withdrawal from 23
temperature, body 247 total sleep time (TST) 251. See also sleep Tripp, Peter 209, 254–255
in biofeedback 39 duration trizolam 195
circadian rhythm of lv, 55, 63, 139 of adults 12 TRT. See total recording time
in constant routine test 55 of infants 6 trypanosomiasis 221
in delayed sleep phase syndrome 60 REM sleep percent of 193 tse-tse fly 221
exercise and l, 83, 247 of short sleepers 202 TST. See total sleep time
Factor S and 84 siestas and 203 tuberculosis xviii
in hibernation 95 by sleep stage 228 tuberomammillary nucleus (TMN) 134
nadir of 139 toxic agents xxx, 251 tumescence 255. See also erections
in REM sleep 248–249 toxin-induced sleep disorder 251 during sleep
thermoregulation of 248–249 trace alternant 251 twitches 255
warm baths and 247, 261 tracheostomy xxii, xxxvii, 122, 245– Tylenol PM 165
temperature, environmental 95, 247, 246, 251–252 type-1 oscillator. See circadian pacemaker
249 tranquilizers 252 tyramine 135
temporal isolation 58, 63, 203, 247 transient insomnia 114, 203, 252
temporal lobe seizures 199 transient psychophysiological insomnia. U
tension headaches 93 See adjustment sleep disorder UARS. See upper airway resistance
terminal insomnia. See early morning transition disorders, sleep-wake 169, syndrome
arousal 232 ulcer disease, peptic 171
terrifying hypnagogic hallucinations 70, TRD. See tongue retaining device ultradian rhythms 197, 256
98, 248 Treacher Collins syndrome 57 unconscious
thalamo-cortical system 174–175 treatment of sleep disorders xvii–xxxviii, collective 120
Thales of Miletos xxi 252–254. See also specific treatments dreams and 88–89
theobromine 194 in 17th and 18th centuries xxv–xxvii unconsciousness 256
Theogony (Hesiod) xx in 19th century xxvii–xxxii Unisom 165
theophylline 194–195 in 20th century xxxii–xxxviii UPP. See uvulopalatopharyngoplasty
Therasnore 164 ancient xvii–xxiii upper airway obstruction 256–257. See
theriac xxv medieval xxiv–xxv also obstructive sleep apnea syndrome
thermistors 26, 248 prehistoric xvii–xviii adenoids in 5
thermoregulation 248–249 Renaissance xxv endoscopy of 78, 85–86, 237
theta activity 54, 75, 187, 198, 249 successes in 252–254 and hypoxia 104
theta coma 54 triazolam 36, 38, 102 in infants 109, 111
Thorpy, Michael J. 117, 143 triclofos 101 lung disease and 127–128
Thoth (god) xix tricyclic antidepressants 22–23. See also micrognathia and 133
thrombosis 170 specific types snoring and 235
thyroid gland xxx, 97, 103 anticholinergic effects of 3, 21, somnofluoroscopy of 237
thyroid hormone 97, 103 22–23 surgical treatment of 245–246
thyroxine 103 for cataplexy 140, 142 upper airway resistance syndrome
tidal volume 45, 50, 249 common uses for 22 (UARS) 257
time cues. See environmental time cues for confusional arousals 55 upper airway sleep apnea. See obstructive
time management xl for enuresis 10, 23, 218 sleep apnea syndrome
time zone change (jet lag) syndrome for fibrositis syndrome 87 urethane xxxi
xxxvii, 120, 214, 249–250 for headbanging 94 urinary sphincter 218
Argonne diet for 28 for hypnotic-dependent sleep urination, frequent 149. See also sleep
hypnotics and 102, 250 disorder 99 enuresis
reversal of sleep and 197 for insomnia 22 urine sensors 9–10
as short-term insomnia 203 for mood disorders 136 urotoxins xxx
as socially or environmentally for pain 167 uvulopalatopharyngoplasty (UPP)
induced disorder 237 for painful erections 168 xxxvii, 96, 181, 236, 245, 251, 257
as transient circadian rhythm sleep for panic disorders 168 uvulopalatoplasty 124, 236, 257
disorder 52 and periodic limb movement disorder
tiredness, v. sleepiness 220 172 V
Tiu (god) xviii for REM sleep behavior disorder 191 Valerian root 207
TMN. See tuberomammillary nucleus and REM sleep latency 192–193 Valium. See diazepam
tobacco. See smoking REM sleep suppressed by 210 VAS. See visual analogue scale
Tofranil. See imipramine sedative effects of 132 vascular theories of sleep xxvii, xxviii–
tolerance 239, 241, 250, 250 and serotonin 200 xxix
tongue retaining device (TRD) 164, 250 side effects of 22–23 vasointestinal polypeptide (VIP) 258
308 The Encyclopedia of Sleep and Sleep Disorders

vegetative state 54 interdependence of sleep and xlix–lv Withering, William xxvii

vehicular homicide 71, 129 microsleep during 133 Woloshin, Steven 206
velo-cardio-facial syndrome 58 norepinephrine in 156 women
velopharynx 173 rapid eye movements in 187 anxiety disorders in 25
venlafaxine 24 rhythm of liv–lv dreams of 68, 69
ventilation 258. See also breathing in sleep patterns 225 drowsy driving by xli, 71
disorders; hypoventilation wake times 261 fibromyalgia in 86
assisted. See specific types waking center xxxiv, xxxv insomnia in 12
inductive plethysmography of 108 Waldeyer, Heinrich xxix menopause in 12, 132, 133, 219
nasal congestion and 144 war 34 menstrual cycle of 117, 132–133
in neuromuscular diseases 147 warm baths 247, 261 middle-aged 12
periodic breathing 171–172 Wearley, Lorraine 145 nightmares in 148
ventricular arrhythmias 43, 244, weight 261. See also obesity obstructive sleep apnea syndrome
258–259 and carpal tunnel syndrome 44 in 12
ventricular premature complexes 259 and central apnea 47 pregnant. See pregnancy
ventrolateral preoptic area (VLPO) 259 in hypothyroidism 103 sleep choking syndrome in 209
ventrolateral preoptic nucleus 259 ideal 158 sleep disturbance in xl–xli, 12
vertex sharp transients 260 in middle age 12 snoring in 12
vertex sharp waves 121 in nocturnal eating syndrome 151, work xl, xlii, xlv, 203
Vesalius, Andreas xxiii, xxv 261 Wyzinski, Peter W. 91, 188
vigilance 260. See also alertness in obstructive sleep apnea syndrome
vigilance testing 82, 260, 262 158–161, 261 X
viloxazine 142 sleep duration and 159 Xanax. See alprazolam
VIP. See vasointestinal polypeptide and snoring 181, 236 X-oscillator. See circadian pacemaker
viral encephalitis xxxiv weight loss X-rays xxxii. See also cephalometric
Virgil 107–108 through bariatric surgery 32–33 radiographs
visual analogue scale (VAS) 260 through diet 158–159 Xyrem. See gamma-hydroxybutyrate
vitalism xxvi stimulant medications for 241, 242
vitamins 207 Weight Watchers 159 Y
Vivactil. See protriptyline Weitzman, Elliot D. xxxvi, xxxvii, yawning 263
Vivarin 165 xxxviii, 58, 60, 97, 247, 261–262 Yelo 207
VLPO. See ventrolateral preoptic area Welch, H. Gilbert 206 Yin and Yang xx
vocal cord spasms 123 well-being, psychological l–li yoga 82
Vogel, Gerald xxxvi Wells, William Hughes xxxii Yoss, Robert 242
Voit, Carl xxx Wenston, John 206 Yu Hsiung xx
Westbrook, Carol 145
W Westphal, Carl Friedrich Otto xxxi Z
Wadd, William xxxii wet dreams. See nocturnal emissions zaleplon 101–102
wakefulness 261. See also awakening Wever, Kurt xxxv–xxxvi Zantac. See rantidine
armodafinil and 28 Wexler, Haskell 207 Zappert, Julius 94, 120
beta rhythm in 39 White, Harrison xlii zeitgeber 79
v. coma 54 white noise 154 ziprasidone 30
dopamine in 67 Who Needs Sleep (documentary) 207 Zoloft. See sertraline
drowsiness as state of 70–71 Wilkinson auditory vigilance testing 262 zolpidem. See Ambien
eye movement during 83 Williams, Simon xlii, xliii, xliv, 175 zopiclone 102
histamine in 95 Willis, Thomas xxvi, xxxiii Zucker, Irving xxxv
in infants 108, 163 wine xix Zwilling, George 202
 ABOUT THE AUTHORS
Charles P. Pollak, M.D., is the director of the Cen- dation and director of its National Narcolepsy
ter for Sleep Medicine of Cornell University-Weill Registry. Dr. Thorpy has published several books
Medical College at New York Presbyterian Hos- and is the author of more than 50 articles, includ-
pital as well as director of the Institute of Chro- ing peer-reviewed texts in periodicals such as the
nobiology. Dr. Pollak received his medical degree New England Journal of Medicine. In 1993 he was
at the Albert Einstein College of Medicine and awarded one of the sleep field’s highest honors:
subsequently completed his neurology residency the Nathaniel Kleitman Award from the American
there. He is a diplomat of the American Board of Sleep Disorders Association.
Sleep Medicine and he has also been certified as
a clinical polysomnographer from the Association Jan Yager, Ph.D., is a prolific and award-winning
of Sleep Disorder Centers. His areas of research author and sociologist who has written 26 books,
have included narcolepsy and sleep habits of the including Sleeping Well, coauthored with Michael
elderly. J. Thorpy, M.D., and numerous articles that have
appeared in Parade, Fit, Woman’s Day, the New York
Michael J. Thorpy, M.D., board-certified in sleep Times, Harper’s, and other publications. The recipi-
disorders medicine, is the director of the Sleep- ent of a National Science Foundation predoctoral
Wake Disorders Center at Montefiore Medical fellowship in medical sociology and an Alumni of
Center, Bronx, New York, and an associate pro- the Year Special Achievement Award in 2006 from
fessor of neurology at Albert Einstein College of The City University of New York Graduate Center,
Medicine. He is the chairman of the sleep section she has been interviewed on such TV shows as the
of the American Academy of Neurology as well Today Show, Oprah, Good Morning America, and CNN.
as the past secretary of the National Sleep Foun- For more on Dr. Yager, go to: www.drjanyager.com.

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