D.T.max the Secrets of Sleep

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The Secrets of Sleep

rom birth, we spend a third of our live

sleep. After decades of research, we’rtill not sure why.

y D. T. Max

hotograph by Maggie Steber

heryl Dinges is a 29-year-old Army sergeanom St. Louis. Her job is to train soldiers iand-to-hand combat. Specializing in Braziliajitsu, Dinges says she is one of the few womethe Army certified at level 2 combat. Level

volves a lot of training with two attackers one, she explains, with the hope of “you being th

ne guy getting out alive.”

inges may face an even harder fight in the yearhead. She belongs to a family carrying the gen

or fatal familial insomnia. The main symptom oFI, as the disease is often called, is the inabilit



sleep. First the ability to nap disappears, thee ability to get a full night’s sleep, until th

atient cannot sleep at all. The syndrome usuallrikes when the sufferer is in his or her 50s

rdinarily lasts about a year, and, as the namdicates, always ends in death. Dinges ha

eclined to be tested for the gene. “I was afrai

at if I knew that this was something I had,

ould not try as hard in life. I would allowyself to give up.”

FI is an awful disease, made even worse by thct that we know so little about how it workfter years of study, researchers have figured ouat in a patient with FFI, malformed protein

alled prions attack the sufferer’s thalamus,

ructure deep in the brain, and that a damage

alamus interferes with sleep. But they donnow why this happens, or how to stop it, or eass brutal symptoms. Before FFI was investigatedost researchers didn’t even know the thalamu

ad anything to do with sleep. FFI is exceedinglre, known in only 40 families worldwide. But i



ne respect, it’s a lot like the less serious kinds osomnia plaguing millions of people today: It’

retty much a mystery.

we don’t know why we can’t sleep, it’s in parecause we don’t really know why we need t

eep in the first place. We know we miss it if won’t have it. And we know that no matter how

uch we try to resist it, sleep conquers us in thnd. We know that seven to nine hours afteving in to sleep, most of us are ready to get u

gain, and 15 to 17 hours after that we are tirence more. We have known for 50 years that wvide our slumber between periods of deep-waveep and what is called rapid eye movemen

REM) sleep, when the brain is as active as whee’re awake, but our voluntary muscles ar

aralyzed. We know that all mammals and birdeep. A dolphin sleeps with half its brain awak

o it can remain aware of its underwatenvironment. When mallard ducks sleep in a line

e two outermost birds are able to keep half oeir brains alert and one eye open to guar



gainst predators. Fish, reptiles, and insects axperience some kind of repose too.

ll this downtime comes at a price. An anima

ust lie still for a great stretch of time, durinhich it is easy prey for predators. What caossibly be the payback for such risk? “If sleeoesn’t serve an absolutely vital function,” th

nowned sleep researcher Allan Rechtschaffence said, “it is the greatest mistake evolutio

ver made.”

he predominant theory of sleep is that the braiemands it. This idea derives in part fromommon sense —whose head doesn’t feel cleare

fter a good night’s sleep? But the trick is t

onfirm this assumption with real data. How doe

eeping help the brain? The answer may depenn what kind of sleep you are talking abouecently, researchers at Harvard led by Robertickgold tested undergraduates on variou

ptitude tests, allowed them to nap, then testeem again. They found that those who ha



ngaged in REM sleep subsequently performeetter in pattern recognition tasks, such arammar, while those who slept deeply weretter at memorization. Other researchers hav

ound that the sleeping brain appears to repeat attern of neuron firing that occurred while thubject was recently awake, as if in sleep thrain were trying to commit to long-term memor

hat it had learned that day.

uch studies suggest that memory consolidatioay be one function of sleep. Giulio Tononi,

oted sleep researcher at the University oWisconsin, Madison, published an interestinwist on this theory a few years ago: His studhowed that the sleeping brain seems to weed oudundant or unnecessary synapses o

onnections. So the purpose of sleep may be telp us remember what’s important, by letting u

orget what’s not.

leep is likely to have physiological purposes toohat patients with FFI never live long is likel



gnificant. A lot of interest has focused on whaxactly kills them, but we still don’t know. D

ey literally die from lack of sleep? And if nowhat extent does sleeplessness contribute to th

onditions that kill them? Some researchers havound that sleep deprivation impedes wounealing in rats, and others have suggested thaeep helps boost the immune system and contro

fection. But these studies are not conclusive.

n the most famous attempt to figure out why weep, in the 1980s, Rechtschaffen forced rats tay awake in his University of Chicago lab bacing them on a disk suspended on a spindl

ver a tank of water. If the rats fell asleep, thsk would turn and throw them in the waterhen they fell into the water, they immediatel

oke up. After about two weeks of this stricnforcement of sleeplessness, all the rats weread. But when Rechtschaffen performeecropsies on the animals, he could not fin

nything significantly wrong with them. Thergans were not damaged; they appeared to hav



ed from exhaustion — that is, from not sleepingfollow-up experiment in 2002, with mor

ophisticated instruments, again failed to find “a

nambiguous cause of death” in the rats.

t Stanford University I visited William Demene retired dean of sleep studies, a co-discovere

f REM sleep, and co-founder of the Stanfor

leep Medicine Center. I asked him to tell mhat he knew, after 50 years of research, aboue reason we sleep. “As far as I know,” h

nswered, “the only reason we need to sleep tha

really, really solid is because we get sleepy.”

nfortunately, the reverse is not always true; won’t always get sleepy when we need to sleep

nsomnia is at epidemic levels in the develope

orld. Fifty to 75 million Americans, roughly fth of the population, complain about problemeeping. Fifty-six million prescriptions foeeping pills were written in 2008, up 54 percen

ver the previous four years. The revenue foeep centers is expected to approach four and



alf billion dollars by 2011. Yet remarkably littlbeing done to understand the root causes o

somnia. Most medical school students get nore than four hours of training on slee

sorders; some get none. Family doctors’ healtuestionnaires often don't even ask about sleep.

he social and economic costs from th

ndertreatment of sleeplessness are huge. Thnstitute of Medicine, an independent nationacientific advisory group, estimates nearly 2ercent of all serious motor vehicle accidents arssociated with driver sleepiness. It places threct medical cost of our collective sleep debt ans of billions of dollars. The loss in terms oork productivity are even higher. Then there are softer costs — the damaged or los

lationships, the jobs tired people don't have thnergy to apply for, the muting of enjoyment ife’s pleasures.

a medical problem in some less private, lesysterious bodily function were causing suc



idespread harm, governments would declarar on it. But the National Institutes of Healt

ontributes only about $230 million a year teep research — comparable to the amount tha

e manufacturers of the popular sleeping pillunesta and Ambien spent in one season olevision advertising in 2008. The military als

pends money investigating sleep, but its primar

ission is keeping soldiers up and ready to fighot ensuring they get a good night’s rest. As

sult the fight against insomnia is largely left trug companies and commercial sleep centers.

Sleep has been the Rodney Dangerfield o

edicine,” says John Winkelman, medica

rector of the Brigham and Women’s Hospital’

leep Health Center in Brighton, Massachusett

t just gets no respect.”

ne early afternoon last year I paid a visit to thleep Medicine Center at Stanford. The clinic

ounded in 1970, was the first in the countrevoted to the problem of insomnia, and



mains among the most important. The sleeenter sees over 10,000 patients a year and doeore than 3,000 overnight sleep studies. The 1

edrooms that patients occupy looke

omfortable, the beds soft and cozy. Thonitoring equipment was hidden in th

urniture.

he main diagnostic tool at the clinic is tholysomnogram, the main element of which is thectroencephalograph (EEG), which captures thectrical output from a sleeping patient’s brain

s you fall asleep, your brain slows down, and itectrical signature changes from short jaggeaves to longer rolling ones, much the way thovement of the sea smooths out the farther yo

et from shore. In the brain these gentl

ndulations are interrupted periodically by newal of the sudden agitated mental activity oEM sleep. For unknown reasons, REM is thme during sleep when we do nearly all ou

reaming.





n obstructive sleep apnea sufferers, the muscllaxation that comes with sleep allows the sossue of the throat and esophagus to closehutting off the sleeper’s air passage. When th

rain realizes it is not getting oxygen, it sends amergency signal to the body to wake up. Theeper awakes, takes a breath, the brain iplenished, and sleep returns. A night’s sleep fo

n apnea sufferer turns out to really be a hundreicro-naps. Sleep apnea is the behemoth of theep center business. Brigham and Women’

ohn Winkelman says that at his sleep centewo-thirds of those examined are diagnosed wite condition.

pnea is a serious problem, implicated icreased risk for heart attacks and stroke. But

only indirectly a sleep disease. Trusomniacs — people diagnosed with what someep doctors call psychophysiologicasomnia —are people who either can’t get t

eep or can’t stay asleep for no evident reasonhey wake up and don’t feel rested. They li



own and their brains whir. This group makes ubout 25 percent of those seen in sleep clinicccording to Winkelman. The Institute o

Medicine estimates that over all, there are 3

illion people with this condition in the Unitetates.

While apnea can be treated with a device tha

orces air down the sleeper’s throat to keep thrways open, the treatment of classic insomnia iot so clear-cut. Acupuncture may help — it hang had this role in Asian medicine and is beinudied at the University of Pittsburgh sleeenter now.

ypically, psychophysiological insomnia ieated with a two-part approach. First come th

eeping pills, most of which work by enhancine activity of GABA, a neurotransmitter thagulates overall anxiety and alertness in th

ody. Though safer than they once were, sleepin

lls can lead to psychological addiction. Mansers complain that their sleeping-pill slee



eems different, and they feel hungover wheey wake up. “Sleeping pills are not a natura

ay to sleep,” points out Charles Czeisle

rector of the Harvard Work Hours, Health an

afety Group. Pills can make future insomniorse, too, a drawback called rebound insomnia.

he second step in treating true insomniacs i

sually cognitive behavioral therapy (CBT). IBT, a specialized psychologist teaches thsomniac to think about his or her slee

roblems as manageable, even solvable —that’

e cognitive part —and to practice good “slee

ygiene.” Good sleep hygiene mostly amounts t

ied-and-true advice: Sleep in a dark room, go ted only when you are sleepy, don’t exercis

efore bed. Studies have shown that CBT is mor

ffective than sleeping pills at treating long-termsomnia, but many sufferers aren’t convinced

Some people continue in my experience t

ruggle,” says Winkelman. “They’re not super

atisfied with their sleep.”



Winkelman thinks CBT is better at helping somnds of insomniacs than others. Insomnia covermultitude of conditions. Between FFI, which i

xtremely rare, and apnea, which is ver

ommon, there are almost 90 recognized sleesorders and a host of harder to codify reason

eople can't sleep. Some insomniacs suffer fromstless legs syndrome (RLS), an intens

scomfort in their limbs that prevents fallinsleep, or periodic limb movement disordePLMD), which produces involuntary kickinuring sleep. Narcoleptics often have difficultoth staying asleep and staying awake. Theere are people who can’t sleep because o

epression, and people who are depresseecause they can’t sleep. Others have problem

eeping because of dementia or Alzheimer’

sease. Some women sleep badly during theeriods (women are twice as likely to havsomnia as men) and many during menopauselder people in general sleep less well tha

oung. Some insomniacs can’t sleep because thee on medications that keep them awake. Other



e worrying about work or soon having no workne-third of Americans report they have lost slee

the recent economic crisis. Of all these noneepers, patients with insomnia derived from

hysical internal causes — probably excesses ocarcities of various neurotransmitters — are likele ones least able to respond to the treatment.

et for most of these conditions, CBT is offeres a potential cure. Perhaps this is because throblem of insomnia was for a long time thurview mainly of psychologists. In their eyessomnia is generally caused by somethineatable through their tool kit, usually anxiety oepression. By extension, cognitive behavioraerapy asks the sleeper to think about what he o

he is doing wrong, not what is wrong with his o

er body. Winkelman wishes that the two aspectf sleep — the physical and the mental — werore often considered jointly. “Sleep i

xtraordinarily complicated,” he says. “Wh

ould we think that there couldn’t be somethinthe wiring that goes awry too?”



we can’t sleep, perhaps it’s because we’v

orgotten how. In premodern times people slepfferently, going to bed at sunset and rising wite dawn. In winter months, with so long to res

ur ancestors may have broken sleep up inthunks. In developing countries people still ofteeep this way. They bed down in groups and gep from time to time during the night. Some slee

utside, where it is cooler and the effect ounlight on our circadian rhythm is more direcn 2002, Carol Worthman and Melissa Melby omory University published a comparativurvey of how people sleep in a variety oultures. They found that among foraging groupuch as the !Kung and Efe, “the boundaries o

eep and waking are very fluid.” There is nxed bedtime, and no one tells anyone else to g

sleep. Sleepers get up when a conversation ousical performance intrudes on their rest antrigues them. They might join in, then nod of

gain.



o one in developed nations sleeps this waday, at least not on purpose. We go to bed neafixed time, sleep alone or with our partner, o

oft cushions covered with sheets and blankets

We sleep on average about an hour and a half lesnight than we did just a century ago. Some o

ur epidemic of insomnia or sleeplessness irobably just our refusal to pay attention to ou

ology. The natural sleep rhythms of teenagerould call for a late morning wake-up — but therey are, starting high school at 8 a.m. The nigh

hift worker sleeping in the morning is fightinncient rhythms in his or her body that order himr her awake to hunt or forage when the sky iooded with light. Yet he or she has no choice.

We fight these forces at our peril. In Februar

009 a commuter jet en route from Newark tuffalo crashed, killing all 49 aboard and one oe ground. The copilot, and probably the pilo

ad only sporadic amounts of sleep the da

ading up to the crash, leading the Nationaransportation Safety Board to conclude tha



eir performance “was likely impaired becausf fatigue.” This sort of news enrages Harvard’

harles Czeisler. He notes that going withoueep for 24 hours or getting only five hours o

eep a night for a week is the equivalent of ood alcohol level of 0.1 percent. Yet moder

usiness ethic celebrates such feats. “We woul

ever say, ‘This person is a great worker! He’

runk all the time!’” Czeisler wrote in a 200arvard Business Review article.

tarting in 2004, Czeisler published a series oports in medical journals based on a study hi

roup had conducted of 2,700 first-year medicasidents. These young men and women wor

hifts that are as long as 30 hours twice a weekzeisler’s research revealed the remarkabl

ublic health risk that this sleep debt entailedWe know that one out of five first-year residentdmits to making a fatigue-related mistake thasulted in injury to a patient,” he told me in th

pring of 2009. “One in 20 admits to making tigue-related mistake that resulted in the deat



f a patient.” When Czeisler came out with thi

formation, he expected hospitals to thank himnstead many “circled the wagons.” He despair

f anything being done until U.S. employers ge

erious about insomnia and sleepiness. “Monviction is that one day people will look bacn what will be viewed as a barbarous practice.”

ow consider the siesta. The timing of thaditional siesta corresponds to a natural posnch dip in our circadian rhythms, and studie

ave shown that people who catnap are generallore productive and may even enjoy lower ris

f death from heart disease. It is the Spanish whave made the siesta famous. Unfortunatelypaniards no longer live close enough to work to home and nap. Instead some use the afternoo

reak to go out for long lunches with friends anolleagues. Having spent two hours at lunchpanish workers then cannot finish work unteven or eight. But even then they don’t alway

o home. They go out for drinks or dinnestead. (Go to a Spanish disco at midnight an



ou’re likely to be dancing alone; their prime

me TV shows are just ending.)

ately the Spanish have begun to take th

roblem of sleep deprivation seriously. Tholice now question drivers in serious accidentbout how long they slept the night before, ane government has recently mandated shorte

ours for its employees to try to get them homarlier.

What has motivated the Spanish to take actiogainst sleepiness is not so much their accidente — historically among the highest in westerurope — as their flat productivity. The Spanispend more time at work and their productivity iss than most of their European neighbors. “It’

ne thing to log hours, another to get somethinone,” Ignacio Buqueras y Bach, a 68-year-olusinessman who has spearheaded the attempt tet Spaniards to bed earlier, lectured hi

ountrymen in a Madrid newspaper recently.



Every once in a while we have to close ou

yes,” Buqueras told me. “We’re not machines.”

n 2006 a commission formed by Buqueras t

hange things became part of the Spanisovernment. Two years later I had occasion to g

one of the commission’s meetings in the anne

the Congreso de los Diputados, the lowe

ouse of Spain’s legislative branch. Assortment of modern Spanish grandees testifie

the problem. They spoke of accidents by tireorkers, Spanish women doubly exhausted bng work hours and household duties, and sma

hildren deprived of their proper ten to twelvours of sleep. Members were urged to contace television networks to see if they woul

onsider moving prime time earlier.

uqueras kept the meeting moving, exhorting thpeakers to adhere to a “telegraphic brevity.” Bu

e lights were low and the room warm. In th

udience a few participants’ heads began tump to their chests, then pop back up as the



sisted, then their eyes closed more fully, therograms lowering to their laps, as they began tay back their nation’s sleep debt.

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D.T.max the Secrets of Sleep