This book is meant to be read like a sweeping novel. It is not a reference book. I do not want you to skip ahead to the part of the book that you think is most important for you. It’s all important! Think of it as a complete process for understanding and overhauling both your sleep and the way you think about sleep. If you do it my way, you are going to finish this book with a newfound sense of what it means to have healthy sleep.
According to researcher Raymond Rosen, most physicians have received less than two hours of training about the entire field of sleep in their four years of medical education.
Given that our psychiatry lecture about men who fantasize about their wives’ footwear lasted thirty minutes, you can see just how dramatically underrepresented the whole of sleep medicine was in our curriculum.
## Chapter 1: What is Sleep Good For? Absolutely Everything!
There is almost no disease or organ system in which you cannot find some kind of relationship
Sleep as one of the foundational processes within your body that you can actually change.
To me, the three main pillars of good health that we can exert some control over are nutrition, exercise, and sleep.
Sleep is not the absence of wakefulness. Sleep is not a light switch in your braing that is either on or off. Your body is doing amazing things at night while you sleep.
Sleep resides in the brain. If you think your all-nighters or your crazy shift work schedule is no big deal, you might want to sit down before you continue to read. Long-term poor sleep is like bad cosmetic surgery: risky, costly, and not pretty.
### Sleep and the Brain
The brain does have a system for removing waste: the glymphatic system. Discovered in 2015!!
2. When people say scientists don't know why we sleep, they're wrong.
## Chapter 2: Primary Drives.
Cold reading: Sex has been on your mind in the last several ~~days~~
### Food, Water, Sleep, and Sex (Not Necessarily in that Order.
"My psychic secret is all about primary drives".
"We have a primary drive for sleep. Because of this, the longer we go without sleep, the more determined our brains are to get it, ultimately to the point where it is no longer a choice".
"I've slept only two hours in the last fourteen days". Not the case.
Speaking of the Guinness Book of World Records, while they maintain records of virtually every kind of feat imaginable, they no longer recognize sleep-deprivation records. The current record holder, Randy Gardner, set the mark of 11 days and 24 minutes in 1964. During this trial, it became progressively more difficult for Gardner to stay awake. His brain engaged in microsleeps (brief periods of uncontrollable sleep usually lasting less than thirty seconds), and he suffered hallucinations, severe cognitive impairments, and even paranoia. This paranoia has been noted in several sleep-deprivation experiments, the most unfortunate of which was seen in the case of disc jockey Peter Tripp, whose sleep-deprivation publicity stunt of 201 hours seemed to have very lasting psychological effects (not the least of which was a belief that he was an impostor of himself).
True, honest-to-God sleep deprivation is difficult.
If, however, you think you are sleep deprived but you show no tendency to nod off when you are stretched out on a couch, does it really make sense to you, knowing what you know, that you really are sleep deprived?
### The Do-nothing-for-a-really-long-time exercise.
IF YOU ARE SOMEONE WHO believes you are suffering from long-term sleep deprivation, and can’t sleep no matter how hard you try, do this little exercise.
1. Eat a little something and try to use the bathroom. Sleep Exercise 1 is going to take a while.
2. Turn off your cell phone and telephone ringer and ask that your family leave you alone until the experiment is over.
4. Demand total privacy because the situation you’re dealing with is “wicked serious.” Say it just like that and nobody will bother you.
5. Find a comfortable, private place in your house or office to lie down.
6. Kick off your shoes, turn off the lights and lie down there.
7. Do not sleep! Just lie there for the next seven hours.
8. Reflect on your experience.
To put things in perspective, not sleeping for four days and subsequently not being sleepy is analogous to an individual coming into my office saying that he has not eaten for four days and yet strangely feels no hunger and is gaining weight. Yes, I know that toward the end of terminal starvation, the body feels little to no pain, but you get what I mean.
The rats in the dirty cage showed more signs of hyperarousal and did not sleep as well as the rats in the clean cage.
The complaint "I can't sleep" is inaccurate and untrue, so stop reciting this mantra and reinforcing this in your mind-set.
"I don’t sleep. It’s not just me. My mother never slept. She would...”
“No. Stop right there and try again.”
“Uh, I have difficulty sleeping and my mother had difficulties with her sleep too.”
“Much better. Continue.”
Compare sometimes not feeling hungry with getting into bed and simply not feeling like sleeping. Many people are immediately concerned about this development, and the stress it causes may prevent sleep later in the night or even later in the week. For many, the confidence that the boat will right itself when *sleep* is involved simply does not sleep.
Although I often compare the brain’s drive to sleep with its drive to eat, there are subtle differences. Our brains do not technically have the ability to make us eat. We can become terribly hungry and strongly driven to eat, but in extreme cases of anorexia or some kind of volitional hunger strike, an individual could overcome hunger and starve to death. With sleep, however, the brain retains the final say and actually has the power to force sleep on us all.
### How much Sleep Do We Need?
Enough. You need enough sleep.
Questions: How can we get better sleep? Is napping a good thing? How much sleep do we need?
The following are guidelines. Keep in mind that sleep need is as individualized as caloric need.
All through our life, our sleep need is declining.
Young adults: Seven to nine hours.
Older adults, after retirement: Seven to eight hours.
This study did not seem to support the idea that members of modern society were sleeping drastically less than their counterparts from a generation ago.
## Chapter 2 Review.
1. Animalistic primary drives include hunger, thirst, sex, and sleep. Without meeting these needs, you will die (except for sex, the lack of which results in the entire population fizzling out).
2. You sleep. You may not sleep well, but you do sleep.
3. The need for sleep varies from person to person and actually tends to decline as we mature.
There are many things that can cause fatigue, other than lack of sleep.
### Sleepiness: “I’m Not Sleeping; I’m Just Resting My Eyes” and Other Falsehoods.
Sleep that is disfunctional can also make you sleepy.
### The Holes in Your Sleep-
Sleeping apnea: The sleeper awakens over and over because of breathing-related difficulties. He may wake up for an incredibly brief moment, so brief that his brain has no awareness of the awakening. But they can fragment sleep so terribly that sleep's restorative effects are all but negated.
Initally, you can compensate with increased quantity. But if that extra sleep becomes dysfunctional, more sleep won’t make a difference. Finally, your sleep is so poor that you feel like you could sleep for a week and not feel rested. You can put as much water into your gas tank as you’d like, but it doesn’t mean your car will run
Scientific studies have established that if an adult sleeps well, usually six to seven hours will suffice. Many of my patients with sleep problems often feel they need nine hours or more of sleep to feel okay.
Six to seven hours is absolutely fine for some people. For adults over the age of sixty-five, as little as five hours could be appropriate according to the 2015 consensus paper by Nathaniel Watson and his colleagues.
The hunter-gatherer cultures mentioned in the last chapter were averaging only about six and a half hours of sleep each night and yet they appeared to be quite healthy and well adjusted.
Bottom line: There is a tremendous amount of dysfunctional sleep out there, causing excessive sleepiness, and people cannot always “sleep more” to fix the problem.
Patients often lie during this questioning. It’s okay. I’m used to waking people up from my waiting room and seven minutes later asking them, “Ever fall asleep in public?” With a straight face, they respond "No". This is why I strongly suggest spouses come along to inject some reality into these appointments.
Sleep quality vs quantity.
A 2015 study published in the Journal of Neuroscience found that sleep deprivation may impair your ability to properly read facial expressions.
### *Why* and *How* We Sleep: The Homeostatic and Circadian Systems.
There are two main systems in your body that work to produce sleepiness: the homeostatic system and the circadian system. These systems ideally work in concert to produce sleepiness in a way that promotes healthy and fulfilling sleep.
Homeostasis refers to bringing balance or equilibrium to a system; it’s in charge of bringing rest to a system that is not at rest. The longer you go without sleep, the more powerful the drive to sleep and get your system back in balance. In the same way, the longer you read this compelling chapter and ignore the urge you have to urinate, the stronger the drive to pee will be until it’s overwhelming and you can’t concentrate on anything you’re reading—again, the drive to balance.
A chemical called adenosine mediates the homeostatic system of sleep.
As you’re awake for longer and longer periods of time, more adenosine collects in your brain. Because adenosine induces sleepiness, the longer you’re awake, the more likely you are to be sleepy. This is the chemistry behind sleep being a primary drive.
A long time ago, they did an experiment by taking spinal fluid full of adenosine out of a sleepy dog and putting it into a well-rested dog. The infusion made the wakeful dog feel sleepy.
Caffeine blocks adenosine. Ever wonder why Red Bull makes you feel so awake? Caffeine, baby, and lots of it (about 80 milligrams per can or 9.64 milligrams per fluid ounce). Need more? Try a Starbucks double shot at 20 milligrams per ounce (mg/oz) or an espresso at 50 mg/oz. Some of the newer extreme energy drinks can reach levels of more than 100 mg/oz.
Why are these drinks so totally awesome and effective? When you’re awake at 4:30 A.M. organizing your wrapping paper or balancing your checkbook without some Rabid Opossum Dangerous Energy drink,35 you’ll understand how stupid that question is.
These drinks temporarily block the effect of all that accumulating adenosine on that poor noodle of yours that’s screaming for you to put down the remote and go to bed.
Physical activity also increases adenosine, so the harder you exert yourself, the more likely you are to be sleepy. Exercise is a vital part of any sleep program, with hard work often being a fantastic tool to combat occasional difficulty sleeping. We’ll talk more about that in Chapter 6.
Light plays a huge role in our sleep. Ever wonder why? Think we’re genetically and evolutionarily designed to seek out a killer tan? Not really.
Think about the accumulation of adenosine in the brain. If adenosine were allowed to accumulate in the brain unchecked, we would be pretty sleepy by lunchtime and really a mess by 4:00 P.M. This drive to sleep is sometimes referred to as homeostatic pressure.
This is not how sleep works. In reality, for the most part our sleepiness level is not appreciably different at 9:00 A.M. from that at 9:00 P.M. How does that work? What other factors are involved in keeping our sleepiness levels low throughout the day?
Take a poppy and put it in a greenhouse closed off from outdoor light. Establish a twelve-hour on and twelve-hour off light cycle. The flower will thrive. Suddenly turn the lights on and off at random times, keeping everything else the same. Even if the amount of light remains the same, the random timing of the lights will significantly disrupt the natural rhythms of the flower, and it will die. The linking of sunlight and its day-night cycle with a biological rhythm is the basis of circadian rhythms.
In humans, this rhythm is facilitated by a chemical that is different from adenosine. It is called melatonin.
Melatonin is produced in conditions of darkness. Makes us sleepy.
raccoons have the opposite response to melatonin (!)
That spike in sleepiness is the reason it is so temping to sneak a little nap after lunch. In fact, in some cultures, a postlunch siesta is the norm, not the exception. Are these cultures right to give in to that urge to nap every day? Some scientists think so. I think a nap in the afternoon is fine as long as it does not affect your ability to sleep at night.
Most likely, these systems are working just fine, but you are disrupting them in some way.
## Chapter 3 Review.
1. Fatigue refers to a lack of energy, rather than a desire to sleep.
2. True sleepiness is caused by one of three things: medication, sleep deprivation, or sleep dysfunction.
4. Our sleep is based on two systems, the homeostatic and circadian.
5. You are or you are not sleepy. If you were brave enough to take some sleepiness assessments, you should have a feel for how sleepy you are or are not.
"We have a primary drive for sleep. Because of this, the longer we go without sleep, the more determined our brains are to get it, ultimately to the point where it is no longer a choice".
Annoying sentences. I'm going to keep tab of them at the end:
- Like syndicated episodes of Law & Order, their eating, exercising, and sleeping happen at all hours of the day and night.
- ... the brain retains the final say and actually has the power to force sleep on us all. We hope this doesn’t occur when we are driving home from work.
- ...need only seven to eight hours of sleep, leading them to continually ask, “What do I do with the other sixteen hours of my day? There’s nothing good on TV anymore.”
- 4. Something about rats sleeping in dirty cages.
- Here’s a step-by-step guide to becoming sleep deprived:
Purchase the first season of Breaking Bad.
Stay up too late watching Walt White slowly change from mild-mannered high-school chemistry teacher to ruthless drug kingpin Heisenberg.
Panic when the clock reads three hours before you need to be up for work on Monday.
Go to sleep.
Feel like crap on Monday as you limp along beating yourself up for the TV bingeing.
Vow to go to bed early tonight.
Repeat steps 1 to 6 until Breaking Bad is over and then replace with Mad Men
- Are you falling asleep while you eat? If so, you get a point, but forget the points, videotape yourself, and send a copy to America’s Funniest Home Videos; they love stuff like this, and you might just win some money!
- Are you struggling to stay awake in a car? Give yourself 1 point if you are! Are you the driver? You win! Collect 20 points and proceed directly to Boardwalk, which you may purchase if it’s not already owned.
- Imagine you and your partner are at a party and a flirty acquaintance strikes up a conversation. As you politely converse, your partner gives you “the look,” which basically means “wrap it up or prepare for a painful car ride home.” A 2015 study published in the Journal of Neuroscience found that sleep deprivation may impair your ability to properly read facial expressions. In other words, not getting enough sleep might make you misinterpret threatening looks and lead to a difficult night sleeping on the living room couch.
