Sleep and Its Effects on Wellness

8/9/2019 Sleep and Its Effects on Wellness

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SLEEPLESS AT STANFORD

What All Undergraduates Should Know About How Their

Sleeping Lives Affect Their Waking Lives

William . Dement, M.D., Ph.D.

Stanford University Center of Excellencefor the Diagnosis and Treatment of Sleep Disorders

Stanford UniversitySeptember, 1997

| How much sleep do we need? What is sleep debt? | What causes us to feel sleepy? | America is a sleepy society |What is the biological clock? What does it do for us? | Drowsiness is red alert! | What is sleep? | What are sleepdisorders? | Should Stanford undergraduates (and others) know about sleep disorders? | How common are sleep

disorders? | Are student health physicians familiar with sleep disorders? | One more time! Drowsiness is red alert! |

This document describes some of the key facts about sleep, biological rhythms, and sleepdeprivation that should be well known to every Stanford student as well as everyone everywhere.It will be occasionally updated.

A recent survey of Stanford undergraduates revealed that their number one complaint was notgetting enough sleep! heard a validation of this complaint from the lips of a well knownalumnus, Tiger Woods, who said that one of the best things about his choice to leave Stanfordfor the professional golf circuit was that he could now get enough sleep. Although I offer anundergraduate course on sleep and dreams once each year, it is clear that it does not meet theneed for all students to have some information about this topic. Most entering students have

previously received no teaching whatsoever about sleep. In contrast, nearly all entering studentshave received a great deal of information about two other health basics, nutrition and physicalfitness.

Thus, an amazing paradox exists in our educational system. We have learned that theconsequences of pervasive sleep deprivation and undiagnosed sleep disorders are collectivelyone of our nation's biggest and most serious problems. Falling asleep at the wheel and in other


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hazardous situations is a leading cause of death and disability. A single sleep disorder,obstructive sleep apnea, is now known to afflict 30 million Americans.

The paradox is that our society remains a vast reservoir of ignorance about sleep deprivation andsleep disorders. The benefits of the hard earned knowledge about normal and pathological sleep

have not been passed on to the general public and practicing physicians. Millions of people aresuffering and thousands are dying each year without ever knowing the true cause of their problems.

Why is this? Teaching about sleep and dreams, the nature and consequences of sleep deprivation,and common sleep disorder symptoms is essentially absent from the undergraduate and graduatecurriculum in our colleges and universities. Perhaps the saddest omission of all is that moststudent drivers learn nothing about the dangers of driving drowsy in their training programs, andan astounding number soon die and kill others because they fall asleep at the wheel. Fifty-five

percent of drowsy driving fatalities occur under the age of 25.

Although I am directing this message to entering freshman students at Stanford University, I amalso striving to bring these topics into the mainstream of the national educational system. Inevery classroom in America, students must learn that healthy sleep, along with physical fitnessand good nutrition, form the fundamental triumvirate of health. However healthy we think weare, students and non-students alike, we must realize that we cannot be healthy unless our sleepis healthy!

How much sleep do we need? What is sleep debt?

Each of us has a specific daily sleep requirement. The average sleep requirement for collegestudents is well over eight hours, and the majority of students would fall within the range of thisvalue plus or minus one hour. If this amount is not obtained, a sleep debt is created. All lost sleepaccumulates progressively as a larger and larger sleep indebtedness. Furthermore, your sleepdebt does not go away or spontaneously decrease. The only way to reduce your individual sleepdebt is by obtaining extra sleep over and above your daily requirement.

The powerful brain mechanism that regulates the daily amount of sleep is called the sleephomeostat. By increasing the tendency to fall asleep progressively in direct proportion to theincreasing size of the sleep debt, this homeostatic process ensures that most people will get theamount of sleep they need, or close to it. The elevated sleep tendency together with theassociated drowsiness and an intense desire for sleep would ordinarily prevent most people from

becoming dangerously sleep deprived because they would go to bed early, or sleep late, whensuch excessive daytime sleepiness occurred.

However, in our society we are prone to ignore or resist nature's signal that we need more sleep,and we often resist far too long. At this point, we cannot resist falling asleep. Depending onwhen and where this happens, falling asleep can be tragic, or merely inconvenient. As far as iscurrently known, nothing can change an individual's fundamental daily sleep requirement.


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What causes us to feel sleepy?

To repeat, the size of your sleep debt determines the strength of the tendency or ability to fallasleep. If your sleep debt is zero, sleep is impossible. If your sleep debt is very low, only a smallamount of stimulation is required to keep you awake. If your sleep debt is very large, no amountof stimulation can keep you awake.

Think of your sleep debt as a very heavy load. You are carrying with the help of twocompanions. Together, the three of you can hold it up. One of your companions is pretty strong.This companion is your biological clock. The other companion is not quite so strong, andrepresents transient external stimulation, e.g. noise, light, excitement, anger, pain, and so on. If one of your companions drops out, you and the other may be able to manage. If both companionsdrop out and you are left alone, you absolutely cannot hold up the heavy sleep debt and you arecrushed. In other words, you cannot stay awake no matter how hard you try. Even withoutexternal stimulation, it is usually easy to stay awake and alert if your stronger companion, the

biological clock, is helping you.

With the above image in mind, it should be clear that the things we usually assume cause us to become drowsy or to fall asleep actually do not cause us to become drowsy or to fall asleep.Their true role is to unmask any tendency to fall asleep that is present already. If you believe that

boredom, a warm room, or a heavy meal causes sleep, you are completely wrong! If boredom, awarm room, or anything else seems to cause you to feel drowsy, you have a sleep debt and youneed to be stimulated in order to stay awake. If you frequently feel sleepy or drowsy in any dullor sedentary situation, you almost certainly have a very large sleep debt. A large sleep debtmakes us vulnerable to apathy, inattention, and unintended sleep episodes. Errors, accidents,injuries, deaths, and catastrophes can be the result, not to mention poor grades.

America is a sleepy society.

How many Americans are seriously or dangerously sleep deprived? There is no doubtwhatsoever that vast numbers of us in school, in the workplace, in the transportation industry, ina variety of service industries, and particularly, in shift work situations, are carrying adangerously large sleep debt.

In Gallup Poll surveys, 56% of the adult population reports that drowsiness in the daytime is a problem. In one scientific study where sleepiness was measured objectively in more than onethousand people who said they had no problem with daytime drowsiness, 34% were found to bedangerously sleepy. Considering that the subjects in this study were chosen specifically becausethey did not complain about daytime sleepiness, this result proves without a doubt that asignificant percentage of the population carries out daily tasks and activities while dangerouslysleepy.


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Here at Stanford, we have studied samples of undergraduates, nurses, and medical students. Wefound that 80 percent were dangerously sleep deprived. By dangerously sleep deprived, I mean,of course, that these individuals are at high risk for some sort of accident involving unintendedsleep or impaired performance. In all walks of life, it is likely that sleep deprivation hasconsequences - difficulty studying, diminished productivity, tendency to make mistakes,

irritability, fatigue. For most people, the accumulation of a huge sleep debt appears to havehappened so gradually that they erroneously blame their tiredness and fatigue on many other things such as a virus, depression, stress, changing metabolism, growing older, and so do their doctors.

What is the biological clock? What does it do for us?

The biological clock is a term applied to the brain process which causes us to have 24-hour fluctuations in body temperature, hormone secretion, and a host of other bodily activities. Itsmost important function is to foster the daily cycle of sleep and wakefulness. The major role of the biological clock in the regulation of sleep and wakefulness is to provide an internal and very

powerful wake-up signal to the rest of the brain.

This powerful signal is called clock-dependent alerting, and when present, it powerfully opposesthe tendency to fall asleep. In the absence of any other stimulation, the process of clock-dependent alerting alone can usually keep us wide awake throughout the entire day. This may not

be true if we are carrying a fairly large sleep debt. In ordinary circumstances, clock-dependentalerting is always synchronized with the daytime hours. However, if we travel rapidly to other time zones, it may occur during the sleeping hours, and we experience "jet lag."

Drowsiness is red alert!

I sincerely hope that sleep deprived students will take the following advice very seriously.Drowsiness is red alert! Drowsiness is the last step before falling asleep, not the first. Drowsinessmay mean you are seconds from a disaster. If everyone responded as if it were an emergencywhen they became aware of feeling drowsy, an enormous amount of human suffering andcatastrophic events would be avoided.

What is sleep?

We should certainly define the basic biological state that we have been discussing. Most of thecharacteristics that people invoke to define sleep- immobility, eye closure, snoring- can bereadily simulated in the waking state. We should ask then, what is the most fundamentaldifference between a human being awake and a human being asleep?

Answer: The crucial event that occurs as we fall asleep is an abrupt shut down of the neural processes that allow us to perceive the world around us. At one moment we are awake, and can


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see and hear. A fraction of a second later we are asleep, and we are completely blind andcompletely deaf. Another way of saying this is that sleep is a behavioral state of complete

perceptual disengagement from the environment. Sleep is an active process in which sensorystimulation is blocked or modified in some way such that we cease to be conscious of the worldaround us. In fact, research over the past couple of decades has decisively established that the

sleeping brain is an active brain. Because so many people believe that sleep occurs when the brain is "turned off," I like to say, "If that is your image of sleep, then hear this, 'the brain never sleeps!'"

Of course, there is much more to say about what sleep is and what the sleeping brain does, butnot here. That would make this document far too long.

What are sleep disorders?

Sleep disorders are illnesses and disturbances of sleep and wakefulness that are caused byabnormalities existing only during sleep or abnormalities of specific sleep mechanisms. Theseabnormalities typically produce symptoms during wakefulness that are easily recognized if the

person is aware of their significance, but the fundamental pathology exists during sleep. Thoughthe symptoms that exist during wakefulness can be helpful in recognizing the possible existenceof a sleep disorder, an absolute certainty generally requires an examination of the patient duringsleep utilizing a procedure called polysomnography, also widely known as a "sleep test."

Should Stanford undergraduates know about sleepdisorders?

Absolutely! Particularly if you carry the knowledge through your entire lives. And it is notdifficult. The six year old son of one of my sleep specialist colleagues once diagnosed a specificsleep disorder in a man sitting nearby on a bus. Everyone should certainly know that sleepdisorders exist and when to seek help. Almost all sleep disorders can be effectively treated or cure, and there is absolutely no reason to suffer needlessly. Unfortunately, the vast majority of sleep disorders victims do suffer needlessly because most people do not know about sleepdisorders.

In the annual surveys I carry out in my course, almost all students know someone, usually a parent or close relative, who has totally unambiguous sleep disorder symptoms.

How common are sleep disorders?

Though some are rare, most sleep disorders appear to be highly prevalent. The national prevalence has been established scientifically for one specific disorder, obstructive sleep apnea.This disorder afflicts 24 percent of adult males and 9 percent of adult females which extrapolates


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to 30 million Americans. Of these, about 20 million are in the early stages, and about 10 millionhave progressed to a level of severity that requires treatment. Of greater relevance to students isthat we found the problem in about 8 percent of a fairly large sample. The Restless LegsSyndrome has been estimated to afflict at least 12 million Americans. A recent Gallup Poll hasestablished a national prevalence of 14 percent for chronic insomnia. The same poll reported that

half of all adults have had difficulty sleeping at one time or another.

Are student health physicians familiar with sleep disorders?

In 1991, the answer to this question was a resounding no. In 1997, the answer is only slightly better. Although serious sleep disorders are relatively uncommon in the undergraduate population, they are unfortunately far from absent. In the vast majority of cases, undergraduateswho have specific sleep disorders do not receive proper diagnosis and treatment.

One more time! "Drowsiness is red alert!"

The single most important thing to remember from this document is that drowsiness means youare seconds away from sleep. Seconds away from sleep may mean seconds away from death. If you are behind the wheel, just a few seconds of sleep can lead to a catastrophic disaster. Manyfreshmen may not do very much driving, but if you are a passenger, pay attention to the personwho is driving. Recently, my limousine driver fell asleep at the wheel. If I had not been payingattention, I would not be here today. All this can be avoided with one simple rule, immediatelystop any potentially dangerous activity when you feel drowsy. Encourage others to do likewise.

Drowsiness is red alert! Learn to be sensitive to your level of drowsiness. Being sensitive to your sleep tendency and responding appropriately may save your life.

Please note: Information is often taken directly from the faxes that we receive. There mayconsequently be some mistakes. If you see a mistake, please E-mail: Nodmaster . We welcomeyour comments, suggestions, or notification of a sleep related event or sleep activist information.

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