Why We Sleep: Unlocking the Power of Sleep and Dreams

"Why We Sleep" is one of the scarier books I've read lately.  Not regularly getting 8 hours of sleep a night?  Prepare for cancer, Alzheimers, traffic fatalities, and more!  UC Berkeley professor Matthew Walker is basically the Malcom Gladwell of sleep - he does a great job of communicating the current state of the art in sleep science and translating it into practical knowledge you can use in daily life.  Walker walks a fine line between technical detail and popular appeal and manages to pull it off nicely.  He helps lighten the tone with a couple of irreverent observations about several of the scientific studies too.  I found his sections on the role of sleep in memory formation particularly interesting and was scared straight by his commentary on sleep, mental illness, and Alzheimers.  Some of these studies - particularly for shorter-term effects - are beautifully designed and clearly demonstrate the importance of getting good sleep.  I'll be making sure to get a regular 8 hours from here on out!

Also, thinking back to my high school days of homework until 1AM and then the 6:07AM bus ride... after reading this book I can hardly believe I'm still alive!  Walker couldn't be more direct with what he thinks about the early start-times of schools across the US:

More than 80 percent of public high schools in the United States begin before 8:15 a.m. Almost 50 percent of those start before 7:20 a.m. School buses for a 7:20 a.m. start time usually begin picking up kids at around 5:45 a.m. As a result, some children and teenagers must wake up at 5:30 a.m., 5:15 a.m., or even earlier, and do so five days out of every seven, for years on end. This is lunacy.

My highlights below

PART 1 - This Thing Called Sleep

CHAPTER 1 - To Sleep . . .

Routinely sleeping less than six or seven hours a night demolishes your immune system, more than doubling your risk of cancer. Insufficient sleep is a key lifestyle factor determining whether or not you will develop Alzheimer’s disease.

Worse, should you attempt to diet but don’t get enough sleep while doing so, it is futile, since most of the weight you lose will come from lean body mass, not fat.

Tragically, one person dies in a traffic accident every hour in the United States due to a fatigue-related error. It is disquieting to learn that vehicular accidents caused by drowsy driving exceed those caused by alcohol and drugs combined.

As one sleep scientist has said, “If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process has ever made.”

I am a professor of neuroscience and psychology at the University of California, Berkeley.

CHAPTER 2 - Caffeine, Jet Lag, and Melatonin

Kleitman and Richardson were to be their own experimental guinea pigs. Loaded with food and water for six weeks and a pair of dismantled, high-standing hospital beds, they took a trip into Mammoth Cave in Kentucky, one of the deepest caverns on the planet—so deep, in fact, that no detectable sunlight penetrates its farthest reaches. It was from this darkness that Kleitman and Richardson were to illuminate a striking scientific finding that would define our biological rhythm as being approximately one day (circadian), and not precisely one day.

Sunlight acts like a manipulating finger and thumb on the side-dial of an imprecise wristwatch. The light of the sun methodically resets our inaccurate internal timepiece each and every day, “winding” us back to precisely, not approximately, twenty-four hours.

Any signal that the brain uses for the purpose of clock resetting is termed a zeitgeber, from the German “time giver” or “synchronizer.”

An adult’s owlness or larkness, also known as their chronotype, is strongly determined by genetics. If you are a night owl, it’s likely that one (or both) of your parents is a night owl.

Owls are thus often forced to burn the proverbial candle at both ends. Greater ill health caused by a lack of sleep therefore befalls owls, including higher rates of depression, anxiety, diabetes, cancer, heart attack, and stroke.

For every day you are in a different time zone, your suprachiasmatic nucleus can only readjust by about one hour.

Scientists have studied airplane cabin crews who frequently fly on long-haul routes and have little chance to recover. Two alarming results have emerged. First, parts of their brains — specifically those related to learning and memory — had physically shrunk, suggesting the destruction of brain cells caused by the biological stress of time-zone travel. Second, their short-term memory was significantly impaired.

One consequence of increasing adenosine in the brain is an increasing desire to sleep. This is known as sleep pressure, and it is the second force that will determine when you feel sleepy, and thus should go to bed.

You can, however, artificially mute the sleep signal of adenosine by using a chemical that makes you feel more alert and awake: caffeine.

Caffeine has an average half-life of five to seven hours. Let’s say that you have a cup of coffee after your evening dinner, around 7:30 p.m. This means that by 1:30 a.m., 50 percent of that caffeine may still be active and circulating throughout your brain tissue. In other words, by 1:30 a.m., you’re only halfway to completing the job of cleansing your brain of the caffeine you drank after dinner.

First, after waking up in the morning, could you fall back asleep at ten or eleven a.m.? If the answer is “yes,” you are likely not getting sufficient sleep quantity and/or quality. Second, can you function optimally without caffeine before noon? If the answer is “no,” then you are most likely self-medicating your state of chronic sleep deprivation.

CHAPTER 3 - Defining and Generating Sleep

All these signals still flood into the center of your brain, but it is here, in the sensory convergence zone, where that journey ends while you sleep. The signals are blocked by a perceptual barricade set up in a structure called the thalamus (THAL-uh-muhs). A smooth, oval-shaped object just smaller than a lemon, the thalamus is the sensory gate of the brain.

This dramatic deceleration of neural time may be the reason we believe our dream life lasts far longer than our alarm clocks otherwise assert.

In this way, sleep may elegantly manage and solve our memory storage crisis, with the general excavatory force of NREM sleep dominating early, after which the etching hand of REM sleep blends, interconnects, and adds details.

What you are hearing is a sleep spindle — a punchy burst of brainwave activity that often festoons the tail end of each individual slow wave. Sleep spindles occur during both the deep and the lighter stages of NREM sleep, even before the slow, powerful brainwaves of deep sleep start to rise up and dominate. One of their many functions is to operate like nocturnal soldiers who protect sleep by shielding the brain from external noises. The more powerful and frequent an individual’s sleep spindles, the more resilient they are to external noises that would otherwise awaken the sleeper.

By severing perceptual ties with the outside world, not only do we lose our sense of consciousness (explaining why we do not dream in deep NREM sleep, nor do we keep explicit track of time), this also allows the cortex to “relax” into its default mode of functioning. That default mode is what we call deep slow-wave sleep. It is an active, deliberate, but highly synchronous state of brain activity. It is a near state of nocturnal cerebral meditation, though I should note that it is very different from the brainwave activity of waking meditative states.

The steady, slow, synchronous waves that sweep across the brain during deep sleep open up communication possibilities between distant regions of the brain, allowing them to collaboratively send and receive their different repositories of stored experience.

When it comes to information processing, think of the wake state principally as reception (experiencing and constantly learning the world around you), NREM sleep as reflection (storing and strengthening those raw ingredients of new facts and skills), and REM sleep as integration (interconnecting these raw ingredients with each other, with all past experiences, and, in doing so, building an ever more accurate model of how the world works, including innovative insights and problem-solving abilities).

Mere seconds before the dreaming phase begins, and for as long as that REM-sleep period lasts, you are completely paralyzed. There is no tone in the voluntary muscles of your body.

CHAPTER 4 - Ape Beds, Dinosaurs, and Napping with Half a Brain

Without exception, every animal species studied to date sleeps, or engages in something remarkably like it.

However, insects, amphibians, fish, and most reptiles show no clear signs of REM sleep — the type associated with dreaming in humans. Only birds and mammals, which appeared later in the evolutionary timeline of the animal kingdom, have full-blown REM sleep.

The mystery deepens when we consider pinnipeds (one of my all-time favorite words, from the Latin derivatives: pinna “fin” and pedis “foot”), such as fur seals. Partially aquatic mammals, they split their time between land and sea. When on land, they have both NREM sleep and REM sleep, just like humans and all other terrestrial mammals and birds. But when they enter the ocean, they stop having REM sleep almost entirely.

That humans (and all other species) can never “sleep back” that which we have previously lost is one of the most important take-homes of this book, the saddening consequences of which I will describe in chapters 7 and 8.

This humble passerine bird has evolved an extraordinary biological cloak of resilience to total sleep deprivation: one that it deploys only during a time of great survival necessity. You can now imagine why the US government continues to have a vested interest in discovering exactly what that biological suit of armor is: their hope for developing a twenty-four-hour soldier.

It is perhaps unsurprising that in the small enclaves of Greece where siestas still remain intact, such as the island of Ikaria, men are nearly four times as likely to reach the age of ninety as American males.

This body-balancing act was the challenge and danger of tree sleeping for our primate forebears, and it markedly constrained their sleep.

While there remains some debate, many believe that Homo erectus was the first to use fire, and fire was one of the most important catalysts — if not the most important — that enabled us to come out of the trees and live on terra firma. Fire is also one of the best explanations for how we were able to sleep safely on the ground.

From these clues, I offer a theorem: the tree-to-ground reengineering of sleep was a key trigger that rocketed Homo sapiens to the top of evolution’s lofty pyramid. At least two features define human beings relative to other primates. I posit that both have been beneficially and causally shaped by the hand of sleep, and specifically our intense degree of REM sleep relative to all other mammals: (1) our degree of sociocultural complexity, and (2) our cognitive intelligence. REM sleep, and the act of dreaming itself, lubricates both of these human traits.

From this REM-sleep-enhanced emotional IQ emerged a new and far more sophisticated form of hominid socioecology across vast collectives, one that helped enable the creation of large, emotionally astute, stable, highly bonded, and intensely social communities of humans.

What may at first blush have seemed like a modest asset awarded by REM sleep to a single individual is, I believe, one of the most valuable commodities ensuring the survival and dominance of our species as a collective.

CHAPTER 5 - Changes in Sleep Across the Life Span

Through speech or song, expecting parents will often thrill at their ability to elicit small kicks and movements from their in utero child. Though you should never tell them this, the baby is most likely fast asleep. Prior to birth, a human infant will spend almost all of its time in a sleep-like state, much of which resembles the REM-sleep state.

Autistic individuals show a 30 to 50 percent deficit in the amount of REM sleep they obtain, relative to children without autism.

Alcohol is one of the most powerful suppressors of REM sleep that we know of.

Almost half of all lactating women in Western countries consume alcohol in the months during breastfeeding. Alcohol is readily absorbed in a mother’s milk. Concentrations of alcohol in breast milk closely resemble those in a mother’s bloodstream: a 0.08 blood alcohol level in a mother will result in approximately a 0.08 alcohol level in breast milk.

In contrast to the single, monophasic sleep pattern observed in adults of industrialized nations, infants and young kids display polyphasic sleep: many short snippets of sleep through the day and night, punctuated by numerous awakenings, often vocal.

That balance will finally stabilize to an 80/20 NREM/REM sleep split by the late teen years, and remain so throughout early and midadulthood.

The changes in deep NREM sleep always precede the cognitive and developmental milestones within the brain by several weeks or months, implying a direction of influence: deep sleep may be a driving force of brain maturation, not the other way around.

Those individuals who developed schizophrenia had an abnormal pattern of brain maturation that was associated with synaptic pruning, especially in the frontal lobe regions where rational, logical thoughts are controlled — the inability to do so being a major symptom of schizophrenia. In a separate series of studies, we have also observed that in young individuals who are at high risk of developing schizophrenia, and in teenagers and young adults with schizophrenia, there is a two- to threefold reduction in deep NREM sleep.

Adolescents face two other harmful challenges in their struggle to obtain sufficient sleep as their brains continue to develop. The first is a change in their circadian rhythm. The second is early school start times.

The reason is not simply that children need more sleep than their older siblings or parents, but also that the circadian rhythm of a young child runs on an earlier schedule. Children therefore become sleepy earlier and wake up earlier than their adult parents.

That older adults simply need less sleep is a myth. Older adults appear to need just as much sleep as they do in midlife, but are simply less able to generate that (still necessary) sleep.

Poor memory and poor sleep in old age are therefore not coincidental, but rather significantly interrelated.

PART 2 - Why Should You Sleep?

CHAPTER 6 - Your Mother and Shakespeare Knew

Ironically, most all of the “new,” twenty-first-century discoveries regarding sleep were delightfully summarized in 1611 in Macbeth, act two, scene two, where Shakespeare prophetically states that sleep is “the chief nourisher in life’s feast.”

In doing so, sleep had delightfully cleared out the hippocampus, replenishing this short-term information repository with plentiful free space.

Fitting the notion of a long-wave radio signal that carries information across large geographical distances, the slow brainwaves of deep NREM had served as a courier service, transporting memory packets from a temporary storage hold (hippocampus) to a more secure, permanent home (the cortex). In doing so, sleep had helped future-proof those memories.

Counter to earlier assumptions in the twentieth and twenty-first centuries, sleep does not offer a general, nonspecific (and hence verbose) preservation of all the information you learn during the day. Instead, sleep is able to offer a far more discerning hand in memory improvement: one that preferentially picks and chooses what information is, and is not, ultimately strengthened. Sleep accomplishes this by using meaningful tags that have been hung onto those memories during initial learning, or potentially identified during sleep itself.

Those who remained awake across the day showed no evidence of a significant improvement in performance. However, fitting with the pianist’s original description, those who were tested after the very same time delay of twelve hours, but that spanned a night of sleep, showed a striking 20 percent jump in performance speed and a near 35 percent improvement in accuracy. Importantly, those participants who learned the motor skill in the morning — and who showed no improvement that evening — did go on to show an identical bump up in performance when retested after a further twelve hours, now after they, too, had had a full night’s sleep.

It is practice, followed by a night of sleep, that leads to perfection.

CHAPTER 7 - Too Extreme for the Guinness Book of World Records

Every hour, someone dies in a traffic accident in the US due to a fatigue-related error.

Ten days of six hours of sleep a night was all it took to become as impaired in performance as going without sleep for twenty-four hours straight.

When participants were asked about their subjective sense of how impaired they were, they consistently underestimated their degree of performance disability.

After being awake for nineteen hours, people who were sleep-deprived were as cognitively impaired as those who were legally drunk. Said another way, if you wake up at seven a.m. and remain awake throughout the day, then go out socializing with friends until late that evening, yet drink no alcohol whatsoever, by the time you are driving home at two a.m. you are as cognitively impaired in your ability to attend to the road and what is around you as a legally drunk driver.

Operating on less than five hours of sleep, your risk of a car crash increases threefold. Get behind the wheel of a car when having slept just four hours or less the night before and you are 11.5 times more likely to be involved in a car accident.

The heady cocktail of sleep loss and alcohol was not additive, but instead multiplicative.

After thirty years of intensive research, we can now answer many of the questions posed earlier. The recycle rate of a human being is around sixteen hours. After sixteen hours of being awake, the brain begins to fail.

Approximately 80 percent of truck drivers in the US are overweight, and 50 percent are clinically obese. This places truck drivers at a far, far higher risk of a disorder called sleep apnea, commonly associated with heavy snoring, which causes chronic, severe sleep deprivation. As a result, these truck drivers are 200 to 500 percent more likely to be involved in a traffic accident. And when a truck driver loses his or her life in a drowsy-driving crash, they will, on average, take 4.5 other lives with them.

It is during this end phase of flight, known in the aviation industry as “top of descent to landing,” that 68 percent of all hull losses — a euphemism for a catastrophic plane crash — occur.

The researchers set to work answering the following question, posed by the US Federal Aviation Authority (FAA): If a pilot can only obtain a short nap opportunity (40–120 minutes) within a thirty-six-hour period, when should it occur so as to minimize cognitive fatigue and attention lapses: at the start of the first evening, in the middle of the night, or late the following morning? It first appeared to be counterintuitive, but Dinges and Rosekind made a clever, biology-based prediction. They believed that by inserting a nap at the front end of an incoming bout of sleep deprivation, you could insert a buffer, albeit temporary and partial, that would protect the brain from suffering catastrophic lapses in concentration. They were right. Pilots suffered fewer microsleeps at the end stages of the flight if the naps were taken early that prior evening, versus if those same nap periods were taken in the middle of the night or later that next morning, when the attack of sleep deprivation was already well under way.

No matter what you may have heard or read in the popular media, there is no scientific evidence we have suggesting that a drug, a device, or any amount of psychological willpower can replace sleep.

Analysis of the brain scans revealed the largest effects I have measured in my research to date. A structure located in the left and right sides of the brain, called the amygdala — a key hot spot for triggering strong emotions such as anger and rage, and linked to the fight-or-flight response — showed well over a 60 percent amplification in emotional reactivity in the participants who were sleep-deprived.

With a full night of plentiful sleep, we have a balanced mix between our emotional gas pedal (amygdala) and brake (prefrontal cortex). Without sleep, however, the strong coupling between these two brain regions is lost. We cannot rein in our atavistic impulses—too much emotional gas pedal (amygdala) and not enough regulatory brake (prefrontal cortex).

A similar relationship between a lack of sleep and violence has been observed in adult prison populations; places that, I should add, are woefully poor at enabling good sleep that could reduce aggression, violence, psychiatric disturbance, and suicide, which, beyond the humanitarian concern, increases costs to the taxpayer.

There is no major psychiatric condition in which sleep is normal. This is true of depression, anxiety, post-traumatic stress disorder (PTSD), schizophrenia, and bipolar disorder (once known as manic depression).

I am not suggesting that all psychiatric conditions are caused by absent sleep. However, I am suggesting that sleep disruption remains a neglected factor contributing to the instigation and/or maintenance of numerous psychiatric illnesses, and has powerful diagnostic and therapeutic potential that we are yet to fully understand or make use of.

I find it to be an ethically difficult experiment to appreciate, but the scientists had importantly demonstrated that a lack of sleep is a causal trigger of a psychiatric episode of mania or depression. The result supports a mechanism in which the sleep disruption — which almost always precedes the shift from a stable to an unstable manic or depressive state in bipolar patients — may well be a (the) trigger in the disorder, and not simply epiphenomenal.

When we compared the effectiveness of learning between the two groups, the result was clear: there was a 40 percent deficit in the ability of the sleep-deprived group to cram new facts into the brain (i.e., to make new memories), relative to the group that obtained a full night of sleep.

While at Harvard University, I was invited to write my first op-ed piece for their newspaper, the Crimson. The topic was sleep loss, learning, and memory. It was also the last piece I was invited to write.

In other words, if you don’t sleep the very first night after learning, you lose the chance to consolidate those memories, even if you get lots of “catch-up” sleep thereafter. In terms of memory, then, sleep is not like the bank. You cannot accumulate a debt and hope to pay it off at a later point in time. Sleep for memory consolidation is an all-or-nothing event.

More than 40 million people suffer from the debilitating disease. That number has accelerated as the human life span has stretched, but also, importantly, as total sleep time has decreased. One in ten adults over the age of sixty-five now suffers from Alzheimer’s disease.

Making matters worse, over 60 percent of patients with Alzheimer’s disease have at least one clinical sleep disorder.

The disruption of deep NREM sleep was therefore a hidden middleman brokering the bad deal between amyloid and memory impairment in Alzheimer’s disease. A missing link.

Although the glymphatic system — the support team — is somewhat active during the day, Nedergaard and her team discovered that it is during sleep that this neural sanitization work kicks into high gear. Associated with the pulsing rhythm of deep NREM sleep comes a ten- to twentyfold increase in effluent expulsion from the brain. In what can be described as a nighttime power cleanse, the purifying work of the glymphatic system is accomplished by cerebrospinal fluid that bathes the brain. Nedergaard made a second astonishing discovery, which explained why the cerebrospinal fluid is so effective in flushing out metabolic debris at night. The glial cells of the brain were shrinking in size by up to 60 percent during NREM sleep, enlarging the space around the neurons and allowing the cerebrospinal fluid to proficiently clean out the metabolic refuse left by the day’s neural activity.

One piece of toxic debris evacuated by the glymphatic system during sleep is amyloid protein — the poisonous element associated with Alzheimer’s disease.

From this cascade comes a prediction: getting too little sleep across the adult life span will significantly raise your risk of developing Alzheimer’s disease. Precisely this relationship has now been reported in numerous epidemiological studies, including those individuals suffering from sleep disorders such as insomnia and sleep apnea. Parenthetically, and unscientifically, I have always found it curious that Margaret Thatcher and Ronald Reagan—two heads of state that were very vocal, if not proud, about sleeping only four to five hours a night — both went on to develop the ruthless disease. The current US president, Donald Trump — also a vociferous proclaimer of sleeping just a few hours each night — may want to take note.

CHAPTER 8 - Cancer, Heart Attacks, and a Shorter Life

In the Northern Hemisphere, the switch to daylight savings time in March results in most people losing an hour of sleep opportunity. Should you tabulate millions of daily hospital records, as researchers have done, you discover that this seemingly trivial sleep reduction comes with a frightening spike in heart attacks the following day. Impressively, it works both ways. In the autumn within the Northern Hemisphere, when the clocks move forward and we gain an hour of sleep opportunity time, rates of heart attacks plummet the day after.

The global health cost of diabetes is $375 billion a year. That of obesity is more than $2 trillion.

Independent of one another, the research groups found far higher rates of type 2 diabetes among individuals that reported sleeping less than six hours a night routinely.

When your sleep becomes short, you will gain weight. Multiple forces conspire to expand your waistline. The first concerns two hormones controlling appetite: leptin and ghrelin. Leptin signals a sense of feeling full. When circulating levels of leptin are high, your appetite is blunted and you don’t feel like eating. Ghrelin, in contrast, triggers a strong sensation of hunger.

At fault were the two characters, leptin and ghrelin. Inadequate sleep decreased concentrations of the satiety-signaling hormone leptin and increased levels of the hunger-instigating hormone ghrelin.

Of relevance to this behavior is a recent discovery that sleep loss increases levels of circulating endocannabinoids, which, as you may have guessed from the name, are chemicals produced by the body that are very similar to the drug cannabis. Like marijuana use, these chemicals stimulate appetite and increase your desire to snack, otherwise known as having the munchies.

Take it to the extreme by sleep-depriving an individual for twenty-four hours straight and they will only burn an extra 147 calories, relative to a twenty-four-hour period containing a full eight hours of sleep. Sleep, it turns out, is an intensely metabolically active state for brain and body alike.

Based on evidence gathered over the past three decades, the epidemic of insufficient sleep is very likely a key contributor to the epidemic of obesity. Epidemiological studies have established that people who sleep less are the same individuals who are more likely to be overweight or obese.

Three-year-olds sleeping just ten and a half hours or less have a 45 percent increased risk of being obese by age seven than those who get twelve hours of sleep a night.

Sample the hormone levels circulating in the blood of these tired participants and you will find a marked drop in testosterone relative to their own baseline levels of testosterone when fully rested. The size of the hormonal blunting effect is so large that it effectively “ages” a man by ten to fifteen years in terms of testosterone virility.

There was a clear, linear relationship with infection rate. The less sleep an individual was getting in the week before facing the active common cold virus, the more likely it was that they would be infected and catch a cold.

Cancers are known to use the inflammation response to their advantage. For example, some cancer cells will lure inflammatory factors into the tumor mass to help initiate the growth of blood vessels that feed it with more nutrients and oxygen. Tumors can also use inflammatory factors to help further damage and mutate the DNA of their cancer cells, increasing the tumor’s potency.

The sleep-deprived mice suffered a 200 percent increase in the speed and size of cancer growth, relative to the well-rested group.

Not getting sufficient sleep when fighting a battle against cancer can be likened to pouring gasoline on an already aggressive fire. That may sound alarmist, but the scientific evidence linking sleep disruption and cancer is now so damning that the World Health Organization has officially classified nighttime shift work as a “probable carcinogen.”

Deprive a mouse of sleep for just a day, as researchers have done, and the activity of these genes will drop by well over 200 percent.

The less sleep an individual obtains, or the worse the quality of sleep, the more damaged the capstone telomeres of that individual’s chromosomes.

PART 3 - How and Why We Dream

CHAPTER 9 - Routinely Psychotic

In fact, there are four main clusters of the brain that spike in activity when someone starts dreaming in REM sleep: (1) the visuospatial regions at the back of the brain, which enable complex visual perception; (2) the motor cortex, which instigates movement; (3) the hippocampus and surrounding regions that we have spoken about before, which support your autobiographical memory; and (4) the deep emotional centers of the brain — the amygdala and the cingulate cortex, a ribbon of tissue that sits above the amygdala and lines the inner surface of your brain — both of which help generate and process emotions. Indeed, these emotional regions of the brain are up to 30 percent more active in REM sleep compared to when we are awake!

REM sleep can therefore be considered as a state characterized by strong activation in visual, motor, emotional, and autobiographical memory regions of the brain, yet a relative deactivation in regions that control rational thought.

CHAPTER 10 - Dreaming as Overnight Therapy

At the heart of the theory was an astonishing change in the chemical cocktail of your brain that takes place during REM sleep. Concentrations of a key stress-related chemical called noradrenaline are completely shut off within your brain when you enter this dreaming sleep state. In fact, REM sleep is the only time during the twenty-four-hour period when your brain is completely devoid of this anxiety-triggering molecule.

Most compelling to me, however, were the repetitive nightmares reported in PTSD patients — a symptom so reliable that it forms part of the list of features required for a diagnosis of the condition.

It turns out that the drug prazosin, which Raskind was prescribing simply to lower blood pressure, also has the fortuitous side effect of suppressing noradrenaline in the brain. Raskind had delightfully and inadvertently conducted the experiment I was trying to conceive of myself.

Mutually informed by each other’s work, and based on the strength of Raskind’s studies and now several large-scale independent clinical trials, prazosin has become the officially approved drug by the VA for the treatment of repetitive trauma nightmares, and has since received approval by the US Food and Drug Administration for the same benefit.

With the absence of such emotional acuity, normally gifted by the re-tuning skills of REM sleep at night, the sleep-deprived participants slipped into a default of fear bias, believing even gentle- or somewhat friendly looking faces were menacing.

CHAPTER 11 - Dream Creativity and Dream Control

Scientists had gained objective, brain-based proof that lucid dreamers can control when and what they dream while they are dreaming. Other studies using similar eye movement communication designs have further shown that individuals can deliberately bring themselves to timed orgasm during lucid dreaming, an outcome that, especially in males, can be objectively verified using physiological measures by (brave) scientists.

PART 4 - From Sleeping Pills to Society Transformed

CHAPTER 12 - Things That Go Bump in the Night

Approximately one out of every nine people you pass on the street will meet the strict clinical criteria for insomnia, which translates to more than 40 million Americans struggling to make it through their waking days due to wide-eyed nights.

Without belaboring the point, insomnia is one of the most pressing and prevalent medical issues facing modern society, yet few speak of it this way, recognize the burden, or feel there is a need to act. That the “sleep aid” industry, encompassing prescription sleeping medications and over-the-counter sleep remedies, is worth an astonishing $30 billion a year in the US is perhaps the only statistic one needs in order to realize how truly grave the problem is.

Cataplexy is therefore an abnormal functioning of the REM-sleep circuitry within the brain, wherein one of its features — muscle atonia — is inappropriately deployed while the individual is awake and behaving, rather than asleep and dreaming.

Scientists have examined the brains of narcoleptic patients in painstaking detail after they have passed away. During these postmortem investigations, they discovered a loss of almost 90 percent of all the cells that produce orexin.

Despite wonderful work by many of my colleagues, narcolepsy currently represents a failure of sleep research at the level of effective treatments.

For the first symptom of narcolepsy — daytime sleep attacks — the only treatment used to be high doses of the wake-promoting drug amphetamine.

Soon after turning forty-two years old, Michael Corke died of a rare, genetically inherited disorder called fatal familial insomnia (FFI). There are no treatments for this disorder, and there are no cures. Every patient diagnosed with the disorder has died within ten months, some sooner. It is one of the most mysterious conditions in the annals of medicine, and it has taught us a shocking lesson: a lack of sleep will kill a human being.

CHAPTER 13 - iPads, Factory Whistles, and Nightcaps

five key factors have powerfully changed how much and how well we sleep: (1) constant electric light as well as LED light, (2) regularized temperature, (3) caffeine (discussed in chapter 2), (4) alcohol, and (5) a legacy of punching time cards.

Nightly alcohol will disrupt your sleep, and the annoying advice of abstinence is the best, and most honest, I can offer.

To successfully initiate sleep, as described in chapter 2, your core temperature needs to decrease by 2 to 3 degrees Fahrenheit, or about 1 degree Celsius. For this reason, you will always find it easier to fall asleep in a room that is too cold than too hot, since a room that is too cold is at least dragging your brain and body in the correct (downward) temperature direction for sleep.

The need to dump heat from our extremities is also the reason that you may occasionally stick your hands and feet out from underneath the bedcovers at night due to your core becoming too hot, usually without your knowing.

A bedroom temperature of around 65 degrees Fahrenheit (18.3°C) is ideal for the sleep of most people, assuming standard bedding and clothing.

Our biased sensitivity to cool blue light is a vestigial carryover from our marine forebears.

CHAPTER 14 - Hurting and Helping Your Sleep

No past or current sleeping medications on the legal (or illegal) market induce natural sleep. Don’t get me wrong — no one would claim that you are awake after taking prescription sleeping pills. But to suggest that you are experiencing natural sleep would be an equally false assertion.

Those taking sleeping pills were 4.6 times more likely to die over this short two-and-a-half-year period than those who were not using sleeping pills.

One frequent cause of mortality appears to be higher-than-normal rates of infection.

Consider that the original Star Wars movies — some of the highest-grossing films of all time — required more than forty years to amass $3 billion in revenue. It took Ambien just twenty-four months to amass $4 billion in sales profit, discounting the black market.

One of the more paradoxical CBT-I methods used to help insomniacs sleep is to restrict their time spent in bed, perhaps even to just six hours of sleep or less to begin with. By keeping patients awake for longer, we build up a strong sleep pressure — a greater abundance of adenosine. Under this heavier weight of sleep pressure, patients fall asleep faster, and achieve a more stable, solid form of sleep across the night.

Published in the prestigious journal Annals of Internal Medicine, the conclusion from this comprehensive evaluation of all existing data was this: CBT-I must be used as the first-line treatment for all individuals with chronic insomnia, not sleeping pills.

All twelve suggestions are superb advice, but if you can only adhere to one of these each and every day, make it: going to bed and waking up at the same time of day no matter what. It is perhaps the single most effective way of helping improve your sleep, even though it involves the use of an alarm clock.

CHAPTER 15 - Sleep and Society:

A hundred years ago, less than 2 percent of the population in the United States slept six hours or less a night. Now, almost 30 percent of American adults do.

A 2007 report entitled “Leave No Marks: Enhanced Interrogation Techniques and the Risk of Criminality” offers a disquieting account of such practices in the modern day. The document was compiled by Physicians for Human Rights, an advocacy group seeking to end human torture. Telegraphed by the report’s title, many modern-day torture methods are deviously designed to leave no evidence of physical assault. Sleep deprivation epitomizes this goal and, at the time of writing this book, is still used for interrogation by countries, including Myanmar, Iran, Iraq, the United States, Israel, Egypt, Libya, Pakistan, Saudi Arabia, Tunisia, and Turkey.

Proof comes from a recent scientific study demonstrating that one night of sleep deprivation will double or even quadruple the likelihood that an otherwise upstanding individual will falsely confess to something they have not done.

Several US federal courts hold a similarly damning view of these practices, ruling that sleep deprivation violates both the Eighth and Fourteenth Amendments of the United States Constitution regarding protection from cruel and inhuman punishment. Their rationale was sound and impenetrable: “sleep,” it was stated, must be considered a “basic life necessity,” which it clearly is.

More than 80 percent of public high schools in the United States begin before 8:15 a.m. Almost 50 percent of those start before 7:20 a.m. School buses for a 7:20 a.m. start time usually begin picking up kids at around 5:45 a.m. As a result, some children and teenagers must wake up at 5:30 a.m., 5:15 a.m., or even earlier, and do so five days out of every seven, for years on end. This is lunacy.

Forced by the hand of early school start times, this state of chronic sleep deprivation is especially concerning considering that adolescence is the most susceptible phase of life for developing chronic mental illnesses, such as depression, anxiety, schizophrenia, and suicidality. Unnecessarily bankrupting the sleep of a teenager could make all the difference in the precarious tipping point between psychological wellness and lifelong psychiatric illness.

Only then did scientists realize the rather profound conclusions of the experiment: REM sleep is what stands between rationality and insanity.

Published in his seminal papers and book Genetic Studies of Genius, Terman found that no matter what the age, the longer a child slept, the more intellectually gifted they were.

Terman believed that this swing to an early-morning model of education would damage, and damage deeply, the intellectual growth of our youth. Despite his warnings, nearly a hundred years later, US education systems have shifted to early school start times, while many European countries have done just the opposite.

In a study that was started by Dr. Ronald Wilson at Louisville School of Medicine in the 1980s, which continues to this day, hundreds of twin pairs were assessed at a very young age. The researchers specifically focused on those twins in which one was routinely obtaining less sleep than the other, and tracked their developmental progress over the following decades. By ten years of age, the twin with the longer sleep pattern was superior in their intellectual and educational abilities, with higher scores on standardized tests of reading and comprehension, and a more expansive vocabulary than the twin who was obtaining less sleep.

When the Mahtomedi School District of Minnesota pushed their school start time from 7:30 to 8:00 a.m., there was a 60 percent reduction in traffic accidents in drivers sixteen to eighteen years of age. Teton County in Wyoming enacted an even more dramatic change in school start time, shifting from a 7:35 a.m. bell to a far more biologically reasonable one of 8:55 a.m. The result was astonishing — a 70 percent reduction in traffic accidents in sixteen- to eighteen-year-old drivers.

School bus schedules and bus unions are a major roadblock thwarting appropriately later school start times, as is the established routine of getting the kids out the door early in the morning so that parents can start work early.

Most people know the name of the common ADHD medications: Adderall and Ritalin. But few know what these drugs actually are. Adderall is amphetamine with certain salts mixed in, and Ritalin is a similar stimulant, called methylphenidate. Amphetamine and methylphenidate are two of the most powerful drugs we know of to prevent sleep and keep the brain of an adult (or a child, in this case) wide awake.

Based on recent surveys and clinical evaluations, we estimate that more than 50 percent of all children with an ADHD diagnosis actually have a sleep disorder, yet a small fraction know of their sleep condition and its ramifications.

Why did we ever force doctors to learn their profession in this exhausting, sleepless way? The answer originates with the esteemed physician William Stewart Halsted, MD, who was also a helpless drug addict.

To Halsted, sleep was a dispensable luxury that detracted from the ability to work and learn. Halsted’s mentality was difficult to argue with, since he himself practiced what he preached, being renowned for a seemingly superhuman ability to stay awake for apparently days on end without any fatigue. But Halsted had a dirty secret that only came to light years after his death, and helped explain both the maniacal structure of his residency program and his ability to forgo sleep. Halsted was a cocaine addict. It was a sad and apparently accidental habit, one that started years before his arrival at Johns Hopkins.

Throughout the course of their residency, one in five medical residents will make a sleepless-related medical error that causes significant, liable harm to a patient. One in twenty residents will kill a patient due to a lack of sleep.

CHAPTER 16 - A New Vision for Sleep in the Twenty-First Century

Few people realize that the annual financial cost of the flu in the US is around $100 billion ($10 billion direct and $90 billion in lost work productivity).

Rather than required hours with relatively hard boundaries (i.e., the classic nine to five), businesses need to adapt a far more tapered vision of hours of operation, one that resembles a squished inverted-U shape. Everyone would be present during a core window for key interactions—say, twelve to three p.m. Yet there would be flexible tail ends either side to accommodate all individual chronotypes.

Conclusion - To Sleep or Not to Sleep

This silent sleep loss epidemic is the greatest public health challenge we face in the twenty-first century in developed nations.

About the Author

MATTHEW WALKER, PHD, is a professor of neuroscience and psychology at UC Berkeley, the director of its Sleep and Neuroimaging Lab, and a former professor of psychiatry at Harvard University.