sleep is an intensive care unit (ICU). The combination of serious illness, serious drugs, constant monitoring, bright lighting and the aftereffects of surgery ensures that ICU patients are often subjected to severe sleep deprivation. And yet the ICU houses the sickest people in the hospital, with the greatest need for sleep. American researchers conducted an experiment to see if implementing regular ‘quiet times’ during the day would help ICU patients to get more sleep. Each day for two two-hour periods, lighting levels in the unit were reduced and the staff made a concerted effort to minimise noise. The ‘quiet-time’ regime worked: the patients were 60 per cent more likely to sleep during these quiet periods than at other times of the day. More flexibility over when patients are given their medication can also help them to get more sleep.
Sadly, the apparent neglect of sleep in hospitals is another reflection of the general disregard for sleep in medicine and society as a whole. Lack of sleep really does have very little to recommend it.
Sleep rock thy brain.
William Shakespeare, Hamlet (1601)
Now it is time to peer beneath the surface at the strange state of existence known as sleep – or, to be more precise, the two strange states of existence known as sleep.
All of human life is spent in one of three states. You are very familiar with one of them: it is called the waking state, or consciousness, and it forms the subject matter for almost everything that has ever been said, written, acted, painted or composed about humanity. When scientists analyse the mind, when novelists dissect the human condition and when biographers portray the lives of eminent individuals, it is the waking state they almost invariably describe. However, there are two other distinct states of existence that together account for at least a third of each life. They labour under the workaday names of Rapid Eye Movement (REM) sleep and Non-Rapid Eye Movement (NREM) sleep, and we are about to take a closer look at them.
A night’s sleep is a complex and cyclic process, comprising several distinct patterns of brain activity and behaviour, with alternating episodes of NREM sleep and REM sleep. We will follow the sleep cycle from the beginning, starting with the transition from the waking state. But before we do that, a quick word about how scientists know what is going on when we are asleep.
Brains wave.
Owen Flanagan, Dreaming Souls (2000)
The sleeping brain reveals what is going on inside itself in various ways, both electrically and chemically. Since the middle of the twentieth century, the main tool for monitoring sleep has been the electroencephalograph. This machine exploits the fortunate fact that varying patterns of electrical activity within the brain manifest themselves as varying patterns of voltage changes on the surface of the scalp.
The brain comprises billions of nerve cells, or neurons, and although the electrical activity of an individual neuron is too faint to be detected outside the skull, it is possible to monitor the gross patterns generated collectively by large numbers of neurons. These show up as minute voltage changes, which can be detected by electrodes stuck onto the scalp. (The very first electrodes were small pins that were stuck into the scalps of stoical volunteers.) Thus, the brain emits electrical signals revealing information about its inner state. These tiny voltage patterns are amplified and displayed as the familiar ‘brain waves’ of the electroencephalogram, or EEG. (Confusingly, the machine is called an electroencephalograph, while the graph it produces is called an electroencephalogram, or EEG. To avoid nausea, I will use EEG to denote both the machine and its output.)
The EEG was invented in the 1920s by a psychiatrist named Hans Berger. It really came into its own in the 1950s when, as we shall see, it enabled the discovery of REM sleep. Before the invention of the EEG, scientists could only assess sleep by observing overt body movements, or the lack of them. Scientists still find it useful to record sleepers’ body movements, especially in studies of sleep patterns under natural conditions where the use of EEG would be too intrusive or too expensive. Nowadays, body movements are usually logged automatically, using a miniature recorder worn on the wrist.
Sleep laboratories use an extension of the EEG called the polysomnograph – a sort of somnolent variation on the polygraph. A polysomnograph records the EEG brain waves, together with other informative measures of the sleeper’s physiological state and behaviour. Electrodes placed near the corners of the eyes detect movements of the eyeballs, producing a trace known as the electro-oculogram, or EOG. Other electrodes placed on the chin and neck monitor the muscle tone (producing an electromyogram, or EMG) while electrodes on the chest record the heart rhythms (electrocardiogram, or ECG). Additional devices may record whole body movements, breathing, the flow of air through the nose and mouth, and the concentration of oxygen in the blood. In the early days of sleep science, these measurements were recorded as continuous pen traces on miles of rapidly unfurling paper, but nowadays the outputs are usually stored digitally.
In recent decades, brain scanning has become an increasingly important tool in sleep research. One of the main brain-scanning techniques is called positron emission tomography (PET). PET scans reveal the local patterns of blood flow and oxygen uptake within small areas of the brain by measuring how rapidly the tissue is using energy. Unlike some brain-scanning techniques, PET does not require the subject to sleep inside a large, claustrophobia-inducing scanning device. It therefore allows scientists to monitor sleep under conditions that are slightly closer to normality. Even so, the sleeping subject’s head needs to be kept absolutely still, which is usually achieved by pinning the head down with a special mask (the stuff of some people’s nightmares).
Most measurements of sleep are made in specialised sleep laboratories rather than people’s own homes. The underlying assumption is that the sleep patterns observed in the laboratory closely resemble the real thing. Fortunately, this turns out to be a broadly valid assumption. Comparisons have confirmed that for most people there is a reasonably good concordance between their sleep patterns at home and in the sleep laboratory. But there are some systematic differences. In particular, people tend to sleep for a slightly shorter period under laboratory conditions and to wake up slightly earlier than they would normally. They also have less bizarre dreams and fewer wet dreams. (Wouldn’t you?)
Falling asleep again, what am I to do?
Warm beds: warm full blooded life.
James Joyce, Ulysses (1922)
Falling asleep is not an abrupt process, like turning off a light, although it can seem like that because you usually forget about it. Recordings of brain-wave activity and other physiological variables show that falling asleep is in fact a continuous process, which starts from a state of relaxed drowsiness and ends in the first or second stages of unequivocal sleep.
During that process of falling asleep you may find yourself temporarily suspended for several minutes between the worlds of waking consciousness and sleep. This transition phase is often accompanied by strange thoughts, dreamlike images and occasional hallucinations. In one of his short stories, Washington Irving described how the mind can roam far and wide while it is in this pre-sleep
