The Science of Sleep

How Rest Works Wonders • What Kids Need • The New Dream Therapy

Contents

1. Cover

2. Title

3. Copyright

4. FOREWORD / The Power of Sleep

5. Maintenance for Your Mind

6. The 9 New Sleep Rules

7. Can You Sleep Yourself Slim?

8. Bedtime Battles

9. Sleep and the Teenage Brain

10. Doctor’s Orders: Go Back to Bed

11. The Dream Therapist

12. Tuning Out Bad Dreams

13. Sleep Like a Pro

14. The Truth About Sleeping Pills

15. A Simple Plan for Rest

16. Wake Up to Your Creativity

17. PHOTO ESSAY / A World of Slumber

18. Credits

Parts of this book were previously published in TIME and on Time.com.

ART AND SCIENCE Ted Spagna’s time-lapse photography is paired with an electroencephalogram to illuminate what it means, for one man, to sleep through the night.

The Power of Sleep

Bedtime advice from the father of integrative medicine

BY ANDREW WEIL, M.D.

WHO HAS NOT EXPERIENCED THE RESTORATIVE power of a good night’s sleep? And how many of us have longed for that experience when it was not available?

Sleep of sufficient quantity and quality is an integral element of a healthy lifestyle. Lacking it, both physical and emotional well-being suffer. Despite a great deal of research on the physiology of sleep, no one really knows why we sleep. How odd that we spend a third or so of each day in an unconscious state or, perhaps more accurately, a state in which ordinary waking consciousness is suspended.

The brain is quite busy during sleep, cycling through various levels of neuronal arousal each night. Is this activity a necessary sort of housekeeping to maintain optimum function? We do not know. Perhaps the daily rhythm of sleeping and waking will always be a mystery: something we experience but will never fully understand.

Most adults need seven to eight hours of uninterrupted sleep a night, but some individuals need more and some much less. In general, young people require more; some teenagers need to sleep nine hours a day, which would likely not surprise people who have adolescents in the house. Patterns of sleep—what experts call “sleep architecture”—change as we age. Older people tend to get sleepy earlier but have more difficulty falling asleep and staying asleep, and they often feel tired during the day.

Good sleep includes dreaming, another mysterious experience and one that is poorly understood. Everyone dreams, even those who say they don’t. Not everyone can recall their dreams regularly unless they practice relating them immediately on waking to a bed partner or a recording device or writing them down in a journal. (For more about dreaming, see John Cloud’s “Tuning Out Bad Dreams,” in which he tries to put an end to a lifetime of nightmares, and “The Dream Therapist,” about the field of dreaming as therapy.)

A heated debate currently rages between followers of Sigmund Freud, who believe that dreams reveal unconscious conflicts and desires, and neuroscientists, who regard dreams as meaningless productions of the sleeping brain. In any case, if people are deprived of the opportunity to dream—by waking them at the onset of the phase of sleep associated with dreaming—their well-being suffers, even if they get the amount of sleep they are used to.

But whatever its purpose, good sleep too often eludes us. Judging by sales of prescribed and over-the-counter sleep medications, numerous people in our society have difficulty falling asleep and staying asleep. Sadly, none of these drugs reproduce natural sleep. All suppress dreaming, many interfere with cognition, and some are highly addictive. (To learn about the pharmaceuticals on the market, see “The Truth About Sleeping Pills.”)

So many factors can interfere with sleep: excessive use of caffeine and other stimulants, bodily aches and pains, ambient noise and light, an uncomfortable mattress, anxiety and depression, an overactive mind. The term “sleep hygiene” covers all the habits, practices and environmental influences that determine how we sleep, and if you suffer from chronic insomnia, analysis of your sleep hygiene by a professional may highlight changes that will solve the problem without resorting to drugs.

If you have trouble sleeping on a regular basis, don’t overlook the possibility that stimulants, including coffee, may be involved. Many of us are unaware of their profound effects on the nervous system, and there’s great individual variability in our sensitivity to caffeine. For the most sensitive, a single cup of coffee in the morning may be the main cause of nighttime insomnia. And aside from familiar beverages like coffee, tea and cola, caffeine is used in various over-the-counter medications, energy drinks and some dietary supplements. If you take these products, you may have no idea how much of the drug you’re actually consuming.

Stimulants can also be non-pharmacological. Noise can be a culprit, as can watching exciting media (including the news) before bed and being in the company of people who are anxious. All of this can stimulate the nervous system and interfere with your body’s winding-down period before rest.

I often give advice about nutrition, and I like to think of it not just in the narrow sense of food for the body but in the broader sense of what we choose to experience and how the choices affect our minds and emotions. An overstimulated mind and inability to disengage from thinking are among the most common obstacles to falling asleep. In addition to reducing mental stimulation, turning your attention toward the breath is a good way to practice withdrawing from the flow of thoughts. Relaxation training and meditation techniques, such as mindfulness-based stress reduction, can be very helpful for people with sleep problems (and for the rest of us too).

When I take a medical history, one of the questions I always ask is “How well do you sleep?” Too often, the answer I get is “Not so well.” I then ask whether the problem is with falling asleep or staying asleep and inquire in depth about sleep hygiene. Usually I can identify the likely cause or causes of the problem and suggest remedies. If not, I will refer the patient to a sleep expert or clinic. Fortunately, as more physicians and allied health professionals are trained in integrative medicine and lifestyle analysis, more are paying attention to how their patients sleep.

This book reviews the science of sleep, an active field of research with great relevance to health and well-being. I believe the information in these pages will increase your understanding of all those hours you spend asleep—and, most important, motivate you to make them more refreshing.

ANDREW WEIL is the founder and director of the Arizona Center for Integrative Medicine, a clinical professor of medicine at the University of Arizona and the author of many books, including Spontaneous Healing and Spontaneous Happiness.

Maintenance for Your Mind

New research shows that a good night’s rest isn’t a luxury—it’s critical for the health of your brain as you age

BY ALICE PARK

WHEN OUR HEADS HIT THE PILLOW each night, we tend to think we’re surrendering. Not just to exhaustion, though there is that. We’re also surrendering our minds, taking leave of our focus on sensory cues, like noise and smell and blinking lights. It’s as if we’re powering ourselves down like we do the electronics at our bedside—going idle for a while, only to spring back into action when the alarm blasts hours later.

That’s what we think is happening. But as scientists are now revealing, that couldn’t be further from the truth.

In fact, when the lights go out, our brains start working—but in an altogether different way than when we’re awake. At night, a legion of neurons springs into action, and like any well-trained platoon, the cells work in perfect synchrony, pulsing with electrical signals that wash over the brain with a soothing, hypnotic flow. Meanwhile, data processors sort through the reams of information that flooded the brain all day at a pace too overwhelming to handle in real time. The brain also runs checks on itself to ensure that the normally exquisite balance of hormones, enzymes and proteins isn’t too far off-kilter. And all the while, cleaners follow in close pursuit to sweep out the toxic detritus that the brain doesn’t need and that can cause all kinds of problems if it builds up.

This, scientists are now learning, is the brain on sleep. It’s nature’s panacea, more powerful than any drug in its ability to restore and rejuvenate itself and the rest of the body. Getting the recommended seven to eight hours each night can improve concentration, sharpen planning and memory skills, and maintain the fat-burning systems that regulate our weight. If every one of us slept as much as we’re supposed to, we’d all be lighter, less prone to developing Type 2 diabetes, and most likely better equipped to battle depression and anxiety. We might even lower our risk of Alzheimer’s disease, osteoporosis and cancer.

The trouble is, sleep works only if we get enough of it. While plenty of pills can knock us out, none so far can replicate all of sleep’s benefits, despite decades’ worth of attempts in high-tech pharmaceutical labs.

Which is why, after we’ve long treated rest as a good-if-you-can-get-it obligation, scientists are making the case that it matters much more than we think. They’re not alone in sounding the alarm. With up to 70 million of us not getting a good night’s sleep on a regular basis, the Centers for Disease Control and Prevention considers insufficient sleep a public-health epidemic. In fact, experts argue, sleep is emerging as so potent a factor in better health that we need a societal shift—and policies to support it—to make sleep a nonnegotiable priority.

THE CONSEQUENCES OF SKIMPING

Despite how great we feel after a night’s rest—and putting aside what we now know about sleep’s importance—we stubbornly refuse to swallow our medicine, pushing off bedtime and thinking that feeling a little drowsy during the day is an annoying but harmless consequence. It’s not. Nearly 40% of adults have nodded off unintentionally during the day in the past month, and 5% have done so while driving. Insomnia or interrupted sleep nearly doubles the chance that workers will call in sick. And half of Americans say their uneven sleep makes it harder to concentrate on tasks.

Those poor sleep habits are trickling down to the next generation: 45% of teens don’t sleep the recommended nine hours on school nights, leading 25% of them to report falling asleep in class at least once a week, according to a National Sleep Foundation survey. It’s a serious enough problem that the American Academy of Pediatrics recently endorsed the idea of starting middle and high schools later to allow for more adolescent shut-eye.

Health experts have been concerned about our sleep-deprived ways for some time, but the new insights about the role sleep plays in our overall health have brought an urgency to the message. Sleep, the experts are recognizing, is the only time the brain has to catch its breath. If it doesn’t, it may drown in its own biological debris—everything from toxic free radicals produced by hardworking fuel cells to spent molecules that have outlived their usefulness.

“We all want to push the system, to get the most out of our lives, and sleep gets in the way,” says Sigrid Veasey, a leading sleep researcher and a professor of medicine at Perelman School of Medicine at the University of Pennsylvania. “But we need to know how far we can really push that system and get away with it.”

CLEAN SLEEP Maiken Nedergaard, left, and Lulu Xie of the University of Rochester Medical Center found, by studying mice, that our brains do a better job of clearing out cellular waste during sleep.

Veasey is learning that brain cells that don’t get their needed break every night are like overworked employees on consecutive double shifts—eventually, they collapse. Working with mice, she found that neurons that fire constantly to keep the brain alert spew out toxic free radicals as a byproduct of making energy. During sleep, they produce antioxidants that mop up these potential poisons. But even after short periods of sleep loss, “the cells are working hard but cannot make enough antioxidants, so they progressively build up free radicals and some of the neurons die off.” Once those brain cells are gone, they’re gone for good.

The brains of mice are considered good proxies in lab research for human brains. Veasey found that after several weeks of restricted sleep, the mice she studied were “more likely to be sleepy when they are supposed to be active and have more difficulty consolidating [the benefits of] sleep during their sleep period.”

It’s the same thing that happens in aging brains, she says, as nerve cells get less efficient at clearing away their garbage. “The real question is: What are we doing to our brains if we don’t get enough sleep? If we chronically sleep-deprive ourselves, are we really aging our brains?” she asks. Ultimately, the research suggests, it’s possible that a sleep-deprived brain belonging to a teen or a 20-year-old will start to look like that of a much older person.

“Chronic sleep restriction is a stress on the body,” says Peter Liu, a professor of medicine at Harbor-UCLA Medical Center and L.A. Biomedical Research Institute. And the cause of that sleep deprivation doesn’t always originate in family strife, financial concerns or job-related problems. The way we live now—checking our phones every minute, hyperscheduling our days or our kids’ days, not taking time to relax without a screen in front of our face—contributes to a regular flow of stress hormones like cortisol, and all that artificial light and screen time is disrupting our internal clocks. Simply put, our bodies don’t know when to go to sleep naturally anymore.

This is why researchers hope their new discoveries will change once and for all the way we think about—and prioritize—those 40 winks.

GARBAGEMEN FOR YOUR BRAIN

“I was nervous when I went to my first sleep conference,” says Maiken Nedergaard, the chatty and inquisitive co-director of the Center for Translational Neuromedicine at the University of Rochester. “I was not trained in sleep, and I came to it from the outside.” In fact, as a busy mother and career woman, she saw sleep the way most of us probably do: as a bother. “Every single night, I wanted to accomplish more and enjoy time with my family, and I was annoyed to have to go to bed.”

Because she’s a neuroscientist, however, Nedergaard was inclined to ask a seemingly basic question: Why do our brains need sleep at all? There are two competing evolutionary theories. One is that sleeping organisms are immobile and therefore less likely to be easy targets, so perhaps sleep provided some protection from prey. The time slumbering, however, took away from time spent finding food and reproducing. Another points out that sleeping organisms are oblivious to creeping predators, making them ripe for attack. Since both theories seem to put us at a disadvantage, Nedergaard thought there had to be some other reason the brain needs those hours offline.

All organs in the body use energy, and in the process, they spew out waste. Most take care of their garbage with a local system, recruiting immune cells like macrophages to gobble up the garbage and break it down or linking up to the network of vessels that make up the lymph system, the body’s drainage pipes.

The brain is a tremendous consumer of energy, but it’s not blanketed in lymph vessels. So how does it get rid of its trash? “If the brain is not functioning optimally, you’re dead evolutionarily, so there must be an advantage to exporting the garbage to a less critical organ like the liver,” says Nedergaard.

Indeed, that’s what her research shows. She found that an army of previously ignored cells in the brain, called glial cells, turn into a massive pump when the body sleeps. During the day, glial cells are the unsung personal assistants of the brain. They cannot conduct electrical impulses like other neurons, but they support them as they send signals zipping along nerve networks to register a smell here and an emotion there. For decades, they were dismissed by neuroscientists because they weren’t the actual drivers of neural connections.

But Nedergaard found in clinical trials on mice that glial cells change as soon as organisms fall asleep. The difference between the waking and sleeping brain is dramatic. When the brain is awake, it resembles a busy airport, swelling with the cumulative activity of individual messages traveling from one neuron to another. The activity inflates the size of brain cells until they take up 86% of the brain’s volume.

When daylight wanes and we eventually fall asleep, however, those glial cells kick into action, slowing the brain’s electrical activity to about a third of its peak frequency. During those first stages of sleep, called non-REM (rapid eye movement), the firing becomes more synchronized rather than haphazard. The repetitive cycle lulls the nerves into a state of quiet, so in the next stage, known as REM, the firing becomes almost nonexistent. The brain continues to toggle back and forth between non-REM and REM sleep throughout the night, once every hour and a half.

At the same time, the sleeping brain’s cells shrink, making more room for the brain and spinal cord’s fluid to slosh back and forth between them. “It’s like a dishwasher that keeps flushing through to wash the dirt away,” says Nedergaard. This cleansing also occurs in the brain when we are awake, but it’s reduced by about 15%, since the glial cells have less fluid space to work with when the neurons expand.

This means that when we don’t get enough sleep, the glial cells aren’t as efficient at clearing the brain’s garbage. That may push certain degenerative brain disorders that are typical of later life to appear much earlier.

Both Nedergaard’s and Veasey’s work also hint at why older brains are more prone to developing Alzheimer’s, which is caused by a buildup of amyloid protein that isn’t cleared quickly enough.

“There is much less flow to clear away things in the aging brain,” says Nedergaard. “The garbage system picks up every three weeks instead of every week.” And like any growing pile of trash, the molecular garbage starts to affect nearby healthy cells, interfering with their ability to form and recall memories or plan even the simplest tasks.

The consequences of deprived sleep, says Mary Carskadon, a professor of psychiatry at Brown University, are “scary, really scary.”

RIGHTSIZING YOUR SLEEP

All this isn’t actually so alarming, since there’s a simple fix that can stop this nerve die-off and slow the brain’s accelerated ride toward aging. What’s needed, says Carskadon, is a rebranding of sleep that strips away any hint of its being on the sidelines of our health.

As it is, sleep is so undervalued that getting by on fewer hours has become a badge of honor. Plus, we live in a culture that caters to the late-nighter, from 24-hour grocery stores to online shopping sites that never close. It’s no surprise, then, that more than half of American adults don’t get the recommended seven to nine hours of shut-eye every night.

Whether or not we can catch up on sleep—on the weekend, say—is a hotly debated topic among sleep researchers; the latest evidence suggests that while it isn’t ideal, it may help. When Liu brought chronically sleep-restricted people into the lab for a weekend of sleep during which they logged about 10 hours per night, they showed improvements in the ability of their insulin to process blood sugar. That suggests that catch-up sleep may undo some but not all of the damage that sleep deprivation causes, which is encouraging, given how many adults don’t get the hours they need each night. Still, Liu isn’t ready to endorse the habit of sleeping less and making up for it later. “It’s like telling people you only need to eat healthy during the weekends, but during the week you can eat whatever you like,” he says. “It’s not the right health message.”

Sleeping pills, while helpful for some, are not necessarily a silver bullet either. “A sleeping pill will target one area of the brain, but there’s never going to be a perfect sleeping pill, because you couldn’t really replicate the different chemicals moving in and out of different parts of the brain to go through the different stages of sleep,” says Nancy Collop, director of the Emory University Sleep Center. Still, for the 4% of Americans who rely on prescription sleep aids, the slumber they get with the help of a pill is better than not sleeping at all or getting interrupted sleep. At this point, it’s not clear whether the brain completes the same crucial housekeeping duties during medicated sleep as it does during natural sleep, and the long-term effects on the brain of relying on sleeping pills aren’t known either.

Making things trickier is the fact that we are unaware of the toll sleep deprivation takes on us. Studies consistently show that people who sleep less than eight hours a night don’t perform as well on concentration and memory tests but report feeling no deficit in their thinking skills. That just perpetuates the tendency to dismiss sleep and its critical role in everything from our mental faculties to our metabolic health.

The ideal is to reset the body’s natural sleep-wake cycle, a matter of training our bodies to sleep similar amounts every night and wake up at roughly the same time each day. An even better way to rediscover our natural cycle is to get as much exposure to natural light as possible during the day, while limiting how much indoor lighting, including from computer and television screens, we see at night. And of course, the best way to accomplish that is by making those seven to nine hours of sleep a must, not a luxury.

DAY IS DONE Spending time with a favorite book, a few minutes of meditation, or doing gentle exercises such as stretching or yoga can all be effective ways to ease into a good night’s sleep.

“I am now looking at and thinking of sleep as an ‘environmental exposure,’ ” says Carskadon—which means we should look at sleep similarly to how we view air-pollution exposure, secondhand smoke or toxins in our drinking water. If she and other researchers have their way, checking up on sleep would be a routine part of any physical exam, and doctors would ask about our sleep habits in the same way they query us about diet, stress, exercise, our sex life, our eyesight—you name it. And if we aren’t sleeping enough, they might prescribe a change, just as they would for any other bad health habit.

Some physicians are already taking the initiative, but no prescription works unless we actually take it. If our work schedule cuts into our sleep time, we need to make the sleep we get count by avoiding naps and exercising when we can during the day; feeling tired will get us to fall asleep sooner. If we need help dozing off, gentle exercises or yoga-type stretching can also help. Creating a sleep ritual can make sleep something we look forward to rather than something we feel obligated to do, so we’re more likely to get our allotted time instead of skipping it. A favorite book, a warm bath or other ways to get drowsy might prompt us to actually look forward to unwinding at the end of the day.

Given what scientists are learning about how much the body—and especially the brain—needs a solid and consistent amount of sleep, in-the-know doctors aren’t waiting for more studies to prove what we as a species know intuitively: that cheating ourselves of sleep is depriving us of one of nature’s most powerful and beneficial drugs.

“We now know that there is a lasting price to pay for sleep loss,” says Veasey. “We used to think that if you don’t sleep enough, you can sleep more and you’ll be fine tomorrow. We now know if you push the system enough, that’s simply not true.”

YOUR BODY ON SLEEP

During the day, the body is more focused on getting things done than taking care of itself. That changes when we sleep, as more energy is devoted to repairing cells, churning out helpful proteins, and more.

BONE

Wear and tear is remedied with intensified bone building

PANCREAS

Without sleep, we become less able to break down sugar from our diet

SKIN

Beauty rest is when cells churn out growth factors to repair damage and maintain elasticity

MUSCLES

Recovery from injuries like muscle tears happens during sleep

BRAIN

The cells shrink, squeezing out debris from a busy day

WHEN SHOULD SCHOOL START?

The American Academy of Pediatrics supports later school start times for teens. More than 1,000 high schools have already done this, and their students have shown improvements in grades and attentiveness in class.

IS SCREEN TIME MESSING WITH OUR SLEEP?

Any light at night, including the glow from phones, tablets and laptops, can throw off our body clocks. Our brains are fooled into thinking it’s day, so sleep signals don’t get heard.

The 9 New Sleep Rules

It’s not rocket science, but it does take some diligence to get your best night’s sleep—every night. Here’s how

BY SARAH BEGLEY

ANYONE WHO HAS NODDED OFF ON THE subway, faked alertness in a meeting at work or skipped a workout because of drowsiness understands the consequences of insufficient sleep. Aside from being unpleasant, however, it can result in weight gain, depression and even decreased brain volume. Scientists are also beginning to understand that our health doesn’t rely only on the quantity of sleep—a non-negotiable seven to eight hours, by the way—but also quality. So what to do? Some of the proven tips for better sleep are obvious: don’t drink coffee too late in the day; give yourself time to wind down before lights-out; keep stress out of the bedroom as much as possible. But as our world adapts to new trends and technologies, so must our sleep habits. Research is yielding new insights and antidotes to the tossing and turning that make sleep less restorative than we need it to be.

1. Stop using the snooze button

Even when you get a solid eight hours, dozing off for a few more minutes after the alarm can have the opposite of its intended effect. That’s because you may slide into a new sleep cycle, leading to the groggy sensation that researchers call sleep inertia. This impairs things like alertness, memory and reaction time, and it creates the impression that you got a lot less rest than you did. If you snooze because you’re so tired you can’t peel yourself out of bed, something else is probably wrong. Try setting a stricter bed- and wake time, and be sure to let more natural light into your bedroom in the morning to reset your circadian rhythm.

2. Try to see the (day) light

Speaking of which: a study in the Journal of Clinical Sleep Medicine found that the brains of office workers whose desks were far from windows received fewer light/dark cues—and had out-of-whack circadian rhythms as a result. Compared with their windowed colleagues, they got 46 fewer minutes of sleep per night. Though the study looked at a small group of participants, its logic is in line with what scientists have long known about our sleep patterns.

3. Shut down that tablet

You may find that reading before bed helps you wind down, but opt for a paperback over an iPad. A study in Proceedings of the National Academies of Sciences found “iPad readers had a delayed circadian rhythm, indicated by melatonin levels, of more than an hour.” Further, “participants who read from the iPad were less sleepy before bedtime, but sleepier and less alert the following morning after eight hours of sleep.” Do your best to avoid electronics that emit blue light (yup, your phone counts) right before bed.

4. Nix the nightcap

Alcohol may make you feel drowsy, but it’s bad for your sleep cycles. Research published in Alcoholism: Clinical & Experimental Research showed that the brain waves of those who drank before bed had more delta activity (associated with deep sleep) but also more alpha activity (associated with resting, but not sleeping, phases). The benefits of falling asleep quickly were counteracted by these disruptive alpha patterns, which means it’s best to set aside the chardonnay earlier in the night.

5. Pay attention to the moon

Strange but true: the moon may impact your sleep. Current Biology reported that study participants who slept in a completely dark lab got an average of 20 fewer minutes of sleep per night on the days shortly before or after a full moon and also showed lower levels of melatonin (the hormone that makes you sleepy) and 30% less EEG activity, which is associated with deep sleep. This monthly anomaly seems to be ingrained in our circadian rhythm, and even though you can’t do much about it, you might try going to bed extra early the day before a big meeting if it takes place close to the time of a full moon.

6. Beware the night shift

Unfortunately, many workers with overnight schedules have no choice but to be on duty when others are sleeping, but the science is clear: the night shift is bad for your health. A study in the American Journal of Preventive Medicine followed nearly 75,000 nurses and found that those who worked rotating night shifts had an 11% higher risk of early death than those who did not. If they worked that schedule for more than 15 years, their risk of dying from heart disease was 38% higher than their peers’. They also had heightened risks for several types of cancer. So far, researchers don’t know how to counteract the havoc wreaked by uncommon sleep cycles, but they recommend that workers who can’t avoid these schedules pursue healthy living with diligence in other areas, like diet and exercise.

7. Burn energy

To catch more z’s, you may need to spend more time on the treadmill. A study in the Journal of Clinical Sleep Medicine found that older adults who suffered from insomnia were able to sleep 45 to 60 minutes longer per night by exercising for 30 minutes three or four afternoons a week. The catch: on individual days, a workout was not likely to make falling asleep easier. It took regular exercise over an extended period of time (about four months) to significantly and consistently give them longer nights of sleep.

8. Take an intermission

Historians now know that our ancestors slept very differently from us. While most adults today go to bed and stay in bed, in the past people slept for a period, woke up for an hour or so, and then went back to sleep. Virginia Tech professor A. Roger Ekirch reported that this “segmented sleep” made for all kinds of nocturnal break activities, from reading to praying to having sex. There’s no reason to force yourself to switch from consolidated sleep to segmented sleep, but if you find that you wake in the night, don’t stress yourself out trying to doze off again—you’re following in the path of your forebears.

9. Seek medical help

According to the American Academy of Dental Sleep Medicine, 18 million Americans have sleep apnea, a disorder in which the airway becomes blocked, causing sufferers to snore loudly and stop breathing for short periods. This not only results in drowsiness from poor sleep quality but can raise blood pressure to a dangerously high level. The standard treatment, a special mask worn during sleep that facilitates continuous positive airway pressure (CPAP), helps the user sleep better and, research shows, reduces inflammation—thus helping prevent the long-term side effects of the disorder.

Can You Sleep Yourself Slim?

It sounds too good to be true, but the research is starting to stack up

BY ALEXANDRA SIFFERLIN

WHEN YOU WANT TO SLIM DOWN, the plan probably looks a bit like this: Step one, toss out the junk food; step two, pull out the running shoes; and step three, renew that gym membership (and actually use it). But a growing body of evidence suggests that getting a good night’s sleep should be on—or at least near—the top of the list.

Few experts would disagree with the idea that we’ve become a nation in need of a pick-me-up. We stay up too late, we wake up too early and, increasingly, we’re overweight. While there’s plenty of data showing that poor sleep can lead to weight gain and possibly even obesity, some new research also shows that the opposite may also be true: that getting the right amount of good quality sleep may actually help you shed a few pounds.

“Getting a full night of sleep is one of the most underappreciated factors contributing to healthy weight maintenance,” says Matthew Walker, a professor of psychology and neuroscience at the University of California, Berkeley, who studies the effect of sleep on weight.

Like all weight-loss strategies, sleep is not a quick fix, but consistently clocking a quality night’s sleep could be the secret sauce for your weight-loss plan. So keep the following lessons in mind when optimizing your sleep schedule for a more favorable number on the scale. Here’s why.

1. IT CAN REDUCE YOUR CRAVINGS FOR UNHEALTHY FOOD

It takes a lot of willpower to order a salad over a pizza, and research shows that how much sleep you’ve clocked can make or break your resolve. In a small but intriguing study published in the journal Nature Communications, Walker and his research team put 23 healthy, non-obese men and women through two sleep-related tests. In the first experiment, the men and women got a full eight hours of sleep, and in the second they were sleep-deprived for one night. The following day, they were placed in a brain scanner and asked to rate how desirable certain foods were to them, from a piece of fruit to things like ice cream. After a full night of rest, the people in the study tended to prefer healthier foods. But when they were sleep-deprived, the same men and women not only craved more junk food, but the area of their brains in charge of making rational decisions—like healthy food choices—was inhibited. Overall, the sleep-deprived people wanted foods that contained on average 600 calories more than what they craved when they were well rested.

“We are finding that getting a full night of sufficient sleep actually helps you reboot and refresh the circuits of the human brain, allowing it to make optimal food choices,” says Walker. “These food choices may put you on

a path toward weight control, rather than weight gain.”

And it’s not just pulling an all-nighter that can throw off your weight regulation. A 2013 study by University of Colorado researchers showed that losing a few hours of sleep a night for a few nights in a row can result in weight gain.

2. IT CAN HELP YOU FEEL FULLER, LONGER

Getting a good night’s rest not only helps you fight the urge to reach for a bag of chips, it also keeps your hunger pangs in check. Take a study of 1,024 volunteers that showed that when people didn’t get enough sleep, their hormone levels became unbalanced. Their levels of the hormone leptin, which is responsible for feeling full, dropped, and the levels of the appetite-inducing hormone ghrelin went up. Researchers think sleep helps our bodies keep those hunger hormones in line, making sure we feel hungry only when we should.

3. IT MAKES YOU MORE LIKELY TO STICK TO YOUR DIET

In 2012, Charles Elder, a researcher at the Kaiser Permanente Center for Health Research, recruited 472 obese adults into a weight-loss program that included weekly group meetings and counseling on diet and exercise. Elder and his colleagues measured a variety of factors, including levels of sleep, stress and depression. “At the beginning of the study, the people who told us they were sleeping six to eight hours a night ended up doing better in the weight-loss program than those who were sleeping less than six or more than eight hours,” says Elder. Stress mattered too. People who had low stress and were sleeping more than six but no more than eight hours a night were about twice as likely to have success in the program as people who had higher baseline stress and who were sleeping too much or too little.

Elder’s study is not the only one to make the connection. A 2014 study of women ages 25 through 65 who were classified as overweight or obese and participated in a seven-month weight-loss intervention showed that women who had fragmented sleep and woke up five or more times a night lost less weight than the women who had higher-quality sleep.

“The data makes us think that we should be paying attention to sleep patterns when we are offering sleep-management programs,” says Elder.

4. YOU’RE MORE LIKELY TO EXERCISE

“Losing weight takes a lot of energy, and if you are sleeping too much it’s going to impact your energy level, and sleeping too little can have effects on your ability to focus and concentrate on all the tasks at hand,” Elder says. And though he can’t say for sure, Elder believes that one of the main reasons getting enough sleep is linked to successful weight loss is that it provides you with the drive you need to stick to your goals. Other research has shown that people who are sleepy often say they exercise less, opting instead for sedentary activities like watching TV.

5. SLEEP LEADS TO BETTER CALORIE BURN

While you sleep, you’re likely to burn somewhere between 50 and 100 calories an hour. According to Walker, “When you dream, your brain can be as—if not more—active than when you’re awake.”

Experts are now learning that getting the right amount of sleep encourages a healthy metabolism, and skimping on sleep throws it out of whack. For example, a 2012 study published in the Annals of Internal Medicine showed that when a small group of men and women got only four hours of sleep a night, their bodies became more insulin-resistant, a red flag for obesity and diabetes.

Other research has shown that sleeping in cooler temperatures can stimulate a type of fat called brown fat, which burns more calories and has been shown to improve insulin sensitivity. In a 2014 study, a group of healthy men spent a month sleeping in a 66° room. After just one chilly month, the men had a 42% increase in brown fat and a 10% increase in metabolic fat activity. Sleeping in a cool room may sound like an easy fix, but it’s no cakewalk. Simply turning up the AC and wrapping up in a blanket doesn’t count. The researchers suspect the act of shivering is one of the primary drivers of the effect, so you have to really feel the chill.

No expert suggests that sleeping, without other behavioral modifications, will help you lose weight, but since many weight-loss plans are hard to sustain, there’s no harm in turning your attention to turning in for the night. After all, doing what’s best for your metabolism while you rest may be just as important as what you do when you rise.

Bedtime Battles

A hundred years of scientific research reveals that kids are sleeping less than ever. But does it really matter?

BY BONNIE ROCHMAN

HERE’S WHAT A CHILD’S BEDTIME LOOKS like to couples expecting their first baby: the nursery is softly lit, the child is sweetly sleepy, the last page of Goodnight Moon has been read. After that comes the final tuck-in, the gentle kiss and, finally, the quiet tiptoe out of the room.

So how often does this happen after the kids arrive? The answer—rounding to the closest zero—is, well, zero. Or at least that’s the way it seems. Wartime over bedtime is as fixed a part of childhood as teething and potty training, except that it goes on much, much longer and is much, much more exasperating than expecting parents know. It’s not for nothing that last year’s exquisitely titled faux children’s book Go the F--- to Sleep reached No. 1 on the Amazon.best-seller list a month before it was released. But the battle to get kids down for the night does not just drive parents to distraction; it causes them to worry. Children of all ages need a fixed amount of sleep every night, right? So what happens if your kids consistently fail to get theirs?

This is surely not the first generation of parents to fret about these things. It’s not even the first generation to believe that all the new technology surrounding—and overstimulating—their kids is making the problem worse than it’s ever been. According to a recent study from the University of South Australia, the issue has been debated for at least 100 years, and while eras may pass and the recommended hours of sleep may change, one thing remains stubbornly consistent: kids do not get as much rest as professionals think they need to be healthy mentally and physically. The question is whether the professionals are right.

The Australian study, published in the journal Pediatrics, began as a straight-ahead exercise in scientific spelunking, with investigators looking for every population-wide paper about kids and sleep duration published from the end of the 19th century through 2009. They discovered more than 200 of them—with one French study dating all the way back to 1897—and two trends were immediately evident.

First, the amount of sleep recommended for every age group has declined steadily over time, dropping an average of 0.71 minutes per year. Now, 0.71 minutes is only about 43 seconds, which does not amount to much over the course of a night. But over 112 years, that adds up to about one hour and 20 minutes—and that’s

not nothing.

At the same time, the amount of sleep that kids got kept almost perfect pace, dropping about 0.73 minutes per year. No matter how low the recommended-sleep bar gets, most children never quite clear it.

Two more constants: societal hand-wringing over children’s lack of sleep and a tendency to blame the hectic pace of modern living. As far back as the late 1800s, an editorial in the British Medical Journal attributed increasing sleeplessness to the stress and hurry of everyday life, made worse by the gaslights and trolley cars suddenly filling the streets. In 1905 one study noted that “this is a sleepless age and more and more . . . we are turning night into day.” Says Tim Olds, a professor of health and sciences at the University of South Australia and the senior author of the new study: “Throughout the 100-year period, we have been blaming whatever the new technology is: radio, TV, the Internet. Information is coming in so fast that we never wind down.”

Consistent over time, too, is the parental belief that kids need a sufficient amount of sleep in order to grow. This, it turns out, is not just a myth. Studies show that about 60% of a child’s growth hormone is secreted during sleep. “What we don’t know,” says Jodi Mindell, associate director of the Sleep Center at the Children’s Hospital of Philadelphia, “is if a child doesn’t get enough sleep, do you lose that secretion, or does it just shift to daytime?” What’s clearer—and a relatively new finding—is that getting too little sleep may have a role in obesity. One Israeli study found the effect in babies as young as 6 months. (Research on adults confirms it has that affect on grownups, too.)

SLEEP TIGHT American children, on average, sleep less than those in almost all other countries—and a full hour less than those in Australia.

So if everyone agrees on the value of sleep, why is the recommended amount always in flux? The troubling answer, according to Olds and his colleagues, is that those recommendations are for the most part subjective. “Every so often, a group of blokes get together and say, ‘What do you recommend, boys? Should we push it up to 9 hours, 15 minutes?’ ” says Olds. “It really is like that, honestly. It’s an arbitrary public-health line in the sand that people draw.”

Plenty of researchers disagree with this—and do so vehemently. Olds’s research, which he considers “quite innocuous, something of a cameo study, really,” has generated a flurry of controversy, with no fewer than 78 sleep experts and professionals deriding his scholarship as “a great disservice to children and families” in a response in Pediatrics. Others have sent him fan mail. People view sleep, he says, as “a lightning rod for their troubles.”

There’s more than just professional bickering involved here. The fact is, sleep is a notoriously tricky thing to study. Every individual’s physiology is different, and just knowing how much sleep a child gets is not the same as knowing how much that child needs. Ten hours may be too little for one 8-year-old and too much for another. And the best research tool yet discovered—asking a child, Do you feel sleepy?—lacks a certain objective rigor.

Still, Canadian research has found that as many as 68% of teens report feeling “really sleepy” in the morning, and 23% suspect their grades have suffered as a result. But both adults and kids go through cycles of high and low energy during the day, which can reflect when a person last ate, the particular activity he or she is engaged in at any given moment, and other variables. The key metric should not be how many hours of sleep you logged the night before but how many you need to perform at your peak, and there’s almost no data about that—in part because of the ethical implications of depriving subjects of sleep and then sending them to work or to school. “We’re not saying kids don’t need more sleep,” says Olds. “My hunch is, yes, they do. But we haven’t seen good evidence of that.”

None of this stops the 21st-century descendants of 19th-century scientists from issuing sleep guidelines of their own. In the U.S., the most often cited sleep recommendations are from the National Sleep Foundation in Arlington, Va. [see them at left]. What’s especially noteworthy, particularly to the bewildered parents of teenagers, who seem to be up at all hours, is that adolescents require a minimum of eight hours. In fact, kids in that age group may simply be shifting their internal clocks, going to bed in the wee hours and getting up at noon because that’s what their bodies need at that stage of development. Most teens emerge from this vampiric stage none the worse for it, though parents should try to keep things from getting out of hand. “It’s best to keep them in the proper time zone,” says Mindell.

A final wild card in all discussions of sleep duration is the way guidelines change from country to country. Australian children, for example, sleep almost a full hour per day more than American kids, who sleep less than kids in nearly all other countries. And different cultures have different tolerances for sleepy children. In Japan it’s more or less accepted that students sometimes doze off in class because they’ve stayed up late studying the night before.

The best advice for parents, as with so many things, is simply to know your kids. Observe their body clocks by noting how long they sleep on weekends and holidays when there’s no need to get out of bed for school. Track their grades as they sleep more or less. And above all, try to stay calm. They do eventually go the, er, heck to sleep. Just never as easily as Mom or Dad would like.

The guidelines—at least for now

Recommended amount of sleep

BABIES 3 to 11 months

HOURS 14 to 15

TODDLERS 1 to 3 years

HOURS 11 to 14

PRESCHOOLERS 3 to 5 years

HOURS 11 to 13

ELEMENTARY SCHOOLERS 6 to 13 years

HOURS 10 to 11

Why Bed-Sharing Is a Bad Idea

The latest thinking is unequivocal: don’t do it

BY ALEXANDRA SIFFERLIN

Bonding with a baby early in life is critical for his or her development, but medical experts warn that allowing infants to sleep with their parents in bed is too close for comfort.

Roughly 14% of infants in the U.S. share a bed with an adult or another child, a proportion that doubled since 1993. Parents might think that kind of snuggling strengthens a connection, but pediatric sleep experts caution that the consequences could be deadly. Topping the list of concerns is the risk of sudden infant death syndrome (SIDS), the leading cause of death from ages one month to one year.

“There are so many things that are not safe about bed-sharing,” says Jeffrey Colvin, a pediatrician at Children’s Mercy Hospital in Kansas City. “All those blankets and pillows are associated with an increased risk of SIDS, but even if you get rid of those, there is still an adult in the bed.” In a recent study, Colvin examined 8,207 infant deaths and found that the most common cause was bed-sharing.

Even if parents don’t accidentally roll on top of their child, it’s possible they will scoot too close to their baby’s face, not leaving enough breathing room or inadvertently covering the mouth or nose. “Especially for infants under three months, they simply don’t have the ability to get out of the way,” says Colvin.

In 2012 a meta-analysis of studies looking at SIDS and bed-sharing published in the Journal of Pediatrics showed that bed-sharing was associated with nearly three times the incidence of SIDS, and the risk was 10 times as high when the infant was less than three months old.

“We didn’t say you can’t bring the baby into bed for cuddles or rocking, but you shouldn’t go to bed with the child,” says Robert Carpenter of the London School of Hygiene & Tropical Medicine, who has studied the topic.

Some argue that the studies don’t properly account for where a child is sleeping, whether it’s a bed, chair or couch—the latter two are considered very dangerous places for babies to sleep. But that’s not enough to sway experts. “The data coming out doesn’t always agree, and it’s a little bit messy,” says Michael H. Goodstein from the task force on SIDS of the American Academy of Pediatrics (AAP). “But we are always looking at this issue.”

Even though sleeping recommendations have changed throughout the years—doctors used to say babies should sleep on their stomach, for instance—the risks for bed-sharing are clear-cut. “Parents have a right to approach their doctors’ advice with some skepticism,” says Colvin. “But what I tell them is that back in the 1970s and ’80s, doctors advised parents based on their gut feelings. Now our advice is based on research.”

That doesn’t mean parents need to leave baby all alone. While the AAP recommends that babies not sleep in the same bed as their parents, sleeping in the same room is just fine and actually encouraged. Rather than putting the baby in harm’s way, sleeping nearby reduces the risk for SIDS by half.

Sleep and the Teenage Brain

The emerging consensus among top doctors? Early school start times hurt kids

BY ALICE PARK

ANYONE WITH A TEENAGER IN THE house is well aware of the daily struggle: It’s “I don’t want to go to bed yet; I’m not tired” in the evening followed by “I’m not ready to get up yet; I’m exhausted” in the morning. Something about the decade between 12 and 22 seems to put adolescents in a parallel world in which they’re wide-eyed and alert when the sun goes down and drowsy when it rises. Should we just call it a case of teens being teens?

Not really, say researchers. While contrarianism is baked into adolescence for many young people, their oddly calibrated body clocks have less to do with rebellion than the needs of the brain and the body at that stage in development. And experts are now saying rather than fighting it—forcing teens to sleep early, and rise even earlier—it’s time to accept and even embrace it. Because the consequences of not tending to the unique sleep needs of the teenage brain could come with untold consequences.

The American Academy of Pediatricians (AAP) is getting behind this idea, coming out in favor of later school start times for middle and high schoolers in 2013, based on growing scientific evidence that when it comes to sleep, teens really are different from the rest of us. That evidence is based in some sound biology, which says that giving adolescents more time to slumber in the morning is better for their mental and physical health.

“The evidence is clearly mounting both in terms of understanding the repercussions that chronic sleep loss has on the health, safety and performance of adolescents,” says Judith Owens, director of sleep medicine at Children’s National Medical Center in Washington, D.C. “And there is also really compelling data supporting the fact that delaying school start times is a very important intervention that can mitigate some of the impact of sleep loss.”

Some of the consequences of that sleep loss showed up dramatically in a 2006 poll conducted by the National Sleep Foundation (NSF). Among 1,602 teens who answered questions about their sleep habits, 87% of high school students said they didn’t get nine to 10 hours of sleep, which researchers say they need to function at their best and promote healthy mental and physical development; most average around seven hours of sleep on weeknights. And the effects of that deprivation may show up in their grades; about 30% of students reported falling asleep in class at least once a week, and studies consistently connect less sleep with lower grades in school and on standardized tests.

That’s why the idea of letting teens start school later is starting to garner wider national support—but it hasn’t happened overnight. Before endorsing the idea, the AAP’s Adolescent Sleep Working Group took four years to review the existing studies on how inadequate sleep among teens—anything less than 8.5 to nine hours a night on school days—can contribute to health issues such as obesity, diabetes, mood changes and behavior problems.

The AAP even analyzed studies linking poor

sleep to increased reliance on substances like caffeine, tobacco and alcohol and the effect of sleep deprivation on academic performance. The evidence, they concluded, supports giving teens more time in bed by delaying the time they have to be at school until at least 8:30 a.m. Even a half-hour delay, some studies showed, can have dramatic effects on children’s health and academic performance.

“We know that implementation of our recommendations will be challenging,” says Cora Breuner, a professor of pediatrics and adolescent medicine at Seattle Children’s Hospital at the University of Washington and a member of the AAP working group. “But we stand behind these recommendations and strongly ask that they be considered for the health of our children.”

STAY UP LATE Teens have a body clock that keeps them up at all hours, often reading or on their computers.

LETTING THE BIOLOGY DO THE SLEEPING

Not everyone is convinced, though, that later start times are the answer, partly because it’s so hard to draw a cause-and-effect line between poor sleep and some of the particularly unhealthy trends that emerge during adolescence, such as substance use, unprotected sex and other risky behaviors. Does poor sleep affect teen health, or is it a result of the whirlwind of physical and emotional changes that occur during adolescence?

“There’s a lot of research supporting the notion that adolescents are more and more sleep deprived,” says David Curtis, a psychologist at Texas Children’s Hospital. “However, the research isn’t great about clearly identifying why that is. So it’s a bit of a chicken-and-egg argument.”

What the data do show is that our need for sleep changes over time. As we get older, we need less sleep. Infants spend most of the day and night slumbering as their bodies and brains continue to develop, but between ages 5 and 13, that changes to a recommended maximum of 11 to 13 hours a night. Teens and adults need slightly less, eight to 10, but recent polls show that up to one third of U.S. teens don’t get this many hours on a regular basis.

Part of the reason has to do with teens’ still-developing bodies, as data strongly suggest that puberty may biologically wire teens to stay up late and wake up late, which means that forcing them to bed earlier won’t do much good. Something in the hormonal changes occurring during that period of development shifts their body clocks—which regulate the balance between sleeping and being awake—to later, like daylight savings in reverse. “The sleep pressure signal builds up as you stay awake during the day and is relieved at night. But that process gets a little slower during adolescence,” says Mary Carskadon, a professor of psychiatry and human behavior at Brown University Medical School and director of the Sleep and Chronobiology Research Lab at Bradley Hospital. “That makes it easier for teens to stay awake a little longer.”

It’s not that they need less sleep—they still need about eight to nine hours a night—but their sense of tiredness may come later at night, so they can’t fall asleep earlier even if they want to.

Adding to this biological pressure to be night owls are other forces that are reinforcing teens’ tendency to sleep at night and wake in the morning. Cell phones, computers and 24-7 social media connections mean that the conversation among teens never sleeps—and therefore they don’t either. (Add to that the growing research that all that screen time affects our circadian rhythms, throwing off the natural cues that would otherwise tell us when we’re sleepy or when it’s time to be alert.)

THE DOMINO EFFECT

In the NSF survey, more than half of the teens reported feeling unhappy, depressed or hopeless about the future and feeling worried or anxious most of the time. Those with the highest incidences of these symptoms also reported the most troubled sleep—not getting enough hours at night and feeling sleepy during the day or taking longer to fall asleep at night.

Understanding how this connection between mood and sleep works is especially critical since there’s also evidence that some people march down the path toward depressive symptoms when they don’t get enough sleep. Genes may be responsible for that. A recent study of college students found that some people inherit a specific form of a gene involved in regulating the brain’s mood chemical serotonin. That gene makes them more vulnerable to depressive symptoms when they don’t sleep well. If they do get enough sleep, they aren’t as prone to feeling the blues.

“That makes us think about sleep as an environmental exposure,” says Carskadon, who conducted the study. “That means your sleep environment could be an exposure that makes you more vulnerable to certain problems.” The students she studied showed higher risk for depression. It’s possible that poor sleep influences other genes, too, making people more vulnerable to conditions like heart disease and cognitive problems.

In fact, other studies have linked poor sleep and the incidence of ADHD among children, although whether the attentional problems trigger sleep disturbance or whether sleep deficits can make ADHD worse is still being studied.

And it’s not just the brain but the body that feels the effects of insufficient sleep. A study of 270,000 eighth-, 10th- and 12th-grade students at 130 public and private schools across the country revealed that over the 20-year study period, adolescents, not surprisingly, got less and less sleep. And by asking teens two questions about their sleep habits—how often they slept for at least seven hours a night and how often they slept less than they should—researchers got a better idea about why. They uncovered a possible period effect—something that affects all the students at every age—that contributed to their sleeping fewer hours.

The researchers found that the largest drop in the average number of adolescents reporting at least seven hours of sleep nightly occurred during two consecutive time periods: 1991–1995 and 1996–2000. That time corresponds almost exactly with the increase in childhood obesity. Obesity has been tied to health disturbances such as sleep apnea, and the simultaneous decrease in the amount of sleep teens get and the increase in their average body-mass index suggests a strong connection. It’s unclear what is cause and what is effect, however, since sleeping less also disturbs the normal metabolic functions that help minimize fat deposition.

LET THEM SLEEP IN

SAVED BY A (LATER) BELL? There is a national movement to push back school start times to accommodate the sleep needs of young people’s developing bodies and brains.

One way to break that cycle, say a growing number of sleep experts, may be to let teens start school later in the day. That way, they won’t be fighting their bodies’ natural desire to stay up longer yet won’t be depriving themselves of the eight to nine hours of shut-eye they need. And so far, the studies are encouraging.

In fact, in the 70 school districts, and more than 1,000 schools, that have adopted later start times for high school students, teachers, parents and the students themselves are seeing substantial benefits. In one district that pushed back start times by one hour, half of the students reported getting eight or more hours of sleep, compared with 37% who had prior to the shift.

Owens and her colleagues also conducted a study among students at an independent school that delayed start times by 30 minutes. That was enough to move bedtimes ahead by an average of 18 minutes, something that surprised her and her team. They also found that the delay increased the percentage of students getting eight or more hours of sleep a night. “Anecdotally, a lot of the students said they felt better with the extra half hour of sleep they got in the morning, and that motivated them to go to bed earlier as well,” she says. “They said they could focus better and concentrate better and that it took them less time to get their homework finished so they could go to bed earlier.”

Of course, having high school students start later may have a domino effect on everything from their extracurricular activities, including sports, which often occur after school, to child care for parents who rely on older children to take care of their younger siblings after school. That’s what makes it a challenge for many communities that aren’t ready to make such drastic changes.

But some districts are proving that it’s possible. Some schools, for example, have created after-school programs in which younger children can remain at school in a supervised setting until their older siblings or parents can take them home. And in communities in Minnesota and Massachusetts, where elementary school students are starting school earlier to accommodate later bus service for older students, volunteers have manned the stops to ensure that younger children are safe while they wait to be picked up during early morning hours.

“Communities and school districts really need to go all in and make a commitment [to it],” says Carskadon. “Where it doesn’t work is where schools just dabble and say they will try it for six months to see how it works.”

With the AAP firmly behind the idea of starting teens’ school day later, she and other sleep experts hope that school policies will soon take their cue from teen biology. “The hope is that this statement will galvanize communities,” says Carskadon. “Now they have another tool in their tool kit, and another set of evidence and advice to take to school committees and school boards, to get communities moving on addressing adolescent sleep.”

Given the state of the data on how poor sleep affects adolescent development, adds Owens, “to do nothing is really to do harm. The status quo of starting schools at 7:15 or 7:20 is not in the best interest of the students.”

Doctor’s Orders: Go Back to Bed

Your doctor could soon be prescribing shut-eye as prevention—and treatment—for ADHD, depression and even obesity

BY ALEXANDRA SIFFERLIN

AFTER BEING DIAGNOSED WITH brain and lung cancer in 2011, Lynn Mitchell, 69, was averaging about an hour of solid sleep a night. No one could blame her; her twin diagnoses were serious, and mulling her treatment options caused her mind to race at all hours. Add to that the side effects of her treatment and the pain she was in, and she was paying for all of it in sleep.

In the mornings she was incoherent. She was so tired, she says, that she was slurring her words, and her already disrupted balance—a side effect of the brain cancer—was exacerbated, making basic movements increasingly difficult. When she shared this with her doctors at the Perelman Center for Advanced Medicine at the University of Pennsylvania Hospital, she expected them to tell her something else was wrong. She didn’t expect what they said next, however: Go see a sleep therapist.

Mitchell was relieved at how benign it sounded compared with the chemotherapy she had cycled through and the gene-therapy trial she was currently undergoing. Both induced nausea and fatigue—terrible symptoms for anyone but especially someone who can’t sleep them off—and she didn’t welcome the idea of piling on another intense therapy in the name of healing. But sleep? How could sleep improve her cancer?

The therapist reviewed her evening regimen and worked with her to adjust her habits and cement some new ones. She was told to get under the covers only when she was extremely tired and to stop watching TV in bed. She stopped drinking caffeinated coffee in the evening and learned breathing exercises to relax and help ready her mind for a night of rest. It was all quite simple and commonsense and, most important to her at that stage in her treatment, it was non-invasive. No extra pills, no additional hours on an IV.

Now Mitchell’s hour of shut-eye has been replaced by seven to nine hours—the recommended amount for healthy adults, though many Americans fall short of that target—and the results have been unmistakable to Mitchell and her doctors. “Once I fall asleep, I sleep soundly,” she says. “I’m alert in the morning, my balance is better, and I feel peppier.”

With her cancer symptoms in check, Mitchell says, she feels as if her treatment response is improving. She also recently found out that her brain cancer is shrinking and her lungs are clear. More than half of cancer patients experience sleep problems, according to the National Cancer Institute, and while better rest can’t take all the credit for Mitchell’s improvement, a growing body of evidence suggests that it can play a crucial role.

That’s why leading physicians are doing what Mitchell’s did: adding sleep therapy to the treatment plan for diseases like cancer, but also for depression and attention deficit hyperactivity disorder (ADHD).

Allan Rechtschaffen, a pioneer of sleep research at the University of Chicago, once said, “If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process ever made.” Today, research is increasingly proving this to be true.

NATURE’S THERAPIST

HIT THE HAY Sleep therapy is increasingly included in treatment plans for diseases such as cancer, as well as depression and ADHD.

The field of sleep therapy to treat or complement the treatment of disease is still rather small, but experts think it will grow—in part because it’s non-invasive but also because it’s very easy and inexpensive to administer.

Mitchell worked with a sleep therapist for about nine weeks, but some research has found that sleep issues—and perhaps some of the problems that come along with them—can improve with sessions of cognitive behavioral therapy for insomnia (CBT-I), the principles of which can be fairly straightforward.

With CBT-I, patients are often told to keep a diary for several weeks leading up to talk-therapy sessions in order to help identify the things possibly interfering with a good night’s rest. They are also instructed to go to bed at roughly the same time every night; eliminate stimuli like TV or bright lights from the street in the bedroom; learn how to relax through things like breathing exercises; and find ways to unwind so that going to sleep feels calming as opposed to stressful.

This kind of therapy is showing some early yet extraordinary promise in the treatment of depression. One study found that curing sleep problems with talk therapy literally doubled the likelihood of a full recovery from depression. The results were so dramatic that some experts are heralding sleep therapy as the first major development in the treatment of depression since the introduction of antidepressant drugs.

“I think it’s increasingly likely that this kind of sleep therapy will be used as a possible complement to standard care,” John M. Oldham, the chief of staff at the Menninger Clinic, a psychiatric hospital, told the New York Times. “We are the court of last resort for the most difficult-to-treat patients, and I think sleep problems have been extremely underrecognized as a critical factor.”

It’s not just depression that is alleviated by sound sleep, and doctors of all disciplines seem to be taking notice. David Rapoport, director of the sleep medicine program at New York University School of Medicine, says the NYU Sleep Disorders Center has long seen patients come in because they’re always tired or they never fall asleep. But Rapoport says the center is receiving an increasing number of patients sent by their doctor for other diseases that may have at least partial roots in sleep problems—which range from Type 2 diabetes and obesity to ADHD and heart failure.

For instance, mild sleep apnea, which disrupts solid rest, may cause behavioral problems for children at school; if they’re tired from a lack of sleep, they may have a harder time paying attention in class. This, some experts think, may result in a diagnosis of ADHD, when in fact the child may just be exhausted. (Sleep deprivation makes adults groggy, but in kids, it tends to present in the opposite way: children get wired, cranky and wound up, making it difficult for them to sit still and focus.)

CLIMBING THE WALLS Unlike adults, children often respond to sleep deprivation by being wired and wound up, which is why it is sometimes misdiagnosed as ADHD.

“No one is saying ADHD does not exist, but there’s a strong feeling now that we need to rule out sleep issues first,” Merrill Wise, a pediatric neurologist and sleep medicine specialist, told the New York Times. Indeed, studies have shown kids with ADHD are more likely to have insufficient sleep—and now researchers are trying to determine if that’s caused by the ADHD or, in some cases, if it’s the other way around.

The chicken-egg question turns up a lot in the discussion of diseases that are correlated with sleep problems. For instance, doctors and scientists have known for some time that a lack of sleep can interfere with the body’s metabolic functions, suggesting that it can exacerbate, if not cause, Type 2 diabetes and obesity. Lack of sleep can interfere with the neuroendocrine system, causing “increased appetite, enhanced sensitivity to food stimuli, and, ultimately, a surplus in energy intake,” according to a paper published in the journal The Lancet Diabetes & Endocrinology. And in the conclusion of a Lancet study, the researchers urged health professionals to begin prescribing sleep to prevent and treat those metabolic disorders.

Research also suggests that a lack of sleep can lead to problems later on in life. A 2014 study published in the journal Sleep found a link between older men with poor sleep quality and cognitive decline, though exactly why this is the case is not fully understood.

And while the mechanisms between sleep loss and metabolic disorders are well understood, researchers are hard at work trying to understand—and possibly prove—how a lack of sleep can drive other diseases at the biological level. There’s a reason why you feel sleepy when you get the flu, for instance. According to David Gozal, an expert in pediatric sleep disorders at the University of Chicago School of Medicine, there are certain molecules in the brain that are responsible for inducing sleepiness, which is a typical reaction to infection. It’s part of the evidence showing that sleep can help fight disease.

“It’s common knowledge that sleep is needed for day-to-day function,” says Rapoport. “What isn’t common knowledge is that it really matters—it’s not just cosmetic.”

THE NEW SLEEP Rx

The message that all people, sick or not, should exercise regularly and eat a healthy diet is well worn, but sleep is the third element of basic self-care and, increasingly, disease prevention and possibly treatment, say sleep experts.

Plus, “it’s probably easier to change than diet or exercise,” says Michael Grandner, a sleep researcher at the University of Pennsylvania. “It may also give you more of an immediate reward if it helps you get through your day, but we take it for granted.”

The challenge is that sleep is still often looked at as a “get it if you can” luxury as opposed to a critical pillar of health. “Many doctors, lawyers and executives stay up late and get up early and burn the candle at both ends,” says Richard Lang, the chair of preventative medicine at the Cleveland Clinic. “Making sure they pay attention to sleep in the same way they pay attention to diet and exercise is crucial.”

But while 70% of physicians agree that inadequate sleep is a major health problem, only 43% say they counsel their patients on the benefits of adequate sleep. Compare that with 100% of physicians who say they ask their patients about smoking or 93% who say they talk to their patients about their diets.

Yet the Centers for Disease Control and Prevention (CDC) says that “insufficient sleep has major health consequences in adults, adolescents, and young children,” pointing to strong evidence that adults who get insufficient sleep—meaning less than seven hours a night on a regular basis—are much more likely to die of heart disease, have metabolic disorders like glucose intolerance and have mood disorders. In 2013 the agency called upon health experts to begin putting sleep—as a means to prevent illness—center stage. “Sleep should be viewed as being as critical to health as diet and physical activity,” the CDC said in its report.

“Sleep won’t kill cancer, but under certain circumstances, getting better sleep will improve your odds of recovery,” says Gozal. “It will make cancer possibly less aggressive and potentially more responsive to the chemotherapy or treatment so that your body is fighting more effectively.”

And though sleep isn’t solely responsible for Mitchell’s turnaround, her doctors think it’s certainly played a role. Despite her cancer, Mitchell greatly improved her quality of life by prioritizing sleep, and that’s enough to support prescribing better shut-eye.

“Every physician should ask about sleep,” says Gozal. “Sleep is a life-sustaining function, and we should treat it like that.”

The Dream Therapist

In a mysterious experiment, one woman tests the promise that we can sleep our way to better mental health

BY MANDY OAKLANDER

THE FIRST TIME I DIALED UP MY DREAM therapist, I didn’t realize how personal it would get. It’s just dreaming, I told myself. What could I learn that a dream dictionary couldn’t decode?

Underestimating my own dreams was my first mistake. Underestimating Rubin Naiman was my second.

I’d found him by asking Google a throwaway question: Can dreams improve emotional health? The query led to Rubin Naiman, Ph.D., his face framed in a cloud of white hair. A sleep and dream expert at the Arizona Center for Integrative Medicine at the University of Arizona, Naiman believes that many of our modern ailments are due to dream deprivation rather than sleep deprivation. Dreams, he thinks, are the most potent antidepressant known to man. Treat your bed as a flying carpet—your portal to other worlds—and you’ll find optimal emotional health on the other side.

Sign me up, I thought. I’d love to get in a little unconscious mental workout. I emailed Naiman and asked if he’d like to take me on a dream journey. “This would be a dream come true,” he replied.

I wasn’t looking to get into anything terribly psychologically rigorous with Naiman; that’s what my waking-life therapist is for—though I rarely bring up dreams. Waking life is for figuring out who you really are, I thought. Dreaming life is for feeling like all your teeth are falling out.

Not so, said Naiman. He asked if I have trouble sleeping (not at all) and if I find it difficult to wake up in the morning (doesn’t everyone?). Not Naiman. Before bed, he pops a supplement of the sleep hormone melatonin and slips deep into the waters of sleep. Waking eight hours later, he and his partner lie in bed and talk about the dreams they’ve had. “It’s a beautiful process and it’s incredibly intimate,” he says. These dreams follow him throughout his day, he says, weaving their way into his waking life in a way that’s available to anyone, me included. I would just have to learn how.

It should come as no surprise that Naiman was voted “most eccentric” at his high school, after which he embarked on a path to becoming a rabbi. Then he changed course, quite literally following his dreams—the nighttime kind— becoming a clinical psychologist.

“Dreaming is a second gut,” Naiman says. “It sifts through all of the experiences we consume during the day.” I knew intuitively that I needed a dream-sized dose of Ex-Lax. I couldn’t remember the last time I’d dreamed, and the only ones that stuck out were the recurring anxiety dreams I had about writing. Whenever a deadline loomed or I procrastinated too long on a story, the same dream came. Onstage in the spotlight, I was the lead of my high school ballet but hadn’t learned any of the steps.

In our first phone session, I told this to the dream doctor, speaking quietly, hoping my co-workers couldn’t hear what I was saying. “That’s a stage-fright dream, huh,” he mused. “Interesting. Huh, huh, huh.” He started to laugh. “Great. Sorry. Yeah. And so what happens after that?”

Great? I thought. They’re awful! Could he train me to have better dreams instead? Ever so gently, Naiman explains, “It’s really important to consider that dreaming is a healing process, rather than something that you need to take up arms against.”

The fact that I am having anxiety dreams while also wanting to wring every drop of “usefulness” from them is not a coincidence, he says. Like nearly everyone else on the planet, I am wake-centric. “If you look at all sleep research, we pretty much ask the same thematic question,” Naiman says: “ ‘Hey, sleep, what can you do to make us better waking people?’ ” Sleep is the servant of our daytime selves—and that’s just backward, Naiman insists.

Instead of trying to snap out of my anxiety dream, Naiman told me, I should start a conversation with it. “When we turn to the dream with a willingness to make peace, it starts to morph and it can bring us some very beautiful experiences,” he says. “Our dreams are dark, black, sooty like coal, and we find the most precious gem, metaphorically, in a dark place.” These dreams could help heal me, he said, but I’d have to get a bit dirty.

I hang up, embarrassed that I’d just bared my insecurities within earshot of my colleagues and my boss, when my researcher neighbor pops up from behind our cubicle partition. “My anxiety dream,” she tells me, “is that we’re shipping the magazine and I haven’t checked a word.”

I promise her I’ll try to get to the bottom of both of our worst-case-scenario dreams, starting tonight. Armed with strict orders from my dream doctor, I’d dim the lights an hour before bed to boost melatonin and bridge the worlds of consciousness. I’d have a journal waiting to capture my dreams in the morning. And I’d find a soothing alarm to replace the one that jars me out of sleep. I vowed to stay with my dream for a few minutes upon waking instead of rocketing out of bed. “The dream is all around you,” he said. “Let it come to you, as if somebody is whispering it in your ear.”

The dream world is not the preferred playground for most scientists. Dreams are all different, subjective and impossible to randomize. But even though not everyone believes with Naiman’s ferocity in the paramount importance of dreams, many scientists agree that dreams have meaning—even Robert McCarley, the Harvard neurophysiologist who was part of the duo credited with what’s called the “activation-synthesis theory,” popularized as the idea that dreams result from the random firing of neurons and are devoid of intrinsic meaning. “It was misinterpreted,” McCarley says of that explanation of his theory. “We kept saying it was, but it’s such a convenient bogeyman.”

When the brain is activated by the brain stem’s biological rhythm, McCarley explains, there are images generated that are related to life, some of which can help dreamers gain insights about their attitudes toward other people. “[Dreaming] may be a way of processing emotionally relevant information,” he says.

Others caution against reading much of anything into dreams. Ross Levin, a behavioral sleep specialist in New York, says they rarely come up in his treatment of patients. Besides stress dreams signaling that, hey, you might be stressed, there’s just not a lot of evidence that dreams are a source of real meaning, he says. “For the most part, it’s kind of a fishing expedition.”

The next morning, I was exhausted from a night of nervous, excited dream chasing. “I woke up periodically trying to remember the dreams I’d had,” I wrote in my journal. I captured three dreams the first night, starring a rotating cast of family members, friends and co-workers. “It’s the first time I’m remembering these dreams, and they seem so obviously connected to my anxieties,” I wrote. As soon as I put them to paper, they melted away.

I did this for a week. Some nights were dreamier than others, but a few days’ worth gave me plenty of new material to share with Naiman. Before our second phone call, I slipped away from the open ears of the office to hide in the lobby. I told Naiman my most dramatic dream of the week: I’m torn between attending a wedding and going to a street-art festival. In the dream, I chose art—and was seized by a mysterious figure who put me in a chokehold and made the motion of slicing open my throat.

Naiman was delighted. “Dreams are so honest, and they speak in a symbolic language,” he said. What I had seen as a stranger’s attempt at murder, he interpreted as a freeing of my throat, the part of the body associated with self-expression. “It’s an image of opening your throat,” he said. He then pointed out that many of my dreams contain a mystery man: an adventurous, masculine, wildly free type. “We call it animus,” he said. These alter egos show up in dreams and speak to our deepest desires, Naiman explained. And mine, it turns out, is a dark, mysterious rebel trying to be heard.

“It makes me wonder about the man side of you,” he said. “If this guy was given a voice, given a pen, what might he say?” I had my next assignment. “Talk to the dark side,” Naiman told me. “I suspect your anxiety will recede.”

As I do with all tasks, I procrastinated a tad on my alter-ego writing assignment. For a few days in a row, I let my lovely chime alarm lull me awake—and then I snoozed, avoiding the dream diary next to my bed.

But a couple of nights later, when I finally sat down to channel that dark voice, my lights low and melatonin high, it came eerily easy to me. And when I woke the next morning, more pages flowed from me than had in a long time, and in a voice far freer and more confident than the one I recognize as my own.

Instead of being anxious, I found I was having fun. Wow, I thought. Maybe my dreams cured me after all. “Keep talking and they just might,” said Naiman. I had listened to my dreams, and they were finally talking back.

Tuning Out Bad Dreams

Nightmares can do more than ruin a good night’s sleep. Scientists are finding new ways to control them—and improve the health of mind and body

BY JOHN CLOUD

ON A GOOD NIGHT, I GET FIVE HOURS. Like 60 million other Americans, I suffer from insomnia.

But I have a peculiar kind of sleeplessness: most nights, it is nightmares that wake me. Some are petrifying—a spectral beast is about to kill me—and some are mere stress dreams: I turn in a story that is just a blank page. For years, I thought nothing could be done about my nightmares. After all, dreams are encased in the unconsciousness of sleep. Right?

Maybe not. Researchers have begun to discover not only that we can learn to have fewer nightmares but also that we can change their content. Because the No. 1 complaint of troops returning from Afghanistan and Iraq is insomnia—and because so many veterans have nightmares about what they saw in combat—the Department of Defense (DOD) has poured millions of dollars into the study of dreams. One project, at the University of Pittsburgh School of Medicine, won a $4 million grant to study how veterans can have fewer, or at least less intense, nightmares. Other researchers have received funding from the National Institutes of Health to investigate why so many Americans have such awful nightmares that they say they have trouble working or sustaining relationships.

In other words, researchers are now studying the science of the dreaming mind in a way unprecedented in psychology. The primitive Freudian theories—that dreams indicate unexplored sexual desires or poor mothering or hidden anxiety—have been discarded as sleep science has advanced.

One new theory is that dreams and nightmares aren’t a secondary symptom of mental illness but rather a primary psychological problem. In other words, dreams themselves may cause mental illness, not the other way around. They may result from neurological misfirings that have nothing to do with psychology but instead have to do with the functions of the brain. Or both theories could be true. Partly driven by my sleeplessness, I set out to find researchers in dream science who could explain why nightmares occur and how, exactly, we can learn to change them.

SLEEPLESS SOLDIERS

The first person to help clarify these questions wasn’t a scientist but a Marine veteran. Ryan Stocker started having chronic nightmares after he got home from his second deployment. Sleep was rare in Iraq, but when it did come, it was a pleasantly blank interlude. After Stocker got back to Pennsylvania, however, falling asleep became terrifying.

Some Iraq and Afghanistan veterans I met dreamed of gore and fear: body parts they’d cleaned from roadsides or the terror of climbing into a truck for a mission. For Stocker, the nightmares were mostly about being deployed a third time. In dreams, he would step off a plane and smell the hot, dry air and groan, “Man, I’m back again.” The nightmares got so bad that he and a friend who had served with him slept in their living room on separate couches rather than in their bedrooms. “That felt safer,” he told me.

After Stocker was discharged in September 2008, he finished an undergraduate degree in psychology at Slippery Rock University. He wasn’t sure what he wanted to do—he had thought about firefighting—but when he heard about a University of Pittsburgh study of veterans who had trouble sleeping, he applied for an internship.

It was a fortuitous opportunity. Stocker began working under professor of psychiatry and psychology Anne Germain, a leading researcher in the study of nightmares and post-traumatic stress disorder (PTSD). Germain is supervising the university’s $4 million DOD and National Institutes of Health study on how both current service members and veterans can sleep better. “At the DOD, there used to be a mentality—and I think it’s still there, but it’s shifting—that sleep is a luxury,” she told me. “But compromising sleep actually compromises physical, psychological decision-making—how well you can aim at a target.”

The Pentagon became alert to sleep research partly because of studies by a retired Army colonel, Charles Hoge, a physician and leading expert on PTSD. In 2007 the American Journal of Psychiatry published an influential paper by Hoge and four colleagues showing that more than 70% of veterans with PTSD symptoms reported trouble sleeping. No other condition—not panic or pain or inability to work—was as common. And because treating people who are constantly tired is often pointless, gaining a better understanding of sleep and dreams became a priority.

The research helped prompt the Pentagon to develop something called a Warfighter Sleep Kit, which includes a DVD that begins with a screen reading, “Sleep is essential to survival.” The DVD says service members should avoid caffeine, nap only when necessary and, whenever they are safe enough to sleep, wear a camouflage mask and earplugs. The kit includes the mask and plugs.

Germain helped develop the sleep kit. Her research has explored two approaches to mitigating nightmares. One involves a drug called prazosin. Developed in the 1960s as a hypertension treatment, prazosin didn’t turn out to be especially effective in lowering blood pressure. But for reasons not well understood, those who took it reported that they slept better and had fewer nightmares. Few psychiatrists used prazosin for nightmares until the 2000s, but they made the remarkable discovery that in many patients, it doesn’t stop all dreams, just the very bad ones. The drug’s usefulness for nightmares suggests that they stem from a brain or circulation disorder. (In other research, Germain and her colleagues found that prazosin also reduced insomnia and daytime PTSD symptoms in veterans.)

The other treatment Germain has looked at is purely psychological. In August 2001, the Journal of the American Medical Association published a seminal paper on a new psychological treatment for nightmares called imagery rehearsal therapy (IRT). The paper discussed 168 sexual-abuse victims who reported chronic nightmares. The participants were asked to consider the idea that although trauma may induce nightmares, those bad dreams can become habitual—a behavior not unlike daytime panic attacks, which can seem uncontrollable but can be limited through certain kinds of behavioral therapy.

Like daytime panic attacks too, those repetitive dreams turned out to be something like a learned behavior, one that can be unlearned through daytime psychotherapy. Freud and others thought dreams were immune to conscious thought, but the JAMA paper demonstrated that the opposite is true.

Imagery rehearsal therapy is simple: you begin by imagining a dream you would like to have. The dream doesn’t have to be some optimistic reverie about puppies and sunshine. You can imagine any dream you want—boring, anodyne, even gloomy—just not your nightmares. You then write down the new one, and every day, you take a few minutes, preferably with eyes closed, to think about that dream.

The JAMA paper showed remarkable results. Patients who underwent imagery rehearsal therapy dropped from an average of six nightmares per week to just two or three. The IRT patients reported 40% fewer PTSD symptoms such as shame and emotional numbness. The patients in a control group who had been wait-listed for IRT—but had spoken with a psychologist about their bad dreams—actually showed a small increase in their number of nightmares. The findings held up even after six months, and further studies have replicated the JAMA results.

I tried IRT for my nightmares and found it useful. But I was still skeptical. Studies have shown that prazosin is just as beneficial as IRT in helping people have better dreams, which raises a crucial question: Are dreams psychological, physiological or both? And if we don’t know, how can we understand the sleeping brain?

In our conversations, Germain had repeatedly mentioned one of her mentors, Barry Krakow, the primary author of the JAMA paper. With some diplomatic restraint, she said he had since become “controversial” because although he still uses IRT in his practice, he has developed an unusual new theory about how to treat nightmares.

BREATHING LESSONS

I met Krakow at his New Mexico sleep lab, the Maimonides International Nightmare Treatment Center, which sits incongruously in a dreary Albuquerque office park alongside mortgage firms and title companies.

Krakow started his career as an emergency-room doctor at the University of New Mexico School of Medicine, but in his spare time, he began working with two UNM psychiatrists, Robert Kellner and Joseph Neidhardt, who were developing the idea that dreams could be controlled with daytime therapy. Their idea formed the germ of IRT and eventually led to the JAMA paper.

Since its publication, Krakow has become an acclaimed figure in sleep research, and patients from around the world travel to Albuquerque to see him. But in the past decade, after seeing so many people with insomnia and bad dreams, Krakow has become convinced that a rather simple physiological problem may explain most bad dreams: having trouble breathing.

THE DREAM DOCTOR Lucid-dreaming expert Stephen LaBerge uses a light-induction mask to train patients to know when they are dreaming.

It’s not just a hunch. When you sleep at Krakow’s lab, a technician attaches 16 sensors to your head, chest and legs. A tube is affixed to your nostrils. For most patients, the ordeal is uncomfortable, but eventually they fall asleep.

Intricate detail emerges from these sleep studies, which show not only how deeply you sleep but also how much you snore, how your body moves during the process and how much you dream—and precisely when your dreams begin and end. Krakow, who reads the results with Talmudic intensity, can tell you exactly when you enter and leave rapid-eye-movement (REM) sleep, the state in which we become more aware of dreams. He can also tell you if you wake from REM sleep because of a leg jerk or a problem breathing even if you have no memory of waking up at all.

Over the years, Krakow began to notice that at least 90% of patients who came to him with persistent nightmares had either full-blown sleep apnea—a disorder in which your breathing pauses, sometimes for more than a minute, while you sleep—or a milder form of the disorder called upper-airway-resistance syndrome. He showed me several data sets collected after various sleep studies. In every case, the dream state was preceded by or coincided with an episode of disturbed breathing.

“Breathing events can savage REM sleep,” he told me. And when they do so, dreams can burst through the cover of REM sleep to become nightmares that wake us.

Krakow isn’t sure why this happens, but one theory is that chronic nightmares result when patients have trouble getting oxygen to their brain during sleep. Because they are asleep, their brain cannot indicate to their bodies that the hippocampus is being starved. And so the body has evolved a way for an oxygen-deprived mind to awaken: nightmares. Krakow’s conclusion is that if you treat breathing disorders, you may eliminate nightmares.

Krakow is among a growing number of sleep doctors who believe that many if not most sleep disorders, not just persistent nightmares but also ordinary insomnia, are caused by the brain’s reaction to apneas or other airflow limitations. And so over the past 20 years, the treatment of sleep problems has, among many researchers, begun shifting from the psychological realm toward the pulmonary one.

The change has opened a vast new market in sleep medicine, which has become big business. The most common treatment for serious sleep apnea is the continuous-positive-airway-pressure machine, or CPAP (pronounced “see-pap”), which is sort of like a humidifier that pushes air into your mouth. The best CPAPs cost as much as $5,000. ResMed, the leading CPAP producer, is a publicly traded company that reported net income of almost $350 million in 2014. In the past few years, sleep doctors have also begun prescribing a drug called armodafinil, to be used in concert with CPAPs. Armodafinil, a stimulant-like medication that patients can take in the morning to ensure they don’t nap, is expensive.

Thousands of medical professionals in specialties such as cardiovascular care and ear-nose-throat treatment have begun to include sleep medicine in their practices or have switched exclusively to sleep. In 1996, there were only 337 facilities accredited by the American Academy of Sleep Medicine; today there are more than 2,000. The market-research giant IBISWorld estimated that sleep-disorder clinics in the U.S. earned a combined $6 billion in revenues in 2011—a figure that is growing by double digits every year.

The figures are so dazzling that it’s tempting to think physicians and CPAP manufacturers are just cashing in. Surely disordered sleep is not just disordered breathing. Yet even researchers with no profit motive agree that the pulmonary system is key to understanding disordered sleep and the dreams that can come with it.

“The oxygen story is the biggest story here,” says Murali Doraiswamy, head of the division of biological psychiatry at Duke University. “Intuitively, it makes sense. The brain uses a disproportionate amount of oxygen. We think that when the brain is going to sleep, it is shutting down. But oxygen is also going on and off during sleep. That could be a very simple mechanism we’ve overlooked in the search to explain dreams.”

The sleep-apnea explanation is seductive: bad dreams are simply the result of a narrow airway. But the explanation isn’t fulfilling. Surely nightmares, with all their marbled psychological tissue, can’t just be neurological firings after what amounts to a deep wheeze. If dreams are random physiological events, why can we control their content with IRT?

There’s also the phenomenon of lucid dreaming—being able to realize you’re dreaming and then control the dream as it occurs. From a fellow nightmare sufferer in New York, I had heard about a way to train yourself to dream lucidly—an approach that combines psychological and physiological techniques to consciously enter bad dreams as they occur and rewrite them. It sounded silly, as if someone were trying to turn the movie Inception into real life. But it was also a really cool idea.

REFORMULATING YOUR DREAMS

Stephen LaBerge often wears a puckish grin, which goes nicely with his white hair, which stands on end as though he’s been electrocuted. In 1980 LaBerge earned a Ph.D. in psychophysiology, the study of how the body, brain and mind interact. In the years since, especially when teaching at Stanford University, he has become something of a dream guru. He believes that dreams aren’t walled off from daytime life but are as manageable as any behavioral experience you may have when you’re awake.

LaBerge is the leading figure behind the idea of lucid dreaming. Clients from around the world seek his help in trying to control their bad dreams. LaBerge and I met at the Newport Beach, Calif., house of one of those clients, Edward Pope, who told me he is an investor in aerospace and other technologies. His opulent home sits behind a gate on a hill overlooking the Pacific.

At Stanford, LaBerge became convinced that the question of whether dreams are physiological or psychological is not only unanswerable but also irrelevant. He posited that if people practice dream recall—writing in a dream journal morning after morning—they can begin, while asleep, to recognize when they are dreaming. “Dreams and waking experiences are more alike than different,” he wrote in his 2004 book Lucid Dreaming. “Much of what happens during your night life will be little different from what happens during your day life.”

LaBerge’s theories depart radically from the perception of sleep that was dominant for much of the 20th century. In the early 1950s, scientists identified REM sleep, and eventually many came to believe that dreaming most often occurs during REM. That’s not quite right—dreams during REM aren’t necessarily more frequent than dreams during other sleep states. They are more memorable, though. But sleep physicians have assumed that REM is so deep that no conscious thought can penetrate it.

LaBerge and others challenged this idea. Germain at the University of Pittsburgh offered the best explanation of how sleeping life and waking life are more similar than we assume. In lectures around the country, she is often asked, “Why do you care so much about sleep?” Her response: “Why do you care about wakefulness? Maybe the only point of being awake is to sleep.”

After all, it is during sleep that our immune systems gather strength, and it is during sleep that we consolidate memories. It is both a joke and a fact that most men either fall asleep or want to after sex (although many women do too). Perhaps one biological necessity is linked to the other. Sleep specialists who treat insomniacs routinely recommend that the bed be used not for reading or TV or texting but only for sleep and sex. Germain’s idea suggests that the species has survived not because we hunt, gather, work and socialize but because we spend a third of our lives asleep and then a small but crucial portion having sex.

LaBerge spent part of his early career studying people in high REM-sleep activation—the deepest sleep we experience, which can be dense with dreams. REM sleep has at least two physiological phases: one in which our eyes move left and right and another in which we breathe rapidly. LaBerge created a device that covers your eyes as you sleep and flashes white lights when your eyes begin moving left and right. The idea behind what he calls the DreamLight seems Pavlovian. After you’ve worn it for days or weeks, your brain will begin to recognize when you’re in deep sleep and, therefore, when you’re dreaming. At that point, you can take conscious control.

PRODUCTIVE SLEEP This electroencephalogram (EEG) traces electrical activity in the brain of a sleeping patient. The test can help determine the cause of sleep apnea, among other disorders.

The device is an important part of his physiological training. Another involves a sort of extreme form of IRT: you ask yourself five to 10 times a day whether you’re dreaming. The question becomes rote. The idea is that you come to ask it of yourself even while dreaming. At least I think that’s the idea. LaBerge has conducted no controlled trials to prove any of this, but his notion of dream control is at least more appealing than wearing a CPAP mask for the rest of your life. After all, when you wake up with a large tube attached to your face, it’s easy to think you’re having a terrible dream. Which is funny and a bit sad: the best solution we have for nightmares resembles the very thing it’s meant to prevent.

As for myself, the solution was rather boring: many hours of psychotherapy, rigorous exercise and the occasional Ambien. It’s been frustrating, because most sleep doctors aren’t trained in psychology, and most psychologists don’t have the medical training to understand airway problems. And so sleep physicians prescribe biological treatments—Ambien to go to sleep, CPAPs to stay asleep, armodafinil to stay awake—and psychologists prescribe cognitive therapy to resolve the anxiety of going to bed, staying in bed and then facing the day.

More effective sleep treatments will combine both approaches, but right now a total cure for insomnia remains a dream.

Fright Night

Psychological and physical treatments can help put nightmares to rest

Approximate percentage within each age group who have frequent nightmares

80% Frequent nightmares are experienced by of patients with post-traumatic stress disorder

75% of patients with sleep-disordered breathing

TREATMENTS

Imagery rehearsal therapy

A patient chooses a desirable dream and thinks about it for a fewminutes each day

Apnea therapy

A machine pushes air into the mouth and nose through a mask at night

Medication

The hypertension drug prazosin reduces nightmares but not all dreams

Sources: Barry Krakow, M.D.; Patrick McNamara, Ph.D.

A Nightmare Quiz Just how bad are your dreams?

Everyone has nightmares, but bad dreams can indicate—or even cause—psychological problems. Check yes or no for each statement to see what your dreams may mean for your mental health

1. I have disturbing dreams at least once a week.

YES

NO

2. I often wake up because of bad dreams.

YES

NO

3. As I go to sleep, I feel like I am falling or being paralyzed.

YES

NO

4. My nightmares are caused by stress over work or relationships.

YES

NO

5. I get anxious before bedtime because I think I might have a nightmare.

YES

NO

6. I have the same terrible nightmare repeatedly.

YES

NO

7. I remember the fear during bad dreams but not all the details.

YES

NO

8. During nightmares, I experience not only anxiety but also anger or shame.

YES

NO

9. When I remember a bad dream, I dwell on it the next day.

YES

NO

10. My spouse or partner tells me I have night terrors, which I don’t remember.

YES

NO

ANSWER KEY

A yes response to statement 1, 2, 5, 6, 7, 8 or 9 could be a sign of nightmare disorder, which the Diagnostic and Statistical Manual of Mental Disorders defines as repeatedly awakening from frightening dreams that begin to affect waking life.

A yes response to 3, 4 or 10 does not indicate a problem with nightmares. Dreams of falling and being paralyzed are so common that they don’t indicate a disorder. Having the same dream every night is also common. And night terrors are more physiological than psychological.

Sleep Like a Pro

Being at the top of your game takes work. Here, secrets from athletes, CEOs, cops, airplane pilots and others

BY JUDY MCDONALD

THERE ARE MANY THINGS WE MORTALS have in common. We all need to eat at semi-regular intervals. We all need shelter from the elements and safety from harm. And we all need sleep. But how we go about each of them—and especially, we are learning, the last—can make a big difference in how well we live.

Take this year’s Super Bowl combatants, the New England Patriots and the Seattle Seahawks. Both teams go through rigorous training and have players blessed with incredible skill and power. But is that the only secret to these peak performers’ success? In fact, both teams have another thing going for them: they’ve emphasized the importance of good sleep. Patriots quarterback Tom Brady, to give one example, attributes much of his success on the field to his insistence on rest. “The decisions I make always center around performance enhancement,” he has said. “I love the game, but I also know that if I want to do it for a long time, I have to do things differently than the way guys have always done it.” Brady told ESPN that “doing things differently” means going to bed well before people his age typically do.

That’s because Brady, like many of the world’s more disciplined and successful people, understands that without proper rest, he would find it nearly impossible to muster a winning mind-set. Likewise, Seahawks head coach Peter Carroll has introduced guided-meditation sessions for his players—and has found an advocate in his star quarterback, Russell Wilson. Wilson believes that “having that innovative mind-set” relaxes him enough to focus come game time.

In 2014 the National Collegiate Athletic Association (NCAA) quietly created a mental-health task force that made sleep its No. 1 priority. Urban Meyer, head coach of the current NCAA football champions, the Ohio State Buckeyes, says that he “sees a day when players’ sleep patterns are monitored.”

But it’s not just in the world of sports. Warren Buffett, who may be the world’s most successful investor, is similarly greedy about his sleep, recommending rest even over profit. He arrived at Salomon Brothers in the early 1990s with this advice to every worker in the New York office: “Why don’t you go home and get a good night’s rest, and we’ll meet again tomorrow.”

Research suggests these A-gamers are onto something. The University of Ottawa—where I am associate director of the Operational Readiness Unit at the McLaughlin Centre for Risk Science in the Faculty of Medicine—has conducted extensive studies focusing on a new discipline called operational readiness. It looks at applied research and correlates it with the performances of Olympic athletes and people in high-risk occupations, like police and surgeons, whose standards of excellence have life-and-death consequences. And our ongoing work makes it clear that effective sleeping and resting practices impact our technical, physical and mental readiness.

So what can we learn from them? Plenty. For starters, these are elite performers who, because of the nature of their work, are often in situations where eight straight hours of sleep can be hard to come by. And while uninterrupted sleep is ideal, it’s not always practical. Here are 10 of their secrets, compiled by researchers at the University of Ottawa.

1. DON’T TRY TO JUST TOUGH IT OUT

EARLY TO BED New England Patriots quarterback Tom Brady attributes much of his success on the field to his good sleep habits.

“The old-school approach of toughing it out is completely bogus, not to mention counterproductive,” maintains Charles Czeisler, director of the division of sleep medicine at Harvard Medical School. Traditional sports and professional environments are changing to improve sleep habits and enhance performance. Research links sleep deprivation to serious health and performance consequences. In safety-sensitive environments, sleep needs to be part of what’s called operational fatigue risk management.

Czeisler, known around the National Basketball Association (NBA) as the “sleep doctor,” recommends something simple for maximizing elite athletic skills: more sleep. Czeisler, who is also a consultant to NASA and the Secret Service, offers generally accepted advice: naps before games or shifts and seven to nine hours each night. It’s the sleep after an event or a lesson, however, that is most important. “Interestingly, if you don’t sleep the night after training, then even if you sleep the next night or the next night, you never learn.”

Sleep helps build long-term memories, and fully incorporating the day’s lessons requires a full sleep. Without the last two hours of the night, important steps in integrating the new memories are missing.

When asked, more than a quarter of NCAA athletes across a variety of sports said that an overwhelming schedule was the part of their college experience they would most like to change. The U.S. Olympic Committee’s stance is the same: more sleep. Its team of mental-health professionals recognized that obtaining enough quality sleep, addressing circadian sleep-cycle factors and using alertness strategies will enhance athletic performance under pressure.

That’s because sleep deprivation influences not only mental but also physical health and performance. In 2013, Steven Feinsilver, director of the Center for Sleep Medicine at Mount Sinai School of Medicine in New York, reported that “getting too little sleep can have serious health consequences, including depression, weight gain, heart disease and probably mortality.”

Limited sleep was cited as affecting police officers’ health and their job performance. Forget bad guys and gunfire: several police studies confirmed that shift work contributes to many undiagnosed and untreated sleep problems and excessive fatigue. The lack of sleep in other professions—surgery, air traffic control—puts people and operations at risk.

Czeisler advises that companies should not expect workers to log more than 16 hours in a row, or to drive or work after an overnight flight. “We now know that 24 hours without sleep, or a week of sleeping four or five hours a night, induces an impairment equivalent to a blood alcohol level of 0.1%,” he says. “We would never say, ‘This person is a great worker—he’s drunk all the time,’ yet we continue to celebrate people who sacrifice sleep for work.”

2. PUT SLEEP ON THE CALENDAR

HEAL THYSELF Smart surgeons learn to balance their work and rest in order to minimize fatigue and perform at optimal levels.

Jennifer Lopez insists that eight hours of sleep is her “secret weapon.” But those bold enough to take on big challenges also expect to do things differently. Despite the complexity, peak performers know how to make sleep a priority.

Surgeons accommodate sleep through discipline. Their day is planned to be as consistent and predictable as possible. The night before an operation, you don’t party, you don’t drink, you don’t take a Valium before bed, and you go to bed early so you’re there nice and rested. “If you’re disciplined and you’re doing a lot of surgery, you can’t do much else in life,” one surgeon told me. “It’s just like training for the Olympics. You do it to the exclusion of everything else.”

Many NBA coaches have taken sleep doctor Czeisler’s advice and focus on sleep to get peak performance from their players. With home and away games, players face a rigorous schedule. During playoffs, players and coaches rarely get more than two or three hours of sleep between back-to-back games. A typical night game ends at about 10 p.m. After showering, dressing, doing media interviews and having a late-night dinner, most players will not get to sleep until 2 a.m. or even later if the team is traveling. They miss out on the crucial post-game sleep and are just generally sleep-deprived.

The morning shoot-around has been a staple practice of the NBA game-day routine since the early 1970s. With the growing interest in sleep science, however, several teams have already dropped the early-morning practice altogether, recognizing that the players, if they’re going to be at their best, need more sleep time to recharge and perform better.

3. DEVELOP COPING SKILLS—STRESS IS THE ENEMY OF REST

Mental well-being, much as we can treat it like a luxury, is critical if you want to be fully functional. How do surgeons fall asleep after having performed an unsuccessful operation? Personal performance and frustrations with technical limitations are prevalent. They must reconcile unimaginable disappointments and failures. “There have been many, many, many times in my life where I’ve come out and wished I’d have done something different. There’s the old scenario of doing too little or too much,” one physician told me.

Ultimately, those who succeed learn that effective coping strategies are essential, and that doesn’t mean shoving them under the rug. Disappointments must be resolved to clear consciences and prepare the mind and the body for rest.

Here’s what one of our subjects told me in our research about peak performance: “People who are good at their job learn from their mistakes. You’re not always right. I’ve made hundreds of mistakes—and some pretty serious ones—but I learned from them. I accepted the ribbing and the lumps, and I moved on. That’s what makes the difference in good students, parents and people. You have to be humble.”

Another strategy? Being truthful and communicating. “If you’re honest with yourself and you’re honest with your patients,” one doctor told me, “you can function because you have a clear conscience. That helps a lot in putting up with the stress.”

Police officers often report that they rely on a good work-life balance to feel rested between shifts. “Sometimes you have to take a break. Do something unrelated that will clear your mental and physical state—just to get recharged,” advises one cop. Days off are significant for recovery: “You have to refresh yourself. There are times we work weeks straight, no days off. I know my body, and I know that if I keep pushing, pushing, pushing, I’ll break down.”

Intuitive as this may be, it’s also critically important, because there’s strong evidence that anxiety and depression can both cause insomnia, as well as the other way around: lack of sleep is strongly associated with depression and other mood disorders.

4. CREATE A LITTLE RITUAL FOR YOURSELF

Consistent routines before going to bed, whether a hot bath or an herbal tea, can quiet body and mind. Professional athletes have specific rituals in place to alleviate physical pain and anxiety. These range from visualization exercises to numerous sleep aids—white noise, dark blinds, earplugs and breathing apparatuses.

Most experts don’t recommend over-the-counter drugs, because they don’t alleviate significant insomnia. The Australian Sports Commission issued a comprehensive list of strategies for getting more sleep without sleeping pills. Practical suggestions included relieving muscle twitches by stretching, self-massaging and taking a casual stroll; writing a to-do list in bed to reduce anxiety; and avoiding caffeine, alcohol and large meals within four hours

of bedtime.

Mental training exercises can create a feeling of calm. By performing them repeatedly, a relaxed state can be reached more quickly. Here are some suggestions from the pros:

Visualization can help calm the mind. Close your eyes and think of a tranquil place, like somewhere by the ocean or whatever comes to mind for you, and put yourself there, visualizing everything around you—the sand, the sound of the wind and the waves, the warmth of the sun on your skin, the smell of the saltwater. Some experts recommend using the sun as a focal point during visualization. Feel the sun on your body—on your left arm; your right arm; left leg; right leg. Move across your whole body, relaxing it part by part.

KEEPING TIME Our internal circadian clocks regulate periods of sleepiness and wakefulness throughout each 24-hour period. Staying up late or traveling across time zones can disrupt the cycle.

Slow, deep breathing sends calming signals to the brain, which in turn can slow heart rate and nervous activity, prepping the body for rest.

Breathing exercises, particularly when performed ritualistically before bed, can also prepare the body for rest. To give it a try, inhale through your nose, which allows your body to process the air more efficiently, and let your belly move outward. As your abdomen relaxes, room is created for your diaphragm to drop. Then exhale through your nose and let your belly move inward so that your diaphragm presses up. Make each breath a little slower than the last.

5. GET A (HORMONAL) HANDLE ON TIME ZONES

Jet lag is more than a mere time adjustment—it’s a circadian-rhythm disorder that can cause sleepiness and, in some cases, insomnia too. A regimen of physical and mental discipline can alleviate the effect of long-distance air travel on sleep. In addition, the supplement melatonin may be a natural remedy.

Michael Tyshenko, a molecular biologist and research chair of population health studies at the University of Ottawa, recommends going to bed at the same time every night to regularize your body’s natural melatonin release.

The following advice came from a successful international business consultant: “Pay attention to how your body reacts as you adjust to time changes. Some people take melatonin before going to bed, but I use it differently. I have no problem falling asleep in the evening, but I often wake up around 2 a.m. or so, then have trouble getting back to sleep. So that’s when I take it to get back to sleep.” He also finds that personal wake-up routines, such as exercising, getting sun exposure and avoiding alcohol for the first few days, can speed up the adjustment. With business meetings, he often defers decision-making until he feels in step. “Some say one day of adjustment for every hour of time change. I find you need about a week at either end, whether it is a difference of six hours, 10 hours, or more. For important events it is helpful to allow extra time to become localized and acclimatized. That’s why Olympic athletes arrive a month ahead of competitions.”

6. BE A SMARTER TRAVELER

Your internal body clock is only one of many factors affected by air travel that can exacerbate sleeplessness. Extended sitting in an airplane, being in a compressed-air cabin chamber, eating on an unpredictable schedule—all take a physical toll.

A seasoned flight attendant shared his practices in dealing with ongoing overseas travel. First, he recommends slowly sipping water during flights. “Dehydration makes you feel like [you’re in] a revolving restaurant,” he said. “That’s why you can’t sleep: because your body doesn’t feel right. Better to pee than not drink. Some airline personnel augment their personal water with electrolytes or vitamins. I just drink plain water.”

Second, switch time zones on the plane. Force yourself to sleep on the plane if

it’s nighttime at your destination. When deplaning, get into your new time zone, too. That means if you arrive in the morning, force yourself to stay awake. “Walk around and enjoy the day,” the flight attendant said. Finally, “go to bed early the first night—sometimes even at 5 or 6 p.m.—and have a long sleep. You will be very tired and will need it.”

He advocates this discipline so as to avoid the spiral of waking up at 2 a.m., not getting back to sleep for two or three hours, having to sleep during the day, then waking again during the night. “In the morning you can tell who is in the new time zone and who is not: at the end of the day they are still joking around.”

7. BE WHERE YOU ARE

Mindfulness is a form of mediation that can be integrated into one’s life as personal mental training, and plenty of research shows it can have a dramatic impact on sleep. If sitting still on a cushion with your eyes closed feels daunting, other relaxation techniques that emphasize putting your attention on the present moment can also help, such as breathing exercises and yoga. An easy way to start is to take a seat, take a breath and simply commit to being aware of the present moment.

A recent article in Harvard Business Review reported that “the business world is abuzz with mindfulness.” Best known for sharpening focus, it also aids in dealing with insomnia, handling conflict and building team relationships under pressure. The U.S. Olympic Committee and many in the NBA are now committed to it.

This skill of remaining “in the moment” has become a worldwide phenomenon in professional sports in particular. Irish tennis champion Kieran McGeeney, for instance, says this: “I used to freeze up whenever I made a mistake—I was sure that I wasn’t in the same league as the [Roger] Federers and the Andy Murrays. Now when I blow a serve or shank a backhand, I still get those flashes of self-doubt, but I know how to handle them: I acknowledge the negative thoughts and let them slide by, focusing on the moment.”

Ted Bober, associate director of clinical services for the physician health program at the Ontario Medical Association, trains surgeons, physicians and other professionals. He explains that being mindful allows self-monitoring of fatigue that results in making decisions in skilled, levelheaded ways.

Charles Francis, the author of Mindfulness Meditation Made Simple, says “mindfulness is fast becoming an integral part of professional training . . . giving companies a competitive advantage in their industry. Not only does it improve our mental abilities—which makes us more productive—but it also improves leadership skills.”

8. WHEN YOU ARE UNDERSLEPT AND DRAINED, HAVE A PLAN

Here’s some irony: for peak performers, long workdays and interrupted sleep patterns are frequently standard occupational hazards. And although health experts agree that’s not ideal, it happens. And when it does, these professionals have insight into how to stay on your game when you’re exhausted.

Maintaining alertness during low-workload periods requires considerable mental stamina and can cause even more fatigue. Air-traffic-control studies in both the U.S. and Canada in which human attentiveness in air traffic incidents was examined, for instance, show that operational errors occur most frequently during conditions of low rather than high traffic.

Similarly, surgeons recognize that when their concentration is interrupted, it is more difficult to be alert, relaxed and meticulous. “If I’ve been up all night the night before, it makes everything more painful,” a surgeon told us. “It affects some of the more mundane aspects of the operation, not the operation itself.” Dealing with the lulls is essential.

Here’s what doctors recommend: bringing backup. “The way I cope with fatigue is usually having somebody senior to scrub in with me,” says one, “and sometimes I step out for a little while, take a break and come back in.”

When fatigued, police also find strength in numbers. “Even when I’m tired, I don’t want to lose to bad people,” one officer says. “Call me chicken, but I’m going to bring some friends with me.”

9. LEARN TO REST—ANYWHERE

Thomas Edison once said, “Personally, I enjoy working about 18 hours a day. Beside the short catnaps I take each day, I average about four to five hours of sleep per night.”

Sleep experts are mixed on the benefits of napping, cautioning that catching up on sleep through micro rests doesn’t cut it. But most doctors agree that if you aren’t getting enough sleep at night, napping can be a boon.

The New York Times reports that napping is important in the NBA. LeBron James swears by his siesta. Derrick Rose sleeps three hours before every night game. Kobe Bryant checks into a hotel before home games for his pregame nap. Similarly, a traditional one-, two- or three-hour afternoon snooze is critical to many hockey players’ game prep.

Some experts think that’s overkill. Charles Samuels is the medical director of Calgary’s Centre for Sleep and Human Performance and has worked with Canadian Olympians. He also serves as a sleep doctor for the NHL’s Calgary Flames. He warns that a nap is a survival technique, not a replacement for quality sleep—and it should be limited to 30 minutes. “Players need to maintain a routine where they get a dominant amount of nighttime sleep and only use the nap as a recovery strategy.”

Bill Gates shares this view. He used to work through the night, relying on midday naps for rest, but realized that he couldn’t enjoy a high quality of life that way: “I like to get seven hours of sleep a night because that’s what I need to stay sharp and creative and upbeat.”

In jobs that require high-stakes shift work, however, napping is better than nothing. “Do I use coffee to fight fatigue?” one police officer said to me. “Not necessarily. I’ll nap. I’ll take a lunch hour and lie down. It could be the last hour of your shift when the big call comes in.” Surgeons, who can be called upon at all hours in cases of emergency, say the same.

Even a quick break to relax can restore energy, aid in anticipating the next step and renew a positive perspective. For example, police and surgeons are taught to take a brief time-out to refocus. They learn to pause—standing still, taking a deep breath, clasping their hands together or even whistling—in order to reassess their mind-set before they act.

POWER NAP Thomas Edison in the Blue Ridge Mountains while on a camping trip with President Warren Harding in 1921

10. STUDY YOUR GENETICS

Genetics can influence your preferred sleep patterns—there’s research showing that most of us are naturally morning people or night people—which means you should work with what you’ve got to achieve your best personal performance.

Some researchers believe that circadian coaching can help you control your predisposition. It may be possible, for instance, to teach natural late risers how to obtain optimal body temperature, heart rate, reaction time and concentration when events start earlier in the day (and vice versa for early risers preparing for late-day competitions).

Heredity may influence both the quantity and quality of your sleep, and people with certain genetic variations are much more vulnerable to the adverse effects of sleep loss, leaving them prone to insomnia. To optimize whatever your natural inclinations are, be consistent with your sleeping patterns. The best athletes can perform at a high level consistently—which means that consistency is definitely key. To put it into practice in your own life, make sure to allocate enough time for both sleeping preparations—winding down, eliminating distractions—and sleep. Be consistent with your bedtime routines, and try to go to bed around the same time each night to train your body for a consistent melatonin release.

The Truth About Sleeping Pills

Not all sleep aids are the same. Here’s what science has to say about the effectiveness—and safety—of the many options out there

BY MAIA SZALAVITZ

EVERYONE SUFFERS THE OCCASIONAL sleepless night, but when a few restless evenings become weeks or months of insomnia, craving for sleep can become greater than for any food or drug—and the latter is what many of us turn to. A record number of Americans turn to sleeping pills at least once each month; 60 million prescriptions are written per year. But are these medications safe? How addictive are they? And which ones really work best and have the fewest side effects?

ELUSIVE The search for a good night’s sleep is a struggle for many, but these days there are more options than in the past.

These questions have become all the more complicated by research suggesting that most of the currently approved drugs are linked to increased risk for Alzheimer’s disease and dementia. On the other hand, so is sleep loss itself. Insomniacs face risk every way they turn, and the solutions are not straightforward—but there is hope.

Experts agree that natural sleep is the best sleep, but many think sleeping pills have a place for some people, for limited lengths of time.

“There’s no doubt that healthy sleep of adequate duration that is appropriately timed to the light and dark cycle and occurs without the presence of sleep illness is crucial to human health,” says Nathaniel Watson, a professor of neurology at the University of Washington in Seattle and director of the University’s Medicine Sleep Center. Sleep affects every aspect of well-being. “Cardiovascular functioning, metabolic health, mental health,” he says.“We spend one third of our life doing it, so it’s obviously going to be important to every disease known to mankind.”

That’s why, when insomnia occurs, early diagnosis and treatment are critical, say experts. It may help prevent a short-term issue from becoming a chronic problem—and one that needs serious interventions in the form of pharmaceutical or over-the-counter drugs.

“The wrong approach is to automatically give medication and think you’ve accomplished something,” says Timothy Morgenthaler, the president of the American Academy of Sleep Medicine and a professor of medicine at the Mayo Clinic. “It may be harmful. You need to take a good history and evaluate the patient to determine the cause,” he adds.

First, says Morgenthaler, conditions like depression and sleep apnea need to be ruled out. Both are common in the U.S., with depression affecting around 9% and sleep apnea affecting about 4% of the population. Sleeping pills alone can’t treat depression, although they may sometimes be prescribed for a short time in addition to other treatments. Other promising research shows that a kind of talk therapy—called cognitive behavioral therapy for insomnia (CBT-I)—can dramatically improve rates of full recovery from depression and sleeplessness. And because people with depression are at higher risk of addiction, experts caution it’s especially important to make sure the sleep issue is “primary insomnia” and not part of depression or another mental illness. Most mental illnesses, in fact, are accompanied by sleep disturbances, and research shows that some sleep issues can be eliminated with proper treatment of the underlying illness.

Sleep apnea, which is thought to be massively underdiagnosed, involves sleep interruption due to repeated brief cessations of breathing—and it can’t be treated with sleeping pills. The oxygen loss and sleep deprivation that come along with it increase risk for high blood pressure, heart disease, stroke and metabolic problems—and sleeping pills don’t address the respiratory difficulties that underlie it, so they can’t help.

But if primary insomnia is diagnosed, there are many different types of medication for it, including one that came onto the market just this year. They have varied advantages—and disadvantages. Here’s what you need to know.

THE NEWCOMER: BELSOMRA

The Food and Drug Administration recently approved a new drug called Belsomra (suvorexant), and it works in an entirely different way from previous medications. It was inspired by research on narcolepsy, a condition whose primary symptom is suddenly falling asleep at inappropriate times. People with narcolepsy have lost neurons containing a neurotransmitter called orexin, and this affects their ability to stay awake. This prompted scientists to wonder if blocking the action of this chemical at the right time might in fact help people sleep.

It does. “We’re hopeful that it’s going to really provide a new and, in many cases, more helpful alternative to what’s currently available,” says David Michelson, the vice president of neurosciences at Merck Research, a division of the company that makes the drug.

SLEEP SOLUTIONS Approximately 4% of Americans take prescription pills to help them make it through the night. Many more depend on over-the-counter medicines, while others endure their sleeplesness.

While it is a controlled substance, Belsomra does not seem to directly affect reward pathways in the brain the way many sleep medications do, which could mean that it has less potential for misuse. “It helps you fall asleep and also keeps you asleep,” Michelson says, noting that studies of people who have taken it for up to a year do not show that they suffer withdrawal symptoms or worse insomnia than they had previously when they stop. The most common side effect is sleepiness the next day, which, as with all sleeping pills, can impair driving.

“It’s an exciting development to have drugs with a novel mechanism of action,” says University of Washington sleep expert Watson.

But Michael Perlis, director of the behavioral sleep medicine program at the University of Pennsylvania’s Perelman School of Medicine, notes that with new drugs, many risks are unknown. “Large-scale, longitudinal comparative studies are needed to assess whether it has superior efficacy, durability and safety,” he says.

PROS It may work when other drugs have failed; seems to have less risk of misuse or dependence.

CONS It’s still new, which means that long-term risks are unknown.

THE OLD STANDBYS: OVER-THE-COUNTER ANTIHISTAMINES

When people suffer insomnia, the first drugs they turn to aren’t always the best. Over-the-counter drugs like Unisom, Benadryl and Sominex contain antihistamine medicines like diphenhydramine or doxylamine succinate, which were approved by the FDA for treating sneezing and allergies—but not for inducing sleep. The drugs, do, however, make people sleepy. Since they were approved by the FDA at a time when the restrictions were different, there is little data on their long-term safety and efficacy, even though consumers typically assume they are safer than prescription drugs.

The long-term risks are “unknown,” says Perlis, adding that “nothing” is known about how effective they are. Moreover, these drugs fall into a class of medications known as anticholinergics, which are associated with confusion in the elderly and increased risk for dementia.

It’s unclear whether they actually cause or hasten dementia, however, or whether conditions that these medications are used to treat—such as insomnia and allergies—are themselves responsible for the elevated risk. But studies show that the more anticholinergics a person takes, the greater the odds of dementia.

“You can also get dizziness and urinary retention,” says Watson. “When a patient comes to me [who has been using them], I typically move to a more traditional sleeping pill.”

OTC antihistamines do have one clear advantage besides convenience, however: they are not linked with withdrawal symptoms upon cessation, and they don’t appear to cause addictive behavior.

PROS They’re easy to get hold of.

CONS There’s not sufficient data on their long-term safety, and experts have noted correlations between their use and dementia.

THE “MOTHER’S LITTLE HELPERS”: BENZODIAZEPINES

Benzodiazepines are some of the most widely used prescription sleep aids, and they include drugs like Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam) and Ativan (lorazepam). Roughly 9% of Americans between the ages of 65 and 80 take a drug that contains benzodiazepine. But they do have significant downsides, experts caution.

First, for about one in three people who take them daily for six months or more, benzodiazepines produce significant physical dependence. This includes unpleasant withdrawal symptoms like anxiety, sleeplessness, muscle spasms, irritability and hypersensitivity.

In itself, physical dependence isn’t addiction: with physical dependence, people need a substance to function, but that is not necessarily a problem if it makes their lives better. With addiction, in contrast, people compulsively take drugs even when this makes life worse. Benzodiazepine addiction is less common than physical dependence, however, and mainly occurs in people who also misuse other types of drugs, including alcohol. Nonetheless, benzodiazepine withdrawal is notoriously difficult even without addiction. “I think people are wise to be concerned,” Morgenthaler says.

Like anticholinergics, benzodiazepines have also recently been linked to increased risk for dementia, but researchers are not convinced that the link is causal. Because both benzodiazepine use and the risk of dementia rise with age, Perlis says, the link could be simply a third variable that causes both dementia and need for sleep medication.

Other research shows that older people who take benzodiazepine are at an increased risk of falls and fractures, cognitive problems and getting into car accidents.

“The studies that exist show stable effects for up to a year without dose escalation,” says Perlis, which suggests that their effectiveness doesn’t quickly fade out. Benzodiazepines are not recommended for long-term use for most people unless none of the alternatives work.

PROS They are effective.

CONS These drugs come with a high risk of physical dependence, falls and fractures and possible risk for dementia.

THE NEW GO-TO: THE “Z” DRUGS

Another class of medications, known colloquially as the Z drugs, work on the same neurotransmitter in the brain that benzodiazepines affect, but in a slightly different way. These include Ambien (zolpidem), Lunesta (eszopiclone) and Sonata (zaleplon), and they are generally seen as safer than benzodiazepines, though there are some caveats.

“They have a lower side-effect profile and perhaps less chance for abuse,” says Watson. Some are approved for long-term use, and while “rebound insomnia” can occur when people quit, Morgenthaler says that they are easier to stop taking than the benzodiazepines.

The Z drugs have occasionally been linked with strange side effects, like driving or having sex while unconscious, but the experts emphasize that they are rare.

“The biggest concern with the Z drugs is that some patients have had sleepwalking, sleep talking and sleep driving,” says Morgenthaler. “When people first start taking them, we encourage them to be in a safe sleeping environment,” he says, in order to find out if this occurs and minimize any associated risks.

In 2012, a study published in the online edition of the British Medical Journal looked at the risks associated with zolpidem. After controlling for variables that could affect the data—age, gender, smoking, obesity, cancer history, and so on—the researcher found that people taking the drug were more than three times as likely to have died during the study period, compared with those who had not. That data does not prove causation, but it concerns some experts.

PROS The Z drugs are effective and come with less dependence risk than benzodiazepines.

CONS There is risk of “blackout” behavior and rebound insomnia; serious side effects require more research.

THE TIME SHIFTERS: MELATONIN

An additional option for sleep-deprived folks is the hormone melatonin, which can be taken in supplement form. There is also a drug called Rozerem (ramelteon), which targets melatonin receptors in the brain. Melatonin receptors help regulate the body clock that times sleep and wakefulness, and these drugs work to align your internal cycles with your sleep needs. They don’t knock you out the same way other sleep aids do.

Melatonin is often recommended for people with sleep loss associated with “out of sync” sleep like jet lag or shift work, though research does not actually support it as a jet-lag cure. Scientists have shown, however, that people who take melatonin and ramelteon fall asleep more quickly and stay asleep slightly longer than those who take a placebo pill.

PROS Rozerem is the only sleeping pill that isn’t a controlled substance, and neither the drug nor the supplement appear to cause dependence.

CONS They don’t work for everyone and can lead to day-after drowsiness.

THE OFF-LABEL Rx: ANTIPSYCHOTICS AND TRAZODONE

Though they were not approved to help people sleep, two more drugs are sometimes used for insomnia: a first-generation antidepressant approved in 1981—Desyrel (trazodone)—that appears to cause sleepiness; and medications known as “atypical” antipsychotics like Seroquel (quetiapine). When they’re prescribed for sleep, they’re being used off-label, which means that they have not been FDA-approved as sleep aids.

From a scientific perspective, little is know about the effectiveness of either as a sleep aid. In terms of risks, trazodone is linked with a rare but potentially harmful side effect in men: priapism, or an erection that lasts four or more hours and requires urgent medical attention. It can also cause drowsiness the next day, and like all antidepressants, trazodone can bring upon a host of other side effects, too.

Atypical antipsychotics are also sometimes used off-label for sleep, though a study published in 2012 found “data were inconclusive for the use of these medications for insomnia.” The drugs have been shown to increase risk for diabetes and cardiovascular disease. While they have little risk of addiction or dependence, the other side effects make them inappropriate as a first-line choice for insomnia, experts say. “They are going to have greater risk for substantial side effects,” says Watson.

PROS They have little or no addiction risk.

CONS There is not much evidence for their efficacy and could come with serious side effects.

THE NO-DRUG APPROACH: COGNITIVE BEHAVIORAL THERAPY AND MEDITATION

Physicians agree that drugs shouldn’t be the first-line treatment for insomnia, and for people who don’t want to take—or want to stop taking—pharmaceutical drugs, there is a new science-supported strategy. A review of research suggests that CBT-I, the talk therapy approach to insomnia treatment, is as effective as sleep aids and has the added benefit of being a treatment with results that last. “Medical and behavioral interventions have about the same potency during treatment,” says Perlis, one of the authors of the review. “The difference is, CBT-I effects are sustainable after treatment is discontinued.”

CBT-I has several components. The best known is sleep hygiene, which includes avoiding alcohol and late-day caffeine, reducing light exposure before bedtime (no phones or other screens) and having a regular bedtime.

People typically think of these measures—and often dismiss them as impractical or undesirable—when it comes to sleep therapy. But Perlis says they’re the least important. “It’s the weakest link,” he says, “By itself, sleep hygiene can be almost useless.”

A NEW DAY A kind of cognitive behavioral therapy called CBT-I is becoming the first line of defense against insomnia. Unlike pills, it has no side effects and can be long-lasting.

A more crucial aspect of CBT-I is sleep restriction. This means that if you know that you can sleep for only six hours, go to bed six hours before you have to get up—no sooner, no later. It also means avoiding naps or other attempts to “catch up” on sleep. And lying around worrying about your insomnia is out too. “If you can’t sleep, don’t try,” Perlis says. Instead, people whose sleep woes are due to nighttime worrying are taught ways of handling it in the moment.

Finally, there’s stimulus control. This means using your bed only for sleep and sex—and getting up as soon as you realize you can’t sleep. “You should never be in bed and awake,” Perlis says, even as he acknowledges that it is difficult to make yourself get up when you are warm and comfortable. “Get out of bed and be awake somewhere else,” he advises.

For those who seek it, CBT-I is quite effective. “In eight sessions 50% to 70% of people respond, and 30% remit,” Perlis says, meaning that most people get some relief and almost a third see their insomnia go away completely. Many insurers won’t pay for it, however, and qualified providers can be hard to find. “It makes me very sad,” he says. Online versions may help fill this gap; there’s even a free app available from the U.S. Department of Veterans Affairs, called CBT-I Coach.

There is also research that mindfulness meditation and other relaxation technique can improve the quality of sleep and ease insomnia. A randomized clinical trial—considered to be a rigorous and reliable kind of scientific research—split a group of people in two. One group underwent mindfulness training and the other was given sleep-education training. The researchers found that in the mindfulness group insomnia, depression and fatigue were significantly improved compared to the other group. The research was published this year in the journal JAMA Internal Medicine.

Whether the best course for you is meditation, supplements or drugs, the most important thing is picking one that won’t keep you up at night—literally and metaphorically.

A Simple Plan for Rest

You can find a drug-free strategy for better sleep in the palm of your hand

BY FRANCINE RUSSO

IF YOU’VE CAUGHT WIND OF THE RECENT research suggesting that screen time may be to blame for your poor sleep, you’d be forgiven for rolling your eyes at the following advice: One of the more effective treatments for your sleep problem might actually be your smartphone.

That’s because when it comes to science-backed strategies for treating sleep disturbances, the gold standard recommended by the National Institutes of Health and the American Academy of Sleep Medicine is something called cognitive behavioral therapy for insomnia (CBT-I). CBT-I is a kind of talk therapy that focuses on changing behaviors and thought patterns that can contribute to poor sleep. But although it’s proved in numerous solid studies to be effective as a long-term solution, it’s not widely available.

Even if you’re willing to seek out a sleep expert who is qualified to offer CBT-I, you may not find one near you; there are only a few hundred experts who practice CBT-I in the whole country. That’s why the CBT-I app comes in especially handy.

“I do not think many doctors know about CBT-I,” says Rachel Manber, a professor of psychiatry and behavorial sciences at Stanford University Medical Center. “Some provide sleep-hygiene recommendations. However, like dental hygiene, sleep hygiene is best thought of as preventive rather than treatment.” Such recommendations include sleeping in a dark room, sticking to regular bedtimes, and avoiding caffeine and exercise before bed.

CBT-I, meanwhile, has been proven to undo sleep problems, even when they’ve existed for a very long time. Most CBT-I treatments take four to six weeks to be fully effective, which explains why this method pales in comparison with the immediate, if not long-lasting, benefit of sleeping pills. But now Israeli scientists have come up with a way to potentially streamline the therapy for some, by bypassing a sleep lab and delivering the treatment via smartphone.

SleepRate was developed by Uli Gal-Oz and physician Anda Baharav, who has a background in sleep medicine and research at Tel Aviv University, and it’s designed to help people who can’t or don’t want to go to a sleep clinic.

Baharav, SleepRate’s founder, says the app can detect sleep disturbances by mathematically defining the connection between sleep, heart rate and respiration. The Israeli researchers have combined their diagnostic method with a smartphone adaptation of a Stanford University proprietary CBT-I treatment to bring the therapy to more people with sleep disorders.

Anyone with an iPhone or Android phone can download the app kit, which comes with the sleep plan and a heart-rate monitor worn across the chest. It costs about $100, plus shipping.

Here’s how it works: While you’re sleeping, the app collects audio through your phone—are you snoring? is your partner moving around a lot? is there a TV on in the other room?—and data from the heart-rate monitor to get a snapshot of what’s going on in and around you when you’re resting.

In the morning, the app sends all that information to the cloud for analysis based on algorithms from the Stanford Center for Sleep Sciences and Medicine. You do this for five nights in your own bed. You also record how you feel about your sleep and alertness before you start the program and then again every evening and morning for the five days of the assessment.

The app keeps track of all the information in a sleep diary and provides the results from the previous night’s sleep in an easy-to-read graphic that you will have a hard time not obsessing over. It will tell you how long it takes you to reach stable sleep, how many times you wake during the night, the sequence of your sleep stages throughout the night and how much quality sleep you get.

The audio provides clues to sleep problems, too. “If you’re used to living in New York City, for example,” Baharav says, “the traffic and sirens may not wake you, but your fridge banging on at 4 a.m. might.” So your sleep plan might include a service call from your appliance company—or a new fridge.

After the five-night assessment, you get a personalized sleep plan based on your particular sleep issues. The plan tells you when to go to bed and when to wake up, recommends exercises to help you unwind and forget about the day’s worries, and even offers ideas for how to spend the one to two hours before bed to make sure you have a winding-down routine that sets you up for rest.

BY THE NUMBERS The SleepRate app comes with a heart sensor that tracks your sleep depth and interruptions and your responses to noise and light.

Based on the information you entered, for instance, your smartphone screen will alert you when it’s time to start your buffer-time activity with something like a cartoon of someone sitting quietly on a sofa.

The suggestions are offered sequentially over four to six weeks to give you time to learn the new behaviors—much like how cognitive behavioral therapy works, where new habits and patterns are strengthened through repetition. And when it comes to sleep targets, if you don’t reach a goal, you try again. When you do hit your target, such as getting out of bed at the same time for several days in a row, the program adjusts and provides a new one for you. You can pull up your sleep data at any time to examine your own patterns and trends and, lest you lose your resolve over some of your goals, the app is there to remind you what not to do as well: “No! Don’t take a nap now.”

There are other user-friendly CBT-I kits available, including CBT-I Coach, which doesn’t have the same technological components of SleepRate but supports the work you may be doing with a therapist. SleepRate has lots of fans among experts, though. Shelby Harris, director of the Behavioral Sleep Medicine Program at the Sleep-Wake Disorders Center of Montefiore Medical Center in New York, says SleepRate is “more comprehensive, since it also takes into account medical causes for insomnia.”

Because there is a shortage of qualified CBT-I practitioners, Harris sees such apps as viable and welcome first-line efforts for people with insomnia. If the programs don’t work, she says, then patients can see a sleep specialist about their other options.

And what about people who don’t have a diagnosable sleep disorder but are simply sleep-deprived? Could such a program help parents of babies and young children, for instance, find more good-quality sleep? Baharav says that’s coming soon. Stay tuned.

Wake Up to Your Creativity

New research explains why your brain may be at its most inventive when you’re asleep

BY JEFFREY KLUGER

SLEEP IS, AS ANCIENT MAPS ONCE labeled uncharted territories, where the dragons be. To go to sleep is to enter a world entirely like our own and entirely unlike it, too. You can board a plane that’s really a car that flies to Russia, except it’s the moon and your mom is there—until she’s your dad. Dreams can be prosaic or repetitive (exactly how many times can you show up at the same party in your underwear before you remember to put something on?), but whatever they are, they remain mysterious. The sleeping brain runs its absurdist-movie loop all night long, always taking care to conceal what’s behind it. Right?

John Huston, 1963

No longer. Neuroscientists have a growing arsenal of tools—fMRIs, PET scans, high-density EEGs—to watch the nocturnal brain at work and see how it ticks throughout the sleep cycle. To the surprise and delight of researchers, that’s finally helping explain one of the mind’s most ineffable qualities: creativity.

We’ve all slept on a problem and had it sort itself out by morning. But that’s only a small part of what the brain on nighttime autopilot can do. Paul McCartney famously said that he came up with the melody for “Yesterday” in a dream; Elias Howe, the inventor of the sewing machine, is said to have solved the problem of the machine’s needle when he dreamed of an attack by warriors carrying spears with holes in the tips. “Dreams are just thinking in a different biochemical state,” says Harvard University psychologist Deirdre Barrett, author of The Committee of Sleep. “In the sleep state, the brain thinks much more visually and intuitively.”

The hunt for the source of human creativity has been going on for as long as people have been creating. It drives all of us to wonder how celebrated inventors came up with ideas that became the next big thing. And it drives us to wonder how we’ll find our own next brainstorm when we need it. It’s no secret that sleep can be a well of good ideas—what we’re learning now is how to dip into it.

YOU, UNCENSORED

Diego Rivera, 1943

The act of sleeping, as researchers have long known, is a lot more complicated than just conking out for the night. There are two principal cycles of sleep: rapid eye movement (REM) and non–rapid eye movement (NREM), and they alternate. NREM sleep starts as a light doze—sleep at no greater than snorkeling depth—and steadily progresses to deeper levels at which muscles relax, heart rate and respiration slow, and body temperature drops.

REM sleep usually begins about 90 minutes after the start of the first NREM cycle and is the true blue ocean of sleep. Heart rate and respiration accelerate, and brain activity, as measured by electroencephalograms (EEGs), increases too—a function of dreaming. For this reason, muscles become paralyzed, lest you act out the scenes unspooling in your head. Know those dreams in which you’re trying to run away from something but can’t seem to move your legs? That’s not your imagination.

Most REM sleep comes in the last four hours of sleep, says cognitive neuroscientist Jessica Payne of Notre Dame University. “Dreams in the early, NREM phase can be kind of literal. It’s in the REM phase that you get all these crazy binding errors.”

“Binding errors” is one of those lovely scientific terms that mean pretty much what they sound like. Your waking brain is orderly, your sleeping brain is fragmented, and as with all broken things, the bits can get reassembled the wrong way. But “the wrong way” suggests that there’s just one way, and the genius of sleep is that it allows you to explore other, untried avenues.

In a frequently cited 2009 study, investigators at UCLA and the University of California, San Diego, recruited a group of volunteers and had them solve a type of word puzzle known as the remote-association test (RAT). In a typical RAT question, subjects are given three words and asked to determine a fourth word that links them all. The answer for the words “broken,” “clear” and “eye,” for example, would be “glass.” The volunteers had to take the test twice; between the two sessions, they were told to take a 40-minute nap. Some just rested in that interval, others dozed, and some tumbled into the depths of REM sleep. In Round 2 of the tests, participants who got a slug of REM improved 40%, while the other volunteers saw their scores go down. Sleep, it appeared, sharpened their brains’ ability to find links among words.

A 2004 study from the University of Lübeck in Germany approached the same idea in a more revealing way. Subjects were required to complete math problems that relied on algorithms, but hidden deep within the formulas was an elegant arithmetical shortcut. About 25% of the subjects discovered it on their own. But that figure jumped to 59% when volunteers were given a chance to get eight hours of sleep and then come back for more.

“If you have an idea about a simpler solution and it’s been working itself out in your head, you still tend to use the familiar one,” says cognitive neuroscientist Howard Nusbaum of the University of Chicago. When you sleep, the better answer has a chance to emerge.

RODENT REHEARSAL

Brain probes show that rats that run mazes during the day practice them mentally when they’re asleep

SLEEP SPIN-OFF

One study found that 8% of all dreams play a significant role in waking-life creativity

THE HARD DRIVE IN YOUR HEAD

The key to the brain’s ability to make such good use of downtime is something it shares with your computer: the capacity to run multiple programs at once. The aha moment you experience when you’ve been trying to remember the name of a song and three hours later it hits you is no accident. “Conscious awareness is able to focus on only one thing at a time,” says Barrett, “but problems go on getting processed under the radar.”

Sleeping doubles down on this. The prefrontal cortex performs a traffic-cop role, doing more than just keeping the brain focused on a conscious task. It also screens out thoughts that it decides you oughtn’t think of at all. The forbidden concepts aren’t just things that are socially inappropriate—though those are on the list—but also those deemed rationally inappropriate. In sleep, that brake on your imagination comes off, which explains the German math study.

At the same time, the prefrontal censor is dialing itself down, the brain’s visual centers, in the occipital lobe at the back of the head, are dialing up. The hallucinogenic quality of dreams is a result of the visual centers’ mixing images at will. That’s usually just chaff, but not always. One night in 1816, Mary Shelley dreamed of a man assembled from bits beyond the grave—and went on to write Frankenstein.

Katharine Hepburn, 1947

Just as important as which regions of the brain are working is how they communicate. We think of the left hemisphere as the rational, mathematical region and the right as the creative, more bohemian one, and that’s a fair division. But a new study conducted by neuroscientist Lisa Aziz-Zadeh of the University of Southern California found that the brain is not quite so bifurcated.

When architecture students undergoing functional magnetic resonance imaging (fMRI) brain scans were asked to perform a visual-spatial task—arranging geometric shapes in their heads to see if they could be assembled into a square or a triangle—the right, artistic hemisphere carried the load. When they were given a slightly more creative task—arranging a circle, a C and an 8 in various ways to form a face—the right hemisphere called on the assistance of the left. “The specific regions that are active during the creative process largely depend on the kind of task the person is engaged in,” says Aziz-Zadeh.

A 2008 study at the University of Rome found something similar. With the help of EEGs, investigators tracked communication between hemispheres when subjects were awake, in NREM sleep and in REM. In the waking and NREM states, information traveled mainly from left to right, consistent with the idea that the left brain controls the right. During REM sleep, however, there was no preferred direction. The right can thus come out of the shadows.

DNA DREAMS

Genetics determines how much sleep you need, but people who require fewer hours don’t get less of a creative boost from it

PRIORITIZING

The harder the task, the more sleep tends to help, since the brain focuses first on the problems that proved the most challenging in waking hours

Synapses—the cell-to-cell links that serve as the bits of the brain’s operating system—play an important role too. Each brain cell can link to more than just one other, and it would seem that the more connections there are, the better, since that makes for a richer system. That’s indeed true, but only to a point. Too many connections can lead to chaotic free association rather than organized thought. So the brain must periodically clear out the synaptic underbrush—analogous to “running a repair-and-cleaning program on your computer to defrag the hard drive,” says psychologist William Killgore of Harvard Medical School.

The hormone cortisol rises during REM, then helps form new and imaginative ideas from the data that survives the defrag. Cortisol is a stress hormone and tends to fracture memory. It has the same effect when we’re asleep, and Payne believes this encourages the unbinding and rebinding of images that can define dreams. “The brain dislikes fragmentation, so it weaves narratives,” she says. “And that, in turn, gives rise to novel thinking.”

Dopamine is another ingredient in the brain’s secret creative sauce. Harvard psychologist Shelley Carson points out that dopamine levels rise in pleasure centers of the brain both when we’re dreaming and when we’re being creative. This serves as a reward and reinforcement that keeps the dreams—and ideas—flowing.

CONTROLLING THE PROCESS

SLEEPING BEAUTY Actress Tilda Swinton sleeps in a glass box for an art project at New York’s Museum of Modern Art in 2013.

As with all other matters scientific, the question of causation comes up. Are we all equally imaginative in our sleep, or do people who are already creative in their waking hours retain that edge at night? Much as it would be nice to think that sleep is a great democratizer, the fact is, creative types may indeed have an advantage around the clock. Psychologist David Watson of the University of Notre Dame tracked 200 subjects over three months and found that those who scored high on creativity scales when they were awake tended to remember their dreams more.

“One reason is that they simply have more vivid and interesting dreams,” he says. “That’s linked to having an active fantasy life; the daytime behavior shades over into the night. This is a case of the rich getting richer.”

That’s not to say the creative middle class can’t aspire to join that metaphorical 1%. The best strategy for remembering dreams is keeping a journal next to your bed, says Watson. Avoiding alcohol and caffeine is also wise, since they scramble the NREM and REM cycles. Barrett’s studies suggest that engaging in some type of pre-bedtime priming—contemplating a problem you’d like to solve—increases the likelihood that sleep will bring some answers. Up to a third of the subjects in one of her sample groups reported that priming had helped them find a solution that had eluded them during the day.

None of this guarantees that a good night’s sleep is the panacea for what ails you creatively. But neither does it change the fact that the odds are in your favor. You have problems every day, and you go to bed every night. But even if you don’t think of yourself as creative, your sleeping brain will sometimes prove otherwise.

A World of Slumber

Whether sleep happens in a hammock or tent, under the stars or in a bed, the need for it is universal

SLEEPING ON THE JOB An onion vendor at a vegetable market in China’s Shanxi province makes good use of his time while waiting for customers.

CLOSE QUARTERS Tommy Caldwell, on the ropes, and Kevin Jorgeson spent 18 nights on the Dawn Wall of El Capitan in Yosemite National Park before the first climbers to complete a free climb of the wall.

Sisters snuggle up in Miami.

BABY BLANKETS A young child sleeps in a market stall in Cusco, Peru, presumably as family members work nearby.

EXPOSED A man takes a nap on the street in Calcutta, India, next to his rickshaw

A Sami reindeer herder named Nils Peder Gaup spends the night in a tent called a lavut on the mountainous tundra of northern Norway, some 200 miles above the Arctic Circle, where he says he feels most at home.

SWEET DREAMS Like other 10-year-olds, Maya, of Brooklyn, N.Y., needs plenty of sleep every night.

MISSING OUT A toddler sleeps as other family members watch live coverage of Pope Francis’s first visit to the Philippines, Asia’s largest Catholic nation, during his tour of Manila to see the destruction of Typhoon Haiyan.

Photo Credits

COVER (clockwise from top left) Yukim/Getty Images; Walter Zerla/Getty Images; GK Hart/Vikki Hart/Getty Images; James Holmes/Science Source BACK COVER Getty Images TITLE Juliana Sohn CONTENTS 2–3 Ted Spagna/Science Source/Getty Images FOREWORD 4 RubberBall Productions/Getty Images 7 Dorling Kindersley/Getty Images MAINTENANCE FOR THE MIND 9 Photo illustration by Timothy Goodman for TIME 12 University of Rochester Medical Center/AP 15 (from left) Oliver Rossi/Getty Images; Steve Coll/Getty Images; Mike Powell/Getty Images SLEEP RULES 17 (clockwise) Elena Elisseeva/Brand X/Getty Images; Hero Images Inc./Corbis; iStock by Getty Images 18 (clockwise) Pixhook/Getty Images; Ed Freeman/Stone/Getty Images; iStock by Getty Images 19 (clockwise) Erik Isakson/Blend Images/Getty Images; Kate Brady/Getty Images; Juanmonino/Getty Images SLEEP YOURSELF THIN 21 Alamy; (dream) Getty Images (2) 23 Zack Blanton/Getty Images BEDTIME BATTLES 25–27 Juliana Sohn (2) 29 Ale Ventura/PhotoAlto/Getty Images TEENAGE BRAIN 31 Image Source/Alamy 32 Tim the Oyster Guy 35 Hero Images/Gallery Stock DOCTOR’S ORDERS 37 Kathy Quirk-Syvertsen/Getty Images 39 Science Source Photo Library/Corbis 40–41 John Lund/Tom Nenpark/Getty Images DREAM THERAPIST 43 James Steinberg/theispot.com TUNING OUT BAD DREAMS 47 Photo illustration by Lincoln Agnew for TIME 51 Lou Brooks/theispot.com 52 Louie Psihoyos/Corbis 55 Alan Hobson/Science Source/Getty Images SLEEP LIKE A PRO 57 David Plunkert/theispot.com 59 Rob Carr/Getty Images 60 The Image Bank/Getty Images 62 Anne-Michelle Gallero for TIME; (vitruvian man) VladSt/Getty Images 65 Bettmann Corbis SLEEPING PILLS 67 Jacques Loic/Getty Images 68–69 Jekaterina Nikitina/Gallery Stock 70 GIPhotoStock/Science Source 73 Dieter Spannknebel/Getty Images A SIMPLE PLAN FOR REST 75 Christopher Bissell/Getty Images 77 (phone) Getty Images; (app) courtesy of SleepRate WAKE UP to YOUR CREATIVITY 79 Phillip Toledano for TIME 80 Pete Turner/Getty Images 81 Fritz Henle/Science Source 82 MGM/Kobal Collection 83 Jannis Werner/Demotix/Corbis A WORLD OF SLumber 84–85 Jon Woo/Reuters/Corbis 86 Corey Rich/Aurora Photos 87 Maggie Steber/National Geographic Creative/Corbis 88–89 Nicolaus Czarnecki/ZUMA Wire/Corbis 90 Raquel Maria Carbonell Pagola/LightRocket/Getty Images 91 Erika Larsen/Redux 92–93 Erin Patrice O’Brien 94–95 Damir Sagolj/Reuters/Corbis CREDITS 96–97 Gregg Segal/Gallery Stock

The numbers in this section reference the page numbers of the print version of this text.

POWER PODS A short stop at a restorative nap machine gives people an alternative to the mid-afternoon coffee break in offices such as Google’s and on a few college campuses.

Managing Editor Nancy Gibbs

CREATIVE DIRECTOR D.W. Pine

DIRECTOR OF PHOTOGRAPHY Kira Pollack

The Science of Sleep

EDITOR Siobhan O’Connor

DESIGNER Anne-Michelle Gallero

PHOTO EDITOR Crary Pullen

WRITERS Sarah Begley, John Cloud, Jeffrey Kluger, Judy McDonald, Mandy Oaklander, Alice Park, Bonnie Rochman, Francine Russo, Alexandra Sifferlin, Maia Szalavitz, Andrew Weil

REPORTER Elizabeth Bland

EDITORIAL PRODUCTION David Sloan

TIME INC. BOOKS

PUBLISHER Margot Schupf

VICE PRESIDENT, FINANCE Vandana Patel

EXECUTIVE DIRECTOR, MARKETING SERVICES Carol Pittard

EXECUTIVE DIRECTOR, BUSINESS DEVELOPMENT Suzanne Albert

EXECUTIVE DIRECTOR, MARKETING Susan Hettleman

PUBLISHING DIRECTOR Megan Pearlman

ASSOCIATE DIRECTOR OF PUBLICITY Courtney Greenhalgh

ASSISTANT GENERAL COUNSEL Simone Procas

ASSISTANT DIRECTOR, SPECIAL SALES Ilene Schreider

ASSISTANT DIRECTOR, FINANCE Christine Font

SENIOR MANAGER, SALES MARKETING Danielle Costa

SENIOR MANAGER, CATEGORY MARKETING Bryan Christian

MARKETING MANAGER Isata Yansaneh

ASSOCIATE PRODUCTION MANAGER Kimberly Marshall

ASSOCIATE PREPRESS MANAGER Alex Voznesenskiy

ASSISTANT PROJECT MANAGER Hillary Leary

EDITORIAL DIRECTOR Stephen Koepp

ART DIRECTOR Gary Stewart

SENIOR EDITORS Roe D’Angelo, Alyssa Smith

MANAGING EDITOR Matt DeMazza

COPY CHIEF Rina Bander

DESIGN MANAGER Anne-Michelle Gallero

ASSISTANT MANAGING EDITOR Gina Scauzillo

EDITORIAL ASSISTANT Courtney Mifsud

Special thanks: Allyson Angle, Don Armstrong, Katherine Barnet, Brad Beatson, Jeremy Biloon, John Champlin, Ian Chin, Susan Chodakiewicz, Rose Cirrincione, Assu Etsubneh, Alison Foster, Kristina Jutzi, David Kahn, Jean Kennedy, Amanda Lipnick, Samantha Long, Amy Mangus, Robert Martells, Nina Mistry, Melissa Presti, Danielle Prielipp, Kate Roncinske, Babette Ross, Dave Rozzelle, Matthew Ryan, Ricardo Santiago, Divyam Shrivastava

Copyright © 2015 Time Inc. Books

Published by Time Books, an imprint of Time Inc. Books

1271 Avenue of the Americas, 6th floor, New York, NY 10020

All rights reserved. No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer, who may quote brief passages in a review. TIME and the Red Border design are protected through trademark registration in the United States and in the foreign countries where TIME magazine circulates.

eISBN: 978-1-68330-2-582

We welcome your comments and suggestions about Time Books. Please write to us at: Time Books, Attention: Book Editors, P.O. Box 361095, Des Moines, IA 50336-1095. If you would like to order any of our hardcover Collector’s Edition books, please call us at 800-327-6388, Monday through Friday, 7 a.m.–9 p.m. Central Time.

Table of Contents

Cover

Title

Copyright

FOREWORD / The Power of Sleep

Maintenance for Your Mind

The 9 New Sleep Rules

Can You Sleep Yourself Slim?

Bedtime Battles

Sleep and the Teenage Brain

Doctor’s Orders: Go Back to Bed

The Dream Therapist

Tuning Out Bad Dreams

Sleep Like a Pro

The Truth About Sleeping Pills

A Simple Plan for Rest

Wake Up to Your Creativity

PHOTO ESSAY / A World of Slumber

Credits