My Sleep and I

Reasons for reading this book

This book is organised in chapters aiming to provide a personalised view of normal and abnormal sleep.

The first section – My Sleep – provides a small theoretical review of the functions of sleep, explaining why we should sleep

The other sections talk about normal sleep, bad sleep, good and bad habits, sleep risks and stories around sleep disorders. Each chapter is a small history collected in real life, which is followed by a simple scientific explanation, with international references.

The main aim is to allow the recognition of your own possible problems so that you achieve better sleep and better quality of life.

So:

If you go late to bed

If we sent messages throughout the night

If you play with your PlayStation and/or work with your pc until quite late

If you are sleepless before your tests, exams or conferences

If you go to the disco and come home after sun rise

If you are sleepy because you curtail your sleep

If you wake up tired

If you wake up with a dull headache

If nobody and nothing can wake you up

If you wake with the noise of a fly

If you suffer from insomnia and don’t sleep well

If you snore or stop breathing

If you don’t have a restorative sleep

If you fall asleep anywhere

If strange things occur while you sleep

If you are more tired upon awakening than at sleep onset

If you are unable to follow regular schedules

If you are dissatisfied with your sleep

If you have strange or unpleasant dreams

If you dream across the night and wake up exhausted

If you sleep well but would like to know why

Then,

This book is for you

A secondary didactic aim also exits

So:

If you want to understand

How sleep matters in your daily life

How sleep matters for your health

How sleep matters for your survival

How sleep matters for your success

How sleep matters for your quality of life

Why your sleep is not good

Which are the risks of sleep curtailing

Which disorder you likely have

Which are the risks of a poor sleep

Which are the consequences of sleeping too much

How habits interfere with your health and your sleep

Then,

This book is for you

A tertiary aim exists

So:

If you are a beginner in sleep medicine

Want to understand patients’ complaints in their own words

Need to have simple bibliographic reviews of each theme

If you are a professional needing fast and simple updates

Then,

This book is for you

Contents

Reasons for reading this book

A. My Sleep

1. Why Sleep?

a) Survival

b) Physical health

c) Mental Health and Cognition

d) Wellbeing, happiness, longevity

2. How are Societies influencing sleep?

B. Sleep biodiversity

1. I LOVE SLEEPING

2. STRONG, FRAGILE AND NORMAL SLEEPERS

3. A NAP? YES OR NO

4. I SLEEP A LITTLE, I SLEEP A LOT

5. NOTHING CAN WAKE ME UP

6. SLEEP FROM THE NEWBORN BABY TO GRANNY

C. What is a bad Sleep?

1. Sleeping too little

MY PROBLEM? I DON’T SLEEP

2. Sleeping badly

I STOP BREATHING, I THINK I AM GOING TO DIE

3. Sleeping too much

THEY SAY I AM A SLEEPYHEAD

4. Moving a lot

I DON’T FIND MY SLEEP POSITION

5. Making odd sounds

MY GIRLFRIEND CANNOT STAND MY SNORING

Strange behaviours

YOU WERE WALKING AROUND THE HOUSE

6. Uncommon hours to sleep

WEEKENDS PARTIES END AT 6AM

D. Importance of daily habits: Good and Bad Routines

1. I KEEP A MEDITERRANEAN DIET

2. WALKING THE DOG

3. HAVE A HOBBY, ENJOY NATURE, BE HAPPIER

4. MY DAILY SCHEDULES ARE WELL ORGANIZED

5. I LYE ON BED ALL DAY

6. I DON’T LIKE GYMS

7. THE BRAVE NEW WORLD: SCREENS AND INTERNET

8. RUINING SLEEP

9. SLEEP IS A WASTE OF TIME

10. I DON’T HAVE TIME TO SLEEP

11. I CAN’T BE QUIET. I MUST DO SEVERAL THINGS AT THE SAME TIME

E. Risks of Bad or Unregulated Sleep

1. Risks for your heart

SEVERAL TIME ZONES IN THE SAME DAY

2. Accident risks

WHEN I WOKE UP, I WAS UNDER A LORRY

3. Overweight risks

WHEN I WAKE UP IN THE MORNING THERE ARE CRUMBS IN THE ROOM

4. Chronic disease risks

EVERYTHING HURTS, EVERYTHING IS TIRING

5. Cancer risks

I AM PAYING FOR WHAT I HAVE DONE

6. Dementia risks

SHE WAS A SHORT SLEEPER

7. Lower Performance

I FAILED THE RACE COMPETITION

8. Depression

EVERYTHING STARTED WITH MY DIVORCE

9. Sexual life impact and problems

MY SEXUAL LIFE IS NOT GOING WELL

10. Marital risks

MY MARRIAGE IS BROKEN. I CAN’T HANDLE SHIFTS

F. Sleep Stories

1. Falling Asleep and Waking Up

HERE COMES THE SANDMAN

I FALL DOWN AT SLEEP ONSET

A MONSTER VISITS MY ROOM OR MY SLEEP

I HAVE SOME STRANGE FITS AT SLEEP ONSET

WAKING UP IS REALLY DIFFICULT

I CANNOT MOVE UPON AWAKENING

HE SEEMS A BAD CONTROLLED ROBOT

2. Sleeping too little and sleeping badly

I STAY UP ALL NIGHT

I DON’T SLEEP SINCE MY BABY IS BORN

I HAVE NO PROBLEMS FALLING ASLEEP, BUT I AWAKE UP OFTEN

I SLEEP 7 HOURS BUT I WAKE UP EXTREMELY TIRED

I WAKE IN THE MIDDLE OF THE NIGHT

MY MOOD IS TERRIBLE

I HAVE NOT SLEPT SINCE I WAS A CHILD

NOTHING I TAKE CAN MAKE ME SLEEP

I AM A MESS

I CANNOT SLEEP, BUT I DO SLEEP BETTER AT MY BROTHER’S

I USED TO SLEEP WELL, NOT NOW

3. Strange movements during sleep

I CANNOT STAND MY LEGS

MY WIFE SAYS I SEEM LIKE A HORSE

SHE GRINDS HER TEETH

4. Pain and Sleep

MY HEAD AND MY SLEEP ARE KILLING ME

I DON’T KNOW WHAT COMES FIRST: THE PAIN OR THE INSOMNIA

A BOMB IS EXPLODING IN MY HEAD

AT 3am I WAKE UP WITH A HEADACHE

MY HEADACHES ARE TERRIBLE

HEADACHES ARE MY ALARMCLOCK

5. The bad sounds of Sleep

PEOPLE TELL ME I SNORE

MY HUSBAND CANNOT STAND MY NOISE

THE CPAP CHANGED MY LIFE

I DON’T LIKE THE MACHINE

HE SOUNDS LIKE A MOTORBIKE

6. Sleeping too much

SLEEPINESS IS NOT LAZINESS

REALLY OUT OF IT

I SPEND MY LIFE SLEEPING

I SPEND THE DAY LYING DOWN SLEEPING

7. Unregulated sleep

I ALWAYS ARRIVE LATE

I GO TO BED VERY EARLY

I TRAVEL A LOT

I AM FLYING EAST, TO LISBON, WHAT SHOULD I DO?

I AM ADRIFT

8. Strange Behaviours during Sleep

I HAVE VIOLENT DREAMS

I HATE DOCTORS

I AM SURE MY HUSBAND IS BETRAYING ME

SHE TRIED TO TAKE HER OWN LIFE DURING SLEEP

MY WIFE HAS MADE ME SLEEP IN THE LIVING ROOM

MY MOTHER GETS UP IN THE NIGHT AND STARTS COOKING

WHEN I WAKE UP IN THE MORNING THERE ARE CRUMBS IN THE ROOM

I AM AFRAID OF SLEEPING WITH HIM

I HAVE HORRIBLE NIGHTMARES

I AM ASHAMED OF WHAT I AM GOING TO TELL

I HAVE A PROBLEM WHICH IS DIFFICULT TO MENTION

G. Glossary

A. My Sleep

1. Why Sleep?

We sleep to assure our survival, our physical health, our mental health, adequate performance in whatever field, quality of life and wellbeing, and a long and happy life

a) Survival

Survival is a fundamental and universal feature of living beings. Sleep appeared millions of years ago in pluricellular animals and persisted through evolution, despite the danger of exposure to predators. Sleep achievements were biologically superior when compared to the predation danger, since they assured survival. Interspecies transmission of sleep was quite successful, and, in that way, sleep exists in all animals so far studied.

In humans sleep survival is assured since foetal life, the preborn baby dreams most of the time, in his dreams he is learning the behaviours which will assure survival upon birth: crying in a way that someone will take care of him, rooting (infant’s tendency to turn their head towards a touch stimulus, which facilitates nipple approach), sucking for feeding (babies adjust sucking pressure based on the flow of milk by sensing the upcoming flow), head turning (ability to lift and turn head to keep airway clear)¹ and motor protection by the Moro reflex².

In adult life besides the positive sleep functions upon cognition, decision making, performance and health which are essential for survival, dreams of the sleeping brain are fundamental survival tools, since they allow behaviour training without danger.

Furthermore, during sleep brain monitors the environment, microarousals keep the brain and body prepared for any eventuality, and arousal threshold shows a marked duality, it is high for non-relevant stimuli, and low for relevant ones: we will wake when the baby cries or someone tries to open the door.

b) Physical health

Sleep is together, with nutrition and physical activity, a fundamental pillar of HEALTH³

Risks to our body related to bad sleep or sleep deprivation are numerous.

Why?

During sleep periods, anabolic hormones (the growth hormone, prolactin and testosterone) are systematically and regularly produced, and the catabolizing hormones are regulated, particularly cortisol and the thyroid stimulating hormone, which increase in case of sleep deprivation.

It all happens in a way that, while you sleep, you grow or repair tissues in different organs while reproductive functions and cell division are regulated. In the morning while waking up, cortisol is at an adequate level, for the day to start well. But if you do not get enough sleep, anabolic hormones diminish and catabolizing hormones increase, and health risks start to appear.

Sleep has a core need. It should not be neither too short nor too long. Health risks occur in the extremes of sleep duration⁴,⁵.

Hypertension, cardiovascular and cerebrovascular problems appear with increased risks. Sleep duration between 6-8h has the lowest risk of cardiovascular events⁶.

Furthermore, growth impairment can occur in children, while in adults the impact is upon tissue repair: wrinkles and weaker bones may become a problem.

On the other hand, sleep is essential in energy regulation and in homeostasis, for temperature control, which goes down while we sleep, and for energy control through feeding, in a balance that diminishes our hunger, if you sleep, or increases it in case of sleeplessness. For all this, having not enough sleep leads to fatigue, increases weight gain risk in all age groups, namely young children, together with the increased prevalence of type 2 diabetes.

Sleep has also a narrow and complex relation with immunity, and not sleeping increases the chance for infectious diseases and eventually auto-immune diseases.

While asleep, cell division is controlled, therefore short sleep, out of hours sleep or irregular sleep increase the chance of cancer in both genders.

Sleep deprivation also has behavioural consequences such as higher chance of trauma, unintentional accidents in children, adolescents and adults.

Good sleep, Good Health!

Synthesis: the risks and consequences of poor sleep for physical health are terrible. In all ages and in all continents, not enough sleep or too much sleep, increase the risk of obesity, hypertension, type II diabetes, accidents, cancer, cardio/cerebro vascular and autoimmune diseases

c) Mental Health and Cognition

Sleep is essential for learning, memory, decision making, creativity and emotional balance.

Sleep disturbances impact emotions, cognition and mental health

Why?

Because during sleep, our brain, released from the focus given to the external world, shifts and focus on itself and towards our body; and both these dialogues are essential to our health.

During Sleep, the old paradigm a sound mind in a sound body reaches its maximum intensity.

Our brain takes care of itself, increasing the intensity of sleep in more stimulated areas while awake, reconnecting important circuits and bonding quick interconnections between cerebral zones that speak with one another, while disconnecting unnecessary circuits to rest, and deleting irrelevant information while strengthening those which matters, i.e., a clean-up function of not useful information and toxic metabolites.

Since one does not learn what one does not like, a sleeping brain stabilizes emotions; since, in order to learn one must try, our brain creates, through dreams, virtual realities where, without risk, one can argue, run, fight, talk or cry, in a safe learning environment. Innovative dreams are about the impossible or the never seen, fostering the creativity required for creative work and for survival.

In teenagers and children, loss of sleep increases distractibility and irritability, in opposition to adequate sleep, which consolidates memory. In these ages risk behaviours, such as violence and fights, drugs, early sex, excessive screen time and sedentarism increase with sleep deprivation.

On the other hand, sleep deprivation affects memory of neutral and positive stimuli. This effect leads to remembering negative stimuli, and enhances behavioural tendencies towards impulsiveness and negative feelings, and, to a lower expression of emotional stimuli.

The connection between Sleep and Intellect has been indirectly appraised through correlations between some sleep characteristics, namely sleep spindles, and the IQ (Intelligence Quotient).

It is known that a sleep episode following a learning period will enhance what was previously learned. This is said to be true for verbal tasks, motor tasks, special orientation tasks and more specialized performances, such as playing music.

On the other hand, the daytime apprenticeship of a motor task is related and linearly correlated with the increase of delta activity and sleep spindles, in the following sleeping period, in the contralateral motor region.

The effects of sleep upon memory consolidation have been described in early 19th and 20th century, but there is presently a significant number of papers on the matter, restating this sleep function. On the other hand, sleep enhances and protects declarative memory.

It is known since the 1960’s that declarative memory is affected by sleep or by sleep deprivation. A 36h sleep deprivation significantly diminishes the temporal sequence retention, even if aided by heavy doses of caffeine, and affects the correct perception of our own performance.

The idea that sleep enhances creativity was put forward by reports concerning several scientists and artists who have reported that creation of their masterpieces occurred right after waking up, after a dream or during a hypnagogic state.

A more detailed disclosure is due to Kekulé, concerning a dream that led him to the discovery of the benzene ring. Others can be also mentioned: The discovery of the sewing machine gearings, Dali’s paintings, Mr. Jeckyll’s Book by Stevenson, Paul McCartney’s Imagine, Kurosawa’s Dreams film, amongst many others.

The effect of sleep is not only to code and consolidate memories or learning, but rather to integrate them into new associative schemes, that through generalization or integration, could show new perspectives or directions, giving reason to the popular saying: The pillow brings good advice.

Several experiments were conducted towards proving this integration capacity again, in adults as well as in pre-lingual children.

In summary, nocturnal sleep allows, for all age groups, the consolidation of memories, and enhances concepts of information generalization, and the identification of hidden solutions.

Knowledge concerning the effects of sleep on emotions comes from the increase in irritability and bad temper after a sleep deprivation night, characteristics that worsen if sleep deprivation is repeated. Nonetheless, it is also known that acute deprivation can also have an antidepressant effect, used for years ago in the treatment of serious depressions.

On the other hand, it is known that both stress and positive or negative emotions happening during the day affect sleep.

An increase in positive events contributes to a better subjective sleep, and a good night’s sleep enhances the recognition of images with positive emotional components. Negative events worsen sleep to many people, either good or bad sleepers.

In this perspective, sleep deprivation functions both as a bomb for irritability outbreaks in normal life and may explain depressive humour in many psychiatric disturbances.

Thus, the habit of sleeping less in intellectual workers of many working fields, from universities to finances and politics, significantly affects reasoning capabilities (memory, learning, creativity), executive functions and emotional abilities, which are essential to the execution of the intellectual tasks at hand.

To think right, it’s important to sleep right!

Synthesis: Depression, insomnia and risk behaviours in all ages, burnout, dementia, some neurologic and psychiatric diseases are not only increasing in prevalence, but also revealing their high societal costs. Their relationship with sleep is clear.

d) Wellbeing, happiness, longevity

Health-related quality of life (HRQOL) is an individual’s or a group’s perceived physical and mental health over time. It is a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning. Studies evaluating HRQOL in relation to sleep duration in large epidemiologic studies in adults⁷ and

adolescents⁸ and in sleep disorders Insomnia, narcolepsy⁹, proved the deleterious effect of sleep reduction and sleep dysfunction upon HRQOL.

Both short and long sleep duration are associated with a greater risk of premature death¹⁰.

One aspect of life fulfilment deals with successful ageing and longevity. The relationship between happiness and longevity has been studied in USA: the risk of death over the follow-up period is 6% among individuals who are pretty happy and 14% higher among those who are not happy, independently of marital status, socioeconomic status, census division, and religious attendance¹¹.

Sleep well, Live longer!

Synthesis: The relationship between sleep and health related quality of life, happiness and longevity is clear.

¹ https://www.physiopedia.com/Understanding_Newborn_Behaviour#:~:text=

The%20newborn%20has%20three%20survival,and%20events%20in%20the%20environment.

² Edwards CW, Al Khalili Y. Moro Reflex. [Updated 2023 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542173/

³ Knutson KL. Associations between sleep, diet, and exercise: implications for health and well-being.In: Foundations of Sleep Health, Eds F.Javier Nieto, Donna J. Petersen, Academic Press, 2022, Chapter 6,Pages 123-131, ISBN 9780128155011, https://doi.org/10.1016/B978-0-12-815501-1.00013-2.

⁴ Itani O, Jike M, Watanabe N, Kaneita Y. Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Med. 2017 Apr;32:246-256. doi: 10.1016/j.sleep.2016.08.006. Epub 2016 Aug 26. PMID: 27743803.

⁵ Jike M, Itani O, Watanabe N, Buysse DJ, Kaneita Y. Long sleep duration and health outcomes: A systematic review, meta-analysis and meta-regression. Sleep Med Rev. 2018 Jun;39:25-36. doi: 10.1016/j.smrv.2017.06.011. Epub 2017 Jul 5. PMID: 28890167.

⁶ Wang C, Bangdiwala SI, Rangarajan S, Lear SA, AlHabib KF, Mohan V, Teo K, Poirier P, Tse LA, Liu Z, Rosengren A, Kumar R, Lopez-Jaramillo P, Yusoff K, Monsef N, Krishnapillai V, Ismail N, Seron P, Dans AL, Kruger L, Yeates K, Leach L, Yusuf R, Orlandini A, Wolyniec M, Bahonar A, Mohan I, Khatib R, Temizhan A, Li W, Yusuf S. Association of estimated sleep duration and naps with mortality and cardiovascular events: a study of 116 632 people from 21 countries. Eur Heart J. 2019 May 21;40(20):1620-1629. doi: 10.1093/eurheartj/ehy695. PMID: 30517670; PMCID: PMC6528160.

⁷ Reis C, Dias S, Rodrigues AM, Sousa RD, Gregório MJ, Branco J, Canhão H, Paiva T. Sleep duration, lifestyles and chronic diseases: a cross-sectional population-based study. Sleep Sci. 2018 Jul-Aug;11(4):217-230. doi:10.5935/1984-0063.20180036. PubMed PMID: 30746039; PubMed Central PMCID: PMC6361301.

⁸ Matos MG, Marques A, Gaspar T, Paiva T Perception of quantity and quality of sleep and their association with healthrelated quality of life and life satisfaction during adolescence. Health Edu Care, 2017 2(2): 1-6. ISSN: 2398-8517

⁹ David A, Constantino F, Santos JM, Paiva T. Health-related quality of life in Portuguese patients with narcolepsy. Sleep Med. 2012 Jan 24. [Epub ahead of print] PubMed PMID: 22281002.

¹⁰ Cappuccio FP, D’Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010 May;33(5):585-92. doi: 10.1093/sleep/33.5.585. PMID: 20469800; PMCID: PMC2864873.

¹¹ Lawrence EM, Rogers RG, Wadsworth T. Happiness and longevity in the United States. Soc Sci Med. 2015 Nov;145:115-9. doi: 10.1016/j.socscimed.2015.09.020. Epub 2015 Sep 18. PMID: 26421947; PMCID: PMC4724393

2. How are Societies influencing sleep?

With the discovery of electricity, industrial and technological development allowing control over energy, food production, telecommunications, internet, artificial Intelligence, spatial industry, the social paradigms changed.

To have, To win, Success, No limits become mandatory rules.

With globalization international societies changed and developed new habits and new work modalities.

Society is now continuously on, first 24h per day, and then 7 days per week. Enjoyments changed and extended through the night. In this setting, Sleep became an embarrassment for work, productivity, amusement and economic interests.

Therefore, since last century, people have been sleeping less and less, and this deficit extends to all age categories.

The El Dorado of progress has however its black sides: The number of poor is increasing, and millions are beneath the poverty threshold; divorce and single parent families increase; wars and social instabilities emerge in several continents; uncertainty must be taken seriously; knowledge and erroneous myths circle freely on the internet; the climate crisis is in progression.

Sleep deprivation and related illnesses are serious issues. Societal economic costs related to sleep deprivation in the richest world countries are huge: $680 Billion are lost each year across five OECD countries (USA, Canada, UK, Japan, Germany) due to insufficient sleep¹².

The warnings about the risks of this sleeplessness are many, but in the global society they do not speak loud enough, choked by the systematic challenges and incentives in the opposite direction.

Sleeplessness is quite expensive!

Synthesis: Citizens must protect themselves against the 24/7 society, trying to take most of the benefits and the least of pain

¹² Hafner M, Stepanek M, Taylor J, Troxel WM, van Stolk C. Why Sleep Matters-The Economic Costs of Insufficient Sleep: A Cross-Country Comparative Analysis. Rand Health Q. 2017 Jan 1;6(4):11. PMID: 28983434; PMCID: PMC5627640.

In the following stories YOU are the MAIN THEME and the TARGET AUDIENCE

B. Sleep biodiversity

Humans are ecosystems, either individually or as groups (family, city, country etc).

A sustainable ecosystem is one that, over the normal cycle of disturbance events, maintains its characteristic diversity of major functional groups, productivity, and rates of biogeochemical cycling¹³.

Sustainable ecosystems have a marked biodiversity. Biodiversity is patent inter genders, inter ages, inter individuals, inter countries, inter regions, inter races, etc.

Biodiversity is essential for humans and its reduction is considered among the possible causes of extinction. It is, in fact, one of the possible explanations of Neanderthals’ extinction

So, let’s be different!

Sleep follows this biodiversity; there are marked interindividual differences in the multiple sleep features.

Sleep characteristics and parameters are usually distributed in the population with a gaussian distribution, i.e. a distribution with a bell shape, the most common are at the dome of the bell, the least common at the outer borders.

¹³ Principles of Ecosystem Sustainability https://www.journals.uchicago.edu/doi/epdf/10.1086/285969

1. I LOVE SLEEPING

I love sleeping.

I have my little routines before sleeping. After taking off my make-up, I brush my teeth and so on, go to bed, read a little - I always have a book to read at night – and after reading a few pages I turn off the light.

In bed I like to feel the sheets against my skin and stretching my body so I can get into a comfortable position to sleep. I like to stretch and yawn.

It’s what cats do, stretching out in enjoyment, their muscles taut with obvious pleasure.

I switch off the light and do not even realise I am falling asleep.

I am certainly not one to count sheep. I think I do