Yawn! Your Visit to a Sleep Center

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Your Situation

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Dr. Taryn A. Myers, Virginia Wesleyan College

Circadian rhythm

The daily patterns roughly following the 24-hour cycle of daylight and darkness; 24-hour cycle of physiological and behavioral functioning.

Narcolepsy

A neurological disorder characterized by excessive daytime sleepiness, which includes lapses into sleep and napping.

REM sleep behavior disorder

A sleep disturbance in which the mechanism responsible for paralysis during REM sleep is not functioning, resulting in the acting out of dreams.

Obstructive sleep apnea hypopnea

A serious disturbance of non-REM sleep characterized by complete absence of air flow (apnea) or reduced air flow (hypopnea).

Sleepwalking

Disturbance of non-REM sleep characterized by complex motor behavior during sleep.

Sleep terrors

A disturbance of non-REM sleep, generally occurring in children; characterized by screaming, staring fearfully, and usually no memory of the episode the following morning.

Cataplexy

Sudden episodes of total loss of muscle tone or strength that occur when a person is awake.

Sleep paralysis

Temporary paralysis that strikes just before falling asleep or upon waking up.

Hypnagogic hallucinations

Imaginary sensations experienced during Stage 1 sleep.

Electroencephalogram (EEG)

A recording technology that detects electrical energy in the brain and displays information that can be interpreted.

Theta waves

Brain waves that indicate the early stage of sleep.

Non-rapid eye movement (non-REM or NREM)

The nondreaming sleep that occurs during sleep Stages N1 to N3.

Delta waves

Brain waves that indicate a deep sleep.

Stage R

Also known as rapid eye movement (REM) sleep; the stage of sleep associated with dreaming and characterized by bursts of eye movements, with brain activity similar to that of a waking state, but with a lack of muscle tone.

Alpha waves

Brain waves that indicate a relaxed, drowsy state.

Beta waves

Brain waves that indicate an alert, awake state.

Rapid eye movement (REM)

The stage of sleep associated with dreaming and characterized by bursts of eye movements, with brain activity similar to that of a waking state, but with a lack of muscle tone.

Sleep hygiene

Behavioral prescriptions to make sleep better and longer (Stepanski & Wyatt, 2003, p. 215).

Insomnia

A sleep disorder characterized by an inability to fall asleep or stay asleep, impacting both the quality and the quantity of sleep.

asiseeit/Getty Images

You were having such a great dream about getting straight As, but then the voice of the professor congratulating you starts to become more and more clear as she repeats your name. You realize that it is your professor’s voice in real life, and you have fallen asleep in class—again. How embarrassing! Your professor voices her concern for you:
“This is the third time in the past two weeks you have either looked like you have fallen asleep or actually dozed off in my class. Are you feeling ok? I’m getting concerned. You should figure out what’s going on so that it doesn’t negatively affect your grade in my class.”

Hauri, P. (1992). Sleep hygiene, relaxation therapy, and cognitive interventions. In P. J. Hauri (Ed.). Case Studies in Insomnia (pp. 64–84). New York, NY: Plenum

ESS © MW Johns 1990-1997. Used Under License. Murray W. Johns. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale, Sleep, 1991; 14 (6): 540-545. Contact information and permission to use: Mapi Research Trust, Lyon, France. – Internet: https://eprovide.mapi-trust.org

National Institutes of Health. (2012). Tips for getting a good night’s sleep. Medline Plus, 7, 20.

Stepanski, E. J., & Wyatt, J. K. (2003). Use of sleep hygiene in the treatment of insomnia. Sleep Medicine Reviews, 7, 215–225.

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Your professor is probably right. You decide to see your doctor while you are home on break. Your doctor asks you questions about your sleeping habits, and you tell her that you have been having a hard time falling asleep and staying asleep. Your doctor decides to refer you for a sleep study. See your referral below.

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What You Need to Know

You have never heard of a sleep study, so you are a little nervous. You decide to do some research online. While performing a search, you find the website for the center where you will do your sleep study:

circadian rhythms.

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Why might disturbances in your circadian rhythms cause sleep problems?

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Here at The Sandman Sleep Center, we conduct sleep studies to help us diagnose a variety of possible sleep disorders. Click on each of the six sleep disorders listed here to learn their definitions.

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Now that you have reviewed the sleep disorders that The Sandman Sleep Center will check for when you undergo your sleep study, match the diagnosis with its defining characteristics below. Create matches by selecting the circle next to an option in the left column. Then click on the circle next to the option in the right column where you want to make the match.

Insomnia

Narcolepsy

Obstructive sleep apnea hypopnea

REM sleep behavior disorder

Sleep terrors

Sleepwalking

Screaming, inconsolable child; usually no memory of the episode the next day

Expressionless face; open eyes; may sit up in bed, walk around, or speak gibberish; upon awakening has limited recall

Poor sleep quantity or quality; tendency to wake up too early; can’t fall back asleep; not feeling refreshed after a night’s sleep

Upper throat muscles go limp; airway closes; breathing stops for 10 seconds or longer; sleeper awakens, gasping for air

Dreamers vocalize and act out dreams; violent and active dreams are common; upon awakening the dream is remembered; risk of injury to self and sleeping partners

Irrepressible need to sleep; daytime napping; cataplexy; sleep paralysis; hypnagogic hallucinations

Use arrows to choose items. Press space to grab or place one.

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What can you expect during your sleep study at The Sandman Sleep Center?

The studies are not painful, although you might feel slightly awkward or uncomfortable. You will come to a lab room, which will look like a hotel room or even like your bedroom at home. Once there, you will have devices placed on or around you.

Watch the video below to see what you will experience during the study:

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Sleep Studies - Your Night in the Sleep Laboratory.

A sleep study, also called a "polysomnogram", is an overnight study of your sleep, which takes place in a specialized laboratory. It is conducted by a trained technologist, and is designed to detect problems with your sleep. The goal of the study is to have a natural night of sleep that is as uncomplicated and comfortable as possible.

When you come to the laboratory, a technologist will greet you and show you the location of the bedroom, bathroom, and control room. The technologist will stay through the night to ensure safety and proper procedures. High quality tracings will be obtained. There is a TV camera in the room to monitor your sleep, as well as an intercom to communicate with the technologist. It is standard practice to videotape sleep studies, in case any unusual activity occurs during testing.

When it is time, you will change into your nightclothes, and the sleep study technologist will hook up many electrodes. This does not cause pain. The electrodes are metal and shaped like a tiny cup about a quarter inch in diameter. They attach to wires, which go to amplifiers, so that electrical signals can be recorded.

Because the position of the electrodes is quite important, the technologist will measure your head and mark it for placement. The scalp will be cleaned thoroughly, in order to get a good signal. The electrodes will then be attached with either glue or paste. The technologist may scratch the scalp gently to improve the electrical connection.

Altogether, about seven electrodes will be applied to the scalp. Electrodes will also be applied around the eyes, to detect eye movement. Recording eye movements helps the technologist determine which stage of sleep you are in. Electrodes are also placed on the chin, in order to monitor muscle tone.

Next, a snoring sensor, which is a tiny microphone, will be placed on the neck. Sensors will be taped near the nose and mouth to detect airflow when you are breathing. Belts will be placed around your chest and abdomen to detect the movement associated with breathing. A sensor that shines a bright red light will be placed on your finger. This sensor monitors the amount of oxygen in your blood. EKG sensors will be placed on your chest to monitor your heart rate.

Finally, some electrodes will be attached to the muscles on your legs and sometimes your arms to monitor muscle tone. You may wonder if you will be able to sleep with all these wires attached. Most people sleep quite well. You can be easily unhooked whenever you want to move around and go to the bathroom. You should be able to sleep in any position that is comfortable for you.

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According to the video, your sleep during the sleep study should feel:

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Please prepare for your sleep study by filling out the questionnaire below.

Your results will be shared with our sleep technicians. Rate each item on this sleepiness scale from 0–3, with “0” being no chance of dozing, “1” being a slight chance of dozing or sleeping, “2” being a moderate chance of dozing or sleeping, and “3” being a high chance of sleeping.

Situation	Chance of Dozing of Sleeping
Sitting and reading
Watching TV
Sitting inactive in a public place
As a passenger in a motor vehicle for an hour or more
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic

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Your level of sleepiness is {model.total}.
If your score is above 10, then you are likely struggling with a sleep disorder. The sleep study will be beneficial in diagnosing your sleeping disturbance. If your score is below 10 but you are still experiencing difficulty sleeping and/or trouble staying awake during the day, then the sleep study will still be beneficial in diagnosing your sleep disturbance.

Which of the symptoms listed above are the most problematic for you as a student (as described in this activity)?

Answers will vary but should include the point that falling asleep during the day, especially during class, for example, can be very detrimental to one’s ability to learn and pay attention. Similarly, not being able to sleep at night can be both frustrating and can leave you less alert and less focused.

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The day of your sleep study is here! After you sign some forms, the receptionist hands you some paperwork to review.

The Sandman Sleep Center: Stages of Sleep

As part of your sleep study, we will assess how you progress through the stages of sleep. At each stage of sleep, your brain will exhibit different types of waves. The electroencephalogram (EEG) you will be wearing will measure your brain waves while you sleep. The stages of sleep usually follow the natural progression below:

In Stage N1 sleep, referred to as “light sleep,” your brain will exhibit theta waves. The N stands for non-rapid eye movement (non-REM or NREM) sleep.

Stage N2 sleep is slightly deeper, and your brain will exhibit sleep spindles (little bursts of electrical activity that may be associated with memory consolidation and intelligence) and K-complexes (large waves seen during stage 2 of sleep).

Stage N3 is the deeper stage of sleep in which your brain will exhibit delta waves. It can be most difficult to wake someone up from this stage.

In Stage R sleep, your brain will exhibit patterns similar to the alpha waves and beta waves exhibited when you are awake, which is also known as rapid eye movement (REM) sleep and is when most dreams occur.

Woman wearing a cap fitted with a network of electrodes for use in electroencephalography (EEG) studies to measure electric current flows within the neurons of different parts of the brain. Photographed at the Oxford Centre for Human Brain Activity, UK.

James King-Holmes / Science Source

Sleep research: various traces of subject awake M872/0116 Rights Managed Credit: JAMES HOLMES/SCIENCE PHOTO LIBRARY Caption: Sleep research: series of false-colour traces showing typical brain & muscle activity in a subject who is awake. Numbered from top to bottom, 1 & 2 are electroencephalograms (EEG) of brain activity; 3 is an electrooculogram (EOG) of movement in the right eye; 4 an EOG of the left eye; 5 is an electrocardiogram (ECG) trace of heart activity. Finally, 6 & 7 are electromyograms (EMG) showing activity in the laryngeal (6) and neck (7) muscles. Sleep comprises cycles of 5 distinct stages; 1-4 are stages of increasingly deeper sleep known as non-rapid eye movement (NREM), and a 5th stage of lighter, rapid eye movement (REM) sleep.

James King-Holmes / Science Source

This sleep study participant wears electrodes that will measure her brain waves and body movements during sleep.

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Using what you have just learned from your handout on sleep stages, label the diagram of sleep stages below, by dragging and dropping each sleep stage name into the correct spot. The figure on the left illustrates how deep the stages are and the figure on the right shows the brain waves associated with each stage. Move items by dragging them to the correct location or by selecting an item and then selecting the location where it should move.

Label the diagram of sleep stages that illustrates how deep the stages are on the lefthand side and the associated brain waves on the righthand side by dragging each definition to the appropriate place. Alternatively, select each item and press the 1, 2, 3, 4, or 5 buttons to match it with the corresponding stage. When all the stages have been labeled, select the “Check answer” button. Select the “Reset” button to restart the activity.

Correct! Stage R, or REM sleep, looks the most like being awake, and the other three stages of sleep progress in depth according to their stage number.

Actually, Stage R, or REM sleep, looks the most like being awake and should be placed directly below “Awake,” and the other three stages of sleep progress in depth according to their stage number (N1, N2, and N3).

Stage N1

Stage N2

Stage N3

REM Sleep

Awake

Choose an item and place it in an empty area

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Skills You Can Use

A few days after your sleep study, you return to your primary care doctor’s office to discuss your results. She tells you that your results indicate a diagnosis of insomnia, meaning that you are having difficulty both falling and staying asleep, which leads to the sleepiness and inability to stay awake you experience during the day. Your doctor presents you with a handout listing tips for what she calls sleep hygiene, which she says means engaging in behaviors that will help you improve your sleep by making it both longer and better. View her handout with tips below.

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Your doctor further explains that are to make sure that you get on a regular schedule, avoid any substances that can alter your sleep/wake cycle, and not force yourself to sleep when your body is not ready to do so.

Which of these tips do you think would be most useful in solving your sleep problems (as presented in this activity)? Please explain.

Answers will vary but should include the point that establishing a regular sleep schedule should help your body get back on a circadian cycle. Answers could also indicate that using substances like caffeine and nicotine could actually keep you up at night.

Which of these tips do you think would be most difficult to implement? Please explain.

Answers will vary but should include the idea that college students often stay up late working on their assignments, so they will be using screens and often consume caffeine to help them do so. Also, college students’ beds are often the only comfortable sitting space they have in their rooms, so they will watch TV or do homework there.

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Think It Through!

Your doctor also recommends biofeedback as a possible treatment for your insomnia. She shows you the following video in her office to educate you about this possibility:

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REPORTER: If you're among millions of Americans who can't get enough sleep, you should know that it could be the root of other health issues, such as obesity. Relief can come in the form of unconventional and non-invasive therapy.

RAE TATTENBAUM: We're going to do a little baseline.

REPORTER (VOICEOVER): Insomnia lead Myron Congdon to seek another alternative to taking sleep medication.

MYRON CONGDON: Sometimes I would get out for a couple of hours, and sometimes I would just simply stay awake and toss around in bed.

REPORTER (VOICEOVER): That would lead to three to four hours of sleep a night.

RAE TATTENBAUM: The software is giving his central nervous system feedback.

REPORTER (VOICEOVER): Now Myron is undergoing a mix of neuro and biofeedback

RAE TATTENBAUM: Let the background noise just be background.

REPORTER (VOICEOVER): training perfected by psychotherapist Rae Tattenbaum in West Hartford. Relaxation techniques, she says, can only go so far.

RAE TATTENBAUM: Relaxation is good. However, what we really need is balance. And most people are too tense to practice the relaxation exercises.

REPORTER (VOICEOVER): This technology

RAE TATTENBAUM: He's creating a complete state of balance.

REPORTER (VOICEOVER): monitors the turbulence causing the imbalance in his central nervous system.

RAE TATTENBAUM: What causes turbulence? Worry, aggravation, habits.

REPORTER (VOICEOVER): That turbulence triggers an interruption.

RAE TATTENBAUM: He's hearing an interruption, and what he's feeling is a sense of well-being and relaxation

REPORTER (VOICEOVER): a feeling Myron was deprived of, due to the lack of sleep.

MYRON CONGDON: Fuzzy during the day time, at times. Yawning at times when you don't want to be yawning, when you're supposed to be paying attention to someone else.

REPORTER (VOICEOVER): Weekly sessions have lead to sleeping better.

MYRON CONGDON: What I'm getting is going back to sleep much more often than I was able to before.

RAE TATTENBAUM: With this technology, you sleep an hour longer, and you return to sleep faster.

REPORTER (VOICEOVER): Also part of the process-- getting ready to go to sleep.

RAE TATTENBAUM: Breathing patterns, what you watch, what you read before you go to sleep.

REPORTER: The success rate for this training is about 75%.

How is biofeedback similar to and different from the sleep hygiene tips given to you by your doctor? Which would you prefer to try for treating your insomnia and why?

Answers will vary but should include the point that both techniques include the idea of preparing your body for sleep and keeping on a regular schedule. You may prefer biofeedback because it is interesting technology and effective, or you may prefer sleep hygiene because you can accomplish these tasks on your own without having to seek more medical assistance.

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In the video, psychotherapist Rae Tattenbaum emphasizes which of the following as important for helping people to sleep?

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Myron, the patient shown in the video, says which of the following about his sleep habits after using biofeedback?

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In Your Own Words

Randy Faris/Corbis

You return to campus after the break and are back in the class where you fell asleep. You have been implementing the techniques suggested by your doctor, and you find that you can stay awake in class without difficulty now. Your professor has even commented on how much more alert you seem to be.

After this activity, how have your ideas about sleep changed? If a friend complained about being tired, would you think he or she might be suffering from a sleep disturbance? Should he or she seek help for this sleep disturbance? How could your friend improve his or her sleep?

Answers will vary but should include a discussion of sleep disturbances, how sleep studies can help to diagnose them, and how sleep hygiene or other techniques can help to improve sleep.

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Your Scientific World