Larry McMahan has electrodes glued to his head, to his neck, to his chest, and to his legs. There are 18 in all, each with a different colored wire running from his skin to a small white and grey control box.
As Shawn Kimbro, a sandy-haired polysomnography technician at Baptist Hospital, adds the final touches--two thick belts around McMahan's chest and a three-pronged nose and mouth wire--the bearish Sevier County sheriff's detective groans.
"You expect me to sleep with this thing?" he asks, trying to lie back on his narrow hospital bed without crushing any wires.
"That's what everybody says," Kimbro answers reassuringly.
Sleep is what McMahan is here to do. The gregarious veteran investigator and father of two has checked in for a night at Baptist's Sleep Disorders Center. After talking to several doctors, he thinks he probably has a form of sleep apnea--a condition in which people repeatedly stop breathing during the night, leading to restless sleep, daytime fatigue, and potentially deadly health problems. This one-night study will chart McMahan's sleep patterns and, he hopes, provide a treatable diagnosis.
McMahan is a minority case, part of the approximately 10 percent of Americans who have severe sleep disorders. But he is an exception mostly in the degree of his sleep deprivation. In the 1990s, sleep experts say, almost nobody is getting their 40 winks. A combination of modern technology and lifestyle patterns has conspired against our natural sleep cycle, with consequences that can be disastrous. As scientists learn more, they're blaming sleep deprivation for everything from car accidents to heart attacks to depression.
"We're not quite as bad as a sleep apnea patient, but we're not too far away from it, either, because most of us don't get anywhere near nine to 10 hours of sleep," says Dr. Bill Finley, director of the Sleep Disorders Center at St. Mary's Hospital.
But Dr. Roseanne Barker, a neurologist who directs the Baptist center, knows what sleep advocates are up against. In a whispery voice, she sighs, "In our culture, not sleeping is equated with success and ambition and being a go-getter."
Now I Lay Me Down to Sleep
That sleep is important no one disputes. Laboratory animals that are not allowed to sleep for weeks at a time become increasingly disturbed and manic and eventually die. Researchers assume the same would be true of humans (although there's some speculation that we might only go insane rather than actually perish). But asking a sleep expert why exactly sleep is so crucial--what functions it actually serves--is like asking a geologist the purpose of rocks.
"That is the question," nods Finley, a wiry biological psychologist with eyebrows that look permanently furrowed. "Whoever could really give a satisfactory answer to that would get a Nobel prize. The simple answer is, we sleep to stay awake. So then the question is, why do we stay awake? To sleep?"
Metaphysics aside, researchers do know an awful lot about sleep. The relatively new field of study has made dramatic strides in recent decades, with new discoveries coming all the time.
Finley says serious sleep research got underway in the late 1940s, but the findings and theories were relatively crude and not much use to doctors for several decades. When patients complained about any kind of sleeping problem, most physicians simply wrote a prescription for one tranquilizer or another.
"Until the 1960s or early '70s, probably the most commonly prescribed medicine was for sleep, but nobody knew what they were doing," Finley says. "So people would show up at their doctor's office and say, 'I can't sleep,' and the doctor would give them barbiturates, which are very dangerous."
Breakthroughs came in the 1970s with the recognition of sleep apnea, narcolepsy (which can cause a loss of muscle control known as cataplexy), and other specific disorders. Pioneering researcher William Dement established the first modern sleep center at Stanford University. Others quickly followed, leading to the establishment of the American Sleep Disorders Association (ASDA), which sets professional guidelines and grants accreditation to centers that meet them.
According to ASDA spokesman Greg Mader, the Minnesota-based organization has grown from three accredited centers in 1977 to 337 in 1996. Three of those are in Knoxville--at St. Mary's, Baptist, and Fort Sanders Regional Medical Center. In the past five years alone, 138 new centers have opened.
"[That's] the best measure we have of the growth of the industry," Mader says. "Certainly, more patients are becoming aware that they don't necessarily have to put up with a bad night's sleep, that something can be done for them."
The ASDA's logo is a black and white yin-yang sign, symbolic of the interdependence of sleep and wakefulness.
In people with regular sleeping habits, sleep is governed by 24-hour biological cycles called circadian rhythms. On a schedule in sync with patterns of natural light and darkness, our bodies signal in a variety of ways that it's time to sleep. Production of various hormones--including human growth hormone and melatonin--rises and falls depending on the sleep cycle. The rhythms don't only demarcate actual sleep and wakefulness. There's a well-documented trough, for example, between about 2 and 4 p.m. when most people report feeling sleepy. This corresponds with the period of deepest sleep between 2 and 4 a.m.
Within the sleep cycle, scientists have identified five stages. Stages one and two are light sleep--people awakened out of stage one might not even realize they'd been asleep. Stages three and four are known as "delta sleep," named for the long delta waves that show up in brain activity (the brain registers much shorter alpha waves while awake). Then there's the best-known phase, the only one with a rock band named after it: REM, rapid-eye movement. REM sleep generally sets in after about 90 minutes and is characterized by high levels of brain activity, in addition to the eye rolling that gives it its name. Researchers believe REM is where most dreaming takes place.
"Sleep is an active process," Barker says. "In particular in dreaming, the amount of energy, the glucose being used by the brain, is about the same as when we're awake."
What's the brain doing with all that energy? A lot, apparently. REM sleep seems to be especially important for laying down long-term memory, somewhat akin to transferring data from a computer disk to a hard drive. (It's possible artists were on to this even before scientists. In Gabriel Garcia Marquez's novel 100 Years of Solitude, when a village is hit by a plague of insomnia, the villagers have to start labeling things--household appliances, animals, trees--because they keep forgetting what they are.)
If REM is crucial to mental functioning, the other stages of sleep seem important for physical reasons. Simply put, they allow our bodies to rest and gather strength for the next day. Heart rate, kidney functioning, and respiration all slow, and muscles relax. People with a sleep disorder known as periodic limb movement--in which arms and legs jerk uncontrollably through the night--complain of chronic pain, because their muscles and joints get no relief. The body's immune system is also weakened by lack of sleep. In other words, there's nothing that can be wrong with you that sleep deprivation won't make worse.
Sleepless in Menlo Park
Understanding why we need sleep is one thing. Understanding why we don't get enough of it is another. Finley has a simple answer: blame it on Edison.
"Thomas Edison was an individual who among all of his many eccentricities felt that sleep was a waste of time," Finley says. "He felt that if we could bring daylight into our nighttime hours, we could do away with sleep altogether...He really intended to eliminate sleep for all of us when he invented the electric light bulb.
"He did partly achieve his goal, in that societies around the world started to sleep about two hours less a night after the invention of the light bulb."
From a pre-Edison level of nine to 10 hours of sleep a night, Finley says the average sleep time in industrialized societies is now seven to eight hours.
The difference is especially striking in winter months, when for thousands of years long nights meant more hours of sleep. Now, humans are essentially on a year-round summer sleep cycle.
Of course, some people say that's all they need. Barker says the surest measure of whether a person's had enough sleep is simply whether they feel like they've had enough sleep. Those who wake up every morning feeling well-rested and don't get overly tired during the day are doing fine. Those who need loud alarm clocks and big doses of caffeine to get awake and stay awake probably aren't.
Amy Weber, for example, is tired. The University of Tennessee senior's eyes are slightly glazed, and she slumps in her lightweight sweatshirt.
"Yesterday, I didn't even go to bed," she says. "I walked into the bedroom four minutes before my alarm was set to go off."
Her lack of sleep was a matter of necessity--Weber, an advertising major, had a large group project due for her campaigns class. She thought she'd be done with it by 10 or 11 p.m., but problems kept coming up.
Baylor Johnson, another advertising student, is familiar with the problem.
"Once it gets late at night, it's impossible," he says. "It takes two hours to get something done that would take you 20 minutes during the day."
"I know a lot of people pull all-nighters studying for tests," adds classmate Ally Wirchansky.
It's no surprise to this trio that college students are one of the most chronically sleep-deprived segments of the population. They estimate they get an average of six hours of sleep each night, with the occasional seven or eight hours on weekends.
Part of the problem is the college lifestyle, a combination of homework, tests, outside jobs, and, of course, partying that doesn't leave much time for golden slumbers.
But there's a biological component, too. According to experts, sleep patterns change dramatically during the teen years. The biological clock that governs sleepiness and wakefulness begins a phase delay, which means people from their mid-teens through their early 20s don't feel tired until later in the evening--sometimes as late as 1 a.m. At the same time, for not fully understood biological reasons, members of this age group need as much as two more hours of sleep a night than they do as pre-teens or as mature adults.
"Teenagers aren't [only] killing themselves on the roads because they're drinking and driving; they're killing themselves because they're sleep-deprived," Barker says.
Some states have taken steps to address the problem, mandating high schools to start classes as late as 8:30 or 9 a.m. instead of 7:30 or 8. But in college, where the sleep deprivation factors are even higher, a ban on 8 o'clock classes is unlikely.
The UT students don't downplay the effects of poor sleep.
"I don't feel as healthy; I feel run down a lot," Weber says. "Like now, I don't feel that good. My voice is scratchy...Once I'm up, you can function for a little while. It starts to affect me at about 2 o'clock in the afternoon. I cannot keep my eyes open."
For Lisa Hatfield, being a student was nothing compared to her current occupation: mother of a newborn daughter. Hatfield, who lives in Sequoyah Hills with her husband Curt, managed to get a good eight hours of sleep a night while going through UT's law school--she graduated in December--even while working 20 hours a week.
Then came Aneigé, named after the snowstorm that coincided with her arrival in January. Cradling the pink-faced infant against her chest, the 27-year-old Hatfield admits the last two months have been rough on her sleep schedule.
"I find I get dizzy sometimes from lack of sleep," she says, gently rubbing her daughter's back. "I get crankier, grouchier; it's harder to deal with her."
Aneigé often won't go to sleep until 11 or midnight and wakes up hungry three or four hours later. Since Hatfield is breastfeeding--and because she is taking several months off while her husband works full-time--she answers the early-morning cries. After feeding, mother and child sleep another few hours. Aneigé does take naps during the day, but Hatfield is hard-pressed to join her.
"Every time they get to sleep, you want to clean house, do laundry, eat lunch," she says.
In a month or so, the baby will start sleeping through the night. But Hatfield has no illusions about resuming her old sleeping habits.
"I think it'll make it better, but I don't think it'll every be like it was before I had children," she says. "You're always on their schedule."
Snores and More
It doesn't actually take Larry McMahan long to get to sleep in Baptist's sleep center. With the help of an Ambien pill--currently the most popular sleep medicine--McMahan is into stage one sleep by 10:45 p.m.
Sleep tech Kimbro is in the next room, along with fellow techs Myron Willis and Kevin Plemons, who are each monitoring their own patients. The room looks at first glance like the control station of a TV studio, with black and white monitors stacked on shelves full of high-tech equipment.
But the TV screens, linked to closed-circuit infrared cameras in each bedroom, are secondary. The most important information is displayed in a series of continuous jagged lines on screens hooked up to Pentium 133 computers. Here's where all the data gathered by the electrodes and sensors on a patient's body comes in. The top two lines show eye activity, followed by channels for brainwaves, jaw muscles, limb movements, heart rate, respiration, and blood oxygen content. Put together, they give a complete picture of a patient's physical state.
Kimbro, tall, lean, and bearded, watches McMahan's chart attentively. Soon, the previously regular hills and valleys of the 40-year-old detective's breathing line starts to waver. In intervals of at first five to 10 seconds and then 20 to 30 seconds, the line flattens out, showing no air entering or leaving McMahan's lungs. The breaks are followed by an audible cough from McMahan that briefly shakes his whole body out of sleep.
"Obstructive apnea, arousal," Kimbro says, tracing the line on the screen with his finger. "Larry's got it."
What McMahan has--obstructive sleep apnea--is the disorder most commonly seen at sleep centers. Finley calls it the centers' "bread and butter." It's generally caused by soft tissue in the neck and throat relaxing too much during sleep and pinching off the airway. It occurs most often in middle-aged, overweight people, although being overweight is less a cause than a symptom: as people get less sleep, they feel less energized, exercise less, and gain weight. Also, human growth hormone, which helps metabolize fat, is released during deep sleep, which many apnea sufferers never reach.
Apnea is hereditary, and its onset is usually preceded by snoring. While snoring was long seen as a sign of deep sleep, doctors say it's actually an indication of at least a partial obstruction in the airway.
"I like to think snoring is never normal," Barker says.
Snoring was what first alerted McMahan to his problem. It became prominent enough that his 8-year-old daughter recently called home from a slumber party at a friend's house to say she couldn't sleep because she "couldn't hear Daddy snore." His wife, awakened by his "freight train" wheezing, noticed the snores were interrupted by periods of no breathing. And while McMahan is oblivious to his nocturnal noises, he has seen an impact on his waking hours.
"I can tell that some days I don't think clearly," he says. "Things bog down, I don't get a whole lot accomplished."
Barker says people with chronic apnea have up to 20 times higher risks of heart attacks and strokes, along with higher rates of depression and a host of other problems. Fortunately, the condition is mostly treatable.
The most popular medical response is Continuous Positive Airway Pressure, a relatively recent innovation universally known as C-PAP. It's a small plastic mask that fits over a patient's nose, with a hose leading to a small air pump. The machine maintains enough pressure to keep the airway from collapsing. Properly used, Barker says, it has about a 90 percent success rate.
Kimbro, who has been a sleep tech for three years (after several years administering lie-detector tests for the National Security Agency), is a true believer in C-PAP treatment.
"C-PAP is one of the best medical inventions that's come out in a long time," he says. "It's just wonderful. People come in--they're just turning cartwheels after they use it."
Bob Hill isn't turning cartwheels, exactly, but he is impressed by the results of C-PAP.
Hill, a beefy 33-year-old control systems specialist, spent a night in St. Mary's sleep center last month for diagnosis. As he assumed, he has a moderate apnea disorder.
Like McMahan, he had noticed a lack of alertness in his work, and his wife had complained repeatedly about his snoring. Pregnant with the couple's first child last year, she moved into a different bedroom to escape Hill's slumbering snorts.
After using C-PAP at home for about a week, he said his wife reports his snores have greatly decreased. For himself, he has noticed he feels better in the mornings and throughout the day. But he's not quite ready to commit to C-PAP for life.
"I'm sleeping well with it, but I'm still getting used to having this thing hanging off my face," he says.
Sleep It Off
But if most sleep-deprived people don't have problems as serious as apnea, they don't have solutions as simple as C-PAP, either. No medical machine is going to help with long hours at work, ferrying children to school or sports, or worries about money, relationships, and health problems that keep many people awake.
There are, however, some simple guidelines for getting a good night's sleep.
If you're really serious about it, Finley says, just fight back against Thomas Edison. When it gets dark, don't turn on the lights or the TV. Light a candle to read by, and see how long it takes to get sleepy.
"You'll struggle with that for two or three days, and then you'll be going to bed at 8 p.m. and getting up at 7 or 8 a.m. and feeling terrific," he says.
Barring such a Spartan approach, the experts say, at least try to go to bed and get up at the same time every day. Develop some regular, low-stress ritual--reading, watching TV, taking a bath--for the half-hour or hour before bed. Don't let the bedroom become a second living room--keep TVs and other distractions in other rooms, so the bed is reserved for sleep.
What you eat and drink has a big impact on sleep as well. Caffeine is an obvious no-no, but Barker says alcohol is almost as bad. Although some people rely on a drink or two to sedate them before bed, Barker says alcohol has a rebound effect that actually interferes with sleep after the depressant wears off.
Kimbro, who pointedly sips from a mug of ice water even though he works night shifts, has horror stories about coffee drinkers.
"We've got people who come in here and say, 'Well, I can't get to sleep unless I've had two cups of coffee,'" he says. In fact, the patients are caffeine addicts who need the coffee to stave off headaches. But the caffeine then disrupts their sleep.
But Barker says not to sweat it if you have a restless night or two. Most people can make up lost sleep with longer hours in bed the next day, through naps, earlier bedtimes, or sleeping in. There are limits to running up a sleep deficit, however. The favorite trick of college students--trying to make up a week's worth of sleep on Saturday night--doesn't work.
As in so many other parts of our lives, Barker says, "Most Americans tend to build a larger and larger debt."
Hatfield is one of them. Two months as a mom have conditioned her to get by on five or six hours of sleep. And with the possibility of more children on the horizon, along with her taking the bar exam in July and starting a career as a lawyer, she doesn't expect to get much more.
"I don't want to compromise my time with my kids no matter what, but I really need to work," she says. "So I anticipate sleep will get pushed aside."
She's aware of the trade-offs, but like so many other working parents, she's willing to cope.
"I would just say it's worth it," she says. "You do what you have to do, and I wouldn't trade being a mother for the world."
Looking down at her daughter, she adds, "even when you're cranky," and kisses the baby's forehead.
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