The Critical Importance Of Sleep

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Most people who come to see me complaining of fatigue are worried something is wrong with them physically but turn out only to be sleep deprived.  Sleep seems to be something we all wish we did more, making us for the most part a chronically and persistently sleep-deprived society. Though some studies suggest large differences exist in how much sleep different people need to function normally, the range varying from less than 6 to more than 9 hours, and that short sleepers and long sleepers run in families (suggesting a genetic component for people operating on the extremes of the sleep curve), other studies suggest as many as 33% of us don’t get enough sleep to satisfy our basal sleep need (the amount of sleep needed on a nightly basis to perform optimally).

The reasons for this are numerous. Many of us find our best or only time to socialize is late at night. Some find nighttime their only time to relax and unwind, or spend time with their children, or pursue their hobbies. Others are so busy and need to accomplish so much that their daytime work cuts into their nighttime sleep. But unless you make up your accumulated sleep debt (the extra amount of sleep you need to return to normal functioning after being deprived of a normal amount of sleep over time) at some point during the week (commonly accomplished on the weekends), you will find yourself becoming chronically fatigued.

A small amount of sleep debt often makes itself felt initially by a mild to moderate dropping off of energy roughly between 3 and 5 p.m. in the afternoon. But more severe sleep debt, if allowed to accumulate, can have the following detrimental effects:

  1. Weight gain (or a reduced ability to lose weight). This appears to occur via changes in hormone levels, specifically a decrease in serum leptin (a hormone which causes satiety) and an increase in serum ghrelin (a hormone which causes hunger). It should be noted no studies have shown definitively that sleep-deprived patients actually weigh more than non-sleep deprived patients, however.
  2. Chronic severe fatigue.
  3. Irritability.
  4. Decreased ability to concentrate.
  5. Depression. Interestingly, depression can cause fatigue, can be caused by fatigue, and can therefore be confused with fatigue.
  6. Impaired short-term memory.
  7. Decreased libido.
  8. Poor judgment.
  9. Increased risk of car accidents, which can be higher than in people who drive while intoxicated.
  10. Decreased productivity.
  11. Decrease in resistance to viral infections.


In the same way we often only realize the benefit of a medication when it’s stopped and we start to feel worse, just how severely sleep deprivation is impairing our functioning may only become apparent when we improve it. Make a commitment to get the amount of sleep your body tells you that you need—no matter what—and note what, if anything, improves. See how you rate the quality of your life in general when you’re getting adequate sleep compared to when you’re not. The difference may surprise you.

Certainly quality of sleep is as important as quantity, but often is something over which we have less control as it frequently results from a disease like restless leg syndrome or obstructive sleep apnea. If you’re getting what has in the past been for you an adequate amount of sleep but now find yourself chronically fatigued, you should consult your physician to see if something is disordering the quality of your sleep.

Finally, even if you have every intention of sleeping an appropriate number of hours, you may have difficulty doing so. Difficulty falling asleep is often due to churning thoughts, either from anxiety or excitement. Frequent awakenings can be due to anything from nocturia (the need to urinate at night) to depression. Once your doctor has ruled out organic causes, one technique that often helps to induce sleep (whether the difficulty occurs when you first lie down or after you’ve been awakened) is called a paradoxical intervention. Often being unable to fall asleep several nights in a row actually induces performance anxiety, i.e., the expectation that falling asleep will be difficult creates anxiety that actually prevents sleep. People often lie awake for hours struggling to fall asleep, miserable. To use a paradoxical intervention, you would instead lie in bed with the conscious intention to stay awake. If the diagnosis of performance anxiety is correct, it’s astonishing how often paradoxical intervention works.

We should all be merciless about defending our sleep. As a direct primary care physician, I spend much of my time encouraging patients to get adequate sleep. We often think we can sacrifice it temporarily for a variety of reasons—and certainly if we do so infrequently, we won’t likely suffer any adverse effects. The problem comes in when we do so repeatedly, thinking perhaps because initially we don’t suffer any negative consequences that we can continue to function normally with an inadequate amount in the long term. But nothing could be further from the truth. If for no other reason that when we’re well rested we feel more capable of handling the obstacles that invariably arise in life, we should make every effort to conceive of our sleep as a top priority rather than something we just happen to do at the end of the day.

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  • Thanks so much for this post. I’m going to forward it to my two children who are in their thirties and who often complain of being fatigued. I know that lack of sleep (for the very reasons you mention—nighttime is the only time to do fun things, etc.) is the culprit.

    Your post also highlights the difference between chronic fatigue and Chronic Fatigue Syndrome, the relatively rare but devastating condition where no matter how much sleep (even good quality sleep) a person gets, he/she wakes up unrefreshed, similar to the feeling of severe jet lag. I know because I’ve suffered from CFS. It was triggered by a severe viral infection in 2001. The fever and cough went away, but I never got well. It cost me my career as a law professor. Chronic Fatigue Syndrome is such a poor choice of names for this syndrome (which appears to be 4-5 different conditions/illnesses that have yet to be divided into subsets by medical science although some dedicated doctors are working on it). One reason it’s a poor name is that people confuse it with the very “chronic fatigue” that you write about.

    Your post has provided me with a great way of showing others that they don’t have CFS; they’re just chronically fatigued because they ignore over and over their body’s need for a good night’s sleep!

    Thanks again.

    Toni: Thanks for your comment. You hit the critical difference exactly between chronic fatigue, which can, as you say, often be remedied by good sleep, and Chronic Fatigue Sydrome, which can’t.


  • I had serious sleep problems when younger, Alex, and the following routines were very helpful to me.

    Quietly relaxing in the latter part of the evening.

    Trying to put myself to sleep has the opposite effect. Instead of clamping the eyes tight fix them on an insignificant object.

    A change of scene and thoughts. This may seem very difficult but it can be helpful in salvaging a night’s sleep: get out of bed, have a wash, make a hot non-alcohol drink, and watch TV, read or do a crossword for awhile. Try to enjoy it and don’t rush back. Often in a half to one hour drowsiness comes, with the mind cleared of whatever was buzzing in there. An hour lost from bed could very well be followed with a short but restful 4-5 hours sleep.

    Alcohol may help you to relax and go to sleep, but it is only short term, and the net result is less and poor sleep overall.

    Grandpa Ken: Excellent suggestions, all.


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  • Hi, Alex,

    Very useful information! I suppose there is more to the saying, “I need my beauty sleep”…with a restful sleep, people become more beautiful inside and out.

  • My three adult children take very strong prescription sleeping pills. I keep telling them that this is not good for their brains. Is there an article you can recommend that I supports my theory?

    Nina: Actually, there aren’t many long-term studies on the effects of sleeping pills to argue for or against your theory. I will tell you that several of my patients who suffer from primary insomnia have been taking them for years without any apparent adverse side effects (though take that with a small grain of salt as this is anecdotal only). I do think sleeping pills are terribly over-prescribed, but in certain people they can be extremely helpful.


  • I am 78, and have had trouble with sleeping for 4 years.

    I take ambien every night and am worried that I’m addicted. My doctor says it is not an addictive drug, but is not seemingly concerned about my “habit.” I know I can be psychologically addicted to ambien, but I don’t know what I can do about it. I have tried twice to just let it be, stay awake all night for a couple of nights and see if then I can sleep. It doesn’t happen. I take ambien and feel ok the next day.

    I know you don’t prescribe, but I wonder if there are any suggestions that might be made to help this problem. I really think it is not healthy to take a drug every night. I suspect there are others out there who have the same problem but I don’t know them.

    Donna: In fact, as I noted in response to another comment, there aren’t many long-term studies to suggest whether people suffer adverse effects from taking drugs like ambien long term. Anecdotally, it doesn’t seem to be a problem. I would say, though, that if you aren’t escalating the dose (needing to or wanting to), getting high off of it, or getting anything else besides a good night sleep, that you probably wouldn’t be considered truly addicted. In the right patients, sleeping pills can be a boon, providing restful sleep to people who really struggle to get it. On the other hand, several studies have suggested they’re no more effective than good sleep hygiene techniques. Despite that, I will say I have numerous patients who’ve done everything they can in good faith to improve their sleep but seem only to be able to get a good night’s rest with a medication.

    If you want to try to sleep without ambien after having been on it for years, you may need to taper it slowly as some of the difficulty you have in sleeping without it may be due to minor withdrawal. If you want to attempt that, I’d recommend only doing so under the supervision of your doctor.

    I also wonder what, if anything, happened four years ago to kick off your insomnia.


  • Thank you. I love this web site. So glad I stumbled on it. Whether or not I find it easy to get to sleep or whether I stay awake tonight, I will be taking all these ideas into account and try to assess what I can do to enhance sleep. Since it is an ongoing problem (four years now), I don’t count on instant success. However, I wonder if with age there is a (maybe genetic) problem with sleeping. Many oldsters complain of that. I don’t feel like an oldster though. I look and act less so, I’m told.

    True? Or pandering?

    Donna: Many older people do have trouble sleeping for a variety of reasons, unfortunately. Doesn’t make you an oldster, though! Glad you’re enjoying the site.


  • Is it possible for people who need 9 to 10 hours of sleep to adjust the body to require less? It is just such a waste of time! I’m not talking about 6 hours, going down to the average 8 would be enough. Can it be done without health consequences?

    Maria: Tough call. Probably pretty hard to readjust the amount of sleep your body tells you that you require. Experience is the best teacher. If you consistently get only 8 hours and feel fatigued, your body is telling you its set point is higher and there’s probably not much you can do about it.


  • Reading your blog has become my Monday ritual. I learn something each time. It is a new perspective as well as some good suggestions. Thank you.

    Anne: Glad you’re enjoying it!


  • I would hazard a guess that there is a genetically predetermined set point for sleep time required for optimal function, much as a set point for weight per individual. You get what you get. It may not be what you want, or what fits in with your chosen schedule.

    I manage two chronic autoimmune diseases; fatigue and night sweats are daily (nightly?) features. Fatigue is poorly understood as a symptom. Most people can relate to feeling tired, but do not have a frame of reference for this being a backdrop to daily living.

  • I don’t have trouble—usually—falling asleep, but I ALWAYS wake up frequently during the night. I usually don’t have trouble falling back to sleep, but I’ve always been worried about the way I don’t sleep through the night. I don’t feel fatigued, but it’s hard to tell sometimes, as I’ve been maintaining an 80 pound weight loss for over 20 years, and since I’m always exercising and maintaining a low-cal diet—sometimes I am fatigued. And, yes, I do feel I have chronic depression—it comes and goes. Any thoughts? Thank you!

    Debbie: Classically, depression causes early morning awakenings, so if depression is your dominant problem, the awakenings may be occurring as a result. I would recommend you consult with your physician if you haven’t already.


  • I have found the best way to fall asleep is to listen to Clear Channel. They have a talk show host on l0 to 2 every evening that is so boring you’ll be asleep in five minutes!

    Try it…it is better than any sleeping pill! BK

  • This is indeed an important problem and your observations are correct; however, I believe you have omitted a more troubling motivation for this behavior. It is a solipsistic notion of dominance over the natural world, which even extends to the limitations of our physical selves.

    Many humans, particularly in the west, act as though they are exempt from such mundane considerations as getting enough sleep, and from the consequences of ignoring them, presumably by virtue of their evolutionary superiority.

    This is not only foolish and irresponsible, but also dangerous, and not just for themselves. As you probably know, each year in the US alone, the cost of fatigue-related illness, errors and lost productivity runs into the tens of billions. I remember reading that three of the worst industrial accidents of the 20th century: the cyanide release in Bhopal, India, the reactor explosion in Chernobyl and the incident at Three Mile Island in Pennsylvania, all were caused by the mistakes of sleep-deprived operators in the middle of the night.

    What we need are more Buddhist Physicians teaching us to forsake hubris and arrogance and live in harmony with our bodies and the universe. Keep up the good work!

  • Absolute quiet for sleeping is a rarity in today’s civilization. I have had the good fortune to live where it is really quiet—how refreshing and peaceful it was. Now I live in an apartment which is not too bad, as apartments go, but noise and interruptions at night are inevitable.

    I don’t know how people stand it who live in really noisy places—I mean more the residence itself than traffic noise which you can train yourself to see as waves on the beach. Wild animals need a certain amount of space to thrive—I think humans are not that different—have you ever seen a cougar or wolf in a cage that is too small?

  • I guess I stumbled on paradoxical intention on my own (after years of performance anxiety). When I wake during the night, I just tell myself, “That’s all right. It’s just a pleasure to lie in my warm comfortable bed and rest. I’ll feel fine tomorrow even if I don’t fall back asleep.” As Grandpa Ken says, it is very important not to clamp the eyes shut; I try to keep them open. Or, if when I wake up I can tell it is not the middle of the night but fairly close to the time for the alarm, I resist looking at the time and say, “Outstanding! That last hour of sleep is the BEST.”

  • Good post! I think it is important to know how much sleep your body needs. For years I thought I couldn’t do without at least 8 1/2 hours of sleep. Recently I wrote a post about an experiment I did where I would go to bed at 8:30 and wake up at 3 a.m. At 3 I would write, do some work, and pray and meditate.

    So it was only 6 1/2 hours of sleep but I felt great! Now I wake up at 3 a.m. 4 or 5 time a week.

  • Nice blog. It’s true, lack of sleep is what lies behind most chronic conditions. Americans need to slow down, not only so they can allow themselves more time for sleep, but so their body isn’t wound up with stress when they actually do hit the pillow, making a good night’s rest difficult.

    FoodFitnessFreshair: I agree with your last statement but (as much as I believe in the importance of sleep) not with your first, that lack of sleep lies behind most chronic conditions. It can certainly make the experience of many of them worse, but to ascribe lack of sleep as the true cause of the plethora of chronic conditions to which human beings are subject is probably overstating the case.


  • Funny, I chronically wake up after 6 hours of sleep, then go back to bed thinking it is not enough. Will try spending the extra 2 hours reading/meditating to see if there is a change in my performance, as I wonder if too much sleep also causes negative effects. 😉

  • I think most people in the U.S. are sleep deprived (probably the world). People just don’t focus enough on the amount of, and quality of sleep. I recently started to go to bed earlier and I invested in a posturepedic bed. I actually feel a lot more energetic and healthy now.

  • Thanks, Alex. I have never even been tempted to increase the dosage so I guess I’m doing ok. But it was reassuring to receive your comment.

  • After many nights of insomnia I recognized that working with anything mathematical close to bed time apparently was too much mental stimulation for my brain to be able to “wind down.” This also included looking at my digital clock radio and mentally registering the numbers.

    I sleep much sounder when I do not pay bills before bed, and when I block the viewing window on the illuminated clock face. Another great sleep aid is to keep a stack of boring reading material on the bedside table! I have a copy of Patterson’s The Jester that I’m now into my 9th year of trying to get past the fourth chapter!

  • What are you thoughts on the enforced sleep deprivation of med students and especially residents? I know that that the maximum shift lengths are steadily going down, but even 24 hours without sleep seems like a lot! I’m quite afraid that I will seriously hurt someone at the end of a shift, since I’ve always been someone that needs at least 6 hours of sleep a night to function.

    Med Student: Twenty-four hours without sleep is a lot. Yet I found that if I was busy the entire time, I didn’t feel the fatigue until the next day. The key for me was making up the lost sleep on my post-post call day. I’d often come home at 5 pm, eat a sandwich, and fall into bed. That way, on the day after my post call day, I was refreshed.


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