Dreamland

Adventures in the Strange Science of Sleep

By David K. Randall

W.W. Norton. 304 pp. $25.95

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Reviewed by Lawrence W. Brown


Communicating science to the nonprofessional audience without losing its meaning is an art rarely achieved. Most scientists do not have the literary skills and most journalists miss the fine points that distinguish true advances from the cure of the day.

Let's hear it for sleepwalking journalist David Randall; not all patients are so determined to study their disorder or so successful in making accessible the one-third of our lives that we spend in what he calls Dreamland.

"If my doctor couldn't tell me more about sleep, I reasoned, then I would go out and search for the solutions myself," Randall writes. His research led him to some of the leading clinical and basic investigators in the field of sleep disorders, and he has an uncanny ability to find the personal story or the apt historical anecdote to enliven the science.

It is almost impossible to imagine life without artificial light, TV, computers, and all the other conveniences we have come to expect. But mankind has only been living with universal electricity for little more than a century. And in that time we have learned to defy the natural order of light and dark.

Teenagers are sleeping on average 1.5 hours less than they did at the turn of the last century, people are shopping and banking in the wee hours of the morning, and we are becoming an increasingly obese and sedentary nation, with the result of an epidemic of sleep apnea.

While many of us are willing to sacrifice sleep as a cost of our busy schedules and the competition with more interesting or exciting alternatives, Randall describes how sleep deprivation can lead to increased absenteeism and lower grades in high school, military disasters from Guadalcanal to the Gulf War, and industrial accidents such as an oil refinery fire in Texas that caused 15 deaths and 170 injuries. He reports the startling fact that one in five accidents involving a commercial truck is caused by the driver falling asleep at the wheel.

Dreamland may highlight a few Ripley Believe-It-Or-Not issues, but it mostly sticks to the science and uses the oddities to make points rather than to revel in sensationalism. Randall reviews the controversy over the sleep version of the Twinkie defense, describing the case of an admitted Canadian murderer found not guilty by virtue of a new legal category, "non-insane automatism." While clearly there are many cases of sleepwalking, it is hard to imagine a confusional arousal in which one kills a person, stuffs the body in a trunk, and then drives miles to bury the evidence - all while asleep.

There are other fascinating insights into the world of sleep. Imagine Las Vegas bookmakers taking into account a West Coast home team's biologic clock advantage when hosting an East Coast opponent for Monday Night Football. It turns out that jet lag can also affect elite athletes late at night when they push their bodies beyond the natural performance peaks of their body rhythms. A related example (missed by the author) is the well-documented spike in auto accidents on the days after we "spring ahead" for daylight savings time, since sleep deprivation is so widespread and so severe that even one more hour of sleep loss can make a difference.

Randall has studied the field, and he highlights many of the leading figures in sleep research, while making their investigations both relevant and compelling. When a toddler resists sleep, is it better to "Ferberize" him and let him cry it out, or is attachment parenting a healthier alternative? Should babies have their own room or is co-sleeping in the family bed a healthier alternative? Philadelphia's own Jodi Mindell (my colleague at the Children's Hospital of Philadelphia's Sleep Disorders Center) provides some answers in the book. She has surveyed sleep approaches throughout the world and concluded that for most children, any consistent routine will work, but there are biological differences in some that require individualized approaches.

Sleep medicine is a young discipline - rapid eye movement sleep was first recognized in the 1950s, and it was not until the development of effective treatments for obstructive sleep apnea that interest really exploded. At this point, there are sleep laboratories opening daily, and both clinical and basic research is expanding at a rapid pace. So it is not surprising that the author has provided only a sampling of the highlights. Randall includes little discussion of sleep in other species or how understanding the genome of the fruit fly can provide insight into humans. There is nothing on how premature infants, who spend the majority of time asleep in the state associated with dreaming, become toddlers with sleep architecture approaching adult organization.

Nor is there anything on why our natural daily cycle is longer than 24 hours (at least until old age, when it shortens significantly, thus possibly explaining the allure of the early bird special). Randall does not explain the universality of a biological clock in the animal kingdom, nor why congenitally blind children or adults in an environment without outside cues (like cave dwellers or astronauts) can disconnect their body rhythms from the 24-hour clock, thus turning night into day. There is a discussion of the challenges of REM behavior disorder that allows individuals to literally act out their dreams, to the unfortunate detriment of their spouses, but nothing about the relationship to degenerative disorders including Parkinson's disease.

Perhaps we all need a good night's sleep as we wait for Dreamland: The Sequel.

Lawrence W. Brown, M.D., is associate professor of neurology and pediatrics and codirector of the pediatric neuropsychiatry program at Children's Hospital of Philadelphia.