Biological Systems Influenced by Biological Systems Influenced by Psychological Stress: SleepPsychological Stress: Sleep

Martica Hall, Ph.D.Martica Hall, Ph.D.For the PMBC-II Sleep Assessment & Resources CoreFor the PMBC-II Sleep Assessment & Resources CorePittsburgh Mind-Body Center Summer InstitutePittsburgh Mind-Body Center Summer Institute

Pittsburgh, PAPittsburgh, PA

June 5, 2008June 5, 2008

Outline for today’s Outline for today’s presentationpresentation

What is it? What is it?

How is it measured? How is it measured?

What affects it?What affects it?

Is sleep related to psychological stress?Is sleep related to psychological stress?– Classic StudiesClassic Studies– Research Program on Heart Rate Variability During SleepResearch Program on Heart Rate Variability During Sleep

EXTRA MATERIAL: Is sleep related to health?EXTRA MATERIAL: Is sleep related to health?

Where do we go from here?Where do we go from here?

Overview: Description of sleepOverview: Description of sleep

What is sleep?What is sleep? behavioral state of relative quiescencebehavioral state of relative quiescence reversible changes in consciousness and physiologyreversible changes in consciousness and physiology seen in all mammals seen in all mammals essential to health and functioningessential to health and functioning

What drives sleep? What drives sleep? prior wakefulnessprior wakefulness circadian rhythmscircadian rhythms Habit Habit CircumstanceCircumstance

Overview: Functions of sleepOverview: Functions of sleep

Ecological/ environmental advantageEcological/ environmental advantage Improves the quality of wakefulnessImproves the quality of wakefulness

– AlertnessAlertness

– MoodMood

– Cognitive (especially frontal lobe) functionsCognitive (especially frontal lobe) functions Integration of experience; learningIntegration of experience; learning Resensitization of receptors (e.g., norepinephrine, Resensitization of receptors (e.g., norepinephrine,

serotonin)serotonin) Metabolic, inflammatory effectsMetabolic, inflammatory effects LongevityLongevity

Assessment of sleep-wake statesAssessment of sleep-wake states

Self-report questionnairesSelf-report questionnaires Sleep-wake diariesSleep-wake diaries: Daily recording of sleep times and : Daily recording of sleep times and

characteristicscharacteristics Observer ratingsObserver ratings: Unreliable: Unreliable ActigraphyActigraphy: Motion-sensitive accelerometer worn on : Motion-sensitive accelerometer worn on

wristwrist PolysomnographyPolysomnography (PSG): Modification of (PSG): Modification of

electroencephalography (EEG)electroencephalography (EEG)– EEGEEG

– Eye movementsEye movements

– Muscle toneMuscle tone

ActigraphyActigraphy

Daytime Daytime activity peaksactivity peaks

Nighttime Nighttime inactivityinactivity

Actigraph Actigraph taken offtaken off

Polysomnography:Polysomnography: Relaxed wakefulness Relaxed wakefulness (Stage w)(Stage w)

C3-REF

C4-REF

O1-REF

O2-REF

LOC-REF

ROC-REF

EMG

A

REMs

PSG:PSG: Stage 1 sleepStage 1 sleep

A

B

CEMG

ROC-REF

LOC-REF

C3-REF

C4-REF

O1-REF

O2-REF

PSG:PSG: Stage 2 sleepStage 2 sleep

C3-REF

C4-REF

LOC-REF

O1-REF

02-REF

ROC-REF

EMG

S K

PSG:PSG: Stage 3 sleepStage 3 sleep

PSG:PSG: Stage 4 sleepStage 4 sleep

LOC-REF

C3-REF

C4-REF

O1-REF

O2-REF

ROC-REF

EMG

PSG:PSG: Rapid-eye-movement (REM) sleepRapid-eye-movement (REM) sleep

C3-REF

C4-REF

O1-REF

02-REF

LOC-REF

ROC-REF

EMG

Factors that affect sleepFactors that affect sleep

AgeAge– Increased wakefulness during sleep periodIncreased wakefulness during sleep period

– Decreased Stage 3/4 NREMDecreased Stage 3/4 NREM

– Earlier timingEarlier timing

– Greater daytime sleepinessGreater daytime sleepiness Sex (women have longer sleep, more Stage 3/4 Sex (women have longer sleep, more Stage 3/4

NREM)NREM) Timing: Sleep is best at night!Timing: Sleep is best at night! Illnesses, medicationsIllnesses, medications

Sleep in healthy young and older adultsSleep in healthy young and older adults

20 year old woman 71 year old woman

Sleep stages across the life spanSleep stages across the life spanOhayon et al., SLEEP 2004; 27: 1255-73Ohayon et al., SLEEP 2004; 27: 1255-73

Min

ute

s

Age (years)

Be mindful of Be mindful of circadian circadian rhythms!rhythms!

Examples of Examples of humanhumancircadian circadian rhythmsrhythmsCzeisler and Khalsa, 2000Czeisler and Khalsa, 2000

Core body temperature

Urine volume

Thyroid StimulatingHormone

Growth Hormone

Prolactin

Parathyroid Hormone

Motor activity

Cortisol

Time

Family Conflict in Childhood and Family Conflict in Childhood and Later InsomniaLater Insomnia Gregory et al., Gregory et al., SLEEPSLEEP, 2006, 2006

N = 1037, 52% maleN = 1037, 52% male

Dose-Response Relationship Between Dose-Response Relationship Between Chronicity of Family Conflict and Later Chronicity of Family Conflict and Later Insomnia Insomnia Gregory et al., Gregory et al., SLEEPSLEEP, 2006, 2006

Number of assessments at which family scores in top quartile for family conflictNumber of assessments at which family scores in top quartile for family conflict

Gene by Environment Interactions Reveal Vulnerability to Stress-Related Sleep Disturbances Brummet et al., Psychosomatic Medicine (2007)

Caregivers homozygous for the s allele had greater subjective sleep Complaints compared to all other groups (p < .01)

Perceived Discrimination as a Mediator ofthe Race-Sleep Relationship Thomas et al., Health Psychology (2006)

37 African Americans (mean age 36.08 + 1.36) percent Stage 4 1.34 + 0.4456 Caucasian Americans (mean age 35.57 + 0.96) percent Stage 4 3.89 + 0.51

Mid-life patients w/ insomnia and good sleeper controls, n=64)Mid-life patients w/ insomnia and good sleeper controls, n=64)Data = self-report daily diaries collected over 3 weeks. Stressors were naturally occurring events.Data = self-report daily diaries collected over 3 weeks. Stressors were naturally occurring events.

Prospective assessment of stress, coping, arousal and sleep Morin, Rodrigue & Ivers, Psychosomatic Medicine (2003)

Research Program on Heart Rate Research Program on Heart Rate Variability During SleepVariability During Sleep

How is it evaluated? How is it evaluated? Why is it important?Why is it important?Is it related to stress?Is it related to stress?

Heart Rate Heart Rate VariabilityVariability

Proximal Proximal Indices of HealthIndices of Health

Health OutcomesHealth Outcomes

Heart Rate Variability: Why is it important?Heart Rate Variability: Why is it important?

Heart Rate Heart Rate VariabilityVariability Proximal Proximal

Indices of HealthIndices of Health Health OutcomesHealth Outcomes

HRV HRV duringduringSleepSleep

Heart Rate Variability & Health: It’s not just a Heart Rate Variability & Health: It’s not just a waking phenomenonwaking phenomenon

Why am I interested in HRV during sleep?Why am I interested in HRV during sleep?

Fundamental beliefFundamental belief: Sleep is an essential restorative behavior that affects and : Sleep is an essential restorative behavior that affects and can be affected by stress and other negative affective states. These can be affected by stress and other negative affective states. These relationships are critical to health and functioning.relationships are critical to health and functioning.

Research programResearch program: Focuses on characterizing the bi-directional relationship : Focuses on characterizing the bi-directional relationship between stress and sleep and its impact on health and functioning.between stress and sleep and its impact on health and functioning.

Why HRV during sleepWhy HRV during sleep? Evaluation of HRV during sleep provides non-invasive, ? Evaluation of HRV during sleep provides non-invasive, continuous measure of autonomic nervous system regulation during sleep. continuous measure of autonomic nervous system regulation during sleep.

QEKG techniques allow us to parse signal into vagal and sympathovagal QEKG techniques allow us to parse signal into vagal and sympathovagal components.components.

These data allow us to test and refine hypotheses about the pathways linking These data allow us to test and refine hypotheses about the pathways linking stress, sleep and health.stress, sleep and health.

Psychological stress and related negative affective states have been associated with prolonged physiological arousal during sleep. Might they elicit changes in heart rate variability during sleep?

We evaluated this hypothesis in two studies using autoregressive spectral analysis of the EKG during NREM and REM sleep.

Study 1: Acute Laboratory stress in 64 healthy undergraduates.

Study 2: Stress-related coping behaviors in patients with insomnia.

Whether these relationships generalize to older adults and across racial/ethnic groups is not known.

Initial foray into evaluating HRV during sleepInitial foray into evaluating HRV during sleep

SleepSCORE SleepSCORE SWAN Sleep StudySWAN Sleep StudyNeurobiology of InsomniaNeurobiology of Insomnia Sleep in Renal DiseaseSleep in Renal DiseaseTreatment of Sleep Disorders in PTSDTreatment of Sleep Disorders in PTSD Sleep Apnea and the Metabolic SyndromeSleep Apnea and the Metabolic SyndromeDepression in CHF PatientsDepression in CHF Patients Sleep Deprivation and StressSleep Deprivation and StressSleep and HRV in Premature InfantsSleep and HRV in Premature Infants Brain Metabolism during SleepBrain Metabolism during Sleep

Assessment of HRV during sleepAssessment of HRV during sleepusing MindWareusing MindWare

Study SampleStudy Sample

Participants were recruited from the Heart Strategies Concentrating Participants were recruited from the Heart Strategies Concentrating on Risk Evaluation (HeartSCORE) community study of population on Risk Evaluation (HeartSCORE) community study of population disparities in cardiovascular risk. disparities in cardiovascular risk.

HeartSCORE eligibility criteria were: age 45 – 75 years, resident of HeartSCORE eligibility criteria were: age 45 – 75 years, resident of the greater Pittsburgh metropolitan area and absence of comorbid the greater Pittsburgh metropolitan area and absence of comorbid conditions expected to limit life expectancy to < 5 years. conditions expected to limit life expectancy to < 5 years.

The SleepSCORE study included a sub-sample of HeartSCORE The SleepSCORE study included a sub-sample of HeartSCORE participants, stratified by gender, race and Framingham Risk.participants, stratified by gender, race and Framingham Risk.

SleepSCORE exclusion criteria were pregnancy, current treatment SleepSCORE exclusion criteria were pregnancy, current treatment of sleep apnea, regular use of sleep medications, nighttime shift of sleep apnea, regular use of sleep medications, nighttime shift work, medication for diabetes, or prior diagnosis of CVD events or work, medication for diabetes, or prior diagnosis of CVD events or interventional cardiology procedures. interventional cardiology procedures.

Participant CharacteristicsParticipant Characteristics

PercentPercent Mean (s.d.)Mean (s.d.)MalesMales 54%54%

African AmericanAfrican American 42%42%

BMIBMI 29.6 (4.9)29.6 (4.9)

Income (below $40,000)Income (below $40,000) 46%46%

Education (no college degree)Education (no college degree) 50%50%

Smoke (current)Smoke (current) 7% 7%

Perceived Stress (PSS)Perceived Stress (PSS) 4.1 (2.6)4.1 (2.6)

Symptoms of Depression (CES-D)Symptoms of Depression (CES-D) 7.5 (7.6)7.5 (7.6)

Symptoms of Anxiety (STAI)Symptoms of Anxiety (STAI) 6.3 (5.4)6.3 (5.4)

Hostility (CM-Ho)Hostility (CM-Ho) 1.5 (1.4)1.5 (1.4)

Sleep CharacteristicsSleep Characteristics

Mean (s.d.)Mean (s.d.)

Sleep Quality (PSQI)Sleep Quality (PSQI) 6.3 (3.1) 6.3 (3.1)

Time Spent Asleep (mins.)Time Spent Asleep (mins.) 361.0 (66.9)361.0 (66.9)

Sleep Efficiency (percent)Sleep Efficiency (percent) 77.0 (11.1) 77.0 (11.1)

NREM Stage 1 (percent)NREM Stage 1 (percent) 9.2 (5.9) 9.2 (5.9)

NREM Stage 2 (percent)NREM Stage 2 (percent) 61.4 (9.2) 61.4 (9.2)

NREM Stage 3+4 (percent)NREM Stage 3+4 (percent) 6.5 (7.3) 6.5 (7.3)

REM Sleep (percent)REM Sleep (percent) 22.8 (6.0) 22.8 (6.0)

AHIAHI 4.6 (17.5) 4.6 (17.5)

NREM differs from Wakefulness & REMNREM differs from Wakefulness & REM

HF PowerHF Power LF:HFLF:HF

Brachial artery diameter is a significant correlate Brachial artery diameter is a significant correlate of LF:HF HRV during NREM sleepof LF:HF HRV during NREM sleep

r = 0.25, p < .01r = 0.25, p < .01

NREM Period

1 2 3 4

Lo

g(L

F:H

F)

0.4

0.6

0.8

1.0

1.2

1.4

NREM Period

1 2 3 4

Lo

g(L

F:H

F)

0.4

0.6

0.8

1.0

1.2

1.4

Brachial artery diameter is a significant correlate Brachial artery diameter is a significant correlate of LF:HF HRV throughout NREM sleepof LF:HF HRV throughout NREM sleep

BAD > 3.7BAD > 3.7 BAD BAD << 3.7 3.7

HEALTH SLEEPSLEEP

Sleep Restriction/DeprivationSleep Restriction/DeprivationSleep DurationSleep DurationSleep ContinuitySleep ContinuitySleep ArchitectureSleep ArchitectureSleep/Wake RhythmsSleep/Wake RhythmsSleep DisordersSleep Disorders

Extra MaterialExtra MaterialMind-Body Sleep Research: Bridging the Gap Mind-Body Sleep Research: Bridging the Gap Between Behavioral Medicine and Sleep MedicineBetween Behavioral Medicine and Sleep Medicine

Sleep Restriction: Sleep Restriction: Sleepiness & PerformanceSleepiness & Performance(n= 16, sleep restriction to 33% below habitual sleep duration)(n= 16, sleep restriction to 33% below habitual sleep duration)

Dinges et al., SLEEP. 20:267-77 (1997).

Sleep deprivation effects on cognitive Sleep deprivation effects on cognitive function function Drummond et al., Drummond et al., NeuroreportNeuroreport, 1999, 1999

Normal sleep – Activation of PFC, parietal, pre-motor cortex

Following sleep deprivation – Decreased activation

fMRI during serial subtraction task

Sleep Restriction & Glucose Sleep Restriction & Glucose MetabolismMetabolismSleep Restriction & Glucose Sleep Restriction & Glucose MetabolismMetabolism

Glucose Glucose EffectivenessEffectiveness30 – 40% decrease30 – 40% decrease

Sympathovagal Sympathovagal BalanceBalance(trend) increase(trend) increase

Spiegel et al., Spiegel et al., LancetLancet, , 354:1435-9 (1999).354:1435-9 (1999).

Ghrelin : Leptin Ghrelin : Leptin 70% increase70% increase

Carbohydrate Carbohydrate CravingCraving30% Increase30% Increase

Spiegel et al., Spiegel et al., Ann Ann Intern. MedIntern. Med, 141:846-, 141:846-50 (2004).50 (2004).

GLUCOSGLUCOSEE(mg/dL)(mg/dL)

LEPTINLEPTIN(ng/ml)(ng/ml)

Sleep Duration and Mortality -- one example:Sleep Duration and Mortality -- one example:Kripke et al., 2003, Kripke et al., 2003, Arch Gen PsychiatryArch Gen Psychiatry, 59:131-136., 59:131-136.

Sleep Duration and Cardiovascular Disease Sleep Duration and Cardiovascular Disease (CVD)(CVD)Ayas et al., Ayas et al., Arch Intern MedArch Intern Med, 163:205-209, 2003., 163:205-209, 2003.Heslop et al., Heslop et al., Sleep MedicineSleep Medicine, 3:305-314, 2002., 3:305-314, 2002.Qureshi et al., Qureshi et al., NeurologyNeurology, 48:904-11, 1997., 48:904-11, 1997.

<<55 66 77 88 >>99RRRR RRRR RRRR RRRR

Total CHDTotal CHD 1.391.39 1.181.18 1.101.10 ---- 1.381.38Nonfatal MINonfatal MI 1.521.52 1.321.32 1.231.23 ---- 1.351.35Fatal CHDFatal CHD 1.121.12 0.910.91 0.830.83 ---- 1.451.45

Sleep Duration and HealthSleep Duration and HealthSleep Duration and HealthSleep Duration and Health

3.03.02.752.752.52.52.252.252.02.01.751.751.51.51.251.251.01.00.750.750.50.5

< 6< 6 6 7 8 >86 7 8 >8

Mo

rtal

ity

Haz

ard

s R

atio

Mo

rtal

ity

Haz

ard

s R

atio

Sleep Duration, Compared to Reference of 7 HoursSleep Duration, Compared to Reference of 7 Hours

CrudeAdjusted 1Adjusted 2

Markers of Inflammation Attenuate the Markers of Inflammation Attenuate the Relationship Between Short Sleep and Relationship Between Short Sleep and Mortality: The Health ABC Study of Older AdultsMortality: The Health ABC Study of Older Adults

Markers of Inflammation Attenuate the Markers of Inflammation Attenuate the Relationship Between Short Sleep and Relationship Between Short Sleep and Mortality: The Health ABC Study of Older AdultsMortality: The Health ABC Study of Older Adults

Hall, Newman et al. (under review)Hall, Newman et al. (under review)

Sleep Continuity: Survival as a Function of PSG-Assessed Sleep LatencyDew et al., Psychosomatic Medicine (2003)

Latency, < 30 min.

Latency, > 30 min.

0 100 200 300 400 500 600 700 800 900 1000

Weeks

1.0

0.8

0.6

0.4

0.2

0.0

Cum

ulat

ive

Sur

viva

l

Log rank test = 9.63

p = .002

Sleep Duration & the Metabolic SyndromeSleep Duration & the Metabolic SyndromeHall et al., SLEEP (2008)Hall et al., SLEEP (2008)

Sleep Duration & the Metabolic SyndromeSleep Duration & the Metabolic SyndromeHall et al., SLEEP (2008)Hall et al., SLEEP (2008)

AimAim To evaluate the relationship between reported To evaluate the relationship between reported habitual sleep duration and the metabolic syndrome in a habitual sleep duration and the metabolic syndrome in a community sample of healthy men and women.community sample of healthy men and women.

HypothesisHypothesisShort sleep duration is associated with an increased risk Short sleep duration is associated with an increased risk of having the metabolic syndrome after adjusting for of having the metabolic syndrome after adjusting for age, sex, race, and symptoms of depression.age, sex, race, and symptoms of depression.

StudyStudy: Adult & Human Behavior Project (AHAB; HL-: Adult & Human Behavior Project (AHAB; HL-04962)04962)Exclusions: clinical history of atherosclerotic disease; Exclusions: clinical history of atherosclerotic disease; cancer diagnosis or treatment w/in the past year; cancer diagnosis or treatment w/in the past year; chronic liver or kidney disease; use of insulin, weight chronic liver or kidney disease; use of insulin, weight loss or psychotropic medications.loss or psychotropic medications.

Reported Habitual Sleep Duration (hrs/night)Reported Habitual Sleep Duration (hrs/night)Reported Habitual Sleep Duration (hrs/night)Reported Habitual Sleep Duration (hrs/night)600600

500500

400400

300300

200200

100100

00

< 6 6 to < 7 7 to 8 >8 to < 9 < 6 6 to < 7 7 to 8 >8 to < 9 >> 9 9

nu

mb

er

nu

mb

er

Metabolic Syndrome and its NCEP-Defined Metabolic Syndrome and its NCEP-Defined ComponentsComponentsMetabolic Syndrome and its NCEP-Defined Metabolic Syndrome and its NCEP-Defined ComponentsComponents

< 6 6 to <7 7 to 8 >8< 6 6 to <7 7 to 8 >8n = 187n = 187 n = 402 n = 525 n = 100 n = 402 n = 525 n = 100

Metabolic SyndromeMetabolic Syndrome 1.591.59 1.34 1.34 ref ref 1.691.69 (1.1 – 2.4)(1.1 – 2.4) (.99 – 1.9) (.99 – 1.9) (1.00 – 2.9)(1.00 – 2.9)

Abdominal ObesityAbdominal Obesity 1.551.55 1.48 1.48 ref 1.51 ref 1.51 (1.1 – 2.2) (1.1 – 2.0)(1.1 – 2.2) (1.1 – 2.0) (.96 – 2.4) (.96 – 2.4)

GlucoseGlucose 1.621.62 1.13 1.13 ref ref 1.681.68 (1.1 – 2.4)(1.1 – 2.4) (.83 – 1.5) (.83 – 1.5) (1.04 – 2.7)(1.04 – 2.7)

Blood PressureBlood Pressure 1.07 1.07 .94 .94 ref .98 ref .98 (.73 – 1.6) (.70 – 1.3)(.73 – 1.6) (.70 – 1.3) (.6 – 1.6) (.6 – 1.6)

TriglyceridesTriglycerides 1.21 1.21 1.42 1.42 ref .92 ref .92 (.80 – 1.8) (.80 – 1.8) (1.03 – 2.0)(1.03 – 2.0) (.51 – 1.7) (.51 – 1.7)

High DensityHigh Density 1.24 1.24 1.15 ref 1.52 1.15 ref 1.52 LipoproteinsLipoproteins (.86 – 1.8) (.85 – 1.5) (.86 – 1.8) (.85 – 1.5) (.98 – 2.4) (.98 – 2.4)

DAY 1 DAY 1 DAY 4 DAY 4

DAILY: Fill out Sleep Diary and Wear Wrist ActigraphDAILY: Fill out Sleep Diary and Wear Wrist Actigraph(LENGTH OF STUDY: 1 menstrual cycle or 35 days)(LENGTH OF STUDY: 1 menstrual cycle or 35 days)

DAY 14DAY 14 FINAL FINAL STUDY STUDY

DAYDAY

PSG Sleep PSG Sleep Study Study

(3 nights)(3 nights)

SWAN Sleep Study: ProtocolSWAN Sleep Study: Protocol Hall et al. (under preparation)Hall et al. (under preparation)

SWAN Sleep Study: ProtocolSWAN Sleep Study: Protocol Hall et al. (under preparation)Hall et al. (under preparation)

Core SWAN Visit w/in 6 months pre- or post-sleep study:Core SWAN Visit w/in 6 months pre- or post-sleep study:Metabolic Syndrome determination by clinic blood pressure; Metabolic Syndrome determination by clinic blood pressure;

blood draw; waist measurement; height & weight. blood draw; waist measurement; height & weight.

Shiftwork and Ulcers Shiftwork and Ulcers Drake et al., Drake et al., SLEEP (SLEEP (2004)2004)

20362036 174 174 360 360

N = 2,570N = 2,57018 – 6518 – 6552% Male52% Male

Insomnia Epidemiology Insomnia Epidemiology Ohayon, Ohayon, Sleep Med RevSleep Med Rev, 2002, 2002

Insomnia symptoms + daytime consequences

9-15%

Insomnia symptoms-Overall prevalence 30-48%-Often or always: 16-21%-Moderate to extreme: 10-28%

Insomnia diagnosis

6%Direct economic costsDirect economic costsof insomnia in the US of insomnia in the US are estimated ~ $14 billionare estimated ~ $14 billion

Insomnia Is a Risk FactorInsomnia Is a Risk Factorfor Psychiatric Disordersfor Psychiatric Disorders

0

2

4

6

8

10

12

14

16

18

Depression* Anxiety* Alcohol Drug*

Inci

denc

e (%

) M

ore

Tha

n 3.

5 Y

ears

Insomnia (n = 240) No Insomnia (n = 739)

*95% CI for odds ratio excludes 1.0.Breslau N et al. Biol Psychiatry. 1996;39:411-418.

0

1

2

3

Relative Risk

Association of insomnia and CHD Association of insomnia and CHD events events Schwartz, Schwartz, J Psychosom ResJ Psychosom Res, 1999; 47:313-33, 1999; 47:313-33

Combined estimate

Individual studies

Meta-analysis of seven cohort and longitudinal studies

Sleep disorders are under-diagnosedSleep disorders are under-diagnosed

As many as 95% of people with a sleep problem remain As many as 95% of people with a sleep problem remain unidentified and undiagnosed unidentified and undiagnosed

Few health care providers question patients about sleepFew health care providers question patients about sleep

Little content in medical schoolsLittle content in medical schools

Essentially everything learned about sleep is in post-Essentially everything learned about sleep is in post-graduate courses (a booming academic business) graduate courses (a booming academic business)

Sleep Disorders are CostlySleep Disorders are Costly

Possibly 100,000 motor vehicle accidents annually Possibly 100,000 motor vehicle accidents annually are sleep-related.are sleep-related.

The annual direct cost estimate of sleep-related The annual direct cost estimate of sleep-related problems is problems is $16 billion$16 billion, with an additional , with an additional $50-$100 $50-$100 billionbillion in indirect costs: in indirect costs:– AccidentsAccidents– LitigationLitigation– Property destruction Property destruction – Hospitalization Hospitalization – DeathDeath

Sleep disorders medicine and mind-body Sleep disorders medicine and mind-body interactionsinteractions

Sleep medicine is in its adolescence as a fieldSleep medicine is in its adolescence as a field

Understanding mind-body interactions with respect to sleep is in Understanding mind-body interactions with respect to sleep is in its infancyits infancy

Fundamental processes relating sleep as a mediator of M-B Fundamental processes relating sleep as a mediator of M-B processes is very much neededprocesses is very much needed