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UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Raynaud’s and Sleep Apnea

There was an interesting Q&A article on Raynaud's in the New York Times. This is what I responded with:

 

Notice how almost everyone one of you with Raynaud's can't (or prefer not to) sleep on your back. The reason for this is that due to smaller jaw structures and narrowing of your upper airway, you literally can't breathe properly when you sleep. When normally on your back, your tongue fall back partially due to gravity. But if you have a smaller mouth, the tongue takes up relatively more space and falls back a bit more completely. This becomes a problem when when you're in deep sleep, since all your muscles (including your throat muscles) begin to relax. In this situation, you'll stop breathing and wake up to turn over to your side or stomach. This is something that began when you were a child, and most people compensate by normally sleeping only on their sides or stomach. 

Problems occur when you're suddenly forced to sleep on your back, such as from an injury or after undergoing an operation

Despite being able to compensate by avoiding the back position, it's usually not good enough. By definition, you won't be able to achieve deep, efficient sleep, which causes a low-grade physiologic stress response. This activates the sympathetic (fight or flight) nervous system which tends to constrict blood flow and nervous innervation to low-priority organs and body parts, such as your hands, feet, skin, digestive and reproductive organs. This is also why Raynaud's is also associated with autoimmune conditions.

Chronic low-grade physiologic stress over-activates your immune system, resulting in your body attacking its' own tissues. Not only is your immune system over-reactive, but your nervous system is also overly activated, leading you to be en garde, edgy, and hypersensitive in general. These symptoms are seen often in people with upper airway resistance syndrome.

Inefficient sleep leads to chronic fatigue issues. But most people compensate by staying active during the day, or participating regularly in intense physical activity.

Typically, most people with Raynaud's improve as they get older. But as you gain weight, many of you will begin to develop obstructive sleep apnea. Notice how one or both of your parents may snore heavily and have have cardiovascular disease. If you don't gain weight, then your Raynaud's may last longer. 

This is also why anything that helps to calm your nervous system (meditation, yoga, acupuncture, biofeedback, etc.) can help your symptoms. It also explains why when the breathing problem is taken care of definitively, Raynaud's symptoms can improve.

My Magic Sleep Sofa-Pillow

Due to various reasons (my father visiting, and my 1 year old son sleeping in a Pack-And-Play crib in the living room), I ended up sleeping on our old leather sofa the other night. Although I only slept for 5 hours, I woke up much more refreshed than my usual night's sleep. I do remember that I had a similar experience a few months ago when I had a bad cold with severe cough, and I  felt better sleeping on the same sofa. Now I realize that it wasn't a coincidence. The curvature of the armrest is a low gentle slope, with my feet resting on the other side's armrest (preventing me from sliding down). 

What I realized was that due to the armrest lifting up my upper back/shoulders and tilting back my head slightly, my airway must have opened up. This is a normal situation for almost everyone. Whenever you tilt your head forward slightly, the space behind your tongue narrows, whereas tilting the head back opens the airway. This is also why in many cases, "Contour" pillows have this same effect: By lifting up your neck and cocking your head back slightly, you're opening up your airway. Most contour pillows, however, don't function the way they're meant to work, since as you slide down, the the lower part of the pillow that's raised ends up tilting your head slightly forward. 

As a result of this experience, since I like to sleep on my back, I added a bit of support using a rolled up towel, just below my Contour Pillow, slightly lifting up my shoulders. Not too surprisingly, I did seem to sleep better. Next, I'm going to add one more thing: Breathe Right strips. By artificially opening up my nasal passageways by using these nasal dilator strips, perhaps I can finally sleep more deeply and wake up much more refreshed in the morning.

Does sleeping in strange environment or bed make you sleep better or much worse than your normal nights' sleep? Please enter your answers in the comments box below.

Hair Loss and Sleep Apnea?

This is what I posted to the NY Times Blog for an article on hair loss in women:

 

Hair loss in women is a serious condition with lots of conventional explanations. One area that's never mentioned is the connection to poor sleep quality, especially due to breathing problems at night. A significant percentage of men and women have undiagnosed sleep-breathing problems, with the end extreme being called obstructive sleep apnea. 

 

It's estimated that about 1/4 of all men and 1/10 of all women have at lease mild sleep apnea, and 90% are not diagnosed. However, there's a variation of sleep apnea called upper airway resistance syndrome (UARS), where you'll stop breathing while sleeping, but not long enough to be called obstructive sleep apnea. 

 

Typically these people (more typically thin women) will have colds hands or feet, prefer not to sleep on their backs, feel tired all the time, no matter how long they sleep, and will usually have at least one parent that snores heavily.

 

These multiple arousals lead to a chronic low-grade physiologic stress response which heightens the nervous system (and immune system). During times of stress, blood is shunted away from low-priority organs like the GI  system, reproductive organs, the distant extremities and the skin. Chronic lack of blood flow can lead to a number detrimental effects, including hair loss.

 

It's also been shown that chronic physiologic stress also raises your cortisol levels, lowers your thyroid levels, and alters your estrogen/progesterone/testosterone balance. 

 

There are also anecdotal reports of people who report hair regrowth after starting sleep apnea treatment.

 

If you have any of the symptoms mentioned above, you should get checked for UARS. In many cases, UARS progresses into obstructive sleep apnea, especially after menopause. Even if it doesn't help your hair loss, being diagnosed may prevent complications of sleep apnea, including hypertension, diabetes, weight gain, anxiety, depression, and heart disease.

A Link Between Endometriosis and Sleep Apnea?

Endometriosis is a common condition that's estimated to occur in about 5 to 10% of all women. It's characterized by pelvic and abdominal pain, along with infertility, and not too surprisingly, hypothyroidism, chronic fatigue syndrome, fibromyalgia, autoimmune conditions, allergies and asthma. 

 

Does this list sound familiar? Right — upper airway resistance syndrome (UARS). Doing some more research, I came across a health-related website (CureTogether.com, an open source health research site) that anonymously aggregates patients' symptoms and and other conditions to give you statistical data. Here are the top symptoms and the top associated conditions for endometriosis.

 

If you look down the list of associated conditions, many are also seen in patients with UARS. Since endometriosis is more commonly seen in women during the reproductive years, you may not see obstructive sleep apnea as often. I'm willing to bet that many of these women will go on to develop obstructive sleep apnea, especially when much older and if they gain weight after menopause. If you look at their parents, one or both parents will snore heavily. In addition, Raynaud's (cold hands for feet) is also a common feature in both endometriosis and UARS.

 

Knowing that upper airway resistance syndrome can cause profound changes in women's physiology, all these findings are not surprising.

 

Do you or anyone you know have endometriosis? If so, how many of the above symptoms or conditions do you see? Please enter your observations in the comments box below.

Sleep Apnea and Breast Cancer: Is There A Connection?

There’s been a lot of press coverage recently about the new mammography screening recommendations for breast cancer. The United States Preventive Service Task Force recently recommended that women begin routine mammography screening at age 50, rather than 40. This is an important issue for me as my aunt died from metastatic breast cancer in her early 40s. 

 

One thing that I see over and over again is how obstructive sleep apnea can affect every aspect of your health, from your mood, to diabetes, to heart disease. You may think that cancer and sleep apnea are totally separate conditions, but with the human body, everything is ultimately connected in one way or another. This lead me ask the question: Do sleep apnea and cancer have a common origin?

 

In my practice, anytime I see a patient with a history of breast cancer, I almost consistently see the following: cold hands or feet, unrefreshing sleep, an inability to sleep on their backs, and a severely snoring parent, typically with cardiovascular disease. What’s remarkable is that when I examine their airways with a fiberoptic camera, the space behind the tongue is usually very narrow, especially when they lie flat on their backs. This anatomy leads to repeated obstructions and arousals, especially when sleeping on their backs and in deep sleep, when muscles relax the most. For this reason, these women prefer not to sleep on their backs.

 

In my book, Sleep, Interrupted, I describe a process where due to poor breathing and inefficient sleep, a physiologic stress state is created, which leads to lack of proper blood flow to certain parts of the body that are considered unimportant when you’re in a fight or running from a tiger. These areas include the digestive system, reproductive organs, your hands and feet, and your skin, amongst others. 

 

During periods of stress (whether internal/physiologic or external/emotional), there can be severe blood flow restriction to any of these body areas. As an example of how dramatic this can be, there’s a description of a man who was severely injured during battle, and most of his abdominal wall was missing, with his bowels clearly visible. While he was recovering in bed, his doctors noticed that whenever he was angry or in pain, his bowels were dark and dusky, whereas when he was happy, his bowels looked pink and healthy. Similarly, there can be dramatic fluctuations in blood flow to the breasts depending on the woman’s mood and stress-inducing states.

 

One common finding in both cancer and sleep apnea research fields is that hypoxia (lack or oxygen) in tissues can lead to production of signals that tell the body to bring in more blood and nutrients. As a result, a number of inflammatory mediators are released, including the well-known vascular endothelial growth factor (VEGF). VEGF promotes local growth of blood vessels in oxygen-poor areas. Imagine if this process happened all the time, with slow but gradual growth of local tissues, with activation of genes and proteins that promote more inflammation and more cell reproduction. 

 

We know that chronic overstimulation of any tissue can lead to cell replication that can go out of control. Chronic overstimulation of breast tissue can initially lead to localized benign growths or cysts, and some of these can end up transforming into malignancies. Perhaps some women with certain genes may be more susceptible to this transformation. This same process can also be described for prostate cancer.

 

Most younger breast cancer survivors probably won’t have obstructive sleep apnea if tested. But what they most likely will have is upper airway resistance syndrome, which results in multiple microscopic obstructions and arousals that prevents deep, efficient sleep. This can cause the nervous system to become hypersensitive, with increased physiologic states of stress. As they gain weight later on in life, many will progress into formal sleep apnea. 

 

Studies show that breast cancer survival is poorer in obese patients. Similar findings are also found with prostate cancer. This is possibly explained by the fact that the more obese you are, the more likely you’ll have obstructive sleep apnea. Having obstructive sleep apnea significantly increases your risk of dying in general.

 

Granted, what I’m describing here is a very different perspective in explaining breast cancer, and is sure to be controversial in some people’s minds. However, rather than trying to explain breast cancer from a molecular, genetic, or organ level, wouldn’t you agree that it’s much more satisfying when you can explain this illness from a whole-person perspective? As much as Western medicine tries to deny it by fragmenting care to different specialties, we know intuitively that whether it’s the breast, the heart, the mind or the prostate gland, everything is ultimately connected.

 

What’s your opinion on this important issue? Please enter your comments in the box below.

Is the XMRV the True Cause Of Chronic Fatigue Syndrome?

Q: Severe OSA or UARS?

Q:
Hello Dr. Park,
 
I am a 24 year old male and have been suffering from moderate-severe sleep problems for at least 7 years now.  For as long as I can remember, I have had issues waking up in the morning.  No matter how hard I try or what methods are used, I couldn’t get up when desired.  In the past 2 years I have noticed a big decrease in my level of energy.  Oftentimes I feel fatigued to the point where my day is compromised. 
 
In early April I had a sleep study performed which found that I had severe OSA.  Apparently I stopped breathing up to 85 times an hour when I was on my back, which was slightly worse than when I was on my side or stomach.  I have been using the CPAP for almost 2 months now and honestly don’t feel that much better.  I would say that it is a little easier to wake-up in the morning, but that’s about it.  I still suffer from fatigue and lack of energy throughout the day.  My doctor is saying that the CPAP has returned my AHI to normal levels, but I am not noticing the difference.
 
In my attempt to locate more information, I came across your journal entry “Tired of Being Tired” to learn more about UARS.  My main question, is how possible is it that I have a moderate-severe OSA as well as UARS?
 
I greatly appreciate your assistance and service and wish you the best!

JPBESpoke

A:  Sorry to hear about all that you’re going through. It must be frustrating. If you’re using CPAP regularly and have data from the machine that confirms it (good compliance and no leaks with minimal AHIs), then the best thing to do is to be patient. You’ve had this condition for years, and sometimes it can take months (sometimes 6-12) to begin to feel better.

It does sound like you do have upper airway resistance syndrome, but you also have severe obstructive sleep apnea. What I see is that some people with UARS go on to develop what may look like chronic fatigue syndrome. Your involuntary nervous system is severely unbalanced, and you have to give it time to come back into alignment. Your situation is complicated and and endoscopic exam will only confirm what you already know. But it’s probably a good idea to take one look to make sure there’s nothing else that’s going on.  By definition, you’re susceptible to any of the somatic syndromes, since these are intimately linked to sleep-breathing problems.

There are also many studies that show that people with untreated obstructive sleep apnea have significant brain abnormalities with various degrees of injury. Years of hypoxia can cause temporary or permanent injury. You can imagine how multiple areas of damage throughout the brain can give various signs or symptoms such as chronic fatigue, numbness, hormonal imbalances, etc. This is not proven as of yet, but if you look at all the research in this area, it’s a reasonable explanation. This is why sometimes it can take months or over a year to begin to feel better.

When Exercise Becomes Hazardous To Your Health

As the obesity numbers keep climbing, everyone wants to eat less and to exercise more. This is great if you’re able to exercise moderation and common sense. But if you’re already sick and your frame of reference is unhealthy to begin with, it’s difficult to know when enough is enough. 

Just as those with anorexia diet excessively to cover up their faulty body image, some people with sleep breathing problems like upper airway resistance syndrome (UARS), or obstructive sleep apnea (OSA), abuse exercise as a means to cope with the lethargy created by their chronic sleep deprivation.

Addicted to Exercise

A lot of patients I see with UARS and OSA become exercise junkies in the same way that people who don’t sleep enough become coffee addicts. Rather than consume substances to give them a "high", these exercise addicts crave the endorphin fix they get while working out to overcome the constant fatigue they feel from not getting the quality sleep they need. Many of them admit that If they miss even one day of working out, they’ll get agitated, moody, and sometimes downright catatonic. 

For these people, exercise or any physical activity is a coping mechanism for the constant energy drain they feel. The problem is, like any drug, too much exercise, if it’s used to deter them from taking care of their underlying sleep breathing problem, will manifest later into health complications that no amount of exercise may be able to cure. 

What’s Your Sleep Position?

Obviously, not everyone who exercise excessively do so to compensate for an underlying sleep breathing problem. One quick and simple way I use to discern who is and who is not susceptible to having a sleep breathing problem is to ask whether or not they can or like to sleep on their backs. You see, those with sleep breathing problems can only sleep on their sides or more commonly their stomachs. The reason being, that they’ll have difficulty breathing when they’re sleeping otherwise. 

To summarize, my sleep-breathing paradigm proposes that all modern humans have difficulty breathing at night to various degrees due to our unique upper airway anatomy. The voice box is located underneath the tongue, as opposed to animals, where the voice box is located behind the tongue. This location of the voice box under the tongue is necessary for complex speech and language. But this is also what makes our airway vulnerable and unprotected, making us more prone to having the various breathing and swallowing problems that we, as modern humans have. 

What’s worse, it’s thought that due to a radical change in our diets (highly processed foods and refined sugars) over the past century, our jaws are getting narrower and we have more dental crowding. Furthermore, dentists have stated that introduction of bottle-feeding to infants can aggravate dental crowding and malocclusion, which makes everything much worse. All these factors aren’t the only reason for everyone’s sleep problems, but they are problematic if your anatomy is already predisposed. 

So what does breathing have to do with sleep quality? There are two components to this issue: When lying flat on your back, your tongue falls back partially, due to gravity. This narrows the breathing passageway behind your tongue to various degrees. As you fall asleep, the deeper level of sleep you enter, the more your muscles relax, and at a certain point, your tongue can fall back and obstruct your breathing. The more narrow your airway (due to smaller jaws or inflammation due to a cold or allergies), the more likely you’ll stop breathing and wake up to turn over. When you were young, you tossed and turned and eventually figured out that you can sleep much better when sleeping on your side or stomach. The problem is that even on your side or stomach, it’s never perfect, and you’re not able to get deep, efficient sleep, no matter how long you sleep.

Sleep Among Athletes

It’s also not too surprising that many personal trainers and fitness professionals have very similar features: Almost invariably they prefer to sleep only on their sides or stomachs. The same can be said about bodybuilders—a personal trainer/natural body builder friend of mine told me that almost every one in her gym snores. Snoring, incidentally, is a very common trait amongst those who have OSA or UARS. 

Professional football players also have a much higher incidence of obstructive sleep apnea. About 1/3 of all linemen were found to have mild or moderate sleep apnea. Many people assume that this is due to the abnormally thick necks that many football players have. However, it’s not only the fat in the neck—it’s also the muscle mass that impinges on the soft tissues of the upper airway. So in theory, the more muscle bulk you have in your neck, the more breathing problems you’ll have while sleeping, and therefore more fatigue to cope with. This in turn, makes you work all that much harder than let’s say, someone else who may not be sleep deprived, to get the same level of intensity.  It’s hard to say which came first, the sleep breathing problem, or the intense work outs, but once it’s started, it ends up being a self-perpetuating vicious cycle. 

Sleeplessness Can Aggravate Injuries

As a long time track and field enthusiast, I know how important it is to eat right and exercise–especially as you get older. Running helped invigorate me after being cloistered for days studying for finals during medical school, and it still helps me maintain my health while balancing the demands of my work and family. Yet, there are times when I’ve let the running take control. This often happens when I’m outpaced by someone in my age group, or when I’m coping with a stressful event. During these times, I’d often train to the point of illness or injury—at which point, I’m temporarily unable to do the one thing that keeps me healthy and sane.

In this way, if you’re an exercise junky, you’re also more prone to having injuries. It’s like that saying: "The higher you climb, the harder you fall." Unfortunately, once injured, it becomes all that much harder to gain the momentum back. What often occurs is common trap for any athlete but much worse if you have UARS or OSA. The sudden lack of activity can cause you to eat more due to increased levels of stress from increased sleep deprivation. As you gain weight, your upper airway narrows even further, leading to worse deep sleep quality. Another scenario that can happen is if you injure your neck or shoulder. This will prevent you from being able to sleep on your side or stomach, which again, aggravates the vicious cycle.

What I just described may seem a little far fetched, but if you are prone to constant fatigue, snore, or have any other chronic health problems like chronic sinusitis, nasal congestion, throat problems, then the sleep breathing paradigm can potentially explain and help you avoid the various health complications you may experience down the road. One way to see where you’re headed is to look at your parents. More often than not, one or both your parents may snore heavily, and in many cases will have one or more of the complications of untreated obstructive sleep apnea: depression, anxiety, diabetes, hypertension, heart disease, heart attack or stroke. 

The best way for you to stay healthy and fit is to eat well, exercise, and most importantly, to sleep better.
 
 

CPAP for Upper Airway Resistance Syndrome?

I recently came across a post on a sleep apnea support forum where a member asked about upper airway resistance syndrome (UARS) and how being on CPAP took care of a variety of his medical problems:

"So many things are better on the CPAP: 

My severe peripheral neuropathy of 5 years is almost gone. 
All the aches and pains are pretty much gone. 
My peripheral edema is gone. 
The age spots on my face are going away. 
I’m not huffing and puffing just doing simple things (like walking my son to his classroom.) 
My night sweats are gone. 
No more getting up to go to the bathroom at night. 
My heat intolerance is resolving -no longer sweat when I blow dry and curl my hair. 
I can exercise again and it’s enjoyable.  I no longer come home and go straight to bed. 
I don’t get so sore after exercise. 
My calf muscles are relaxing.  They used to just stay contracted all the time and I couldn’t get them to relax. 
My morning tremors are gone. 
Haven’t lost any weight, but dropped two pant sizes."

Fortunately, this person tolerated and responded very well to CPAP, whereas most people with UARS can’t stand having anything on their faces due to their hypersensitive nervous systems. Unfortunately, he was given CPAP by mistake before it was approved and the insurance company is refusing to pay for it anymore. Since his AHI was below the cut-off line of 5 for diagnosing obstructive sleep apnea (his was 1.9), officially he didn’t have sleep apnea. But he did stop breathing 8 times every hour on average. This is the dilemma with UARS.

My point here is that if the anatomic sleep-breathing problem is fixed definitively, regardless of the method (CPAP, dental devices or surgery), the patient will feel better. I describe a similar, very dramatic story about a young woman with even worse problems in my book, Sleep, Interrupted.

 

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