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By: Tamara Sellman on July 11th, 2019

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Book Review: The Science of Sleep

book review

mendelson book coverI first learned about this author through a really helpful episode of Sleep Talk, a podcast produced and aired last February by Drs. Moira Junge and David Cunningham.

The focus of that episode was sleeping pills, and author Dr. Wallace Mendelson gave a fascinating historical play-by-play of the rise of hypnotics, sedatives and other sleep-inducing agents. It’s worth listening to if you’re still intimidated by this wide category of pharmaceutical sleep aids.

About The Science of Sleep: What It Is, How It Works, and Why It Matters 

Is this book about the science of sleep or the history of sleep?

It’s not a complaint to say that the role of historical perspective is actually more powerful in TSoS  than the actual science.

However, I do think that titling this book The History of Sleep wouldn’t make it particularly alluring, and, let’s face it, TSoS  seems to be marketed to a general audience as opposed to a textbook readership so it needs to have jacket appeal.

The science is there, definitely. But for the sleep technologist, it’s pretty basic. It touches on brain waveforms, a simple overview of polysomnography and the biology of sleep disorders, for instance. To be fair, discussions about genetics and neuroscience add some scientific heft to TSoS.

Still, TSoS  really isn’t super “science-y” not like Principles and Practices of Sleep Medicine or the AAST’s latest edition of Fundamentals of Sleep Technology.

Yet, I would argue that, for someone coming into a new polysomnography or respiratory program, or for general practitioners, TSoS  could be a great building block text.

In fact, were I to run a PSG program locally, I think I would choose this title to teach the basic concepts of sleep science to brand-new sleep technology and respiratory students before moving into more practical hands-on training.

Mendelson does, indeed, have a fantastic gift for delivering scientific concepts by way of a compelling historical and cultural context; this is the strength of TSoS, hands down (as well as its format, which I'll discuss later).

Personally, I think the way scientists arrived at the foundations of sleep medicine are intriguing, and knowing that these convoluted pathways to meet goals that weren’t necessarily pointed toward a better understanding of sleep are what makes this field so interesting for both the uninitiated and the professional.

Who is this book actually for?

I can’t quite decide who the TSoS  audience is, but I can tell you who this book doesn’t serve.

If you’re an advanced  sleep technologist or longtime sleep physician, then there are only a few things that might be new for you in these pages, but, to be fair, they’re relevant and worth your time and consideration.

Otherwise, it’s a toss-up. This book could be used as a:

  • preliminary textbook for training new sleep or respiratory technologists or sleep nurses
  • sleep primer for ordinary, nonmedical readers who appreciate topics like human biology
  • window into sleep health for the primary care physician or other non-sleep medical professional who is interested in learning more without seeking a credential
  • refresher course for sleep technologists who want to review basics

About Wallace B. Mendelson, MD

Dr. Mendelson is now retired after 40 years of serving as a professor, sleep researcher and clinician.

He has worked as professor of psychiatry and clinical pharmacology at the University of Chicago, served as director of the sleep laboratory for the intramural program for the National Institute of Mental Health (NIMH), and directed the Cleveland Clinic sleep disorder center and the sleep research laboratory at the University of Chicago.

In other words, Mendelson has been an ardent and inspiring leader and teacher in the development of sleep medicine as a legitimate field of research and clinical care.

What’s to Be Admired in TSoS

An accessible narrative

Mendelson’s storytelling skill is apparent from the introduction. There, he shares a story about how Alexander the Great prioritized sleep before the critical battle of Gaugamela and won. Such an old story should ignite passion and support for good sleep as a part of athletic performance among today’s top sports trainers and their clientele.

Mendelson continues to share similar anecdotes throughout TSoS  in a way that is more than ephemeral, but relevant.

His writing style is mostly nontechnical, whenever possible. This “soft” approach makes the concepts he delivers easier to grasp without “dumbing them down.” In areas where the discussion is technical of necessity, he still manages to keep the language and ideas accessible, a struggle for many medical writers coming from academia.

One gets the sense that Mendelson didn’t write TSoS  to show off what he knows, or to compete with his peers, but to teach the subject in a way that is driven by lifelong passion.

Fresh approaches

Many books have been written about sleep medicine and technology, and the problem that arises from this is the sense of sameness from one book to the next.

Mendelson shares some fresh ideas about old themes that I found refreshing.

For instance, his section on “Wet and Dry Physiology” approaches the process of sleep and waking from a neuroscience vantage point, looking at electrical phenomena in the brain as “dry neurophysiology” and comparing it to the “wet neurophysiology” that describes brain chemistry.

Attention to neurobiological theories is also a contemporary focus that seems to be the future for much of sleep research today. Whether sleep technologists will be required to understand these more granular aspects of sleep is a good question, but those who are interested in working in sleep research should trust in Mendelson’s trail of breadcrumbs.

Another interesting comparison he makes involves the differences between slow wave sleep deprivation and REM sleep deprivation. This reflects recent new research highlighting the distinct values of both stages, highlighting the specific neurobiological goals and rhythms of each.

Mendelson also addresses the problems of sleep during menstruation, which is a topic that is rarely, if ever, discussed just about anywhere. In addition, TSoS  breaks out hormone discussions not only as a focus on women’s health, but in light of the impacts of their imbalances on metabolism. After all, diabetes and other metabolic conditions are not gender specific, and estrogen and testosterone are not the only hormones with sleep-disrupting imbalances.

The section, “How are certain hormones secreted during sleep?” is enlightening and inclusive. In this section, Mendelson goes into good detail about human growth hormone (HGH), cortisol, leptin and grehlin, and other hormones that sometimes get lost in the conversation.

In addition, TSoS  includes solid updates on senior sleep and includes references to Alzheimer’s disease and other age-related impacts on sleep that are often glossed over in other texts.

Also deserving kudos is the super relevant section on mental health and sleep, and especially the discussion about homeostatic pressure in cases of depression, which was, for me, eye opening. Mendelson also does not limit the discussion of PTSD and sleep to those suffering from combat fatigue, which is inclusive and relevant.

In the sleep disorders chapter, Mendelson does a good job of clarifying the distinctions between restless legs and periodic leg movement disorder (PLMD). He also opens up the narcolepsy discussion through the lens of genetics and new research that could reveal it conclusively as an autoimmune condition. This, based on research done following the recent spike of narcolepsy patients following flu vaccinations in Europe.

Updated priorities

The way Mendelson prioritized content is also interesting. He leads with the most compelling problem facing us all — sleep deprivation — well before he launches into more formal discussions about sleep disorders.

I think this is smart for four reasons:

  1. Sleep deprivation is a huge societal problem requiring ongoing public education.
  2. Understanding why we need to sleep can often be taught by showing what happens when we don’t sleep.
  3. Sleep deprivation is relatable to all readers even if and when sleep disorders aren’t part of the conversation (not everyone who is sleep deprived has a bona fide sleep disorder).
  4. So many of us conflate sleep deprivation and insomnia, which can lead to dangerous assumptions and oversights.

I also appreciated how Mendelson separated circadian rhythm sleep into its own chapter, and that the section, “Techniques to improve sleep without a pill” exists at all. It’s a rich area of research already, and the more we understand of the huge impact of rhythmicity on sleep — both as technologists and as human beings in need of sleep — the more we can make changes individually and as a society (such as with the Start School Later effort) to make sleep accessible for all.

The section of circadian rhythm genetics, “Models of Circadian Regulation,” also provides a terrific summary of a complex topic, and “Sleep in Medical Disorders” reminds readers that there are so many things that can cause disordered sleep, including specific chronic medical conditions and medications.

Meanwhile, the section describing the mechanisms of sleep aids will be useful to sleep technologists who deal with lots of patients using pharmaceuticals to abate their sleeplessness.

I have to say that I also marveled at the fact that Mendelson included the section, “Sleep in Alcohol Dependence.” That’s a tenacious miracle in a world so focused on opioids. This groundbreaking discussion might spur, of necessity, more frank discussion among all of us about substance abuse at large.

Format matters

One thing I admire about TSoS  is the way in which it’s been structured. Chapters are mostly comprised of subjects that span full-page spreads (usually of two or four pages) with clear titles at the top. I see the value in this, not as a former production editor, but as a reader who may need to flip through the book for specific information after the fact.

Each of these sections stands alone and offers a solid topic summary. While it’s still preferable to read TSoS  straight through if you’re in it to learn, this design makes it much easier to return to it as a handy reference.

I also really love the physical design of TSoS. It resembles a solid, accessible biology textbook, with full-color images and tables throughout. The page design if attractive, dynamic and appealing — hardly intimidating, even though the content is substantial.

The sidebar notes can be interesting as well. I did not know, for instance, that the word “nightmare” does not have horses in its origin story (see page 133).

It’s also nice to see Mendelson reference contemporary peers throughout TSoS, such as Drs. Daniel Buysse. Rosalind Cartwright, David Dinges and Meir Kryger.

Missteps in TSoS

There aren’t many, truth be told.

I personally feel like the section on dreaming, and the chapter on animal sleep, are probably there to bolster interest from a general audience. While these are fascinating topics, which in some ways satisfy the promise of the book’s title, they may be superfluous for healthcare professionals reading TSoS  for concrete information about human sleep-wake processes. But that’s assuming this is the only audience forTSoS.

That said, there are a few lost opportunities in this book. For instance, very little was referenced in regard to changing morning school start times in any of the discussions about circadian rhythms, adolescent sleep or sleep hygiene. Nor were the contemporary problems of light pollution and blue light exposure addressed in the section on circadian disruptions, though the latter does come later, in the section that discusses sleep hygiene.

Sleep apnea and snoring are given good coverage, but upper airway resistance syndrome is missing from the discussion and other forms of sleep-breathing disorders are somewhat glossed over. Also, treatments for sleep apnea were discussed, including hypoglossal nerve stimulation, PAP and surgery, but Mendelson wrote of oral appliances that “although there is very active work in the area, in the United States they generally have not yet been formally approved for treatment of OSA,” which might draw the ire of the dental sleep medicine community, which passed joint guidelines on this protocol with the AASM in 2015.

Active research into pharmaceutical options for sleep-breathing disorders (most notably, cannabinoid options like dronabinol) were not discussed at all. This may be out of self- preservation, given the deep divide in the medical community about the value of using cannabis-related treatments for a myriad of health concerns. The author might be making the timelessness of the book’s content — giving it a chance to “age well” — a priority, however, which is fair and reasonable.

There’s also an unfortunate typo describing idiopathic hypersomnia (IH) as “a type of insomnia” (page 110), which would be forgivable except that so much about IH is already so confusing even among sleep medicine practitioners.

Finally, new reduced dosage rules by the FDA for women using zolpidem in 2013 weren’t updated in Mendelson’s graphic (page 161), which is unfortunate.

Final analysis

No book will hit all the beats, but TSoS  hits most of them. I really liked reading Mendelson’s book and will keep it on my shelf as a handy reference. I think this is a useful text for teaching 21st century perspectives on sleep medicine because it’s reader friendly and thorough without being unnecessarily inaccessible. Mendelson introduces refreshing new areas of focus usually ignored in other books that seek to demystify the human sleep-wake process.

THE SCIENCE OF SLEEP: What it is, how it works, and why it matters.
©2017, Wallace B. Mendelson, MD. University of Chicago Press
|| ISBN: 978-0-226-38716-1 || 176 pages. Available in hardcover and
digital versions