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Meir Kryger MD, FRCPC Thomas Roth PhD Cathy A. Goldstein MD William C.
Professor Director
Department of Pulmonary Critical
Sleep Disorders Center
Associate Professor
Department of Neurology
Dement MD
Lowell W. and Josephine Q. Berry
Care and Sleep Medicine Henry Ford Hospital University of Michigan
Professor of Psychiatry and
Yale University Detroit, Michigan Ann Arbor, Michigan
Behavioral Sciences
New Haven, Connecticut
Stanford University School of
Medicine
Department of Sleep Sciences &
Medicine
Palo Alto, California
Principles and Practice of
SLEEP
MEDICINE
Seventh Edition
ELSEVIER
1600 John F. Kennedy Blvd.
Ste 1600
Philadelphia, PA 19103-2899
PRINCIPLES AND PRACTICE OF SLEEP MEDICINE ISBN: 978-0-323-66189-8

Copyright © 2022 by Elsevier, Inc. All rights reserved. VOLUME 1 ISBN: 978-0-323-88220-0
VOLUME 2 ISBN: 978-0-323-88221-7
Richard L. Horner retains the copyright of original figures/images only in Chapter 22, Respiratory Physiology:
Central Neural Control of Respiratory Neurons and Motoneurons during Sleep.
William Joseph Herring retains the copyright and has provided us exclusive rights to publish Chapter 49,
Orexin/Hypocretin.
Dante Picchioni, Shervin Abdollah, Veda Elisabeth Cost, and Hannah Gura are NIH employees and their con-
tribution, Chapter 58, The Neurobiology of Dreaming, is in the public domain.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.
The cover illustration: “Sleeping Girl or Young Woman Sleeping is an oil on canvas painting by an unknown 17th cen-
tury artist active in Rome, sometimes dated to c.1620 and previously attributed to Theodoor van Loon or Domenico
Fetti.” Wikipedia.org: https://en.wikipedia.org/wiki/Sleeping_Girl_(17th_century_painting)
Previous editions copyrighted 2017, 2011, 2005, 2000, 1994, and 1989.
ISBN: 978-0-323-66189-8
Senior Acquisitions Editor: Melanie Tucker

Senior Content Development Strategist: Lisa Barnes
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Kate Mannix
Design Direction: Amy Buxton
Printed in Canada
Last digit is the print number: 9 8 7 6 5 4 3 2 1

We dedicate this volume to
Barbara Kryger, Jay and Shelley Gold, Emily and Michael Kryger, Steven Kryger and Barr Even
Toni Roth, Daniel and Jeanne Roth, Adam and Carol Roth, Jonathan and Cheyna Roth, Andrea and Justin Leibow
Tadd, Evan, and Cole Hiatt, Larry and Tamara Goldstein, and Carolyn Hiatt
v
In Memoriam
William C. Dement
1928–2020
William C. Dement, the father of sleep medicine, was the I (MK) met Bill for the first time in 1978 at a sleep meeting
inspiration for Principles and Practice of Sleep Medicine and was being held in Stanford. After I gave my presentation (I think I
a chief editor starting with the first edition in 1989. was the only pulmonary trained person in the room) Bill came
Bill was a brilliant scientist, mentor, teacher, and leader. He over to me and said, “My God, you’re just a kid.” I guess I was.
did some of the ground-breaking research on rapid eye move- That was the beginning of a beautiful friendship.
ment sleep; mentored many of the most productive scientists In about 1985, we had been discussing and thinking about
doing sleep research; taught the most popular course ever at whether a sleep medicine textbook was needed. We were hesi-
Stanford University, Sleep and Dreams; and played a key role tant to proceed and were actually discouraged by some col-
in advocating for the importance of sleep to science, govern- leagues who told us there wasn’t enough science to warrant a
ments, and the public. He has affected millions of lives! textbook. When presented with the question, Bill said, “You
I (TR) met Bill for the first time in 1972 when he came to can’t have a field without a textbook!” The rest is history. The
Cincinnati for a CME course on sleep medicine. He invited first edition came out in 1989; it had 730 pages. The sixth edi-
me to give two lectures and we spent most of the day together. tion (2017) was exactly 1000 pages longer. Bill was instrumen-
During that day I learned about his intellect, passion for edu- tal in creating the field of sleep medicine. His contributions
cating the public about sleep medicine, and importantly, his will never be forgotten. We will miss him.
generosity. Over the next 40 years we had many interactions;
in every instance they reinforced those initial impressions. It is Meir Kryger Tom Roth Cathy Goldstein
important recognize that without Bill Dement, the book you
are holding would not exist.
From the Performing Arts From Literature
Every Tuesday, Queen Elizabeth II of the United Kingdom Blessings on him who first invented sleep.—It covers a man
(played by Dame Helen Mirren) had a private audience with her all over, thoughts and all, like a cloak.—It is meat for the
Prime Minister in the Private Audience Room on the first floor hungry, drink for the thirsty, heat for the cold, and cold for
of Buckingham Palace. This is dramatized in Peter Morgan’s play the hot.—It makes the shepherd equal to the monarch, and
The Audience. In this scene, Elizabeth is meeting with Prime the fool to the wise.—There is but one evil in it, and that
Minister Gordon Brown. is that it resembles death, since between a dead man and a
sleeping man there is but little difference.
Elizabeth: So, back to your weekend, and all this From DON QUIXOTE
industriousness. Were you up very early? By Saavedra M. de Cervantes
Brown: Four thirty. ------------------------------------
Elizabeth: Oh, dear.
Brown: It’s all right. I never sleep much. “To sleep! To forget!” he said to himself with the serene
Elizabeth: Since when? confidence of a healthy man that if he is tired and sleepy,
Brown: Since always. he will go to sleep at once. And the same instant his head
Elizabeth: Harold Wilson always used to say, “The main did begin to feel drowsy and he began to drop off into
requirement of a Prime Minister is a good night’s sleep forgetfulness. The waves of the sea of unconsciousness had
… and a sense of history.” Mrs. Thatcher taught herself begun to meet over his head, when all at once—it was as
to need very little towards the end. But I’m not sure how though a violent shock of electricity had passed over him.
reassured I am by that. I like the idea of any person with He started so that he leapt up on the springs of the sofa, and
the power to start nuclear war being rested. (A beat.) leaning on his arms got in a panic on to his knees. His eyes
Besides, lack of sleep can have a knock-on effect in other were wide open as though he had never been asleep. The
areas. heaviness in his head and the weariness in his limbs that he
Brown: Such as? had felt a minute before had suddenly gone.
Elizabeth: One’s general sense of health.
From ANNA KARENINA, Part IV, Chapter XVIII
A silence. By Leo Tolstoy
And happiness. ------------------------------------
A silence.
And equilibrium. The Body Electric
Brown looks up. A silence.
Every cell in our bodies contains a pore
I gather there’s been some concern …
like a door, which says when to let in
Brown: About what?
the flood of salt-ions bearing their charge,
Elizabeth: Your happiness. Don’t worry. You wouldn’t be the
but the power in us moves much slower
first in your position to feel overwhelmed. Despondent.
than the current that rushes into wires
She searches for the right word.
Depressed. to ignite the lamp by which I undress,
am told to undress by sparks that cross
From Morgan, Peter. THE AUDIENCE, Faber and Faber, 2013. the gap of a synapse to pass along
Used with permission of Mr. Peter Morgan. the message, It’s time for sleep. As I pull
------------------------------------ back the sheets, ease into bed, I think
if I could only look beneath my skin,
But the tigers come at night I’d see my body as alive as Hong Kong,
With their voices soft as thunder veins of night traffic crawling along
As they tear your hope apart the freeways as tiny faces inside taxis
As they turn your dream to shame. look up from the glow of their phones,
From I Dreamed a Dream, LES MISÉRABLES, with permission, Cameron sensing that someone is watching.
Mackintosh, producer © 1985 Alain Boublil Music Ltd. Used with
permission 1991, CMI. James Crews, Dec. 3, 2020. New York Times Magazine. Used with
permission of the poet.
Contributors
Ghizlane Aarab, MD Amy W. Amara, MD
Associate Professor Associate Professor
Department of Oral Kinesiology Department of Neurology
The Academic Center for Dentistry University of Alabama at Birmingham
Amsterdam, The Netherlands Birmingham, Alabama
Sabra Abbott, MD, PhD Sonia Ancoli-Israel, PhD

Assistant Professor Professor Emeritus
Department of Neurology Professor of Research
Center for Circadian and Sleep Medicine Department of Psychiatry
Northwestern University Feinberg School of Medicine University of California, San Diego
Chicago, Illinois La Jolla, California
Shervin Abdollahi, BS Anna Anund, PhD

Research Analyst (Contractor) Reserach Director
National Institute of Neurological Disorders and Stroke Department of Human Factors
Bethesda, Maryland Swedish National Road and Transport Research Institute;
Associate Professor
Philip N. Ainslie, PhD Rehabilitation Medicine
Professor Linköping University
Department of Health and Exercise Sciences Linkoping, Sweden
The University of British Columbia
Kelowna, British Columbia, Canada Taro Arima, DDS, PhD
Lecturer
Cathy Alessi, MD Division of International Affairs
Director Graduate School of Dental Medicine
Geriatric Research, Education and Clinical Center Hokkaido University
VA Greater Los Angeles Healthcare System; Sapporo, Japan
Professor
Department of Medicine J. Todd Arnedt, PhD
David Geffen School of Medicine Departments of Psychiatry and Neurology
University of California, Los Angeles University of Michigan Medical School
Los Angeles, California Ann Arbor, Michigan
Richard P. Allen, PhD Isabelle Arnulf, MD, PhD

Professor Sleep Disorders Unit
Department of Neurology Pitie-Salpetriere University Hospital
Johns Hopkins University Sorbonne University
Baltimore, Maryland Paris, France
Fernanda R. Almeida, DDS, MSc, PhD Vivian Asare, MD

Associate Professor Assistant Professor
Oral Health Sciences Department of Medicine (Pulmonary, Critical Care, and
University of British Columbia Sleep Medicine)
Vancouver, British Columbia, Canada Yale University School of Medicine
New Haven, Connecticuit
Aurelio Alonso, DDS, MS, PhD
Department of Anesthesiology Lauren Asarnow, PhD
Orofacial Pain–Duke Innovative Pain Therapies Assistant Professor
Center for Translational Pain Medicine Psychiatry
Duke University School of Medicine
Durham, North Carolina University of California–San Francisco
San Francisco, California
Neesha Anand, MD
Critical Care Fellow
University of Pittsburgh
Pittsburgh, Pennsylvania
xi
xii Contributors
Hrayr Attarian, MD Siobhan Banks, PhD

Professor Professor
Department of Neurology UniSA Justice and Society
Northwestern University University of South Australia
Chicago, Illinois Magill, South Australia
Alon Y. Avidan, MD, MPH Nicola L. Barclay, BA(Hons), MSc, PhD

Director Sleep and Circadian Neuroscience Institute (SCNi)
University of California, Los Angeles Sleep Disorders Center; Nuffield Department of Clinical Neurosciences
Professor University of Oxford
Department of Neurology Oxford, Great Britain
University of California, Los Angeles,
Los Angeles, California Steven R. Barczi, MD
Professor of Medicine
Nicoletta Azzi, MD Department of Medicine
Sleep Disorders Center University of Wisconsin School of Medicine & Public Health;
Department of Medicine and Surgery Director of Clinical Programs
University of Parma Madison VA Geriatric Research, Education, and Clinical
Parma, Italy Center
Wm. S. Middleton Veterans Affairs Hospital
M. Safwan Badr, MD,MBA Madison, Wisconsin
Professor
Department of Internal Medicine Mathias Basner, MD, PhD, MSc
The Liborio Tranchida MD Endowed Chair Professor of Sleep and Chronobiology in Psychiatry
Wayne State University Unit for Experimental Psychiatry
Detroit, Michigan Division of Sleep and Chronobiology
Department of Psychiatry
Helen A. Baghdoyan, PhD Perelman School of Medicine
Beaman Professor University of Pennsylvania
University of Tennessee Philadelphia, Pennsylvania
Knoxville, Tennessee;
Joint Faculty, Biosciences Division Claudio L.A. Bassetti, MD
Oak Ridge National Laboratory Professor
Oak Ridge, Tennessee Chairman and Head
Neurology Department
Sébastien Baillieul, MD, PhD Inselspital University Hospital
Pneumology-Physiology Department Bern, Switzerland
Grenoble Alpes University Hospital;
INSERM U1300, HP2 Laboratory Celyne Bastien, PhD
Grenoble Alpes University School of Psychology
Grenoble, France Laval University
Quebec City, Quebec, Canada
Benjamin Baird, PhD
Wisconsin Institute for Sleep and Consciousness Christian R. Baumann, MD
Department of Psychiatry Department of Neurology
University of Wisconsin–Madison University Hospital Zurich
Madison, Wisconsin Zurich, Switzerland
Fiona C. Baker, PhD Louise Beattie, PhD

Director, Center for Health Sciences Institute of Health and Wellbeing
SRI International; University of Glasgow
Honorary Senior Research Fellow Glasgow, Great Britain
Brain Function Research Group
School of Physiology Bei Bei, DPsych(Clinical), PhD
University of the Witwatersrand NHMRC Health Professional Research Fellow
Johannesburg, Gauteng, South Africa Clinical Psychologist
School of Psychological Sciences
Thomas J. Balkin, PhD Monash University
Senior Scientist Clayton, Victoria, Australia
Behavioral Biology Branch
Walter Reed Army Institute of Research
Silver Spring, Maryland
Contributors xiii
Gregory Belenky, MD University of Michigan

Research Professor Ann Arbor, Michigan
Sleep and Performance Research Center
Washington State University Josiane L. Broussard, MD
Spokane, Washington Assistant Professor
Department of Health and Exercise Science
Amy Bender, MS, PhD Colorado State University
Adjunct Assistant Professor Fort Collins, Colorado
Department of Kinesiology
University of Calgary; Daniel B. Brown, JD
Senior Research Scientist Partner, Taylor English Duma, LLP
Calgary Counselling Centre Atlanta, Georgia
Calgary, Canada
Luis F. Buenaver, PhD
Suzanne M. Bertisch, MD, MPH Assistant Professor of Psychiatry and Neurology
Division of Sleep and Circadian Disorders Director, Johns Hopkins Behavioral Sleep Medicine
Brigham and Women’s Hospital Program
Harvard Medical School Johns Hopkins University School of Medicine
Boston, Massachusetts Baltimore, Maryland
Carlos Blanco-Centurion, PhD Helen J. Burgess, PhD

Department of Psychiatry and Behavioral Sciences Professor
Medical University of South Carolina Department of Psychiatry
Charleston, South Carolina University of Michigan
Ann Arbor, Michigan
Benjamin T. Bliska, DDS
Faculty of Dentistry Keith R. Burgess, MBBS, MSc, PhD, FRACP, FRCPC
University of British Columbia Clinical Associate Professor
Vancouver, British Columbia, Canada Department of Medicine
University of Sydney
Konrad E. Bloch, MD Sydney, Australia
Professor
Respiratory Medicine, Sleep Disorders Center Orfeu M. Buxton, PhD
University Hospital Zurich Professor
Zurich, Switzerland Department of Biobehavioral Health
Pennsylvania State University
Bradley F. Boeve, MD University Park, Pennsylvania
Professor of Neurology
Department of Neurology Daniel J. Buysse, MD
Mayo Clinic UPMC Professor of Sleep Medicine
Rochester, Minnesota Professor of Psychiatry and Clinical and Translational Science
University of Pittsburgh School of Medicine
Patricia Bonnavion, MD Pittsburgh, Pennsylvania
Lab of Neurophysiology
ULB Neuroscience Institute Sean W. Cain, PhD
Université Libre Bruxelles Associate Professor
Brussels, Belgium School of Psychological Sciences
Turner Institute for Brain and Mental Health
Scott B. Boyd, DDS, PhD Monash University
Professor of Oral and Maxillofacial Surgery, Retired Faculty Clayton, Victioria, Australia
Department of Oral and Maxillofacial Surgery
Vanderbilt University School of Medicine J. Lynn Caldwell, BS, MA, PhD
Nashville, Tennesee Senior Research Psychologist
Naval Medical Research Unit Dayton
Alessandro Bracci, DDS Wright-Patterson Air Force Base, Ohio
Adjunct Professor
Department of Neuroscience John A. Caldwell, BS, MA, PHD
School of Dentistry, Senior Scientist
University of Padova Fatigue and Sleep Management
Padova, Italy Coastal Performance Consulting
Yellow Springs, Ohio
Tiffany Braley, MD
Associate Professor of Neurology Michael W. Calik, PhD
Department of Neurology Assistant Professor
Multiple Sclerosis and Sleep Disorders Centers Department of Biobehavioral Nursing Science
xiv Contributors
Assistant Professor Eduardo E. Castrillon, DDS, MSc, PhD

Center for Sleep and Health Research Associate Professor
University of Illinois Chicago College of Nursing Section for Orofacial Pain and Jaw Function
Chicago, Illinois Department of Dentistry and Oral Health
Aarhus University
Francisco Campos-Rodriguez, MD Aarhus, Denmark
Respiratory Department
Hospital Valme Lana M. Chahine, MD
Seville, Andalucía Assistant Professor
Craig Canapari, MD University of Pittsburgh
Associate Professor Pittsburgh, Pennsylvania
Department of Pediatrics
Yale University Etienne Challet, PhD
New Haven, Connecticuit Institute of Cellular and Integrative Neurosciences
Strasbourg, France
Michela Canepari, PhD
Department of Humanities, Social and Cultural Enterprises Philip Cheng, PhD
University of Parma Assistant Scientist
Parma, Italy Division of Sleep Medicine
Thomas Roth Sleep Disorders and Research Center
Michelle T. Cao, DO Henry Ford Health System
Clinical Associate Professor Detroit, Michigan;
Department of Neurology Research Assistant Professor
Stanford University School of Medicine Department of Psychiatry
Palo Alto, California; University of Michigan School of Medicine
Clinical Associate Professor Ann Arbor, Michigan
Psychiatry and Behavioral Sciences
Stanford University School of Medicine Ronald D. Chervin, MD, MS
Redwood City, California Professor of Neurology
Michael S. Aldrich Collegiate Professor of Sleep Medicine
Colleen E. Carney, PhD Director, Sleep Disorders Center
Professor University of Michigan Health System
Department of Psychology Ann Arbor, Michigan
Ryerson University
Toronto, Ontario, Canada Soo-Hee Choi, MD, PhD
Associate Professor
Michelle Carr, PhD Department of Psychiatry
Department of Psychiatry Seoul National University College of Medicine;
University of Rochester Medical Center Associate Professor
Rochester, New York Department of Psychiatry
Seoul National University Hospital
Santiago Carrizo, MD Seoul, Korea
Servicio de Neumología
Hospital Universitario Miguel Servet Ian M. Colrain, PhD
Zaragoza, Spain President
SRI Biosciences
Mary A. Carskadon, PhD SRI International
Professor, Psychiatry and Human Behavior Menlo Park, California;
Alpert Medical School of Brown University; Professorial Fellow
Director, Chronobiology and Sleep Research Melbourne School of Pscyhological Sciences
EP Bradley Hospital The University of Melbourne
Providence, Rhode Island Parkville, Victoria, Australia
Diego Z. Carvalho, MD Veda Elisabeth Cost, BA
Assistant Professor Research Fellow
Center for Sleep Medicine National Institute of Neurological Disorders and Stroke
Department of Medicine Bethesda, Maryland
Mayo Clinic College of Medicine and Science
Rochester, Minnesota Anita P. Courcoulas, MD
Professor of Surgery
Anna Castelnovo, MD Division of Minimally Invasive Bariatric and General Surgery
Faculty of Biomedical Sciences University of Pittsburgh Medical Center
Università della Svizzera Italiana Pittsburgh, Pennsylvania
Lugano, Switzerland
Contributors xv
Michel A. Cramer Bornemann, MD, DABSM, FAASM David de Ángel Solá, MD

Lead Investigator Staff Physician
Sleep Forensics Associates; Department of Pediatrics
Visiting Professor, Sleep Medicine Yale School of Medicine
Fellowship, Minnesota Regional Sleep Disorders Center New Haven, Connecticut;
Hennepin County Medical Center Faculty Physician
Minneapolis, Minnesota; Department of Neurology
Co-Director of Sleep Medicine Services VA Caribbean Healthcare Systems;
CentraCare Faculty Physician
Saint Cloud, Minnesota Department of Pediatrics
San Juan City Hospital
Ashley F. Curtis, PhD San Juan, Puerto Rico
Assistant Professor
Psychiatry Luis de Lecea, PhD
Psychological Sciences Department of Psychiatry and Behavioral Sciences
University of Missouri Stanford University
Columbia, Missouri Palo Alto, California
Charles A. Czeisler, PhD, MD Massimiliano de Zambotti, PhD

Frank Baldino, Jr., Ph.D. Professor of Sleep Medicine Principle Scientist, Human Sleep Research
Department of Medicine Center for Health Sciences
Director SRI International
Division of Sleep Medicine Menlo Park, California
Harvard Medical School;
Chief, Division of Sleep and Circadian Disorders Tom Deboer, PhD
Department Medicine Associate Professor
Brigham and Women’s Hospital Cell and Chemical Biology
Boston, Massachusetts Leiden University Medical Center
Leiden, The Netherlands
Michael Czisch, MD
Max Planck Institute of Psychiatry Lourdes DelRosso, MD
Munich, Germany Associate Professor
Department of Pediatrics
Armando D’Agostino, MD, PhD Seattle Children’s Hospital
Department of Health Sciences University of Washington
Università degli Studi di Milano Seattle, Washington
Milan, Italy
William C. Dement, MD†
O’Neill F. D’Cruz, MD Lowell W. and Josephine Q. Berry Professor of Psychiatry
OD Consulting and Neurological Services, PLLC and Behavioral Sciences
Chapel Hill, NC Stanford University School of Medicine
Department of Sleep Sciences & Medicine
Steve M. D’Souza, MD Palo Alto, California
Resident
Eastern Virginia University Medical School Jerome A. Dempsey, PhD
Norfolk, Virginia Professor Emeritus
Population Health Sciences;
Meg Danforth, PhD Director
Clinical Psychology John Rankin Laboratory of Pulmonary Medicine
Duke University Faculty Practice in Psychology University of Wisconsin–Madison
Durham, North Carolina Madison, Wisconsin
Yves Dauvilliers, MD, PhD Massimiliano DiGiosia, DDS
Professor Orofacial Pain Clinic
Sleep Unit, Department of Neurology Division of Diagnostic Sciences
Gui de Chauliac Hospital Adams School of Dentistry
Montpellier, France University of North Carolina at Chapel Hill
Chapel Hill, North Carolina
Drew Dawson, PhD
Professor
Appleton Institute
Central Queensland University
Wayville, Australia †Deceased.
xvi Contributors
Derk-Jan Dijk, PhD Jeanne F. Duffy, MBA, PhD

Professor Division of Sleep and Circadian Disorders
Surrey Sleep Research Centre Departments of Medicine and Neurology
Department of Clinical and Experimental Medicine Brigham and Women’s Hospital;
Faculty of Health and Medical Sciences Division of Sleep Medicine
University of Surrey; Harvard Medical School
Investigator Boston, Massachusetts
Dementia Research Institute Care Research and Technology
Centre Peter R. Eastwood, PhD
Imperial College London Director, Flinders Health and Medical Research Institute
University of Surrey Dean of Research and Matthew Flinders Fellow
Guildford, Great Britain College of Medicine and Public Health
Flinders University
David F. Dinges, MS, MA(H), PhD Adelaide, South Australia
Professor and Director, Unit for Experimental Psychiatry
Chief, Division of Sleep and Chronobiology Danny J. Eckert, PhD
Department of Psychiatry Professor and Director
Pereleman School of Medicine Adelaide Institute for Sleep Health
University of Pennsylvania Flinders Health and Medical Research Institute
Philadelphia, Pennsylvania Flinders University
Bedford Park, South Australia
G. William Domhoff, PhD
Distinguished Professor Emeritus and Research Professor in Jack D. Edinger, PhD
Psychology Professor
Department of Psychology Department of Medicine
University of California National Jewish Health
Santa Cruz, California Denver, Colorado;
Adjunct Professor
Jillian Dorrian, PhD, MBiostat Psychiatry and Behavioral Sciences
Professor and Dean of Research Duke University Medical Center
Behavior-Brain-Body Research Centre Durham, North Carolina
University of South Australia
Adelaide, South Australia Bradley A. Edwards, PhD
Department of Physiology
Anthony G. Doufas, MD, PhD School of Biomedical Sciences and Biomedical Discovery
Professor Institute
Department of Anesthesiology, Perioperative and Pain Monash University
Medicine Melbourne, Victoria, Australia
Stanford University School of Medicine
Palo Alto, California Jason G. Ellis, MD
Northumbria Sleep Research
Luciano F. Drager, MD, PhD Faculty of Health and Life Sciences
Associate Professor of Medicine Northumbria University
Department of Internal Medicine Newcastle, United Kingdom
University of Sao Paulo
Sso Paulo, Brazil Daniel Erlacher, PhD, MD
Institute of Sport Science
Christopher L. Drake, PhD, FAASM, DBSM University of Bern
Director of Sleep Research Bern, Switzerland
Division of Sleep Medicine
Henry Ford Health System; Gregory Essick, DDS, PhD
Professor Professor
Department of Psychiatry and Behavioral Neuroscience Division of Comprehensive Oral Health
Wayne State University School of Medicine Adams School of Dentistry
Detroit, Michigan University of North Carolina at Chapel Hill
Martin Dresler, PhD
Radboud University Medical Center Marissa A. Evans, MS
Department of Cognitive Neuroscience Department of Psychiatry
Donders Institute for Brain, Cognition, and Behavior University of Pittsburgh
Nijmegen, The Netherlands Pittsburgh, Pennsylvania
Contributors xvii
Véronique Fabre, PhD Karl A. Franklin, MD, PhD

Neuroscience Paris Seine Assistant Professor
INSERM Department of Surgery
Sorbonne Université Paris Surgical and Preoperative Sciences
Paris, France Umeå University
Umeå, Sweden
Francesca Facco, MD
Associate Professor of Medicine Neil Freedman, MD, FCCP
Department of Obstetrics, Gynecology, and Reproductive Head, Division of Pulmonary and Critical Care
Sciences Department of Medicine
University of Pittsburgh School of Medicine NorthShore University Healthsystem;
Pittsburgh, Pennsylvania Clinical Professor of Medicine
University of Chicago Pritzker School of Medicine
Ronnie Fass, MD Chicago, Illinois
Director, Division of Gastroenterology and Hepatology
Department of Medicine Liam Fry, MD, CMD, FACP
MetroHealth Medical Center; Division Chief of Geriatrics and Palliative Medicine
Professor of Medicine Department of Internal Medicine
Case Western Reserve University University of Texas Dell Medical School;
Cleveland, Ohio President
Austin Geriatric Specialists
Luigi Ferini-Strambi, MD Austin, Texas
Professor of Neurology
Department of Clinical Neuroscience Patrick M. Fuller, MS, PhD
Università Vita-Salute San Raffaele Professor of Neurological Surgery
Milano, Italy Vice Chair of Research
University of California, Davis School of Medicine
Julio Fernandez-Mendoza, PhD, CBSM, DBSM Sacramento, California
Associate Professor
Director, Behavioral Sleep Medicine Program Constance H. Fung, MD, MSHS
Sleep Research & Treatment Center Geriatric Research, Education and Clinical Center
Department of Psychiatry and Behavioral Health VA Greater Los Angeles Healthcare System;
Penn State University College of Medicine Associate Professor
Penn State Health Milton S. Hershey Medical Center Department of Medicine
Hershey, Pennsylvania David Geffen School of Medicine
University of California, Los Angeles
Fabio Ferrarelli, MD, PhD Los Angeles, California
Associate Professor of Psychiatry
Department of Psychiatry Carles Gaig, MD, PhD
University of Pittsburgh Multidisciplinary Sleep Unit
Pittsburgh, Pennsylvania Neurology Department
Hospital Clinic Barcelona
Raffaele Ferri, MD Barcelona, Spain
Sleep Research Centre
Department of Neurology I.C. Philippa H. Gander, PhD, FRSNZ, ONZM
Oasi Research Institute - IRCCS Professor Emeritus
Troina, Italy Sleep/Wake Research Centre
Massey University
Stuart Fogel, PhD Wellington, New Zealand
Associate Professor
School of Psychology Sheila N. Garland, PhD
University of Ottawa Associate Professor
Ottawa, Ontario, Canada Department of Psychology, Faculty of Science
Discipline of Oncology, Faculty of Medicine
Jimmy J. Fraigne, PhD Memorial University
Senior Research Associate St. John’s, Newfoundland, Canada
Department of Cell & Systems Biology
University of Toronto Philip R. Gehrman, PhD
Toronto, Canada Associate Professor
Paul Franken, PhD University of Pennsylvania Perelman School of Medicine
Associate Professor Philadelphia, Pennsylvania
Center for Integrative Genomics
University of Lausanne
Lausanne, Switzerland
xviii Contributors
Martha U. Gillette, PhD R. Curtis Graeber, BA, MA, PhD

Alumni Professor Honorary Fellow
Cell and Developmental Biology Sleep/Wake Research Centre
Professor Massey University
Beckman Institute for Advanced Science & Technology Wellington, New Zealand
Molecular and Integrative Physiology
Director Michael A. Grandner, PhD, MTR
Neuroscience Program Assistant Professor
University of Illinois at Urbana-Champaign Department of Psychiatry
Urbana, Illinois University of Arizona
Tucson, Arizona
Kevin S. Gipson, MD, MS
Assistant in Pediatrics Harly Greenberg, MD
Department of Pediatrics Professor of Medicine
Massachusetts General Hospital; Northwell Sleep Disorders Center;
Instructor Chief, Division of Pulmonary, Critical Care, and Sleep Medicine
Harvard Medical School Professor of Medicine
Boston, Massachusetts Donald and Barbara Zucker School of Medicine at
Hofstra-Northwell
Peter J. Goadsby, MD, PhD, DSc New Hyde Park, New York
University of California, Los Angeles Alice M. Gregory, BSc, PhD
Los Angeles, California; Professor
National Institute for Health Research–Wellcome Trust Department of Psychology
King’s Clinical Research Facility Goldsmiths
King’s College London University of London
London, United Kingdom London, Great Britain
Avram R. Gold, MD Edith Grosbellet, PhD

Associate Professor of Clinical Medicine Institute of Cellular and Integrative Neurosciences
Pulmonary, Critical Care, and Sleep Medicine Strasbourg, France
Stony Brook University School of Medicine
Stony Brook, New York Ludger Grote, MD, PhD
Professor
Cathy A. Goldstein, MD Sleep Disorders Center
Associate Professor of Neurology Department of Respiratory Medicine
Sleep Disorders Center Sahlgrenska University Hospital
University of Michigan Health System Gothenburg, Sweden
Ann Arbor, Michigan
Ronald Grunstein, MBBS, MD, PhD, FRACP
Joshua J. Gooley, PhD Professor
Associate Professor Sleep and Circadian Research Group
Program in Neuroscience and Behavioral Disorders Woolcock Institute of Medical Research
Duke-NUS Medical School Sydney, Australia
Singapore
Christian Guilleminault, MD, BioL†
Nadia Gosselin, PhD Professor
Associate Professor Department of Psychiatry and Behavioral Sciences
Department of Psychology Sleep Medicine Division
Université de Montréal; Stanford University School of Medicine
Researcher Redwood City, California
Center for Advanced Research in Sleep Medicine
Hôpital du Sacré-Coeur de Montréal Andrew Gumley, MD
Montreal, Quebec, Canada Institute of Health and Wellbeing
University of Glasgow
Daniel J. Gottlieb, MD, MPH Glasgow, United Kingdom
Medical Service
VA Boston Healthcare System; Hannah Gura, BS
Division of Sleep and Circadian Disorders Research Fellow
Departments of Medicine and Neurology National Institute of Mental Health
Brigham and Women’s Hospital; Bethesda, Maryland
Harvard Medical School
Boston, Massachusetts †Deceased.
Contributors xix
Monika Haack, MD Luke A. Henderson, BSc, PhD

Associate Professor of Neurology Professor
Department of Neurology Department of Anatomy and Histology
Beth Israel Deaconess Medical Center Brain and Mind Centre
Boston Massachusetts University of Sydney
Sydney, Australia
Martica H. Hall, PhD
Professor Rebecca C. Hendrickson, MD, PhD
Department of Psychiatry Northwest Network Mental Illness Research Education and
Clinical and Translational Science Clinical Center (MIRECC)
University of Pittsburgh Department of Psychiatry and Behavioral Sciences
Pittsburgh, Pennsylvania University of Washington
Seattle, Washington
Erin C. Hanlon, PhD
Research Associate Professor Alberto Herrero Babiloni, DDS, MS
Department of Medicine PhD Candidate
Section of Pediatric and Adult Endocrinology, Diabetes, and Department of Experimental Medicine
Metabolism McGill University
University of Chicago CUISS NIM
Chicago, Illinois Montreal, Quebec, Canada
Ronald M. Harper, PhD W. Joseph Herring, MD, PhD

Distinguished Professor Associate Vice President
Department of Neurobiology Clinical Neuroscience
David Geffen School of Medicine Merck & Co., Inc.
Distinguished Professor Kenilworth, New Jersey
Brain Research Institute
University of California at Los Angeles Elisabeth Hertenstein, MD
Los Angeles, California University Hospital of Psychiatry and Psychotherapy
University of Bern
Krisztina Harsanyi, MD Bern, Switzerland
Assistant Professor
Department of Pediatrics David Hillman, MBBS, FANZCA
University of Alabama at Birmingham Emeritus Physician
Birmingham, Alabama Sir Charles Gairdner Hospital;
Clinical Professor
Eric Heckman, MD Medical School, Surgery and School of Human Sciences
Instructor in Medicine University of Western Australia
Division of Pulmonary, Critical Care, and Sleep Medicine Perth, Australia
Department of Medicine
Beth Israel Deaconess Medical Center Max Hirshkowitz, PhD
Harvard Medical School Professor (Emeritus)
Boston, Massachusetts Department of Medicine
Baylor College of Medicine
Jan Hedner, MD, PhD Houston, Texas
Professor
Sleep and Vigilance Disorders Aarnoud Hoekema, MD, DMD, PhD
Department of Internal Medicine Oral and Maxillofacial Surgery
Sahlgrenska University Hospital Tjongerschans Hospital
Gothenburg, Sweden Heerenveen, The Netherlands;
Department of Oral Kinesiology
Brent E. Heideman, MD Academic Centre for Dentistry Amsterdam
Clinical Felow Amsterdam, The Netherlands
Division of Allergy, Pulmonary, and Critical Care Medicine Birgit Högl, MD
Vanderbilt University Medical Center Head of the Sleep Disorders Clinic
Nashville, Tennessee Department of Neurology
Innsbruck Medical University
Raphael Heinzer, MD, MPH Innsbruck, Austria
Director
Center for Investigation and Research in Sleep (CIRS)
University Hospital of Lausanne;
Associate Professor
University of Lausanne
Lausanne, Switzerland
xx Contributors
Richard L. Horner, PhD Chandra L. Jackson, MD

Professor Epidemiology Branch
Department of Medicine and Department of Physiology National Institute of Environmental Health Sciences
University of Toronto; National Institutes of Health
Canada Research Chair in Sleep and Respiratory Department of Health and Human Services
Neurobiology Research Triangle Park, North Carolina;
Toronto, Ontario, Canada Division of Intramural Research
National Institute on Minority Health and Health
Amanda N. Hudson, BS, MA Disparities
Graduate Research Assistant National Institutes of Health
Sleep and Performance Research Center Department of Health and Human Services
Elson S. Floyd College of Medicine Bethesda, Maryland
Washington State University
Spokane, Washington Shahrokh Javaheri, MD
Professor Emeritus
Steven R. Hursh, PhD Department of Pulmonary Critical Care and Sleep
President University of Cincinnati
Institutes for Behavior Resources, Inc.; Cincinnati, Ohio;
Adjunct Professor Adjunct Professor
Department of Psychiatry and Behavioral Biology Department of Cardiology
Johns Hopkins University School of Medicine The Ohio State University
Baltimore, Maryland Columbus, Ohio
Nelly Huynh, DDS Sogol Javaheri, MD, MPH, MA
Faculty of Dental Medicine Physician
Université de Montréal Department of Sleep Medicine
Montréal, Quebec, Canada Brigham and Women’s Hospital
Boston, Massachusetts
Mari Hysing, MD
Department of Psychosocial Science Peng Jiang, PhD
University of Bergen Research Assistant Professor
Bergen, Norway Center for Sleep and Circadian Biology
Northwestern University
Octavian C. Ioachimescu, MD, PhD, MBA Evanston, Illinois
Section Chief and Medical Director
Sleep Medicine Center Yandong Jiang, MD, PhD
Atlanta VA Clinic Professor
Decatur, Georgia; Department of Anesthesiology
Professor of Medicine University of Texas, Houston
Department of Medicine Health Science Center
Division of Pulmonary, Critical Care, and Sleep Medicine Houston, Texas
Emory University School of Medicine
Atlanta, Georgia Hadine Joffe, MD, MSc
Paula A. Johnson Professor of Psychiatry in the Field of
Mary Ip, MD Women’s Heath
Chair and Professor Executive Director of Mary Horrigan Connors Center for
Department of Medicine Women’s Health and Gender Biology
The University of Hong Kong Executive Vice Chair for Academic and Faulty Affairs
Hong Kong, China Department of Psychiatry
Brigham and Women’s Hospital
Alex Iranzo, MD, PhD Harvard Medical School
Neurologist Boston, Massachusetts
Neurology Service
Hospital Clinic de Barcelona David A. Johnson, MD, MACG, FASGE, MACP
Institut d’Investigació Biomèdiques; Professor of Medicine and Chief
Associate Professor Department of Internal Medicine
University of Barcelona Division of Gastroenterology and Hepatology
Barcelona, Spain Eastern Virginia Medical School
Norfolk, Virginia
Bilgay Izci Balserak, PhD
Associate Professor
Department of Biobehavioral Health Science
Center for Sleep and Health Research
University of Illinois College of Nursing
Chicago, Illinois
Contributors xxi
Karin Johnson, MD, FAASM, FAAN Douglas Kirsch, MD

Associate Professor Medical Director
UMMS - Baystate Regional Campus Department of Sleep Medicine
Neurology at UMMS-Baystate; Professor
Medical Director Department of Medicine and Neurology
Baystate Health Regional Sleep Program Atrium Health
Springfield, Massachusetts Charlotte, North Carolina;
Professor
Anne E. Justice, MA, PhD Department of Medicine
Assistant Professor of Population Health Sciences University of North Carolina School of Medicine
Geisinger Health System Chapel Hill, North Carolina
Danville, Pennsylvania
Christopher E. Kline, PhD
Marc Kaizi-Lutu, BA Assistant Professor of Health and Physical Activity
Unit for Experimental Psychiatry Department of Health and Human Development
Division of Sleep and Chronobiology University of Pittsburgh
Department of Psychiatry Department of Health and Physical Activity
Perelman School of Medicine Pittsburgh, Pennsylvania
University of Pennsylvania
Philadelphia, Pennsylvania Melissa P. Knauert, MD, PhD
Assistant Professor
David A. Kalmbach, PhD Section of Pulmonary, Critical Care and Sleep Medicine
Thomas Roth Sleep Disorders & Research Center Department of Internal Medicine
Division of Sleep Medicine Yale University School of Medicine
Henry Ford Health System New Haven, Connecticuit
Detroit, Michigan
Kristen L. Knutson, PhD
Elissaios Karageorgiou, MD, PhD Associate Professor
Division Chief Department of Neurology
Sleep & Memory Center Northwestern University
Scientific Director Chicago, Illinois
Neurological Institute of Athens
Athens, Greece Abigail L. Koch, MD, MHS
Assistant Chief
Eliot S. Katz, MD Division of Pulmonary Medicine
Assistant Professor of Pediatrics Miami VA Healthcare System
Harvard Medical School; Miami, Florida
Division of Pulmonology
Boston Children’s Hospital George F. Koob, MD
Boston, Massachusetts National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health
Brendan T. Keenan, MS Bethesda, Maryland
Co-Director, Biostatistics Core
Division of Sleep Medicine Sanjeev V. Kothare, MD, FAAN, FAASM
Department of Medicine Director, Division of Pediatric Neurology
University of Pennsylvania Perelman School of Medicine Department of Pediatrics
Philadelphia, Pennsylvania Cohen Children’s Medical center
New Hyde Park, New York;
Sharon Keenan, PhD Director, Pediatric Neurology Service Line for Northwell
Director Health
Department of Sleep Medicine Professor of Pediatrics and Neurology
The School of Sleep Medicine, Inc. Zucker School of Medicine at Hofstra Northwell
Palo Alto, California Lake Success, New York
Thomas Kilduff, PhD
Center Director, Center for Neuroscience
Biosciences Division
SRI International
Menlo Park, California
xxii Contributors
Kyoshi Koyano, DDS, PhD Hans-Peter Landolt, PhD

Professor Human Sleep Psychopharmacology Laboratory
Department of Implant and Rehabilitative Dentistry Institute of Pharmacology and Toxicology
Faculty of Dental Science Sleep and Health Zürich
Kyushu University University Center of Competence
Fukuoka, Japan University of Zürich
Zürich, Switzerland
James M. Krueger, PhD, MDHC
Regents Professor Jessica Lara-Carrasco, PhD
Integrative Physiology and Neuroscience Clinical Psychologist
Washington State University Hôpital Maisonneuve-Rosemont
Spokane, Washington CIUSSS del’Est-de-l’île-de-Montéal
Montreal, Quebec, Canada
Meir Kryger, MD, FRCPC
Professor Gilles Lavigne, DMD, FRCDI, PhD
Pulmonary, Critical Care, and Sleep Medicine Professor
Yale University School of Medicine Faculty of Dental Medicine
New Haven, Connecticuit Université de Montréal
CIUSS NIM and CHUM-Stomatology
Andrew D. Krystal, MD, MS Montréal, Quebec, Canada
Ray and Dagmar Dolby Distinguished Professor
Department of Psychiatry Michael Lazarus, PhD
University of California, San Francisco International Institute for Integrative Sleep Medicine
San Francisco, California University of Tsukuba
Tsukuba, Japan
Samuel T. Kuna, MD
Professor of Medicine Han-Hee Lee, MD
Department of Medicine Department of Cell and Systems Biology
Perelman School of Medicine at the University of Pennsylvania; University of Toronto
Chief Toronto, Ontario, Canada
Sleep Medicine Section
Department of Medicine Guy Leschziner, MBBS, MA, PhD, FRCP
Corporal Michael J. Crescenz Veterans Affairs Medical Center Consultant Neurologist
Philadelphia, Pennsylvania Sleep Disorders Centre
Guy’s and St Thomas’ NHS Trust;
Scott Kutscher, MD Professor of Neurology and Sleep Medicine
Associate Professor Institute of Psychiatry, Psychology, and Neuroscience
Department of Sleep Medicine King’s College London
Stanford University London, Great Britain
Redwood City, California
John A. Lesku, PhD
Stephen LaBerge, PhD Associate Professor
Research Associate School of Life Sciences
Department of Psychology La Trobe University
Stanford University Melbourne, Australia
Palo Alto, California
Christopher J. Lettieri, MD
Annie C. Lajoie, MD Professor of Medicine
Respirology Fellow Department of Pulmonary, Critical Care, and Sleep Medicine
Department of Respirology Uniformed Services University of the Health Sciences
Institut Universitaire de Cardiologie et de Pneumologie de Bethesda, Maryland
Québec
Quebec City, Quebec, Canada Vicki Li
Project Assistant
Amanda Lamp, BS, MS, PhD Research Institute
Research Assistant Professor California Pacific Medical Center
Sleep and Performance Research Center San Francisco, California
Washington State University
Spokane, Washington Paul-Antione Libourel, PhD
Neurosciences Reseach Center of Lyon (CRNL)
Team SLEEP
Lyon, France
Contributors xxiii
Melissa C. Lipford, MD Atul Malhotra, MD

Center for Sleep Medicine Professor of Medicine
Department of Neurology Peter C. Farrell Presidential Chair in Respiratory Medicine
Division of Pulmonary and Critical Care Medicine Department of Pulmonary, Critical Care, and Sleep
Mayo Clinic Medicine
Rochester, Minnesota University of Southern California, San Diego;
Research Chief of Pulmonary, Critical Care, and Sleep
Frank Lobbezoo, DDS, PhD Medicine
Professor and Chair University of California, San Diego School of Medicine
Department of Orofacial Pain and Dysfunction La Jolla, California
Academic Centre for Dentistry Amsterdam (ACTA)
Amsterdam, The Netherlands Raman K. Malhotra, MD
Associate Professor of Neurology
Geraldo Lorenzi-Filho, MD, PhD Washington University School of Medicine
Associate Professor Saint Louis, Missouri
Department of Cardio-Pulmonology
University of Sao Paulo Beth A. Malow, MD, MS
Sao Paulo, Brazil Professor
Department of Neurology and Pediatrics
Judette Louis, MD, MPH Director
James M. Ingram Professor and Chair Sleep Disorders Division
Department of Obstetrics and Gynecology Department of Neurology and Pediatrics
Morsani College of Medicine Vanderbilt University Medical Center
University of South Florida Nashville, Tennessee
Tampa, Florida
Rachel Manber, PhD
Brendan P. Lucey, MD, MSCI Professor
Associate Professor of Neurology Psychiatry and Behavioral Sciences
Sleep Medicine Section Head Stanford University
Washington University School of Medicine Palo Alto, California
Saint Louis, Missouri
Daniele Manfredini, DDS, MSc, PhD
Ralph Lydic, PhD Professor
Professor School of Dentistry
Department of Psychology University of Siena
University of Tennessee Siena, Italy
Knoxville, Tennessee;
Joint Faculty Jim Mangie, BS
Biosciences Division Aeronautical Studies Program Director
Oak Ridge National Laboratory Pilot Fatigue Flight Operations Delta Air Lines
Oak Ridge, Tennessee Atlanta, Georgia
Madalina Macrea, MD, PhD, MPH Edward Manning, MD, PhD

Department of Pulmonary and Sleep Medicine Intensivist, Pulmonologist
Salem Veterans Affairs Medical Center Veterans Affairs Connecticut Healthcare System;
Salem, Virginia; Instructor
Associate Professor Pulmonary and Critical Care Medicine
University of Virginia Yale School of Medicine
Charlottesville, Virginia New Haven, Connecticut
Mary Halsey Maddox, MD Pierre Maquet, MD, PhD

Associate Professor Sleep and Chronobiology Laboratory
Department of Pediatrics GIGA-Cyclontron Research Center/In Vivo Imaging
University of Alabama at Birmingham University of Liège;
Birmingham, Alabama Professor
Mark W. Mahowald, MD† Liège University Hospital
Professor of Neurology Liège, Belgium
University of Minnesota Medical School;
Visiting Professor
Minnesota Regional Sleep Disorders Center
Hennepin County Medical Center
Minneapolis, Minnesota
†Deceased.
xxiv Contributors
Jose M. Marin, MD Christina S. McCrae, PHD

Head Professorr
Respiratory Sleep Disorders Unit Department of Psychiatry
Hospital Universitario Miguel Servet; University of Missouri-Columbia
Professor of Respiratory Medicine Columbia, Missouri
University of Zaragoza Dennis McGinty, PhD
Zaragoza, Spain Adjunct Professor
Department of Psychology
Marta Marin-Oto, MD University of California
Respiratory Department Research Service
Clinica Universidad de Navarra VA Medical Center, GLAHS
Pamplona, Spain Los Angeles, California
Jennifer L. Martin, PhD Andrew W. McHill, PhD

Associate Director for Clinical and Health Services Research Research Assistant Professor
Geriatric Research, Education and Clinical Center Oregon Institute of Occupational Health Sciences
VA Greater Los Angeles Healthcare System; Oregon Health & Science University
Professor Portland, Oregon
David Geffen School of Medicine Reena Mehra, MD, MS
University of California, Los Angeles Professor of Medicine
Los Angeles, California Sleep Disorders Center, Neurologic Institute
Cleveland Clinic Lerner College of Medicine of Case
Miguel A. Martínez-Garcia, MD, PhD Western Reserve University;
Servicio de Neumologia Respiratory Institute
Hospital Universitario y Politécnico La Fe Department of Molecular Cardiology
Valencia, Spain; Lerner Research Institute
Centro de Investigación Biomédica en Red de Enfermedades Heart and Vascular Institute
Respiratorias (CIBERES) Cleveland, Ohio
Madrid, Spain
Emmanuel Mignot, MD, PhD
Kiran Maski, MD, MPH Director
Associate Professor Center For Sleep Sciences and Medicine
Department of Neurology Stanford University
Boston Children’s Hospital Palo Alto, California
Katherine E. Miller, PhD
Ivy C. Mason, PhD Cpl. Michael J Crescenz VA Medical Center
Postdoctoral Research Fellow Philadelphia, Pennsylvania
Medical Chronobiology Program
Division of Sleep and Circadian Disorders Brienne Miner, MD, MHS
Departments of Medicine and Neurology Assistant Professor
Brigham and Women’s Hospital; Department of Internal Medicine
Research Fellow Section of Geriatrics
Division of Sleep Medicine Yale University
Department of Medicine New Haven, Connecticut
Boston, Massachusetts Jennifer W. Mitchell, PhD
Department of Cell & Developmental Biology
Christopher R. McCartney, MD Neuroscience Program
Professor of Medicine University of Illinois at Urbana-Champaign
Department of Medicine Urbana, Illinois
Division of Endocrinology and Metabolism
University of Virginia School of Medicine Murray Mittleman, MD, DrPH
Charlottesville, Virginia Associate Professor
Colleen McClung, PhD Harvard Medical School;
Professor Associate Professor
Departments of Psychiatry and Clinical and Translational Department of Epidemiology
Science Harvard School of Public Health
University of Pittsburgh School of Medicine Boston, Massachusetts
Pittsburgh, Pennsylvania
Contributors xxv
Vahid Mohsenin, MD Thomas Nesthus, PhD, FRAeS, FasMA

Professor (Emeritus) Engineering Research Psychologist
Department of Medicine Aerospace Human Factors Research Division
Yale University FAA, Civil Aerospace Medical Institute
New Haven, Connecticuit Oklahoma City, Oklahoma
Babak Mokhlesi, MD, MSc Natalie Nevárez, MD

J. Bailey Carter Professor of Medicine Department of Psychiatry and Behavioral Sciences
Chief, Division of Pulmonary, Critical Care and Sleep Stanford University
Medicine Palo Alto, California
Co-Director, Rush Lung Center
Department of Internal Medicine Tore Nielsen, PhD
Rush University Medical Center Professor
Chicago, Illinois Department of Psychiatry and Addictology
Université de Montréal;
Jacques Montplaisir, PhD Director, Dream & Nightmare Laboratory
Professor Center for Advanced Research in Sleep Medicine
Department of Psychiatry CIUSSS du Nord-de-l’Île-de-Montréal (Hôpital du
Université de Montréal; Sacré-Coeur)
Center for Advanced Research on Sleep Medicine Montreal, Quebec, Canada
CIUSSS du Nord-de-l’Île-de-Montréal
Hôpital du Sacré-Coeur de Montréal Christoph Nissen, MD
Montreal, Quebec, Canada University Hospital of Psychiatry and Psychotherapy
University of Bern
Charles M. Morin, PhD Bern, Switzerland
Professor
Department of Psychology Eric A. Nofzinger, MD
Director Adjunct Professor
Center for the Study of Sleep Disorders Department of Psychiatry
Canada Research Chair in Sleeping Disorders University of Pittsburgh
Laval University Pittsburgh, Pennsylvania
Quebec City, Quebec, Canada
Christopher B. O’Brien, BS
Mary J. Morrell, PhD Department of Psychology
Professor of Sleep and Respiratory Physiology University of Tennessee
National Heart and Lung Institute Knoxville, Tennessee
Imperial College
London, Great Britain Louise M. O’Brien, PhD, MS
Associate Professor
Tanvi H. Mukundan, MD Division of Sleep Medicine
Program Director, Sleep Associate Professor
Veterans Administration Department of Obstetrics & Gynecology
Portland, Oregon Associate Research Scientist
Oral & Maxillofacial Surgery
Erik Musiek, MD, PhD University of Michigan
Associate Professor Ann Arbor, Michigan
Washington University School of Medicine Bruce O’Hara, PhD
Saint Louis, Missouri Professor
Department of Biology
Carlotta Mutti, MD University of Kentucky
Sleep Disorders Center Lexington, Kentucky
Department of Medicine and Surgery
University of Parma Yo Oishi, PhD
Parma, Italy International Institute for Integrative Sleep Medicine
University of Tsukuba
Alexander D. Nesbitt, BM BCh, PhD, FRCP Tsukuba, Japan
Consultant Neurologist and Sleep Physician
Sleep Disorders Centre and Department of Neurology Eric J. Olson, MD
Guy’s and St Thomas’ NHS Foundation Trust Division of Pulmonary and Critical Care Medicine
London, Great Britain Center for Sleep Medicine
Mayo Clinic
Rochester, Minnesota
xxvi Contributors
Jason C. Ong, PhD Milena K. Pavlova, MD, FAASM

Associate Professor Medical Director, Faulkner Sleep Testing Center
Department of Neurology Department of Neurology
Center for Circadian and Sleep Medicine Brigham and Women’s Hospital;
Northwestern University Feinberg School of Medicine Associate Professor of Neurology
Chicago, Illinois Department of Neurology
Mark R. Opp, PhD Boston, Massachusetts
Professor and Chair
Integrative Physiology John H. Peever, PhD
University of Colorado Boulder Professor
Boulder, Colorado Department of Cell and Systems Biology
University of Toronto
Edward F. Pace-Schott, PhD Toronto, Ontario, Canada
Assistant Professor of Psychiatry
Harvard Medical School Philippe Peigneux, PhD
Boston, Massachusetts; Full Professor
Massachusetts General Hospital Neuropsychology and Functional Neuroimaging at Centre
Charlestown, Massachusetts for Research in Cognition and Neurosciences
Universite Libre de Bruxelles
Allan I. Pack, MB, ChB, PhD, FRCP Bruxelles, Belgium
John Miclot Professor of Medicine
Division of Sleep Medicine Yüksel Peker, MD, PhD
Department of Medicine Professor
University of Pennsylvania Perelman School of Medicine Department of Pulmonary Medicine
Philadelphia, Pennsylvania Head of Sleep Medicine Unit
Koç University School of Medicine
John Park, MD Istanbul, Turkey
Associate Professor of Medicine
Division of Pulmonary and Critical Care Medicine Rafael Pelayo, MD
Mayo Clinic Clinical Professor
Rochester, Minnesota Sleep Medicine Division
Stanford Univeristy School of Medicine
Liborio Parrino, MD Stanford, California
Professor
Department of Medicine and Surgery Thomas Penzel, MD
University of Parma Research Director of Sleep Center
Parma, Italy Interdisciplinary Sleep Medicine Center
Charité–Universitätsmedizin Berlin
Sara Pasha, MBBS Berlin, Germany
Assistant Professor
Pulmonary, Critical Care, and Sleep Medicine Jean-Louis Pépin, MD, PhD
University of Kentucky Pneumology-Physiology Department
Lexington, Kentucky Grenoble Alpes University Hospital;
INSERM U1300, HP2 Laboratory
Michael Paskow, MPH Grenoble Alpes University
Associate Director Grenoble, France
Epidemiology, Global Real-World Evidence Generation
Washington, DC Michael L. Perlis, PhD
Susheel P. Patil, MD, PhD, ATSF University of Pennsylvania
System Director, UH Sleep Medicine Philadelphia, Pennsylvania
Section Chief, Sleep Medicine
Division of Pulmonary, Critical Care, and Sleep Medicine Lampros Perogamvros, MD
Clinical Associate Professor of Medicine Department of Medicine
Case Western Reserve University School of Medicine University Hospitals of Geneva
Cleveland, Ohio University of Geneva
Geneva, Switzerland
Alexander Patrician, MSc
Department of Health and Exercise Sciences
The University of British Columbia
Kelowna, British Columbia, Canada
Contributors xxvii
Dominique Petit, PhD Stacey Dagmar Quo, DDS, MS

Research Associate School of Dentistry
Center for Advanced Research in Sleep Medicine University of California San Francisco
CIUSSS du Nord-de-l’Île-de-Montréal – Hôpital du Sacré- San Francisco, California
Coeur de Montréal
Montreal, Quebec, Canada Shadab Rahman, PhD
Instructor in Medicine
Megan E. Petrov, PhD Division of Sleep Medicine
Assistant Professor Harvard Medical School;
College of Nursing and Health Innovation Associate Neuroscientist
Arizona State University Division of Sleep and Circadian Disorders
Phoenix, Arizona Departments of Medicine and Neurology
Brigham and Women’s Hospital
Dante Picchioni, PhD Boston, Massachusetts
Scientist (contractor)
National Institute of Neurological Disorders and Stroke David Raizen, MD, PhD
Bethesda, Maryland Associate Professor of Neurology
Perelman School of Medicine
Grace W. Pien, MD, MSCE University of Pennsylvania
Assistant Professor of Medicine Philadelphia, Pennsylvania
Johns Hopkins University School of Medicine Preethi Rajan, MD
Baltimore, Maryland Division of Pulmonary, Critical Care, and Sleep Medicine
Wilfred R. Pigeon, PhD Northwell Heath;
Professor Donald and Barbara Zucker School of Medicine at
Psychiatry & Public Health Sciences Hofstra-Northwell
University of Rochester Medical Center New Hyde Park, New York
Rochester, New York;
Executive Director Shantha Rajaratnam, MD
Center of Excellence for Suicide Prevention School of Psychological Sciences
U.S. Department of Veterans Affairs Turner Institute for Brain and Mental Health
Canandaigua, New York Monash University
Melbourne, Victoria, Australia
Margaret A. Pisani, MD, MPH
Associate Professor Kannan Ramar, MD
Internal Medicine–Pulmonary, Critical Care, and Sleep Center for Sleep Medicine
Yale University Division of Pulmonary and Critical Care Medicine
New Haven, Connecticuit Mayo Clinic
Rochester, Minnesota
Melanie Pogach, MD, MMSc
Assistant Professor of Medicine Winfried J.︎ Randerath, MD
Tufts University School of Medicine Department of Clinic of Pneumology
SEMC/SMG Pulmonary, Critical Care, and Sleep Medicine Bethanien Hospital
Director, Chronic Respiratory Failure Program Institute of Pneumology at the University of Cologne
St. Elizabeth’s Medical Center Solingen, Germany
Brighton, Massachusetts
Karen Raphael, PhD
Donn Posner, PhD Professor
Department of Psychiatry and Behavioral Science Department of Psychiatry and Behavioral Sciences
Stanford University University of Washington;
Palo Alto, California Behavioral Sciences Director
Mental Illness Research, Education and Clinical Center
Ronald Postuma, MD, MSc VA Puget Sound Health Care System
Professor Seattle, Washington
McGill University Murray Raskind, MD
Montreal, Quebec, Canada Professor
Department of Psychiatry and Behavioral Sciences
Naresh Punjabi, MD, PhD University of Washington;
Division of Pulmonary and Critical Care Medicine Behavioral Sciences Director
Department of Medicine Mental Illness Research, Education and Clinical Center
Johns Hopkins University VA Puget Sound Health Care System
Baltimore, Maryland Seattle, Washington
xxviii Contributors
Kavita Ratarasarn, MBBS James A. Rowley, MD

Associate Professor Professor of Medicine
Department of Medicine Chief, Pulmonary, Critical Care & Sleep Medicine
Medical College of Wisconsin Wayne State University School of Medicine
Milwaukee, Wisconsin Detroit, Michigan
Niels C. Rattenborg, PhD David B. Rye, MD

Group Leader Sleep Center
Avian Sleep Department of University
Max Planck Institute for Ornithology Emory University
Seewiesen, Germany Atlanta, Georgia
Susan Redline, MD, MPH Ashima S. Sahni, MD

Peter C. Farrell Professor of Medicine Assistant Professor of Clinical Medicine
Department of Medicine Division of Pulmonary, Critical Care, Sleep and Allergy
Brigham and Women’s Hospital University of Illinois Hospital and Health Science System
Beth Israel Deaconess Medical Center; Chicago, Illinois
Harvard Medical School Charles Samuels, MD, CCFP, DABSM
Boston, Massachusetts Clinical Assistant Professor
Family Medicine
Kathryn J. Reid, PhD Adjunct Professor
Research Professor Faculty of Kinesiology
Ken and Ruth Davee Department of Neurology University of Calgary;
Center for Circadian and Sleep Medicine CANMedical Director
Northwestern University Feinberg School of Medicine Centre for Sleep and Human Performance
Chicago, Illinois Calgary, Alberta, Canada
Kathy Richards, PhD, RN, FAAN, FAASM Anne E. Sanders, MS, PhD, MS
Research Professor Assistant Professor
School of Nursing Divison of Pediatric and Public Health
University of Texas at Austin Adams School of Dentistry
Austin, Texas University of North Carolina at Chapel Hill
Samantha Riedy, PhD, RPSGT
Senior Statistician Clifford B. Saper, MD, PhD
Behavioral Biology Branch James Jackson Putnam Professor of Neurology and
Walter Reed Army Institute of Research Neuroscience
Silver Spring, Maryland Harvard Medical School;
Dieter Riemann, PhD Beth Israel Deaconess Medical Center
Department of Psychiatry and Psychotherapy Boston, Massachusetts
Medical Center–University of Freiburg;
Faculty of Medicine Michael J. Sateia, MD, FAASM
University of Freiburg Professor of Psychiatry (Sleep Medicine), Emeritus
Freiburg, Germany Geisel School of Medicine at Dartmouth
Hanover, New Hampshire
Timothy Roehrs, PhD
Senior Bioscientist Josée Savard, PhD
Division of Sleep Medicine Professor
Thomas Roth Sleep Disorders and Research Center School of Psychology
Henry Ford Health System; Université Laval
Professor CHU de Québec-Université Laval Research Center
Department of Psychiatry & Behavioral Neuroscience Quebec City, Quebec, Canada
Wayne State University
Detroit, Michigan Marie-Hélène Savard, PhD
Research Associate
Thomas Roth, PhD CHU de Québec Cancer Research Center
Director Québec City, Québec, Canada
Thomas Roth Sleep Disorders and Research Center
Henry Ford Hospital
Detroit, Michigan
Contributors xxix
Thomas E. Scammell, MD Bernardo Selim, MD

Professor Assistant Professor of Medicine
Department of Neurology Section of Pulmonary and Critical Care
Beth Israel Deaconess Medical Center; Department of Medicine, Sleep Medicine
Professor Mayo Clinic
Department of Neurology Rochester, Minnesota
Boston Children’s Hospital;
Professor Frédéric Sériès, MD
Harvard Medical School Centre de pneumologie
Boston, Massachusetts Department of Medicine
Institut Universitaire de Cardiologie et de Pneumologie de
Matthew T. Scharf, MD, PhD Québec
Assistant Professor Quebec City, Quebec, Canada
Medical Director, Robert Wood Johnson Sleep Laboratory
Comprehensive Sleep Center Barry J. Sessle, PhD
Division of Pulmonary and Critical Care Medicine Professor
Robert Wood University Medical School Department of Physiology
Rutgers University Neuroscience Platform
New Brunswick, New Jersey University of Toronto
Toronto, Ontario, Canada
Steven M. Scharf, MD, PhD
Director Amir Sharafkhaneh, MD, PhD
University of Maryland Sleep Disorders Center; Professor of Medicine
Professor of Medicine Department of Medicine
University of Maryland School of Medicine Baylor College of Medicine
Baltimore, Maryland Sleep Disorders & Research Center
Medical Care Line
Frank A.J.L. Scheer, PhD, MSc Michael E. DeBaky VA Medical Center
Professor of Medicine Houston, Texas
Harvard Medical School; Katherine M. Sharkey, MD, PhD
Director, Medical Chronobiology Program Associate Professor
Department of Medicine and Neurology Department of Medicine
Brigham and Women’s Hospital Associate Professor
Boston, Massachusetts Psychiatry & Human Behavior
The Warren Alpert Medical School of Brown University
Logan Schneider, MD Providence, Rhode Island
Staff Neurologist
Stanford/VA Alzhemier’s Center Paul J. Shaw, PhD
MIRECC Investigator Professor
Department of Psychiatry and Behavioral Sciences Department of Neuroscience
Palo Alto Veteran’s Affairs Healthcare System Washington University in St. Louis
Palo Alto, California St. Louis, Missouri
Michael Schredl, PhD Ari Shechter, PhD

Head of Research Assistant Professor of Medical Science
Sleep Laboratory Department of Medicine
Central Institute of Mental Health; Columbia University Medical Center
Medical Faculty New York, New York
Mannheim/Heidelberg University
Mannheim, Germany Stephen H. Sheldon, DO
Professor of Pediatrics and Neurology
Sophie Schwartz, PhD Northwestern University Feinberg School of Medicine
Professor of Neuroscience Sleep Medicine Center
Department of Neurosciences Division of Pulmonary and Sleep Medicine
University of Geneva Ann & Robert H. Lurie Children’s Hospital of Chicago
Geneva, Switzerland Chicago, Illinois
Paula K. Schweitzer, PhD Fahmi Shibli, MD

Director of Research Research Fellow
Sleep Medicine and Research Center MetroHealth Medical Center;
St. Luke’s Hospital Visiting Scholar
Chesterfield, Missouri Case Western Reserve University
Cleveland, Ohio
xxx Contributors
Priyattam J. Shiromani, PhD Anne C. Skeldon, PhD

Professor Department of Mathematics
Department of Psychiatry Faculty of Engineering and Physcial Sciences
Medical University of South Carolina University of Surrey;
Charleston, South Carolina UK Dementia Research Institute Care Research and
Technology Center
Tamar Shochat, DSc Imperial College London
Full Professor University of Surrey
Department of Nursing Guildford, United Kingdom
University of Haifa
Haifa, Israel Carlyle Smith, MD
Psychology Department
Francesca Siclari, MD Trent University
Center for Investigation and Research on Sleep Peterborough, Ontario, Canada;
University Hospital Lausanne Neuroscience Department
Lausanne, Switzerland Queens University,
Kingston, Ontario, Canada
Jerome M. Siegel, PhD
Professor of Psychiatry and Biobehavioral Sciences Michael T. Smith, PhD
David Geffen School of Medicine Professor of Psychiatry, Neurology and Nursing
University of California, Los Angeles; Director, Division of Behavioral Medicine
Chief Neurobiology Research Johns Hopkins School of Medicine
Veterans Affairs Greater Los Angeles Healthcare Baltimore, Maryland
System
Los Angeles, California Virend K. Somers, MD, PhD
Alice Sheets Marriot Professor of Medicine
T. Leigh Signal, Bav, MA (hons), PhD Department of Cardiovascular Medicine
Lecturer Mayo Clinic
Sleep/Wake Research Centre Rochester, Minnesota
School of Health Sciences
Massey University Kai Spiegelhalder, MD PhD
Wellington, The Netherlands Department of Psychiatry and Psychotherapy
Medical Center–University of Freiburg
Michael H. Silber, MBChB Faculty of Medicine
Professor of Neurology University of Freiburg
Center for Sleep Medicine Freiburg, Germany
Mayo Clinic College of Medicine Arthur J. Spielman, PhD, FAASM†
Rochester, Minnesota Cognitive Neuroscience Doctoral Program
The City College of the City University of New York
Norah Simpson, PhD Center for Sleep Medicine
Clinical Associate Professor Weill Cornell Medical College
Psychiatry and Behavioral Sciences New York, New York
Stanford University School of Medicine
Palo Alto, California Victor I. Spoormaker, PhD, MD
Max Planck Institute of Psychiatry
Mini Singh, MBBS Munich, Germany
Assistant Professor
Department of Neurology Erik K. St. Louis, MD, MS
Medical University of South Carolina Associate Professor
Charleston, South Carolina Center for Sleep Medicine
Departments of Neurology and Medicine
Børge Sivertsen, MD Mayo Clinic College of Medicine
Department of Health Promotion Rochester, Minnesota
Norwegian Institute of Public Health
Bergen, Norway Robert Stansbury, MD
Associate Professor and Director
Lillian Skeiky, BS WYU Sleep Evaluation Center
Graduate Research Assistant Section of Pulmonary, Critical Care, and Sleep Medicine
Sleep and Performance Research Center Department of Medicine
Elson S. Floyd College of Medicine West Virginia University School of Medicine
Washington State University Morgantown, West Virginia
Spokane, Washington
†Deceased.
Contributors xxxi
Murray B. Stein, MD, MPH Steven T. Szabo, MD, PhD

Distinguished Professor Assistant Professor
Psychiatry and Public Health Psychiatry and Behavioral Sciences
University of California, San Diego Duke University Medical Center;
La Jolla, California; Attending Psychiatrist
Staff Psychiatrist Mental Health Service Line
Psychiatry Service Durham Veterans Administration Medical Center
Veterans Administration San Diego Healthcare System Durham, North Carolina
San Diego, California
Ronald Szymusiak, PhD
Robert Stickgold, PhD Adjunct Professor
Professor Department of Medicine
Department of Psychiatry David Geffen School of Medicine
Beth Israel Deaconess Medical Center; University of California, Los Angeles;
Professor Research Scientist
Department of Psychiatry Research Service
Harvard Medical School VA Greater Los Angeles Healthcare System
Boston, Massachussetts Los Angeles, California
Katie L. Stone, MA, PhD Mehdi Tafti, PhD

Senior Scientist Department of Biomedical Sciences
Research Institute University of Lausanne
California Pacific Medical Center Lausanne, Switzerland
San Francisco, California
Renaud Tamisier, MD, PhD, MBA
Riccardo Stoohs, MD Professor of Medicine
Director Section of Pulmonary and Physiology Medicine
Sleep Disorders Clinic Departmetn of Thorax and Vessel Medicine
Somnolab Director, Sleep Disorders CCenter
Dortmund, Germany Université Grenoble Alpes
Grenoble, France
Robyn Stremler, RN, PhD, FAAN
Associate Professor Esra Tasali, MD
Lawrence S. Bloomberg Faculty of Nursing Associate Professor
University of Toronto; Department of Medicine
Adjunct Scientist Section of Pulmonary/Critical Care
The Hospital for Sick Children University of Chicago
Toronto, Ontario, Canada Chicago, Illinois
Patrick J. Strollo Jr., MD, FACP, FCCP, FAASM Daniel J. Taylor, MD, PhD
Professor of Medicine and Clinical and Translational Science Professor
Pulmonary, Allergy, and Critical Care Medicine Department of Psychology
Vice Chair for Veterans Affairs University of Arizona
Department of Medicine Tucson, Arizona
Vice President, Medical Service Line
VA Pittsburgh Health System Mihai C. Teodorescu, MD
Pittsburgh, Pennsylvania Associate Professor
Shannon S. Sullivan, MD University of Wisconsin
Clinical Professor Madison, Wisconsin
Division of Pediatric Pulmonary, Asthma, and Sleep
Department of Pediatrics Matthew J.W. Thomas, PhD
Division of Sleep Medicine Associate Professor
Department of Psychiatry School of Health, Medical, and Applied Sciences
Stanford University Appleton Institute
Palo Alto, California Central Queensland University, Australia
Peter Svensson, DDS, PhD, Dr.Odont Robert Joseph Thomas, MD, MMSc
Professor and Head Associate Professor of Medicine
Section for Orofacial Pain and Jaw Function Division of Pulmonary, Critical Care, and Sleep Medicine
Department of Dentistry and Oral Health Department of Medicine
Aarhus University Beth Israel Deaconess Medical Center
Aarhus, Denmark Harvard Medical School
xxxii Contributors
Michael J. Thorpy, MD Margo van den Berg, PhD

Professor of Neurology Lecturer
The Saul R. Korey Department of Neurology Sleep/Wake Research Centre
Albert Einstein College of Medicine at Yeshiva University; School of Health Sciences
Director Massey University
Sleep-Wake Disorders Center Wellington, New Zealand
Montefiore Medical Center
Bronx, New York Hans P.A. Van Dongen, MS, PhD
Professor and Director
Lauren A. Tobias, MD Sleep and Performance Research Center
Assistant Professor Elson S. Floyd College of Medicine
Pulmonary, Critical Care, and Sleep Medicine Washington State University
Yale University School of Medicine Spokane, Washington
New Haven, Connecticuit
Eus Van Someren, MD
Giulio Tononi, MD, PhD Netherlands Institute for Neuroscience
Professor Amsterdam, The Netherlands
University of Wisconsin Olivier M. Vanderveken, MD, PhD
Madison, Wisconsin Department of Ear, Nose and Throat, Head and Neck Surgery
Antwerp University Hospital;
Irina Trosman, MD Professor
Attending Physician, Sleep Medicine Faculty of Medicine and Health Sciences
Health System Clinician of Pediatrics (Pulmonary Medicine) University of Antwerp
Northwestern University Feinberg School of Medicine Antwerp, Belgium
Chicago, Illinois
Gilles Vandewalle, PhD
Fred W. Turek, PhD Sleep and Chronobiology Laboratory
Charles E.& Emma H. Morrison Professor of Biology GIGA-Cyclontron Research Center/In Vivo Imaging
Departments of Neurobiology and Physiology University of Liège
Director, Center for Sleep and Circadian Biology Liège, Belgium
Northwestern University
Evanston, Illinois Andrew W. Varga, MD, PhD
Assistant Professor
Raghu Pishka Upender, MD, MBA Department of Medicine
Medical Director, Associate Professor Icahn School of Medicine at Mount Sinai
Department of Neurology New York, New York
Vanderbilt University Medical Center
Nashville, Tennessee Ivan Vargas, PhD
Department of Psychological Science
Andrew Vakulin, PhD University of Arkansas
FHMRI Sleep Health Fayetteville, Arkansas
Flinders Heath and Medical Research Institute
College of Medicine and Public Health Bradley V. Vaughn, MD
Flinders University Professor of Neurology
Adelaide, Austria Department of Neurology
University of North Carolina
Philipp O. Valko, MD Chapel Hill, North Carolina
Neurology
University Hospital Zurich Øystein Vedaa, PhD
Zurich, Switzerland Department Director
Department of Health Promotion
Eve Van Cauter, PhD Norwegian Institute of Public Health
Frederick H. Rawson Professor Bergen, Norway;
Department of Medicine Researcher
Section of Pediatric and Adult Endocrinology, Diabetes, and Department of Mental Health
Metabolism Norwegian University of Science and Technology
University of Chicago Trondheim, Norway
Chicago, Illinois
Contributors xxxiii
Richard L. Verrier, PhD Terri E. Weaver, PhD, RN

Associate Professor Dean and Professor
Department of Medicine Biobehavioral Nursing Science
Harvard Medical School Professor
Beth Israel Deaconess Medical Center Division of Pulmonary, Critical Care, Sleep, and Allergy
Boston, Massachussetts University of Illinois Chicago College of Medicine
Chicago, Illinois
Alexandros N. Vgontzas, MD
Professor of Psychiatry Gerald L. Weinhouse, MD
Department of Psychiatry and Behavioral Health Associate Physician
Director, Sleep Research and Treatment Center Brigham and Women’s Hospital;
Penn State University College of Medicine Assistant Professor of Medicine
Penn State Health Milton S. Hershey Medical Center Harvard Medical School
Hershey, Pennsylvania Boston, Massachusetts
Aurelio Vidal-Ortiz, MD Pnina Weiss, MD

Laboratory of Sleep Neuroscience Vice Chair of Education
Ralph H. Johnson VA Medical Center Department of Pediatrics
Charleston, South Carolina Yale University School of Medicine
New Haven, Connecticut
Aleksandar Videnovic, MD, MSc
Associate Professor Nancy Wesensten, PhD
Department of Neurology Air Traffic Organization Safety and Technical Training
Harvard Medical School/MGH Safety Services (AJI-15)
Boston, Massachusetts Federal Aviation Administration
Washington, DC
Martha Hotz Vitaterna, PhD
Research Professor Sophie West, MD
Department of Neurobiology Lead
Deputy Director Newcastle Regional Sleep Centre
Center for Sleep and Circadian Biology Newcastle upon Tyne Hospitals National Health Service Trust
Northwestern University Newcastle upon Tyne, United Kingdom
Evanston, Illinois
Ephraim Winocur, DMD
Lauren Waggoner, BS, MA, PhD Clinical Assistant Professor in Orofacial Pain (ret.)
Fatigue Scientist Section of Function, Dysfunction & Pain in the Stomato-
Flight Safety, CSSC gnathic System,
Delta Air Lines, Incorporated Department of Oral Rehabilitation
Atlanta, Georgia The Maurice and Gabriela Goldschleger School of Dental
Medicine
Arthur S. Walters, MD Tel Aviv University
Professor of Neurology Tel Aviv, Israel
Vanderbilt University School of Medicine William Wisden, MA, PhD
Nashville, Tennessee Professor
Department of Life Sciences
Erin J. Wamsley, PhD UK Dementia Research Institute
Associate Professor Imperial College London
Department of Psychology London, Great Britain
Furman University
Greenville, South Carolina Lisa F. Wolfe, MD
Associate Professor of Medicine
Paula L. Watson, MD Division of Pulmonary, Critical Care, and Sleep Medicine
Assistant Professor Northwestern University Feinberg School of Medicine
Pulmonary, Critical Care, and Sleep Medicine Chicago, Illinois
Vanderbilt University Medical Center
Nashville, Tennessee
xxxiv Contributors
Christine Won, MD, MS Antonio Zadra, PhD

Associate Professor Professor
Department of Medicine (Pulmonary, Critical Care, and Department of Psychology
Sleep Medicine) Université de Montréal;
Yale University School of Medicine; Researcher
Medical Director Center for Advanced Research in Sleep Medicine
Yale Centers for Sleep Medicine Hôpital du Sacré-Coeur de Montréal
New Haven, Connecticuit Montreal, Quebec, Canada
Jean Wong, MD, FRCPC Phyllis C. Zee, MD, PhD

Staff Anesthesiologist Professor
Anesthesia and Pain Management Department of Neurology
Toronto Western Hospital; Director, Center for Circadian and Sleep Medicine
Staff Anesthesiologist Northwestern University Feinberg School of Medicine
Department of Anesthesia and Pain Management Chicago, Illinois
Women’s College Hospital;
Associate Professor Jamie M. Zeitzer, PhD
Department of Anesthesia Associate Professor
University of Toronto Stanford Center for Sleep Sciences
Toronto, Ontario, Canada Stanford University;
Health Science Specialist
Kenneth P. Wright, Jr., PhD Mental Illness Research, Education, and Clinical Center
College Professor of Distinction VA Palo Alto Health Care System
Department of Integrative Physiology Palo Alto, California
University of Colorado Boulder
Boulder, Colorado Eric Zhou, PhD
Faculty
Lora Wu, PhD Division of Sleep Medicine
Senior Research Officer Harvard Medical School;
Sleep/Wake Research Centre Staff Psychologist
Massey University Perini Family Survivors’ Center
Wellington, New Zealand Dana-Farber Cancer Institute;
Staff Psychology
Mark Wu, MD, PhD Department of Neurology
Professor Boston Children’s Hospital
Departments of Neurology, Medicine, and Neuroscience Boston, Massachusetts
Johns Hopkins University
Baltimore, Maryland Andrey V. Zinchuk, MD, MHS
Assistant Professor of Medicine
Don Wykoff, BBA, FRAeS Section of Pulmonary, Critical Care, and Sleep Medicine
President Emeritus, Fatigue Working Group Yale University School of Medicine
Chair, Flight Time Duty Time Committee New Haven, Connecticut
International Federation of Airline Pilots’ Associations
Montreal, Quebec, Canada Ding Zou, MD, PhD
Center for Sleep and Vigilance Disorders
Lichuan Ye, PhD, RN Institute of Medicine
Associate Professor Sahlgrenska Academy
School of Nursing University of Gothenburg
Bouvé College of Health Sciences Gothenburg, Sweden
Northeastern University
Boston, University
Magdy Younes, MD, FRCPC, PhD

Distinguished Professor Emeritus
Department of Internal Medicine
University of Manitoba
Winnipeg, Manitoba, Canada
Foreword
Celebrating PPSM: Connected, Collaborative, Global Sleep Is Essential to Health
From birth of the first edition in 1989 to the seventh edition On behalf of the American Academy of Sleep Medicine
in 2021, Principles and Practice of Sleep Medicine (PPSM) has (AASM) and its more than 11,000 members and accredited
been the gold standard of knowledge for this fast-changing sleep centers, we congratulate the editors for completing a
discipline. Today, sleep medicine is a well-established medical new edition of this landmark textbook in this most challeng-
discipline that stands on a strong foundation of scientific and ing and difficult time marked by a worldwide pandemic. Each
clinical knowledge, but just a little over 30 years ago (which edition of Principles and Practice of Sleep Medicine serves as a
for some of us, seems like only yesterday), the landscape was celebration of how far the field of sleep medicine has come
quite different. A search of PubMed revealed only about 300 in a relatively short period of time. This latest edition show-
publications matching the term “sleep medicine,” compared to cases an even greater understanding of the role of sleep and
nearly 12,000 publications in 2020. The exponential growth the circadian system in other medical disorders and overall
in knowledge has fueled the rapid increase in the number of health. As scientists have tirelessly worked to better compre-
clinical sleep medicine centers and doctoral and postdoctoral hend sleep and wake physiology, this edition contains sections
training programs in the US and all over the world. Advances dedicated to new and exciting pharmacotherapeutics that tar-
in basic and clinical sleep and circadian science continue to get novel receptors in the central nervous system to help treat
open up exciting, innovative approaches to diagnose and treat sleep disorders. Although much has changed in content as you
sleep and circadian disorders, and for defining the role of sleep turn the pages of this latest edition, which describes the lat-
as a fundamental requirement for the maintenance of health est findings in areas such as genetics, chronobiology, and con-
and well-being of people at all stages of life and within the sumer sleep monitoring, one constant remains: this textbook
context of health disparities. serves as the standard reference and guiding light for the field
It was indeed a “dream come true” when in 2017 the Nobel of sleep medicine. Even as the AASM develops innovative
Prize in Physiology or Medicine was awarded for the dis- training models for sleep medicine physicians, obtaining and
covery of the genetic mechanisms of circadian rhythms. The reading Principles and Practice of Sleep Medicine continues to
burgeoning evidence that circadian clocks regulate metabolic, serve as initiation for our trainees and students as they enter
immune, cardiovascular, and neural activity in central and our exciting field, and the textbook remains a reliable compan-
peripheral tissues is gaining attention. Circadian medicine ion for the seasoned clinician to reference while taking care of
is now an emerging clinical specialty. In the past, there was patients with sleep disorders.
an artificial separation of circadian and sleep science, but it is At the AASM, we strive to continue the spirit and deter-
increasingly clear that the alignment of these two systems at mination of our founder, and one of the founding editors of
the molecular, cellular, and system levels is critical for health. this book, Dr. William Dement. Although sleep medicine
The potential of integrating the time domain in medicine has professionals around the world mourn losing him in 2020, his
many implications for the future of sleep medicine, and medi- passion to spread the significance of sleep health has not only
cine as a whole. emboldened sleep clinicians and scientists to carry on this
Since the previous edition of PPSM, sleep medicine has mission, but it also fostered significant progress in educating
become even more connected, collaborative, and global. The our public policy makers and society about the importance
World Sleep Society, founded in 2016, represents individual of sleep. Recently we have seen the creation of the first ever
members and more than 40 sleep societies in the world. Inter- Sleep Health Caucus in the United States Congress, as well
national conferences, courses, and events, such as World Sleep as ongoing progress in legislation to delay school start times,
Congress and World Sleep Day, help promote sleep and cir- ensuring that our adolescents are better able to achieve sleep
cadian health, develop training programs for sleep profession- health. This textbook plays a central role in supporting the
als, and foster the development of sleep medicine worldwide. AASM vision that sleep is recognized as essential to health.
The COVID-19 pandemic highlights that our well-being is The AASM and its members look to this textbook to properly
deeply interconnected and reinforces the importance of global care for patients, train our clinicians and scientists, and also
collaboration to translate scientific discoveries into the clinic allow other specialists to learn about how sleep is essential for
and share new perspectives in sleep and circadian medicine. the health of their patients.
This edition of PPSM celebrates the vision and contributions The textbook represents what we have accomplished as a
of the pioneers and giants of our field and delivers the most field thanks to sleep clinicians and scientists, past and pres-
comprehensive state of knowledge of this exciting interdisci- ent, and perhaps more importantly, it also provides a road-
plinary field. map for researchers, whose findings will undoubtedly appear
in future editions. Completed during a worldwide pandemic,
Phyllis C. Zee, MD, PhD this textbook highlights the resiliency of our many colleagues
Director, Center for Circadian and Sleep Medicine to continue to explore sleep and circadian science through
Northwestern University Feinberg School of Medicine research, and it is a testimony to the many sleep specialists
President-Elect World Sleep Society and clinicians who continue to provide evidence-based, up-to-
date clinical care for their patients with sleep disorders while
enduring the pandemic. As with many devastating events,
growth and progress emerge out of necessity, exemplified in
our field through advances such as embracing telemedicine,
xxxv
xxxvi Foreword
utilizing home diagnostic testing and monitoring of sleep Raman K. Malhotra, MD, FAASM
disorders, and recognizing the prevalence of sleep health dis- President, American Academy of Sleep Medicine
parities. Undoubtedly, adaptation and innovation within sleep (2021-2022)
medicine will allow us to rise up to future challenges and dis- Associate Professor of Neurology, Sleep Medicine Center
ruption within the field. The AASM and its members applaud Washington University in St. Louis School of Medicine
the editors and all of the authors for completing this influen-
tial tome amid such obstacles. We thank them for their efforts,
which will further the AASM’s mission of advancing sleep
care and enhancing sleep health to improve lives.
Acknowledgments
We have been working on Principles and Practice of Sleep Medi- Cathy Carroll, Todd Hummell, and Dolores Meloni. They
cine for about a third of a century. Thousands of people have fueled the dream that helped establish a new field of medicine.
been involved in the production of the seven editions. This Many people helped in the preparation of the content of
has been a challenge to produce a volume during a pandemic. this volume, the seventh edition, including those listed below.
Contributors and Elsevier staff worked in the context of lock- The staff members at Elsevier who helped this book in its
downs, isolation, evacuations, while some were caring for seventh journey were Nancy Duffy, Laura Kuehl-Schmidt,
hospitalized patients, while others caring for outpatients. As Lisa Barnes, Kate Mannix, Melanie Tucker, Amy Buxton, and
much as we would like to personally thank each person, there many others involved in production and design for both the
is no way that we can thank them all. Some have retired, some printed volume and the online content.
have died, and some have made important contributions in We also must acknowledge the family members of all the
the production of the various editions but are unknown to us. people involved in the book because they indirectly helped pro-
This group includes secretaries, copyeditors, artists, designers, duce a work that we believe may have had important positive
people who dealt with the page proofs, internet programmers, impact on the lives of thousands, perhaps millions, of people.
and those who physically produced the books. Finally, we wish to thank the many hundreds of authors
We would like to acknowledge all the extraordinary Elsevier and the magnificent work of the section editors and their
editors who gave birth to each previous edition of the book. deputy editors. All their contributions were so great that they
These include Bill Lamsback, Judy Fletcher, Richard Zorab, cannot be measured.
Section and Deputy Editors

1E 1989 Mark Sanders Jerome Siegel
Fred Turek Fred Turek
Mary Carskadon
Frank Zorick
Michael Chase 6E 2017
Richard Ferber 4E 2005 Sonia Ancoli-Israel
Christian Guilleminault
Michael Aldrich Robert Basner
Ernest Hartmann
Ruth Benca Gregory Belenky
Meir Kryger
J. Christian Gillin Dan Brown
Timothy Monk
Max Hirshkowitz Daniel Buysse
Anthony Nicholson
Shahrokh Javaheri Jennifer DeWolfe
Allan Rechtschaffen
Meir Kryger Max Hirshkowitz
Gerald Vogel
Mark W. Mahowald Shahrokh Javaheri
Frank Zorick
Wallace B. Mendelson Andrew Krystal
2E 1994 Jacques Montplaiser Gilles Lavigne
John Orem Kathryn Aldrich Lee
Michael Aldrich
Timothy Roehrs Beth A. Malow
Mary Carskadon
Mark Sanders Timothy Roehrs
Michael Chase
Robert Stickgold Thomas Roth
J. Christian Gillin
Fred Turek Thomas Scammell
Jerome Siegel
Ernest Hartmann 5E 2011 Robert Stickgold
Meir Kryger
Sonia Ancoli-Israel Katie L. Stone
Anthony Nicholson
Gregory Belenky Fred Turek
Allan Rechtschaffen
Ruth Benca Bradley V. Vaughn
Gary Richardson
Daniel Buysse Erin J. Wamsley
Thomas Roth
Michael Cramer-Bornemann Christine Won
Frank Zorick
Charles George
Max Hirshkowitz 7E 2021
3E 2000
Meir Kryger Sabra Abbott
Michael Aldrich
Gilles Lavigne Cathy Alessi
Michael Chase
Kathryn Aldrich Lee Fiona C. Baker
J. Christian Gillin
Beth A. Malow Bei Bei
Mark W. Mahowald Gregory Belenky
Max Hirshkowitz
Wallace B. Mendelson Daniel B. Brown
Mark W. Mahowald
Jacques Montplaisir Jennifer Laurel DeWolfe
Wallace B. Mendelson
Tore Nielsen Christopher L. Drake
R.T. Pivik
Mark Sanders Julio Fernandez-Mendoza
Leon Rosenthal
xxxvii
xxxviii Acknowledgments
Section and Deputy Editors—cont’d

Constance H. Fung Eric A. Nofzinger Renaud Tamisier
Max Hirshkowitz John Park Robert Joseph Thomas
Shahrokh Javaheri Rafael Pelayo Bradley V. Vaughn
Thomas Kilduff Samantha Riedy Erin J. Wamsley
Andrew D. Krystal Thomas Scammell Nancy Wesensten
Hans-Peter Landolt Paul J. Shaw Lisa F. Wolfe
Gilles Lavigne Stephen H. Sheldon Christine Won
Guy Leschziner Jerome M. Siegel Kenneth P. Wright, Jr.
Beth A. Malow Robert Stickgold Phyllis C. Zee
Jennifer Martin Erik K. St. Louis Andrey V. Zinchuk
Kiran Maski Shannon Sullivan
Preface
This edition of PPSM had a very difficult gestation. It was during the following: “Ideas cause ideas and help evolve new ideas.
the pandemic that washed over our unprotected planet in brutal They interact with each other and with other mental forces
waves. All our lives were upended and changed. Our beloved in the same brain, in neighboring brains, and thanks to global
friend and co-editor, Bill Dement, died. Most of us knew people communication, in far distant, foreign brains. And they also
infected with COVID or who had died of COVID. We were interact with the external surroundings to produce in toto a
all deeply concerned that our families and friends might be burstwise advance in evolution that is far beyond anything to
affected. That was the context of the gestation of the book. hit the evolutionary scene yet, including the emergence of the
Before the pandemic, Cathy Goldstein had joined the senior living cell.” Jacques Monod3 wrote the following in Chance
editorial team of the book. Section editors and authors had and Necessity: “For a biologist it is tempting to draw a parallel
agreed to contribute. Then, in early 2020, contributors in Europe between the evolution of ideas and that of the biosphere. For
were impacted, followed by contributors from other continents. while the abstract kingdom stands at a yet greater distance
Some contributors, when contacted, told us they were in the above the biosphere than the latter does above the non-living
hospital with COVID or had family members with COVID. universe, ideas have retained some of the properties of organ-
Many contributors were conscripted to take care of hospitalized isms. Like them they tend to perpetuate their structure and to
patients. Some contributors were banished from their offices breed; they too can fuse, recombine, segregate their content;
with work from home orders and did not have access to the indeed they too can evolve, and in this evolution selection
things they needed to complete their chapters. Even the forest must surely play an important role.” Hofstadter has called
fires in California impacted the book, trapping some authors, this universe of ideas the ideosphere analogous to the bio-
while others had to evacuate their homes. And at the end of the sphere. The ideosphere’s counterpart to the biosphere gene
day, all the contributors produced magnificent chapters. has been called meme by Richard Dawkins.4 He wrote “just
The book has 22 sections, including a new section on as genes propagate themselves in a gene pool by leaping from
“Transition from Childhood.” About 75% of the sections have body to body via sperm or eggs, so memes propagate them-
new editors. The book retains its philosophical underpinnings selves in the meme pool by leaping from brain to brain. … If
with content from the diverse disciplines (basic and clinical) a scientist hears or reads about a good idea, he passes it on
with contributors from 4 continents. to his colleagues and students. He mentions it in his articles
While the book was being produced, several contributors and his lectures. If the idea catches on it can be said to propa-
from this and previous editions died: Richard Allen, Rosalind gate itself spreading from brain to brain … memes should
Cartwright, Bill Dement, Christian Guilleminault, Mark be regarded as living structures, not just metaphorically but
Mahowald, Art Spielman, and Mario Terzano. Their contri- technically.”
butions to medicine will impact the field for generations to Thus, this textbook represents an attempt to summarize the
come. May their memories be a blessing and an inspiration. body of science and ideas that up to now has been transmitted
Just as some of the greatest wines come from grapes that verbally, in articles, and in a few more specialized books. The
survive in the most difficult terrains, we believe that this edi- memes in this volume are drawn from a variety of disciplines,
tion, having weathered a difficult gestation, has produced a including psychology, psychiatry, neurology, pharmacology,
volume worthy of the field of sleep medicine and continues internal medicine, pediatrics, and basic biological sciences.
the vision outlined over 30 years ago. That a field evolves from multidisciplinary roots certainly has
precedents in medicine. The field of infectious diseases has its
Meir Kryger in microbiology, and its practitioners are expected to know
Cathy Goldstein relevant aspects of internal medicine, surgery, gynecology, and
Tom Roth pediatrics. Similarly, oncology has its roots in surgery, hema-
tology, and internal medicine, and its practitioners today must
also know virology and molecular biology. Patients with sleep
FIRST EDITION PREFACE
problems have in the past ‘fallen through the cracks.’ It is not
Medical disorders related to sleep are obviously not new. Yet uncommon to see a patient with classic narcolepsy who has
the discipline of sleep disorders medicine is in its infancy. seen five to ten specialists before a diagnosis is finally made.
There is a large body of knowledge on which to base the dis- There is a clinical need for physicians to know about sleep and
cipline of sleep disorder medicine. We hope that this textbook its disorders.
will play a role in the evolution of this field.
Douglas Hofstadter reviewed how ideas and concepts
evolve and are transmitted.1 In 1965, Roger Sperry2 wrote
1Hofstadter DR. Chapter 3. In: Metamagical Themas: Questing for the Essence of
Mind and Pattern. Toronto: Bantam Books; 1986.

2Sperry R. Mind, brain, and humanist values. In: Platt JR, editor. New Views of the 3Monod J. Chance and Necessity. New York: Vintage Books; 1972.
Nature of Man. Chicago: The university of Chicago Press; 1965. 4Dawkins R. The Selfish Gene. Oxford: Oxford University Press; 1976. p. 206.
xxxix
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libraries of Arabic literature, to compile local histories and poems,
and, in a measure, to become centres for the propagation of
intellectual thought.
That is the condition in which Leo Africanus found them in the
sixteenth century, when he first revealed their existence to an
incredulous and largely unlettered Western world; in which the
pioneer explorers of the nineteenth century found them; in which the
political agents of Great Britain found them ten years ago when
destiny drove her to establish her supremacy in the country. That is
the condition in which they are to-day in this difficult transition stage
when the mechanical engines of modern progress, the feverish
economic activity of the Western world, the invading rattle of another
civilization made up of widely differing ideals, modes of thought, and
aims, assailed them.
Will the irresistible might wielded by the new forces be wisely
exercised in the future? Will those who, in the ultimate resort, direct
it, abide by the experience and the advice of the small but splendid
band of men whose herculean and whole-hearted labours have
inscribed on the roll of British history an achievement, not of
conquest, but of constructive statesmanship of just and sober
guidance nowhere exceeded in our management of tropical
dependencies? Will they be brought to understand all that is
excellent and of good repute in this indigenous civilization; to realize
the necessity of preserving its structural foundations, of honouring its
organic institutions, of protecting and strengthening its spiritual
agencies? Will they have the patience to move slowly; the sympathy
to appreciate the period of strain and stress which these
revolutionary influences must bring with them; the perception to
recognize what elements of greatness and of far-reaching promise
this indigenous civilization contains? Or will they, pushed by other
counsellors, incline to go too fast both politically and economically,
impatiently brushing aside immemorial ceremonies and customs, or
permitting them to be assaulted by selfish interests on the one hand
and short-sighted zeal on the other? Will they forget, amid the
clamorous calls of “progress” and “enlightenment” that their own
proclaimed high purpose (nobly accomplished by their
representatives) of staying the ravages of internal warfare and
healing open wounds will be shamed in the result if, through their
instrumentality, the seeds of deeper, deadlier ills are sown which
would eat away this fine material, destroy the lofty courtesies, the
culture and the healthy industrial life of this land, converting its
peoples into a troubled, shiftless mass, hirelings, bereft of economic
independence and having lost all sense of national vitality? Thoughts
such as these must needs crowd upon the traveller through these
vast spaces and populous centres as he watches the iron horse
pursue its irrevocable advance towards the great Hausa cities of the
plains, as he hears the increasing calls from the newly opened tin
mines for labour, from the Lancashire cotton-spinner for cotton and
markets; as he takes cognisance of the suggestions already being
made to break the spirit of the new and admirable land-law, and of
the efforts to introduce a militant Christian propaganda; as he listens
in certain quarters to the loose talk about the “shibboleths” and
“absurdities” of indigenous forms and ceremonies, the
cumbrousness of native laws and etiquette.
CHAPTER IV
THE LIFE OF THE PEOPLE—THE LONG-DISTANCE TRADER
A broad, sandy road, piercing a belt of shea trees, gnarled and

twisted, their bark figured like the markings of a crocodile’s back,
from which peculiarity you can distinguish the true shea from the so-
called “false” shea, or African oak. From the burnt grasses, golden
flowers destitute of leaf companionship peep timidly forth as though
fearful of such uncongenial surroundings. The heat rays quiver over
the thirsty soil, for it is Christmas time and no rain has fallen for nigh
upon four months. On the summit of a blackened sapling, exquisite
in its panoply of azure blue and pinkey-buff, a bird of the size of our
English jay but afflicted with a name so commonplace that to
mention it in connection with so glorious a visitant would be cruel,
perches motionless, its long graceful tail feathers waving ever so
slightly in the still air. The sun beats downward shrewdly, and
combined with the gentle amble of the patient beast beneath you,
induces drowsiness. You find yourself nodding in the saddle until the
loosening grip of thighs jerks the rider once more into sentiency. It is
hot, dreamily, lethargically hot. All the world seems comatose, the
unfolding panorama unreal as if seen through a fog of visionary
reverie. But there is nothing fanciful about the rapidly approaching
cloud of dust ahead, which emits a swelling murmur of confused
sound. It takes shape and substance, and for the next half-hour or
so, drowsiness and heat are alike forgotten in the contemplation of a
strange medley of men and animals. Droves of cattle, among them
the monstrous horned oxen from the borders of Lake Chad,
magnificent beasts, white or black for the most part. Flocks of
Roman-nosed, short-haired, vacant-eyed sheep—white with black
patches. Tiny, active, bright brown goats skipping along in joyful
ignorance of impending fate. Pack-bullocks, loaded with potash,
cloth, hides and dried tobacco leaves, culinary utensils, and all
manner of articles wrapped in skins or in octagon-shaped baskets
made of parchment, tight drawn in a wicker framework, which later—
on the return journey—will be packed with kolas carefully covered
with leaves. A few camels, skinny and patchy, and much out at
elbows so to speak, similarly burdened. The drivers move among
their beasts. Keeping in the rear, with lengthy staves outstretched
over the animal’s back, they control any tendency to straggle across
the road. Tall spare men, for the most part, these drivers, small-
boned, tough and sinewy. Hausas mainly, good-featured, not
unfrequently bearded men, often possessed of strikingly handsome
profiles, with clean-shaven heads and keen cheerful looks. But many
Tuaregs are here also from the far-distant north, even beyond the
Nigerian border; their fierce eyes gleaming above the black veil
drawn across the face, covering the head and falling upon the robe
beneath, once white, now stained and rent by many weeks of travel.
From the shoulders of these hang formidable, cross-handled swords
in red-leather tasselled scabbards. Nor are the Hausas always
innocent of arms, generally a sword. But here is a professional
hunter who has joined the party. You can tell him from his bow held
in the right hand and the quiver of reed-arrows barbed—and, maybe,
poisoned—slung across his back. The legs of the men are bare to
the knees, and much-worn sandals cover their feet. Some carry
loads of merchandise, food and water-gourds; others have their
belongings securely fastened on bullock or donkey. Women, too,
numbers of them, splendid of form and carriage, one or both arms
uplifted, balancing upon the carrying pad (gammo) a towering load of
multitudinous contents neatly held together in a string bag. Their
raiment is the raiment of antiquity, save that it has fewer folds, the
outer gown, commonly blue in colour, reaching to just below the
knees, the bosom not generally exposed, at least in youth, and
where not so intended, gravely covered as the alien rides by; neck,
wrists and ankles frequently garnished with silver ornaments. Many
women bear in addition to the load upon the head, a baby on the
back, its body hidden in the outer robe, its shiny shaven head
emerging above, sometimes resting against the soft and ample
maternal shoulders, sometimes wobbling from side to side in
slumber, at the imminent risk, but for inherited robustness in that
region, of spinal dislocation. Children of all ages, the elders doing
their share in porterage, younger ones held by the hand (nothing can
be more charming than the sight of a youthful Nigerian mother
gladsome of face and form teaching the young idea the mysteries of
head-carriage!). Two tired mites are mounted upon a patient ox, the
father walking behind. A sturdy middle-aged Hausa carries one child
on his shoulders, grasps another by the wrist, supporting his load
with his free hand. A gay, dusty crowd, weary and footsore, no
doubt, tramping twenty miles in a day carrying anything from forty to
one hundred pounds; but, with such consciousness of freedom, such
independence of gait and bearing! The mind flies back to those
staggering lines of broken humanity, flotsam and jetsam of our great
cities, products of our “superior” civilization, dragging themselves
along the Herefordshire lanes in the hop-picking season! What a
contrast! And so the trading caravan, bound for the markets of the
south, for Lokoja or Bida—it may well be, for some of its units,
Ibadan or Lagos—passes onwards, wrapped in its own dust, which,
presently, closes in and hides it from sight.
A NIGERIAN HUNTER STALKING GAME WITH THE HEAD OF THE GROUND

HORNBILL AFFIXED TO HIS FOREHEAD.
(Copyright.) (Photo by Mr. E. Firmin.)

Throughout the dry season the trade routes are covered with such
caravans and with countless pedestrians in small groups or in twos
or threes—I am told by men who have lived here for years and by
the natives themselves, that while highway robbery is not unknown,
a woman, even unattended (and I saw many such) is invariably safe
from molestation—petty traders and itinerant merchants, some
coming north loaded with kolas, salt and cloth, others going south
with butchers’ provender, potash, cloth, grass, and leather-ware,
etc., witness to the intensive internal commerce which for centuries
upon centuries has rolled up and down the highways of Nigeria.
A TRADING CARAVAN.
CHAPTER V
THE LIFE OF THE PEOPLE—THE AGRICULTURIST
Allahu Akbar! Allahu Akbar! The sonorous tones perforate the

mists of sleep, heralding the coming of the dawn. Ashadu Allah, ila-
allahu, ila-allahu! Insistent, reverberating through the still, cold air—
the night and first hours of the day in these latitudes are often very
cold. A pause. Then the unseen voice is again raised, seeming to
gather unto itself a passionate appeal as the words of the prayer flow
more rapidly. Ashadu an Muhammad rasul ilahi! Haya-al essalatu!
Haya al el falahi! Kad Kamet essalatu! Another pause. The myriad
stars still shine in the deep purple panoply of the heavens, but their
brilliancy grows dimmer. The atmosphere seems infused with a
tense expectancy. Allahu Akbar! Allahu Akbar! La illaha, ila-Allahu,
ila-Allahu. Muhammad Rasul ilahi. Salallah aleiheiu, ... Wassalama.
The tones rise triumphant and die away in grave cadence. It thrills
inexpressibly does this salute to the omnipotent Creator ringing out
over every town and village in the Moslem Hausa States. “God the
Greatest! There is no God but the God!” And that closing, “Peace!” It
has in it reality. Surely it is a good thing and not a bad thing that
African man should be reminded as he quits his couch, and as he
returns to it, of an all-presiding, all-pervading, all-comprehending
Deity? His fashion may not be our fashion. What of that? How far are
we here from the narrow cry of the “Moslem peril”! Whom does this
call to God imperil? The people who respond to it and prostrate
themselves in the dust at its appeal? Let us be quite sure that our
own salvation is secured by our own methods, that the masses of
our own people are as vividly conscious of the Omnipotent, as free
and happy in their lives, as these Nigerian folk, ere we venture to
disturb the solemn acknowledgment and petition that peal forth into
the dusk of the Nigerian morn.
FRUIT-SELLERS.
WATER-CARRIERS.
And now a faint amber flush appears in the eastern sky. It is the
signal for many sounds. A hum of many human bees, the crowing of
countless roosters, the barking of lean and yellow “pye” dogs, the
braying of the donkey and the neigh of his nobler relative, the
bleating of sheep and the lowing of cattle. The scent of burning wood
assails the nostrils with redolent perfume. The white tick-birds, which
have passed the night close-packed on the fronds of the tall fan-
palms, rustle their feathers and prepare, in company with their
scraggy-necked scavenging colleagues the vultures, for the useful if
unedifying business of the day. Nigerian life begins, and what a busy
intensive life it is! From sunrise to sunset, save for a couple of hours
in the heat of the day, every one appears to have his hands full.
Soon all will be at work. The men driving the animals to pasture, or
hoeing in the fields, or busy at the forge, or dye-pit or loom; or
making ready to sally forth to the nearest market with the products of
the local industry. The women cooking the breakfast, or picking or
spinning cotton, or attending to the younger children, or pounding
corn in large and solid wooden mortars, pulping the grain with
pestles—long staves, clubbed at either end—grasped now in one
hand, now in the other, the whole body swinging with the stroke as it
descends, and, perhaps, a baby at the back, swinging with it; or
separating on flat slabs of stone the seed from the cotton lint picked
the previous day. This is a people of agriculturists, for among them
agriculture is at once life’s necessity and its most important
occupation. The sowing and reaping, and the intermediate seasons
bring with them their several tasks. The ground must be cleared and
hoed, and the sowing of the staple crops concluded before the early
rains in May, which will cover the land with a sheet of tender green
shoots of guinea-corn, maize, and millet, and, more rarely, wheat.
When these crops have ripened, the heads of the grain will be cut
off, the bulk of them either marketed or stored—spread out upon the
thatch-roofed houses to dry, sometimes piled up in a huge circle
upon a cleared, dry space—in granaries of clay or thatch, according
to the local idea; others set aside for next year’s seeds. The stalks,
ten to fifteen feet in height, will be carefully gathered and stacked for
fencing purposes. Nothing that nature provides or man produces is
wasted in this country. Nature is, in general, kind. It has blessed man
with a generally fertile and rapidly recuperative soil, provided also
that in the more barren, mountainous regions, where ordinary
processes would be insufficient, millions of earth-worms shall
annually fling their casts of virgin sub-soil upon the sun-baked
surface. And man himself, in perennial contact with Nature, has
learned to read and retain many of her secrets which his civilized
brother has forgotten. One tree grows gourds with neck and all
complete, which need but to be plucked, emptied and dried to make
first-rate water-bottles. A vigorous ground creeper yields enormous
pumpkin-shaped fruit whose contents afford a succulent potage,
while its thick shell scraped and dried furnishes plates, bowls, pots,
and dishes of every size, and put to a hundred uses: ornaments, too,
when man has grafted his art upon its surface with dyes and carved
patterns. A bush yields a substantial pod which when ready to burst
and scatter its seeds is found to contain a fibrous substance which
resembles—and may be identical with, I am not botanist enough to
tell—the loofah of commerce, and is put to the same uses. From the
seeds of the beautiful locust-bean tree (dorowa), whose gorgeous
crimson blooms form so notable a feature of the scenery in the
flowering season, soup is made, while the casing of the bean affords
a singularly enduring varnish. The fruit of the invaluable Kadenia or
shea tree is used for food, for oil, and medicinally. The bees receive
particular attention for their honey and their wax, the latter utilized in
sundry ways from ornamenting Korans down to the manufacture of
candles. As many as a dozen oblong, mud-lined, wicker hives closed
at one end, the other having a small aperture, may sometimes be
seen in a single tree. Before harvest time has dawned and with the
harvesting, the secondary crops come in for attention. Cassava and
cotton, indigo and sugar-cane, sweet potatoes and tobacco, onions
and ground-nuts, beans and pepper, yams and rice, according to the
locality and suitability of the soil. The farmers of a moist district will
concentrate on the sugar-cane—its silvery, tufted, feathery crowns
waving in the breeze are always a delight: of a dry, on ground-nuts:
those enjoying a rich loam on cotton, and so on. While the staple
crops represent the imperious necessity of life—food, the profits from
the secondary crops are expended in the purchase of clothing, salt
and tools, the payment of taxes, the entertainment of friends and
chance acquaintances (a generous hospitality characterizes this
patriarchal society), and the purchase of luxuries, kolas, tobacco,
ornaments for wives and children. It is a revelation to see the cotton-
fields, the plants in raised rows three feet apart, the land having in
many cases been precedently enriched by a catch-crop of beans,
whose withering stems (where not removed for fodder, or hoed in as
manure) are observable between the healthy shrubs, often four or
five feet in height, thickly covered with yellow flowers or snowy bolls
of white, bursting from the split pod. The fields themselves are
protected from incursions of sheep and goats by tall neat fencing of
guinea-corn stalks, or reeds, kept in place by native rope of
uncommon strength. Many cassava fields, the root of this plant
furnishing an invaluable diet, being indeed, one of the staples of the
more southerly regions, are similarly fenced. Equally astonishing are
the irrigated farms which you meet with on the banks of the water-
courses. The plots are marked out with the mathematical precision of
squares on a chess-board, divided by ridges with frequent gaps
permitting of a free influx of water from the central channel, at the
opening of which, fixed in a raised platform, a long pole with a
calabash tied on the end of it, is lowered into the water and its
contents afterwards poured into the trench. Conditions differ of
course according to locality, and the technique and industry
displayed by the farmers of one district vary a good deal from the
next. In the northern part of Zaria and in Kano the science of
agriculture has attained remarkable development. There is little we
can teach the Kano farmer. There is much we can learn from him.
Rotation of crops and green manuring are thoroughly understood,
and I have frequently noticed in the neighbourhood of some village
small heaps of ashes and dry animal manure deposited at intervals
along the crest of cultivated ridges which the rains will presently
wash into the waiting earth. In fact, every scrap of fertilizing
substance is husbanded by this expert and industrious agricultural
people. Instead of wasting money with the deluded notion of
“teaching modern methods” to the Northern Nigerian farmer, we
should be better employed in endeavouring to find an answer to the
puzzling question of how it is that land which for centuries has been
yielding enormous crops of grain, which in the spring is one carpet of
green, and in November one huge cornfield “white unto harvest,” can
continue doing so. What is wanted is an expert agriculturist who will
start out not to teach but to learn; who will study for a period of say
five years the highly complicated and scientific methods of native
agriculture, and base possible improvements and suggestions,
maybe, for labour-saving appliances, upon real knowledge.
Kano is, of course, the most fertile province of the Protectorate,
but this general description of agricultural Nigeria does not only
apply to Kano Province. I saw nothing finer in the way of deep
cultivation (for yams and guinea-corn chiefly) than among the Bauchi
pagans. The pagan Gwarri of the Niger Province have for ages past
grown abundant crops in terraces up their mountainsides whither
they sought refuge from Hausa and Fulani raids. The soil around
Sokoto, where the advancing Sahara trenches upon the fertile belt,
may look arid and incapable of sustaining annual crops, yet every
year it blossoms like a rose. But the result means and needs
inherited lore and sustained and strenuous labour. From the early
rains until harvest time a prolific weed-growth has continuously to be
fought. Insect pests, though not conspicuously numerous in most
years, nevertheless exist, amongst them the locusts, which
sometimes cover the heavens with their flight; the caterpillar, which
eats the corn in its early youth; the blight (daraba), which attacks the
ripening ear. In some districts not so favoured, the soil being of
compact clay with a thin coating of humus, intensive cultivation has
proved exhausting, and it is a study to note how every ounce of
humus is tended with religious care. Very hard work at the right time
is the secret of success for the Nigerian agriculturist. It is little short
of marvellous that with all he has to do he somehow manages to
build our railways and our roads. Indeed, if that phenomenon has in
many respects its satisfactory, it has also its sombre, social side.
One can but hope that the former may outweigh the latter as the
country gradually settles down after the severe demands placed
upon it these last few years.
A GWARRI GIRL.
A HAUSA TRADING WOMAN.
Truly a wonderful country, and a wonderful people, a people who

with fifty years’ peace will double its numbers, a people whom it is
our paramount duty to secure for ever in the undisturbed occupation
and enjoyment of the land, precluding the up-growth of a middle-man
class of landlord from which the native system is free, and being so
free need never be saddled with.
CHAPTER VI
THE LIFE OF THE PEOPLE—THE HERDSMAN AND THE ARTISAN
The word “peasant” as applied to the Fulani is, no doubt, a

misnomer. I employ it merely to distinguish the herdsmen from the
caste of statesmen and governors, evolved in Nigeria by the genius
of Othman Fodio, but, as their recorded history throughout Western
Africa shows, inherent in this mysterious race whose moral
characteristics have persisted through all degrees of admixture with
the negro. The Fulani peasant is but rarely an agriculturist in Nigeria,
but he plays an important, if indirect, part in the agriculture of the
Hausa provinces. Over the face of the land he wanders with his
great herds—which may number upwards of several thousand head
in one herd—of beautiful hump-backed cattle, mostly white, ever
seeking “pastures new.” Speaking under correction, in Borgu only
does his settlement partake of permanency. Elsewhere he is a
wanderer. One month a given district may be full of Fulani camps,
come from where his fellow-man has but the vaguest of notions. The
next, not a single Fulani will be seen within it. But they return, as a
rule, the ensuing year to their old haunts. To the Hausa farmer the
M’Bororoji or “Cow-Fulani” are an invaluable asset, and he enters
into regular contracts with them for turning their cattle on to his fields;
and he buys milk from them. I struck several of their encampments,
at distances hundreds of miles apart. The first, at the crossing of the
Bako, between Badeggi and Bida, was in charge of a patriarch who
might have stepped out of the book of Genesis: a Semite every inch
of him: spare of form, emaciated in feature, with high cheek-bones,
hawk-like nose, flashing, crafty eyes, a long white beard and a
bronzed skin without a trace of black blood.
A FULANI GIRL.
There is no more interesting sight in Nigeria than a Fulani

encampment. It is usually pitched well away from the beaten track,
albeit within convenient distance of a village. You rub your eyes and
wonder if you can really be in the heart of the Dark Continent, as
these gracefully built, pale copper-coloured men and women—one
may say of some of the young girls with the sun shining on their
velvety skins, almost golden coloured—appear tending their herds
and flocks, or standing and sitting at the entrance to their temporary
shelters. Even the latter differ frequently from the African hut,
resembling in shape the wigwam of the North American Indian. As
for the people themselves, you are aware of an indefinable
sentiment of affinity in dealing with them. They are a white, not a
black race.
I have discussed their origin and West African history elsewhere,[8]
and will only say here that delicacy of form, refinement of contour
and simple dignity of bearing distinguish this strange people, just as
the ruling families possess the delicacy of brain and subtlety of
intellect which impress their British over-lords. A fact worth
recording, perhaps, is that while the Hausa woman spins and the
Hausa man weaves cotton, the Fulani woman does both the
spinning and the weaving.
If the agricultural life of the Northern Nigerian peoples is a full one,
the industrial life, especially in the northern provinces of the
Protectorate, is equally so. It is an extraordinarily self-sufficing
country at present, and the peasant-cultivator and artisan are
interdependent, the latter supplying the domestic wants and making
the requisite implements for the former. The variety of trades may be
estimated from the old Hausa system of taxation. This system the
Fulani adopted, modifying it slightly here and there by enforcing
closer adherence to the Koranic law, and we are modifying it still
further by a gradual process tending to merge multiple imposts under
two or three main heads, with the idea of establishing a more
equitable re-adjustment of burdens and to ensure greater simplicity
in assessment. The Hausa system provided that taxes should be
levied upon basket and mat-makers, makers of plant for cotton-
spinners, bamboo door-makers, carpenters, dyers, blacksmiths and
whitesmiths, as well as upon bee-keepers, hunters, trappers and
butchers. Exemption from taxes was granted to shoe-makers, tailors,
weavers, tanners, potters, and makers of indigo; but market taxes
were imposed upon corn measurers, brokers, sellers of salt,
tobacco, kolas, and ironstone.
The chief agricultural implement is the Hausa hoe, the galma, a
curious but efficient instrument, which simultaneously digs and
breaks up the soil and is said to be of great antiquity, but which is
easier to draw than to describe. There is also in daily use among the
Hausas a smaller, simpler hoe and a grass-cutter, while the pagan
favours a much heavier and more formidable-looking tool. This
pagan hoe somewhat resembles our English spade, but is wielded in
quite different fashion. Iron drills, rough hammers and axes, nails,
horseshoes, stirrup-irons and bits are included among the ordinary
forms of the blacksmith’s art. Iron-stone is common in many parts of
the country and is extensively worked, furnaces being met with in
every district where the use of the metal is locally in vogue. It is to be
hoped that “Civilization” will not seek to stamp out this native industry
as the tin-miners have done their best—and, unless the promise
made to the smelters of Liruei-n-Kano by Sir H. Hesketh Bell is not
speedily carried out, but too successfully—to crush the interesting
tin-smelting industry. The history of native tin smelting in Nigeria
furnishes a remarkable proof of the capacity of the Nigerian native,
but is too long to set forth here in detail. Suffice it to say that for a
hundred years, a certain ruling family with numerous branches, has
succeeded in turning out a singularly pure form of the white metal
whose sale as an article of trade brought prosperity to the
countryside. When I left the tin district, owing to unjust and stupidly
selfish interference with immemorial rights, the native furnaces had
been closed for nine months and poverty was beginning to replace
comparative affluence.
PANNING FOR IRON.

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PRINCIPLES AND PRACTICE OF SLEEP MEDICINE ISBN: 978-­0-­323-­66189-­8

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Mind and Pattern. Toronto: Bantam Books; 1986.

A broad, sandy road, piercing a belt of shea trees, gnarled and

A NIGERIAN HUNTER STALKING GAME WITH THE HEAD OF THE GROUND

(Copyright.) (Photo by Mr. E. Firmin.)

Allahu Akbar! Allahu Akbar! The sonorous tones perforate the

Truly a wonderful country, and a wonderful people, a people who

The word “peasant” as applied to the Fulani is, no doubt, a

There is no more interesting sight in Nigeria than a Fulani

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Sabra Abbott, MD, PhD Sonia Ancoli-Israel, PhD

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Derk-Jan Dijk, PhD Jeanne F. Duffy, MBA, PhD

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