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More than two dozen national and international experts contribute their insights
to Clinical Sleep Medicine: A Comprehensive Guide for Mental Health and Other
A Comprehensive Guide for Mental Health and Other Medical Professionals

Medical Professionals. Intentionally designed to be an easily portable resource,
this guide features the most up-to-date information and latest guidelines and
summarizes the pathophysiological mechanisms, epidemiology, clinical presenta-
tions, and management of the six principal categories of adult and pediatric sleep
disorders: insomnia, hypersomnia, sleep-disordered breathing, circadian disorders,
parasomnias, and sleep-related movement disorders.
Each chapter features a section on diferential diagnosis to help readers distin-

guish among the various diseases and disorders. Where there is overlap between
CLINICAL SLEEP MEDICINE

disorders, the guide also provides cross-references to relevant information, and
where new concepts, emerging evidence, and aspects that require further re-
search occur, these are highlighted specifcally and discussed.
This guide provides a robust and in-depth foundation for clinicians, researchers,
and nonmedical professionals who seek to ofer state-of-the-art care to patients
afected by any sleep disorder as well as a resource for the patients themselves.
About the Editors

Emmanuel H. During, M.D., is a Clinical Associate Professor in the De-
CLINICAL SLEEP
partment of Psychiatry and Behavioral Sciences–Division of Sleep Medicine
and the Department of Neurology and Neurological Sciences at Stanford
University and Director of the Stanford Parasomnia Clinic in Redwood City,
California.
Clete A. Kushida, M.D., Ph.D., is a Professor in the Department of Psy-

chiatry and Behavioral Sciences at Stanford University, Division Chief and
Medical Director of Stanford Sleep Medicine, and Director of the Stanford
Center for Human Sleep Research in Redwood City, California. He is found-
MEDICINE
ing President of the World Sleep Society, past President of the World Sleep
Federation, past President of the American Academy of Sleep Medicine, and
founding President of the California Sleep Society.
A Comprehensive Guide for
Mental Health and
During Other Medical Professionals
Kushida
Edited by
Cover design: Rick A. Prather WWW.APPI.ORG Emmanuel H. During, M.D.

Cover Images © peterschreiber.media/
Mrspopman1985
Used under license from Shutterstock
Clete A. Kushida, M.D., Ph.D.

Mental Health and
Other Medical Professionals

Mental Health and
Other Medical Professionals
Edited by
Emmanuel H. During, M.D.

Note: The authors have worked to ensure that all information in this book is accurate
at the time of publication and consistent with general psychiatric and medical standards,
and that information concerning drug dosages, schedules, and routes of administration
is accurate at the time of publication and consistent with standards set by the U.S. Food
and Drug Administration and the general medical community. As medical research and
practice continue to advance, however, therapeutic standards may change. Moreover,
specific situations may require a specific therapeutic response not included in this book.
For these reasons and because human and mechanical errors sometimes occur, we rec-
ommend that readers follow the advice of physicians directly involved in their care or
the care of a member of their family.
Books published by American Psychiatric Association Publishing represent the find-
ings, conclusions, and views of the individual authors and do not necessarily represent
the policies and opinions of American Psychiatric Association Publishing or the Amer-
ican Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
specialdiscounts for more information.
Copyright © 2021 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
First Edition
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Library of Congress Cataloging-in-Publication Data
Names: During, Emmanuel H., 1976– editor. | Kushida, Clete Anthony, 1960– editor.
| American Psychiatric Association Publishing, publisher.
Title: Clinical sleep medicine : a comprehensive guide for mental health and other med-
ical professionals / edited by Emmanuel H. During, Clete A. Kushida.
Description: First edition. | Washington, DC : American Psychiatric Association Publish-
ing, [2021] | Includes bibliographical references and index.
Identifiers: LCCN 2020023156 (print) | LCCN 2020023157 (ebook) | ISBN
9781615373000 (paperback ; alk. paper) | ISBN 9781615373161 (ebook)
Subjects: MESH: Sleep Wake Disorders | Mental Disorders | Mental Health Classifica-
tion: LCC RC547 (print) | LCC RC547 (ebook) | NLM WL 108 | DDC 616.8/498—
dc23
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Contents
Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
1 Introduction
Sleep Disorders and Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Clinical History and Physical Examination in

Sleep Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Logan Schneider, M.D.
3 Diagnosis of Insomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
David N. Neubauer, M.D.
4 Pharmacological Treatment of Insomnia . . . . . . . . . . . . . 61

5 Nonpharmacological Treatment of Insomnia . . . . . . . . 79

Fiona Barwick, Ph.D., D.B.S.M.
6 Narcolepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Taisuke Ono, M.D., Ph.D.
Mari Matsumura, M.P.H.
Seiji Nishino, M.D., Ph.D.
7 Idiopathic Hypersomnia . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Caroline Maness, M.D.
Lynn Marie Trotti, M.D., M.Sc.
8 Adult Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . 147

Chester Wu, M.D.
Christian Guilleminault, M.D.
9 Pediatric Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . 171

Payal Kenia Gu, M.D.
Shannon S. Sullivan, M.D.
10 Sleep-Related Hypoventilation Syndromes. . . . . . . . . 187

William Auyeung, M.D.
Michelle Cao, D.O.
11 Central Sleep Apneas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

Gaurav Singh, M.D., M.P.H.
12 Delayed and Advanced Sleep-Wake

Phase Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Daniella Palermo, M.D.
Katherine M. Sharkey, M.D., Ph.D., FAASM
13 Irregular Sleep-Wake, Non-24-Hour Sleep-Wake,

Jet Lag, and Shift Work Sleep Disorders . . . . . . . . . . . . 245
Daniel Jin Blum, Ph.D.
Jamie M. Zeitzer, Ph.D.
14 Non-REM Parasomnias . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Muna Irfan, M.D.
Carlos H. Schenck, M.D.
Michael J. Howell, M.D.
15 REM Sleep Behavior Disorder. . . . . . . . . . . . . . . . . . . . . . .293
Muna Irfan, M.D.
16 Other Parasomnias
Nightmare Disorder, Recurrent Isolated Sleep Paralysis,
Sleep-Related Hallucinations, Exploding Head Syndrome,
Sleep Enuresis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .311
Joss Cohen, M.D.
Alon Y. Avidan, M.D., M.P.H.
17 Restless Legs Syndrome and Periodic Limb

Movements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .333
Julia Buchfuhrer, D.O.
Mark Buchfuhrer, M.D.
18 Other Sleep-Related Movement Disorders . . . . . . . . . .361

Ambra Stefani, M.D.
Birgit Högl, M.D.
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379
Contributors
William Auyeung, M.D.

Stanford Center for Sleep Sciences and Medicine, Department of Psy-
chiatry and Behavioral Sciences, Stanford University Medical Center,
Palo Alto, California
Alon Y. Avidan, M.D., M.P.H.

Professor, Department of Neurology; Director, Sleep Disorders Center;
and Chair, Faculty Executive Committee, David Geffen School of Med-
icine, University of California–Los Angeles, Los Angeles, California
Fiona Barwick, Ph.D., D.B.S.M.

Clinical Assistant Professor, Department of Psychiatry and Behavioral
Sciences, Division of Sleep Medicine, Stanford University School of
Medicine, Redwood City, California
Daniel Jin Blum, Ph.D.

Adjunct Clinical Instructor, Stanford University School of Medicine,
Department of Psychiatry and Behavioral Sciences, Redwood City, Cal-
ifornia
Julia Buchfuhrer, D.O.

University of California–Irvine, Irvine, California
Mark Buchfuhrer, M.D.

Stanford University School of Medicine, Stanford, California
Michelle Cao, D.O.

Stanford Center for Sleep Sciences and Medicine, Department of Psy-
chiatry and Behavioral Sciences, Stanford University Medical Center,
Palo Alto, California
Joss Cohen, M.D.

Fellow, Department of Neurology, Cedars-Sinai Medical Center, Los
Angeles, California
ix
x Clinical Sleep Medicine

Clinical Associate Professor, Department of Psychiatry and Behavioral
Sciences–Division of Sleep Medicine and Department of Neurology and
Neurological Sciences, Stanford University; Director, Stanford Para-
somnia Clinic, Redwood City, California
Payal Kenia Gu, M.D.

Assistant Professor, Children’s Hospital Los Angeles, Los Angeles, Cal-
ifornia
Christian Guilleminault, M.D.

Professor, Stanford Center for Sleep Sciences and Medicine, Depart-
ment of Psychiatry and Behavioral Sciences, Stanford University Medi-
cal Center, Palo Alto, California
Birgit Högl, M.D.

Professor of Neurology and Sleep Medicine, Medical University of
Innsbruck, Innsbruck, Austria
Michael J. Howell, M.D.

Associate Professor of Neurology, University of Minnesota, Minneapo-
lis, Minnesota
Muna Irfan, M.D.

Assistant Professor of Neurology, University of Minnesota, Minneapo-
lis Veterans Affair Medical Center, Minneapolis, Minnesota

Division Chief and Medical Director, Stanford Sleep Medicine; Director,
Stanford Center for Human Sleep Research; Professor, Department of
Psychiatry and Behavioral Sciences, Stanford University Medical Cen-
ter, Stanford University, California
Caroline Maness, M.D.

Neurology Resident, Emory Sleep Center and Department of Neurol-
ogy, Emory University School of Medicine, Atlanta, Georgia
Mari Matsumura, M.P.H.

Sleep and Circadian Neurobiology Laboratory, Department of Psychia-
try and Behavioral Sciences, Stanford University School of Medicine,
Stanford, California
Introduction xi
David N. Neubauer, M.D.

Associate Professor, Department of Psychiatry and Behavioral Sciences,
Johns Hopkins University School of Medicine, Baltimore, Maryland
Seiji Nishino, M.D., Ph.D.

Taisuke Ono, M.D., Ph.D.

Daniella Palermo, M.D.

Clinical Instructor, Psychiatry and Human Behavior, Alpert Medical
School of Brown University/Rhode Island Hospital, Providence, Rhode
Island

Professor of Psychiatry, University of Minnesota, Minnesota Regional
Sleep Disorders Center, Minneapolis, Minnesota
Logan Schneider, M.D.

Staff Neurologist, Stanford/VA Alzheimer’s Research Center, VA Palo
Alto Health Care System, Palo Alto; Clinical Assistant Professor (affili-
ated), Stanford Sleep Medicine Center, Redwood City, California
Katherine M. Sharkey, M.D., Ph.D., FAASM

Associate Professor, Medicine and Psychiatry and Human Behavior,
Sleep for Science Research Laboratory, Alpert Medical School of Brown
University/Rhode Island Hospital, Providence, Rhode Island
Gaurav Singh, M.D., M.P.H.

Staff Physician, Pulmonary, Critical Care, and Sleep Medicine Section,
Veterans Affairs Palo Alto Health Care System, Palo Alto, California;
Clinical Assistant Professor (affiliated), Division of Pulmonary, Allergy,
and Critical Care Medicine, Stanford University, Palo Alto, California
Ambra Stefani, M.D.

Department of Neurology, Medical University of Innsbruck, Innsbruck,
Austria
xii Clinical Sleep Medicine
Lynn Marie Trotti, M.D., M.Sc.

Associate Professor of Neurology, Emory Sleep Center and Department
of Neurology, Emory University School of Medicine, Atlanta, Georgia
Chester Wu, M.D.

The Menninger Clinic, Department of Psychiatry and Behavioral Sci-
ences, Baylor College of Medicine, Houston, Texas
Jamie M. Zeitzer, Ph.D.

Associate Professor, Stanford University School of Medicine, Depart-
ment of Psychiatry and Behavioral Sciences, Stanford Center for Sleep
Sciences and Medicine, Palo Alto, California
CHAPTER 1
Introduction
SLEEP DISORDERS AND
MENTAL HEALTH
T he importance of sleep for well-being and general and mental health is

increasingly being recognized. Sleep complaints are commonly associ-
ated with mental disorders and are even part of the diagnostic criteria for
some, such as mood and anxiety disorders and PTSD. The relationship
between sleep and psychiatric disorders is intertwined and, in some
cases, bidirectional. Anxiety, psychosis, and depression often result in re-
duced sleep quality (sleep fragmentation, experience of unpleasant, un-
refreshing sleep), quantity (increased or reduced), or pattern (changes in
sleep schedule, loss of sleep consistency). Reciprocally, sleep disorders
can contribute to the exacerbation of psychiatric symptoms and inde-
pendently affect the prognosis. Finally, most psychotropic drugs have an
effect on sleep and arousal and can aggravate a preexisting sleep abnor-
mality.
This chapter aims to familiarize readers with current knowledge on
the mutual effects of sleep and mental health and provide an integrated
framework for students, clinicians, and researchers. It also serves as an in-
troduction to this book, which covers throughout its 18 chapters the six
main categories of sleep disorders: insomnia (Chapters 3–5), hypersom-
nia (Chapters 6–7), sleep-disordered breathing (Chapters 8–11), circadian
disorders (Chapters 12–13), parasomnias (Chapters 14–16), and sleep-
related movement disorders (Chapters 17–18).
1
2 Clinical Sleep Medicine
Psychiatric Disorders and

Sleep Disturbances
MAJOR DEPRESSIVE DISORDER

Sleep disturbances are associated with up to 90% cases of major depres-
sive disorder (MDD) and can include insomnia and hypersomnia—two
diagnostic criteria for MDD—as well as reduced sleep quality and night-
mares (American Psychiatric Association 2013). Contrary to the depres-
sive phase of bipolar disorder, often associated with hypersomnia, in
MDD, insomnia is more common than hypersomnia. Conversely, pa-
tients with one of these complaints are about 10 times more likely to have
MDD than are individuals who are satisfied with their sleep (Breslau et
al. 1996; Ford and Kamerow 1989). Similarly, difficulty falling asleep
and other symptoms of insomnia are associated with a two- to fivefold
increased risk of developing depression at follow-up (Baglioni et al. 2011;
Szklo-Coxe et al. 2010). Early morning insomnia is often considered a
pathognomonic sign of depression, and the presence of insomnia during
an episode of MDD is associated with a worse outcome (Minkel et al.
2017). Other sleep disorders, such as restless legs syndrome (RLS) or un-
derlying obstructive sleep apnea (OSA) increase the risk of a mood disor-
der if left untreated (Earley and Silber 2010; Sharafkhaneh et al. 2005).
Polysomnographic studies consistently show changes in subjects with
depression: increased sleep fragmentation, reduced slow-wave sleep
(SWS) duration and delta power (14 Hz electroencephalographic activ-
ity), and increased REM sleep duration, with reduced sleep-to–REM onset
latency, prolonged first REM sleep period, and increased eye movement
density (number of rapid eye movements per minute of REM sleep).
Among these changes, shortened REM latency and reduced SWS may be
trait markers because they are present even between depressive episodes
(Krystal 2012). REM sleep changes can also be found in asymptomatic
subjects with a strong family history of depression and could therefore be
an endophenotype for depressive disorder (Lauer et al. 1995).
Complaints of hypersomnia are often associated with so-called atyp-
ical depression, as well as with daytime fatigue and increased appetite. In
MDD, hypersomnia appears to be more subjective than objective because
it is usually not corroborated by objective findings of increased total sleep
time (TST) on polysomnography or reduced sleep latency (time needed to
fall asleep) on multiple sleep latency test (MSLT)—the gold-standard pro-
cedure for the evaluation of sleepiness (Nofzinger et al. 1991). The same
is true of seasonal affective disorder. These differences distinguish com-
Introduction 3
plaints of hypersomnia associated with MDD from narcolepsy and “id-

iopathic hypersomnia” (see Chapters 6 and 7, respectively).
Complete sleep deprivation over only one night has dramatic antide-
pressant effects in most patients (Wirz-Justice and Van den Hoofdakker
1999). This effect may be mediated by brain-derived neurotrophic factor
(Giese et al. 2014). Unfortunately, the therapeutic benefit of a single night
of sleep deprivation abates as soon as sleep is restored, even if limited in
duration (Wiegand et al. 1987). Attempts to artificially suppress REM
sleep in the lab over several weeks, an effect observed with antidepres-
sant drugs (due to their serotonergic, noradrenergic, and anticholinergic
effects), have led to inconsistent results (Vogel et al. 1975). Bright light
therapy proved to be useful in the treatment of seasonal affective disor-
der and may also have some utility in the treatment of MDD (Partonen
and Lönnqvist 1998).
Approximately one-third of patients with MDD continue to experi-
ence sleep disturbances despite treatment of their depression (Krystal
2012). Such symptoms are associated with worse outcome, lower rate of
remission, and slower recovery, with an increased risk of relapse in ad-
dition to the persistence of daytime symptoms of fatigue, excessive day-
time sleepiness, and cognitive complaints (Dew et al. 1997; McCall et al.
2000; Reynolds et al. 1997). Sleep symptoms are also associated with in-
creased suicidality and completed suicide, independent of MDD sever-
ity, based on several studies performed across age, ethnic, and cultural
groups (Krystal 2012). As a proof of concept, most studies simultane-
ously treating mood symptoms and comorbid insomnia with pharma-
cotherapy or cognitive-behavioral therapy for insomnia have resulted
in better outcomes in terms of not only sleep but also depression (Krys-
tal 2012). The benefits on mood may be related to specific hypnotic
drugs. For instance, eszopiclone may confer a benefit in terms of mood
symptoms that has not been observed with extended-release zolpidem
(Fava et al. 2011). Pharmacological and behavioral treatments of insom-
nia are topics covered in Chapters 4 and 5.
BIPOLAR DISORDER
Sleep is even more disturbed in bipolar disorder than in MDD. Reduced
need for sleep is one of the diagnostic criteria for manic episodes; how-
ever, this symptom can be misinterpreted as insomnia (American Psy-
chiatric Association 2013). If an individual has reduced sleep needs but
spends the same amount of time in bed, he or she will spend less time
sleeping and experience more sleep fragmentation (Wehr et al. 1987).
The main difference from insomnia is that in mania, reduced sleep du-
ration is not associated with reduced quality of life or daytime function-

ing. During the depressive phase of bipolar disorder, the complaint of
hypersomnia is more common than that of insomnia, although both
may alternate. However, as also seen in the case of MDD, this complaint
is subjective—that is, not corroborated by polysomnography and MSLT
(Nofzinger et al. 1991).
Sleep duration is reduced in mania; however, other changes during
an acute episode are similar to those observed in MDD, including re-
duced SWS, reduced REM sleep latency, and increased eye movement
density.
Manic episodes can be triggered by sleep deprivation in individuals
with bipolar disorder (Wehr 1991). The mechanism remains unknown
but could be related to the robust mood elevation observed after a single
night of sleep deprivation in individuals with depression. The deleteri-
ous effect of sleep loss on mood stability and the natural observation
that manic episodes contribute to sleep loss, which may in turn exacer-
bate mania, have practical implications. Lengthening sleep time can be
used to treat and prevent mania.
In bipolar disorder, sleep disturbances are not limited to decompen-
sation episodes. During periods of euthymia, as many as 70% of patients
with bipolar disorder have sleep disturbance and 55% meet diagnostic
criteria for insomnia (Harvey et al. 2005). Patients also report more day-
time sleepiness on the Epworth Sleepiness Scale compared with control
subjects (St-Amand et al. 2013). In some cases, these could presage a de-
pressive relapse, because one study found that hypersomnia correlates
with depressive symptoms at 6 months (Kaplan et al. 2011).
Sleep disturbances in bipolar disorder are not limited to insomnia
and hypersomnia. Several studies have suggested that circadian distur-
bances may be a core mechanism triggering and perpetuating mood in-
stability and cycling. Sleep disturbances may be prodromal symptoms of
bipolar disorder in children (Anderson and Bradley 2013). Some actigra-
phy studies suggest patients with bipolar disorder have a tendency to ex-
perience delayed sleep phase (evening type) and greater variability in
sleep patterns. This is, however, contradicted by findings of other possi-
ble circadian abnormalities (advanced sleep phase, irregular sleep-wake
cycles) or only a few abnormalities on actigraphy-based studies (Ander-
son and Bradley 2013). Studies show patients with bipolar disorder have
reduced melatonin secretion with reduced circadian amplitude, includ-
ing reduced evening peaks of melatonin and increased sensitivity of mel-
atonin levels to light (Nurnberger et al. 2000). This could be due to lower
activity of N-acetylserotonin O-methyltransferase, an enzyme involved
in melatonin synthesis (Etain et al. 2012). Supporting the hypothesis that
Introduction 5
reduced melatonin drive could contribute to mood instability, treatments

with melatonin agonists such as ramelteon and agomelatine—a drug
not available in the United States—have shown to be beneficial in pa-
tients with bipolar depression (Norris et al. 2013). Nonpharmacological
interventions, including chronotherapy using light or dark therapy or so-
cial rhythms to synchronize biological rhythms, have also shown to be
helpful in bipolar disorder (Anderson and Bradley 2013).
Sleep-disordered breathing has not been systematically studied in
bipolar disorder but can result in sleep fragmentation and sleep debt as
a result of reduced sleep quality. One study found a high risk of OSA in
54% of patients with bipolar I disorder based on a self-assessment tool
(Soreca et al. 2012).
GENERALIZED ANXIETY DISORDER

Among anxiety disorders, the relation between generalized anxiety dis-
order (GAD) and sleep has been the most studied. One of the core fea-
tures of GAD is a complaint of insomnia. Difficulty falling or staying
asleep—that is, initiation or maintenance insomnia—manifests in more
than half of patients with this disorder (Krystal 2012). Conversely, in-
somnia is associated with a twofold increased risk of developing anxiety
disorders later in life (Breslau et al. 1996). In contrast to isolated insom-
nia, which is characterized by worrying about sleep quality, in GAD,
anxiety focuses on other matters. Anxiety-provoking dreams are another
frequent complaint associated with anxiety disorders.
Polysomnographic studies in GAD show increased sleep latency,
greater number of arousals, and more waking after sleep onset. Patients
with GAD have reduced SWS and a relative increase in stage N1 sleep,
which is consistent with self-perception of a lighter sleep (Fuller et al.
1997). Unlike mood disorders, no changes in REM architecture are ob-
served in GAD.
Treatment of insomnia results in better outcomes in GAD; however,
the therapeutic benefit in GAD may vary according to the hypnotic agent
used. For instance, trials using eszopiclone versus extended-release zol-
pidem combined with escitalopram resulted in improved outcomes on
anxiety only with eszopiclone (Fava et al. 2009; Pollack et al. 2008). Sim-
ilar results were found when testing combination treatments in insomnia
and MDD.
POSTTRAUMATIC STRESS DISORDER

Recurrent distressing dreams related to a traumatic event and diffi-
culty with falling or staying asleep are part of the diagnostic criteria in
PTSD (American Psychiatric Association 2013), and sleep complaints in

general are found in nearly all patients with PTSD (Ross et al. 1989).
Trauma-related flashbacks and hallucinations around sleep are com-
mon in PTSD, as well as sleep talking, excessive movements during
sleep, and dream-enactment-like phenomena that can mimic REM sleep
behavior disorder (RBD), especially in combat veterans (see Chapter 15).
Differentiating between PTSD-related nocturnal behaviors and RBD
dream enactment requires polysomnography to determine whether REM
atonia is preserved (in PTSD) or lost (in RBD). Differentiating PTSD from
RBD can be challenging, because both disorders share common clinical
features, and a subset of patients with trauma-associated nocturnal be-
haviors can present with a loss of normal REM atonia. This rare condition,
reported in young adults after combat, was coined “trauma-associated
sleep disorder” (Rachakonda et al. 2018). Insomnia can develop due to a
fear of sleeping and experiencing nightmares as well as a general hyper-
arousal and hypervigilant state in PTSD, which is thought to be related to
heightened noradrenergic tone (Berridge et al. 2012).
Polysomnographic studies in PTSD show reduced SWS and REM
sleep but increased eye movement density during REM, with increased
REM-related arousals. They less consistently show reduced TST and in-
creased sleep fragmentation (Krystal 2012), although these are common
complaints in patients with PTSD. The same disconnect between subjec-
tive experience and objective findings can be seen in patients with in-
somnia, a phenomenon known as “paradoxical insomnia.”
Daytime and nighttime sleep complaints before deployment predict
future onset of PTSD and depression, according to a large prospective
longitudinal study in soldiers (Koffel et al. 2013). Studies show that the
treatment of sleep symptoms with pharmacotherapy (eszopiclone, pra-
zosin) or behavioral therapy is associated with a reduction of daytime
PTSD symptoms (Krystal 2012). Whether this result is merely a conse-
quence of improved sleep or due to specific action on PTSD is unclear.
The α1-adrenergic antagonist prazosin has been widely used to reduce
daytime symptoms of PTSD and PTSD-related nightmares when taken at
bedtime; however, its efficacy on sleep symptoms could not be confirmed
in a recent, larger randomized controlled study (Raskind et al. 2018).
SCHIZOPHRENIA
Although sleep disturbances are not among the core symptoms of
schizophrenia, they are common in this disorder. Schizophrenia is asso-
ciated with a reduced need for sleep, daytime sleepiness, and insomnia,
which can be severe during the acute phase of the illness. Nightmares
Introduction 7
and frightening dreams are often reported in schizophrenia. Some stud-

ies have reported circadian abnormalities in individuals with schizo-
phrenia, with a tendency to experience a reversed sleep-wake cycle (i.e.,
being awake during the night and sleeping during the day) (Hofstetter
et al. 2003; Martin et al. 2005). Sleep-disordered breathing and RLS/
periodic limb movement (PLM) are also overrepresented in schizophre-
nia, which can be due to the iatrogenic effects of psychotropic treatments
as well as to alcohol and illicit drugs (Kalucy et al. 2013). As discussed
later, benzodiazepines increase upper airway collapsibility and thus the
risk of OSA via muscle relaxation (see Chapter 8), and most antipsy-
chotic drugs increase the risk of RLS/PLM (see Chapter 17).
As in other psychiatric disorders, the relationship between sleep ab-
normalities and clinical relapse n schizophrenia may be bidirectional.
Sleep disturbances are common findings in the weeks to months preced-
ing psychotic exacerbations in patients with schizophrenia; however, it
is unclear whether these abnormalities are early manifestations of clini-
cal relapse or contribute to psychotic decompensation (Krystal 2012).
Polysomnographic studies in schizophrenia have shown a number
of abnormalities, most of which are shared with other psychiatric disor-
ders: increased sleep fragmentation, decreased amount of SWS with re-
duced delta power (reduced amplitude of slow oscillations in stage 3
non-REM sleep), and reduced REM sleep, REM sleep latency, and eye
movement density in REM sleep when untreated (Krystal 2012). Among
these abnormalities, some studies suggest that increased sleep fragmen-
tation correlates with positive symptoms of schizophrenia (hallucina-
tions, delusions, disorganized thoughts) and reduced SWS density with
negative symptoms (affective blunting, aboulia, alogia).
Psychotropic Drugs and Sleep

Most psychotropic drugs have consequences on sleep and wake states,
ranging from insomnia and disturbed sleep to excessive daytime seda-
tion, nightmares, dream enactment, RLS, and sleep-disordered breathing.
These effects vary according to medication class and specific pharmaco-
logical profiles and are summarized in Table 1–1.
ANTIDEPRESSANTS
Due to their serotonergic or noradrenergic and anticholinergic effects,
most antidepressants inhibit REM sleep, which manifests in prolonged
REM sleep latency and overall reduced REM sleep duration. The thera-
8
TABLE 1–1. Relation between psychotropic drugs and sleep disturbances
Antidepressants Anxiolytics Antipsychotics
Insomnia Most (nonsedating) antidepressants can β-Blockers inhibit melatonin

disrupt sleep. release and can cause
insomnia.
Hypersomnia Sedative antidepressants (mirtazapine, Benzodiazepines cause Most antipsychotic drugs are sedative.
trazodone, amitriptyline, nortriptyline) sedation.
can cause sleepiness; bupropion,
desipramine, and MAOIs can reduce
hypersomnia.
Sleep-disordered Benzodiazepines increase Antipsychotic drugs that result in
breathing risk of OSA via upper weight gain increase risk of OSA.
airway muscle relaxation.
Parasomnia Serotonergic and anticholinergic drugs β-Blockers can cause
can trigger or worsen RBD (potentially nightmares.
injurious dream enactment); REM sleep
rebound and excessive/vivid dreams
can occur upon cessation of most
antidepressants.
Sleep-related Serotonergic and antihistaminic agents Antidopaminergic drugs can trigger
movement disorders can trigger or worsen RLS. or worsen RLS, which must be
distinguished from akathisia.
Note. MAOIs=monoamine oxidase inhibitors; OSA=obstructive sleep apnea; RBD=REM sleep behavior disorder; RLS=restless legs syndrome.
Clinical Sleep Medicine
Introduction 9
peutic effect of these drugs may, to some extent, be related to this out-
come, because selective REM suppression protocols in the laboratory
setting can yield clinical benefit of similar magnitude (Vogel et al. 1975).
Few antidepressants, including mirtazapine, trazodone, and doxepin,
promote both SWS density (slow wave amplitudes) and duration (Krys-
tal 2012).
TST varies across drugs, according to their class and individual prop-
erties. For instance, when considering tricyclic antidepressants (TCAs)
as a class, amitriptyline, nortriptyline, and clomipramine result in sleep
consolidation and increased TST, but most other TCAs, especially desip-
ramine, and monoamine oxidase inhibitors can be activating and used
as mild stimulants, thus potentially contributing to insomnia. More com-
monly prescribed, most selective serotonin reuptake inhibitors (SSRIs)
and serotonin-norepinephrine reuptake inhibitors (SNRIs) result in in-
somnia at a rate of up to three times that of placebo (Lam et al. 1990).
Among the SSRIs, however, citalopram has a lower rate of treatment-
emergent insomnia, whereas fluvoxamine has a higher rate (about 30%)
and can also result in daytime sedation.
Bupropion holds a unique place due to its different pharmacological
mechanism—dopamine and norepinephrine reuptake inhibition—with
an overall mild but consistent activating effect. Bupropion is often used
off-label by sleep specialists to reduce excessive daytime sleepiness and
can result in difficulty with sleep onset if it is taken later in the day. This
unique mechanism of action is shared with a newer agent, solriamfetol,
which has been approved for the indication of excessive daytime sleep-
iness in narcolepsy and residual sleepiness associated with OSA despite
treatment.
Low-dose doxepin (3–6 mg) is the only antidepressant approved by
the FDA for the treatment of insomnia and promotes sleep via selective
histamine (H1) blockade. Sedative TCAs (amitriptyline, nortriptyline),
trazodone, and mirtazapine also promote sleep via H1 but also via sero-
tonin-2A (5-HT2A) receptor blockade (see Chapter 4).
Due to their serotonergic properties, all TCAs, SSRIs, and SNRIs can
result in a new onset or exacerbation of RLS symptoms or PLMs, as ob-
served on polysomnogram (Hoque and Chesson 2010; see Chapter 17).
This is a higher concern with antidepressants that have antihistamine
properties (H1 antagonists), such as mirtazapine, or with low-dose dox-
epin. Treatment-induced RLS can occur in up to 28% of patients taking
mirtazapine (Rottach et al. 2008). Preexisting or new symptoms of RLS
should ideally be screened in patients prescribed these drugs, especially
if a complaint of insomnia paradoxically worsens despite their use.
Dream recall can be reduced with certain TCAs but not typically with
SSRIs and SNRIs. Cessation of antidepressant treatments, especially if
abrupt, can result in significant REM sleep rebound and exacerbation of
unpleasant vivid dreams or nightmares (Wilson and Argyropoulos
2005). Importantly, as many as 6% of patients treated with antidepres-
sants can experience abnormal dream enactment during REM sleep, also
known as RBD (see Chapter 15) (Teman et al. 2009). This condition can
lead to serious injuries to self and bed partners and in many adult cases
can progress to a neurodegenerative disorder, sometimes after decades
(Bodkin 2018; Högl et al. 2018; Postuma et al. 2013). This side effect is
likely due to the serotonergic properties of antidepressants and is charac-
terized on polysomnography by increased chin and limb electromyo-
graphic activity during REM sleep instead of the normal muscle atonia
that usually defines this stage of sleep.
MOOD STABILIZERS
Data are limited for most newer agents used for mood stabilization. Lith-
ium is associated with increased SWS and, like antidepressants, REM
sleep inhibition.
ANXIOLYTICS
Benzodiazepine drugs produce a sedative effect via activation of the
GABAA receptor (see Chapter 4). Although often used to improve sleep
quality and reduce sleep fragmentation, benzodiazepines reduce SWS
and increase in proportion the amount of stage N2 sleep, a lighter stage
of sleep. They also increase sleep spindle activity. Benzodiazepines can
potentially aggravate any underlying OSA via relaxation of the upper
airway dilator muscles (see Chapter 8).
β-Blockers, which are sometimes used to treat event-related (perfor-
mance) anxiety, are known to inhibit melatonin production via inhibi-
tion of adrenergic β1 receptors. β-Blockers reduce SWS and REM sleep
and can provoke disturbed sleep, nightmares, and insomnia.
ANTIPSYCHOTICS
Most antipsychotic drugs can have sedative effects, which can be used to
consolidate sleep and reduce sleep complaints. The agents found to have
lower rates of daytime sedation (less than 30%) are quetiapine, ziprasi-
done, and aripiprazole, whereas those with higher rates of excessive day-
time sleepiness include clozapine, thioridazine, and chlorpromazine,
followed by risperidone and olanzapine (Krystal et al. 2008).
Introduction 11
Newer antipsychotics such as quetiapine and ziprasidone were shown

not only to reduce REM sleep and consolidate sleep but also to promote
SWS (Cohrs et al. 2005). Sleep consolidation and SWS enhancement are
also observed with olanzapine and clozapine (Krystal 2012), whereas
low-dose risperidone reduces REM sleep (Sharpley et al. 2003).
As discussed earlier, all antidopaminergic drugs, and thus most an-
tipsychotics, can result in new-onset or exacerbation of RLS (see Chapter
17). This potentially severe and debilitating symptom can interfere with
the ability to sleep and significantly impact quality of life. It is important
to distinguish RLS from akathisia, which does not have a circadian pat-
tern and tends to affect the entire body. RLS mostly or only occurs in the
second part of the day, evening, or night and in most cases affects the
legs more than arms or other body parts.
Several antipsychotic drugs can result in weight gain, thus increasing
the risk of obstructive sleep-disordered breathing (see Chapters 8–10).
This risk is particularly important with olanzapine.
Conclusion
Sleep and mental health are in a relationship of mutual causality. As
summarized in this chapter, current evidence supports the following:
1. Psychiatric disorders affect sleep; hence, sleep symptoms can provide

a window into the psychiatric status of an individual.
2. Impaired sleep contributes to mental illness; therefore, addressing
sleep disturbances as part of a comprehensive and integrated man-
agement plan is not only relevant but also necessary, because most
sleep issues can be treated.
3. In practice, many drugs used to treat psychiatric conditions poten-
tially affect sleep and wake.
The effects of psychotropic drugs on sleep are not limited to the pro-
motion of sleep or wake. Psychotropic drugs can result in altered dream
experiences, nightmares, potentially injurious parasomnias as seen with
RBD, exacerbation of RLS, and obstructive sleep-disordered breathing
such as OSA. We recommend mental health practitioners take a mindful
and systematic approach grounded in a basic understanding of drug
mechanisms and the psychopharmacology of sleep and wake (see Chap-
ters 4, 6, and 7). This should yield success in most clinical situations. Re-
ferral to a sleep specialist is indicated in more challenging situations or
in treatment-resistant sleep disorders.
KEY CLINICAL POINTS

• Sleep disturbances such as insomnia and hypersomnia are associa-
ted with up to 90% cases of major depressive disorder. Treating both
mood and sleep symptoms synergically improves clinical outcomes.
• Acute sleep deprivation has beneficial effects on depression but can
also precipitate manic episodes in patients with bipolar disorder.
• Although most antidepressants can negatively affect sleep, seda-
tive tricyclic agents (nortriptyline, amitriptyline), low-dose doxepin,
mirtazapine, and trazodone can promote sleep.
• Due to their mild stimulant effect, desipramine, bupropion, and
monoamine oxidase inhibitors can reduce hypersomnia.
• All serotonergic drugs can potentially exacerbate restless legs syn-
drome—which should be distinguished from akathisia due to its
circadian pattern—as well as REM sleep behavior disorder, which
can result in injurious dream enactment.
• Due to their myorelaxant effect on the upper airway dilator muscles,
all benzodiazepine drugs can worsen obstructive sleep apnea.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition. Arlington, VA, American Psychiatric Association, 2013
Anderson KN, Bradley AJ: Sleep disturbance in mental health problems and
neurodegenerative disease. Nat Sci Sleep 5:61–75, 2013 23761983
Baglioni C, Battagliese G, Feige B, et al: Insomnia as a predictor of depression: a
meta-analytic evaluation of longitudinal epidemiological studies. J Affect
Disord 135(1–3):10–19, 2011 21300408
Berridge CW, Schmeichel BE, España RA: Noradrenergic modulation of wake-
fulness/arousal. Sleep Med Rev 16(2):187–197, 2012 22296742
Bodkin C: Gender implications, in Rapid-Eye-Movement Sleep Behavior Disor-
der. Edited by Schenck WC, Högl B, Videnovic A. Cham, Switzerland,
Springer, 2018, pp 215–222
Breslau N, Roth T, Rosenthal L, et al: Sleep disturbance and psychiatric disor-
ders: a longitudinal epidemiological study of young adults. Biol Psychiatry
39(6):411–418, 1996 8679786
Cohrs S, Meier A, Neumann AC, et al: Improved sleep continuity and increased
slow wave sleep and REM latency during ziprasidone treatment: a ran-
domized, controlled, crossover trial of 12 healthy male subjects. J Clin Psy-
chiatry 66(8):989–996, 2005 16086613
Dew MA, Reynolds CF III, Houck PR, et al: Temporal profiles of the course of
depression during treatment. Predictors of pathways toward recovery in
the elderly. Arch Gen Psychiatry 54(11):1016–1024, 1997 9366658
Introduction 13
Earley CJ, Silber MH: Restless legs syndrome: understanding its consequences
and the need for better treatment. Sleep Med 11(9):807–815, 2010
20817595
Etain B, Dumaine A, Bellivier F, et al: Genetic and functional abnormalities of
the melatonin biosynthesis pathway in patients with bipolar disorder.
Hum Mol Genet 21(18):4030–4037, 2012 22694957
Fava M, Asnis GM, Shrivastava R, et al: Zolpidem extended-release improves
sleep and next-day symptoms in comorbid insomnia and generalized anx-
iety disorder. J Clin Psychopharmacol 29(3):222–230, 2009 19440075
Fava M, Asnis GM, Shrivastava RK, et al: Improved insomnia symptoms and
sleep-related next-day functioning in patients with comorbid major depres-
sive disorder and insomnia following concomitant zolpidem extended-
release 12.5 mg and escitalopram treatment: a randomized controlled trial.
J Clin Psychiatry 72(7):914–928, 2011 21208597
Ford DE, Kamerow DB: Epidemiologic study of sleep disturbances and psychi-
atric disorders. An opportunity for prevention? JAMA 262(11):1479–1484,
1989 2769898
Fuller KH, Waters WF, Binks PG, et al: Generalized anxiety and sleep architec-
ture: a polysomnographic investigation. Sleep 20(5):370–376, 1997
9381061
Giese M, Beck J, Brand S, et al: Fast BDNF serum level increase and diurnal
BDNF oscillations are associated with therapeutic response after partial
sleep deprivation. J Psychiatr Res 59:1–7, 2014 25258340
Harvey AG, Schmidt DA, Scarnà A, et al: Sleep-related functioning in euthymic
patients with bipolar disorder, patients with insomnia, and subjects with-
out sleep problems. Am J Psychiatry 162(1):50–57, 2005 15625201
Hofstetter JR, Mayeda AR, Happel CG, et al: Sleep and daily activity prefer-
ences in schizophrenia: associations with neurocognition and symptoms.
J Nerv Ment Dis 191(6):408–410, 2003 12826923
Högl B, Stefani A, Videnovic A: Idiopathic REM sleep behaviour disorder and
neurodegeneration—an update. Nat Rev Neurol 14(1):40–55, 2018 29170501
Hoque R, Chesson AL Jr: Pharmacologically induced/exacerbated restless legs
syndrome, periodic limb movements of sleep, and REM behavior disorder/
REM sleep without atonia: literature review, qualitative scoring, and com-
parative analysis. J Clin Sleep Med 6(1):79–83, 2010 20191944
Kalucy MJ, Grunstein R, Lambert T, et al: Obstructive sleep apnoea and schizo-
phrenia: a research agenda. Sleep Med Rev 17(5):357–365, 2013 23528272
Kaplan KA, Gruber J, Eidelman P, et al: Hypersomnia in inter-episode bipolar disor-
der: does it have prognostic significance? J Affect Disord 132(3):438–444, 2011
21489637
Koffel E, Polusny MA, Arbisi PA, et al: Pre-deployment daytime and nighttime
sleep complaints as predictors of post-deployment PTSD and depression in
national guard troops. J Anxiety Disord 27(5):512–519, 2013 23939336
Krystal AD: Psychiatric disorders and sleep. Neurol Clin 30(4):1389–1413, 2012
23099143
Krystal AD, Goforth HW, Roth T: Effects of antipsychotic medications on sleep
in schizophrenia. Int Clin Psychopharmacol 23(3):150–160, 2008 18408529
Lam RW, Berkowitz AL, Berga SL, et al: Melatonin suppression in bipolar and
unipolar mood disorders. Psychiatry Res 33(2):129–134, 1990 2243889
Lauer CJ, Schreiber W, Holsboer F, et al: In quest of identifying vulnerability

markers for psychiatric disorders by all-night polysomnography. Arch Gen
Psychiatry 52(2):145–153, 1995 7848050
Martin JL, Jeste DV, Ancoli-Israel S: Older schizophrenia patients have more
disrupted sleep and circadian rhythms than age-matched comparison sub-
jects. J Psychiatr Res 39(3):251–259, 2005 15725423
McCall WV, Reboussin BA, Cohen W: Subjective measurement of insomnia and
quality of life in depressed inpatients. J Sleep Res 9(1):43–48, 2000
10733688
Minkel JD, Krystal AD, Benca RM: Unipolar major depression, in Principles and
Practice of Sleep Medicine, 6th Edition. Edited by Kryger M, Roth T, De-
ment WC. Philadelphia, PA, Elsevier, 2017, pp 1352–1362
Nofzinger EA, Thase ME, Reynolds CF III, et al: Hypersomnia in bipolar de-
pression: a comparison with narcolepsy using the multiple sleep latency
test. Am J Psychiatry 148(9):1177–1181, 1991 1882995
Norris ER, Burke K, Correll JR, et al: A double-blind, randomized, placebo-
controlled trial of adjunctive ramelteon for the treatment of insomnia and
mood stability in patients with euthymic bipolar disorder. J Affect Disord
144(1–2):141–147, 2013 22963894
Nurnberger JI Jr, Adkins S, Lahiri DK, et al: Melatonin suppression by light in eu-
thymic bipolar and unipolar patients. Arch Gen Psychiatry 57(6):572–579, 2000
10839335
Partonen T, Lönnqvist J: Seasonal affective disorder. Lancet 352(9137):1369–
1374, 1998 9802288
Pollack M, Kinrys G, Krystal A, et al: Eszopiclone coadministered with escitalo-
pram in patients with insomnia and comorbid generalized anxiety disor-
der. Arch Gen Psychiatry 65(5):551–562, 2008 18458207
Postuma RB, Gagnon JF, Tuineaig M, et al: Antidepressants and REM sleep be-
havior disorder: isolated side effect or neurodegenerative signal? Sleep
36(11):1579–1585, 2013 24179289
Rachakonda TD, Balba NM, Lim MM: Trauma-associated sleep disturbances: a
distinct sleep disorder? Curr Sleep Med Rep 4(2):143–148, 2018 30656131
Raskind MA, Peskind ER, Chow B, et al: Trial of prazosin for post-traumatic stress
disorder in military veterans. N Engl J Med 378(6):507–517, 2018 29414272
Reynolds CF III, Frank E, Houck PR, et al: Which elderly patients with remitted
depression remain well with continued interpersonal psychotherapy after
discontinuation of antidepressant medication? Am J Psychiatry 154(7):958–
962, 1997 9210746
Ross RJ, Ball WA, Sullivan KA, et al: Sleep disturbance as the hallmark of post-
traumatic stress disorder. Am J Psychiatry 146(6):697–707, 1989 2658624
Rottach KG, Schaner BM, Kirch MH, et al: Restless legs syndrome as side effect of
second generation antidepressants. J Psychiatr Res 43(1):70–75, 2008 18468624
Sharafkhaneh A, Giray N, Richardson P, et al: Association of psychiatric disor-
ders and sleep apnea in a large cohort. Sleep 28(11):1405–1411, 2005 16335330
Sharpley AL, Bhagwagar Z, Hafizi S, et al: Risperidone augmentation decreases
rapid eye movement sleep and decreases wake in treatment-resistant de-
pressed patients. J Clin Psychiatry 64(2):192–196, 2003 12633128
Soreca I, Levenson J, Lotz M, et al: Sleep apnea risk and clinical correlates in pa-
tients with bipolar disorder. Bipolar Disord 14(6):672–676, 2012 22938169
Introduction 15
St-Amand J, Provencher MD, Bélanger L, et al: Sleep disturbances in bipolar dis-

order during remission. J Affect Disord 146(1):112–119, 2013 22884237
Szklo-Coxe M, Young T, Peppard PE, et al: Prospective associations of insomnia
markers and symptoms with depression. Am J Epidemiol 171(6):709–720, 2010
20167581
Teman PT, Tippmann-Peikert M, Silber MH, et al: Idiopathic rapid-eye-movement
sleep disorder: associations with antidepressants, psychiatric diagnoses, and
other factors, in relation to age of onset. Sleep Med 10(1):60–65, 2009 18226952
Vogel GW, Thurmond A, Gibbons P, et al: REM sleep reduction effects on de-
pression syndromes. Arch Gen Psychiatry 32(6):765–777, 1975 165796
Wehr TA: Sleep-loss as a possible mediator of diverse causes of mania. Br J Psy-
chiatry 159:576–578, 1991 1751874
Wehr TA, Sack DA, Rosenthal NE: Sleep reduction as a final common pathway
in the genesis of mania. Am J Psychiatry 144(2):201–204, 1987 3812788
Wiegand M, Berger M, Zulley J, et al: The influence of daytime naps on the thera-
peutic effect of sleep deprivation. Biol Psychiatry 22(3):389–392, 1987 3814687
Wilson S, Argyropoulos S: Antidepressants and sleep: a qualitative review of
the literature. Drugs 65(7):927–947, 2005 15892588
Wirz-Justice A, Van den Hoofdakker RH: Sleep deprivation in depression: what
do we know, where do we go? Biol Psychiatry 46(4):445–453, 1999 10459393
Another random document with
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he should proceed from Shanghai to Tientsin in a Russian vessel
which “he might borrow for the purpose.” Li Hung-chang’s reply,
telegraphed to Yüan Shih-k’ai for transmission to the Throne, while
outwardly respectful, clearly implies that Her Majesty has been to
blame for the disasters then occurring. “I am sincerely grateful,” he
says, “for Your Majesty’s gratifying confidence in me, but cannot help
recalling to mind the folly which has now suddenly destroyed that
structure of reformed administration which, during my twenty years’
term of office as Viceroy of Chihli, I was able to build up not
unsuccessfully. I fear it will not be possible for me to resume the
duties of this difficult post at a time of crisis like the present, destitute
as I am of all proper and material resources.” He proceeds even to
criticise Her Majesty’s suggestion as to his journey, observing that
“Russia possesses no vessel at Shanghai, and would certainly
refuse to lend if she had one, in view of the state of war now
existing.” Finally, he excuses himself for deferring his departure, on
the ground that the British Minister had requested him not to leave
until the foreign Ministers had been safely escorted from Peking to
Tientsin. “I do not know,” says he, “if any such arrangements for
safely escorting them can be made,” and therefore concludes by
asking Yüan to inform the Throne that he will start northwards,
journeying by land, “as soon as his health permits it.” To this plain-
spoken message from the great Viceroy, Tzŭ Hsi replied in two lines
of equally characteristic directness:—“Li Hung-chang is to obey our
earlier Decree, and to make all haste northwards. The crisis is
serious. Let him make no further excuses for delay.”
In spite of these peremptory orders, Li Hung-chang, who had a
very definite conception of his own predicament, remained at
Shanghai, ostensibly negotiating, but in reality waiting, to see what
would be the outcome of the siege of the Legations. He was
interviewed by The Times correspondent at Shanghai on the 23rd of
July, and then stated that he would not proceed to his post in the
north until convinced by clear proofs that the Empress Dowager had
seen the folly of her ways, and was prepared to adopt a conciliatory
policy towards the outraged foreign Powers. At the end of July, when
it became clear to him that the Court had determined on flight, he
forwarded by special courier a very remarkable Memorial, in which
he called the Throne to task in the plainest possible terms, and
urged an immediate change of policy. This Memorial reached the
Empress before her departure from Peking; certain extracts from it
are well worth reproduction, as showing Li Hung-chang at his best,
and displaying that quality of courageous intelligence which made
him for twenty years the foremost official in China and a world-wide
celebrity:—
“It is to be remembered that between this, our Empire of

China, and the outer barbarians, hostilities have frequently
occurred since the remotest antiquity, and our national history
teaches that the best way to meet them is to determine upon
our policy only after carefully ascertaining their strength as
compared with our own. Since the middle of the reign of Tao-
Kuang the pressure of the barbarians on our borders has
steadily increased, and to-day we are brought to desperate
straits indeed. In 1860 they invaded the Capital and burnt the
Summer Palace; His Majesty Hsien-Feng was forced to flee,
and thus came to his death. It is only natural that His
Majesty’s posterity should long to avenge him to the end of
time, and that your subjects should continue to cherish
undying hopes of revenge. But since that time, France has
taken from us Annam, the whole of that dependency being
irretrievably lost; Japan has fought us, and ousted us from
Korea. Even worse disasters and loss of territory were,
however, to follow: Germany seized Kiaochao; Russia
followed by annexing Port Arthur and Talienwan; England
demanded Wei-hei-wei and Kowloon, together with the
extension of the Shanghai Settlements, and the opening of
new treaty ports inland; and France made further demands for
Kuang-Chou wan. How could we possibly maintain silence
under such grievous and repeated acts of aggression?
Craven would be the man who would not seek to improve our
defences, and shameless would be he who did not long for
the day of reckoning. I myself have enjoyed no small favours
from the Throne, and much is expected of me by the nation.
Needless for me to say how greatly I would rejoice were it
possible for China to enter upon a glorious and triumphant
war; it would be the joy of my closing days to see the
barbarian nations subjugated at last in submissive allegiance,
respectfully making obeisance to the Dragon Throne.
Unfortunately, however, I cannot but recognise the
melancholy fact that China is unequal to any such enterprise,
and that our forces are in no way competent to undertake it.
Looking at the question as one affecting chiefly the integrity of
our Empire, who would be so foolish as to cast missiles at a
rat in the vicinity of a priceless piece of porcelain? It requires
no augur’s skill in divination to foresee that eggs are more
easily to be cracked than stones. Let us consider one recent
incident in proof of this conclusion. Recently, in the attack by
some tens of thousands of Boxers and Imperial troops upon
the foreign Settlements at Tientsin, there were some two or
three thousand foreign soldiers to defend them; yet, after ten
days of desperate fighting, only a few hundred foreigners had
been slain, while no less than twenty thousand Chinese were
killed and as many more wounded. Again, there are no real
defences or fortified positions in the Legations at Peking, nor
are the foreign Ministers and their Legation staffs trained in
the use of arms; nevertheless, Tung Fu-hsiang’s hordes have
been bombarding them for more than a month, and have lost
many thousands of men in the vain attempt to capture the
position.
“The fleets of the Allied Powers are now hurrying forward
vast bodies of their troops; the heaviest artillery is now being
brought swiftly to our shores. Has China the forces to meet
them? Does she possess a single leader capable of resisting
this invasion? If the foreign Powers send 100,000 men, they
will easily capture Peking, and Your Majesties will then find
escape impossible. You will no doubt endeavour once more to
flee to Jehol, but on this occasion you have no commander
like Sheng Pao to hold back the enemies’ forces from pursuit;
or, perhaps, you may decide to hold another Peace
Conference, like that at Shimonoseki, in 1895? But the
conditions to-day existing are in no way similar to those of
that time, when Marquis Ito was willing to meet me as your
Minister Plenipotentiary. When betrayed by the Boxers and
abandoned by all, where will your Majesties find a single
Prince, Councillor, or Statesman able to assist you
effectively? The fortunes of your house are being staked upon
a single throw; my blood runs cold at the thought of events to
come. Under any enlightened Sovereign these Boxers, with
their ridiculous claims of supernatural powers, would most
assuredly have been condemned to death long since. Is it not
on record that the Han Dynasty met its end because of its
belief in magicians, and in their power to confer invisibility?
Was not the Sung Dynasty destroyed because the Emperor
believed ridiculous stories about supernatural warriors clad in
miraculous coats of mail?
“I myself am nearly eighty years of age, and my death
cannot be far distant; I have received favours at the hands of
four Emperors. If now I hesitate to say the things that are in
my mind, how shall I face the spirits of the sacred ancestors
of this Dynasty when we meet in the halls of Hades? I am
compelled therefore to give utterance to this my solemn
prayer, and to beseech Your Majesties to put away from you
at once these vile magic workers, and to have them
summarily executed.
“You should take steps immediately to appoint a high official
who shall purge the land of this villainous rabble, and who
shall see to it that the foreign Ministers are safely escorted to
the headquarters of the Allied Armies. In spite of the great
heat, I have hurried northwards from Canton to Shanghai,
where your Majesties’ Decrees urging me to come to Peking
have duly reached me. Any physical weakness, however
serious, would not have deterred me from obeying this
summons, but perusal of your Decrees has led me to the
conclusion that Your Majesties have not yet adopted a policy
of reason, but are still in the hands of traitors, regarding these
Boxers as your dutiful subjects, with the result that unrest is
spreading and alarm universal. Moreover, I am here in
Shanghai without a single soldier under my command, and
even should I proceed with all haste in the endeavour to
present myself at your Palace gates, I should meet with
innumerable dangers by the way, and the end of my journey
would most probably be that I should provide your rebellious
and turbulent subjects with one more carcass to hack into
mincemeat. I shall therefore continue in residence here for the
present, considering ways and means for raising a military
force and for furnishing supplies, as well as availing myself of
the opportunity of ascertaining the enemies’ plans, and
making such diplomatic suggestions as occur to me to be
useful. As soon as my plans are complete, I shall proceed
northwards with all possible speed.”
The plain-spoken advice of Li Hung-chang was not without effect

on the Empress Dowager. The Decrees issued by her in the name of
the Emperor from Huai-lai on the 19th and 20th of August are the
first indications given to the outside world that she had definitely
decided on a policy of conciliation so as to render possible her
eventual return to the capital—an event which, as she foresaw,
would probably be facilitated by the inevitable differences and
jealousies already existing among the Allies.
In the Edict of the 19th of August, after explaining that the whole
Boxer crisis and the attack on the Legations was the result of
differences between Christian and non-Christian Chinese, she
querulously complains that the foreign Powers, although doubtless
well meaning in their efforts to “exterminate the rebels,” are behaving
in a manner which suggests aggressive designs towards China, and
which shows a lamentable disregard of proper procedure and
friendliness. She naively observes that the Chinese Government had
been at the greatest pains to protect the lives and property of
foreigners in Peking, in spite of many difficulties, and expresses
much surprise at such an evil return being made for her invariable
kindness and courtesy. If it were not for the unbounded capacity of
foreign diplomats, fully proved in the past, in the matter of credulity
where Chinese statecraft is concerned, it would be difficult to regard
utterances like these as the work of an intelligent ruler. But Tzŭ Hsi
was, as usual, justified, for at the very time when these Decrees
were issued, Russia was already using very similar arguments, and
making excuses for the Chinese government, in pursuance of her
own policy at Peking.
In the conclusion of the Decree above referred to, Her Majesty
orders Jung Lu, Hsü T’ung and Ch’ung Ch’i to remain in Peking to
act as peace negotiators, but she admits that, in dealing with
foreigners supported by troops and flushed with success, it may be
difficult for them at the outset to determine on a satisfactory line of
procedure. She leaves it to these plenipotentiaries, therefore, to
determine whether the best course would be to telegraph to the
respective Foreign Offices of the countries concerned, or to consult
with the Consuls-General at Shanghai (sic), with a view to obtaining
friendly intervention! It could not escape so shrewd a person as Tzŭ
Hsi that the atmosphere of Peking at this juncture was not likely to
be favourable to her purposes, and that it would be easier to
hoodwink the Foreign Offices and the Consuls at Shanghai than
those who had just been through the siege.
A Decree of the following day, also in the name of the Emperor, is
couched in a very different strain—a pathetic admission of the
Throne’s guilt, a plea for the sympathy of his people, and an
exhortation to return to ways of wisdom. “Cleanse your hearts, and
remove all doubt and suspicion from your minds, so as to assist us,
the Emperor, in our shortcomings. We have been utterly unworthy,
but the time is at hand when it shall be for us to prove that Heaven
has not left us without sense of our errors and deep remorse.” The
whole document reads with an unusual ring of sincerity, accepting, in
the name of the Emperor, full blame for all the disasters which had
overtaken the country, while reminding the official class that the first
cause of these calamities dates back to the time when they learned
and adopted habits of inveterate sloth and luxury. From depths of
contrition, the Edict admits fully the Throne’s responsibility, “We, the
Lord of this Empire, have failed utterly in warding off calamities from
our people, and we should not hesitate for one moment to commit
suicide, in order to placate our tutelary deities and the gods of the
soil, but we cannot forget that duty of filial piety and service which we
owe to our sacred and aged mother, the Empress Dowager.”
The policy of reform is now clearly enunciated and outlined as an
essential condition of the future government of the Empire. Provincial
and metropolitan officials are ordered to proceed at once to join the
Court, in order that the reform programme may be speedily initiated;
the Yangtsze Viceroys are thanked for preserving order in
accordance with “treaty stipulations,” and Chinese converts to
Christianity are once more assured of the Throne’s protection and
good-will.
These utterances of the Throne, which lost nothing in their
presentation to the respective Powers by Prince Ch’ing and his
colleagues, soon produced the desired effect, and reassured the
Throne and its advisers as to their personal safety. Accordingly, early
in September, we find all the Viceroys and high officials of the
Provinces uniting in a Memorial, whereby the Court is urged to return
at once to the Capital, advice which would never have been given
had there been any question of violent measures being taken by the
Allies against the Empress Dowager. At this time the question of the
future location of the Chinese Capital was being widely discussed at
Court, and there was much conflicting advice on the subject. The
Viceroys’ Memorial was drafted by Yüan Shih-k’ai and forwarded by
him to Liu K’un-yi, at Nanking, for transmission; it definitely blames
the Boxers and their leaders for the ruin which had come upon
China, and rejoices at the thought that “the perplexities which
embarrassed your Majesties in the past have now given place to a
clearer understanding of the situation.” Noting the possibility of the
Court’s leaving T’ai-yüan fu and making “a further progress”
westwards to Hsi-an, the Memorialists deplore the idea and proceed
to show that such a step would be unwise as well as inconvenient.
As an example of the way in which Chinese Ministers of State deal
with questions of high policy and strategy, the following extract from
this Memorial is not without interest:—
“It is true that, in times past, our Capital has been shifted on
more than one occasion of national danger, but in those days
our enemies were not able to push their armies far into the
interior of our country for indefinite periods, and were
compelled to withdraw after brief expeditions. The position of
affairs to-day, however, is very different, so that we can obtain
no reliable guidance from precedents of history. As regards
the province of Shensi, it has always been a centre of wars
and rebellions; its people are poverty stricken, and there is no
trade there. Seven centuries ago, Hsi-an was an Imperial city,
but is now anything but prosperous. Its vicinity to Kansu and
the New Dominion territories, infested with Mahomedan
rebels and adjoining the Russian Empire, renders it most
unsuitable as a site for your Majesties’ Capital. Supposing
that the Allies, flushed with success, should determine on an
advance westwards, what is there to prevent them from doing
so? If ten thousand miles of ocean have not stopped them,
are they likely to be turned back from a shorter expedition by
land?”
After referring to the fact that the cradle of the Dynasty and the
tombs of its ancestors are situated near Peking, and that it is
geographically best fitted to be the centre of Government, the
Memorialists remind the Throne that the foreign Powers have
promised to vacate Peking, and to refrain from annexing any territory
if the Court will return. These ends, they say, will not be attained
should the Court persist in its intention to proceed further westwards,
since it is now the desire of the foreign Ministers that China’s rulers
should return to Peking. In the event of a permanent occupation of
Peking by the Allies, the loss of Manchuria would be inevitable. The
Memorialists predict partition and many other disasters, including
financial distress, and the impossibility of furnishing the Throne with
supplies at Hsi-an or any other remote corner of the Empire. If the
Court’s decision to proceed to Hsi-an is irrevocable, at least a
Decree should now be issued, stating that its sojourn there will be a
brief one, and that the Court will return to Peking upon the complete
restoration of peaceful conditions. “The continued existence of the
Empire must depend upon the Throne’s decision upon this matter.”
The Memorial concludes by imploring their Majesties to authorise
Prince Ch’ing to inform the foreign Ministers that the withdrawal of
the allied armies will be followed by a definite announcement as to
the Court’s return.
In a further Memorial from the Viceroys and Governors, it is stated
that the Russian Minister for Foreign Affairs had suggested to the
Chinese Minister in St. Petersburg, that the location of the Capital at
Hsi-an would certainly prove undesirable, in view of the poverty-
stricken condition of the province, and that their Majesties would no
doubt, therefore, proceed to Lan-chou fu, in Kansu. Referring to this
interesting fact, the Memorialists observe:—
“Those who are in favour of establishing the Capital at Hsi-

an profess to claim that the Yellow River and the T’ung Kuan
Pass constitute natural and impassible frontiers against
attack. They forget, however, that foreign nations possess
artillery of very long range. At T’ung Kuan the Yellow River is
less than two miles wide, and their guns will easily carry twice
that distance. Your Majesties have nothing but the native
artillery, and a few inferior foreign guns, and would never be
able to hold the position. The foreigners would undoubtedly
penetrate far into the interior, and control all the waterways,
thus preventing transport and supplies. Even if one foreign
Power were to find it difficult, there is no doubt that it would be
easy for several of them acting together.
“Moreover, friendly Powers are entitled, by the law of
civilised nations, to send their diplomatic representatives to
our Capital. If peace be made, and the foreign Powers assent
to the proposed change of capital, they will surely insist upon
sending their envoys into Shensi. After their recent
experiences, they will require to have foreign troops to guard
their Legations, whose numbers must necessarily be large, in
proportion to the distance from the coast. Foreign garrisons
would thus have to be established at points in Honan, Shansi
and Chihli, in order to maintain their line of communications,
so that China would eventually be overrun by foreign troops. It
is, therefore, plainly out of the question that the Court should
leave Peking. In times of peace it might have been
suggested, but to think of it after a disastrous war is
impossible. The foreigners are acting in unison; China is
completely disorganised. They have ample resources and
reinforcements; China has none. If we have thoughts of
fighting any foreign Power we must first form alliances with
several others; in any case nothing can be done before an
ample supply of ordnance and munitions of war has been
accumulated. This is no time for considering such
possibilities. We, your Memorialists, venture to suggest that
Your Majesties have failed to take into consideration all these
facts, and in impressing them upon you, we earnestly beg that
you may now come to a wise decision.”
Before coming to a decision, however, Tzŭ Hsi required to be fully

assured that the foreign Powers would not insist on her abdicating
the supreme power as one of the conditions of peace. Convinced on
that point, the hesitation which she had previously shown in regard
to returning to Peking dropped from her like a garment. It had been
freely predicted by conservative officials and the literati that the Old
Buddha would never again wish to see her desecrated capital or to
visit the polluted shrines of her ancestors. In spite of her
superstitious nature, however, she was far too level-headed and far-
seeing a woman to attach supreme importance to sentimental
considerations, or to allow them to weigh heavily in the balance
when the question of her own rulership was at stake. The hesitation
which she had shown and the attention which she had paid to the
advice of those who, like Chang Chih-tung, desired her to establish a
new capital in Central China, were primarily a question of “face.” She
would only return to Peking if guaranteed the full dignity and power
of her former position. But as the peace negotiations proceeded, and
as it became clear to her that along the well-worn path of
international jealousies she might return unpunished, and even
welcomed, to Peking, she proceeded to make preparations for an
early return. Fully informed each day by Prince Ch’ing of the
progress which her plenipotentiaries were making towards the
completion of the Peace Protocol, and overjoyed at its terms, she
waited only until the condition of the roads, always more or less
impassable after the summer rains, had sufficiently improved to
permit of comfortable travelling. During the delay necessitated by the
collecting and packing of the enormous quantity of “tribute” collected
by Her Majesty and the Court during their stay at Hsi-an, she
received definite confirmation of the good news that her treasure
vaults in the capital had not been plundered by the foreign troops—
good news which increased her anxiety to return as quickly as
possible to superintend its removal before any pilfering by the
eunuchs should take place.
It was on the 24th day of the 8th Moon (20th October, 1901) that
the long procession started from Her Majesty’s temporary residence
in the Governor’s Yamên; followed by an enormous retinue, she
commenced her journey by sacrificing to the God of War, the
guardian spirit of her Dynasty (and, it may be added, patron of the
Boxers), at a small temple outside the city gates. From this onward
the Court advanced northward by easy stages of about twenty-five
miles a day, resting first at Ho-nan fu; thence on to K’ai-fêng, where
her sixty-sixth birthday was celebrated and where she remained for
some weeks. The travelling lodges and other arrangements for her
comfort and convenience along the whole line of her route were in
striking contrast to the squalor and privation which the Court had
endured in the flight from Peking.
It was during her stay at K’ai-fêng that the Peace Protocol was
signed at Peking. It was also before her departure from that city, at
the end of the 9th Moon, that Li Hung-chang died. His knowledge of
foreign affairs and remarkable ability in negotiations had been of the
greatest service to his Imperial mistress, and there is no doubt that
the liberal terms granted to China by the victorious Allies were very
largely due to his efforts. Her Majesty, while fully appreciating his
ability, had never treated him with marked favour, and had always
refused to appoint him to the Grand Council, giving as her excuse
that she could not understand his dialect. Upon his death, however,
she conferred upon him an honour which had never before been
granted to any Chinese subject under the Dynasty, namely, that of
having a shrine built to his memory at the capital itself, in addition to
those erected in the provinces where he had borne office.
It was significant of her impartial and intelligent rulership that,
although she had blamed him as originally responsible for the
Japanese War and its disastrous results, she had never approved of
the Emperor’s hasty and vindictive action in removing him from the
Viceroyalty of Chihli. Upon the signing of the Peace Protocol she
conferred additional posthumous honours upon him, taking occasion
at the same time, in an Imperial Decree, to congratulate and thank
Prince Ch’ing, Yüan Shih-k’ai and others, who assisted in bringing
about the settlement of peace terms. In particular she praised the
loyalty of Jung Lu, “who had earnestly advised the annihilation of the
Boxers, and who, in addition to other meritorious services on the
Grand Council, had been chiefly instrumental in protecting the
Legations.”
After a series of magnificent theatrical entertainments in honour of
her birthday, the Court left K’ai-fêng and continued its journey to the
capital. On the eve of her departure Her Majesty took occasion
sternly and publicly to rebuke the Manchu Prefect, Wen T’i,[121] who
had dared to advise her against returning to the capital, and to
predict that the treacherous foreigners would certainly seize her
sacred person—a useful piece of play to the gallery.
At the crossing of the Yellow River, which took place in beautiful
weather, she sacrificed to the River God, in expiation and
thanksgiving. The local officials had constructed a magnificent barge,
in the form of a dragon, upon which she and the ladies of the Court
crossed the stream. It was noticed from this point onwards that
wherever foreigners happened to be amongst the spectators of the
Imperial cortège, she made a point of showing them particular
attention and civility, and before her arrival in Peking she issued a
Decree commanding that Europeans should not be prevented from
watching the procession upon her arrival, and this in spite of the fact
that, in accordance with the usual custom, the Legations had issued
notices forbidding their nationals to appear in the streets during the
passage of the Imperial cortège. Everything indicated, in fact, that
Her Majesty now desired to conciliate the European Powers by all
possible means, and if it be borne in mind that it was part of her
deliberate policy thus to ingratiate herself with foreigners as a means
of furthering her own future policy, her actions lose nothing of
interest, while they gain something from the humorous point of view.
On crossing the borders of the Province of Chihli, Her Majesty
issued a Decree, couched in almost effusive terms of friendliness,
proclaiming that the Emperor would receive the foreign Ministers in
audience immediately upon his return to the Palace, and that the
reception would take place in the central Throne Hall of the sacred
enclosure. Chinese, reading this Decree, and ignorant of the terms
of the Peace Protocol which provided for this particular concession
to the barbarian, would naturally regard it as a spontaneous mark of
the Imperial clemency and goodwill. In the same Edict Her Majesty
proclaimed her intention of receiving the Ministers’ wives in person,
intimating that she cherished most pleasant memories of past
friendly intercourse with them. Here, again, we note fulfilment of a
plan, deliberately conceived and formed upon the best classical
models, “for dealing with strong and savage people.”
At noon on the 6th of January, 1902, the Imperial party arrived by
special train at the temporary station which had been erected close
to the Southern walls of Peking, and adjoining the old terminus at
Ma-chia pu. Large pavilions, handsomely decorated, had been
erected near the station, in which the Old Buddha and the Emperor
were to be received; they were furnished with a throne of gold
lacquer, cloisonné altar vessels and many valuable pieces of
porcelain. Several hundreds of the highest metropolitan officials
were in attendance, and a special place had been provided for
foreigners. As the long train of over thirty carriages drew up at the
station, the keen face of the Old Buddha was seen anxiously
scanning her surroundings from one of the windows of her car. With
her were the young Empress and the Princess Imperial, while the
chief eunuch, Li Lien-ying, was in attendance. Recognising Her
Majesty, every official fell upon his knees, whilst Chi Lu, chief officer
of the Household, officiously shouted to the foreigners to remove
their hats (which they had already done). The first to emerge from
the train was the chief eunuch, who proceeded forthwith to check the
long list of provincial tribute and treasure, mountainous loads of
baggage which had travelled with the Court from the start and under
Her Majesty’s close personal supervision. After the eunuch came the
Emperor, evidently extremely nervous, who, at a sign from Her
Majesty, hurried into his sedan-chair and was swiftly borne away,
without a word or a sign of recognition to any of the officials in
attendance. After his departure, the Empress came out and stood
upon the platform at the end of her carriage. “Quite a number of
foreigners are here, I see,” she was heard to observe. She saluted
them in accordance with the etiquette observed by Chinese women
—bowing and raising her crossed hands. Prince Ch’ing then
advanced to greet Her Majesty, and with him Wang Wen-shao (who
had succeeded Li Hung-chang as Peace Plenipotentiary). They
invited Her Majesty to enter her chair: “There is no hurry,” she
replied. She stood for some five minutes in full view of the crowd,
talking energetically with the bystanders, and looking extremely well
and youthful for her age, until the chief eunuch returned and handed
her the list of baggage and treasure, which she scanned with close
attention and then returned to him with an expression of satisfaction.
After this, at the request of the Viceroy of Chihli (Yüan Shih-k’ai),
the foreign manager and engineer of the railway were presented to
her, and received her thanks for the satisfactory arrangements made
throughout the journey. She then entered her chair, a larger and finer
conveyance than that supplied to the Emperor, and was borne away
towards the Palace; by her side ran one of her favourite eunuchs
repeatedly calling Her Majesty’s attention to objects of interest.
Whenever foreigners were in sight he would inform Her Majesty of
the fact, and by one he was heard distinctly to say: “Look! Old
Buddha, look quickly at that foreign devil,” whereupon the Empress
smiled and bowed most affably. Passing through the Southern gate
of the Chinese city, her bearers carried her straight to the large
enceinte of the Tartar city wall at the Ch’ienmen, where stands the
shrine dedicated to the tutelary God of the Manchus. Here crowds of
foreigners were in waiting on the wall. Looking down on the
courtyard towards the shrine, they saw the Old Buddha leave her
chair and fall upon her knees to burn incense before the image of the
God of War, whilst several Taoist priests chanted the ritual. Rising
she next looked up towards the foreigners, smiling and bowing,
before she was carried away through the gate into the precincts of
the Forbidden City. No sooner had she reached the inner palace (the
Ning Shou kung) at about 2 p.m., than she commanded the eunuchs
to commence digging up the treasure which had been buried there at
the time of her flight; she was gratified beyond measure to find that it
had indeed remained untouched.
Next, with an eye not only upon her future relations with foreigners
but also on public opinion throughout the Empire, she issued a
Decree conferring posthumous honours on the “Pearl concubine,”
who, as it will be remembered, was thrown down a well by her orders
on the morning of the Court’s flight from the Palace. In this Decree
Her Majesty praises the virtue and admirable courage of the dead
woman, which “led her virtuously to commit suicide when unable to
catch up the Court on its departure,” unwilling as she was to witness
the destruction and pollution of the ancestral shrines. Her trustworthy
conduct was therefore rewarded by the granting of a posthumous
title and by promotion of one step in rank in the Imperial harem. The
Decree was generally regarded as fulfilling all reasonable
requirements of atonement towards the deceased, for in China the
dead yet live and move in a shadowy, but none the less real,
hierarchy. Alive, a “Pearl concubine” more or less counted for little
when weighed against the needs of the Old Buddha’s policies; once
dead, however, her spirit must needs be conciliated and
compensated.
Many Europeans who had witnessed the arrival of the Empress
Dowager, remained at the railway station to see the unloading of her
long baggage train, a most interesting and instructive sight. First
were discharged the yellow chairs of the young Empress and the
Princess Imperial, and four green chairs with yellow borders for the
principal concubines; the other ladies of the Court followed in official
carts, two to each vehicle. There were about ninety of them
altogether, and the arrangements for their conveyance were
accompanied by no little noise and confusion, the loquacity of some
of the elder ladies being most noticeable. After their departure the
attention of the eunuchs and minor officials was directed to the huge
pile of the Empress Dowager’s personal baggage, which included
her cooking utensils and household articles in daily use. This
operation, as well as the removal of a very large quantity of bullion,
(every case of which was marked with the name of the province or
city that had sent it as tribute), was for a time superintended by the
Grand Council. But as the work was enough to last for several hours,
it was not long before, led by Jung Lu, they entered their chairs and
left for the City. It was noticed that Jung Lu seemed very infirm, and
was supported as he walked by two attendants of almost gigantic
stature.
From Cheng-ting fu to Pao-ting fu, and thence to Peking, the Court
travelled, for the first time in its history, by train. The following
description of the journey is reprinted, by kind permission of the
editor of The Times, from an article published in that paper in March,
1902. It shows an interesting side of the Empress Dowager’s
character, that of the thrifty mistress of her goods and chattels, and
gives a clear-cut impression of that vigorous personality which
devoted the same close attention to details of transport and domestic
economy as to niceties of Court ceremonial or historical precedents
on vital questions of State; characteristics which inevitably suggest a
marked resemblance between the Old Buddha and le petit Caporal.
“Early on December 31st the Court arrived at Cheng-ting fu,

escorted by a large body of cavalry and accompanied by an
enormous suite of officials, eunuchs and servants. The
baggage was carried by a train of carts, estimated by an eye-
witness at three thousand. The eunuchs numbered between
three and four hundred, and of cooks and other kitchen
servants there were almost as many. To provide
accommodation for such a mass of people was impossible,
especially as all the best quarters in the town had already
been occupied by the high officials who, with their retainers,
had come from the north to welcome the Empress Dowager
on her return. For three days the Court rested in Cheng-ting
fu, during which time the scene was one of indescribable
confusion; baggage, stacked haphazard, filled every available
corner, eunuchs and servants camping around and upon it,
stolidly enduring much physical discomfort with the apathy
peculiar to Asiatics. Yet, so great was the cold (on the night of
January 1st the thermometer stood at two degrees
(Fahrenheit) below zero) that many of these wayfarers gave
way to lamentations and tears. Officials of the lower and
middle grades, unable to obtain a lodging, were compelled to
pass these days in such makeshift shelter as they could find
in the vicinity of the railway station, where swarmed a mob of
undisciplined soldiery. On the second night a fire broke out in
the stables of the Imperial residence, which, though
eventually checked before much damage was done, added
greatly to the general disorder, and might well have had
serious results in the absence of all organisation and control.
The definite announcement of the Court’s intention to leave
for Pao-ting fu on the 3rd of January was received with
unmistakable relief by the hungry, motley crowd which
represented the pomp and pride of Asia’s greatest Empire.
“From the Yellow River to the railway terminus at Cheng-
ting fu—a distance of about two hundred and fifty miles—the
ever-growing Imperial procession had travelled almost
continuously in chairs, litters, carts, and on horse-back,
affording a spectacle which recalled in many of its chief
characteristics those of Europe’s mediæval pageantry as
described by Scott. Every Manchu Prince had a retinue of
horsemen varying from thirty to a hundred in number; along
the frost-bound, uneven tracks which serve for roads in
Northern China, an unending stream of laden waggons
creaked and groaned through the short winter’s day, and on,
guided by soldier torch-bearers, through bitter nights to the
appointed stopping places. But for the Empress Dowager and
the Emperor, with the Chief Eunuch and the ladies of the
Court, there was easy journeying and a way literally made
smooth. Throughout its entire distance the road over which
the Imperial palanquins were borne had been converted into a
smooth, even surface of shining clay, soft and noiseless
under foot; not only had every stone been removed, but as
the procession approached gangs of men were employed in
brushing the surface with feather brooms. At intervals of
about ten miles well-appointed rest-houses had been built,
where all manner of food was prepared. The cost of this
King’s highway, quite useless, of course, for the ordinary
traffic of the country, was stated by a native contractor to
amount roughly to fifty Mexican dollars for every eight yards—
say £1,000 a mile—the clay having to be carried in some
places from a great distance. As an example of the lavish
expenditure of the Court and its officials, in a land where
squalor is a pervading feature, this is typical.
“The hour for leaving Cheng-ting fu was fixed by the
Empress Dowager at 9.30 a.m. on January 3rd. It is significant
of the character of this remarkable woman, now in her sixty-
seventh year, that even in matters of detail she leaves nothing
to chance, nothing to others; the long arm of her
unquestioned authority reaches from the Throne literally to
the servants’ quarters. Without creating any impression of
fussiness, she makes a distinctly feminine personality felt,
and the master-mind which has guided the destinies of China
for the last forty years by no means disdains to concern itself
in minor questions of household commissariat and transport.
It is impossible not to reflect what such a woman might have
been, what she might have done for her people, had there
come into her life some accident or influence to show her, in
their true light, the corruption, dishonesty, and cold-blooded
cruelty of her reign.
“The departure of the Court by a special train, long since
prepared for its reception by the Belgian railway authorities
and Sheng Hsüan-huai, was fixed for 9.30 a.m. in accordance
with Her Majesty’s orders; that Imperial and imperious lady,
however, made her appearance at the station at seven
o’clock, accompanied by the young Empress, the Imperial
concubine, and the ladies-in-waiting. The Emperor had
preceded her, and upon her arrival knelt on the platform to
perform respectful obeisance, in the presence of an interested
crowd. The next two hours were spent by the Empress, who
showed no signs of fatigue, in supervision of the
arrangements for despatching the vast accumulation of her
personal baggage, and in holding informal audiences with
various high dignitaries, military and civil, on the platform.
Amongst others she sent for M. Jadot, and spent some time
in friendly conversation with him, expressing great satisfaction
at the excellent arrangements made for her comfort, and
pleasure at exchanging the sedan chair for her luxuriously-
appointed drawing-room car. She took pains to impress upon
the engineer-in-chief the importance which she attached to
keeping the Court’s baggage and effects within reach,
evincing on this subject much determination of a good-
humoured kind.
“Eventually, after the despatch of four freight trains, her
mind was relieved of this anxiety, but it was to be clearly
understood that the same personal supervision would be
exercised at Pao-ting fu, for in no circumstances could the
impedimenta be sent on in advance to Peking. There is a
touch of feminine nature in this incident which can hardly fail
to bring the Empress Dowager into some degree of kinship
with her fellow-women in other lands; there is also an implied
reflection on the honesty of persons in attendance on the
Court which is not without significance.
“The scene upon the platform was one of remarkable
interest. In utter subversion of all accepted ideas in regard to
the seclusion and privacy in which the Chinese Court is
supposed to live, move, and have its being, there was on this
occasion—and indeed throughout the journey—no sign of
either attempt or wish to guard Their Majesties from
observation and intrusion. The crowd, quietly inquisitive, but
showing no inclination to demonstration of any sort, came and
went at its pleasure; Yüan Shih-kai’s braves, who to the
number of about a thousand travelled to Peking as the
Empress Dowager’s bodyguard, crowded around the Imperial
party, invading even their railway carriages. While the ruler of
the Empire held audience with some of its highest officials,
none of their retainers were employed, as might have been
expected, in keeping the people at a respectful distance; the
scene, in fact, bore striking testimony to that democratic side
of the Chinese character which cannot but impress itself on
every foreign visitor to a Viceroy’s or magistrate’s yamên; in
the present instance, however, it must have been, for all
concerned, a new and remarkable experience.
“To the native spectators, the ladies of the Court with their
eunuch attendants were as much objects of interest as the
foreign railway officials; the Imperial concubine, ‘Chin’ (or
‘Lustrous’) Kuei fei, a lively young person of pleasing
appearance, attracting much attention. This lady, gaily clad
and with lavishly painted face, bestowed upon everything
connected with the train an amount of attention which augurs
well for the future of railway enterprise in China, running from
car to car and chatting volubly with the ladies-in-waiting. All
the ladies of the Court wore pearls in profusion—those of the
Empress being particularly fine—and all smoked cigarettes in
place of the time-honoured water-pipe. Herein again, for the
optimistically inclined, may be found a harbinger of progress.
During the Empress Dowager’s audiences, lasting sometimes
over a quarter of an hour at a time, the Emperor stood close
at her side; invariably silent, generally listless, though his
expression when animated is described as conveying an
impression of remarkable intelligence. The young Empress
has good features, marred, in European eyes, by excessive
use of paint; she, too, appeared to be melancholy, and
showed but little interest in her surroundings. The Emperor
and both Empresses were simply dressed in quiet coloured
silks.
“The special train in which, punctually at 9.30 a.m., the
rulers of China left for their capital consisted of a locomotive
and twenty-one carriages, arranged in the following order:—
Nine freight cars laden with servants, sedan chairs, carts,
mules, &c.; a guard’s van, for employés of the railway; two

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Clinical Sleep Medicine A

Comprehensive Guide for Mental Health

Sleep Medicine and Mental Health A Guide for

Medical imaging for health professionals: technologies

Diagnosing and Treating Children and Adolescents A

Non Obstetric Surgery During Pregnancy A Comprehensive

Business Basics for Private Practice A Guide for Mental

Research Methodology for Allied Health Professionals: A

Perinatal Mental Health : a Sourcebook for Health

Integrative Medicine for Vulnerable Populations: A

A Comprehensive Guide for Mental Health and Other Medical Professionals

Each chapter features a section on diferential diagnosis to help readers distin-

CLINICAL SLEEP MEDICINE

About the Editors

Clete A. Kushida, M.D., Ph.D., is a Professor in the Department of Psy-

Cover design: Rick A. Prather WWW.APPI.ORG Emmanuel H. During, M.D.

A Comprehensive Guide for

A Comprehensive Guide for

Emmanuel H. During, M.D.

ALL RIGHTS RESERVED

Manufactured in the United States of America on acid-free paper

British Library Cataloguing in Publication Data

2 Clinical History and Physical Examination in

4 Pharmacological Treatment of Insomnia . . . . . . . . . . . . . 61

5 Nonpharmacological Treatment of Insomnia . . . . . . . . 79

8 Adult Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . . . . 147

9 Pediatric Obstructive Sleep Apnea . . . . . . . . . . . . . . . . . 171

10 Sleep-Related Hypoventilation Syndromes. . . . . . . . . 187

11 Central Sleep Apneas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

12 Delayed and Advanced Sleep-Wake

13 Irregular Sleep-Wake, Non-24-Hour Sleep-Wake,

14 Non-REM Parasomnias . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

17 Restless Legs Syndrome and Periodic Limb

18 Other Sleep-Related Movement Disorders . . . . . . . . . .361

William Auyeung, M.D.

Alon Y. Avidan, M.D., M.P.H.

Fiona Barwick, Ph.D., D.B.S.M.

Daniel Jin Blum, Ph.D.

Julia Buchfuhrer, D.O.

Mark Buchfuhrer, M.D.

Michelle Cao, D.O.

Joss Cohen, M.D.

Emmanuel H. During, M.D.

Payal Kenia Gu, M.D.

Christian Guilleminault, M.D.

Birgit Högl, M.D.

Michael J. Howell, M.D.

Muna Irfan, M.D.

Clete A. Kushida, M.D., Ph.D.

Caroline Maness, M.D.

Mari Matsumura, M.P.H.

David N. Neubauer, M.D.

Seiji Nishino, M.D., Ph.D.

Taisuke Ono, M.D., Ph.D.

Daniella Palermo, M.D.

Carlos H. Schenck, M.D.

Logan Schneider, M.D.

Katherine M. Sharkey, M.D., Ph.D., FAASM