Journal of Psychiatric Research 35 (2001) 165–172

www.elsevier.com/locate/jpsychires

The first-night effect may last more than one night

O. Le Bona,*, L. Stanerb, G. Hoffmanna, M. Dramaixc, I. San Sebastiana,
J.R. Murphyd, M. Kentosa, I. Pelca, P. Linkowskie
a
Sleep Center, Centre Hospitalier Universitaire Brugmann, Université Libre de Bruxelles, Brussels, Belgium
b
Sleep Laboratory — FORENAP — Centre Hospitalier de Rouffach, France
c
Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium
d
University of Texas, Health Science Center at Houston, Houston, TX, USA
e
Cliniques Universitaires Erasme, Université Libre de Bruxelles, Brussels, Belgium

Received 27 November 2000; received in revised form 2 April 2001; accepted 19 April 2001

Abstract
The first-night effect in sleep polysomnographic studies is usually considered to last for one night. However, a few observations
have indicated that variables associated to rapid eye movement sleep take longer to stabilize. Notwithstanding, current opinion
holds that second nights of recording can be used without restriction for research and clinical purposes. The goal of this study was
to describe the dynamics of habituation to polysomnography in optimal conditions. Twenty-six young, carefully screened, healthy
subjects were recorded in their home for four consecutive full polysomnographies. Repeated measures ANOVA were applied.
Between the two first nights, while there were no differences in sleep duration in non-rapid eye movement sleep, marked mod-
ifications in corresponding spectral power were observed. The dynamics of adaptation of rapid eye movement sleep appeared
to be a process extending up to the fourth night. Similar dynamics in NREMS and REMS homeostasis have been observed
in sleep deprivation studies, and it appears that the same mechanisms may be responsible for the FNE. The longer habituation
process of REMS in particular has important implications for sleep research in psychiatry. # 2001 Elsevier Science Ltd. All rights
reserved.
Keywords: REM; REM latency; NREM; FNE; Habituation; Home polysomnography

1. Introduction adds yet another factor: (4) the change in environment.

The first-night effect (FNE) has been recognized in
sleep polysomnographic studies since 1964 (Rechtschaf-
fen and Verdone) and was later described in more detail
(Agnew et al., 1966). Its main characteristics include:
less total sleep time (TST) and rapid eye movement
sleep (REMS), a lower sleep efficiency index (SEI), more
intermittent wake time, longer REMS latency (RL). No
clear pattern has been described for Non-REMS
(NREMS), on the other hand. The origin of FNE is
probably multifactorial and includes: (1) discomfort
caused by electrodes; (2) limitation of movements by
gauges and cables; (3) potential psychological con-
sequences of being under scrutiny. In most cases, studies
have been performed in specialized sleep units, which
* Corresponding author. Tel.: +32-2-477-25-54; fax: +32-2-477-
25-50.
E-mail address: lebono@ulb.ac.be (O. Le Bon).
0022-3956/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S0022-3956(01)00019-X
The FNE remains a crucial topic in sleep studies, since it
could bias any polysomnography (PSG), whether per-
formed for clinical or research purposes. Though an
unavoidable burden in practice, it can also be seen more
positively from a theoretical perspective as representing
an adaptation process of the brain to external stress
(Hartmann, 1968; Schmidt and Kaelbling, 1971), per-
haps comparable to psychophysiological insomnia
(Wauquier et al., 1991).
The process of returning to steady-state by habitua-
tion in sequential PSG has not been studied extensively.
In fact, most studies of the FNE considered only two
consecutive nights. Two studies compared the first night
versus the mean of two consecutive nights (Browman
and Cartwright, 1980; Edinger et al, 1997) and a two-
week study was performed in healthy controls (Roehrs
et al., 1996), but no specific comparison was reported on
the differences between night 2 and the nights immedi-
ately following. One study focused on the short-term
166 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
stability of five sleep parameters in elderly healthy con-
trols (not including REMS variables) and concluded
that an average of 2 weeks was necessary to achieve
stability for certain measures (Wohlgemuth et al., 1999).
Pioneering work on six consecutive nights was per-
formed as early as 1971 (Schmidt and Kaelbling), which
demonstrated that REMS took more than 1 night to
stabilize. A more recent and extensive study of about 32
healthy subjects in a lab setting demonstrated significant
differences, specifically between the second and the third
night, for REMS latency and REMS time in the first
third of the night, but not for REMS as a whole (Tous-
saint et al., 1995).
Notwithstanding previous findings, present opinion
holds that habituation to polysomnography is a matter
of the first night of recording and that the second night
can be used without restriction for research and clinical
purposes. In practice, a first night (usually referred to as
the habituation night) is spent with partial or full cable
and gauge connections but no actual recording, the sec-
ond night is then recorded and used for comparisons.
The objective of the present study was to analyze the
dynamics of the habituation process to poly-
somnography in optimal conditions. The study covered
four consecutive nights of recordings performed at
home and included a comprehensive set of variables.
The sample was very carefully selected and is larger
than in previous studies of young subjects at home
(Coates et al., 1981; Sharpley et al., 1988).
2. Subjects and method
2.1. Subjects
Eighty-four volunteers, aged 15–45 (mean 27.8, S.D.
9.7, 47 females), were recruited by advertisement and
paid for participation. A comprehensive screening was
made to ensure selection of individuals with no known
existing or previous condition which might correlate
with abnormal sleep. Volunteers first answered a
detailed questionnaire designed to elicit sleep history by
phone. Those meeting questionnaire-based criteria were
then given a structured interview (by O.L. and G.H.),
using the ASDA (1990) criteria for sleep disorders and
axis I DSM-IV (American Psychiatric Association,
1994) criteria for psychiatric diagnoses (except for sleep
disorders).
Inclusion criteria were: regular sleep schedules,
absence of sleep-related complaints or regular naps,
regular weekday work or no employment, no previous
polysomnography and completion of informed consent.
Exclusion criteria were: DSM-IV axis I disorder; perso-
nal or first-degree familial affective disorder (because of
potential influence on REM latency (Giles et al., 1989));
significant somatic condition; excessive daytime sleepiness;
report of periodic limb movements, snoring or sleep
apnea; sleep-apnea index (AHI) >= 5 on the initial
night of monitoring; periodic limb movement episodes
on the initial night of recording; routine consumption of
more than 10 alcoholic beverages (10-g units) per week,
or consumption of illicit drugs; use of psychotropic
drugs within 3 weeks before the study; and, transmer-
idian flights or shift work within 4 weeks preceding the
study. Subjects were requested not to drink alcohol for
a week before entering the protocol and to change their
life habits as little as possible during the time of the
study.
The protocol was approved by the hospital’s Ethics
Committee and informed consent was obtained. The
study was conducted in accordance with the rules and
regulations for the conduct of clinical trials stated by
the World Medical Assembly (Helsinki, Tokyo, Venice
and Hong Kong).
2.2. Methods
Recordings were made between Mondays and Fri-
days, in order to avoid the more irregular weekend
schedules. The technician went to the subjects’ home
around 9 pm, explained the procedure and answered
questions. He then placed three pairs of EEG electrodes
(FZp1-A1; C4-A1; O2-A1), 1 pair of EOG electrodes, a
chin and two inferior limb EMG electrodes, thoracic
and abdominal gauges for respiratory movements and
thermo-resistors around the mouth and the nose. Sub-
jects went to bed at their usual sleep time and connected
the wires, in a very straightforward procedure, to sleep
analyzer Alice (Respironics, Pittsburgh, PA). When the
subjects decided to go to sleep, they launched the poly-
somnography and turned out the light. When they
spontaneously woke up in the morning, they stopped
the recording and removed the electrodes. The same
sequence was repeated for all study nights.
Recordings were randomly analyzed by one of two
well-trained technicians, on a 21’’ screen displaying 30-s
polysomnograph epochs, with the exception of micro-
arousals, which were always scored separately by the
same person. Classical scoring criteria were used
(Rechtschaffen and Kales, 1968). Visual scoring was in
three steps: (1) determination of sleep stages; (2) detec-
tion and quantification of respiratory sleep events and
periodic limb movements; and (3) detection and quan-
tification of microarousals. The inter-rater reliability
was measured in another recent protocol and exceeded
0.90 for all variables (Le Bon et al., 1997a). Sleep effi-
ciency index (SEI) was defined as TST divided by time
in bed (TIB). Sleep onset latency (SOL) was defined as
the time between lights out and the first epoch of stage
2. Intermittent wake time represents the time spent
awake after sleep onset (WASO). A periodic limb
movement episode was defined as five or more periodic
 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
limb movements during more than 20 s. In a modifica-
tion of the criteria established by Bonnet et al. (1992),
microarousals were scored as positive only when asso-
ciated with EMG increases. REMS latency has received
several operational definitions in the past (Knowles et
al., 1982; Reynolds et al., 1983) and none has been
shown to be indisputably superior to the other, thus two
definitions were used here: RL_A was defined as the
time between the first epoch of stage 2 and the first
epoch of stage REMS; RL_B was defined as the time
between the first 10 min of stage 2 not interrupted by
more than 1 min of stage 1 or wake and the first 3 min
of stage REMS.
The intervals between the end of a REMS period and
the beginning of the next were named RL2 to RL6
according to when it occurred during the night.
NREMS/REMS cycles include each REMS episode and
the NREMS episode immediately preceding it. Each
REMS episode began with the first epoch of REMS and
ended after the last epoch of REMS was followed by at
least 15 min of NREMS. A NREMS episode is the time
spent between two consecutive REMS episodes or
between a REMS episode and either the beginning or
end of the night. No other requirement was necessary
for the definition of REMS or NREMS episodes, con-
sidering that the first REMS episode may be very short
and perhaps even virtual (‘‘aborted first-REMS’’;
Dement and Kleitman, 1957).
The spectrogram was computed for all EEG channels.
The sampling rate was 100 Hz. Each channel was cre-
ated by computing the spectrum every 6 s and each 6-s
spectrum was the average of two spectra computed on
two overlapping windows of 5.12 s (0–5.11 and 0.88–
5.99). The signal was multiplied with a 512 point Bar-
tlett window after suppressing the mean from each point
in order to remove the 0 Hz component. The Fast
Fourrier Transform was then applied to estimate spec-
tral power and was averaged for the two overlapping
segments (mV2/Hz). Six frequency bands were analyzed:
Ultra-Slow (0.25–0.8 Hz), Delta (1–3.9 Hz), Theta (4–
7.4 Hz), Alpha (7.5–12.4 Hz), Sigma (12.5–17.9 Hz) and
Beta (18–25 Hz). The data from frontal, central and
occipital origins were averaged. Spectral analysis data
were analyzed as total power per night, and not by
NREMS/REMS cycles, as advocated in a recent study
(Preud’homme et al., 2000). The data presented are for
the spectral power corresponding to visually scored
NREMS and REMS.
2.3. Statistics
Three variables required log transformation to
achieve normal distributions: WASO, SOL and REM
density (RD). ANOVAs with two factors (gender and
age group) were applied to compare repeated measures
collected over 4 nights (RM-ANOVAS). Two age
167
groups were created by splitting the sample at 25 years,
in order to obtain similar size groups. P-values were
Geisser–Greenhouse corrected. Post-hoc comparison
between pairs of nights was performed using simple
(forward: night 1 and night 2 (N1–N2); N1–N3; N1–
N4; backward: N2–N4) or repeated (N2–N3) contrasts
of the RM-ANOVAS. Polynomial contrasts were esti-
mated to determine which equation best fitted the evo-
lution of the means (linear, quadratic and cubic
contrasts were examined). Bedtime was converted in
minutes after at 9 pm. This permitted to enter it as a
decimal and positive variable in the RM-ANOVA.
Hypotheses tests were two-sided and carried out at the
5% significance level. All statistics were computed with
SPSS 9 (SPSS Inc., Chicago, IL).
3. Results
3.1. Descriptive values
Eighty-four subjects responded to our advertisement
(mean age 27.8, range 15–45 years, S.D. 9.7, 47
females). Results from telephone questionnaires and
physician interviews were causes for exclusion of 47
individuals (five parasomnias, five irregular sleep sche-
dules, seven restless legs or suspicion of periodic limb
movements, 10 snoring problems, five excessive daytime
sleepiness, nine anxiety disorders, six affective dis-
orders). First night polysomnography resulted in the
exclusion of an additional six subjects (two periodic
limb movement and four apneic/hypopneic indices over
five). Thirty-one subjects (36.9%) met inclusion criteria
and were considered to be normal control subjects.
Data from five subjects had to be excluded because of
technical problems (two 800 Mb optical disks seriously
damaged during storage, for unknown reasons).
Twenty-six subjects (mean age 26.7, range 15–45 years,
S.D. 9.8, 12 females) completed all aspects of the study
and no missing PSG epochs were observed. The group
was split in two by age: 14 subjects were < 25 years and
12 were >= 25 years. The index of sleep respiratory
disorders in the final 26 subjects was 2.8/h (S.D. 1.49),
and no episodes of periodic limb movements were
observed. Bedtime (mean and range) was respectively
for the four nights: 11:16 pm (10:09 pm–01:05 am),
11:10 pm (09:42 pm–00:51 am), 11:16 pm (09:31 pm–
00:51 am), 11:23 pm (09:53 pm–00:48 am).
3.2. Data analyses
In addition to the descriptive data for each of the 4
nights, Table 1 presents the global results of the RM-
ANOVAS with gender and age group as cofactors, the
contrasts between pairs of nights and the equations that
best fitted the curves across the four nights. Statistically
 168
Table 1
Selected sleep variables and between nights comparisonsa

N1 N2 N3 N4 RM-ANOVA N1–N2 N1–N3 N1–N4 N2–N3 N2–N4 N3–N4 Slope

(mean;S.D.) (mean;S.D.) (mean;S.D.) (mean;S.D.) (P;d.f.;F) (P) (P) (P) (P) (P) (P)

TIB (min) 468.1 (37.6) 470.4 (36.7) 466.9 (52.5) 472.3 (43.1) ns
SPT (min) 445.2 (39.9) 456.5 (35.4) 450.1 (53.8) 454.3 (41.7) ns
TST (min) 408.0 (54.2) 434.6 (40.2) 426.0 (56.1) 431.7 (48.5) (0.060;2.6;2.8)
SEI (TST/TIB) (%) 87.0 (7.8) 92.5 (4.6) 91.3 (6.3) 91.4 (6.1) 0.001;2.7;6.7 0.000 0.014 0.002 ns ns ns Lin>quad
SOLb (min) 13.9 (11.6) 9.7 (8.4) 11.6 (20.0) 12.2 (11.4) ns
WASOb (min) 37.2 (27.2) 21.2 (20.1) 24.0 (26.3) 22.5 (28.3) 0.000;2.8;9.1 0.000 0.001 0.000 ns ns ns Lin>quad
Awakenings (#) 8.6 (6.4) 4.7 (4.3) 5.3 (5.6) 4.9 (6.0) 0.002;2.9;5.9 0.001 0.005 0.002 ns ns ns Lin>quad
Microarousals (/h) 11.8 (6.8) 12.1 (6.1) 12.2 (7.8) 12.1 (5.3) ns

O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172

Mvt Time (min) 7.1 (4.8) 9.1 (5.0) 9.5 (5.0) 10.1 (4.8) 0.003;2.8;5.5 0.017 0.008 0.003 ns ns ns Lin
Stage Shifts (#) 192.1 (41.0) 197.8 (40.2) 190.3 (38.4) 189.7 (40.3) ns
Stage 1 (min) 49.6 (20.1) 51.2 (17.7) 46.7 (16.4) 52.0 (18.0) ns
Stage 2 (min) 185.1 (39.8) 192.6 (40.8) 184.9 (42.3) 189.4 (49.6) ns
Stage 3 (min) 39.2 (14.5) 43.0 (17.6) 38.4 (13.1) 36.5 (14.5) (0.083;2.8;2.4)
Stage 4 (min) 67.9 (32.4) 62.9 (37.8) 63.7 (34.3) 62.1 (39.0) ns
SWS (min) 107.2 (38.9) 105.9 (44.5) 102.0 (38.5) 97.9 (42.0) ns
NREMS (min) 341.9 (33.6) 349.8 (28.2) 333.8 (38.9) 339.4 (38.1) ns
NREMS-US (mV2/Hz) 43590.3 (26271) 63793.8 (47176) 53320.4 (41444) 48150.4 (27238) 0.041;2.7;3.0 004 ns ns ns (.052) ns Quad
NREMS-Delta (mV2/Hz) 24424.7 (13128) 30398.7 (18248) 28068.6 (16612) 27689.4 (16310) 0.022;3.0;3.9 002 ns ns ns ns ns Quad
NREMS-Theta (mV2/Hz) 2961.5 (1184.3) 3498.2 (1745.2) 3430.9 (1397.0) 3673.7 (2195.7) ns
NREMS-Alpha (mV2/Hz) 1059.9 (411.2) 1208.9 (701.9) 1197.8 (565.9) 1328.4 (969.7) ns
NREMS-Sigma (mV2/Hz) 436.2 (177.7) 490.1 (253.6) 497.5 (236.2) 584.7 (468.2) ns
NREMS-Beta (mV2/Hz) 100.8 (30.3) 118.0 (72.4) 124.2 (66.7) 144.9 (118.1) ns
REMS (min) 61.3 (22.6) 77.8 (21.4) 82.1 (25.3) 84.7 (28.9) 0.000;2.6;9.6 0.001 0.000 0.000 ns ns ns Lin>quad
REMS Density$ (/REMS) 12.6 (22.8) 10.0 (17.7) 11.3 (15.1) 10.6 (11.9) ns
Number of cycles (#) 3.8 (1.0) 4.1 (0.8) 4.2 (0.8) 4.2(0.9) (0.079;2.6;2.5)
RL_A (min) 117.9 (42.3) 99.7 (42.8) 88.1 (42.3) 77.0 (40.8) 0.001;2.8;6.7 ns 0.004 0.000 ns .021 ns Lin
RL_B (min) 123.6 (55.1) 110.8 (54.4) 86.3 (44.8) 96.1 (45.0) 0.048;2.4;3.0 ns 0.019 (0.071) ns ns ns Lin
RL2 (min) 123.0 (40.0) 116.4 (39.5) 97.8 (17.3) 112.4 (22.6) 0.027;1.8;4.2 ns 0.002 ns .026 .001 .014 Quad>lin
RL3 (min) 97.6 (24.2) 97.8 (19.5) 112.2 (25.2) 114.0 (38.2) 0.048;2.5;3.0 ns 0.013 (0.076) .021 (.090) ns Lin
RL4 (min) 90.2 (14.8) 91.1 (20.0) 94.0 (22.1) 90.8 (25.0) ns
RL5 (min) 66.5 (13.2) 79.0 (16.0) 84.6 (19.5) 68.2 (21,6) ns
REMS-US (mV2/Hz) 3282.6 (2207.3) 5747.7 (4161.5) 5268.4 (3118.3) 5699.6 (3542.4) 0.005;2.6;5.1 0.001 0.003 0.006 ns ns ns Lin
REMS-Delta (mV2/Hz) 1341.9 (802.9) 2169.5 (1219.7) 2091.4 (992.9) 2244.9 (1318.6) 0.002;2.3;6.7 0.000 0.003 0.004 ns ns ns Lin
REMS-Theta (mV2/Hz) 303.0 (224.6) 440.9 (320.4) 472.6 (281.7) 503.9 (323.6) 0.004;2.3;5.6 0.003 0.001 0.006 ns ns ns Lin
REMS-Alpha (mV2/Hz) 95.3 (56.7) 138.3 (105.8) 153.8 (101.4) 178.5 (150.6) 0.014;1.9;4.9 0.012 0.002 0.009 ns ns ns lin
REMS-Sigma (mV2/Hz) 32.2 (18.1) 49.7 (36.2) 58.4 (40.0) 70.6 (71.0) 0.024;1.7;4.4 0.009 0.003 0.011 ns ns ns Lin
REMS-Beta (mV2/Hz) 14.9 (7.3) 23.2 (16.5) 26.2 (15.6) 29.4 (20.9) 0.001;2.4;7.1 0.008 0.001 0.002 ns ns ns Lin
a
N1, N2, N3, N4, nights 1–4; N1–N2, N1–N3, N1–N4, N2–N3, N2–N4, post-hoc contrasts;; slope as determined by polynomial contrasts : Lin, linear; Quad, quadratic, in decreasing order of
significance when more than one equation fitted the curve
b
Logtransformed for the comparisons; TIB, Time In Bed; SPT, Sleep Period Time; TST, Total Sleep Time; SEI, Sleep Efficiency Index; SOL, Sleep Onset Latency; WASO, Wake after sleep onset;
Microarousals, microarousal index; Mvt time, Movement time; SWS, Slow Wave Sleep ; NREMS, Non Rapid Eye Movement Sleep Time; REMS, Rapid Eye Movement Sleep Time; RL_A, REMS
latency, definition A ; RL_B, REMS latency, definition B; RL2-RL5, intervals between consecutive REMS episodes; NREMS-US, NREMS Ultra-Slow; REMS-US, REMS Ultra-Slow
 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
significant results were observed for SEI, WASO,
Number of Awakenings, Movement Time, REMS,
RL_A, RL_B, RL2, RL3, the spectral frequency bands
Ultra-Slow and Delta corresponding to visually scored
NREMS and all frequency bands for visually scored
REMS. Trends were observed for TST, Stage 3 and
Number of Cycles. No age or gender interaction was
evidenced with the between-night comparison, and RM-
ANOVA for bedtime was not significant (data not
shown).
With the exception of the REMS latency measures,
the variables that were significantly different in the
RM-ANOVA were also significant for the contrasts
between N1–N2, and these differences represent a
rather classic first-night effect. It is interesting to note
that Ultra-Slow in NREMS stages increased by 46%
from N1 to N2, and Delta by 24%, which is in
sharp contrast with the absence of modifications in
NREMS or Slow Wave Sleep (SWS) duration variables.
Also, WASO and the Number of Awakenings on N1
were almost doubled in comparison with consecutive
nights.
The N1–N3 comparisons provided a few important
divergences compared to the N1-N2 pairs. The lower
frequency spectral power bands in NREMS (Ultra-Slow
and Delta) were not significantly different, whereas
associations were found for RL_A, RL_B, RL2 and
RL3. The comparisons between N1 and N4 provided an
almost identical profile as in the N1–N3 comparisons,
except for the absence of significance for RL2 and
trends observed in RL_B and RL3. The comparisons
between N2 and N4 were positive only for RL_A and
RL2 (the contrast for NREMS Ultra-Slow was close to
significance: P=0.052). The N3–N4 comparison
showed a significant contrast only for RL2.
Examination of the means for several NREMS vari-
ables, especially for the lower frequencies power bands
(Ultra-Slow and Delta), showed peaks in N2, although
no contrast proved significant between N2–N3 or N2–
N4 for these values. The best-fit equation for the
NREMS variables significant in the ANOVA (lower
frequencies power bands) was quadratic. In contrast,
evolution of the means of REMS variables significant in
the ANOVA (REMS, measures of REMS latencies,
REMS spectral power) revealed gradual increments
until N3 in all cases, except in lower frequencies power
bands. The comparisons of the various measures of
REMS latencies were not significant in N1–N2, yet
proved significant in N1–N3 (RL_A, RL_B, RL2,
RL3), and in some cases in N1–N4 (RL_A), N2–N3
(RL2, RL3) and N2–N4 (RL_A, RL2). The slopes were
linear or predominantly linear except in all REMS rela-
ted variables, except for RL2.
As an illustration of the gradual progression of
REMS related data, Fig. 1 presents a scattergram of the
four sequential RL_A.
169
Movement Time showed a progression globally simi-
lar to that of REMS related variables.
4. Discussion
In this study of the dynamics of the habituation pro-
cess to polysomnography, divergent patterns appeared
according to the variables studied. Whereas NREMS
duration parameters were not significantly influenced by
the habituation phenomenon, the intensity of NREMS
(Slow Wave Activity, SWA), measured by spectral ana-
lysis in the Ultra-Slow and Delta frequency bands,
showed marked differences between N1 and N2, yet no
significant differences between N1 and N3. This sig-
nificant difference was due to a deficit in SWA in the
first night compared to N2. Interpretation of these
results is difficult as the mean power on N3 cannot be
not different from two significantly different values, that
is, mean power on N1 and N2. Examination of the
means showed a peak of SWA on N2. From the trend
observed between N2 and N4 for NREMS Ultra-Slow
power band and the quadratic equation that best fitted
the curves across the 4 nights for NREMS Ultra-Slow
and Delta power bands, we infer that a rebound in
SWA was present on N2 with respect to the directly
consecutive nights.
In contrast, the habituation process appeared to be
different for paradoxical sleep: REMS, RL, RL2, RL3
and the spectral power bands in REMS showed a con-
tinuous progression across sequential nights, at least
until N3. The differences became significant only in
comparisons between the first and the third night for the
various measures of REMS latency. The pattern of
evolution until the fourth night was more complex,
showing a further increase in the differences for RL_A
(N2-N4 pair). The slopes of the best-fit equations were
linear or predominantly linear in all cases except in
REMS-related lower frequencies power bands.
Fig. 1. Bivariate scattergram of the RL_A in function of the con-
secutive nights (RL_A in minutes).
170 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
These data can be compared with outcomes from
sleep suppression and recovery studies and we can
speculate that the same type of mechanism is operating
in the habituation process. On one hand, the increase
observed in SWA on N2 is consistent with the data on
SWA recovery after sleep suppression (Borbély et al.,
1981; Brunner et al., 1993) and could be compatible
with the Two-Process Model proposed by Borbély
(1982). On the other hand, the longer delay before the
achievement of steady-state for REMS is in agreement
with studies on REMS homeostasis, showing a more
protracted and progressive habituation process com-
pared to NREMS (Endo et al., 1998). Furthermore, the
two first REMS episodes were shown to be displaced
toward the end of the night (longer RL and RL2 on N1)
starting from N1 and to recover subsequently in linear
increments, whereas the opposite was true of the third
REMS episode (shorter RL3 on N1). This pattern of
stabilization is more in favor of an internal homeostasis
for REMS and a slower regulation than of an antag-
onistic influence by SWA, which would probably have
affected the second night more specifically.
Thus, a two-part sequence is suggested: an increased
state of vigilance or arousal is observed on the first
night, as demonstrated by an almost two-fold increase
in the number of awakenings and the WASO in com-
parison with further nights, resulting in lower SEI,
SWA and REMS. We speculate that this first night,
marked by a poor efficiency in relationship with a global
arousal effect due to the novelty of the situation, has an
effect on consecutive nights which is similar to that of a
partial sleep deprivation. The second night shows an
important increase of SWA that is not paralleled by
increased NREMS duration, and a more limited
increase of REMS. We speculate that it corresponds
mainly to a recovery night after a partial sleep depriva-
tion on N1. The N3 may correspond to a steady-state
for SWA (see first paragraph for this topic), whereas
steady-state would be reached in N3 or even N4 for
REMS, according to the variables and the definitions
used.
This slower adaptation of REMS and RL to sleep
recording has important implications for psychiatry.
Shortened RL remains a frequent and puzzling phe-
nomenon in a broad spectrum of affective and anxiety
disorders, and several theories compete to explain their
origin (see Le Bon et al., 1997b for a discussion). The
present observation revealed that the RL_A observed
on N4 was more than 40 min shorter than in the usually
discarded N1, but also significantly more than 22 min
shorter than in N2, which is the night that is often used
for comparison with patient groups. Now, if the habi-
tuation process is comparable between subjects and
patients, comparisons could be rightfully performed
using the corresponding night in both groups. However,
various studies have shown that different populations
exhibit different habituation processes. FNE has been
reported to be present to a lesser degree in inpatients
with depression (Mendels and Hawkins, 1967; Kupfer et
al, 1974; Toussaint et al, 1995; Rotenberg, 1997),
insomnia (Coates et al., 1981; Edinger et al., 1997) and
PTSD (Saletu et al., 1996; Woodward et al., 1996). In
inpatients suffering from sleep respiratory disorders,
one night of recording alone is generally accepted for
diagnostic purposes (Lord et al., 1991; Mendelson,
1994), although a recent study in a large group of
apneic-hypopneic patients (Le Bon et al., 2000) showed
typical FNE, as well as a substantial under-diagnosis of
respiratory events when only the first night is con-
sidered. In the use of plethysmographies for the detec-
tion of male impotence, the FNE is considered to be
marginal (Kader and Griffin, 1983).
Comparison of the velocity of habituation in different
subject groups has never been performed, to our
knowledge. If patients have already reached their steady
state on the second night while control subjects are still
affected by a habituation process, false positive differ-
ences in REMS latencies will be observed, leading to
systematic bias. Consequently, until the habituation
patterns for these parameters over more than 3 nights
are better known in patients and healthy controls
groups, it is not safe to assume that the second night is
an adequate basis for comparison. The wisest option in
the meantime may be to discard a minimum of two and
perhaps three consecutive habituation nights in place of
one as is usually performed, and use the next night(s) as
a basis for comparison. This is especially true for studies
on REMS and REMS latency, which show a prolonged
habituation process, and perhaps also for spectral ana-
lyses. At the very least, the cut-offs for the determina-
tion of REMS latencies should be adapted in function
of the habituation process. It is also interesting to note
that REM density, which has also been associated with
depression (Foster et al., 1976), was not shown to be
influenced by the habituation process in our study.
Another interesting result from this study is the pre-
sence of a habituation process in a home setting. It is
generally considered that no habituation is needed in
such cases and that the change in environment is more
significant than the procedure of sleep recording itself.
Previous studies performed at home in young healthy
subjects have not demonstrated FNE (Coates et al.,
1981; Sharpley et al., 1988). Conflicting results have
been found in older age groups, however, with some
evidence of FNE in one study (Wauquier et al., 1991)
that was not replicated subsequently in a cross-over
study (Edinger et al., 1997). Two studies also tended to
favor environmental changes (sleep unit versus home
setting (Coble et al., 1974; Browman and Cartwright,
1980)) as being a more important factor than poly-
somnography per se to explain FNE. These studies
advocated the use of better accommodations for
 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
patients in sleep units or for the generalization of home
studies. The differences between the first 2 nights in our
study appear to be of the same magnitude as what is
usually described in hospital sleep units. A larger num-
ber of subjects and perhaps the rigorous definition of
healthy controls in the present sample may explain the
discrepancy with previous reports on home recordings.
Hence, home recordings, which are impractical in most
psychiatric studies anyway, may still have to demon-
strate advantages over hospital polysomnography. Only
more double-blind cross-over studies will be able to
demonstrate this without ambiguity. The difference of
setting also precludes the present conclusions from
being extended without caution to sleep laboratories
studies.
Even though a rather large group of 26 subjects was
analyzed here, the logical issue of a discrepancy between
some comparisons in lower frequencies spectral power
bands (see earlier) could not be resolved. This may be
due to the presence of large inter- and intra-subject
variability that is commonly observed in sleep studies
and even larger samples should be examined in the
future.
A limitation of this study was that no data on
women’s menstrual cycle was available. However, no
interaction with gender or age was observed and sub-
jects served as their own controls. Also, no data on
bedtime on weekends preceding the study were avail-
able, which could potentially affect the first recording
night. However, bedtime means were very similar from
night to night and RM-ANOVA did not reveal sig-
nificant differences. These variables are hence not likely
to have influenced results in a significant manner.
In conclusion, the habituation to polysomnography
affected differently NREMS, SWA and REMS. To be
on the safe side, at least two and perhaps even three
habituation nights should be discarded before compar-
ing nights, at least for studies on REMS and REMS
latencies. The longer delay before the achievement of
steady state for REMS bears important consequences in
psychiatric research.
Acknowledgements
The authors wish to thank Philippe Dupont, Anita
Bessemans and Marleen Bocken, for their meticulos-
ness, constant help and availability. This work was
supported by SOMALCPE (Brussels), a private organi-
zation dedicated exclusively to research in psychiatry.
References
Agnew HW, Webb WB, Williams RL. The first-night effect: an EEG
study of sleep. Psychophysiology 1966;2:263–6.
American Sleep Disorders Association. International classification of
171
sleep disorders. Diagnostic and coding manual (1990). Lawrence,
Kansas: Allen Press, 1990.
American Psychiatric Association. Diagnostic and statistical manual
of mental disorders. 3rd ed. Washington, DC: American Psychiatric
Association Press, 1994.
Bonnet M, Carley D, Carskadon M, et al. (Atlas Task Force). EEG
arousals: scoring rules and examples. Sleep 1992;15:173–84.
Borbély AA. A two-process model of sleep regulation. Human Neu-
robiology 1982;1:195–204.
Borbély AA, Baumann D, Brandeis D, Strauch I, Lehmann D. Sleep
deprivation: effect on sleep stages and EEG power density in
man. Electroencephalography and Clinical Neurophysiology
1981;51:483–93.
Browman CP, Cartwright RD. The first-night effect on sleep and
dreams. Biological Psychiatry 1980;15:809–12.
Brunner DP, Dijk DJ, Borbély AA. Repeated partial sleep deprivation
progressively changes the EEG during sleep and wakefulness. Sleep
1993;16(2):100–13.
Coates TJ, George JM, Killen JD, Marchini E, Hamilton S, Thor-
ensen CE. First-night effect in good sleepers and sleep-maintenance
insomniacs when recorded at home. Sleep 1981;4:293–8.
Coble P, McPartland RJ, Silva WJ, Kupfer DJ. Is there a first-night
effect ? (A revisit.). Biological Psychiatry 1974;9:215–9.
Dement W, Kleitman N. Cyclic variations in EEG during sleep and
their relation to eye movement, body motility, and dreaming. Elec-
troencephalography and Clinical Neurophysiology 1957;9:673–90.
Edinger JD, Fins AI, Sullivan RJ, Marsh GR, Dailey DS, Hope TV,
Young M, Shaw E, Carlson D, Vasilas D. Sleep in the laboratory
and sleep at home: comparisons of older insomniacs and normal
sleepers. Sleep 1997;20(12):1119–26.
Endo T, Roth C, Landolt HP, Werth E, Aeschbach D, Achermann P,
Borbély AA. Selective REM sleep deprivation in humans: effects on
sleep and sleep EEG. American Journal of Physiology
1998;274:R1186–0R1194.
Foster FG, Kupfer DJ, Coble P, McPartland RJ. Rapid eye move-
ment sleep density. An objective indicator in severe medical-depres-
sive syndromes. Arch Gen Psychiatry 1976;33(9):1119–23.
Giles DE, Kupfer DJ, Roffwarg A, Rush J, Biggs M, Etzel B. Poly-
somnographic parameters in first-degree relatives of unipolar pro-
bands. Psychiatry Research 1989;27:127–36.
Hartmann E. Adaptation to the sleep laboratory and placebo effect.
Psychophysiology 1968;4:389.
Kader GA, Griffin PT. Reevaluation of the phenomena of the first-
night effect. Sleep 1983;6:67–71.
Knowles JB, MacLean AW, Cairns J. Definitions of REM latency:
some comparisons with particular reference to depression. Biolog-
ical Psychiatry 1982;17(9):993–1002.
Kupfer DJ, Weiss BL, Detre TP, Foster FG. First-night effect revis-
ited: a clinical note. Journal of Nervous and Mental Disease
1974;159:205–9.
Le Bon O, Verbanck P, Hoffmann G, Murphy JR, Staner L, De
Groote D, Mampunza S, Den Dulk A, Vacher C, Kornreich C, Pelc
I. Sleep in detoxified alcoholics: impairment of most standard sleep
parameters and increased risk for sleep apnea, but not for
myoclonias — a controlled study. Journal of Studies on alcohol
1997a;58(1):30–6.
Le Bon O, Staner L, Murphy JR, Hoffmann G, Pull C, Pelc I. Critical
analysis of theories advanced to explain short REM sleep latencies
and other sleep anomalies in several psychiatric conditions. Journal
of Psychiatric Research 1997b;31(4):433–50.
Le Bon O, Hoffmann G, Tecco J, Staner L, Noseda A, Pelc I, Lin-
kowski P. Mild to moderate sleep respiratory events: one negative
night may not be enough. Chest 2000;118(2):353–9.
Lord S, Sawyer B, O’Connell D, King M, Pond D, Eyland A, Mant A,
Holland T, Hensley MJ, Saunders N. Night-to-night variability of
disturbed breathing during sleep in an elderly community sample.
Sleep 1991;14:252–8.
172 O. Le Bon et al. / Journal of Psychiatric Research 35 (2001) 165–172
Mendelson WB. Use of the sleep laboratory in suspected sleep apnea
syndrome: is one night enough? Cleveland Clinical Journal of Med-
icine 1994;61:299–303.
Mendels J, Hawkins DR. Sleep laboratory adaptation in normal sub-
jects and depressed patients (‘‘first-night effects’’). Electro-
encephalography and Clinical Neurophysiology 1967;22:556–8.
Preud’homme X, Lanquart JP, Mendlewicz J, Linkowski P. Char-
acteristics of spontaneous sleep with varying NREMS episodes in
healthy men: implication for delta activity homeostasis. Sleep
2000;23(2):193–203.
Rechtschaffen A, Kales A, editors, A manual of standardized termi-
nology techniques and scoring system for sleep states of human
subjects. Washington, DC: US Government Printing Office, 1968.
Rechtschaffen A, Verdone P. Amount of dreaming: effect of incentive,
adaptation to laboratory, and individual differences. Perceptual and
Motor Skills 1964;19:947–58.
Reynolds CF 3rd, Taska LS, Jarrett DB, Coble PA, Kupfer DJ. REM
latency in depression: is there one best definition? Biological Psy-
chiatry 1983;18(8):849–63.
Roehrs T, Shore E, Papineau K, Rosenthal L, Roth T. A two-week
sleep extension in sleepy normals. Sleep 1996;19(7):576–82.
Rotenberg VS, Kayumov L, Indurski P, Hadjez J, Kimhi R, Sirota P,
Bichucher A, Elizur A. REM sleep in depressed patients: different
attempts to achieve adaptation. Journal of Psychosomatic Research
1997;42(6):565–75.
Saletu B, Klösch G, Gruber G, Anderer P, Udomratn P, Frey R.
First-night effects on generalized anxiety disorder (GAD)-based
insomnia: laboratory versus home sleep recordings. Sleep
1996;19:691–7.
Schmidt HS, Kaelbling R. The differential laboratory adaptation of
sleep parameters. Biological Psychiatry 1971;3:33–45.
Sharpley AL, Solomon RA, Cowen PJ. Evaluation of first-night effect
using ambulatory monitoring and automatic sleep stage analysis.
Sleep 1988;11:273–6.
Toussaint M, Luthringer R, Schaltenbrand N, Carelli G, Lainey E,
Jacqmin A, Muzet A, Macher JP. First-night effect in normal sub-
jects and psychiatric inpatients. Sleep 1995;18:463–9.
Wauquier A, Van Sweden B, Kerkhof GA, Kamphuisen HA. Ambu-
latory first-night sleep effect recording in the elderly. Behavior and
Brain Research 1991;42:7–11.
Wohlgemuth WK, Edinger JD, Fins AI, Sullivan RJ. How many
nights are enough? The short-term stability of sleep parameters in
elderly insomniacs and normal sleepers. Psychophysiology
1999;36(2):233–44.
Woodward SH, Bliwise DL, Friedman MJ, Gusman FD. First-night
effect in post-traumatic stress disorder inpatients. Sleep 1996;19:312–7.