1. Sleep and Sleep Disorders
Dr. Y R Bhattarai
TMU

2. Normal sleep Measured by eletroencephalogram (EEG)
Sleep is made up two physiological stages.
Measured by eletroencephalogram (EEG)
Non-rapid eye movement (NREM) sleep
Stage characterized by
Slowing of the EEG rhythms
High muscle tone
Absence of eye movements
Brain is inactive while the body is active

3. REM sleep Rapid eye movement (REM) sleep
Spontaneous rapid eye movement
Dreaming
Body movement is absent
Sexual arousal
Brain is active and body is inactive
heart rate, blood pressure, respiration are
variable

7. NREM and REM sleep
Awake (stage 0) : alpha waves (8-12cps, low voltage)‏
NREM sleep : increasing depth
Stage 1: very light sleep, transition from wakefulness to sleep, drowsy reduced alpha activity
Stage 2: medium depth of sleep, occupies about half the night in adults. EEG shows sleep spindles and k complexes
DELTA SLEEP
Stage 3: deeper sleep than stage2
Stage 4: very deep stage of sleep.
REM sleep: Dream sleep. EEG is active mimicking that of the wakening stage. low voltage, mixed frequency with sawtooth waves.

8. Sleep cycles
NREM and REM sleep alternate cyclically throughout the night.
Start with NREM 80 minutes followed by REM 10 minutes
Cycles repeat 3-6 times per night
Sleep latency: time needed before you actually fall asleep. Typically less than 15 minutes. Increased in many disorders like insomnia.

10. Neurotransmitters of sleep
Serotonin: initiates sleep
Acetylcholine: linked to REM sleep Increased during sleep
Norephinephrine: linked to REM sleep Decreased during sleep
Dopamine: linked to arousal and wakefulness. Increased during sleep

11. Chemical effects on sleep
Benzodiazepines: suppresses stage 4 and when used chronically, increases sleep latency
Alcohol intoxications: suppresses REM
Alcohol and barbiturate withdrawal: REM rebound.
Major depression: increased REM time, multiple awakenings and early morning awakening.

12. Question?
How many hours do we need for sleep per night?

13. Sleep requirements Neonates: 16-18hrs/24 hrs 1year: 12hr 10year: 10hr
From infancy to old age
Total sleep time decreases
REM percentage decreases
Stage 3 and 4 tend to vanish

14. A case…..
While studying for an important exam, Michael, a third year college student has been unable to sleep for the past several days. At night he lies awake and imagines himself doing poorly on the exam and failing medical school. During the day, he is tired and frequently falls asleep during his classes.
Provisional diagnosis?

15. Sleep Disorders
Disorders of initiating and maintaining sleep: insomnia
Disorders of excessive somnolence:
hypersomnia
Parasomnias like night terrors, nightmares and sleepwalking.

16. Insomnia
A disorder characterized by difficulties in initiating or maintaining sleep.
Most common sleep complaint
15% of people have chronic insomnia.
Brief insomnia is most often associated with anxiety: examination
Persistent insomnia is most difficulty in falling asleep.
Chronic insomnia if insomnia persists for more than 6 months

17. Risk factors
Situational stressors : job problem, marital discord; study pressure.
Aging: the older the age, the lesser the sleep
Drugs: caffeine, alcohol, withdrawal from some drugs
Psychiatric disorders (especially in women): depression, etc
Sex: more common in females.

18. Physical & psychiatric symptoms
Predominant complaint is difficulty in initiating or maintaining sleep
Affects the patient’s level of functioning
Frequent yawning and tiredness during the day

19. Treatments for insomnia
Psychotherapy: change the cognition
Medication:
Benzodiazepine: reduce time in Delta sleep
They should be considered for a short period of time
If used for prolonged time, rebound insomnia occurs.

20. Treatment for insomnia...
Behavioral intervention strategies
Progressive relaxation techniques
Biofeedback : muscle feedback, relaxation training
Sleep restriction
Stimulus control
Hot bath several hours before bed

21. Treatment for insomnia....‏
Sleep hygiene techniques
Regular sleep-wake schedule
Reduced light and noise
Eliminate caffeine, smoking, alcohol
Cool room
Exercise during the day
Reduce activity at night
Avoiding daytime naps

22. Differential diagnosis
Medical: CNS lesions, endocrine diseases, aging, alcohol, diet, medications
Psychiatric: anxiety, tension, depression etc

23. Hypersomnia Excessive sleepiness
Complaint in narcolepsy and sleep apnea syndrome

24. Narcolepsy
Sleep attack: fall sleep while doing something, last 15 minutes for a period of greater than 3 months
This is an abnormality of REM sleep.

25. Physical and psychiatric symptoms
Sleep attack: most common symptom
Cataplexy: a sudden loss of muscle tone,
often initiated by an intense emotion
Sleep paralysis: unable to move a muscle when awake and conscious
Hypnogogic and hypnopompic hallucinations: visual or auditory hallcinations may precede sleep or occur during the sleep attack.
Report falling asleep quickly at night.

26. Treatment
Forced naps at a regular time of day is usually the treatment of choice
If medications need to be prescribed, psycho stimulants are preferred.
If cataplexy are present, antidepressants like TCAs are preferred.

27. Case…
An overweight man reports having difficulties in his marriage because of his snoring at night. During the day, he reports feeling tired.
What's the provisional diagnosis?

28. Sleep apnea
Disorder characterized by the cessation of airflow at nose or mouth during sleep.
Each apneic episodes usually last longer than 10 seconds.
Characterized by loud snore followed by a heavy pause
Physical and psychiatric presenting symptoms
Excessive sleepiness during the day
Loud snoring at night
Decreased attention span
Complain of being tired during the day time.
Decreased memory
Hyperirritability

29. Treatment for sleep apnea
Behavioral intervention: sleep position training,weight loss, exercise, and alcohol reduction
Mechanical intervention: clear the airway
Surgery
Sometimes progesterone, the respiratory stimulants, can be given.

30. Sleep disorders common to children
Enuresis (bed- wetting)‏
Sleepwalking disorder
Sleep terror disorder:
no memory of the event
Nightmares: memory of
the event upon awakening.
Sleep talking

31. When we are sleeping… An active disengagement from our environment;
Shut out sensory input;
Cease to be aware of the outer world;
Brain waves change;
Eye movement slow;
Dream;
Memory close…

32. Thanks !