Sleep and sleep disorders

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Sleep and sleep disorders

• By
• Ahmed Abdellatif,MD.,
• Professor of Psychiatry,
• Cairo University.

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Definition

• Sleep is an ACTIVE process. It is a reversible
  state of unresponsiveness to stimuli of the
  outside world and to responses within the brain
  which underlie perception.

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Sleep Architecture

• Normal sleep has 2 essential phases
• - Non rapid eye movement sleep (NREM)
• 4 stages strong reduction of
  physiological functioning.
• - Rapid eye movement sleep (REM).
  highly active brain with physiological
  levels similar to awake state .

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EEG shows the following

• In the awakening state Alpha waves (9 to 10 Hz
  ) Alpha activity
• NREM sleep S (Synchronized) sleep (75 -
  80)
• stage 1 Law amplitude Theta waves (3 to 7Hz
  ) with vertex sharp waves initiation to
  sleep(5) stage 2
  Sleep spindles triphasic k complex
  Light sleep (50 )

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• Slow Wave Sleep (SWS) Deep sleep
  ( stages 3 4 ) (15-20)
• stage 3 Delta waves represent 20- 50
  -(½- 1 Hz with amplitude greater than 75 mV )
  High voltage activity.
  Stage 4 Delta waves more
  than 50 .
• In stages 3 4(deep sleep) nocturnal
  enuresis sleep walking night terrors may occurs
• Most of stage 4 occurs in 1st third of the night.

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• REM sleep D (Desynchronized ) sleep
• Law amplitude mixed frequencies (Theta Beta
  waves) Sawtooth waves rolling of eyes Law
  amplitude.
• Most of REM sleep occurs in the last third of
  night. 1st episode occurs after a latency of 90
  minutes and is the shortest (less than 10
  minutes) later REM lasts from 15 to 40 minutes (4
  to 5 episodes)

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Features of non-REM sleep

• reduced recall of dreaming if woken
• reduced complexity of dreams
• increased parasympathetic activity
• upward ocular deviation with few or no eye
  movements
• abolition of tendon reflexes
• decreased heart rate
• decreased systolic blood pressure
• decreased respiratory rate
• decreased cerebral blood flow
• penis not usually erect

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Features of REM sleep

• increased recall of dreams if woken
• increased complexity of dreams
• increased sympathetic activity
• transient runs of conjugate eye movements
• maximal loss of muscle tone
• increased heart rate
• increased systolic blood pressure
• increased respiratory rate
• increased cerebral blood flow
• occasional myoclonic jerks
• penile erection or increased vaginal blood
  flow
• increased protein synthesis (in rat brains)

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Neuroanatomy of sleep

• Wakefulness
• -Reticular formation
• -Thalamic Nuclei (intra laminar midline)
• -Subthalamus
• -Hypothalamus
• SWS
• -Raphe Nuclei of Brain stem (sleep promotion)
• -Thalamic Nuclei (non specific)
• - Hypothalamus

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Neurophysiology of sleep

• Neurotransmitters of wakefulness
• -AcetylCholine (cortex)
• -Noradrenaline (cortex)
• -peptides
• -Histamine
• -Corticotrophin releasing hormone
• -Thyrotrophin releasing hormone
• -Vasoactive intestinal polypeptide
• -ACTH TRH

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• Neurotransmitters of SWS
• - GABA
• -5HT ( acting to reduce sensory output to
  inhibit motor activity )
• -Alpha-melanocyte secreting hormone
• - Somatostatin

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• The monoaminergic model of the sleep-wake cycle
• nREM sleep is associated with serotonergic
  neuronal activity, originating in the raphe
  complex
• REM sleep is associated with noradrenergic
  neuronal activity, originating in the locus
  coerulus
• The cellular model of the sleep-wake cycle
• pontine gigantocellular tegmental fields (nucleus
  reticularis pontis caudalis)
• acetylcholine is responsible for causing the
  onset of REM sleep these are known as the on
  cells
• these cells are inhibited by the dorsal raphe
  nuclei (5-HT) and the locus
• coeruleus (NA) known as the off cells

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SLEEP WAKE CYCLE

• During sleep All decrease
• Corticosteroids-catecholamine- reflexes- cardiac
  output peripheral BP gastric acid ,metabolic
  ,heart, respiratory rates ,cerebral blood flow
  brain temprature
  GH Prolactin are secreted
• During REM Thermoregulation stops (No shivering
  or sweating)POIKILOTHERMIC CONDITION
• Near paralysis of all muscles

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Classification of sleep disordersDysomnias

• 1- DIMS - disorders of initiating and
  maintaining sleep
• a) Psychophysiological insomnia - transient and
  persistent
• b) DIMS associated with psychiatric disorder
• c) DIMS associated with drug and alcohol abuse
• d) Other conditions
• i) restless leg syndrome

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2- DOES - disorders of excessive somnolence

• a) Psychophysiological DOES - transient and
  persistent
• b) DOES associated with psychiatric disorder
• c) DOES associated with drug and alcohol abuse
• d) Sleep apnea
• e) Narcolepsy
• f) Idiopathic CNS Hypersomnia
• g) Other medical conditions

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Dysfunction associated with sleep, the sleep
stages, and partial arousals(the Parasomnias)

• a) Sleep walking
• b) Night terrors
• c) Sleep related enuresis
• d) Dream anxiety attacks (nightmares)
• e) Sleep-related epilepsy
• f) Bruxism
• g) Head banging (a.k.a. jacatio capitis
  nocturnis)
• h) Body rocking
• i) Sleep paralysis
• j) Painful nocturnal penile erections

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• . Disorders of the sleep-wake cycle
• a) transient - jet lag or shift work
• b) persistent - people who frequently change
  their cycle e.g. business men

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Insomnia

• Epidemiology
• 50 lifetime prevalence
• more common in
• females
• the elderly
• unemployed
• separated
• lower socioeconomic class
• Neurological causes
• Psychiatric Illness
• 40 have a concurrent psychiatric disorder

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Restless Leg Syndrome

• Deep sensation of creeping inside the calves
  sitting or lying down ,not painful
• Interferes with sleep and falling asleep
• - Peak middle age
• - 5 of population

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Excessive daytime sleepiness

• Aetiology
• 1- Insufficient night sleep
• 2- Pathological causes
• -Obstructive sleep apnea
• -Narcolepsy
• -Drug effect
• -Kleine Levin syndrome
• - Depression

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Obstructive sleep apnea

• 2 of population males third are obese- late
  middle age
• Aetiology Airways obstructed by fatty tissues
  leading to cessation of respiration many times
  per night
• CP LOUD SNORING (95) DAYTIME SLEEPINESS(90)
  unrefreshed sleep morning headache confusion,
  enuresis

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Narcolepsy

• characterized by excessive sleepiness
  associated with REM sleep phenomena such
• as
• 1. Cataplexy
• a) sudden temporary episodes of paralysis with
  muscle tone, precipitated
• by strong emotion
• b) occurs in most cases
• 2. Sleep paralysis
• a) a transient and generalized inability to move
  or speak during the
• transition between sleep and wakefulness
• b) typically occur while falling asleep
• c) the paralysis is flaccid, and usually complete
• d) episodes usually last only a few seconds, and
  less than one minute
• 3. Hypnagogic hallucinations
• a) occur while falling asleep

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The Kleine Levin syndrome

• -Uncommon (100 cases) affect young men
  ( onset in early adolescence ), self limiting ,
  remission occurs spontaneously before 40
• -Period of hypersomnia ( one or several weeks )
• -Alternating with periods of normal sleep
  -Marked by withdrawal from social activities,
• return to bed at first opportunity , apathy
  ,confusion irritability, loss of sex inhibition,
  delusions , or hallucinations.

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Parasomnias1- Abnormality of REM sleep

• Nightmares
• an awakening from REM sleep to full
  consciousness with detailed dream recall
• usually occur in the 1st third of nocturnal
  sleep
• causes
• frightening experiences during the day
• PTSD
• fever
• psychotropic drugs
• alcohol detoxification

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Abnormality of nREM sleep1- Night terror
disorder

• sometimes familial
• begins and ends in childhood
• child awakes terrified and may scream, and
  usually appears confused
• occurs in stage 3-4 sleep
• usually occur in the 1st third of nocturnal
  sleep
• there is little or no dream recall

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2- Sleep walking (somnambulism)

• an automatism occurring during deep non-REM
  sleep (stages 3 and 4), usually in
• the early part of the night
• affects 1 of the population
• MgtF
• associated with enuresis
• most common between the ages of 5 and 12 years
• 15 of this age group sleepwalk at least once
• may be familial
• possibly due to an abnormality of deep sleep
  subject goes from deep sleep to
• wakefulness

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Circadian Rhythm sleep disorders

• Circadian means following 24 Hours rhythm
• Pacemaker of this rhythm is the Suprachiasmatic
  Nucleus ( SCN)
• TYPES OF DISORDERS
• Transient jet lag or shift work
• Persistent in some jobs

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The effects of drugs on sleep
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Alcohol

• Biphasic effect
• - In the first half of night decrease sleep
  onset latency ( promotes sleep initiation ) ,
  increase deep sleep , decrease REM sleep
• - In the second half rebound increase in REM
  sleep
• Chronic use disruption of all stages of sleep
• Withdrawal decrease total sleep time nREM
  sleep

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Sleep and psychiatric illness

• 1. Depression
• a) reduced stage 3 and 4
• b) reduced REM latency
• c) REM occurs earlier in night
• 2.schizophrenia
• a) reduced slow wave sleep
• b) reduced REM
• 3. Anxiety
• a) increased stage 1 and 2
• b) reduced effecieny of sleep
• 4. Panic disorder
• a) increased sleep latency

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• 5. Alcoholism
• a) increased delta
• b) increased REM sleep
• c) increased alpha activity
• 6. Alzheimers disease
• a) increased sleep
• b) fragmentation
• c) reduced sleep efficiency

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Sleep and Age

• As we get older
• -We have more difficulty in initiating sleep
• - We awaken more often
• -We take more time to fall back to sleep
• -we fall asleep frequently during the day
• Studying sleep is by using polysomnography in
  Sleep Lab

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• THANK Y0U

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• disturbance of sleep continuity
• more time awake
• increased sleep fragmentation
• early morning wakening
• disturbance in the sleep architecture
• decreased slow wave sleep
• disturbance in REM sleep
• shortened REM latency
• more REM activity (higher in first ½ of the
  night)
• higher REM density
• sleep deprivation (esp. deprivation of REM
  sleep) has a beneficial effect on mood in
  depressed patients
• antidepressants destroy REM sleep - there is a
  rebound of REM sleep on discontinuation