NORMAL SLEEP

AND
SLEEP DISORDERS
 Normal sleep
A natural periodic
state of rest for the
mind and body, in
which the eyes
usually close and
consciousness is
completely or
partially lost, so that
there is a decrease
in bodily movement
and responsiveness
to external stimuli.

It is one of the most significant of human behaviors, occupying

roughly one third of human life.
 Remember
Total sleep time in the healthy young adult
approximates 7.5-8 hours.
In the full-term newborn, sleep cycles last
approximately 60 minutes (50% NREM, 50%
REM, alternating through a 3-4 h interfeeding
period).
The newborn sleeps approximately 16-20 hours
per day; these numbers decline to a mean of 10
hours during childhood.
 Normal sleep
Normal Sleep is divided into :
1. Awake state
Beta waves
Alpha waves
2. Sleep state
NREM
Stage 1
Stage 2
Stage 3
Stage 4
REM
NREM and REM occur in alternating cycles, each lasting approximately 90-100
minutes, with a total of 4-6 cycles
 Normal sleep
Awake state
Awake state is characterized by beta waves
and alpha waves on EEG.
1. Beta waves over the frontal lobes are
commonly seen with active mental
concentration.
2. Alpha waves over the occipital and parietal
lobes are seen when a person relaxes with
closed eyes.

Sleep latency (period of time from going to bed to falling

asleep) is normally less than 10 minutes.
 Normal sleep
Sleep state
NREM (75-80%)
REM (20 -25%)
with each cycle lasting app. 70-100 min.
In NREM sleep, most physiological functions are markedly lower
than in wakefulness.
REM sleep is a qualitatively different kind of sleep, characterized
by a high level of brain activity and physiological activity levels
similar to those in wakefulness.
About 90 minutes after sleep onset, NREM yields to the first
REM episode of the night.
This REM latency of 90 minutes is a consistent finding in normal adults;
shortening of REM latency frequently occurs with such disorders as
depressive disorders and narcolepsy.
 Normal sleep
NREM sleep is a peaceful state relative to waking
Pulse rate is slowed
Respiration rate is slowed
Blood pressure is low
Episodic, involuntary body movements are present
 Normal sleep

NREM (75 percent)

Stage 1: 5 percent
Stage 2: 45 percent
Stage 3: 12 percent
Deepest
Stage 4: 13 percent Portion

REM (25 percent)

REM is characterized by low voltage,
desynchronized EEG whereas NREM is
more variable on EEG
Stage 1 : (somnolence or drowsy sleep)
Theta waves
Lightest stage (5%) of sleep
Characterized by peacefulness, slowed pulse and
respiration, decreased blood pressure, episodic body
movements, looses some muscle tone, sudden twiches
Stage 2 :
Largest percentage (45%) of sleep time
Bruxism is seen
Sleep spindle and K-complex
Muscular activity decreases and conscious awareness of
external environment disappears
Stages 3 & 4 :
Delta waves (slow-wave sleep)
25% of the sleep time
Deepest and most relaxed stage of sleep
When persons are aroused 30 minutes to 1 hour after sleep
onsetusually in slow-wave sleepthey are disoriented, and
their thinking is disorganized.
Brief arousals from slow-wave sleep are also associated with
amnesia for events that occur during the arousal.
The disorganization during arousal from stage 3 or stage 4 may
result in specific problems, including enuresis, somnambulism,
and stage 4 nightmares or night terrors.
Dreams (rare) and nightmares occur but are not recollected
Decreased heart rate and respiratory rate
Thermoregulation maintained
REM Sleep :
25% of the sleep time
REM sleep has also been termed paradoxical sleep.
Pulse, respiration, and blood pressure in humans are all high
during REM sleepmuch higher than during NREM sleep and
often higher than during waking.
Decreases with age
Active dreaming present with memory
Penile and clitoral erections
Near-total paralysis of the skeletal (postural) muscles is seen.
Because of this motor inhibition, body movement is absent
during REM sleep
Loss of thermoregulation( Poikilothermia prevails)
Commonly seen just before awakening
A person who is deprived of REM sleep one night (e.g., because of
inadequate sleep, repeated awakenings, or sedative use) has
increased REM sleep the next night (REM rebound).
REM period occurs about every 90 to 100 minutes during the night. The first REM
period tends to be the shortest, usually lasting less than 10 minutes; later REM
periods may last 15 to 40 minutes each. Most REM periods occur in the last third
of the night, whereas most stage 4 sleep occurs in the first third of the night
 Electroencephalogram Electrooculogram Electromyogram
Wakefulness Low-voltage, mixed frequency Eye movements and High tonic activity
activity. Alpha (813 cps) eye blinks and voluntary
activity with eyes closed movements
NREM sleep
Stage I Low-voltage, mixed frequency Slow eye Tonic activity
activity. Theta (37 cps) activity, movements slightly decreased
vertex sharp waves from wakefulness
Stage II Low-voltage, mixed frequency None Low tonic activity
background with sleep spindles
(1214 cps bursts) and K
complexes (negative sharp wave
followed by positive slow wave)
Stage III High-amplitude (75 V) slow None Low tonic activity
waves (2 cps) occupying 20 to 50
percent of epoch
Stage IV High-amplitude slow waves None Low tonic activity
occupy >50% of epoch
REM sleep Low-voltage, mixed frequency REMs Tonic atonia with
activity Saw-tooth waves, theta phasic twitches
activity, and slow alpha activity
Sleep Measure Normal Young Depressed Normal
Adult Young Adult Elderly Adult
Sleep latency About 10 < 10 minutes > 10 minutes
minutes
REM latency About 90 <90 minutes <90 minutes
minutes
Sleep efficiency About 100% < 100% < 100%
Percentage About 25% < 25% < 25%
delta
Percentage About 25% > 25% < 25%
REM
Neurotransmitters involved in sleep
Acetylcholine :
increased levels increase total sleep time and REM sleep
decreased levels aging , Alzheimers disease
Dopamine :
increased levels decrease total sleep time
antipsychotics block dopamine receptors improve
sleep
Nor epinephrine :
increased levels decrease both sleep time and REM
sleep
Serotonin :
increased levels increase both sleep time and delta sleep
Neurotransmitters involved in sleep
Serotonin :
Increased levels increase both sleep time and delta sleep.
Prevention of serotonin synthesis or destruction of the dorsal
raphe nucleus of the brainstem, which contains nearly all the
brain's serotonergic cell bodies, reduces sleep for a considerable
time.
Synthesis and release of serotonin by serotonergic neurons are
influenced by the availability of amino acid precursors of this
neurotransmitter, such as L-tryptophan.
Ingestion of large amounts of L-tryptophan (1 to 15 g) reduces
sleep latency and nocturnal awakenings.
Conversely, L-tryptophan deficiency is associated with less time
spent in REM sleep.
Neurotransmitters involved in sleep
Melatonin :
Melatonin secretion from the pineal gland is inhibited by bright
light, so the lowest serum melatonin concentrations occur during
the day.
The suprachiasmatic nucleus of the hypothalamus may act as the
anatomical site of a circadian pacemaker that regulates melatonin
secretion and the entrainment of the brain to a 24-hour sleep-wake
cycle.
 Methods of sleep study
1. Observation of a sleeping person to see
externally visible changes
2. EEG
3. POLYSOMNOGRAPHY
Continuous EEG ( occipital & parietal leads)
EOG
EMG
ECG
Oxymetry
 Factors affecting sleep

Age
Sex
Environmental factors
Associations
Physical illness
Psychiatric illness
Drugs
Coffee, tea , alcohol
smoking
Classification of sleep disorders(DSM)
DYSSOMNIAS PARASOMNIAS
Problems with timing, Abnormalities in
quality & amount of physiology or in behaviour
sleep during sleep or the
Includes ; transition between sleep
Insomnia and wakefulness
Hypersomnia Includes :
Narcolepsy Sleep walking
Sleep apnea Sleep terror disorder
Circadian rhythm Nightmare disorder
sleeping disorder Bruxism
REM sleep disorder
 Insomnia
Difficulty falling asleep
or staying asleep leads to
sleepiness during day or
causes problems fulfilling
social or occupational
obligations
The disorder is not due to
the effects of medication,
drugs of abuse, or a
medical condition
 Hypersomnia
Hypersomnia manifests as excessive amounts
of sleep, excessive daytime sleepiness
(somnolence), or sometimes both
The term somnolence should be reserved for
patients who complain of sleepiness and have a
clearly demonstrable tendency to fall asleep
suddenly in the waking state, who have sleep
attacks, and who cannot remain awake; it
should not be used for persons who are simply
physically tired or weary.
 Narcolepsy
Patients with narcolepsy have sleep attacks
during day, despite of having a normal
amount sleep at night
More common in adolescents and young
adults.
Possible genetic role
Associated with changes in HLA-DR2 genes
(chromosome 6)
 Sleep Apnea
Patients with sleep apnea stop breathing for
brief intervals.
Low oxygen and high CO2 levels in the blood
awakens the patient repeatedly during night.
Types :
Central sleep apnea
Obstructive sleep apnea
Mixed
 Central sleep apnea
Central sleep apnea (CSA), which tends to occur in the
elderly, results from periodic failure of central nervous
system (CNS) mechanisms that stimulate breathing.
The airway is not blocked but the brain fails to signal
the muscles to breathe.
Little or no respiratory efforts, resulting in less air
reaching the lungs.
The polysomnogramic features of CSA are similar to
those of OSA, except that, during the periods of apnea, a
cessation of respiratory effort is seen in the abdominal
and chest expansion leads.
 Nightmare disorder
This disorder is typified by repeated awakenings from
sleep with detailed recall of frightening dreams.
The person quickly becomes alert and oriented upon
awakening.
Occurs during REM sleep
Some persons have frequent nightmares as a lifelong
condition; others experience them predominantly at
times of stress and illness..
Comfort, reassurance, tricyclic drugs, benzodiazepines
may help
 Sleep terror disorder
Repetitive experiences of fright in which a person screams in fear
in the first third of the night during deep NREM (stages III and
IV) sleep
The person cannot be awakened
Once awakened, the individual is confused and finds it difficult to
relay the detail of his/her dream
During each episode the patient shows evidence of marked fear
and autonomic arousal, such as rapid breathing, rapid heartbeat
and sweating.
responds poorly to the efforts of others to provide comfort.
Occurs during delta (slow wave ) sleep
Comfort, reassurance, benzodiazepines may help
Onset in adolescence may indicate temporal lobe epilepsy
 Sleep-Related Bruxism
Bruxism, tooth grinding, occurs throughout the night, most
prominently in stage II sleep.
According to dentists, 5 to 10 percent of the population has
sufficient bruxism to produce noticeable damage to teeth.
The condition often goes unnoticed by the sleepers, except for an
occasional jaw ache in the morning, but bed partners and
roommates are consistently awakened by the sound.
Treatment consists of a dental bite plate and corrective
orthodontic procedures
 Useful links
Sleep and Sleep disorder tutorial
http://www.nlm.nih.gov/medlineplus/sleepdisorders.ht
ml