Unit V - Sleep
Unit V - Sleep
Unit V - Sleep
SLEEP
SLEEP
Sleep is a state of irreversible unconsciousness in which brain is les responsive to external stinuli. During
sleep we are functionally blind and deaf.
CHILDREN - Non selecive - They dont respond to sound beyond 100 decibel
They sleep beyond 16-18 hours.
There is correlation betwwen age and sleep.
ADULTS - Selective; especially mothers with babies. Sounds such as cry of baby, threathening sounds,
are always noticed.
There is a discrimination between discriminant and non discriminant sounds.
Sensory gating/ Critical gating; selectively filter out; we are more sensitive to emotionally relevant
stimuli
Sleep is reversible and interruptive. But during comma we can't wake up when we want to. Sleep is
qualitatively or different from other states such as wakefulness. Brain either uses similar amount or
more oxygen than in the level of wakefulness.
1. EEG - The two properties of of brain waves such as amplitude and frequency are studied. They are
inversely related.
WHY DO WE SLEEP?
1. Consolidation of memory
4. Dreaming.
Evolutionary significance of sleep is not so evident. Sleep is present since evolutionary history. If there is
something within us, it has a significance or else they would have been eliminated.
Evidences.
When we dont get enough sleep, memory functioning gets messed up.
There are no evidences regarding tissue repair that happens during sleep. Not attributable to sleep
functions.
Ecological cost is high - to sleep at night. More vulnerable to threat while sleeping at night. It is
compensated through sensory threat.
SLEEP STAGES
According to the American Academy of Sleep Medicine, there are three high-frequency waves of alert
wakefulness. Then, as the person falls asleep, there is a sudden transition to a period of stage 1 sleep
EEG.
The stage 1 sleep EEG is a low-voltage, high frequency signal that is similar to, but slower than, that of
alert wakefulness
There is a gradual increase in EEG voltage and a decrease in EEG frequency as the person progresses
from stage 1 sleep through stages 2 and 3.
Accordingly, the stage 2 sleep EEG has a slightly higher amplitude and a lower frequency than the stage
1 EEG; in addition, it is punctuated by two characteristic wave forms: K complexes and sleep spindles.
Each K complex is a single large negative wave (upward deflection) followed immediately by a single
large positive wave (downward deflection).Each sleep spindle is a 0.5- to 3-second waxing and waning
burst of 9- to 15-Hz waves
The stage 3 sleep EEG is defined by a predominance of delta waves—the largest and slowest EEG waves,
with a frequency of 1 to 2 Hz.Once sleepers reach stage 3 EEG sleep, they stay there for a time, and then
they retreat back through the stages of sleep to stage 1. After the first cycle of sleep EEG—from initial
stage 1 to stage 3 and back to emergent stage 1—the rest of the night is spent going back and forth
through the stages. Each cycle tends to be about 90 minutes long and that, as the night progresses,
more and more time is spent in emergent stage 1 sleep, and less and less time is spent in the other
stages, particularly stage 3. There are brief periods during the night when the person is awake, although
he or she usually does not remember these periods of wakefulness in the morning
Initial stage 1, stage 2, and stage 3 sleep are sometimes referred to as NREM 1 (N1), NREM 2 (N2), and
NREM 3 (N3), respectively. NREM 3 is often referred to as slow-wave sleep (SWS), after the delta waves
that characterize it.
The sleep associated with emergent stage 1 EEG is often called REM sleep, after the associated rapid eye
movements; whereas all other stages of sleep together are called NREM sleep (non-REM sleep).
SLEEP DISORDERS
Classification of sleep disorders are given by International classification of sleep disorders and DSM.
DSM is more interested in pathological/clinical part and it's treatment.
1) Dysomnia - Wrong way of sleeping. ( Do not involve physical movements while asleep)
2) Parasomnia - Sleep occurs 'alongside'. Happens while/during sleep.Happens during deep sleep (slow
wave sleep; stage 3 and 4). Mostly happens when there's stress. ( Accompanied with physical or
unwanted behaviour during sleep)
Bruxism - characterized by clenching of the teeth during sleep and can result in arousals. Often
the activity is severe or frequent enough to result in symptoms of temporomandibular joint pain
or wearing down of the teeth
Sleep walking (Somnambulism) - More common in children. It is a slow wave sleep disorder. This
disorder is not characterised by acting out of dreams, because it is immposible to have dreams
in stage 3 and 4. During somnambulism, eyes are open but the individual is not conscious of
their action. And they don't hold any memory of it later. It happens due to sudden arousal of
deep sleep.
Sleep terrors/Night terrors - Associated with feelings of fear, scraeming screeching and piercing.
It is common amon children who are 2-6 years of age. It is a non-rem phenomena.
Sleep terror is a physiological reaction without any dream content. No visual imagery is involved.
When waking up children cry.
[NOTE : Something that happens at REM sleep is called as NIGHTMARES. It is a rem stage
parasomnia that happens along with sleep. Visual imagery is present.]
Confusional arousal - Characterised by confusion mentaly or behavioraly. Happens immediately
after arousal from night sleep or day time sleep. It happens in children.
Somniloqui - Talking during sleep.
Sexsomnia - Highly rare. First reported in australia during 1996.
REM sleep behaviour disorder- involves abnormal behaviors that occur in REM sleep and result
in injury or sleep disruption. The behaviors are often violent with dream enactment that is
action filled. The disorder can occur in narcolepsy, and many patients with Parkinson’s disease
have REM sleep behavior disorder. The delayed emergence of a neurodegenerative disorder can
occur, especially in men >50 years of age.
Dream inactment - Acting out during dream. Basically during REM sleep, muscles are paralysed.
Muscle atonia lacks here. It is more common among among people with parkinson's and
narcolepsy.
Recurrent isolated sleep paralysis - This happens when the person is unable to perform
voluntary movements at the sleep onset or awakening. Ventilation is usually unaffected.
Hallucinatory experiences often accompany the paralysis.
Nightmares - REM version of night terror. Awakening with intense anxiety and fear.
Sleep-related dissociative disorders - It involve a disruption of the integrative features of
consciousness,memory, identity, or perception of the environment. This disorder can occur in
the transition from wakefulness to sleep or after an awakening from stage 1 or 2 sleep. A history
of physical or sexual abuse is common in such patients. These patients fulfill the DSM-IV criteria
for dissociative disorder.
Sleep eneuresis - It is recurrent involuntary voiding that occurs during sleep. Enuresis is
considered primary in a child who has never been dry for 6 months or longer, whereas
otherwise, it is called secondary enuresis.
Catathrenia - Sleep related groaning - is an unusual disorder in which there is a chronic, often
nightly, expiratory groaning that occurs during sleep. The affected person is often unaware of
the groaning. The disorder is rare and the pathophysiology is unknown. It has been suggested
that catathrenia is a variant of a sleep-related breathing disorder because treatment by means
of continuous positive airway pressure has been reported to be successful
Exploding head syndrome - It is characterized by a loud imagined noise or sense of a violent
explosion that occurs in the head as the patient is falling asleep or during waking in the night.
Sleep related hallucination - The individual experiences hallucinatory experiences. Happens
during sleep onset or during awakening. They may be difficult to distinguish from vivid dreams
or nightmares, and are usually complex images that occur when the patient is clearly awake.
Sleep related eating disorder - It involves recurrent eating and drinking episodes during arousals
from nocturnal sleep. The eating behavior is uncontrollable and often the patient is unaware of
the behavior until the next morning. It can be associated with sleepwalking and can be
medication-induced
Parasomnia due to drug or substance - It has a close temporal relationship between exposure to
a drug, medication, or biological substance
DYSOMNIA
Collection of sleep disorders that causes excessive sleep/difficulty in falling/maintain or continue sleep.
This negatively impact quality or quantity of sleep.
Types of dysomnias.
3 broad classification
These are due to internal dysfuntions and malfunctions such as illnesses or medical problems
step 3 - co2 in blood increases which leads the body in drive mode. It triggers chemoreceptors which in
turn triggers the motorneurons and lead to wakefulness.
The person is continuously interrupted during sleep, which causes excessive daytime sleeping and
tiredness.
2.Narcolepsy
It is derived from greek words 'Narke' (Numbness) and 'Lepsis'(Seizure).
Narcolepsy is the most widely studied disorder of hypersomnia. It occurs in about 1 out of 2,000
individuals (Arango, Kivity, & Schoenfeld, 2015)
It has two prominent symptoms. First, persons with narcolepsy experience severe daytime sleepiness
and repeated, brief (10- to 15-minute) daytime sleep episodes. Individuals with narcolepsy typically
sleep only about an hour per day more than average; it is the inappropriateness of their sleep episodes
that most clearly defines their condition.
4 symptoms of narcolepsy.
1. Sleep attack
2. Cataplexy - Complete loss of muscle tone.
3. Sleep paralysis - The inability to move just as one is falling asleep or waking up
4. Hypnogogic Hallucinations - dream like experiences during wakefulness.
3. Insomnia
Insomnia includes all disorders of initiating and maintaining sleep (Ellis et al., 2011)
Many cases of insomnia are iatrogenic (physician created)—in large part because sleeping pills (e.g.,
benzodiazepines)
It is an obstructive apnea
Restless leg syndrome - characterized by the complaint of a strong, nearly irresistible urge to
move the legs, often accompanied by uncomfortable or painful symptoms. The sensations are
worse at rest and occur more frequently in the evening or during the night. Walking or moving
the legs relieves the sensation.
Sleep apnea - The patient with sleep apnea stops breathing many times each night. Each time,
the patient awakens, begins to breathe again, and drifts back to sleep. Sleep apnea usually leads
to a sense of having slept poorly and is thus often diagnosed as insomnia. However, some
patients are totally unaware of their multiple awakenings and instead complain of excessive
sleepiness during the day, which can lead to a diagnosis of hypersomnia. Sleep apnea disorders
are of two types:
(1) obstructive sleep apnea results from obstruction of the respiratory passages by muscle spasms or
atonia (lack of muscle tone) and often occurs in individuals who are vigorous snorers
(2) central sleep apnea results from the failure of the central nervous system to stimulate respiration.
Sleep apnea is more common in males, in people who are overweight, and in the elderly (Badran et al.,
2015).
Periodic limb movement disorder is characterized by periodic, involuntary movements of the limbs,
often involving twitches of the legs during sleep.Most patients suffering from this disorder complain of
poor sleep and daytime sleepiness but are unaware of the nature of their problem.
Sleep restriction therapy - First, the amount of time that an insomniac is allowed to spend in bed is
substantially reduced. Then, after a period of sleep restriction, the amount of time spent in bed is
gradually increased in small increments, as long as sleep latency remains in the normal range. Even
severe insomniacs often benefit from this treatment.
5.Hypersomnia
Inadequate sleep hygiene is a disorder associated with common daily activities that are inconsistent
with good-quality sleep and full daytime alertness. Such activities include irregular sleep onset and wake
times, stimulating and alerting activities before bedtime, and substances (e.g., alcohol, caffeine,
cigarette smoke) ingested near to sleep time. These practices do not necessarily cause sleep disturbance
in other people. For example, an irregular bed-time or waketime that produces insomnia in one person
may not be important in another.
Consuming 25 percent or more of the daily calories after dinner. It reduces sleep quality and interferes
with sleep latency. It leads to lack of synchronization between food habits and circadian rhythm.
CIRCADIAN RHYTHM
The world in which we live cycles from light to dark and back again once every 24 hours. Most surface-
dwelling species have adapted to this regular change in their environment with a variety of circadian
rhythms (circadian means “lasting about a day”). For example, most species display a regular circadian
sleep–wake cycle. Humans take advantage of the light of day to take care of their biological needs, and
then they sleep for much of the night; in contrast, nocturnal animals, such as rats, sleep for much of the
day and stay awake at night.
Our circadian cycles are kept right on their once-every 24-hours schedule by temporal cues in the
environment.The most important of these cues for the regulation of mammalian circadian rhythms is
the daily cycle of light and dark. Environmental cues, such as the light–dark cycle, that can entrain
(control the timing of) circadian rhythms are called zeitgebers , a german word that means “time givers.”
In controlled laboratory environments, it is possible to lengthen or shorten circadian cycles somewhat
by adjusting the duration of the light–dark cycle.
Circadian rhythms in constant environments are said to be free-running rhythms, and their duration is
called the free-running period. Free-running periods vary in length from individual to individual, are of
relatively constant duration within a given individual, and are usually longer than 24 hours—about 24.2
hours is typical in humans living under constant moderate illumination ( Czeizler et al., 1999)
Many animals display a circadian cycle of body temperature that is related to their circadian sleep–wake
cycle: They tend to sleep during the falling phase of their circadian body temperature cycle and awaken
during its rising phase.
How does the 24-hour light–dark cycle entrain the sleep–wake cycle and other circadian rhythms?
To answer this question, researchers began at the obvious starting point: the eyes. They tried to identify
and track the specific neurons that left the eyes and carried the information about light and dark that
entrained the biological clock. Cutting the optic nerves before they reached the optic chiasm eliminated
the ability of the light–dark cycle to entrain circadian rhythms; however, when the optic tracts were cut
at the point where they left the optic chiasm, the ability of the light–dark cycle to entrain circadian
rhythms was unaffected.
This finding led to the discovery of the retinohypothalamictracts, which leave the optic chiasm and
project to the adjacent suprachiasmatic nuclei
The two photic pathways are-direct path (Retino hypothalamic pathway) and indirect pathaway
(Retinogeniculate pathway).
The non-photic pathways are by the raphe nuclei . The non light stimulus that contributes to sleep
wake cycle are social interactions, physical activity, stess, caffeine, feeding cycle for infants, food cycles
fpr adults and ambient temperature. This is alsp how blind entrain.
'Our behaviour'
SCN regulates the secreation of melatonin. It usually begins 2 hrs before the natural sleep for the body
to process. The synthethetic melatonin works more faster than natural melatonin. The timing of
secreation of melatonin is used to find the circadain rhythm disorder.
Researchers through chronobiological studies have identified that there are non-SCN timekeepers of
sleep
1. Delayed sleep wake phase disorder - It is characterised by sleeping at morning and being active at
night. Treatment: Melatonin and ligh therapy
2. Advanced sleep phase disorder - Finding it difficult to stay awake during night.
3. Irregular sleep wake rhythm disorder - Fragmented sleep - Multiple wake up between sleep cycle.
common among in older children with developmental disorders and people with dementia. Causes due
to degenration of SCN neurons
4. Non 24-hour sleep wake disorder (Free running rhythm disorder or Hyper nycthemeral syndrome)-
non synchronization of sleep cycle. absence of entrainment; extending of 24 hours cycle; extremely
difficult to treat.
5. Jet lag - A disruption of circadian rhythms due to crossing time zones is known as jet lag. Travelers
complain of sleepiness during the day, sleeplessness at night, depression, and impaired concentration.
All these problems stem from the mismatch be-tween internal circadian clock and external time
6. Shift work disorder - People who sleep irregularly—such as pilots, medical interns, and shift workers
in factories—ind that their duration of sleep depends on when they go to sleep. When they have to
sleep in the morning or early afternoon, they sleep only briely,even if they have been awake for many
hours. People adjust best to night work if they sleep in a very dark room during the day and work under
very bright lights at night, comparable to the noonday sun.
SLEEP INTERVENTIONS
1. Sleep education - These interventions included information on sleep health, sleep cycles,
consequences of insufficient sleep, and/or sleep hygiene tips. Methods such as seminars, pamphlets,
telephone calls, and online information are used to deliver sleep education.
2. Behavior Change Methods (BCM) - Used in infants and children.Examples of BCM are standardized
bedtimes, scheduled awakenings, positive routines, controlled comforting, and gradualextinction (i.e.,
parents leave children alone for extended periods, ignoring protests and crying.
There is substantial evidence that BCM in infants and children (as managed by parents) increases sleep
duration and quality.There is also some encouraging (but more limited) evidence for other populations
such as athletes, and shift workers
4. Physical Exercise Interventions - Aerobic exercise, shadow boxing, pilates, and low-intensity exercises.
5. Mind body exercise - Separate intervention type, combining physical activity with meditative
components.Common forms of MBE were tai chi, yoga, and Qigong, but there are also less-common
techniques, such as the Rességuier method, which promotes patient awareness of bodily perceptions
and control.
7. Environmental Interventions - Daytime bright light therapy, nature sounds, white noise, noise
reduction . Environmental interventions were often conducted in monitored facilities, such as hospitals
or care facilities.
9. Later School Start Interventions - Delaying of school start time by 20-85 minutes.
11. Other Types of Interventions - dietary interventions, hypnosis, biofeedback therapy, magnet therapy,
drinking herbal tea,acupuncture, cryostimulation (where the body is exposed temporarily to extremely
cold temperatures), and infrared light treatment.
SLEEP HYGIENE.
‘Sleep hygiene’ is the term used to describe good sleep habits.Considerable research has gone into
developing a set of guidelines and tips which are designed to enhance good sleeping, and there is much
evidence to suggest that these strategies can provide long-term solutions to sleep difficulties.
1. Get regular
5. Avoid alchohol
11. Exercise
12. Eat balanced and healthy diet