1. Electrophysiology of Sleep STAGES OF SLEEP A. NON-REM – 75% Stage 1 -( 5%) 3 to 7 cps theta waves, vertex sharp wave Stage 2 - (45%) 12 to 14 cps with sleep spindles and K complex Stage 3 - (12%) ½ to 2 cps delta waves Stage 4 – (13%) ANTERIOR HYPOTHALAMUS, PRE-OPTIC AREA, DORSAL MEDULLARY RETICULAR FORMATION & NUCLEUS OF THE TRACTUS SOLITARIUS

2. Stages of Sleep Stage 3 and 4- arousal characteristics when awakened – disorganized thinking, disoriented, brief arousals associated with amnesia for events occurring during the arousal Problems : enuresis, somnambulism, nightmares and sleep terror

3. STAGES OF SLEEP B. REM SLEEP – 25% Low voltage, mixed frequency(theta and slow alpha) SAW TOOTH WAVES REM- ON CELLS – DORSOLATERAL PONTINE RETICULAR FORMATION AND THE NEURONS VENTRAL AND LATERAL TO THE LOCUS CERULEUS (cholinergic) REM-OFF CELLS- LOCUS CERULEUS & DORSAL RAPHE NUCLEI ( Noradrenergic)

4. EVENTS DURING STAGES OF SLEEP NON- REM SLEEP SLOW EYE MOVEMENT MUSCLES RELAXED SOME TONE IN POSTURAL MUSCLE GROUPS VITAL SIGNS STABLE RARE PENILE ERECTION RARE DREAMS INC. AFTER EXERCISE AND STARVATION REM SLEEP RAPID EYE MOVEMENT FREQUENT MUSCLE TWITCHING DECREASED MUSCLE TONE ABSENT BODY MOVEMENT VS FLUCTUATING COMMON DREAMS & PENILE ERECTION Inc. brain 02 use, dec. ventilatory response to inc. C02, poikilothermic condition

5. SLEEP REGULATION & FUNCTION SEROTONIN- INCREASE SLEEP MELATONIN- circadian pacemaker DOPAMINE- INCREASE AROUSAL increase need with physical work, exercise, illness, pregnancy, mental stress and inc. mental activity SLEEP- RESTORATIVE FUNCTION NORMAL THERMOREGULATION AND ENERGY CONSERVATION NON REM – inc. after exercise and starvation ?metabolic need

6. Sleep and Depression, AD Marked shortened REM latency (< 60 min.) >% of REM sleep Shift in REM distribution Supersensitivity to acetylcholine Transient improvement of depression during sleep deprivation Reserpine- increase REM cause depression AD decreased REM and Stage 3 and 4

7. Sleep deprivation and requirement REM DEPRIVED PATIENTS ARE IRRITABLE AND LETHARGIC WITH SUBSEQUENT INCREASE IN NUMBER AND AMOUNT OF REM SLEEP SLEEP REQUIREMENTS A. SHORT SLEEPERS- REQUIRE LESS THAN 6 HOURS SLEEP(EFFICIENT, AMBITIOUS, SOCIALLY ADEPT B. LONG SLEEPERS- REQUIRE MORE THAN 9 HRS. OF SLEEP; MORE REM PERIODS AND MORE RAPID EYE MOVEMENTS(mildly depressed, anxious, socially withdrawn)

8. SLEEP DISORDER-DYSSOMNIA DISORDER OF QUANTITY OR TIMING OF SLEEP

9. Dyssomnia 1. Primary Insomnia 2. Psychophysiological Insomnia 3. Primary Hypersomnia 4. Narcolepsy 5. Breathing related sleep disorder 6. restless leg syndrome

10. DYSSOMNIADiagnostic Criteria for Primary Insomnia A.THE PREDOMINANT COMPLAINT IS DIFFICULTY INITIATING OR MAINTAINING SLEEP,OR NONRESTORATIVE SLEEP FOR AT LEAST ONE MONTH b. the sleep disturbance (or asso. daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other areas of functioning c. no other sleep disorder, such as narcolepsy no other mental disturbance d. not due to substance or general medical condition

11. Psychophysiological Insomnia AKA conditioned insomnia Work and relationships are satisfying Other characteristics: 1. excessive worry of not being able to sleep 2. trying too hard to sleep 3. rumination 4. inc. muscle tension when attempting to sleep 5. able to sleep away from the bedroom, being able to sleep when not trying SLEEP STATE MISPERCEPTION

12. SLEEP HYGIENE ARISE AT THE SAME TIME DAILY LIMIT DAILY IN BED TIME TO THE USUAL AMOUNT PRESENT BEFORE THE SLEEP DISTURBANCE DISCONTINUE- CAFFEINE, NICOTINE, ALCOHOL, STIMULANTS AVOID DAYTIME NAPS GRADED EXERCISE EARLY IN THE DAY

13. SLEEP HYGIENE AVOID EVENING STIMULATION TRY 20 MIN. HOT BATH SOAKS EAT REGULAR MEALS AT DAYTIME, AVOID LARGE MEALS NEAR BEDTIME PRACTICE EVENING RELAXATION TECHNIQUES MAINTAIN COMFORTABLE SLEEPING CONTIONS

14. DYSSOMNIA CRITERIA FOR PRIMARYHYPERSOMNIA A. THE PREDOMINANT COMPLAINT IS EXCESSIVE SLEEPINESS FOR AT LEAST ONE MONTH ( OR LESS IF RECURRENT) AS EVIDENCED BY PROLONGED SLEEP EPISODES OR DAYTIME SLEEP EPISODES THAT OCCUR ALMOST DAILY B. THE EXCESSIVE SLEEPINESS IS NOT BETTER ACCOUNTED FOR BY INSOMNIA AND DOES NOT OCCUR EXCLUSIVELY DURING THE COURSE OF ANOTHER SLEEP DISORDER

15. DIAGNOSTIC CRITERIA FOR NARCOLEPSY (primary hypersomnia) A. IRRESISTIBLE ATTACKS OF REFRESHING SLEEP THAT OCCUR DAILY OVER AT LEAST 3 MONTHS B. PRESENCE OF ONE OR BOTH OF THE FOLLOWING: 1. CATAPLEXY- brief episodes of sudden bilateral loss of muscle tone, most often in association with intense emotion 2. recurrent intrusions of elements of REM sleep into the transition bet. Sleep and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep paralysis at the beginning or end of sleep episodes

16. DIAGNOSTIC CRITERIA FOR CIRCADIAN RHYTHM SLEEP DISORDER A . PERSISTENT OR RECURRENT PATTERN OF SLEEP DISRUPTION LEADING TO EXCESSIVE SLEEPINESS OR INSOMNIA THAT IS DUE TO A MISMATCH BETWEEN THE SLEEP WAKE SCHEDULE REQUIRED BY A PERSON’S ENVIRONMENT AND HIS CIRCADIAN SLEEP WAKE PATTERN BCD

17. CIRCADIAN SLEEP DISORDER SPECIFY TYPE: A. DELAYED SLEEP PHASE TYPE- A PERSISTENT PATTERN OF LATE SLEEP ONSET AND LATE AWKENING TIMES WITH INABILITY TO FALL ASLEEP AND AWAKEN AT A DESIRED EARLIER TIME B. JET LAG TYPE C. SHIFT WORK TYPE

18. PARASOMNIAS ABNORMAL BEHAVIOR DURING SLEEP OR THE TRANSITION BETWEEN SLEEP AND WAKEFULNESS

19. DIAGNOSTIC CRITERIA FOR NIGHTMARE DISORDERS A. REPEATED AWAKENINGS FROM THE MAJOR SLEEP PERIOD OR NAPS WITH DETAILED RECALL OF EXTENDED AND EXTREMELY FRIGHTENING DREAMS, USUALLY INVOLVING THREATS TO SURVIVAL, SECURITY OR SELF ESTEEM, THE AWAKENINGS GENERALLY OCCUR DURING THE SECOND HALF OF THE SLEEP PERIOD

20. NIGHTMARE DISORDERS B. ON AWAKENING FROM THE FRIGHTENING DREAMS, THE PERSON RAPIDLY BECOMES ORIENTED AND ALERT C. THE DREAM EXPERIENCE OR THE SLEEP DISTURBANCE RESULTING FROM THE AWAKENING CAUSES SIGNIFICANT DISTRESS D. NO OTHER MENTAL DISORDER, OR INTAKE OF PHYSIOLOGICAL SUBSTANCE

21. DIAGNOSTIC CRITERIA FOR SLEEP TERROR DISORDER A. RECURRENT EPISODES OF ABRUPT AWAKENING FROM SLEEP USUALLY OCCURING DURING THE FIRST THIRD OF THE MAJOR SLEEP EPISODE AND BEGINNING WITH A PANICKY SCREAM B. INTENSE FEAR AND SIGNS OF AUTONOMIC AROUSAL SUCH AS TACHYCARDIA, RAPID BREATHING, SWEATING DURING EACH EPISODE C. RELATIVE UNRESPONSIVENESS TO EFFORTS OF OTHERS TO COMFORT THE PERSON DURING THE EPISODE D. NO DETAILED DREAM IS RECALLED AND THERE IS AMNESIA FOR THE EPISODE EF

22. DIAGNOSTIC CRITERIA FOR SLEEPWALKING DISORDER A. REPEATED EPISODES OF RISING FROM BED DURING SLEEP AND WALKING ABOUT, USUALLY OCCURING DURING THE FIRST THIRD OF THE MAJOR SLEEP EPISODE B. WHILE SLEEPWALKING THE PERSON HAS A BLANK STARING FACE IS RELATIVELY UNRESPONSIVE AT EFFORTS TO COMMUNICATE AND CAN BE AWAKENED WITH A GREAT DEAL OF DIFFICULTY C. ON AWAKENING THE PATIENT HAS AMNESIA OF THE EPISODE D. WITHIN SEVERAL MINUTES AFTER AWKENING FROM THE SLEEPWALKING EPISODE, THERE IS NO IMPAIRMENT OF MENTAL ACTIVITY OR BEHAVIOR E. COMMON CRITERIA

23. INSOMNIA RELATED TO ANOTHER PSYCHIATRIC ILLNESS Insomnia in depression-normal sleep onset, repeated awakenings Insomnia in mania- reduction in need for sleep Insomnia in schizophrenia- reduction of total sleep time , slow wave sleep, REM

24. SUBSTANCE INDUCED SLEEP DISORDER SOMNOLENCE- AMPHETAMINE, COCAINE, CAFFEINE (WITHDRAWAL) SUSTAINED USE OF CNS DEPRESSANT INSOMNIA- bzdp, BARBITURATES (WITHDRAWAL)