study notes

1. Mental health II
Geofry ouma

2. Stages of Sleep: REM and Non-REM
Sleep Cycles
 REM- Rapid eye movement.
 NREM- non –rapid eye movement.
 There are five different stages of sleep including both REM (rapid eye movement) and NREM (non-
rapid eye movement) sleep. The five stages make one sleep cycle which usually repeat every 90 to 110
minutes.
 Stage 1 non-REM sleep marks the transition from wakefulness to sleep. This stage typically lasts less
than 10 minutes and is marked by a slowing of your heartbeat, breathing, and eye movements , as
well as the relaxation of your muscles.
 The brain transitions from alpha waves (having a frequency of 8 to 13 Hz, common to people who
are awake) to theta waves (with a frequency of 4 to 7 Hz). This stage is sometimes referred to as
somnolence, or ‘drowsy sleep`. Sudden twitches and hypnic jerks also known as positive
myoclonus are associated with this stage. Some people may also experience hypnagogic
hallucinations which can be troublesome to them. The subject loses some muscle tone and most
conscious awareness of the external environment.

3.  Stage 2 non-REM sleep is a period of light sleep before you enter deeper sleep, lasts
roughly 20 minutes. Stage two is characterized by further slowing of both the
heartbeat and breathing, and the brain begins to produce bursts of rapid, rhythmic
brain wave activity known as sleep spindles.
 Is characterized by `sleep spindles’ (12 to 16 Hz) and ‘K-complexes`. During
this stage, muscular activity as measured by electromyogram (EMG)
decreases and conscious awareness of the external environment disappears.
This stage occupies 45 to 55% of total sleep in adults.
 Stage N3- Deep or slow-wave sleep, is characterized by delta waves,(0.5 to
4Hz), also called the delta rhythms. This is the stage in which such
parasomnias as night terrors, bedwetting, sleepwalking and sleep-talking
occur. This is the deepest period of sleep and lasts 20 to 40 minutes. Your heartbeat
and breathing slow to their lowest levels, and your muscles are so relaxed that it may
be hard to awaken you.

4.  REM sleep occurs 90 minutes after sleep onset, and is a much deeper sleep than any of the three
stages of non-REM sleep. REM sleep is defined by rapid eye movements and an almost complete
paralysis of the body, and a tendency to dream.
 .Characteristics of REM sleep:
1. Muscle atonia- a state in which the motor neurons are not stimulated and thus the body’s
muscles don’t move.
2. Heart rate and breathing rate are irregular during this sleep which is similar to waking
hours.
3. Body temperature is not well regulated.
4. Erections of the penis.
5. Clitoral enlargement, with accompanying vaginal blood flow and transudation
(lubrication).

5. 1. Dyssomnias- A broad category of sleep disorders characterized by
either hyper somnolence or insomnia. The three major subcategories include
intrinsic (arising from the body), extrinsic (secondary to environmental
conditions or various pathologic conditions), and disturbance of circadian
rhythm.
2. Parasomnias.
3. Medical or psychiatric conditions that may produce sleep disorders.
4. Sleeping sickness- A parasitic disease which can be transmitted by Tsetse
fly.
5. Snoring- Not a disorder in and of itself, but it can be a symptom of deeper
problems.
6. Sudden infant death syndrome.

6. • Physical disturbances (for example, chronic pain from arthritis, headaches, fibromyalgia)
• Medical issues (for example, sleep apnea)
• Psychiatric disorders (for example, depression and anxiety disorders)
• Environmental issues (for example, it's too bright, your partner snores)
• Genetics: Researchers have found a genetic basis for narcolepsy, a neurological disorder of sleep
regulation that affects the control of sleep and wakefulness.
• Night shift work: People who work at night often experience sleep disorders, because they cannot
sleep when they start to feel drowsy. Their activities run contrary to their biological clocks.
• Medications: Many drugs can interfere with sleep, such as certain antidepressants, blood
pressure medication, and over-the-counter cold medicine.
• Aging: About half of all adults over the age of 65 have some sort of sleep disorder. It is not clear if it
is a normal part of aging or a result of medications that older people commonly use.

7.  Insomnia is the disturbance of normal sleep pattern and characterized by
an insufficient quantity or quality of sleep.
 A type of dyssomnia.

8. A. A predominant complaint of dissatisfaction with sleep quantity or
quality, associated with one (or more) of the following symptoms:
1. Difficulty initiating sleep. (In children, this may manifest as difficulty
initiating sleep without caregiver intervention.)
2. Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings. (In children, this may manifes as
difficulty returning to sleep without caregiver intervention.)
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or
impairment in social, occupational, educational, academic, behavioral, or
other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.

9. D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively
during the course of another sleep-wake disorder

10. 1. Sleep hygiene education: a moderate intake of easily digested warm food; a
comfortable bed; avoid caffeine, nicotine, alcohol, and excessive fluid intake
in the evening; keep a regular sleep schedule and regular daytime
exercise; limit time in bed; and remove clock from bedroom to avoid
excessive monitoring.
2. Sleep restriction therapy: the patient should keep a sleep log that records
the total sleep duration, bedtime, and wake-up time. The time allowed
in bed is reduced to the total sleep duration and the patient is advised to
increase the time in bed by 15 min on a weekly basis by adjusting the
bedtime.
3. Stimulus control therapy: arise at the same time every morning, avoid
daytime napping, go to bed only when sleepy, use the bed only for sleep,
leave the bed when unable to sleep, and reduce lighting and level of
noise in bedroom.

11. 4. Cognitive therapy aims at correcting cognitive distortions (e.g. being catastrophic
after insomnia) and unrealistic expectations (e.g. must have 10 h uninterrupted
sleep).
5. Behaviour therapy: progressive muscle relaxation techniques for any
associated anxiety.
6. consider nonbenzodiazepine hypnotic agents such as
a. Antihistamines: hydroxyzine.
b. Melatonin receptor agonists: agomelatine and ramelteon.
c. Sedating antidepressants: amitriptyline, mirtazapine, and trazodone.
d. Antipsychotics: low-dose quetiapine.
e. Melatonin: the Maudsley guidelines recommend the use of melatonin for the
treatment of insomnia in children and adolescents.

12. 7. Benzodiazepines are only indicated for short-term use (<4 weeks).
Benzodiazepine hypnotic agents include
a. Benzodiazepines: temazepam, oxazepam, lorazepam, and diazepam
b. Benzodiazepine receptor agonists: zaleplon, zolpidem, and zopiclone.
8. Diet that contain tryptophan such as banana, warm milk, oatmeal ,fish.
These stimulate melatonin production.
9. Bright light therapy uses artificial light to simulate the effects of sunlight on
the body’s circadian rhythms. It is generally used to treat people who have
circadian rhythm sleep disorders or sleep problems associated with jet lag or
shift work.
10. Aromatherapy involves the use of certain scents from herbs, usually
distilled into essential oils.

13. 11. Acupuncture involves the insertion of very fine needles into the body at
specific points. It can have a calming effect on your nervous system and also
stimulates the production of brain chemicals, including serotonin, which
promote sleep.

14.  is a chronic neurological disorder that affects the brain’s ability to control
sleep-wake cycles.
 Onset: first symptom is almost always daytime sleepiness and occurs during
adolescence.
 Characterized by 5 major symptoms.
 Common psychiatric comorbidity: depression, anxiety, substance misuse,
and parasomnia.

15.  Hypersomnia: sleepiness in between sleep attacks.
 Sleep attacks: two to five episodes of sleep attacks per day. Sleep attacks
are irresistible and last for 10–20 min with dreaming. The attacks cause
functional impairments.
 Cataplexy (70%): sudden loss of muscle tone with consciousness lasting for a
few seconds to minutes. The hypotonia causes spontaneous grimaces
and jaw opening with tongue thrusting. Eye and respiratory muscles
are spared. Cataplexy can be precipitated by laughter. Cataplexy
increases the risk of fall and accident.
 Hypnagogic hallucinations (20%–40%): usually visual hallucinations or
dreamlike imagery. Hypnopompic hallucinations are less common than
hypnagogic hallucinations.

16.  Sleep paralysis: mainly affecting ability to speak and movement of four
limbs. Diaphragm is spared in sleep paralysis.

17. A. Recurrent periods of an irrepressible need to sleep, lapsing into
sleep, or napping occurring within the same day. These must have been
occurring at least three times per week over the past 3 months.
B. The presence of at least one of the following:
1. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few
times per month:
a. In individuals with long-standing disease, brief (seconds to minutes)
episodes of sudden bilateral loss of muscle tone with maintained
consciousness that are precipitated by laughter or joking.
b. In children or in individuals within 6 months of onset, spontaneous
grimaces or jaw-opening episodes with tongue thrusting or a global
hypotonia, without any obvious emotional triggers.

18. 2. Hypocretin deficiency, as measured using cerebrospinal fluid (CSF)
hypocretin-1 immunoreactivity values (less than or equal to one-third of
values obtained in healthy subjects tested using the same assay, or less than
or equal to 110 pg/mL). Low CSF levels of hypocretin-1 must not be observed
in the context of acute brain injury, inflammation, or infection.
3. Nocturnal sleep polysomnography showing rapid eye movement (REM) sleep
latency less than or equal to 15 minutes, or a multiple sleep latency
test showing a mean sleep latency less than or equal to 8 minutes and
two or more sleep-onset REM periods

19.  Lifestyle modifications- avoid triggers such as emotions.
 Scheduled napping.
 Stimulants such as methylphenidate.
 Antidepressants such as SSRIs e.g setraline.

20. A. Self-reported excessive sleepiness (hypersomnolence) despite a main
sleep period lasting at least 7 hours, with at least one of the following
symptoms:
1. Recurrent periods of sleep or lapses into sleep within the same day.
2. A prolonged main sleep episode of more than 9 hours per day that
is nonrestorative (i.e., unrefreshing).
3. Difficulty being fully awake after abrupt awakening.
B. The hypersomnolence occurs at least three times per week, for at
least 3 months.
C. The hypersomnolence is accompanied by significant distress or
impairment in cognitive, social, occupational, or other important areas of
functioning.

21. D. The hypersomnolence is not better explained by and does not occur
exclusively during the course of another sleep disorder (e.g., narcolepsy,
breathing-related sleep disorder, circadian rhythm sleep-wake disorder, or a
parasomnia).
E. The hypersomnolence is not attributable to the physiological effects of
a substance (e.g., a drug of abuse, a medication).
F. Coexisting mental and medical disorders do not adequately explain
the predominant complaint of hypersomnolence.

22.  Parasomnias are a partial arousal meaning that a person exhibits symptoms
of being both asleep and awake at the same time. It involves abnormal
movements, behaviors’, emotions, perceptions, dreams. It occurs while falling
asleep, during rapid eye sleep or non rapid eye movement (slow wave sleep)
stages of sleep, or arousal from sleep.
 They include;

23. A) Nightmares: Also called dream anxiety attacks. These vivid events happen
when a person is awakened suddenly from REM sleep by a long frightening
dream that is causing fear or anxiety. They are also associated with
tachycardia, tachypnea, diaphoresis and arousal. It can occur at any time of
the night.
B) Sleep terror disorder; also known as night terrors. It is the most disruptive
arousal disorder that primarily occurs during stages 3 and 4 of non rapid eye
movement sleep. This occurs when a person is suddenly awakened and feels
terrified and confused with intense anxiety. It may also involve loud screams
and extreme panic during sleep followed by motor activities which such as
hitting object or moving in and out of the bedroom. It usually within the first
hours of sleep and only lasts for 15 minutes and then the person returns to
sleep. It’s especially common in children. Most people who experience sleep
terrors don’t remember the event the following morning (amnesia after the
episode)

24. C) Sleep walking; it is also called somnambulism. It arises from slow wave stages of
NREM sleep. It occurs when a person moves around, wanders aimlessly carrying
objects, going outdoors while they are sleeping.
d) Sleep bruxism; also called teeth grinding. It is a common disorder where the
sufferers grind their teeth during sleep. It primarily occurs in stages 1 and 2
or during partial arousal or transitions .This disorder leads to sleep disruption
to the sufferer and the bed partner, wear and fracture of teeth and jaw pain.
Treatment consists of bite plates to prevent dental damage.
e) Sleep talking; Also known as somniloquy. It refers to talking aloud in ones sleep.
It can be quite loud, ranging from simple sounds to long speeches and can occur
many times during sleep.
It usually occurs during transitory arousals from NREM sleep, which is when the
body does not move smoothly from one sleep stage in NREM sleep to another. It
can also occur during REM sleep.

25. F) Sleep paralysis; It occurs when the brain awakes from the REM state but the
body paralysis persists. This leaves the person fully conscious but unable to
move any body part, and has only minimal control over blinking, breathing and
very rarely movement of the jaw. It occurs after waking up or shortly before
falling asleep the state may be accompanied by terrifying hallucinations
and acute sense of danger.
G) Rem sleep behavior disorder; it is a chronic and progressive disease,
common in elderly men.
It involves loss of muscle atonia during the REM sleep with emergence of
complex and violent behaviors hence potential for serious injury, bruises,
lacerations and fractures.

26. H) Confusional arousals, it involves waking during a very deep stage of
sleep. They are occasional thrashings or inconsolable crying among
children and are characterized by movements in bed. Are not common in
adults.
I) Restless leg syndrome: is a disorder in which the sufferers reports
itching, burning, or otherwise uncomfortable sensations in their legs usually
exuberated when resting or asleep. This causes sleep disruption as they wake
to move or scratch their legs. It is relieved by movement. Benzodiazepines e.g.
clonazepam are the treatment of choice, in severe cases levodopa or
uploads may be used.
J) Rhythmic movement disorder; Rhythmic head or body rocking just before or
during sleep and may extend into light sleep. It is usually limited in childhood
and observed in period before sleep. No treatments required in most infants
and young children. Crib padding or helmets may be used. Behaviour
modification, benzodiazepines and tricyclic antidepressants may be effective.

27. k) Sleep enuresis; It is also called bedwetting. It occurs when a person urinates
by accident in his or her sleep. It results from failure to wake up from sleep
when the bladder is full or failure to prevent bladder contraction. Bedwetting is
not a sleep disorder unless it occurs at least twice a week in a person at least
five years of age.

28. Obstructive Sleep Apnea Hypopnea
Central apnea.

29. A. Either (1) or (2):
1. Evidence by polysomnography of at least five obstructive apneas or
hypopneas per hour of sleep and either of the following sleep symptoms:
a. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing
pauses during sleep.
b. Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient
opportunities to sleep that is not better explained by another mental
disorder (including a sleep disorder) and is not attributable to another
medical condition.
2. Evidence by polysomnography of 15 or more obstructive apneas
and/or hypopneas per hour of sleep regardless of accompanying symptoms.

30. A. Evidence by polysomnography of five or more central apneas per hour of
sleep.
B. The disorder is not better explained by another current sleep disorder.

31. (1) behavior modification aimed at improving sleep hygiene and avoiding additional sleep deprivation.
(2) avoidance of supine positioning during sleep
(3) avoidance of ethanol and sedative medications.
(4) Appropriate weight management strategies and compliance with positive airway
support.
(5) Surgical treatment options for breathing-related sleep disorders include (1)
procedures designed to increase upper airway size, (2) procedures designed to
bypass the upper airway, and (3) procedures that ensure weight loss.