Specific Objectives

❏ Identify the normal sleep cycles

❏ Describe EEG, ENG, and physiologic phenomenon associated with each stage
of sleep
❏ Categorize different sleep disorders and describe what is known about their causes

NORMAL SLEEP
Sleep is divided into 2 stages: nonrapid eye movement (NREM) and rapid eye movement
(REM). There are numerous differences between them.

NREM
NREM is a state of sleep characterized by slowing of the EEG rhythms, high muscle tone,
absence of eye movements, and thoughtlike mental activity. The brain is inactive while the
body is active. NREM is made up of 4 stages.

Table I-15-1. NREM

Stage EEG Findings Distribution
Stage 1 Disappearance of alpha wave and appearance of theta wave 5%
Stage 2 K-complexes and sleep spindles 45%
Stage 3 Appearance of delta wave 12%
Stage 4 Continuation of delta wave 13%
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REM
REM is a stage of sleep characterized by aroused EEG patterns, sexual arousal, saccadic eye
movements, generalized muscular atony (except middle-ear and eye muscles), and dreams. The
brain is active and the body is inactive.

Table I-15-2. REM

Stage EEG Findings Distribution
REM Bursts of sawtooth waves 25%

Sleep Facts
Table I-15-3. Sleep Facts (Stage 2–REM)
Stage Fact(s)
Stage 2 Longest of all the sleep stages
Stages 3 and 4 Also called slow wave or delta sleep
Hardest to arouse
Tends to vanish in the elderly
REM Easiest to arouse
Lengthens in time as night progresses
Increased during the second half of the night

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Awake

Stage 1
& REM

Stage 2
Stage 1 sleep and REM sleep (gray) are graphed
on the same level because their EEG patterns are
very similar.
.
Delta

1 2 3 4 5 6 7 8
Hours

A wake-low voltage-random fast-beta waves

fast

low
Drowsy-8 to 12 cps-alpha waves

Stage 1-3 to 7 cps theta waves

theta waves

Stage 2-12 to 14 cps-sleep spindles and K- complexes

sleep spindles K-complexes

Delta sleep-1/2 to 2 cps-delta waves>75

REM sleep-low voltage-random, fast with sawtooth waves

sawtooth waves

Figure I-15-1. Sleep Architecture Diagram Showing Stages of Sleep in Sequence

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Sleep Latency. The time needed before you actually fall asleep. Typically less than 15 minutes
in most individuals; however, may be abnormal in many disorders, such as insomnia, etc.

REM Latency. The period lasting from the moment you fall asleep to the first REM period.
Lasts approximately 90 minutes in most individuals. However, several disorders will shorten
REM latency; these disorders include depression and narcolepsy.

Characteristics of Sleep from Infancy to Old Age

• Total sleep time decreases.
• REM percentage decreases.
• Stages 3 and 4 tend to vanish.

Neurotransmitters of Sleep
• Serotonin: increased during sleep; initiates sleep
• Acetylcholine: increased during sleep; linked to REM sleep
• Norepinephrine: decreased during sleep; linked to REM sleep
• Dopamine: increased toward end of sleep; linked to arousal and wakefulness

Chemical Effects on Sleep

• Tryptophan: increases total sleep time
• Dopamine agonists: produce arousal
• Dopamine antagonists: decrease arousal, thus produce sleep
• Benzodiazepines: suppress Stage 4 and, when used chronically, increase sleep latency
• Alcohol intoxication: suppresses REM
• Barbiturate intoxication: suppresses REM
• Alcohol withdrawal: REM rebound
• Barbiturate withdrawal: REM rebound
• Major depression: shortened REM latency, increased REM time, suppression of delta,
multiple awakenings, and early morning awakening

SLEEP DISORDERS
Narcolepsy
A 35-year-old man was recently hospitalized for the tenth time after he crashed his
car into a post. When questioned, he did not remember the cause of the accident and
had just had his license suspended. His friends reported occasions when he fell
asleep during dinner and during conversations with them.

Definition. A disorder characterized by excessive daytime sleepiness and abnormalities of

REM sleep for a period of greater than 3 months. REM sleep occurs in less than 10 minutes.
Patients feel refreshed upon awakening.

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Physical and Psychiatric Presenting Symptoms

• Sleep attacks: most common symptom
• Cataplexy: Pathognomonic sign, consisting of a sudden loss of muscle tone that may
have been precipitated by a loud noise or intense emotion. If short episode, the patient
remains awake.
• Hypnagogic and hypnopompic hallucinations: Hallucinations that occur as the
patient is going to sleep and is waking up from sleep, respectively.
• Sleep paralysis: Most often occurs during awakening, when the patient is awake but
unable to move.
• Report falling asleep quickly at night

Treatment. Forced naps at a regular time of day are usually the treatment of choice. When
medications are given, psychostimulants are preferred. If cataplexy is present, antidepressants
such as TCAs are preferred. Gamma-hydroxybutyrate (GHB) is also used for narcolepsy–
cataplexy by improving the quality of nighttime sleep.

Sleep Apnea
An overweight man reports having difficulties in his marriage because of his snoring
at night. During the day, he reports feeling tired despite sleeping for 8 hours at night.

Definition. A disorder characterized by the cessation of airflow at the nose or mouth dur-
ing sleep. These apneic episodes usually last longer than 10 seconds each. Characterized by
a loud snore followed by a heavy pause. Considered pathologic if the patient has more than
5 episodes an hour or more than 30 episodes during the night. In severe cases, patients may
experience more than 300 apneic episodes during the night.

Physical and Psychiatric Presenting Symptoms

• Usually seen in obese, middle-aged males
• Sometimes associated with depression, mood changes, and daytime sleepiness
• Spouses typically complain of partner’s snoring, and of partner’s restlessness during
the night
• Complain of dry mouth in the morning
• May have headaches in the morning
• Complain of being tired during the day
• May develop arrhythmias, hypoxemia, pulmonary hypertension, and sudden death

Types of Sleep Apnea

• Obstructive: muscle atonia in oropharynx; nasal, tongue, or tonsil obstruction
• Central: lack of respiratory effort
• Mixed: central at first, but prolonged due to collapse of the airway

Treatment. Continuous positive nasal airway pressure is the treatment of choice. Other
treatment includes weight loss, surgery. Sleeping on one’s side instead of one’s back will help
keep the airways open.

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Insomnia
While studying over the past week for an important exam, Michael, a third-year
medical student, has been unable to sleep for the past several days. At night, he lies
awake and imagines himself doing poorly on the exam and failing medical school.
During the day, he is tired and frequently falls asleep during his classes.

Definition. A disorder characterized by difficulties in initiating or maintaining sleep

Risk Factors/Epidemiology. Typically associated with some form of anxiety or anticipatory

anxiety. Many patients have underlying psychiatric disorders, such as depression, etc. If due to
a psychiatric disorder, seen more frequently in women. Other conditions include PTSD, OCD,
and eating disorders.

Physical and Psychiatric Presenting Symptoms

• Predominant complaint is difficulty initiating or maintaining sleep
• Affects the patient’s level of functioning
• Frequent yawning and tiredness during the day

Treatment. Consider good sleep hygiene techniques, such as arising at same time of the day,
avoiding daytime naps, avoiding evening stimulation, discontinuing CNS-acting drugs, taking
hot baths near bedtime, eating meals at regular times, using relaxation techniques, and
maintaining comfortable sleeping conditions. If these do not work, consider behavioral
modification techniques such as stimulus control. If medications are to be used, consider
zolpidem, eszopiclone, or zaleplon.

Differential Diagnosis
• Medical: pain, CNS lesions, endocrine diseases, aging, brain-stem lesions, alcohol, diet,
medications
• Psychiatric: anxiety, tension, depression, and environmental changes, other sleep disorders

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Parasomnias
Table I-15-4. Parasomnias
Disorder Sleep Stage Characteristics Treatment

Nightmares REM • Memory of the event upon • Usually none

(dream awakening indicated, but may
anxiety • Increases during times of use REM
disorder) stress suppressants such as
TCAs
• Reported by 50% of the
population

Night terrors Stages 3 and • Awakened by scream or • Treatment rarely

(sleep terror 4 intense anxiety required
disorder) • No memory of the event the • If medication is
following day needed, consider
• Seen more frequently in benzodiazepines
children
• More common in boys
• Runs in families

Sleeptalking All stages of • Common in children • No treatment is

sleep • Usually involves a few necessary
words
• May accompany night
terrors and sleepwalking

Sleepwalking Stage 3 and 4 • Sequence of behaviors • Need to assure

without full consciousness patient safety
• May perform perseverative • Use medication such
behaviors as benzodiazepines
• Usually terminates in to suppress stages 3
awakening followed by and 4
confusion
• May return to sleep without
any memory of the event
• Begins at a young age
• More common in boys
• May find neurologic
condition
• Sleep deprivation may
exacerbate

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Practice Questions

1. An overweight man of average height presents to his doctor’s office complaining of feeling tired
during the day. He has missed several days of work due to this problem. Which of the following is
the most likely diagnosis?
(A) Narcolepsy
(B) Insomnia
(C) Sleep apnea
(D) Normal sleep pattern
(E) Hypersomnia

2. Which of the following is the most likely explanation for a young man suddenly falling down but
not losing consciousness?
(A) Syncope
(B) Cataplexy
(C) Sleep paralysis
(D) Medication toxicity
(E) Hypotensive episode

3. Which of the following is the treatment of choice for insomnia?

(A) Long-term use of benzodiazepines
(B) Behavioral techniques
(C) Drinking coffee before bedtime
(D) Regular exercises before bedtime
(E) Frequent naps during the day

1. Answer: C. Patients with sleep apnea have multiple episodes of waking up in the middle of the
night. Therefore, they are tired during the day. These patients are typically unaware that they wake
in the middle of the night.
2. Answer: B. Cataplexy is the sudden loss of muscle tone without loss of consciousness. It is
differentiated from syncope in that syncope typically includes loss of consciousness. Patients with
narcolepsy are usually young and do not have any blood pressure abnormalities.
3. Answer: B. Although benzodiazepines are regularly used for the treatment of insomnia, the best
treatment includes behavioral techniques such as stimulus control. The patient leaves the bed
whenever he is unable to fall asleep, therefore conditioning himself that the bed is only used for
sleeping. Choices C, D, and E will tend to cause insomnia.

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