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The degree of sleep can be detected by using electroencephalography (EG) that record the
brains net electrical activity. Two distinct sleep states have been identified according to the
patter of ECG, namely non-rapid eye movement (NREM) and rapid eye movement (REM)
sleep. NREM is further divided into four stages while the REM sleep typically precedes
them.
1.2 NREM, REM sleep and circadian sleep-wake rhythms
NREM is divided into four stages. Stage 1 account for 4-16% of total overnight sleep and the
EEG reading shows a waves at 4-7Hz. It occurs at the onset of sleep or when aroused from
another stage of sleep where sudden twitches or hypnagogic jerks may develop during the
sleep onset and there is a gradual loss of some muscle tone and consciousness. Stage 2
contribute to 45-55% of overnight sleep and high-frequency bursts (sleep spindles) is shown
on the EEG. There is a complete loss of muscle tone and awareness to the surrounding.
The combination of stage 3 and stage 4 is called delta sleep or slow-wave. Stage 3 occupied
4-6% of total sleep while stage 4 comprised of 12-15% of sleep. Stage 4 has the slowest
activity on the EEG (0.5-4Hz) and is the deepest stage of sleep. Parasomnias such as night
terrors, bed wetting and sleep walking occurred at this stage.
In contrast, REM sleep confer to a quarter of normal sleep time in healthy adults. Although
the EEG pattern of REM sleep is similar to the awake state, there is a complete loss of muscle
tone except for spontaneous movements of the extraocular and middle ear muscles. Besides,
heart rate, blood pressure, respiratory rate and temperature homeostasis have all become
irregular. People who are awoken from REM sleep complaint that they are dreaming but the
content of dream is quickly forgotten.
Generally, the sleep cycles of a typical night begins with the NREM sleep for 80 minutes,
subsequently followed by REM sleep for a future 10 minutes. As the night progresses, NREM
sleep tends to shorten while REM stage begin to lengthen. The total sleep time is different
among individuals, however, it is between 5 to 9 hours. Suprachiasmatic nucleus (SCN) in
the anterior hypothalamus is responsible for the timing of sleep, affected by the light,
exercise, work schedules and social interactions. It also controls the temperature and the
release of growth hormone and cortisol which is links into the sleep-wake cycle. In addition,
pineal gland secretes melatonin into the blood during darkness. Melatonin crosses the bloodbrain barrier to act upon the SCN, thereby linking the light-dark and sleep-wake cycles.
Long-term consequences
Decreased cognitive function
Memory loss
Reduced immune system function
Growth suppression
Increased risk of type 2 diabetes, heart
disease and obesity
A more complex classification system may refer to the DSM-IV and ICD-10. Owing to the
confusing terminology between these two systems, the international classification of sleep
disorder (ICSD-2) had been developed as the third classification system. All these system are
summarised in figure 1. Recently, DSM-V has come out with the latest classification of sleepwake disorders, where it comprises of 10 disorders.
Insomnia disorder
Hypersomnolence disorder
Narcolepsy
Breathing-related sleep disorders
Circadian rhythm sleep-wake disorders
A brief paralysis or inability to move on waking or while falling asleep due to intrusion of
REM atonia into wakefulness. This occasionally occurs in people without narcolepsy.
Other sign and symptoms are
e)
f)
g)
h)
i)
Sleep talking
Frequent awakenings whilst asleep
Nightmare (often violent and terrifying), night terrors, and sleep walking
There is an association with obesity
Secondary depression, anxiety and underachievement at school or work
applied to reduce tolerance or loss of drug efficacy. Besides, scheduled naps may
be used as stimulant dose replacements.
REM sleep-suppressing drugs such as tricyclic antidepressants (clomipramine,
imipramine,protriptyline) or SSRI (venlafaxine, fluoxetine) are used to improve
cataplexy condition because cataplexy is presumably an intrusion of REM sleep
phenomena into the awake state.
Sodium oxybate is also used to improve cataplexy
Careful monitoring of drug refills, general health and cardiac status.