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BIOLOGICAL RHYTHMS
Marga. M. Maramis, dr., SpKJ(K)
Bag./SMF Psikiatri
FK UNAIR/RSU DR. SOETOMO
SURABAYA
2014
Sleep Disorders
Dyssomnia: Sleep disorders are a group of
conditions characterized by disturbance in the
amount, quality, or timing of a person's sleep
hypersomnia, insomnia, narcolepsy, breathingrelated sleep disorder, circadian rhythm sleep
disorder, RLS (Restless Leg Syndrome), PLMD
(Periodic Limb Movement Disorder)
Parasomnia: nightmare, sleep terror, sleep
walking, sleep talking, nocturnal enuresis
Dissomnia
Dissomnia
Gangguan tidur yang menyebabkan penderita
sulit untuk memulai tidur, mudah terbangun,
menyebabkan kantuk yang berlebihan
Terdiri atas: insomnia, hipersomnia, apnea tidur,
narkolepsi, sindroma kaki gelisah, gangguan gerak
anggota badan yang berkala, sindroma fase tidur
lanjut atau tertunda
Insomnia
Sleep deprivation is like food deprivation
Sleep disorders can have a significant
impact on our quality of life and also affect
the way we feel while we are awake
Affect 9-25% population
Short sleeper and long sleeper
Secondary insomnia: is a symptom not a
disease
Insomnia
One or more of the following despite adequate opportunity to
sleep:
- difficulty initiating sleep
- difficulty maintaining sleep
- waking up too early
- nonrestorative or poor quality of sleep
Plus one or more daytime impairment:
- fatigue, malaise, lack of energy, motivation or initiative
- daytime sleepiness
- attention, concentration, memory impairment
- prone to errors or accident at work or while driving
- mood disturbance, irritability, worries about sleep
- physical symptoms due to sleep loss (e.g. tension headache)
Stahl 2008
70
60
48%
50
40
42%
35%
30
20
10
0
None
One
Two or
three
Four or
more
Concentration
Attention
Problem
Solving/Coping
problems
Cant complete task
Reaction Time
Quality of Life
CIRCADIAN FACTORS
Jet lag
Shift work
Sleep scheduling
PSYCHIATRIC
FACTORS
Depression and other
disorder
Medication
MEDICATIONS,
DRUG, ALCOHOL
Acute effects
Tolerance
Withdrawal
Primary Insomnia
Restless Leg
Parasomnia
Periodic Limb Movement Disorder
Excessive Daytime Sleepiness
PSYCHOPHYSIOLOGIC/
CONDITIONING/FACTORS
Psychological factors
Physiologic tension,
arousal
Negative conditioning
Performance
Cognitive function
memory
Quality of life
TRIGGER
FACTOR OF
EXISTING
PSYCHIATRIC
INSOMNIA
OBESITAS
MEDICAL AND
CARDIO
NEUROLOGIC
VASCULAR
OTHER FACTOR
ILLNESS
Snoring
ABNORMALITY
Nonspecific factors
Sleep apnea
Specific factors
Medication
Modified from Carney PR, Berry RB, Geyer JD. Clinical Sleep disorders.
Lippincott William & Wilkins. 2005
The Reality
We spend at least 1/3 of our lives on sleep
Sleep less than 4 or greater than 10 hours per night are
statistically more likely to have a diminished life
expectancy
Sleep is a behavior
Because we remember very little about what happens
while we sleep, we tend to think of sleep more as a state
of consciousness than as behavior
The characterizes sleep is that the insistent urge of
sleepiness
Cant sleep 5 to 10 days: irrational, confused, paranoid,
halusination
Adolescent
Adult
Elderly
Yawning
Normal and physiological behavior
3 month after conception
Some animal (crocodile, fish, bird, snake) also
yawning
It happens 6 seconds
Psychotic patiens seldom yawning
Can become a sign of brain damage (epilepsi,
etc.), brain tumor, bleeding, motion sickness,
withdrawal of drugs, brain infection
Sleep Apnea
Fall asleep and cease to breathe
Especially people who snore
During sleep apnea, the level of carbon dioxide in the
blood stimulates chemoreceptors and the person wake up,
gasping for air; The oxygen level of the blood returns to
normal and the person fall asleep
Most cases caused by an obstruction of the airway that can
be corrected surgically or relieved by a device that attached
to the sleepers face and provides pressurized air that keeps
the airway open
Narcolepsy
Sleep paralysis
A symptom of narcolepsy
REM sleep paralysis
Inability to move just before the onset of sleep or upon
waking in the morning when a person is already lying
down
The mental components of REM sleep intrude into sleep
paralysis: the person dream while lying awake, paralyzed:
hypnagogic hallucinations: when falling asleep
Hypnopompic hallucinations: when waking up
REM sleep phenomena: cataplexy, sleep paralysis,
hypnagogic hallucinations can be alleviated by
antidepressant drugs which facilitate serotonin and
noradrenergic activity
Cataplexy
Cataplexy (jata = down, plexis = stroke), a person will
suddenly wilt and fall like a sack of flour, the person will lie
with fully conscious for a few seconds to several minutes
Phenomena of REM sleep, muscular paralysis occurs at an
appropriate time; this loss of tonus is caused by massive
inhibition of motor neurons in the spinal cord
Cataplexy is usually precipitated by strong emotion or by
sudden physical effort, especially if the patient is caught
unawares;
Laughter, anger, an effort to catch a suddenly thrown object
can trigger a cataplectic attack
People who do not have cataplexy, sometimes lose muscle
strength after a bout of intense laughter
Parasomnia
Parasomnia
Tidak berkaitan dengan proses tidur sendiri
Gangguannya meliputi:
- gangguan tingkah laku tidur REM
- teror tidur
- somnambulism
- ngompol saat tidur
- bruxism
- sindroma kematian bayi mendadak (Sudden Infant Death
Syndrome = SIDS):1-2 dari 1000 kelahiran hidup, bayi
umur 10-12 minggu, Eskimo dan kulit hitam risiko lebih
besar, etiologi tak diketahui
Problem Associated
with Slow-wave Sleep
Some maladaptive behaviors occur during slow-wave
sleep, especially during the deepest phase stage 4
Nocturnal enuresis, somnambulism, pavor nocturnus =
night terrors (anguished screams, trembling, a rapid pulse,
usually no memory of what caused the terror)
No related to REM sleep
No associated with mental disorders or personality
variables
The best treatment for somnambulism and pavor nocturnus
is no treatment at all
Circadian Rhythm
BIOLOGICAL CLOCKS:
THE SUPRACHIASMATIC
NUCLEUS
Primary biological clock located in the
suprachiasmatic nucleus (SCN) of the
hypothalamus
Control over the timing of sleep cycles
Lesions in SCN disrupt circadian pattern but dont
affect the total amount of sleep
Photochemical named melanopsin in the retina
responsible for synchronization of diurnal rhythms
SCN in Hypothalamus
Pineal body
Grow
horm th
one
Body
temperature
Pla
sm
a co
rtis
ol
Melatonin
Melatonin
Secreted by the
pineal gland
Miyamoto. Sleep, 2003; Roth. Sleep, 2005; Rozerem (ramelteon) data sheet, 2005.
Behavioral Therapy
Sleep hygiene
Use bedroom only for sleep
Wake up at same time every day
Avoid caffeine, alcohol, and exercise before bed
Avoid naps
Stimulus control therapy
Reassociate bed with sleep
Leave bedroom if unable to sleep within 20 minutes
Return only when very sleepy
Others:
Relaxation therapy, hypnotherapy
Paradoxical intention therapy
Sleep restriction therapy
Morin and Espie. Insomnia: A Clinicians Guide to Assessment and Treatment.
2003; Bootzin and Perlis. J Clin Psychiatry. 1992; Spielman et al. Sleep 1987.
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