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DOI: 10.5665/SLEEP.1112

Sleep Neurobiology from a Clinical Perspective

Rodrigo A. España, PhD1; Thomas E. Scammell, MD2
Department of Physiology and Pharmacology, Wake Forest University Health Sciences, Winston Salem, NC; 2Department of Neurology, Beth Israel

Deaconess Medical Center, Boston, MA

Many neurochemical systems interact to generate wakefulness and sleep. Wakefulness is promoted by neurons in the pons, midbrain, and pos-
terior hypothalamus that produce acetylcholine, norepinephrine, dopamine, serotonin, histamine, and orexin/hypocretin. Most of these ascending
arousal systems diffusely activate the cortex and other forebrain targets. NREM sleep is mainly driven by neurons in the preoptic area that inhibit
the ascending arousal systems, while REM sleep is regulated primarily by neurons in the pons, with additional influence arising in the hypothala-
mus. Mutual inhibition between these wake- and sleep-regulating regions likely helps generate full wakefulness and sleep with rapid transitions
between states. This up-to-date review of these systems should allow clinicians and researchers to better understand the effects of drugs, lesions,
and neurologic disease on sleep and wakefulness.
Keywords: Waking, arousal, locus coeruleus, tuberomammillary nucleus, dorsal raphe nucleus, thalamus, ventrolateral preoptic area
Citation: España RA; Scammell TE. Sleep neurobiology from a clinical perspective. SLEEP 2011;34(7):845-858.

INTRODUCTION of promoting arousal.3 Soon after the discovery of REM sleep

Sleep medicine physicians often encounter questions that re- in the mid-1950s, Jouvet and others established that this state
quire an understanding of the neurobiology of sleep: How do is driven by circuitry in the pons.4-6 Over the last few decades,
certain brain injuries produce coma or hypersomnolence? Why the latest generations of researchers and clinicians have built on
do antidepressants often reduce REM sleep? Why do people with these ideas and identified many distinct systems, each of which
narcolepsy have trouble staying awake? How do amphetamines contributes to specific aspects of sleep-wake behavior.
improve alertness and wakefulness? To help with these and simi-
lar questions, this paper provides an overview of the basic circuits The Reticular Formation
that control sleep and wakefulness. This paper has evolved from The reticular formation is a heterogeneous region that runs
one we wrote several years ago1 and has been updated to include through the core of the brainstem from the medulla up to the
many of the latest discoveries on the circuits and neurochemistry midbrain and into the posterior hypothalamus. Soon after Moru-
of sleep, more information on drugs that are used in clinical prac- zzi and Magoun showed that the rostral reticular formation can
tice, and some thoughts on medications that are now in clinical tri- activate the cortex, experimental lesions in animals and clini-
als. We hope this will provide the reader with useful perspectives cal observations in patients with strokes or tumors confirmed
on sleep disorders, how drugs influence sleep and wakefulness, that the rostral reticular formation is necessary for generating
and how injuries in different brain regions may affect sleep. wakefulness, as these injuries often produce hypersomnolence
Almost 100 years ago, clinicians and pioneer neuroscientists or coma.7,8 Thus, many researchers hypothesized that the re-
began to identify the general brain regions that regulate sleep ticular formation received inputs from a number of sensory
and wakefulness. After an epidemic of encephalitis lethargica systems and promoted wakefulness via excitatory projections
around 1915-1920, Baron Constantin von Economo found that to the thalamus, hypothalamus, and basal forebrain. More re-
patients with encephalitis of the posterior hypothalamus and cently, researchers have reconsidered the idea of a monolithic
rostral midbrain often had crushing sleepiness, whereas those reticular formation and instead attribute its functions to the
with injury to the preoptic area usually had severe insomnia.2 activity of specific systems that promote arousal using ace-
He thus hypothesized that the preoptic area and adjacent an- tylcholine, glutamate, or monoamine neurotransmitters (e.g.,
terior hypothalamus contained neurons that promoted sleep, norepinephrine, histamine, serotonin, and dopamine). These
whereas neurons in the posterior hypothalamus and rostral neurotransmitters are generally considered to produce arousal
midbrain promoted wakefulness. In the 1940s, Moruzzi and through widespread, often excitatory effects on target neurons.
Magoun found that stimulation of the rostral reticular forma- In addition, they can act as neuromodulators to enhance other
tion caused the EEG of an anesthetized animal to switch from excitatory or inhibitory inputs to these cells. This modulation
slow waves to the low-voltage desynchronized pattern typical can thus amplify neuronal signals over much of the brain to
of wakefulness, suggesting that this general region is capable recruit the many systems necessary for waking behaviors. Thus,
the term reticular formation is helpful anatomically, but more
insight can be gained from understanding the specific cells and
Submitted for publication February, 2011 pathways contained within this general region.
Submitted in final revised form March, 2011
Accepted for publication March, 2011 Wake-Promoting Neurochemical Systems
Address correspondence to: T. E. Scammell: Department of Neurology,
Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA Acetylcholine (ACh)
02215; Tel: (617)-735-3260; Fax: (617)-735-3252; E-mail: tscammel@ The basal forebrain (BF) and brainstem contain large groups of cholinergic neurons that promote wakefulness and REM
SLEEP, Vol. 34, No. 7, 2011 845 Sleep Neurobiology for the Clinician—España and Scammell
cholinergic neurons in the LDT/PPT are mainly active during
wakefulness and REM sleep, and promote cortical activation by
releasing ACh into the thalamus.17,18
Pharmacological studies that manipulate ACh neurotrans-
mission offer further evidence for its importance in the control
of sleep and wakefulness. ACh, nicotine, and muscarinic recep-
tor agonists such as pilocarpine produce desynchronized corti-
BF Thalamus cal activity and increases wakefulness.19,20 Similar effects occur
with physostigmine which blocks enzymatic degradation of
LDT ACh. In contrast, agents that reduce ACh signaling, including
(ACh) the muscarinic antagonists scopolamine and atropine, produce
Raphe immobility and EEG slow waves.21,22
(HA) (NE)
vPAG Norepinephrine (NE)
(DA) NE is produced by several brainstem nuclei and may help
generate arousal during conditions that require high attention
or activation of the sympathetic nervous system. The major
Figure 1—A variety of neurochemical systems promote arousal via source of NE to the forebrain is the locus coeruleus (LC), an
projections to the forebrain. Cortical and subcortical regions are excited elongated nucleus just beneath the floor of the fourth ventricle.
by monoaminergic neurotransmitters including norepinephrine (NE) from LC neurons fire most rapidly during wakefulness, are much less
the locus coeruleus (LC), serotonin (5-HT) from the dorsal and median active during NREM sleep, and are nearly silent during REM
raphe nuclei, histamine (HA) from the tuberomammillary nucleus (TMN); sleep.23,24 Extracellular levels of NE are linearly related to LC
and dopamine (DA) from the substantia nigra, ventral tegmental area,
neuronal activity, with the highest rates of release observed dur-
and ventral periaqueductal gray (SN/VTA/vPAG). Neurons of the basal
forebrain (BF) promote cortical activation using acetylcholine (ACh) ing wakefulness.25 NE is also made by neurons in the ventral
and γ-aminobutyric acid (GABA). Neurons in the laterodorsal and medulla that mediate autonomic responses, and though much
pedunculopontine tegmental nuclei (LDT/PPT) release ACh to excite less studied, these cells may also promote arousal.26
neurons in the thalamus, hypothalamus, and brainstem. Pharmacological studies provide some of the strongest evi-
dence that NE regulates wakefulness and sleep. For example,
infusion of NE or the noradrenergic agonists isoproterenol and
phenylephrine into the lateral ventricle or BF increases behav-
Table 1—Activity profiles of neurotransmitter systems across sleep/
ioral and EEG indices of wakefulness.27 LC neurons are nor-
mally inhibited by NE via α2 receptors, and blockade of this
Neurotransmitter Wakefulness NREM sleep REM sleep negative feedback with yohimbine increases LC activity and
Acetylcholine ↑↑ — ↑↑ also increases wakefulness.28,29 Conversely, bilateral inactiva-
Monoamines ↑↑ ↑ — tion of the LC with the α2-agonist clonidine, or co-administra-
Orexin/Hypocretin ↑↑ — — tion of both α1 and β noradrenergic antagonists (prazosin and
MCH — — ↑↑ timolol) increases NREM sleep.30,31
VLPO/MNPO — ↑↑ ↑↑ The NE system may be especially important in promoting
arousal under conditions that require responding to a behav-
Neuronal activity: ↑↑, rapid firing rate; ↑, slower firing rate; —, little or iorally important stimulus, a cognitive challenge, or stress. In
no firing. broad terms, an animal may be drowsy and inattentive if LC
activity is too low, distractible and anxious if LC activity is
too high, but optimally attentive and aroused with intermedi-
sleep and also participate in learning, memory, and cognition. ate levels of activity. NE tone is clearly linked to cognition as
The BF is a region surrounding the front of the hypothalamus LC neurons in monkeys fire phasically in response to a salient
that includes the medial septum, magnocellular preoptic nucle- stimulus that signals a reward such as food, but these cells do
us, diagonal band of Broca, and substantia innominata (Figure not respond to a distracting stimulus.32 Integrating these ideas,
1). Most BF cholinergic neurons are active during wakefulness Aston-Jones and colleagues have proposed that activity in the
and REM sleep, and they directly promote fast EEG rhythms LC may promote arousal in a way that optimizes attention and
via projections to the cortex and hippocampus (Table 1).9-12 The task performance.33 In addition, the LC and NE neurons in the
BF also contains a large population of neurons that produce the ventral medulla are active during stress.23,34 The necessity of
inhibitory neurotransmitter γ-aminobutyric acid (GABA), and this system is clear in mice lacking NE because after exposure
these likely activate the cortex by reducing activity in inhibitory to a mild stressor, they fall asleep more rapidly than control
cortical interneurons.13,14 mice.35 Similarly, rats with lesions of the LC show considerably
A second major group of cholinergic neurons is found in the less behavioral arousal and cortical activation when confronted
pons within the laterodorsal and pedunculopontine tegmental with novel stimuli.36 On the other hand, excessive NE tone with
nuclei (LDT/PPT). In contrast to the BF, LDT/PPT neurons anxiety might contribute to insomnia, and the α1 antagonist pra-
primarily project to subcortical regions including the thala- zosin can reduce the vivid nightmares and nighttime arousal of
mus, lateral hypothalamus, and BF.15,16 Like most BF neurons, PTSD.37
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Table 2—Effects of commonly used drugs on sleep and waking
Drug Type Examples Pharmacologic Effect Neurobiologic Mechanism Clinical Effects

Selective serotonin Fluoxetine Increase extracellular levels 5-HT inhibits REM sleep- Decreased REM sleep
reuptake inhibitors Fluvoxamine of 5-HT producing cells
(SSRIs) Citalopram

Tricyclic Amitriptyline Increase extracellular levels 5-HT and NE inhibit REM Decreased REM sleep
antidepressants Nortriptyline of 5-HT and NE sleep-producing cells

Traditional, Amphetamine Increase extracellular levels Increased DA and NE Increased wakefulness

amphetamine-like Dextroamphetamine of DA and NE signaling
stimulants Methylphenidate

Wake-promoting, non- Modafinil Increase extracellular levels Increased DA signaling Increased wakefulness
traditional stimulants Armodafinil of DA

Benzodiazepines Diazepam Enhance GABA signaling via GABA inhibits the arousal Increased sleep
Clonazepam GABAA receptors systems

Non-benzodiazepine Zolpidem Enhance GABA signaling via GABA inhibits the arousal Increased sleep
sedative hypnotics Zaleplon GABAA receptors systems

Classic antihistamines Diphenhydramine Block HA H1 receptors Reduced HA signaling Increased sleep


Typical antipsychotics Haloperidol Block DA receptors Reduced DA signaling Increased sleep


Histamine (HA) daytime sleepiness observed with narcolepsy.50-54 This wake-

HA plays an essential role in promoting wakefulness, yet promoting effect is likely mediated by increased HA tone as
little is known about which aspects of arousal it governs.38 The the response to an H3 antagonist is absent in mice lacking H1
tuberomammillary nucleus (TMN) is a small cluster of cells receptors.55
adjacent to the mammillary body at the base of the posterior Which aspects of arousal are mediated by the HA system
hypothalamus. Though few in number, these cells innervate remains unclear. HA improves attention and psychomotor per-
much of the forebrain and brainstem and are the sole source of formance,56 and it may promote motivated behaviors such as
HA in the brain. Similar to the pattern seen in the LC and other food seeking.57 In addition, mice lacking HA have less wake-
monoaminergic nuclei, TMN firing rates and HA release are fulness at the beginning of their active period,58 suggesting that
highest during wakefulness, lower during NREM sleep and HA may be especially important for initiating arousal. As sleep
lowest during REM sleep.39,40 Administration of HA or an H1- inertia upon awakening is common in many patients with id-
receptor agonist increases cortical activation and wakefulness iopathic hypersomnia, it is possible that low HA signaling is a
while reducing NREM and REM sleep.41,42 In contrast, drugs contributing factor.
that reduce HA signaling, including classical antihistamines,
such as the H1 receptor antagonists diphenhydramine, pyril- Serotonin (5-HT)
amine, and low dose doxepin increase NREM and REM sleep Understanding how 5-HT promotes arousal is challenging
(Table 2).41-46 because: there are many sources of 5-HT; 5-HT binds to at least
Over the last several years, a new class of wake-promoting 15 different receptors with varied effects, and 5-HT has been
drugs has been developed to target the autoinhibitory histamine shown to influence many other aspects of behavior including
H3 receptors.47,48 The clinical rationale for these agents appears mood, anxiety, aggression, and appetite. 5-HT is produced by
strong, as many people with narcolepsy or idiopathic hyper- neurons in the dorsal raphe nucleus and other raphe nuclei scat-
somnia have reduced HA levels,49 and blockade of H3 recep- tered along the midline of the brainstem, and together these
tors should increase HA signaling. For example, H3 antagonists neurons innervate many brain regions that can influence sleep/
(or reverse agonists) such as ciproxifan or tiprolisant promote wake behavior, including the preoptic area, basal forebrain, hy-
wakefulness and EEG desynchrony and improve the excessive pothalamus, and thalamus. Early studies suggested that 5-HT
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operidol or chlorpromazine or in patients with Parkinson’s dis-
DA DA terminal
ease who have a loss of DA-producing neurons.74-76 Additionally,
DAT D2 agonists like ropinirole can produce sleepiness via activation
DA receptor of autoinhibitory D2 receptors that reduce DA signaling.77,78
VMAT However, it is unclear which DA neurons actually promote
arousal. DA-producing neurons are most abundant in the sub-
stantia nigra and ventral tegmental area, yet cells in these re-
gions fire in relation to movement or reward but, in general,
have not been found to alter their rates of firing across sleep and
wakefulness.79-82 Nevertheless, extracellular levels of DA are
high during periods of wakefulness and lower during NREM
sleep, suggesting that some DA neurons must be wake-active.81
One candidate population sits in the ventral periaqueductal gray
of the pons, and lesions of these wake-active DA neurons pro-
duce moderate reductions in wakefulness.83 The conditions un-
der which these or other DA wake-promoting neurons fire are
unknown, but in general, DA may naturally promote arousal
when an individual is highly motivated or physically active.
Drugs that increase DA signaling are used frequently to im-
prove excessive daytime sleepiness. Classical stimulants such
as methylphenidate and amphetamine increase extracellular
levels of DA by disrupting the function of the DA transporter
Post-synaptic (DAT), thereby increasing extracellular levels of DA (Figure
2).84 These drugs are usually very effective, but because they
Figure 2—A prototypical dopamine synapse. Under normal conditions, enhance DA signaling in reward and motor pathways, they
action potentials in a DA nerve terminal cause DA-filled vesicles to fuse have high abuse potential and can elicit tics or other movement
with the presynaptic membrane, and DA is released into the synaptic cleft disorders. At higher doses, these stimulants can also block the
where it can bind to postsynaptic DA receptors. DA is removed from the reuptake of NE and 5-HT which can result in tachycardia, ar-
synaptic cleft primarily by the DA transporter (DAT). Once DA is back rhythmias, mania, and psychosis.
inside the presynaptic terminal, it is repackaged into synaptic vesicles Modafinil is frequently prescribed for treating the sleepiness
for future release via the vesicular monoamine transporter (VMAT).
of narcolepsy and some other disorders. Clinically, it promotes
Amphetamines increase the synaptic concentration of DA through two
main mechanisms: Amphetamines interfere with the reuptake of DA wakefulness effectively, usually with fewer side effects than
through the DAT, and they disrupt vesicular packaging of DA which encountered with classical stimulants. Like amphetamines,
increases cytosolic levels of DA which can then leak out through the DAT modafinil disrupts DAT function in humans and rodents,85,86
via reverse transport. and this is a necessary part of its wake-promoting mechanism,
as mice lacking the DAT show no increase in wakefulness
with modafinil,87 and D1 and D2 receptor antagonists can block
might help produce NREM and possibly REM sleep, but more modafinil-induced wakefulness.88 Still, if modafinil acts via the
recent work indicates 5-HT generally promotes wakefulness DAT, it seems surprising that it has less abuse potential than
and suppresses REM sleep. The firing rates of dorsal raphe amphetamines. One possible explanation is that amphetamines
neurons and extracellular 5-HT levels are highest during wake- produce a dramatic efflux of DA into the synapse via reverse
fulness, much lower during NREM sleep, and lowest during transport through the DAT, and this may be very reinforcing. In
REM sleep—a pattern very similar to that of the NE and HA contrast, modafinil may simply block reuptake of DA through
systems.59,60 In support of this wake-promoting role, agonists the DAT, leading to more modest rises in DA that are not as
of the 5-HT1A, 5-HT1B, 5-HT2, or 5-HT3 receptors increase reinforcing. A better understanding of these mechanisms could
wakefulness.61-65 Of clinical relevance, similar effects occur drive the discovery of even better wake-promoting medications.
with selective serotonin reuptake inhibitors (SSRIs) such as
fluoxetine and citalopram that increase wakefulness and reduce Orexin/Hypocretin
REM sleep in both people and rodents.66-70 In addition, drugs The excitatory neuropeptides orexin-A and -B (also known
that block 5-HT2 receptors such as ritanserin or agomelatine are as hypocretin-1 and -2) are synthesized by neurons in the lateral
thought to promote NREM sleep and thus are under develop- and posterior hypothalamus and play essential roles in the regu-
ment as treatments for insomnia.62,64,71-73 lation of wakefulness and sleep.89,90 The orexin neurons project
widely and heavily innervate all the arousal regions described
Dopamine (DA) above, with particularly dense innervation of the LC and TMN
DA has been implicated in the regulation of a variety of be- (Figure 3).89,91 Orexins excite target neurons through the OX1
havioral and physiological processes including motor function, and OX2 receptors. Like most other wake-promoting neurons,
motivation, reward, and learning. Additionally, DA exerts potent orexin neurons fire mainly during wakefulness, especially dur-
wake-promoting effects that are of great clinical relevance. For ing active exploration, and are silent during NREM and REM
example, sleepiness is common with DA antagonists such as hal- sleep.92,93 Orexin levels are highest during wakefulness,94 and
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when injected into the brain, orexins increase arousal and be-
havioral activity while suppressing NREM and REM sleep.95-97
Consistent with this, selective optogenetic activation of orexin
neurons can trigger brief awakenings from sleep.98,99 Addition-
ally, orexin receptor antagonists such as almorexant reduce sleep
latency and increase the amounts of REM and NREM sleep.100-102
The most compelling evidence that orexins are necessary for
the regulation of wakefulness and sleep was the discovery that BF Orexin
narcolepsy with cataplexy is associated with a loss of orexin
signaling.103-107 Dogs with a mutation of the OX2 receptor gene LDT
display many of the classic symptoms of narcolepsy, including (ACh)
cataplexy when presented with palatable foods.104 Further, mice TMN (5-HT) LC
lacking the orexin peptides or the orexin-producing neurons (HA) (NE)
have severe sleepiness and cataplexy.103,108-111 Most importantly, vPAG
people with narcolepsy with cataplexy have a severe (85% to (DA)
95%) loss of the orexin neurons and very low CSF levels of
orexin-A.106,107,112 Less severe loss (20% to 60%) of the orexin
neurons also occurs in other disorders that can cause sleepiness Figure 3—Orexin/hypocretin-producing neurons in the lateral
hypothalamus innervate all of the ascending arousal systems, as well as
such as Parkinson disease, multiple system atrophy, and trau-
the cerebral cortex.
matic brain injury.113-117
In just the last 10 years, much has been learned about the
ways in which orexins promote arousal. In general, it may be neurons are hyperpolarized during NREM sleep, promoting a
best to think of this as a system for sustaining wakefulness as pattern of burst firing and reducing their responsiveness to in-
people and mice with narcolepsy have approximately normal coming sensory stimuli.128 During wakefulness and REM sleep,
amounts of wakefulness, but have great difficulty maintain- ACh depolarizes thalamic neurons to suppress spindles and
ing long periods of wakefulness.110 Orexins may also stabilize slow waves and promote the transmission of single spikes that
sleep as people with narcolepsy often have fragmented sleep, efficiently transmit information to the cortex and drive desyn-
and orexins certainly regulate REM sleep as discussed below. chronized cortical activity.129 During wakefulness, monoamines
In addition, orexins promote arousal responses to homeostatic bolster this effect.119 Extensive damage to the thalamus severely
challenges and drive motivated behaviors such as seeking food. impairs consciousness and the ability to interact with the envi-
Orexins directly excite neurons of the mesolimbic reward path- ronment, but the general patterns of wakefulness, NREM, and
ways, and orexin antagonists can reduce the motivation to seek REM sleep persist, suggesting that the thalamus is not required
drugs of abuse.118-121 The orexin neurons are also activated by for the basic generation of sleep states.130-133
humoral indicators of hunger such as low glucose or high levels The cortex contains a wide variety of neurons, and much less
of ghrelin,122,123 and while normal mice have a clear increase in is known about their activity in relation to sleep/wake states.
arousal when deprived of food, mice lacking the orexin neurons The EEG reflects broad patterns of excitatory and inhibitory
show little response.124 Thus, one can view the orexin system post-synaptic potentials, mainly arising from the dendrites of
as helping sustain wakefulness across much of the day, and in- pyramidal neurons. During wakefulness and REM sleep, these
creasing arousal in motivating conditions. potentials are desynchronized, resulting in low-amplitude fast
activity, but during NREM sleep these signals are synchronized,
Cortical and Thalamic Activity across Sleep and Wakefulness resulting in high-amplitude slow activity. Release of ACh and
All the arousal systems we have discussed thus far are lo- monoamines during wakefulness generally excites cortical neu-
cated in the BF, hypothalamus, or brainstem and exert diffuse rons and increases their responsiveness to incoming sensory
effects on the cortex and many other target regions. These sub- stimuli. Delta waves likely arise from interactions amongst cor-
cortical systems are essential for the generation of sleep/wake tical neurons and may also be influenced by the BF and other
states and for the regulation of the transitions between these subcortical sites. Recent work has identified a population of
states. However, patterns of EEG activity and consciousness it- widely projecting GABAergic neurons within the cortex that are
self arise from interactions between these subcortical systems, uniquely active during NREM sleep, suggesting that these cells
the thalamus, and the cortex. may broadly inhibit other cortical neurons, helping generate
Thalamic neurons relay information to and from the cortex slow waves during NREM sleep.134 In addition, the intensity of
and have intrinsic electrical characteristics that help generate cortical slow waves may reflect prior local activity and changes
some of the cortical rhythms seen in NREM sleep.125,126 The in synaptic strength, as slow waves during NREM sleep are in-
thalamus contains two major types of neurons, glutamatergic creased over supplementary motor cortex after learning a motor
thalamocortical projection neurons that relay sensory, motor, task but decreased with arm immobilization.135-137
and limbic information to the cortex, and GABAergic neurons
in the reticular nucleus of the thalamus that are innervated by The Arousal Network: Interactions among Wake-Promoting
the projection neurons and cortex and in turn inhibit the projec- Neurotransmitter Systems
tion neurons. These reciprocal connections are thought to drive Each of the arousal systems presented above is independent-
some cortical rhythms, including sleep spindles.127 Thalamic ly capable of promoting wakefulness, yet these systems work
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NREM Sleep-Promoting Systems

Preoptic area
In the early 20th century, most researchers thought that sleep
was a passive consequence of inactivity in the arousal systems,
but many experiments have now shown that specific neurons
actively promote sleep. Baron von Economo first observed that
insomnia was common in patients with encephalitis injuring the
VLPO preoptic area (the rostral end of the hypothalamus, just above the
optic chiasm) and the adjacent BF.2 This observation suggested
LDT that this region might contain neurons that promote sleep, and
PPT subsequent research in animals identified sleep-active neurons in
Raphe the ventrolateral preoptic area (VLPO) and median preoptic area
TMN LC (MNPO).139,140 Many neurons in these nuclei fire most frequently
during NREM sleep and to some degree during REM sleep but
SN/VTA are virtually silent during wakefulness.141-143 Interestingly, these
sleep active VLPO neurons show particularly high rates of firing
during deep NREM sleep, and MNPO neurons often begin firing
just before NREM sleep. Lesions of the preoptic area and specifi-
cally of the VLPO markedly reduce sleep, and the sleep that does
occur is light and fragmented.144,145 Collectively, these observa-
Figure 4—NREM sleep pathways. Ventrolateral preoptic area (VLPO) tions suggest that MNPO neurons may help initiate sleep, whereas
neurons are active during NREM sleep and reduce activity in the VLPO neurons may be necessary for the maintenance of sleep.
ascending arousal systems using GABA and galanin. A subset of VLPO
Anatomically, the VLPO and MNPO are well positioned to
neurons is also active during REM sleep.
promote sleep. The neurons in these nuclei contain the inhibi-
tory neurotransmitter GABA and the inhibitory neuropeptide
together to generate behavioral arousal. Anatomically, there are galanin,146,147 and they innervate all the arousal-promoting re-
many interconnections between the systems. For instance, ACh gions, including the LDT/PPT, LC, DR, TMN, and also the
and 5-HT fibers innervate and excite LC neurons, and nearly orexin neurons (Figure 4). Thus, the VLPO and MNPO are hy-
all wake-promoting neurons respond to HA, NE, and orexin. In pothesized to promote sleep by coordinating the inhibition of
addition, these neurotransmitters often produce similar effects arousal regions during NREM and REM sleep.146,148,149
on their targets. For example, all the arousal systems excite tha- Other brain regions contain neurons active in NREM sleep, but
lamic and cortical neurons. These interconnections and parallel these populations are less well understood. For example, parts of
effects may explain why injury to any one of the arousal sys- the BF and lateral hypothalamus contain scattered GABAergic
tems often produces little lasting effect on wakefulness. Func- neurons that are active during NREM sleep.150-152 Some of these
tionally, this is adaptive, as it helps ensure that wakefulness will cells may directly innervate the cortex, and it is possible that they
still occur after injury to any one of the arousal systems. In fact, modulate cortical networks to promote slow wave activity.
there are only a few brain regions in which lesions produce last- Many of the medications now used to treat insomnia do so
ing reductions in arousal. One is the rostral reticular formation by promoting GABA signaling. Benzodiazepines, (e.g., diaz-
in the midbrain and posterior hypothalamus in which lesions epam), barbiturates (e.g., pentobarbital), and the newer non-
from strokes or tumors can produce severe hypersomnolence benzodiazepine agents (e.g., zolpidem) all bind to GABA-A
or even coma, probably from damage to many of the ascending receptors to enhance the effects of GABA.153,154 Gamma hy-
monoaminergic and cholinergic pathways. droxybutyrate (sodium oxybate) promotes very deep sleep,
Wakefulness is a complex and dynamic state, arising from most likely by binding to GABA-B receptors.155 These drugs
networks of neurons driven by homeostatic, affective, cogni- may promote sleep by boosting signaling by the VLPO and
tive, and motivational processes. Thus, it is likely that each other NREM sleep-active populations, but GABA can inhibit
arousal system helps promote specific aspects of behavioral neurons throughout the brain, and the precise pathways through
arousal so that individuals can detect sensory and internal stim- which these drugs work remain unclear.
uli and generate appropriate motor and affective responses.138
For example, NE, HA, and ACh may be particularly important REM Sleep-Promoting Systems
for enhancing attention and responding to novel, stressful, or Soon after the discovery of REM sleep in the mid-1950s,4,5
salient stimuli. Similarly, through its limbic and striatal projec- researchers learned that the pons plays an essential role in the
tions, DA may promote arousal especially when an individual is generation of REM sleep.6 After several decades of work, much
motivated or physically active. The orexin peptides help sustain has been learned, but the specific pathways that generate this
wakefulness and also may help drive goal-oriented behaviors state are still debated (Figure 5).
and locomotion. So, while lesions of some arousal systems ap-
pear to have little effect on the amounts of wakefulness, deficits Acetylcholine
in arousal may be best revealed by carefully examining the re- Many researchers have hypothesized that REM sleep is con-
sponse to specific circumstances and challenges. trolled by cholinergic neurons located in the LDT/PPT. These are
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REM atonia Motor
REM-off neurons

thalamus thalamus



Spinal Spinal
interneurons interneurons

Ventromedial Ventromedial
Medulla Medulla

REM-on REM-on
REM atonia Motor REM atonia Motor
REM-off neurons
REM-off neurons

Figure 5—Pathways that control REM sleep. (A) A classic perspective on REM sleep control involves interactions between the cholinergic and aminergic
systems. REM sleep-active cholinergic neurons in the LDT/PPT activate thalamo-cortical signaling and drive atonia by exciting neurons in the ventromedial
medulla that inhibit motor neurons. During REM sleep, monoaminergic neurons including the LC, DR, and TMN become silent, which disinhibits the LDT/PPT
of motor neurons by NE and 5-HT. (B) Recent observations have expanded on the classic view of REM sleep control. In this model,
and lessens the excitation thalamus
mutual inhibition between REM sleep-on neurons of the sublaterodorsal nucleus (SLD) and REM sleep-off neurons of the ventrolateral periaqueductal gray
and lateral pontine tegmentum (vlPAG/LPT) is thought to regulate transitions into and out of REM sleep. During REM sleep, SLD neurons activate GABA/
glycine neurons in the ventromedial medulla and spinal cord that inhibit motor neurons. At most times, the vlPAG/LPT inhibits the SLD, but during REM sleep,
the vlPAG/LPT may be inhibited by neurons making melanin concentrating hormone (MCH) and other neurotransmitters. Solid lines depict pathways active
during REM sleep, while dashed lines are pathways inactive during REM sleep.
the same nuclei that contain wake-promoting
LPT DRcells, but a subpopu- clearly important for atonia as drugs that block glycine signal-
lation of these cholinergic neurons
are active in both wakefulness ing such as strychnine can markedly increase muscle tone in
and REM sleep or are selectively active in REM sleep.9,156-158 When REM sleep and wakefulness.168,169
injected into the lateral pontine tegmentum (LPT; a heterogeneous
region extending rostrally from the PPT that is lateral to the peri- Monoamines
aqueductal gray), drugs that enhance ACh signaling such as the Monoamines such as NE and 5-HT increase muscle tone
cholinergic agonist carbachol or the acetylcholinesteraseSpinalblocker, by directly exciting motor neurons.170-173 In the genioglossus
neostigmine, elicit intense and long-lasting REM sleep.159-161 Con- muscle, withdrawal of this excitatory tone contributes more to
versely, cholinergic antagonists reduce the duration of REM sleep atonia than the inhibitory effects of GABA and glycine.174,175
bouts.162,163 Furthermore, large lesions that include the LDT/PPT Whether this applies to most muscles is unknown, but it is clear
produce significant reductions in REM sleep,164,165 suggesting that that atonia during REM sleep is probably due to a combination
the LDT/PPT is necessary for REM sleep. of inhibition (GABA and glycine) and a loss of excitation (NE
Neurons REM-on
in the LDT/PPT may help generate the cortical ac- and 5-HT).
atonia of REM REM
tivation and atonia
sleep. The LDT/PPT is the main
neurons Monoamines also inhibit REM sleep itself. During wakeful-
source of ACh to the thalamus, and ACh depolarizes thalamic ness, and to some degree during NREM sleep, the REM-active
neurons to promote the transmission of information through cholinergic neurons are inhibited by 5-HT, NE, and HA.176 This
the thalamus, driving the cortical activation that is probably re- interaction between cholinergic and monoaminergic populations
quired for the complex dreams of REM sleep. The LDT/PPT forms the foundation of the classic model explaining the alterna-
neurons may also activate atonia-promoting neurons in the ven- tion of NREM and REM sleep across the night (Figure 5A).177
tromedial medulla.158,166 These medullary cells release GABA These monoaminergic effects on motor tone and REM sleep
and another inhibitory neurotransmitter glycine onto spinal and may account for many phenomena commonly seen by sleep cli-
brainstem motor neurons during REM sleep, producing hy- nicians. NE and 5-HT reuptake inhibitors often increase muscle
perpolarization and inhibition.167 This descending inhibition is tone during sleep and can unmask REM sleep behavior disor-
SLEEP, Vol. 34, No. 7, 2011 851 Sleep Neurobiology for the Clinician—España and Scammell
der (RBD) and worsen periodic limb movements of sleep.178 ACh.196,197 During wakefulness, high monoaminergic and cho-
These drugs and other antidepressants also strongly suppress linergic tone should thoroughly silence the VLPO, thus disin-
REM sleep, and thus can markedly reduce REM sleep during hibiting the arousal regions and helping ensure the production
overnight polysomnograms or during the MSLT.179 of complete wakefulness. Conversely, during sleep, preoptic
neurons become active and inhibit the arousal regions, thus
GABA disinhibiting their own firing. This mutual inhibition should
Over the last few years, new observations have expanded on produce stable wakefulness and sleep while facilitating rapid
the classic model of REM sleep control (Figure 5B). One region transitions between sleep and wakefulness and minimizing time
that has received significant attention is the sublaterodorsal nu- in drowsy, intermediate states. Similar mutually inhibitory cir-
cleus (SLD; also termed the subcoeruleus, or LCα), which is a cuits may regulate REM sleep as REM sleep-active neurons in
small cluster of cells ventral to the LC that produce GABA or the SLD inhibit and are inhibited by neurons in the vlPAG/LPT
glutamate.180 Many neurons in the SLD are active during REM that are inactive in REM sleep.182
sleep,158,181-183 and they project to the ventromedial medulla and The orexin neuropeptides probably reinforce these mutually
ventral horn of the spinal cord, providing pathways through inhibitory systems. Orexins may stabilize wakefulness by en-
which they may inhibit motor neurons. Activation of the SLD hancing activity in the arousal systems, ensuring full alertness
region elicits atonia and REM sleep-like EEG activity,158 while and long periods of wakefulness despite rising homeostatic
inhibition of the SLD promotes wakefulness and reduces REM pressure across the day.94 During wakefulness and perhaps to
sleep. Most importantly, lesions of the SLD region disrupt a lesser degree in NREM sleep, orexins may excite a variety of
REM sleep atonia and reduce REM sleep.165,180,182,184,185 Neuro- neurons that inhibit REM sleep, including monoaminergic neu-
nal loss near the SLD has been reported in some patients with rons, the vlPAG/LPT, and GABAergic inputs to the SLD.96,198-
RBD,186 suggesting that injury to the SLD may contribute to the 201
However, loss of the orexin neurons in narcolepsy with
inadequate atonia of RBD. cataplexy results in persistent sleepiness, frequent transitions
Another new perspective on the classic view of REM sleep is between states, and odd states such as cataplexy and hypnago-
that the SLD neurons may be strongly inhibited by REM sleep- gic hallucinations in which it seems that elements of REM sleep
suppressing neurons in the mid-pons.149,182,187 These GABAergic mix into wakefulness. Collectively, these symptoms may be
cells are scattered from the ventral part of the periaqueductal best thought of as “behavioral state instability,” a phenomena
gray out into the lateral pontine tegmentum (vlPAG/LPT) and that is likely caused by loss of the stabilizing effects of orexins
lesions of this region substantially increase REM sleep.188 The on the mutually inhibitory circuits that regulate wakefulness,
vlPAG/LPT inhibits the SLD, and the SLD may in turn inhibit NREM, and REM sleep.110,202
the vlPAG/LPT, giving rise to a mutually inhibitory circuit that
may regulate transitions between NREM and REM sleep.149,182 Somnogens
Most of the preceding text describes neural pathways that reg-
Melanin-concentrating hormone (MCH) ulate sleep/wake states, but these states can also be influenced by
Mixed in with the orexin neurons of the lateral hypothalamus diffusible or circulating factors that act upon many brain regions
are a large number of REM sleep-active neurons that produce to promote sleep. In fact, more than 100 years ago, researchers
both MCH and GABA.189-191 These cells innervate nearly all found that the CSF of sleep deprived dogs contained somnogens,
the same target regions as the orexin neurons including the DR substances that promote sleep.203,204 Much evidence now suggests
and LC,192,193 yet in contrast to the excitatory effects of orex- that adenosine, cytokines, prostaglandins, and probably addition-
ins, both MCH and GABA are inhibitory. Electrophysiological al substances serve as natural sleep-generating signals.205
recordings demonstrate that MCH neurons fire at a high rate
during REM sleep, with much less firing during NREM sleep Adenosine
and complete inactivity during wakefulness.152 The amount of During wakefulness, brain metabolic activity is high, and
REM sleep is increased by infusions of MCH into the lateral adenosine may promote sleep in response to this metabolic
ventricles and decreased by a MCH antagonist.191,194 Consistent challenge.206-208 When cells have ample energy, nearly all ad-
with these observations, mice lacking MCH spend less time in enosine is phosphorylated to ATP and adenosine levels are low.
NREM and REM sleep.195 Thus, it seems likely that the MCH However, when cells are fatigued, ATP production is lower,
neurons promote REM sleep by inhibiting the arousal regions. adenosine levels rise, and then adenosine acts as an inhibitory
This pattern is strikingly opposite to that of the orexin neurons neuromodulator. For example, adenosine reduces the activ-
and much remains to be learned about how the activity of these ity of most wake-promoting neurons, but disinhibits VLPO
intertwined systems is organized. neurons. With prolonged wakefulness, adenosine levels rise
in the basal forebrain and other regions, and levels then fall
Mechanisms that Regulate the Transitions between Sleep and during recovery sleep.209 Most likely, the extracellular levels
Wakefulness of adenosine are governed by the activity of astrocytes, the
The systems that promote wakefulness, NREM, and REM support cells of the brain, because manipulations of astrocytes
sleep dynamically interact in a variety of ways to ensure rapid reduce the usual increases in sleep and delta power after sleep
and complete transitions between sleep/wake states.148,149 The deprivation.207,209,210 Furthermore, adenosine receptor agonists
VLPO and other sleep-promoting preoptic neurons inhibit increase sleep and NREM delta power, while caffeine and
monoaminergic and cholinergic wake-promoting neurons, and other drugs that block adenosine receptors promote wakeful-
the preoptic neurons themselves are inhibited by NE, 5-HT, and ness.207,211-213 As caffeine promotes arousal after sleep depriva-
SLEEP, Vol. 34, No. 7, 2011 852 Sleep Neurobiology for the Clinician—España and Scammell
tion,214 it seems likely that adenosine is an important mediator transforming growth factor-α.240,241 This signal is then passed
of everyday sleepiness. through the dorsomedial nucleus of the hypothalamus and on
to brain regions that regulate sleep and wakefulness such as the
Cytokines LC, VLPO, and lateral hypothalamus.242 The SCN also regu-
Cytokines are intercellular signaling peptides released by lates the daily rhythm of body temperature, and through these
immune cells, neurons, and astrocytes, and several cytokines, cycles in temperature, the SCN can entrain circadian activity
including interleukin-1β (IL-1β) and tumor necrosis factor-α in cells throughout the body.243 Circadian rhythms are closely
(TNF-α), promote sleep.215 Administration of IL-1β into the linked to metabolism, and a breakdown in this coordination of
preoptic area of rats reduces firing rates of wake-active neurons central and peripheral rhythms may contribute to the obesity
and promotes NREM sleep.216 Similarly, TNF-α infusions into and glucose intolerance that is common in people with shift
the preoptic area also promote NREM sleep.217 During infec- work sleep disorder or insufficient sleep.244
tions, bacterial cell wall products such as lipopolysaccharide
and muramyl dipeptide may trigger production of these cyto- CONCLUSIONS
kines that then increase NREM sleep and reduce REM sleep.218 Since the days of von Economo and then Moruzzi and Ma-
In addition, these cytokines may promote spontaneous, physio- goun, much has been learned about the neurobiology of sleep
logical sleep as IL-1β and TNF-α mRNA and protein levels are and wakefulness. We now know that neurons producing ACh and
highest around sleep onset, and blockade of IL-1β and TNF-α monoamines such as NE, 5-HT, DA, and HA promote various as-
signaling with antagonists, antibodies, or deletion of their re- pects of wakefulness. In addition, orexins/hypocretins help sus-
ceptors reduces spontaneous NREM sleep.219-221 tain long periods of wakefulness while suppressing REM sleep.
NREM sleep is mainly regulated by neural pathways originating
Prostaglandin D2 in the VLPO and other preoptic regions, yet it is also influenced
Prostaglandin D2 (PGD2) is a lipid derived from fatty ac- by diffusible somnogens such as adenosine. REM sleep is driven
ids that potently promotes NREM sleep.211 Unlike adenosine by neurons in the pons that make ACh and GABA. These dis-
or cytokines which are made in the brain parenchyma, PGD2 coveries provide a useful framework to better understand sleep
is likely synthesized in the basal meninges just below the hy- disorders and the effects of medications on sleep.
pothalamus.222 PGD2 levels in cerebrospinal fluid are highest Nevertheless, despite these advances, many questions of
during the sleep period,223 and PDG2 levels increase with sleep clinical importance remain unanswered. What goes wrong in
deprivation.224 Infusions of PGD2 just below or within the pre- these circuits to cause parasomnias such as sleepwalking and
optic area activate neurons in the VLPO and increase NREM periodic limb movements of sleep? Under what conditions are
and REM sleep, perhaps by increasing local concentrations of specific wake- and sleep-promoting systems especially nec-
adenosine.225-229 Like cytokines, PGD2 may contribute to the essary? How is sleep restorative? What are the functions of
sleepiness seen with inflammation as patients with African NREM and REM sleep? Undoubtedly, future sleep research
sleeping sickness display increased CSF levels of PGD2.230 will provide helpful insights into the underlying causes of sleep
disorders and lead to new and more powerful therapeutics to
Process C and Process S treat them.
The two-process model provides a useful macroscopic per-
spective on the dynamic control of sleep and wakefulness. It is ACKNOWLEDGMENTS
likely that a homeostatic factor (process S) accumulates dur- The authors thank Dr. P. Valko, D. Kroeger, and C. Burgess
ing wakefulness and declines during sleep, and this factor in- for their thoughtful comments on this manuscript. Writing of
teracts with a circadian process (process C) that helps regulate this article was partially supported by research grants from the
the timing of wakefulness and REM sleep.231-233 After a period NIH (NS055367, HL095491).
of wakefulness, delta power in NREM sleep is thought to be a
good indicator of Process S,234,235 and somnogens such as ad- DISCLOSURE STATEMENT
enosine may be the neurobiologic equivalent of Process S as This was not an industry supported study. Dr. Scammell has
disruption of adenosine signaling can blunt the usual increase in consulted for Merck and Cephalon. Dr. España has indicated no
NREM sleep and the intense EEG delta power seen after sleep financial conflicts of interest.
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SLEEP, Vol. 34, No. 7, 2011 858 Sleep Neurobiology for the Clinician—España and Scammell
Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005

From waking to sleeping: neuronal and

chemical substrates
Barbara E. Jones
Department of Neurology and Neurosurgery, McGill University, Montreal Neurological Institute, Montreal,
Quebec H3A 2B4, Canada

Multiple arousal systems maintain waking through the during slow-wave sleep (SWS) and become silent during
actions of chemical neurotransmitters that are released paradoxical sleep (PS), which is also known as rapid-eye-
from broadly distributed nerve terminals when the movement sleep (REMS). It has been suggested that they
neurons fire. Among these, noradrenaline-, histamine- are silenced by other neurons that become active during
and orexin-containing neurons fire during waking with sleep. Precise knowledge of the activity profiles of
behavioral arousal, decrease firing during slow-wave chemically identified neurons during the sleep–wake
sleep (SWS) and cease firing during paradoxical sleep cycle has thus been sought to understand how the
(PS), which is also known as rapid-eye-movement sleep. activities of specific groups of neurons determine the
By contrast, acetylcholine (ACh)-containing neurons alternation from waking to sleeping. Such knowledge also
discharge during waking, decrease firing during SWS helps understanding of how the major stimulant and
and fire at high rates during PS in association with hypnotic pharmacological agents work.
fast cortical activity. Neurons that do not contain ACh, Waking is characterized by cortical activation, which is
including GABA-containing neurons in the basal fore- evident on electroencephalograms (EEGs) recorded from
brain and preoptic area, are active in a reciprocal manner the surface of the cortex by low-amplitude fast activity
to the neurons of the arousal systems: one group (particularly in a gamma range of 30–60 Hz) [2], and
discharges with slow cortical activity during SWS, and behavioral arousal, which is evident on the electromyo-
another discharges with behavioral quiescence and loss gram (EMG) by high-amplitude activity in the postural
of postural muscle tone during SWS and PS. The reci- muscles, particularly in the neck (Figure 1). Sleep is
procal activities and interactions of these wake-active composed of two states: SWS is characterized by high-
and sleep-active cell groups determine the alternation amplitude slow EEG activity in a delta range (1–4 Hz) and
between waking and sleeping. Selective enhancement behavioral quiescence, which is evident as reduced EMG
and attenuation of their discharge, transmitter release activity in the postural muscles; by contrast, PS is charac-
and postsynaptic actions comprise the substrates for terized by the paradoxical association of fast EEG activity
the major stimulant and hypnotic drugs. with complete EMG atonia in the postural muscles. Here,
I review how increasingly refined techniques have been
The neuronal basis of the sleep–wake cycle used to measure the activity profiles of chemically
From early pharmacological and lesion studies, and more- identified neurons in relation to the sleep–wake states
recent gene-knockout studies, we know that wakefulness and their respective EEG and EMG correlates to uncover
is maintained by multiple neuronal systems that use the manner in which specific neurons and their neuro-
different chemical neurotransmitters (reviewed in [1]) transmitters influence waking and sleeping.
(Figure 1). These multiple systems are partially redun-
dant because no one system appears to be absolutely Arousal systems
necessary for wakefulness, although each contributes Ascending reticular activating system
in a unique way to its generation and maintenance [1]. As established by the early work of Moruzzi and Magoun
They include glutamate-, noradrenaline (NA)-, dopamine in the 1940s and 1950s, the brainstem reticular formation
(DA)-, 5-hydroxytryptamine (5-HT)-, histamine-, orexin (RF) is crucial for maintaining cortical activation and
[Orx (also known as hypocretin)]- and acetylcholine behavioral arousal of waking (reviewed in [1]). Projections
(ACh)-containing neurons. These systems share some from neurons concentrated in the oral pontine and mesen-
features including either widespread or diffuse projections cephalic RF ascend into the forebrain where they stimu-
to the cerebral cortex, subcortical relays and brainstem or late cortical activation via a dorsal relay in the thalamus
spinal cord, and mutually excitatory influences on each and a ventral relay through the hypothalamus and basal
other that evoke concerted effects under many conditions. forebrain (Figure 1). Neurons concentrated in the caudal
Single-unit-recording studies show that many neurons pontine and medullary RF facilitate postural muscle tone
in these subcortical arousal systems discharge at their through descending projections onto motor neurons and
highest rates during waking, diminish their activity other neurons in the spinal cord. The RF projection
Corresponding author: Jones, B.E. ( neurons are likely to use glutamate as a neurotransmitter
Available online 23 September 2005 [3]. Neurons of the diffuse thalamocortical projection 0165-6147/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/
Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005 579

Fast EEG (W, PS):

Slow EEG (SWS):



CPu ic
Rt Mes RF
GP scp LC
ac PPTg
PnO 7g Sol s
opt TM
Fast EEG active (gamma+, delta–; W-PS) GiA
Glu Slow EEG active (gamma–,delta+; SWS) SWS EMG:
GABA GABA (α2-adrenoceptor) PS EMG:
Behavioral wake active (EMG+; W)
H Behavioral sleep active (EMG–; SWS-PS)
Orx GABA (α2-adrenoceptor)

Figure 1. The rat brain depicting neurons and their chemical neurotransmitters, and pathways that influence either cortical activity or behavior across the sleep–wake cycle.
Wake (W) is characterized by fast gamma activity on the cortical EEG (upper left) and high postural-muscle tone on the neck EMG (lower right); SWS is characterized by a slow
delta EEG (upper left) and low tone on the EMG (lower right); and PS is characterized by a fast gamma EEG (upper left) and atonia on the EMG (lower right). Neurons that are
active during waking (pale red symbols; see Figures 2 and 3) include those with ascending projections to the cortex, which stimulate fast cortical activity, and others with
descending projections to the spinal cord, which stimulate postural-muscle tone and behavioral waking. Neurons with predominantly ascending projections discharge in
association with fast EEG activity (gammaC), cease firing with delta activity (deltaK), and are active during W and PS (filled pale red symbols). These neurons include
ACh-containing (ACh), glutamate-containing (Glu) and some GABA-containing (GABA) neurons. Neurons that have either more diffuse or descending projections discharge
in association with behavioral arousal and EMG activity (EMGC), cease firing with muscle atonia, are active during W and are silent during PS (open pale red symbols). These
neurons include NA-containing (NA), histamine-containing (H), Orx-containing (Orx) and some putative glutamate-containing (Glu) neurons. Neurons that are active during
sleep (blue and green symbols) include cells whose projections ascend towards the cortex, which dampen fast cortical activity, and those with descending projections to the
brainstem and spinal cord, which diminish behavioral arousal and muscle tone. Neurons with projections to the cortex discharge in association with slow EEG activity
(gammaK/deltaC) during SWS (blue triangles). These include some GABA-containing neurons in the basal forebrain and preoptic area that bear a2-adrenoceptors and are
inhibited by NA. Also shown are GABA-containing neurons of the nucleus reticularis in the thalamus. These discharge in bursts with sleep spindles and slow waves to inhibit
and pace thalamocortical relay neurons. In the basal forebrain and preoptic area, presumed GABA-containing neurons with descending projections and a2-adrenoceptors
increase firing as muscle tone decreases (EMGK) during SWS and PS (green symbols). Also shown are GABA-containing (and/or glycine-containing) neurons in the ventral
medulla that project directly to the spinal cord where they might inhibit motor neurons in the neck and other regions during sleep. Abbreviations: 7g, genu 7th nerve; ac,
anterior commissure; CPu, caudate putamen; Cx, cortex; EEG, electroencephalogram; EMG, electromyogram; Gi, gigantocellular RF; GiA, gigantocellular, a part RF; GiV,
gigantocellular, ventral part RF; GP, globus pallidus; Hi, hippocampus; ic, internal capsule; LDTg, laterodorsal tegmental nucleus; Mes RF, mesencephalic RF; opt, optic tract;
PH, posterior hypothalamus; PnC, pontine, caudal part RF; PnO, pontine, oral part RF; POA, preoptic area; PPTg, pedunculopontine tegmental nucleus; Rt, reticularis nucleus
of the thalamus; s, solitary tract; scp, superior cerebellar peduncle; SI, substantia innominata; SN, substantia nigra; Sol, solitary tract nucleus; Th, thalamus; TM,
tuberomammillary nuclei; VTA, ventral tegmental area. Modified from [71].

relay, which project widely to the cerebral cortex to inhibits target neurons in the brain and spinal cord,
stimulate cortical activation, and some cortically project- depending on the adrenoceptors on each neuron; in
ing neurons of the basal forebrain also use glutamate general, a1-adrenoceptors are associated with depolariz-
[4–6]. Thus, glutamate-containing neurons represent the ation through closing KC channels, and a2-adrenoceptors
backbone of the cortical-activating and behavioral-arousal are associated with hyperpolarization by opening
systems in the brain (Figure 1). Given the importance of KC channels. Through its receptors, NA selectively excites
glutamate, it is not surprising that many anesthetics other systems that are involved in waking and inhibits
(including inhalant anesthetics and ketamine) attenuate those involved in sleep. Stimulation of a1-adrenoceptors
glutamate-mediated neurotransmission [7]. Glutamate- by NA excites many neurons through the forebrain
containing neurons of the arousal systems are regulated [including ACh-containing neurons (see later)], brainstem
by neuromodulatory transmitters that are released by and spinal cord (including motor neurons). Some neurons
other arousal systems. in the brain [including putative sleep-promoting neurons
in the basal forebrain and preoptic area (see later)] are
NA-containing locus coeruleus neurons inhibited by NA acting through a2-adrenoceptors.
NA-containing locus coeruleus (LC) neurons stimulate NA-containing neurons and terminals also bear
cortical activation and behavioral arousal by diffuse a2-adrenoceptors that act through KC and Ca2C channels
projections through the forebrain, brainstem and spinal to diminish activity and NA release. Drugs that antagon-
cord (Figure 1) [3]. LC neurons discharge during waking, ize a1-adrenoceptors, such as prazosin, facilitate sleep
particularly during active waking, decrease firing during onset, probably by blocking the postsynaptic action of
SWS and cease firing during PS [8,9]. NA either excites or NA on many of its target neurons [10]. By contrast,
580 Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005

a2-adrenoceptor antagonists such as yohimbine delay stimulate cortical activation (Figure 1) [3,19,20]. To a
sleep, the main cause of which is likely to involve blocking lesser degree, they also project through the ventral
inhibitory a2-adrenoceptor autoreceptors on NA-containing extrathalamic pathway to the posterior hypothalamus
neurons and, thus, enhancing NA release and stimulation and basal forebrain, and to the brainstem RF. Although
of a1-adrenoceptors. Conversely, a2-adrenoceptor agonists neurons have not been identified by their neurotrans-
such as clonidine, which inhibit NA release, diminish mitter in recording studies in the brainstem, cells in the
arousal and are hypnotic and anesthetic agents [11]. region of ACh-containing pontomesencephalic neurons
Drugs that either stimulate the release, or block the in the laterodorsal and pedunculopontine tegmental
reuptake, of NA, the most important of which include the nucleus (Figure 1) discharge during waking, decrease
amphetamine compounds, either enhance or prolong firing during SWS and increase firing during PS [19,21].
wakefulness. These drugs are used to treat the sleep- Expression of FOS, which reflects neural activity, also
iness (hypersomnolence) and loss of muscle tonus occurs in immunohistochemically identified ACh-contain-
(cataplexy) that occur with narcolepsy, which is the ing neurons following PS rebound after deprivation [22].
sudden onset of SWS and/or PS from waking [10]. The Thus, the discharge of ACh-containing neurons occurs
more recently used drug modafinil, which is used to treat in association with cortical activation but is not linked
hypersomnolence, also appears to enhance NA-mediated to behavioral arousal. Indeed, it is well accepted that
neurotransmission [10,12,13]. injection of ACh agonists such as carbachol into the
pontomesencephalic tegmentum causes cortical activation
Mesencephalic DA-containing neurons accompanied by muscle atonia, a state that resembles PS
In the mesencephalic tegmentum, DA-containing neurons (reviewed in [23]). Accordingly, ACh can act on different
of the substantia nigra and ventral tegmental area are target-cell populations to promote cortical activation and
also important for arousal (reviewed in [1]). These neurons to inhibit muscle tone. In the thalamus, ACh acts on
project to the striatum, basal forebrain and cortex. nicotinic ACh receptors (nAChRs) and muscarinic ACh
Presumed DA-containing neurons discharge in bursts of receptors to facilitate cortical activation [20,24]. It excites
spikes in association with aroused and often positively thalamocortical relay neurons through direct excitatory
rewarding states [14]. Such enhanced activity can occur actions of nAChRs and M1 ACh receptors on relay neurons
during both waking and PS [15], which indicates that and through indirect facilitation by inhibitory actions of
DA normally stimulates central arousal with positive M2 ACh receptors on GABA-containing thalamic reticu-
emotion, but not necessarily behavioral arousal and laris neurons. Similarly, in the brainstem RF ACh might
increased postural muscle tone. Drugs that either block act at different receptors to excite some neurons that are
the reuptake of DA and NA, such as cocaine, or stimulate involved in either cortical activation or motor inhibition,
their release, such as amphetamine, commonly have both and to inhibit other neurons, such as reticulospinal
arousing and positively rewarding effects [16]. It is pos- neurons, that excited motor neurons (reviewed in [23]).
sible that the enhanced release of DA and NA caused by Normally, there is a balance between ACh-mediated and
these drugs promotes both cortical activation and behav- NA-mediated neurotransmission, such that activation of
ioral arousal of waking and, thus, they are useful in both types of neurons maintains a waking state with both
treating hypersomnolence and cataplexy [10]. muscle tone and cortical activation. PS and loss of muscle
tonus can occur when NA-containing neurons are inactive
5-HT-containing raphe neurons and ACh-containing neurons are active. This association
5-HT-containing neurons in the brainstem raphe (which first became evident in the 1970s in an animal model
means midline) nuclei discharge, like the NA-containing in which acetylcholinesterase inhibitors were used to
neurons, maximally during waking, decrease discharge enhance ACh activity: when administered alone, the
during SWS and cease firing during REMS or PS [17], inhibitors stimulated waking, but they stimulated PS
which indicates that they promote wakefulness. However, when administered following depletion of the catechol-
unlike ACh-containing neurons, 5-HT-containing neurons amines by previous administration of reserpine (reviewed
appear to be active in association with less-aroused in [23]). In humans, acetylcholinesterase inhibitors stimu-
waking states, such as during grooming and rhythmic late cortical activation with prolonged waking when
movement in animals. Furthermore, they attenuate administered during waking, but precipitate REMS
cortical activation through inhibitory influences on other when administered during sleep [25] when NA-mediated
neurons of the activating systems, the most important and other arousal systems are inactive.
of which are ACh-containing neurons (reviewed in [1]).
Tricyclic antidepressant drugs that act relatively selec- Histamine-containing tuberomammillary neurons
tively on the reuptake of 5-HT (such as fluoxetine) have Histamine-containing neurons located in the tuberomam-
sedative effects during the day and variable effects on millary nuclei (TM) of the posterior hypothalamus
sleep at night, often including increased movements and stimulate cortical activation through diffuse projections
muscle tone (reviewed in [18]). [26,27] (Figure 1). Presumed, although unidentified,
histamine-containing neurons discharge during waking,
ACh-containing pontomesencephalic neurons decrease firing during SWS and cease firing during PS
ACh-containing neurons of the pontomesencephalic teg- [28]. Through H1 and H2 receptors, histamine depolarizes
mentum project, in parallel with neurons of the RF, to the and excites multiple neurons of the arousal systems in
non-specific thalamocortical projection system where they addition to cortical neurons. Interestingly, histamine does
Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005 581

not inhibit putative sleep-promoting neurons of the pre- ACh-containing basal forebrain neurons
optic region (see later) [29]. Acting largely on H1 receptors, ACh-containing neurons of the basal forebrain have long
antihistamine drugs prescribed for alleviating allergic been known to have an important role in cortical acti-
responses often have side-effects of somnolence and thus vation (reviewed in [38]). They receive input from other
have also been prescribed as hypnotic agents [18,30]. brainstem and hypothalamic arousal systems and, in
turn, have widespread projections to the cortical mantle
(Figure 1). Their stimulation by local delivery of agonists
Orx-containing hypothalamic neurons of the arousal systems, such as AMPA and NA, evokes fast
Orx is a recently discovered peptide in the brain. Like cortical activity, particularly high-frequency gamma
its receptor, Orx is necessary for the maintenance of activity. Conversely, inactivation by lidocaine produces a
waking because narcolepsy occurs in transgenic mice and loss of fast cortical activity and predominance of slow-
dogs with spontaneous mutations that lack Orx or Orx wave activity. In FOS expression studies, ACh-containing
receptors [30–33]. Orx-containing neurons are located in neurons were active during continuous waking
the posterior hypothalamus which has long been known to enforced by sleep deprivation (Figure 2a–c) [39]. In recent
be important in maintaining waking and engaging the electrophysiological studies, ACh-containing basal
sympathetic nervous system (Figure 1). It is likely that forebrain neurons were recorded and identified in
these neurons receive inputs from the ascending fibers naturally waking/sleeping rats [40]. In contrast to
that pass through the lateral hypothalamus from the presumed NA-containing neurons in the LC, presumed
brainstem-activating systems, including the LC, and they histamine-containing neurons in the TM and identified
are excited by NA [34]. Orx stimulates cortical activation, Orx-containing hypothalamic neurons, but like presumed
behavioral arousal and autonomic changes by diffuse pro- ACh-containing neurons in the brainstem, ACh-contain-
jections and excitatory influences on the cerebral cortex, ing neurons in the basal forebrain are active during both
nonspecific thalamocortical projection system, basal fore- waking and PS. Their discharge rate correlates positively
brain ACh-containing neurons, histamine-containing with the power of fast gamma (30–60 Hz) and with theta
TM neurons, NA-containing LC neurons, and spinal cord (4–8 Hz) activity on the EEG across sleep–wake states,
motor and sympathetic neurons (reviewed in [35]). Recently, correlates negatively with slow delta activity (1–4 Hz),
Orx-containing neurons have been recorded in vivo and and does not correlate with the amplitude of the EMG
found to discharge during waking, decrease firing during (Figure 3a–d). Thus, ACh-containing neurons in the basal
SWS and cease firing during PS [36,37]. They are, thus, forebrain stimulate high frequency gamma and theta
assumed to stimulate arousal, and antagonize cortical activity during both waking and PS. This action in the
deactivation and loss of muscle tonus, which occurs in cortex might be mediated by activation of either nAChRs
their absence in cases of narcolepsy. Given their inner- or muscarinic ACh receptors on different cortical inter-
vation and excitation of all other arousal systems, Orx- neurons and/or pyramidal cells [20,38]. As one of the most
containing neurons appear to have a central role in common stimulants, nicotine elicits cortical activation,
stimulating and maintaining waking. However, Orx does and blocking nAChRs diminishes this cortical activation.
not inhibit sleep-promoting neurons in the preoptic region Blocking muscarinic ACh receptors with either scopol-
(see later) [35]. amine or atropine prevents fast cortical activity and

Distribution of ACh and GABA cells FOS expression: sleep deprivation (waking) FOS expression: sleep recovery (sleeping)


(a) ChAT+ (b) (c) c-FOS+, ChAT+




(d) A 9.0 A 8.6 GAD+ (e) A 9.0 A 8.6
1 mm (f) A 9.0 A 8.6 c-FOS+, GAD+

Figure 2. ACh-containing and GABA-containing neurons in levels wA9.0 and A8.6 of the basal forebrain and preoptic area of the rat are active during the wake–sleep cycle.
(a) ACh-containing neurons are immunostained for choline acetyltransferase (ChAT) (open red circles). (d) GABA-containing neurons are immunostained for glutamic acid
decarboxylase (GAD) (open blue triangles). FOS expression, which indicates activity, was examined following 3 h of sleep deprivation with continuous waking (b,e), and
during sleep recovery with almost continuous sleeping (O90% of the time) (c,f). Most of the neurons that express FOS (black dots) also release ACh (filled red circles)
following waking (b) but not following sleeping (c). Neurons that release GABA express FOS (filled blue triangles) following sleep deprivation (e) and following sleep recovery
(f). Thus, the proportion of cells that express FOS and release GABA increases significantly with sleep recovery. Most GABA-containing neurons that express FOS during
sleep immunostain for a2-adrenoceptors. Abbreviations: DBB, diagonal band of Broca nuclei; LPO, lateral preoptic area; MCPO, magnocellular preoptic area; MPO, medial
preoptic area; MnPO, median preoptic nucleus; SIa, substantia innominata, anterior part; VLPO, ventrolateral preoptic area. Modified from [39].
582 Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005

(a) Fast EEG: gamma (b) Slow EEG: delta (c) EMG

1.0 1.0 1.0

Normalized gamma power

Normalized EMG amplitude


Normalized delta power

0.8 0.8

0.6 0.6 0.6

0.4 0.4 0.4

0.2 0.2 0.2

0.0 0.0 0.0


(d) Gamma+/delta–: W-PS active units (e) EMG+: W active units

1.0 1.0
0.9 0.9
Normalized average spike rate

Normalized average spike rate

0.8 0.8
0.7 0.7
0.6 ACh 0.6
0.5 Glu Glu 0.5
0.4 GABA 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0.0 0.0

(f) Gamma–/delta+: SWS active units (g) EMG–: SWS-PS active units

1.0 1.0
0.9 0.9
Normalized average spike rate
Normalized average spike rate

0.8 0.8
0.7 0.7
0.6 0.6
0.5 0.5
GABA (α2– adrenoceptor)
0.4 0.4
0.3 0.3
0.2 0.2
0.1 0.1
0.0 0.0
TRENDS in Pharmacological Sciences

Figure 3. Sleep–wake-related EEG, EMG and unit activity. (a) Normalized gamma power, (b) delta power and (c) EMG amplitude across all sleep–wake stages, and
(d–g) normalized, average unit-spike rate for groups of cells in the basal forebrain are shown. (d) Neurons whose discharge correlates positively with gamma EEG activity,
correlates negatively with delta EEG activity (gammaC/deltaK), and which fire maximally during W and PS include the putative ACh-containing, glutamate-containing and
GABA-containing cells (represented in Figure 1). (e) Neurons whose discharge correlates positively with EMG amplitude (EMGC) and which fire maximally during W include
putative glutamate-containing cells (represented in Figure 1). (f) Neurons whose discharge correlates negatively with gamma and correlates positively with delta EEG activity
(gammaK/deltaC) and which fire maximally during SWS include putative GABA-containing neurons that bear a2-adrenoceptors (represented in Figure 1). (g) Neurons
whose discharge correlates negatively with EMG amplitude (EMGK) and which fire at higher rates during SWS and PS include putative GABA-containing neurons that bear
a2-adrenoceptors (represented in Figure 1). Abbreviations: aW, active wake; qW, quiet wake; tSWS, transition to slow-wave sleep; SWS, slow-wave sleep; tPS, transition to
paradoxical sleep; PS, paradoxical sleep. Based on data from [53].
Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005 583

results in a predominance of slow EEG activity even waking/sleeping animals. The discharge of these cells
while animals appear to be awake and moving with full correlates negatively with gamma EEG activity and
postural-muscle tone (reviewed in [1]). Thus, basal correlates positively with delta EEG activity (Figure 3f )
forebrain ACh-containing neurons have a crucial role in [53]. GABA-containing neurons in the basal forebrain
stimulating and maintaining cortical activation during project with ACh-containing neurons to the cerebral
waking and PS. cortex, where they might influence directly interneurons
In addition to ACh-containing neurons, neurons in and pyramidal neurons [6,42]. The other cortical acti-
the basal forebrain that do not contain ACh also increase vation-off GABA-containing cells in the basal forebrain
their discharge in association with cortical activation might correspond to neurons whose discharge correlates
(Figure 3d). As established in urethane-anesthetized negatively with EMG amplitude and which might, thus,
animals, these ‘cortical activation-on’ cells include puta- dampen behavioral arousal and muscle tone through
tive glutamate-containing and a smaller number of descending projections to the posterior hypothalamus
GABA-containing neurons that project to the cerebral and/or brainstem (Figure 3g). GABA-containing neurons
cortex (Figure 1) [6,41,42]. In addition, other neurons in of the basal forebrain and the preoptic area project
the basal forebrain that do not project to the cortex are caudally into the posterior lateral hypothalamus where
more active with arousal. These neurons probably contain they appear to innervate many neurons including
glutamate and they might correspond to unidentified Orx-containing neurons [43,44,54]. Neurons of the basal
neurons that have been recorded in the basal forebrain in forebrain and preoptic area might also promote sleep by
naturally waking/sleeping rats that discharge in associ- descending projections to either histamine-containing
ation with EMG activity and are presumed to project neurons or NA-containing neurons in the LC [27,55].
caudally to increase behavioral arousal and postural- GABA-containing, sleep-active neurons must be dis-
muscle tone (Figure 3e) [43,44]. tinguished from other GABA-containing neurons by the
way in which they are modulated by the major chemical
Sleep-promoting neurons neurotransmitters of the arousal systems. In vitro
GABA-containing neurons in the basal forebrain and pharmacological studies show that NA depolarizes and
preoptic area excites ACh-containing neurons in the basal forebrain, but
Since early studies in the 20th century it has been known hyperpolarizes and inhibits some of the neurons in this
that neurons in the basal forebrain and preoptic area have area that do not release ACh [56]. Similarly, most neurons
an important role in promoting sleep because lesions in in the ventrolateral preoptic area are hyperpolarized by
these areas result in insomnia (reviewed in [1,45]). NA, and these putative sleep-promoting neurons syn-
Neurons were also recorded in these areas that discharge thesize GABA [29]. In the in vivo recording experiments,
at higher rates during sleep than during waking [46–49]. dual immunostaining shows that the cortical activation-
In the basal forebrain, a sleep-promoting role is, pre- off, GABA-containing cells bear a2-adrenoceptors [57].
sumably, fulfilled by neurons that co-distribute with These cells are heterogeneous in their firing properties;
ACh-containing neurons that promote cortical activation. they include neurons that burst with cortical slow waves
In contrast to ACh-containing and presumed glutamate- and can be activated antidromically from the cortex, and
containing neurons in the basal forebrain, it is evident others that discharge tonically and slowly and are not
from FOS expression that a significant proportion of activated antidromically from the cortex [52]. Thus, they
GABA-containing neurons in this area are active during comprise both types of sleep-active neurons. In addition,
sleep-recovery following sleep-deprivation (Figure 2d–f ) the GABA-containing neurons that express FOS during
[39]. As has also been shown in similar paradigms sleep recovery also bear a2-adrenoceptors (Figure 2) [39].
[27,50,51], GABA-containing neurons in the adjacent Sleep-active neurons in the basal forebrain and preoptic
preoptic area, including the midline, medial, lateral and area are, thus, inhibited by NA-mediated stimulation of
ventrolateral areas, are also active during sleep recovery. a2-adrenoceptors. Accordingly, these neurons are inhi-
Across regions, the proportion of FOS-positive neurons bited by NA during waking and disinhibited when
that release GABA increases significantly during sleep NA-containing LC neurons decrease their discharge with
[39]. The results with FOS parallel results from recording drowsiness, to become active and promote SWS.
studies in anesthetized rats, which show that, whereas
some GABA-containing neurons in the basal forebrain GABA-containing neurons in brainstem and thalamus
discharge at their highest rates in association with cortical GABA-containing neurons in other areas also appear to be
activation (i.e. cortical activation-on), the majority active selectively during sleep to inhibit wake-active
(w60%) discharge at their highest rates in association neurons in many areas, including the brainstem RF and
with cortical de-activation and slow-wave activity LC where local GABA-containing neurons are distributed
(‘cortical activation-off ’) cells [52]. Some of the cortical and express FOS with sleep [3,22,58]. Together with
activation-off cells are activated antidromically from the glycine-containing neurons [59], GABA-containing neu-
cerebral cortex, whereas others are not and, thus, are rons in the caudal medullary reticular formation that
presumed to project either locally or caudally to either the project to the spinal cord are active during PS and might
hypothalamus or the brainstem. The cortically projecting, inhibit spinal motor neurons directly (Figure 1).
cortical activation-off GABA-containing cells might corre- In the thalamus, GABA-containing neurons in
spond in part to chemically unidentified sleep-active the thalamic reticularis inhibit thalamocortical relay
neurons that have been recorded in head-fixed naturally neurons, including those of the nonspecific
584 Review TRENDS in Pharmacological Sciences Vol.26 No.11 November 2005

thalamocortical-projection system, to dampen cortical discharge during SWS and PS. By diffuse projections and
activation [60]. Moreover, their burst pattern of discharge excitatory actions, these neurons simultaneously stimu-
during SWS triggers spindle activity (12–14 Hz) and late cortical activation, behavioral arousal and postural-
induces delta oscillations through the hyperpolarizing muscle tone. NA-containing LC neurons also uniquely
actions of GABA on the relay neurons. inhibit sleep-promoting neurons through a2-adrenocep-
tors. ACh-containing neurons in the brainstem and basal
GABA receptors and hypnotic drugs forebrain are active in association with the cortical acti-
GABA, the main inhibitory neurotransmitter in the brain, vation that occurs during both waking and PS. Further-
is not released in a state-selective manner throughout the more, they induce muscle atonia when not counterbalanced
brain. However, specific GABA-containing neurons, by other arousal systems, most notably NA-containing
including those that bear a2-adrenoceptors in the basal and Orx-containing neurons. GABA-containing neurons
forebrain and preoptic area, and GABA-containing cells that bear a2-adrenoceptors and discharge during sleep
in the brainstem and the thalamic reticularis nucleus, co-distribute with ACh-containing neurons in the basal
release GABA in a state-selective manner according to forebrain and with other neurons across the preoptic area.
their discharge profile, and inhibit target neurons of the Some of these neurons are associated with cortical slow-
arousal systems. It is, thus, not surprising that common wave activity during SWS, whereas others are associated
hypnotic drugs and anesthetics enhance GABA-mediated with diminishing muscle tone through SWS into PS. It is
neurotransmission [7,30,61–63]. Many of these agents act likely that these sleep-active neurons promote sleep when
at GABAA receptors, which are pentameric structures they are relieved from inhibition by noradrenergic affe-
comprising different subunits and linked to a ClK ion rents. Furthermore, they are likely to act via cortical
channel. Many hypnotic agents, including fluorazepam projections that inhibit cortical neurons, local projections
and zolpidem, modulate agonist activity by binding to a that inhibit either local ACh-containing neurons or
benzodiazepine (BZD)-recognition site located between other neurons, and descending projections that inhibit
the a- and g-subunits. Enhancing the postsynaptic action Orx-containing and NA-containing neurons. These neu-
of GABA on the ClK ionophore augments the inhibitory ronal and chemical substrates, which determine the
influence of sleep-promoting neurons on target neurons passage from waking to sleep, are the targets of common
that bear the BZD-recognition site. BZD agonists enhance stimulant and hypnotic drugs.
spindling activity, which is driven by the effects of
GABA-containing reticularis thalamic neurons on the Acknowledgements
thalamocortical relay neurons [60,64] that bear Most of the recent research presented was funded by grants from the
BZD-sensitive (abg) GABA A -receptor subunits [65]. Canadian Institutes of Health Research (CIHR) and U.S. National
Institutes of Health (NIH) and performed at the Montreal Neurological
Other agents, such as muscimol and gaboxadol, which Institute (MNI) by Maan Gee Lee, Ian Manns, Oum Hassani, Mandana
are direct agonists at most GABAA receptor subtypes Modirrousta, Pablo Henny and Lynda Mainville to whom I am most
(including those that contain ab-subunits but might lack grateful. I am also thankful to my collaborators, Angel Alonso at the
g-subunits and instead contain d-subunits), promote MNI and Michel Muhlethaler and colleagues at the Centre Medicale
cortical slow-wave activity and SWS [66,67]. Independent Universitaire (CMU) in Geneva, whose work is also presented.
of the release of GABA and, thus, the activity of
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Neuroscience Vol. 111, No. 2, pp. 231^239, 2002
ß 2002 IBRO. Published by Elsevier Science Ltd
All rights reserved. Printed in Great Britain
PII: S 0 3 0 6 - 4 5 2 2 ( 0 2 ) 0 0 0 3 4 - 9 0306-4522 / 02 $22.00+0.00



Laboratoire de Psychophysiologie, Faculte¤ des Sciences, Universite¤ de Nice-Sophia Antipolis, 06108 Nice Cedex 2, France

AbstractöGABA is the main inhibitory neurotransmitter of the CNS. It is well established that activation of GABAA
receptors favors sleep. Three generations of hypnotics are based on these GABAA receptor-mediated inhibitory processes.
The ¢rst and second generation of hypnotics (barbiturates and benzodiazepines respectively) decrease waking, increase
slow-wave sleep and enhance the intermediate stage situated between slow-wave sleep and paradoxical sleep, at the
expense of this last sleep stage. The third generation of hypnotics (imidazopyridines and cyclopyrrolones) act similarly
on waking and slow-wave sleep but the slight decrease of paradoxical sleep during the ¢rst hours does not result from an
increase of the intermediate stage. It has been shown that GABAB receptor antagonists increase brain-activated behav-
ioral states (waking and paradoxical sleep: dreaming stage). Recently, a speci¢c GABAC receptor antagonist was syn-
thesized and found by i.c.v. infusion to increase waking at the expense of slow-wave sleep and paradoxical sleep.
Since the sensitivity of GABAC receptors for GABA is higher than that of GABAA and GABAB receptors, GABAC
receptor agonists and antagonists, when available for clinical practice, could open up a new era for therapy of troubles
such as insomnia, epilepsy and narcolepsy. They could possibly act at lower doses, with fewer side e¡ects than currently
used drugs. This paper reviews the in£uence of di¡erent kinds of molecules that a¡ect sleep and waking by acting on
GABA receptors. ß 2002 IBRO. Published by Elsevier Science Ltd. All rights reserved.

Key words: GABAA , GABAB , GABAC , biological rhythm.



GABAA binding site 232
Barbiturate binding site 234
Benzodiazepine binding site 234
New-generation hypnotics 234
Steroid binding site 235

Insomnia is one of the most frequent complaints that sleep involved inhibitory processes: ‘the essential
encountered in a doctor’s o⁄ce. Although it is most mechanism of sleep cannot be explained di¡erently as
often related to anxiety, it commonly re£ects a lack of by active inhibition of some functions of the organism’.
central inhibitory processes. Bubno¡ and Heidenhain Although Creutzfeldt et al. (1956) observed true inhibi-
(1881) seem to have been the ¢rst to describe such central tory phenomena at the cortical cellular level, it was
inhibitory processes. They showed that low-intensity Evarts et al. (1960) who studied the recovery cycle of
peripheral and cortical stimulations were able to inhibit cortical evoked potentials induced by radiation stimula-
cortical stimulation-induced motor activities. For sleep^ tion and demonstrated inhibitory mechanisms during
waking behavior, it was Hess (1931) who ¢rst claimed sleep^waking behavior. From the neurochemical stand-
point, since the pioneering work of Krnjevic et al. (1966),
it has been acknowledged that GABA is the principal
*Tel. : +33-4-92-07-61-66; fax: +33-4-92-07-61-62.
inhibitory transmitter and nowadays it is estimated that
E-mail address: (C. Gottesmann). 20% at least of brain neurons are GABAergic (Parades
Abbreviations : CACA, cis-4-amino crotonic acid; EEG, electroen- and Agmo, 1992).
cephalogram; TPMPA, (1,2,5,6-tetrahydropyridine)-methylphos- The pentameric GABAA ionotropic receptor (Fig. 1,
phonic acid. top) was the ¢rst to be identi¢ed, with several classes of

NSC 5488 19-4-02 Cyaan Magenta Geel Zwart

232 C. Gottesmann

subunits K, L, Q, b, N, Z, O and a: K comprising six and the amount of waking (Schneider et al., 1977).
subunits in rats, L four subunits, Q three subunits, and More recent data have established that inhibition of
b three subunits (Mo«hler et al., 1990; Duncan et al., uptake (Fink-Jensen et al., 1992) has little or no e¡ect
1995; Schmid et al., 1995; Barnard et al., 1998; Davies on the duration of sleep stages (Lancel et al., 1998). The
et al., 2000); the Q2 binding site has been shown to com- more speci¢c in£uence of GABA on sleep mechanisms
prise two variants, Q2L and Q2S, which di¡er by eight was principally studied through the action of its agonist
amino acids (Duncan et al., 1995). The GABAA receptor muscimol. Mendelson and Martin (1990) found no in£u-
complex consists of a Cl3 ionophore principally coupled ence on slow-wave sleep and paradoxical sleep in rats.
to GABA, barbiturate, benzodiazepine, steroid, and pic- Lancel et al. (1996a, 1997a) found an increase in both
rotoxin binding sites (McDonald and Olsen, 1994). and the low frequencies of electroencephalogram (EEG)
GABA’s in£uence on its own binding site has been (2^6 c/s) were increased during slow-wave sleep. A sim-
most often studied by the antagonist bicuculline and ilar enhancement of slow-wave activity and the corre-
the agonist muscimol (Sieghart, 1995). However, many sponding sleep stage was observed by Lancel (1997) in
compounds binding to other sites have given rise to rats with another agonist (gaboxadol), the same e¡ect
numerous studies on sleep. The second receptor to be occurring in humans (Faulhaber et al., 1997). Muscimol
identi¢ed was the GABAB receptor (Hill and Bowery, was also used by infusion to identify local structure func-
1981) which is coupled to Ca2þ and Kþ ion channels tions. Injection in the anterior hypothalamus which is
and functions by a metabotropic pathway with a second involved in sleep-generating processes (Von Economo,
messenger. The a⁄nity of GABA to GABAB receptors is 1928; Nauta, 1946; Sterman and Clemente, 1962;
lower than for GABAA receptors (Chu et al., 1990). This Bremer, 1973; Szymusiak and McGinty, 1986; Ogawa
receptor was ¢rst blocked by phaclofen and the agonist and Kawamura, 1988; Sallanon et al., 1989; Cirelli et
most often used is baclofen. The modulation of this al., 1995) produced transient insomnia (Lin et al.,
receptor has given rise to only a few studies on sleep. 1989), and recent results have con¢rmed that anterior
The third receptor identi¢ed is that for GABAC (Fig. 1, hypothalamic neurons (of the ventrolateral preoptic
bottom). Indeed, as early as 1975 (Johnston et al., 1975) nucleus) favoring sleep are GABAergic (Gallopin et al.,
and again later (Parades and Agmo, 1992), it appeared 2000). Moreover, it is known that anterior hypothalamic
that some GABA analogues acted on bicuculline- and GABAergic neurons project to the posterior hypothala-
baclofen-insensitive receptors. These GABAC receptors mus (Gritti et al., 1994) and muscimol injection to pos-
(Drew et al., 1984) were ¢rst observed at the retinal terior hypothalamus target neurons which are involved
level (Feigenspan et al., 1993; Quian and Dowling, in the generation of wakefulness (Von Economo, 1928;
1994), then at the central brain level (Bormann and Ranson, 1939; Nauta, 1946; McGinty, 1969; Lin et al.,
Feigenspan, 1995; Boue-Grabot et al., 2000). This recep- 1999) promoted slow-wave sleep and inhibited paradox-
tor comprises a Cl3 ionophore and several subunits (b1, ical sleep (Lin et al., 1989) even in cats with anterior
b2, b3) (Ogurusu et al., 1997). It is also more sensitive to hypothalamic lesions (Sallanon et al., 1989). Further-
GABA than the GABAA receptor and its desensitization more, there is an increased release of GABA during
is also di¡erent (Quian and Dowling, 1994): ‘while the slow-wave sleep in this posterior hypothalamic area
amplitude of GABAA receptor-mediated currents (Nitz and Siegel, 1996). At the brainstem level, muscimol
decreases notably in the presence of agonists, the time- infusion in the rat pontine reticular formation increases
course of GABAC receptor responses is more sustained’ waking and decreases slow-wave sleep, and the latency of
(Bormann and Feigenspan, 1995). paradoxical sleep occurrence is prolonged (Camacho-
Up to now, insomnia has been principally treated by Arroyo et al., 1991) in such a way that it seems to cor-
compounds acting at the GABAA receptor level. I pro- respond to a suppression followed by a rebound of this
pose to analyze the function of the di¡erent kind of sleep stage. Similar results were obtained recently in cats
GABA receptors and their clinical potentialities. (Xi et al., 1999a), where antisense nucleotide against glu-
tamic acid decarboxylase (when injected in the pons) in-
duces an increase of paradoxical sleep (Xi et al., 1999b).
GABAA RECEPTOR COMPLEX Other data suggest that brainstem ‘GABAergic neurons
could be responsible for inhibiting ‘paradoxical sleep-on’
GABAA binding site neurons during slow-wave sleep and waking and disinhi-
biting them during paradoxical sleep’ (Mallick et al.,
The function of the GABA receptor binding site is to 1999; Maloney et al., 2000). All conclusions based on
open a chloride channel. Some time ago it was shown results with muscimol have to be approached with cau-
that the global central increase of GABA by i.c.v. infu- tion since this compound is also a GABAC receptor ago-
sion of GABA or inhibition of GABA transaminase nist (Bormann and Feigenspan, 1995) and, as already
increased slow-wave sleep and induced a 64% drop of mentioned, the sensitivity of this receptor for GABA is
paradoxical sleep without rebound e¡ect in cats higher than for the GABAA receptor. Several studies
(Karadzic, 1966; Holmes and Sugden, 1975), and did related to GABA were also undertaken at midbrain
not in£uence the recovery of paradoxical sleep after and pontine monoaminergic levels. Nitz and Siegel
selective deprivation in rats (Juan de Mendoza et al., (1997a) showed the highest amount of GABA release
1973). In humans it seemed to have no signi¢cant in£u- during paradoxical sleep in the dorsal raphe nucleus
ence on paradoxical sleep but decreased sleep latency which contains glutamic acid decarboxylase-labeled neu-

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GABA and sleep 233

Fig. 1. Schematic illustration of the GABAA and GABAC receptors. (a) The GABAA receptor, which is a Cl3 pore, has
binding sites for barbiturates, benzodiazepines and neurosteroids. The GABA responses are blocked competitively by bicucul-
line and non-competitively by picrotoxinin. The GABAB receptor agonist baclofen is without e¡ect, like the GABAC receptor
agonist, CACA, and antagonist, TPMPA. The vertebrate GABAA receptor is built from several subunits, some examples of
which are shown on the right-hand side. (b) Each subunit comprises four transmembrane domains. (c) The GABAC receptor
is activated by CACA and antagonized by TPMPA. It is blocked by picrotoxinin. It comprises three subunits (see on the
right). Both receptors are modulated intracellularly by protein kinases. Reprinted from Bormann (2000) with permission of

rons (Ford et al., 1995) and receives a¡erents from di¡er- 1975). However, partial results involving only few cells
ent brain levels (Gervasoni et al., 2000). Moreover, the show that neurons of the locus coeruleus are able to ¢re
infusion of muscimol increases the amount of paradox- without suppressing paradoxical sleep (Gervasoni et al.,
ical sleep (Sastre et al., 1996, 1999; Nitz and Siegel, 1998) as can dorsal raphe nucleus neurons in the normal
1997a). The locus coeruleus, which also contains some animal (Gervasoni et al., 2000) or in the cat with aboli-
GABAergic interneurons (Ijima and Ohtomo, 1988), tion of paradoxical sleep atonia (by pontine lesions)
receives GABAergic terminals from the medullary pre- (Trulson et al., 1981). These data strongly suggest that
positus hypoglossi nucleus (Ennis and Aston-Jones, the GABAergic inhibition of one of these neuron areas is
1989). Recent ¢ndings show that the highest amount of su⁄cient for the appearance of this sleep stage. It should
GABA occurs in the locus coeruleus during paradoxical be noted that, for the raphe nucleus, the inhibition of
sleep (Nitz and Siegel, 1997b) and that the local infusion serotonergic neuron ¢ring during paradoxical sleep could
of the GABA receptor antagonist picrotoxin reduces the be partly consecutive to disfacilitation of serotonergic
duration of paradoxical sleep phases (Kaur et al., 1997). neurons (Levine and Jacobs, 1992; Sakai and Crochet,
It is noteworthy that the locus coeruleus and the dorsal 2000). At the level of the medulla itself, which plays an
raphe nucleus have been shown to be permissive struc- important role in processes inducing slow-wave sleep
tures for paradoxical sleep appearance (Hobson et al., (Batini et al., 1958; Magnes et al., 1961; Bonvallet and

NSC 5488 19-4-02 Cyaan Magenta Geel Zwart

234 C. Gottesmann

Allen, 1963) and paradoxical sleep (Webster et al., 1986; which show that there is no potentiation of sleep by
Vanni-Mercier et al., 1991; Gottesmann et al., 1995; stimulation of the GABAA and benzodiazepine binding
Jouvet et al., 1995), there are GABAergic interneurons. sites (Mendelson and Martin, 1990; Lancel et al., 1997a).
These ‘could T be responsible for the inhibition of para- The stimulation of the benzodiazepine binding site pro-
doxical sleep-o¡ cells presumed to be in part serotonergic motes slow-wave sleep in humans, particularly stage II
or (indirectly for) the disinhibition of paradoxical sleep- (with spindle enhancement) at the expense of stages III
on cells, presumed to be in part cholinergic’ (Holmes et and IV, and inhibits paradoxical sleep (and its eye move-
al., 1994; Holmes and Jones, 1994). ments) (Gaillard et al., 1973; Monti and Altier, 1973;
Borbely et al., 1985; Mendelson and Martin, 1990;
Barbiturate binding site Lancel et al., 1996a). In animals most benzodiazepines,
like barbiturates, increase the intermediate stage and
Barbiturates stimulate K1 and L1 sites and favor the decrease or suppress paradoxical sleep (Gandolfo et al.,
binding of GABA. ‘At higher doses, barbiturate mole- 1994), except for midazolam which increases both the
cules can activate the chloride channel directly, in the intermediate stage and paradoxical sleep in rats at 1
absence of GABA’ (Mo«hler, 1992). Barbiturates (synthe- and 3 mg/kg injected i.p. (Gandolfo et al., 1994) and
sized in 1862) have long been known to induce sleep and increases paradoxical sleep in rabbits at 1 mg/kg injected
they have had clinical applications since 1903. They pro- i.v. (Scherschlicht and Marias, 1983), while Lancel et al.
mote slow-wave sleep and inhibit paradoxical sleep (with (1996a) found a decrease of paradoxical sleep at 3 mg/kg
a rebound e¡ect) (Oswald, 1968). However, in rats i.p. in rats. At the central level, benzodiazepines injected
(Gottesmann, 1964, 1996) and cats (Gottesmann et al., in the dorsal raphe nucleus increase waking (Mendelson
1995; Gottesmann, 1996) these ¢rst-generation hyp- et al., 1987); this result recalls the insomnia induced by
notics, at low and medium doses, massively extend the raphe nucleus lesion in cats (Jouvet and Renault, 1966).
‘intermediate stage’ (Gottesmann, 1967, 1972), the turn-
ing point at the junction of slow-wave sleep and para- New-generation hypnotics
doxical sleep. This stage, also identi¢ed in mice (Glin et
al., 1991), is characterized by high-amplitude cortical The third generation of sedative-hypnotic compounds
spindles and a low-frequency hippocampal theta rhythm. comprises principally the imidazopyridines (zolpidem)
Several arguments suggest that it corresponds to a tran- and the cyclopyrrolones (zopiclone) which also bind to
sient disconnection of the forebrain from the brainstem, the GABAA receptor complex. Zolpidem (Depoortere et
thus constituting a physiological cerveau isole¤ stage al., 1986), which binds to K1, L2, Q2 subunits with a
(Bremer, 1935). Indeed, the thalamic responsiveness preference for the Q2L variant (Duncan et al., 1995), in-
which is controlled by midbrain facilitating in£uences duces sleep at much lower doses than benzodiazepines
(Dumont and Dell, 1958; Steriade, 1970) is the lowest (Depoortere et al., 1986). It reduces sleep latency in
of all sleep^waking stages (Gandolfo et al., 1980) and humans (Lund et al., 1988; Declerck et al., 1992), but
intercollicular transections induce a continuous inter- does not induce signi¢cant changes in night sleep distri-
mediate stage in rats (Gottesmann et al., 1980) and bution although there is a decrease of EEG low fre-
cats (Gottesmann et al., 1984). Finally, barbiturates sup- quency bands (910 Hz), an enhancement of the
press pontine activation responsible for the central and frequency range of spindles (Lancel and Steiger, 1999)
peripheral characteristics of paradoxical sleep and a decrease of paradoxical sleep (Brunner et al.,
(Gottesmann, 1967, 1969, 1996). Consequently, stimula- 1991; Declerck et al., 1992). In rats, zolpidem increases
tion of the barbiturate binding site inhibits the midbrain slow-wave sleep (Depoortere et al., 1995), and decreases
as well as the pontine and mesopontine reticular core paradoxical sleep during the ¢rst 2 h (Gottesmann et al.,
responsible for waking (Moruzzi and Magoun, 1949; 1994) but not on a 6-h recording (Gottesmann et al.,
Steriade, 1996) and paradoxical sleep (Jouvet and 1994; Depoortere et al., 1995). Zopiclone (Stutzmann
Mounier, 1960; Sakai, 1988; Datta and Siwek, 1997) et al., 1993) acts as a partial agonist at the benzodiaze-
respectively. pine receptor level (Concas et al., 1994). ‘The di¡erences
between zopiclone and the classical benzodiazepines that
Benzodiazepine binding site have been reported previously must be due to distinct
interactions of these ligands with recognition site
In 1971 the era of benzodiazepines came fully into domains other than that represented by histidine 101’
being with £urazepam (Mitler, 2000). The binding site (Davies et al., 2000). It reduces sleep latency in humans,
of benzodiazepines on the GABAA receptor complex ‘is decreases stage I, increases stage II, has almost no e¡ect
distinct, but is nonetheless functionally coupled with the on stages III and IV and reduces paradoxical sleep
GABAA binding site and they regulate each other in an (Stutzmann et al., 1993; Lancel and Steiger, 1999). In
allosteric manner. Benzodiazepine agonists enhance the rats, it also decreases sleep latency and increases the
a⁄nity of GABA for its receptor and hence its inhibitory latency of the intermediate stage and paradoxical sleep.
function. Similarly, GABA (or GABAA receptor ago- This last stage is decreased by up to 6 h, but the inter-
nists, like muscimol) increases the a⁄nity of benzodiaze- mediate stage is never increased as is observed under
pine agonists for their receptor’ (Sadzot and Frost, barbiturates and most benzodiazepines (Gauthier et al.,
1990). However, it is worth mentioning two studies 1997a,b; Gottesmann et al., 1998).

NSC 5488 19-4-02 Cyaan Magenta Geel Zwart

GABA and sleep 235

Steroid binding site 1967, 1969; McCarley and Hobson, 1971; McGinty et
al., 1974; Moroz et al., 1977; Vertes, 1977). In the same
Only a few studies have been speci¢cally devoted to way, phaclofen, another antagonist, increased paradoxi-
the steroid binding site for sleep mechanisms. It is well cal sleep when infused in the pontine reticular oralis
known that pregnancy is often associated with sleepiness nucleus of the cat, while waking and slow-wave sleep
and a tendency to increased daily sleeping time. Lancel et were not a¡ected (Xi et al., 2001).
al. (1997b) studied allopregnanolone, which is a neuro- The study of these agonists and antagonists of the
active steroid, and Edgar et al. (1997) studied pregnano- GABAB receptor con¢rms the sleep-inducing properties
lone, another neuroactive steroid, and an active analogue of this receptor.
of it. They induced an increase in slow-wave sleep, allo-
pregnanolone decreasing the EEG slow frequencies (97
c/s) and increasing the spindle frequencies (v13 c/s). A GABAC RECEPTORS
steroid precursor, pregnenolone, did not change the
sleep^waking cycle distribution but promoted the cortical Hitherto, it has been di⁄cult to study the in£uence of
slow waves (0.5^4 c/s) within slow-wave sleep (Lancel et the GABAC receptor on behavior since the agonist trans-
al., 1994). However, studying the in£uence of progester- 4-aminocrotonic acid (TACA) and its cis-enantiomer
one and allopregnanolone with more detailed sleep CACA, the ¢rst compounds acting on this receptor to
stages, Lancel et al. (1996b, 1997b) were able to observe be identi¢ed, were not speci¢c, like the ¢rst antagonists
a pronounced increase in the intermediate stage and a (Bormann and Feigenspan, 1995; Quian and Dowling,
decrease of paradoxical sleep with progesterone. This 1996). However, in 1996 the ¢rst selective antagonist was
e¡ect could be related to the bioconversion (of proges- uncovered: (1,2,5,6-tetrahydropyridine)-methylphos-
terone) into neuroactive metabolites (Lancel, 1999) like phonic acid (TPMPA) (Murata et al., 1996; Ragozzino
allopregnanolone and, to a lesser extent, pregnanolone. et al., 1996).
Consequently, all agonists of GABAA receptor bind- The ¢rst results show that GABA acting at these
ing sites (except the picrotoxin binding site) favor sleep, receptors is also involved in sleep^waking regulation.
although physiological sleep is better respected only with Indeed, TPMPA increases both quiet and active waking
third generation hypnotics. (with hippocampal theta rhythm), decreases total slow-
wave sleep, essentially by decreasing the slow-wave stage
(spindles and the intermediate stage are not signi¢cantly
GABAB RECEPTORS modi¢ed), and also decreases paradoxical sleep (Arnaud
et al., 2001).
These receptors are involved in sleep^waking regula- Regarding the decrease in paradoxical sleep, there are
tion as shown by lethargic (lh/lh) mice which have con£icting results with compounds acting on GABAA
increased numbers of GABAB receptors in the cortex and GABAB receptors. It can be hypothesized that the
and thalamus (Lin et al., 1993, 1995). Moreover, decrease in this sleep stage induced by the GABAC
GABAB receptor antagonists infused in the thalamus receptor antagonist is related to corresponding receptors
decrease EEG slow waves and deep slow-wave sleep located at the neuron level in the dorsal raphe and locus
while light slow-wave sleep is increased (Juhasz et al., coeruleus nuclei (Nitz and Siegel, 1997a,b; Gervasoni et
1994). These compounds are used to alleviate absence- al., 1998, 2000). Their blockade may induce a disinhibi-
epilepsy in humans (Marescaux et al., 1992; Bittinger et tion of monoaminergic in£uences antagonistic to this
al., 1993) partly because of their thalamic impact on sleep stage (and otherwise favoring waking; Berlucchi,
relay and reticular nuclei (Lin et al., 1992), this brain 1997). The contradictory result obtained with GABAA
level having the highest number of GABAB receptors and GABAB receptor acting compounds seems to be
(Crunelli and Leresche, 1991). At this level, the reduction linked to an inhibition of paradoxical executive processes
of GABAA receptor-mediated inhibition markedly (Gottesmann, 1967, 1969, 1996; McCarley and Hobson,
enhances GABAB receptor inhibitory postsynaptic 1971; Sakai, 1988; Xi et al., 1999b, 2001).
potentials in relay cells (Krosigk et al., 1993). Sleep stud-
ies were also undertaken in humans. Guilleminault and
Flagg (1984), in a double-blind study, found a dose- CONCLUSION
related increase in slow-wave sleep and a reduction of
paradoxical sleep with the agonist baclofen, while The three currently identi¢ed GABA receptors have
Finnimore et al. (1995) observed an increase in both similar hypnotic e¡ects when stimulated. Some di¡er-
slow-wave sleep and paradoxical sleep. In rats the recep- ences appear when the quality of sleep is examined.
tor antagonist (CGP 35348) increased slow-wave sleep Slow-wave sleep is enhanced in all cases. It can be
and paradoxical sleep in one study (Puigcerver et al., strongly hypothesized that when antagonists promote
1996) and increased waking and paradoxical sleep in waking, agonists, where available, will increase sleep.
another (Gauthier et al., 1997a,b). The ¢ndings of the The intermediate stage is extended at the expense of
last study are more in accordance with expected physio- paradoxical sleep by barbiturates, most benzodiazepines
logical results since these two behavioral stages are char- and steroids but not by new-generation hypnotics.
acterized by activation of the midbrain (Moruzzi and GABAB and GABAC receptor antagonists used so far
Magoun, 1949; Steriade, 1996) and pons (Gottesmann, are not appropriate compounds for the study of this

NSC 5488 19-4-02 Cyaan Magenta Geel Zwart

236 C. Gottesmann

e¡ect on the intermediate stage, because of its natural ci¢c agonists, when identi¢ed, could be useful
shortness; speci¢c agonists would be more appropriate. compounds in clinical use as hypnotics and perhaps
Finally, paradoxical sleep is decreased by agonistic anti-epileptics, with fewer side e¡ects than current med-
modulators of GABAA receptors, and increased by ications. It is also not excluded that antagonists could be
GABAB receptor antagonists ^ parallel results ^ e¡ective on narcoleptic attacks since there is GABAergic
whereas the ¢rst available GABAC receptor antagonist participation in recent molecules which relieve this dis-
decreases this sleep stage. Altogether, these results show ease (Lin et al., 2000).
the complexity and richness of brain regulation process-
es and could explain why a global in vivo increase in
extracellular GABA by various methods leads to di¡er- NOTE ADDED IN PROOF
ent results.
It seems probable that future research will be directed Kauer et al. (2001) con¢rmed that the medulla prepo-
towards GABAC receptors which could have an impor- situs hypoglossi nucleus regulates paradoxical sleep by
tant function in global behavior organization. Indeed, GABAergic neurons which inhibit locus coeruleus neu-
they are more sensitive to GABA than GABAA and rons.
GABAB receptors and their desensitization is much
slower (Chebib and Johnston, 1999; Bormann, 2000).
Thus, low concentrations of GABA should act preferen- AcknowledgementsöI thank Professor G. Morgan for correction
tially on GABAC receptors. To speculate somewhat, spe- of the English.


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(Accepted 21 January 2002)

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