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•A condition of unsatisfactory quantity and/or quality of sleep, which persists for a considerable period of time, including difficulty falling asleep, difficulty staying asleep, or early final wakening.
Stages of Sleep 

Stage 1

•Stage 1 sleep, or drowsiness, is often described as first in the sequence


•The eyes are closed during Stage 1 sleep, but if aroused from it, a person may feel as if he or she has not slept. Stage 1 may last for five to 10 minutes.
•alpha rythm


Stage 2

•Stage 2 is a period of light sleep during which spontaneous periods of muscle tone mixed with periods of muscle relaxation occur. Muscle tone of this kind can be seen in other stages of sleep as a reaction to auditory stimuli.


•The heart rate slows, and body temperature decreases. At this point, the body prepares to enter deep sleep

Stages 3 and 4

•These are deep sleep stages, with Stage 4 being more intense than Stage 3. These stages are known as slow-wave, or delta sleep.


Non-REM Sleep

•The period of non-REM sleep (NREM) lasts from 90 to 120 minutes, each stage lasting anywhere from 5 to 15 minutes.


•A normal sleep cycle has this pattern: waking, stage 1, 2, 3, 4, 3, 2, REM.
Stage 5, REM 
•REM sleep is distinguishable from NREM sleep by changes in physiological states, including its characteristic rapid eye movements.
•In normal REM sleep, heart rate and respiration speed up and become erratic, while the face, fingers, and legs may twitch.
•Intense dreaming occurs during REM sleep as a result of heightened cerebral activity, but paralysis occurs simultaneously in the major voluntary muscle groups, including the submental muscles (muscles of the chin and neck).
•It is sometimes called paradoxical sleep.
•The first period of REM typically lasts 10 minutes, with each recurring REM stage lengthening, and the final one lasting an hour.
•EEG shows increased activity

REM Sleep
Rapid Eye Movement Stage-

—Brain waves increase to the awake level
—Most dreams occur during this stage
¡If awoken in this stage, most people remember their dreams
—Physical changes during REM
¡Increase in H.R., B.P., and breathing rate
¡Breathing more shallow and irregular
¡Eyes jerk rapidly
¡Limb muscles temporarily paralyzed
¡Some loss of temperature regulation
¡Men may experience erections
—Most people have 3-5 intervals of REM each night
—Infants spend 50% of time in REM
—Adults spend nearly half of time in Stage 2
¡20% in REM, other 30% divided among other stages
¡Progressively spend less time in REM as we age
*Classified as the inability to get enough sleep despite adequate time.
*Symptoms Include:
*Delayed Sleep Onset
*Early Morning Wake-Ups
*Unrefreshing Sleep
*Trouble Maintaining Sleep
*Causes many problems in daytime functioning

 Primary Insomnia-

*Also referred to as Idiopathic
*This is diagnosed when a patient has no other cause of insomnia other than the fact they cannot sleep
*Also been known to be patient confusion and misconception around what is meant and understood to be sleep

 Acute Insomnia-

*This is when a patient suffers from insomnia fewer than 3 times a week for less than a month
*Typically stems from changes in the environment and a short illness the patient might have had


—We spend 1/3 of our lives asleep
—Sleep is an active process
—No organ or regulatory system “shuts down”
¡Slight decrease in metabolic rate
—Some brain activity increases during sleep
¡Delta Waves
¡Many parts of the brain are as active as  awake periods
¡At least 2 hours of dream state per night
—Specific hormones increase during sleep
¡Growth hormone
—Specific cues exist for regulation of sleep
How much sleep do we need?
—Infants   16-20
—Toddlers    12-14
—Pre School   11-13
—School Age  10-11
—Teens  9.5-10

—Most adults need 7 ½ -8 hours to function well

¡About 10% require more or less sleep
¡Pregnant women need more sleep

 Causes of Insomnia-

*Often caused by depression or other psychiatric problems
*Also caused by excess, lasting stress or racing thoughts at bedtime
*Symptoms of insomnia also could be cause by other sleeping disorders such as:
*Restless Leg Syndrome
*Sleep Apnea
Declared a public health problem by
Institutes of Medicine of the National Academies-
—An estimated 50% of Americans are sleep deprived
—30% average less than 6 hours per night
—Estimated 70 million with insufficient sleep
—7 out of 10 have trouble sleeping
—40 million suffer from some long term disorder
—20 million experience occasional problems
—1/3 of Americans have symptoms of insomnia
—The cumulative effects of sleep loss and sleep disorder represent an under recognized public health problem
—2/3 of children have several sleep problems per week
—25%-40% of children have sleep disorders
—10-12% snore regularly
Contributors to Sleep Disorders-
¡Menopause, hot flashes, hormone changes
¡1/3 of older adults have insomnia
¡More nocturnal awakenings, more fitful sleep
¡40% have sleep apnea
¡½ of people with sleep apnea have diabetes
—Arthritis, osteoporosis, dementias, heart disease, lung disease, cancers
—digestive disorders


 Common Sleep Disorders-

—Insomnia 9-12%
—Restless leg syndrome-5%
—Over 80 different disorders

Common Disorders in Children-

—Dyssomnias-disturbance in the amount, timing or quality of sleep
¡Sleep apnea, 1-3%
¡Restless leg syndrome
¡Periodic limb movement

 —Parasomnias-disorders with abnormal behavior or physiological events, interference with sleep stage transition

¡Arousal disorders
÷Night terrors,4-8 yr old
÷Sleep walking, 6-12 yr olds
¢Up to 40% sleep walk
¡Sleep wake transition
÷Sleep talking
¡Nightmares, 3-5%
¡Teeth grinding or bruxism
¡Bedwetting, 15%, boys, age 3+

 Obstructive Apnea in Children-

—Most common sleep disorder
—Occurs in 1-3% of children
—Most common in preschool children
—Symptoms During sleep
¡Restless sleep
¡Interruption of breathing
¡Chronic mouth breathing

 General Symptoms of a Sleep Problem-

¡Performance decrease: academic, physical, etc.
¡Behavioral difficulties
¡Frequent illness
¡Headaches, jaw pain, earaches
¡Depression, anxiety
Daytime sleepiness


In general-
—4 out of 10 adults sleepiness interfere with activities a few days each month
—20% adults sleepiness interferes a few days per week or more
—Direct cost of sleep related problems 16 billion dollars
—Indirect cost 50-100 billion

 Poor Functioning-

—Drowsy driving
¡Sleep deprived, 2-4 times greater risk of an accident
¡100,000 auto accidents
¡71, 000 injuries
¡1,550 deaths
¡20% of all drivers have dozed at least once behind the wheel
¡One night of  sleep deprivation is equal to legal intoxication
¡Chernobyl, Three Mile Island, Challenger, Exxon Valdez
¡Contributed to by errors in judgment from fatigue, sleepiness
More mistakes!-
¡Work Performance and accidents
¡Contributes to job absenteeism, lost productivity
¡Mistakes and work accidents increase
—Medical errors- study with sleepy interns
¡36% more serious errors
÷Of which 31% caused a fatality
¡28% more intercepted errors
¡57% more non-intercepted errors
¡21% more medication errors
¡5.6 times as many serious diagnostic errors

Health Consequences -

—Cardiovascular system-increase in heart disease
¡Increase in blood pressure
¡Increase risk for heart attacks,  strokes, 5 or fewer hours have 45% greater risk
¡Affects appetite regulating hormone
¡Diabetes and impaired glucose tolerance
÷2.5 times more with 5 or less hours of sleep
÷1.7 times more with 6 or fewer hours of sleep
¡Obesity and weight management
¡Increase in stress hormones
¡Thyroid and growth hormones affected
—Immune system-more susceptible to illness
—Nervous system-memory and learning affected
¡Balance is affected, more falls, 2 to 4.5 greater chance of falling
¡Increased risk of tremors, seizures
¡Increase in pain, frequent headaches
—Mental Health
¡Decreased neurotransmitters affecting mood
¡More distress, irritability, depression , alcohol use, suicide
¡Decreased quality of life
—Early death
¡Less than 6 hours of sleep or less per night-
¡15%-30% greater risk of dying, regardless of cause
¡Protective factors of avoiding tobacco, alcohol, and unhealthy foods  lost with sleep deprivation

 Treatment of Disorders-

—Good Sleep Hygiene
—Psychotherapy, stress management
—Relaxation techniques
—OSA treatment
¡Mouth appliance
¡Surgery-tonsils and/or adenoids
¡Weight reduction if obese

CPAP-Continuous positive airway pressure

 Sleep Hygiene
What contributes to good sleep?

¡Relaxing Routine
÷Warm bath/shower
÷Quiet activities
÷Lower lights
¡Regular sleep schedule
÷Go to bed and get up around the same time
÷Limit naps
¡Limit stimulating behaviors before bedtime
÷Limit caffeine after 2 pm
÷Limit alcohol after dinner
÷Limit large or spicy meals
÷Limit vigorous exercise 4-6 hours before bed
—De-stress, learn relaxation techniques 
¡Physical and mental
—Maintain a regular physical activity routine
¡Physical activity helps with stress
¡Fitness reportedly helps with sleep quality
—Do not go to bed hungry or full
¡Light snack of carbos and foods with tryptophan

Practice stimulus control 

¡Bed for sleeping only, limit other activities (except sex!)
÷Eating, reading, watching television, studying, work, hobbies
¡Go to bed when you are drowsy
¡If you don’t fall asleep within 10-15 minutes
÷Get up, leave the bedroom
÷Read or watch something dull
¡Room and bed comfortable
÷Little clutter (Feng Shui the bedroom) 
÷No pets on/in the bed
÷Temperature Cool
÷Lighting low, expose yourself to bright lights during day
÷Bed, sheets, PJ’s comfortable and not binding