Basic features of normal sleep

The scientifi c study of sleep and its disorders is largely confi ned to
the last several decades. Essentially interdisciplinary advances have
displaced earlier speculative accounts including those in psychiatry
concerning the signifi cance of dreams, for example. They are well
described in recent textbooks of sleep disorders medicine (see recommended
sources). Only general points are mentioned here, with
special reference to psychiatry where possible.
The nature of sleep
Sleep has characteristic physiological features which distinguish it
from other states of relative inactivity. Two distinct sleep states have
been defi ned, that is non-rapid eye movement (NREM) sleep and
rapid eye movement (REM) sleep. The onset of sleep is not simply
the shutdown of wakefulness but also the switching between
wakefulness, NREM and REM sleep involve complicated active
neurochemical mechanisms in different parts of the brain.
The functions of sleep
Debate continues about the various theories concerning sleep, each
of which has emphasized physical and psychological restoration
and recovery, energy conservation, memory consolidation, discharge
of emotions, brain growth and various other biological functions
including somatic growth and repair, and maintenance of immune systems. No one theory accounts for all
the complexities of sleep
and it seems likely that sleep serves multiple purposes.
From the practical point of view, the most obvious observation is
that both physical and psychological impairment follows persistent
sleep disturbance. Animals totally deprived of sleep for a long periods
die with loss of temperature regulation and multiple system failure.
As described later, the adverse effects of chronic sleep loss (considered
to be common in modern society) on mood, behaviour,
and cognitive function can be substantial, with various consequences
for personal, social, occupational, educational, and family
functioning.
Sleep stages
Conventionally, standard criteria are used to identify different
sleep stages according to their characteristic physiological features
especially in the electroencephalogram (EEG), electrooculogram
(EOG), and electromyogram (EMG).
NREM sleep is divided into four stages of increasing depth.
Stage I occurs at sleep onset or following arousal from another
stage of sleep. This stage represents 4–16 per cent of the main sleep
period. Stage II contains more slow EEG activity but is still relatively
light sleep. It accounts for 45–55 per cent of overnight sleep.
Stage III (4–6 per cent of total sleep time) contains yet more slow
EEG activity. Stage IV is characterized by the slowest activity and
constitutes 12–15 per cent of sleep. The combination of stages III
and IV is called slow wave sleep (SWS) or delta sleep and is considered
to be the deepest form of sleep from which awakening is
particularly diffi cult. The arousal disorders such as sleepwalking
arise from SWS.
REM sleep is physiologically very different. Brain metabolism is
highest in this stage of sleep. Spontaneous rapid eye movements
are seen and the skeletal musculature is effectively paralysed. Heart
rate, blood pressure, and respiration are all variable, body temperature
regulation ceases temporarily, and penile and clitoral tumescence
occurs. REM sleep usually takes up 20–25 per cent of total
sleep time. Most dreams, including nightmares, occur in REM sleep.
Sleep architecture
NREM and REM sleep alternate cyclically throughout the night
starting with NREM sleep lasting about 80 min followed by about
10 min of REM sleep. This 90 min sleep cycle is repeated three to six
times each night. Each REM period typically ends with a brief
arousal or transition into light NREM sleep.
In successive cycles the amount of NREM sleep decreases and the
amount of REM sleep increases. SWS is usually confi ned to the fi rst
two sleep cycles. The diagrammatic representation of overnight
sleep is known as a hypnogram, a simplifi ed form of which is
shown in Fig. 4.14.1.1.
In addition to this conventional sleep staging, there has been
increasing interest in the microstructural fragmentation of sleep by
frequent, brief arousals (seen mainly in the EEG) lasting a matter
of seconds without obvious clinical accompaniments. This subtle
type of sleep disruption, overlooked by conventional sleep staging,
is increasingly associated with impairment of daytime performance,
mood, and behaviour.
Circadian sleep–wake rhythms
The timing of sleep (but not its amount) is regulated by a circadian
‘clock’ in the suprachiasmatic nucleus (SCN) of the hypothalamus.
The intrinsic circadian sleep–wake rhythm is close to 24 h in human
adults. Other species are different, an extreme example being
dolphins and some other creatures which shut down one cerebral
hemisphere at a time (‘unihemispheric sleep’), allowing them to be
constantly alert. From an early age the individual sleep–wake
rhythm has to synchronize with the 24-h day–night rhythm. The
main zeitgeber by which this is achieved (‘entrainment’) is sunlight
but social cues, such as mealtimes and social activities, are also
important.
The SCN also controls other biological rhythms including body
temperature and cortisol production with which the sleep–wake
rhythm is normally synchronized. In contrast, growth hormone is
locked to the sleep–wake cycle and is released with the onset of
SWS, whatever its timing.
Melatonin is related to the light–dark cycle rather than the
sleep–wake cycle. It is secreted by the pineal gland during darkness
and suppressed by exposure to bright light (‘the hormone of
darkness’). It infl uences circadian rhythms via the SCN pacemaker
which in turn, regulates melatonin secretion by relaying light
information to the pineal gland. The widespread popularity of
melatonin as a sleep-promoting agent is not justifi ed by what little
is known about its action and clinical effectiveness.
Changes with age
Changes in basic aspects of sleep are prominent from birth to old
age, although individual differences are seen at all ages. Changes of
clinical signifi cance include the following:
􀁘 Total sleep time decreases with age. Average daily values are as
follows: newborns 6–18 h; young children 10 h; adolescents 9 h
(although often they obtain signifi cantly less than this); adults
7.5–8 h, including possibly the same in elderly people. The total
amount of sleep includes daytime napping in children up to the
age of about 3 years.
􀁘 SWS is particularly prominent in prepubertal children who sleep
very soundly. Its decline begins in early adolescence and continues
throughout childhood.
􀁘 The proportion of REM sleep declines from 50 per cent or more
of total sleep time in the newborn (more than this in premature
babies) to 20–25 per cent by 2 years. This fi gure remains fairly
constant throughout the rest of life. The high level of REM sleep
in very early life suggests a role in cerebral maturation but the
reason for its persistence throughout life is unclear. Memory
processing appears to depend on sleep. However, people deprived of REM sleep, experimentally or
pathologically, can be relatively
unaffected either emotionally or cognitively. Deep sleep decreases
in the elderly.
􀁘 NREM–REM sleep cycles occur at intervals of 50–60 min in
infants who often enter REM at the start of their sleep period.
This interval between sleep cycles remains until adolescence
when the periodicity changes to 90–100 min, which persists into
adult life. The amounts of NREM and REM in each sleep cycle is
about equal in early infancy. Afterwards, NREM sleep (especially
SWS) predominates in the earlier cycles and REM sleep in the
later cycles.
􀁘 Continuity of sleep is greatest in pre-pubertal children (as
mentioned previously) and least at the extremes of age. Infants
are easily awakened and so are the elderly who also wake spontaneously
more often. Fragmentation of sleep by brief arousals, or
very brief awakenings, is particularly common in old age.
􀁘 Circadian sleep–wake rhythms change considerably in early
development. Full-term neomates show 3–4-h sleep–wake cycles.
Sleep periods have largely shifted to the night and wakefulness to
daytime by 12 months, except for napping which gradually diminishes
and has usually stopped by about 3 years of age. However, a
physiological tendency towards an afternoon nap remains
throughout the rest of the life. Although repeated brief waking at
night is more common in infancy and early childhood than later,
it remains a normal occurrence throughout life, increasing in
frequency again in old age. The clinical problem arises when there
is diffi culty returning to sleep after such awakenings.
principle should not apply to children and the elderly including
demented patients in whom sleep disturbance is particularly
prominent.
Another group on whom further research is particularly required
are people with learning disabilities (intellectual disability).