Sleep
Patterns
PHYSIOLOGICAL PSYCHOLOGY AND
PHARMACOLOGY
SLEEP
Sleep is an important part of your daily
routine you spend about one-third of your
time doing it. Quality sleep and getting
enough of it at the right times is as
essential to survival as food and water.
Without sleep you can’t form or maintain
the pathways in your brain that let you
learn and create new memories, and it’s
harder to concentrate and respond
quickly.
Sleep
Sleep is important to a number of brain functions, including how nerve cells (neurons)
communicate with each other. In fact, your brain and body stay remarkably active
while you sleep. Recent findings suggest that sleep plays a housekeeping role that
removes toxins in your brain that build up while you are awake.
Everyone needs sleep, but its biological purpose remains a mystery. Sleep affects
almost every type of tissue and system in the body from the brain, heart, and lungs to
metabolism, immune function, mood, and disease resistance. Research shows that a
chronic lack of sleep, or getting poor quality sleep, increases the risk of disorders
including high blood pressure, cardiovascular disease, diabetes, depression, and
obesity.
Sleep is a complex and dynamic process that affects how you function in ways
scientists are now beginning to understand. This booklet describes how your need for
sleep is regulated and what happens in the brain during sleep
ANATOMY OF SLEEP
Several structures within the brain are involved with sleep.
The HYPOTHALAMUS, a peanut-sized structure deep inside the brain,
contains groups of nerve cells that act as control centers affecting
sleep and arousal. Within the hypothalamus is the Suprachiasmatic
nucleus (SCN) – clusters of thousands of cells that receive
information about light exposure directly from the eyes and control
your behavioral rhythm. Some people with damage to the SCN
sleep erratically throughout the day because they are not able to
match their circadian rhythms with the light-dark cycle. Most blind
people maintain some ability to sense light and are able to modify
their sleep/wake cycle.
Circadian Rhythm of Sleep
The circadian rhythm of sleep refers to your body’s natural 24-hour internal clock that regulates sleep and
wakefulness, among other physiological processes. It’s controlled by the suprachiasmatic nucleus (SCN) in the
brain’s hypothalamus and is influenced by external cues, especially light and darkness.
1. Sleep-Wake Cycle
Melatonin release: As it gets dark, the brain begins producing melatonin, a hormone that makes you feel
sleepy.
Cortisol release: In the morning, cortisol levels rise to promote wakefulness and alertness.
The ideal circadian rhythm aligns with sleeping at night and being awake during the day.
2. Light Exposure
Light is the primary cue that resets the circadian clock daily.
Exposure to blue light (from screens or sunlight) suppresses melatonin, making it harder to fall asleep.
🕒 3. Chronotypes
Some people are naturally “morning larks” or “night owls”—this is influenced by genetics and affects when
their body feels naturally sleepy or alert.
Phases of the Sleep-Wake Circadian
Cycle
Time Circadian Event
6:00 AM Body prepares to wake (cortisol rises)
9:00 AM Peak alertness
2:00 PM Energy dip—common time for drowsiness
Body temperature peaks, optimal physical
6:00 PM
performance
9:00 PM Melatonin starts rising
10:00 PM - 2:00 AM Deepest sleep typically occurs
4:00 AM Lowest body temperature, melatonin peak
ANATOMY OF SLEEP
The BRAIN STEM, at the base of the brain, communicates with the
hypothalamus to control the transitions between wake and sleep.
(The brain stem includes structures called the pons, medulla, and
midbrain.) Sleep-promoting cells within the hypothalamus and the
brain stem produce a brain chemical called GABA, which acts to
reduce the activity of arousal centers in the hypothalamus and
the brain stem.
The brain stem (especially the pons and medulla) also plays a
special role in REM sleep; it sends signals to relax muscles essential
for body posture and limb movements, so that we don’t act out
our dreams.
ANATOMY OF SLEEP
The THALAMUS acts as a relay for information from the senses to the cerebral cortex
(the covering of the brain that interprets and processes information from short- to
long-term memory). During most stages of sleep, the thalamus becomes quiet,
letting you tune out the external world. But during REM sleep, the thalamus is active,
sending the cortex images, sounds, and other sensations that fill our dreams.
The PINEAL GLAND, located within the brain’s two hemispheres, receives signals from
the SCN and increases production of the hormone melatonin, which helps put you
to sleep once the lights go down. People who have lost their sight and cannot
coordinate their natural wake-sleep cycle using natural light can stabilize their sleep
patterns by taking small amounts of melatonin at the same time each day. Scientists
believe that peaks and valleys of melatonin over time are important for matching
the body’s circadian rhythm to the external cycle of light and darkness.
ANATOMY OF SLEEP
The BASAL FOREBRAIN, near the front and bottom of the brain,
also promotes sleep and wakefulness, while part of the midbrain
acts as an arousal system. Release of adenosine (a chemical
by-product of cellular energy consumption) from cells in the
basal forebrain and probably other regions supports your sleep
drive. Caffeine counteracts sleepiness by blocking the actions of
adenosine.
The AMYGDALA, an almond-shaped structure involved in
processing emotions, becomes increasingly active during REM
sleep.
SLEEP STAGES
There are two basic types of sleep:
Rapid eye movement (REM) sleep and non-REM sleep
(which has three different stages). Each is linked to
specific brain waves and neuronal activity. You cycle
through all stages of non-REM and REM sleep several
times during a typical night, with increasingly longer,
deeper REM periods occurring toward morning.
SLEEP STAGES
Stage 1 non-REM sleep Stage 2 non-REM sleep Stage 3 non-REM sleep
non-REM sleep is the non-REM sleep is a period of non-REM sleep is the period of
changeover from light sleep before you enter deep sleep that you need to feel
wakefulness to sleep. During deeper sleep. Your heartbeat refreshed in the morning. It occurs
this short period (lasting and breathing slow, and in longer periods during the first
several minutes) of relatively muscles relax even further. half of the night. Your heartbeat
light sleep, your heartbeat, Your body temperature drops and breathing slow to their lowest
breathing, and eye and eye movements stop. levels during sleep. Your muscles
movements slow, and your Brain wave activity slows but is are relaxed and it may be difficult
muscles relax with occasional marked by brief bursts of to awaken you. Brain waves
twitches. Your brain waves electrical activity. You spend become even slower.
begin to slow from their more of your repeated sleep
daytime wakefulness cycles in stage 2 sleep than in
patterns. other sleep stages.
SLEEP STAGES
REM sleep first occurs about 90 minutes after falling asleep. Your
eyes move rapidly from side to side behind closed eyelids. Mixed
frequency brain wave activity becomes closer to that seen in
wakefulness. Your breathing becomes faster and irregular, and your
heart rate and blood pressure increase to near waking levels. Most
of your dreaming occurs during REM sleep, although some can also
occur in non-REM sleep. Your arm and leg muscles become
temporarily paralyzed, which prevents you from acting out your
dreams. As you age, you sleep less of your time in REM sleep.
Memory consolidation most likely requires both non-REM and REM
sleep.
SLEEP CYCLE
A sleep cycle is the
progression through the
various stages of NREM sleep
to REM sleep before beginning
the progression again with
NREM sleep. Typically, a
person would begin a sleep
cycle every 90-120 minutes
resulting in four to five cycles
per sleep time, or hours spent
asleep.
SLEEP CYCLE
One does not go straight from deep sleep to REM sleep, however. Rather, a
sleep cycle progress through the stages of non-REM sleep from light to deep
sleep, then reverse back from deep sleep to light sleep, ending with time in
REM sleep before starting over in light sleep again.
For a majority of people, a sleep cycle begins with a short period of Stage 1
sleep whereby the body begins to relax and a drowsy state occurs with slow
rolling eye movements. Stage 2 occurs for longer periods than Stage 1. For
most, Stage 2 sleep comprises approximately 40-60% of total sleep time.
Moving through the sleep cycle, Stage 3 is most often found next in the
progression. This restorative stage does not last as long as Stage 2, lasting
between 5-15% of total time asleep for most adults. For children and
adolescents Stage 3 is much higher in duration.
SLEEP CYCLE
REM can occur at time during the sleep cycle, but on average it
begins 90 minutes following sleep onset and is short in duration as it
is the first REM period of the night. Following REM, the process
resumes starting with periods of Stage 1, 2 & 3 intermixed before
returning to REM again for longer periods of time as sleep time
continues.
How long is a sleep cycle? The first sleep cycle takes about 90
minutes. After that, they average between 100 to 120 minutes.
Typically, an individual will go through four to five sleep cycles a
night
DEEP SLEEP
Deep sleep occurs in Stage 3 of NREM sleep. Brain waves during Stage 3 are called delta waves
due to the slow speed and large amplitude. Of all of the sleep stages, Stage 3 is the most
restorative and the sleep stage least likely to be affected by external stimuli.
Waking a person from deep sleep can be difficult. Following a period of sleep deprivation, a
person experiences extensive time in Stage 3 sleep. Parasomnias such as sleep walking, sleep
talking, night terrors and bedwetting can occur. (There is muscle activity, that’s how people can
talk or kick in their sleep!)
Deep sleep reduces your sleep drive, and provides the most restorative sleep of all the sleep
stages. This is why if you take a short nap during the day, you’re still able to fall asleep at night. But
if you take a nap long enough to fall into deep sleep, you have more difficulty falling asleep at
night because you reduced your need for sleep.
During deep sleep, human growth hormone is released and restores your body and muscles from
the stresses of the day. Your immune system also restores itself. Much less is known about deep
sleep than REM sleep. It may be during this stage that the brain also refreshes itself for new
learning the following day.
IN WHAT STAGE OF SLEEP DO DREAMS
OCCUR?
As an active sleep state, REM is the time when the most vivid dreams occur. The rapid eye
movements that occur can be seen as sharp, rapid movements. Brain waves during REM sleep
are considered to be of low amplitude and mixed frequency consistent with higher activity than
that seen in Stages 2 and 3.
A person may dream 4 to 6 times each night. A French study found that all people do in fact
dream, whether they remember their dreams or not. However, if awoken during REM sleep, a
person often can remember their dreams.
Muscle paralysis often accompanies REM sleep. This muscle atonia or muscle paralysis occurs as a
protective means to keep one from acting out their dreams. Obstructive Sleep Apnea is often the
worst during REM periods due to the lack of muscle tone within the muscles of the airway.
Scientists believe this may be to help prevent us from injury while trying to act out our dreams.
During REM respirations are irregular and shallow and irregularities in heart rate and body
temperature also occur.
HOW SLEEP CYCLE CHANGES WITH AGE
Sleep changes throughout a person’s life. From a newborn, through toddler years, school age,
adolescent and adulthood, sleep is changing.
Newborn (0 – approximately 4 months): Do not have distinctive sleep waves. Sleep is
categorized as “Active”, “Quiet” and “Indeterminate”. Active sleep is the equivalent to REM
sleep and quiet sleep is equivalent to non-REM sleep. A majority of the time, newborns are in
active sleep which allows for frequent arousals or awakenings; this is necessary for regular
periods of feeding.
Infants (Approximately 4 months – 1 year): Standard sleep stage distinction is now apparent.
Sleep becomes more consolidated and sleeping routines can be developed, sleep is typically
10-13 hours per 24 hour period with 2-3 daytime naps occurring.
Toddlers (1 year – 3 years): With sleeping patterns fully developed, children spend
approximately 25% in Stage 3 deep sleep with almost an equal amount of time in REM. Average
sleep time is 9.5-10.5 hours per 24 hour period. Typically naps will reduce to 1 per day most likely
occurring early in the afternoon to allow for proper nighttime sleep.
HOW SLEEP CYCLE CHANGES WITH AGE
Pre-School (3 – 6 years): Sleep time is similar to that of toddlers, approximately 9-10 hours
per 24 hour period. The afternoon nap usually subsides around 3-4 years for a majority of
children. Stage 3 sleep still remains high in relation to total sleep time.
School Age (6 years – 12 years): Sleep time remains unchanged; 9-10 hours per 24 hour
period and Stage 3 remains approximately 20-25% of total sleep time. Restorative sleep
is important for growth and development.
Adolescent (12 years and beyond): Sleep time for adolescents is approximately 9-9.5
hours per 24 hour period. There are physiological changes in circadian rhythm that
occur causing sleep onset to be later. This internal shift is the cause for many
adolescents to have later lights out and the desire to want to “sleep in” in the morning.
As a person ages, the circadian rhythm shifts back and sleep again appears to regulate
to approximately 6.5-8 hours of sleep per 24 hour period as adult.
HOW TO GET A BETTER NIGHT'S SLEEP
There are some things that a person can do to improve their sleep
hygiene to feel well-rested and refreshed, including:
[Link] regularly and eating a healthful diet
[Link] foods that are sugary, fatty, processed or have
caffeine
[Link] spicy foods or having caffeine at bedtime
[Link] the use of computers, TVs, cellphones, and other
electronic devices at least 30 minutes before bed
[Link] a dark and quiet sleeping place
SLEEP DISORDERS
Sleep disorders are conditions that result in changes in the way that you sleep. A
sleep disorder can affect your overall health, safety and quality of life. Sleep
deprivation can affect your ability to drive safely and increase your risk of other
health problems.
Some of the signs and symptoms of sleep disorders include excessive daytime
sleepiness, irregular breathing or increased movement during sleep. Other signs and
symptoms include an irregular sleep and wake cycle and difficulty falling asleep.
There are many different types of sleep disorders. They're often grouped into
categories that explain why they happen or how they affect you. Sleep disorders
can also be grouped according to behaviors, problems with your natural sleep-
wake cycles, breathing problems, difficulty sleeping or how sleepy you feel during
the day.
Insomnia
Sleep disorder in which you have difficulty falling asleep or staying asleep throughout the night.
The condition can be short-term (acute) or can last a long time (chronic). It may also come and
go.
Acute insomnia lasts from 1 night to a few weeks. Insomnia is chronic when it happens at least 3
nights a week for 3 months or more.
Types of Insomnia
There are two types of insomnia: primary and secondary.
Primary insomnia: This means your sleep problems aren’t linked to any other health condition or
problem.
Secondary insomnia: This means you have trouble sleeping because of a health condition (like
asthma, depression, arthritis, cancer, or heartburn); pain; medication; or substance use (like
alcohol).
SLEEP APNEA
In which you experience abnormal patterns in breathing while you are asleep. Sleep apnea is a
potentially serious sleep disorder in which breathing repeatedly stops and starts. If you snore loudly
and feel tired even after a full night's sleep, you might have sleep apnea.
The patient with sleep apnea stops breathing many times each night. Each time, the patient
awakens, begins to breathe again, and drifts back to sleep. Sleep apnea usually leads to a sense of
having slept poorly and is thus often diagnosed as insomnia. However, some patients are totally
unaware of their multiple awakenings and instead complain of excessive sleepiness during the day,
which can lead to a diagnosis of hypersomnia.
Sleep apnea disorders are of two types:
(1) obstructive sleep apnea results from obstruction of the respiratory passages by muscle spasms or
atonia (lack of muscle tone) and often occurs in individuals who are vigorous snorers
(2) central sleep apnea results from the failure of the central nervous system to stimulate respiration.
Sleep apnea is more common in males, in people who are overweight, and in the elderly (Badran et
al., 2015).
RESTLESS LEGS SYNDROME (RLS)
A type of sleep movement disorder. Restless legs syndrome, also called
Willis-Ekbom.
Restless leg syndrome - characterized by the complaint of a strong, nearly
irresistible urge to move the legs, often accompanied by uncomfortable or
painful symptoms. The sensations are worse at rest and occur more
frequently in the evening or during the night. Walking or moving the legs
relieves the sensation.
NARCOLEPSY
It is derived from greek words 'Narke' (Numbness) and 'Lepsis'(Seizure).
Narcolepsy is the most widely studied disorder of hypersomnia. It occurs in about 1 out of 2,000
individuals (Arango, Kivity, & Schoenfeld, 2015).
It has two prominent symptoms. First, persons with narcolepsy experience severe daytime
sleepiness and repeated, brief (10- to 15-minute) daytime sleep episodes. Individuals with
narcolepsy typically sleep only about an hour per day more than average; it is the
inappropriateness of their sleep episodes that most clearly defines their condition.
4 symptoms of narcolepsy.
1. Sleep attack
2. Cataplexy - Complete loss of muscle tone.
3. Sleep paralysis - The inability to move just as one is falling asleep or waking up
4. Hypnogogic Hallucinations - dream like experiences during wakefulness.
causes narcolepsy
Genetic factors - Strong correlation with family members.
Lin andcolleagues (1999) isolated the gene that causes the
disorder. The gene encodes a receptor protein that binds to a
neuropeptide called orexin or Hypocretin. Orexin is involved in
hunger drive and promote wakefulness.
In some people, narcolepsy happens due autoimmune
disorders (The killer t-cells kills orexin producing cells
Environmental factors - Triggers such as strong emotions ,
physical exertions and so on.
REM SLEEP DISORDERS
REM sleep behaviour disorder- involves abnormal behaviors that occur in REM sleep and
result in injury or sleep disruption. The behaviors are often violent with dream enactment
that is action filled. The disorder can occur in narcolepsy, and many patients with
Parkinson’s disease have REM sleep behavior disorder. The delayed emergence of a
neurodegenerative disorder can occur, especially in men >50 years of age.
Dream inactment - Acting out during dream. Basically during REM sleep, muscles are
paralysed. Muscle atonia lacks here. It is more common among among people with
parkinson's and narcolepsy.
Recurrent isolated sleep paralysis - This happens when the person is unable to perform
voluntary movements at the sleep onset or awakening. Ventilation is usually unaffected.
Hallucinatory experiences often accompany the paralysis.
Nightmares - REM version of night terror. Awakening with intense anxiety and fear.
Hypersomnia
Excessive daytime sleepiness.
Struggle to wake up after long hours of sleep.
DYSOMNIA
Dys - bad or difficult sleep.
This negatively impact quality or quantity of sleep.
Wrong way of sleeping. ( Do not involve physical movements while asleep)
Parasomnia - Sleep occurs 'alongside'.
Happens while/during [Link] during deep sleep (slow wave sleep; stage 3 and 4).
Mostly happens when there's stress. ( Accompanied with physical or unwanted behaviour
during sleep)
CIRCADIAN RHYTHM DISORDERS
Delayed sleep wake phase disorder - It is characterised by sleeping at morning and being
active at night.
Treatment: Melatonin and ligh therapy
Advanced sleep phase disorder - Finding it difficult to stay awake during night.
Irregular sleep wake rhythm disorder - Fragmented sleep - Multiple wake up between sleep
cycle. common among in older children with developmental disorders and people with
dementia. Causes due to degenration of SCN neurons.
Non 24-hour sleep wake disorder (Free running rhythm disorder or Hyper nycthemeral
syndrome)- non synchronization of sleep cycle. absence of entrainment; extending of 24 hours
cycle; extremely difficult to treat.
Jet lag - A disruption of circadian rhythms due to crossing time zones is known as jet lag.
Travelers complain of sleepiness during the day, sleeplessness at night, depression, and
impaired concentration. All these problems stem from the mismatch be-tween internal
circadian clock and external time
CIRCADIAN RHYTHM DISORDERS
Shift work disorder - People who sleep irregularly—such as pilots, medical
interns, and shift workers in factories—ind that their duration of sleep
depends on when they go to sleep. When they have to sleep in the
morning or early afternoon, they sleep only briely,even if they have been
awake for many hours. People adjust best to night work if they sleep in a
very dark room during the day and work under very bright lights at night,
comparable to the noonday sun.
Treatment /Medications
Medications for narcolepsy include:
Stimulants. Drugs that stimulate the central nervous system are the primary treatment to
help people with narcolepsy stay awake during the day. Doctors often try modafinil
(Provigil) or armodafinil (Nuvigil) first for narcolepsy. Modafinil and armodafinil aren't as
addictive as older stimulants and don't produce the highs and lows often associated with
older stimulants. Side effects are uncommon, but may include headache, nausea or
anxiety.
Selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake
inhibitors (SNRIs).
Doctors often prescribe these medications, which suppress REM sleep, to help alleviate the
symptoms of cataplexy, hypnagogic hallucinations and sleep paralysis. They include
fluoxetine (Prozac, Sarafem, Selfemra) and venlafaxine (Effexor XR). Side effects can
include weight gain, insomnia and digestive problems.
Treatment /Medications
Tricyclic antidepressants. These older antidepressants, such as protriptyline (Vivactil),
imipramine (Tofranil) and clomipramine (Anafranil), are effective for cataplexy, but many
people complain of side effects, such as dry mouth and lightheadedness.
Sodium oxybate (Xyrem). This medication is highly effective for cataplexy. Sodium
oxybate helps to improve nighttime sleep, which is often poor in narcolepsy. In high doses
it may also help control daytime sleepiness. It must be taken in two doses, one at bedtime
and one up to four hours later.
Drugs affecting calcium channels. Certain medications, such as gabapentin (Neurontin),
gabapentin enacarbil (Horizant) and pregabalin (Lyrica), work for some people with
RLS/WED.
benzodiazepines, these drugs help you sleep better at night,
Treatment/ Therapies
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT-I) can help you control or eliminate negative thoughts and
actions that keep you awake and is generally recommended as the first line of treatment
.Typically, CBT is equally or more effective than sleep medications.
Stimulus control therapy. This method helps remove factors that condition your mind to resist
sleep. For example, you might be coached to set a consistent bedtime and wake time and
avoid naps, use the bed only for sleep and sex, and leave the bedroom if you can't go to sleep
within 20 minutes, only returning when you're sleepy.
Relaxation techniques. Progressive muscle relaxation, biofeedback and breathing exercises are
ways to reduce anxiety at bedtime. Practicing these techniques can help you control your
breathing, heart rate, muscle tension and mood so that you can relax.
Light therapy. If you fall asleep too early and then awaken too early, you can use light to push
back your internal clock. You can go outside during times of the year when it's light outside in
the evenings, or you can use a light box. Talk to your doctor about recommendations.
Sleep restriction. This therapy decreases the time you spend in bed and
avoids daytime naps, causing partial sleep deprivation, which makes you
more tired the next night. Once your sleep has improved, your time in bed
is gradually increased.
Aromatherapy or massage interventions
Other Types of Interventions - dietary interventions
Lifestyle and home remedies for Sleep
Disorders
In some cases, self-care might be a way for you to deal with obstructive sleep apnea and possibly central
sleep apnea. Try these tips:
Lose excess weight. Even a slight weight loss might help relieve constriction of your throat. In some cases,
sleep apnea can resolve if you return to a healthy weight, but it can recur if you regain the weight.
Exercise. Regular exercise can help ease the symptoms of obstructive sleep apnea even without weight
loss. Try to get 30 minutes of moderate activity, such as a brisk walk, most days of the week.
Avoid alcohol and certain medications such as tranquilizers and sleeping pills. These relax the muscles in
the back of your throat, interfering with breathing.
Sleep on your side or abdomen rather than on your back. Sleeping on your back can cause your tongue
and soft palate to rest against the back of your throat and block your airway. To keep from rolling onto
your back while you sleep, try attaching a tennis ball to the back of your pajama top. There are also
commercial devices that vibrate when you roll onto your back in sleep.
Don't smoke. If you're a smoker, look for resources to help you quit.
SLEEP HYGIENE
‘Sleep hygiene’ is the term used to describe good sleep habits.
Considerable research has gone into developing a set of guidelines
and tips which are designed to enhance good sleeping, and there is
much evidence to suggest that these strategies can provide long-
term solutions to sleep difficulties.
1. Get regular
[Link] when sleepy.
3. Get up and try again.
4. Avoid caffeine and nicotine.
5. Avoid alchohol
6. Use bed only for sleeping
7. Avoid taking naps during daytime
8. Develop own sleep rituals.
9. Take a hot bath 1-2 hours before sleep
10. Use a sleep diary
11. Exercise
