Sleep is a special genetically determined state of the human body (and warm-blooded animals, i.e. mammals and birds), characterized by a regular sequential change of certain printing pictures in the form of cycles, phases and stages.
This complex definition of sleep indicates, firstly, that sleep is an integral part of a person’s life, because the need to sleep is genetically predetermined, and secondly, that the state of sleep can only be determined using special objective methods.
For an objective study of sleep and its disorders, polysomnography is used - a method that includes parallel recording of an electroencephalogram (EEG) (usually multi-channel), electrooculogram (EOG), electromyogram (EMG), electrocardiogram (ECG), blood pressure (BP), motor activity ( general and extremities), respiratory movements of the chest and abdominal wall, orogenic air flow, level of oxygen saturation in the blood, severity of snoring, body temperature, penis erection, type of monitoring.
The first three of the above indicators (EEG, EOG and EMG) are basic for identifying the stages and phases of sleep. Based on the analysis of these indicators, a hypnogram is constructed that reflects the dynamics of the stages and phases of sleep during the registration period.
Healthy person sleep hypnogram
Human sleep is a continuum of functional states of the brain - stages 1, 2, 3 and 4 of slow sleep (PMS) and the phase of REM sleep (FBS).
Stage 1 FMS is characterized by a slowdown in the frequency of the main rhythm (characteristic of the relaxed wakefulness of a given person), the appearance of beta and theta waves; a decrease in heart rate (HR), respiratory rate (BH), muscle tone, blood pressure.
Stage 2 FMS (stage "sleep spindles") - so named according to the main EEG phenomenon - "sleep spindles" - sinusoidal oscillations with a frequency of 11.5-15 Hz, an amplitude of more than 25 μV and a duration of 0.5-1.5 sec in addition, K-complexes are also represented in the EEG — high-amplitude waves (2-3 times higher than the background EEG amplitude, mainly represented by theta waves), two-phase or multiphase; from the point of view of vegetative and EMG indicators, the trends described for the 1st stage of FMS develop; episodes of apnea lasting less than 10 seconds may occur in small amounts.
3 and 4 stages are called delta sleep, since the main EEG phenomenon is delta activity (in the 3rd stage, it ranges from 20% to 50%, and in the 4th stage more than 50% of the analysis era); breathing in these stages is rhythmic, slow, blood pressure is reduced, EMG has a low amplitude.
FBS is characterized by fast eye movements (BDG), very low EMG amplitude, "sawtooth" theta rhythm, combined with irregular EEG; at the same time, there is a "vegetative storm" with respiratory and cardiac arrhythmias, fluctuations in blood pressure, apnea episodes (normally lasting less than 10 seconds), penis and clitoris erection.
The stages of PMS and FBS comprise one sleep cycle, and such cycles in a healthy person are from 4 to 6 per night; these cycles are not the same: in the first two, FMS is maximally represented, and in the morning, FBS.
The main function of PMS is restoration (the accumulation of energy, primarily phosphatergic bonds, synthesis of peptides and nucleic acids, in this phase peaks of secretion of growth hormone, prolactin, melatonin are observed, and FBS is information processing and construction of a behavior program.
During physiological aging, the structure of sleep undergoes the following changes: the total duration of sleep decreases, the duration of the superficial stages increases, the time of falling asleep and the time of wakefulness inside sleep increase, the motor activity in sleep increases, fragmentation of sleep occurs, PFB is more preserved in relation to PMS, sleep polyphase is detected (the presence of daytime and nighttime sleep) and daytime microsleeps. Complaints of poor night sleep in people over 60 are 3 to 4 times more common than in middle age.
Physiology of sleep
One of the main questions that worried physiologists since the time of IP Pavlov is the existence of a "sleep center" in the brain. A direct study of the neurons involved in the regulation of sleep-wakefulness showed that the normal functioning of the thalamo-cortical system of the brain, which provides the entire spectrum of conscious human activity in wakefulness, is possible only if there are powerful effects from structures called activating. Due to these effects, the membrane of the vast majority of cortical neurons in the wakeful state is depolarized and only in this state of depolarization can these neurons process and respond to signals coming to them from other nerve cells. There are probably five or six such brain activation systems (they can be arbitrarily called "wake centers"), and they are localized at all cerebral levels: in the reticular formation of the trunk, in the region of the blue spot and dorsal nuclei of the suture, in the posterior hypothalamus and basal nuclei of the anterior brain. In humans, a violation of the activity of any of these systems cannot be compensated at the expense of others, is incompatible with consciousness and leads to a coma.
It seemed logical to assume that if there are “centers of wakefulness” in the brain, then there should be “sleep centers”. However, a detailed study of neurons showed that positive feedback mechanisms, in the form of special neurons, the function of which is the inhibition of activating neurons, and which themselves are inhibited by these neurons, are built into the wakefulness maintenance system. These neurons are scattered in different parts of the brain, although their accumulation in the reticular part of the black substance is noted; common to them is the allocation of the same chemical intermediary - gamma-aminobutyric acid, the main inhibitory substance of the brain. As soon as activating neurons weaken their activity, inhibitory neurons turn on and weaken it even more. The process develops in a downward direction for some time, until a certain “trigger” is triggered and the whole system is transferred to another state - wakefulness or paradoxical sleep. A reflection of this process is the change of patterns in the electrical activity of the brain during a 90-minute human sleep cycle.
Another evolutionarily ancient inhibitory system of the brain uses adenosine as a mediator.
The crucial role of prostaglandin D2 synthesized in the brain in modulating adenosinergic neurons has been shown. Given the fact that all prostaglandin synthase-D of the brain is contained in the meninges and the choroid plexus, the role of this system in the formation of hypersomnia (with traumatic brain injury, meningitis, African "sleeping sickness", etc.) becomes apparent.
In experiments on laboratory animals, it was shown that, as sleep deepens, more and more powerful inhibitory postsynaptic potentials dominate, alternating with activation periods - like a “pack-pause” type. Under these conditions, the ability to process information in the brain is impaired. Discharges of neural activating systems are progressively decreasing. Thus, in slow sleep, cerebral homeostasis is restored and other recovery processes, such as the synthesis of phosphatergic compounds (“energy stores”), growth hormone (growth hormone), proteins and nucleic acids. From this point of view, wakefulness and slow sleep are like “two sides of the same coin”. The absence of a single "center of slow sleep" (taking into account its significance) makes the system of its organization more reliable, not completely dependent on the activity of one center in the event of any disruption in its functioning. At the same time, long-term total suppression of slow sleep is impossible, since it must periodically replace wakefulness and, in conditions of artificial suppression of sleep, the brain goes to various tricks in order to maintain the presence of slow sleep. It is also important that in conditions of slow sleep, the processing of information by the brain does not stop, but changes: from processing exteroceptive (external) the brain moves to interoceptive (internal) impulses. Thus, the function of slow sleep includes not only recovery processes, but also optimization of the control of internal organs.
In contrast to slow sleep, fast (paradoxical) sleep starts from a certain center located in the back of the brain, in the region of the pons and the medulla oblongata. Acetylcholine, glutamic and aspartic acids serve as mediators of these cells. During REM sleep, brain cells are active, but information from the sensory organs (afferent) does not come to them, and the descending (efferent) is not supplied to the muscle system. This is the paradoxical nature of this state. At the same time, information that was received in previous wakefulness and stored in memory is intensively processed; in addition, in a fast sleep, a future behavior program is being formed. Inadequate inclusions of the "center of paradoxical sleep" do occur with some rather rare types of genetically determined pathology (narcolepsy, etc.). In contrast to wakefulness, only activating systems that are localized in the reticular formation of the trunk and use acetylcholine, glutamic and aspartic acids as transmitters function in fast sleep. All other activating systems are turned off, and their neurons are inactive for the entire period of paradoxical sleep. This silence of a significant number of activating systems of the brain is the fundamental fact that determines the difference between wakefulness and paradoxical sleep at the physiological level.
The traditional debated neurochemical agents of importance in organizing the sleep and wake cycle.
- Slow sleep phase: GABA, serotonin
- Slow sleep phase: norepinephrine, acetylcholine, glutamate,
- Wakefulness: norepinephrine, glutamate, acetylcholine, histamine, serotonin.
New neurochemical agents of importance in the organization of the sleep and wake cycle.
- orexin / hypocretin
- delta sleep inducing peptide,
- prostaglandins (PGD2),
- interleukins, muramyl peptide, cytokines.
Very often, waking up, we remain in the grip of strange, bizarre, and sometimes frightening images, pictures or events experienced in a dream. Who are these characters that inhabit our dreams? Aliens of the otherworldly, unknown to us world or or part of our internal structure, our "I"? And the dreams themselves - do they have any rational basis or are they perfect nonsense? The desire to answer these and many other questions made dreams not only the subject of philistine interest, but also an important area of application of scientific methods of cognition.
To the question: do they dream? many would answer in the negative. However, in reality this is not so: it would be more correct to answer that they do not remember their dreams. Most people see several dreams during sleep, regardless of whether their memory is preserved or not. The scientific evidence accumulated over the past decades suggests that everyone sees dreams.
The analysis of dreams cannot be approached as something independent, not related to the state of the body and the characteristics of mental activity. The study of dreams allows us to consider them as an “indicator” of a person’s state, sensitively capturing the slightest manifestation of any ill-being in a state of health or a psychological problem. At the same time, the nature of dreams changes, and the direction of these changes depends on the specifics of the disease. This makes dreaming a valuable clinical material to help diagnose.
The next important conclusion that scientific research has led to is that dreams are an active process that carries a number of important functions for a person. The most important of these is the function of psychological defense. Experimental deprivation of healthy people in REM sleep leads to pronounced changes in the mental sphere of the person, close to neurotic (irritability, tearfulness, high susceptibility to stress). In this regard, it is believed that dreams are crucial for emotional discharge and adaptation to stressful situations.
Unlike the perception of wakefulness, a complex multifaceted world, perceived during sleep, arises within us, and not outside. Therefore, various elements of dreams (symbols, events) are nothing more than projections of certain aspects of a person’s personality and reality directly perceived by him, including those that are rejected and not recognized by the waking consciousness. Therefore, our dreams give us the most complete picture of our multifaceted personality.
By integrating and processing the received emotional information, knowledge and experience, dreams are important in solving creative problems. The diverse experience of inventors, artists and scientists clearly shows what role dreams can play in the creative process. It is enough to recall the numerous scientific discoveries made in a dream (Mendeleev, Kekule, Einstein, Bor), the ingenious products of the dream - creativity of many literary figures (Pushkin, Lermontov, Gogol) and art (Beethoven, Schumann, Wagner, Goya, Bosch).
"Royal Road to the Unconscious" called dreams of Z. Freud. As already mentioned, dreams concentrate in themselves information that affects the most important personal experiences and filter out other, unimportant for a person. This opens up great opportunities for the use of dreams, not only in diagnosis, but also in the treatment of a number of diseases. Since dreams are a kind of “shorthand record” of the patient’s personally significant experiences, the therapist has the opportunity not only to “touch” the patient’s actual problem through dreams, but also to purposefully influence it.
Dreams are always full of symbolism and meaning, and this meaning is individual for each person. The path to comprehending the meaning of dreams is a complex and creative process carried out in the joint work of the therapist and patient. Behind each character of the dream is a whole chain of associations and emotional experiences associated with the individual experience of a person. That is why the interpretation of dreams using "dream books", which appear in abundance on book shelves, is at least an ungrateful and useless affair. Moreover, information obtained from dream books, creating incorrect predictions for the future, can disorient a person and form an incorrect, inappropriate style of behavior, which in itself is fraught with adverse consequences. The analysis of the content and meaning of dreams is a complex process that requires a professional approach.
Mental activity in a dream
"Morning is wiser than the evening" - the proverb says. Each of us can recall situations when, falling asleep with a sense of confusion and helplessness in front of piled up problems, he wakes up in the morning with the feeling that the problems have been solved.
One of the common myths that existed to date, is the perception of sleep as rest for the human body and psyche. Modern scientific research has refuted these misconceptions and provided irrefutable evidence that sleep is an active process and that mental activity exists permanently throughout sleep. This was done thanks to the development of the electroencephalographic technique, which was specially turned into a polygraphic recording specifically for the study of sleep, where electroencephalography (recording the bioelectrical activity of the brain) is only one of its components, and muscle activity, eye movement, and the functional state of internal organs (respiratory rate) are also recorded. heart rate), etc. Now we can say that sleep is a complex condition during which active processes are carried out in the brain. During sleep, the phases of "slow" and "fast" sleep alternate, which, cyclically alternating among themselves, are repeated several times (from 4 to 6) during the night.
During the REM sleep phase, which accounts for 25% of the total sleep cycle, an increase in vegetative activity is noted and rapid movements of the eyeballs are recorded. If a person is woken up during the printing recording of sleep in the laboratory during the stage of REM sleep, he will definitely remember and talk about the dream. The experimental deprivation of a person's REM phase led to changes in their psyche that were close to neurotic. This suggests that the human psyche at the time of "REM sleep" is aimed at the implementation of psychological adaptation to stressful effects.
At present, there is no doubt the presence of mental activity in deep, slow sleep. Despite the fact that when a person wakes up from a slow sleep, dream stories are less common, during a slow sleep, there are objective mental phenomena (e.g., drowsiness, drowsiness), which indicate active mental activity in this period of sleep. The consequences of deprivation (deprivation) of slow sleep are apathy, asthenia, decreased performance, memory and spontaneous activity. The role of mental activity of slow sleep in assimilation of fundamentally new information, memorization, is assumed.
Thus, during the whole dream, the human psyche carries out active work, which at various stages of sleep performs certain functions that are important for subsequent fruitful wakefulness.
Insomnia is a disorder associated with difficulties in initiating (beginning) and / or maintaining sleep. The term "insomnia", often used even by doctors, is inadequate, since objective studies do not reveal a complete lack of sleep in patients who presented such complaints.
Acute, subacute and chronic insomnia are distinguished over the course. In terms of severity - mild, moderate and pronounced.
The clinical phenomenology of insomnia includes presomnic, intrasomnic, and postcommunic disorders.
Abdominal disorders are difficulties starting sleep and the most common complaint is difficulty falling asleep; with a long course, pathological "rituals of going to bed", as well as "fear of bed" and fear of "non-occurrence of sleep" can form. The emerging desire to sleep disappears as soon as the patients find themselves in bed, painful thoughts and memories arise, physical activity intensifies in the desire to find a comfortable pose. The upcoming nap is interrupted by the slightest sound, physiological myoclonus. If falling asleep in a healthy person occurs within a few minutes (3-10 minutes), then in patients it sometimes drags on to 120 minutes or more. A polysomnographic study of these patients showed a significant increase in the time of falling asleep, frequent transitions from stages 1 and 2 of the first sleep cycle to wakefulness. Often, falling asleep by patients is ignored and all this time it seems to them as continuous wakefulness.
Intrasomnic disorders include frequent nocturnal awakenings, after which the patient cannot fall asleep for a long time, and feelings of “superficial”, “shallow” sleep.
Awakenings are caused by both external (primarily noise) and internal factors (frightening dreams, fears and nightmares, pains and autonomic shifts in the form of respiratory failure, heart palpitations, urge to urinate). All these factors can also awaken healthy people who have good sleep. But in patients the threshold of awakening is sharply reduced and the process of falling asleep after an episode of awakening is difficult. The decrease in the threshold of awakening is largely due to insufficient depth of sleep.
Polysomnographic correlations of these sensations are an increased representation of the surface stages (1 and 2 PMS), frequent awakenings, long periods of wakefulness inside sleep, reduction of delta sleep, and an increase in motor activity.
Postcommunic disorders (disorders that occur in the immediate period after awakening) are a problem of early morning awakening, decreased working capacity, and “overwhelming”. Patients are unsatisfied with sleep. Postcommunic disorders include non-imperative daytime sleepiness. Its feature is the difficulty of falling asleep even in the presence of favorable conditions for sleep.
Often, patients complain of too short sleep without specifying the problems of starting or maintaining sleep, and at least 20% of those with insomnia indicate a subjective duration of sleep of less than 5 hours. This figure is important both for patients and for doctors, since it seems to reflect a peculiar physiological minimum of sleep during the night.
The correlations between the subjective assessments of sleep and its objective characteristics are ambiguous, although more often they coincide. Meanwhile, sometimes patients complain of a complete lack of sleep for many nights, however, with an objective polysomnographic study, sleep is not only present, but its duration exceeds 5 hours (sometimes reaching 8 hours), and the sleep structure is not too deformed. This situation is defined as a distorted perception of sleep (or "sleep agnosia"). More often a similar phenomenon is observed in patients suffering from mental illness. It should be emphasized that in such cases, the appointment of sleeping pills (especially with a sleep duration of 6 or more hours) is not rational.
The causes of insomnia are diverse:
- stress (psychophysiological insomnia),
- mental illness;
- somatic diseases;
- psychotropic drugs
- toxic factors
- endocrine metabolic diseases,
- organic brain diseases
- syndromes that occur in a dream (sleep apnea syndrome; motor disturbances in a dream),
- pain phenomena
- external adverse conditions (noise, humidity, etc.),
- shift work,
- change of time zones,
- disturbed hygiene of sleep.
Treatment for insomnia involves two approaches. The first - the most adequate - is to eliminate the factors that cause insomnia. The second - includes measures to normalize sleep itself.
The general tactic is as follows:
- with early manifestations of sleep disorders, the first approach dominates;
- with extensive and sufficiently long insomnia, a combination of both approaches;
- in chronic insomnia, when the factor that caused them became less relevant, the second approach dominates.
Pharmacotherapy of insomnia includes drugs of various chemical groups. Currently, drugs with a short (less than 5 hours) and medium duration (from 5 to 15 hours) half-life are considered the most effective and safe. These include primarily imidazopyridines (the international name is zolpidem, the commercial name is Ivadal), cyclopyrrolones (the international name is zopiclone, the commercial names are imovan, somnol, picclorm) and, secondly, benzodiazepines (international names are midazolam, triazolam). Ethanolamines (international name doxylamine) and melatonin are also used.
In addition to pharmacological methods in the treatment of insomnia, psychotherapy, acupuncture, encephalophony® (“Music of the brain” ® - a method based on obtaining individual music of a person from his electroencephalogram), phototherapy (treatment with bright white light), herbal medicine are used. When identifying the syndrome of "sleep apnea" as the cause of insomnia, the most effective is the treatment of respiratory disorders in sleep using devices that create a constant air flow (CPAP or BiPAP).
Apnea (respiratory arrest in a dream) is a fairly common occurrence, which many do not know about, although they suffer from this dangerous disorder. Sleep brings us satisfaction and relaxation, but sometimes in a dream you can part with life. In the US alone, 12 million people suffer from sleep apnea. People who do not treat this disorder do the same harm to themselves as smokers who smoke a pack of cigarettes daily - says neurophysiologist Dr. Jerome Siegel. According to experts, apnea in a dream brings not only fatigue in the daytime, increased blood pressure, but also seriously damages the brain.
Scientific studies of the behavior of breathing during sleep actually began only in the 70s of our century with the advent of the technique necessary for long-term EEG monitoring and pulse oximetry. Therefore, only in the last three decades, clinical medicine began to approach the correct understanding of obstructive sleep apnea syndrome (CAS).
According to the classification of the main sleep disorders, the concept of dysomnia, in particular, internal sleep disorders, includes sleep apnea syndrome (CCA), in which a person has rather long periods of sleep when he stops breathing, the so-called apnea.
Apnea is a complete stop of the recorded nasal flow of breathing lasting at least 10 seconds, which is caused by a decrease in the airways at the level of the pharynx with persistent respiratory effort (obstructive type) or lack of respiratory effort (central type). Three types of apnea are distinguished: central, obstructive, and mixed sleep apnea (CSA, OCA, and SMA).
Central can be defined as insufficiency of the air flow due to the temporary absence of an impulse from the central nervous system (CNS) to activate respiratory effort, it occurs in individuals with impaired central respiration regulation mechanisms, and is associated with deep, often anatomical damage to the central nervous system and its pathways.
Obstructive apnea syndrome is a serious, potentially life-threatening condition of the patient, characterized by the development of respiratory arrests lasting more than 10 seconds with a development frequency of more than 15 per hour. In obstructive (also called peripheral) apnea, air flow is blocked at the level of the upper respiratory tract, as a result of which the exhaled air, despite excursions of the chest and abdomen, does not reach the lungs, that is, this is an insufficiency of the air flow, despite prolonged respiratory effort.
A significant part of cases of obstructive apnea is due to the discoordination of central impulses to the respiratory and pharyngeal muscles, when the impulse to the inspiratory muscles is not preceded by an impulse that tones the muscles of the pharynx. In this case, muscular dystonia of the pharynx of central genesis develops.
The concept of mixed apnea includes signs of both of the above types. The most common, according to most laboratories that study sleep, obstructive sleep apnea. Although mixed practice actually prevails in general practice. In the classification of sleep apnea, in addition to the division into central, obstructive and mixed forms, which are more likely related to the pathogenesis of the syndrome, there is a division into clinical (nosological) forms.
- Night snoring with episodes of sleepy apnea.
- Pickwick syndrome.
- Sudden apnea in infants (sudden infant death syndrome, death in the cradle).
- Central alveolar hypoventilation and dysrhythmia.
- Ondine's Curse Syndrome.
Nocturnal snoring is manifested by a sound arising on inspiration as air passes through the narrowed nasal and oral parts of the pharynx. It is caused by vibration of the soft palate and ductile structures of the pharynx.
Pickwick syndrome is characterized by obesity, night snoring, arterial hypertension, polycythemia, hyperemia of the face with episodes of OCA.
Sudden apnea of infants (IAGD) occupies a significant place in the structure of mortality in children under the age of one year. Although newborns have short pauses in breathing, present apnea poses a serious threat to life. Apnea is often observed in premature babies. It is believed that this is due to the underdevelopment of the respiratory centers of the brain. Other causes of apnea in infants are defects in the central nervous system, metabolic disorders, and infections.
If breaks in breathing last 10-20 seconds or more, asphyxiation develops - asphyxiation. The child turns pale, the skin becomes cyanotic, bradycardia is observed - interruptions in the heart rhythm. Children with apnea require particularly vigilant monitoring. Parents must master the techniques of artificial stimulation of the breath of newborns with the help of qualified medical staff. During apnea, it is necessary to clear the airways of mucus by aspirating it and carry artificial lung ventilation.
According to the classification of the main sleep disorders, the concept of dysomnia, in particular, internal sleep disorders, includes sleep apnea syndrome (CCA), in which a person has rather long periods of sleep when he stops breathing, the so-called apnea.
It arises due to the imperfect central regulation of respiration in newborns, especially premature infants, aggravated by catarrhal inflammation, hematomas of the upper respiratory tract, rhinitis. The occurrence of VAGD in newborns with an underdeveloped central nervous system can also contribute to overheating in violation of the normal thermal regime. Moreover, in infants, as a rule, mixed sleep apnea syndrome develops. Both central and obstructive mechanisms participate in its occurrence.
Undine's Curse Syndrome is a rare form of central CCA. With this nosological form, automatic control of ventilation is lost, and breathing is regulated only arbitrarily. During sleep, voluntary regulation does not occur and apnea or dysrhythmic hypoventilation occurs. This is observed with tumors, inflammation or dystrophic lesions of the trunk of the brain or cervical spinal cord, as well as with traumatic or surgical damage to the pathways.
We can distinguish such options for sleepy apnea:
The central version of obstructive apnea in the supine position is usually found in patients with mild manifestations of CCA, it is characterized by complaints of snoring and daytime drowsiness, but in the case of polysomnography there are episodes of apnea in the absence of respiratory efforts of the chest and abdominal leads, which is typical for central apnea. This option can be recognized using a sleep video recording by the characteristic noise of the opening of the airways at the end of each apnea episode. The mechanism of this phenomenon can presumably be associated with the suppression of respiratory effort by the decline of the pharynx in supine position. Interestingly, local pharyngeal anesthesia leads to typical manifestations of carotid apnea. Perhaps the sensitive ends of the pharyngeal mucosa are an important trigger for such a response.
Laryngeal version of sleepy apnea is a rare case. It occurs when obstruction of the upper respiratory tract during sleep develops due to a violation of the innervation of the larynx, leading to its overlap, and not due to pharyngeal collapse. Relatives of such patients usually experience unusual snoring, stridorous breathing during sleep, and other symptoms - drowsiness, morning headaches, confusion, sometimes against the background of hypercapnia. It can be caused by both central disorders (Shy-Drager syndrome, Amold-Chiari defect and syringobulbia), and peripheral (damage to laryngeal nerves during surgical interventions on the thyroid gland).
Nighttime laryngeal spasm appears often due to the irritating effect of hydrochloric acid on the vocal cords with gastroesophageal reflux that occurs at night and causes acute stridor. The patient cannot breathe normally, breathing becomes characteristic stridor, and he suddenly wakes up in a panic. The symptom lasts 2-3 minutes.
It is also necessary to define the concept of hypopia - these are respiratory events characterized by a partial decrease in the nasal air flow, a decrease in its amplitude by more than 50% in combination with a drop in blood oxygen saturation by 3-4%, lasting at least 10 seconds. Hypnosis can be of obstructive and central types.
The concepts of apnea and hypopne in the complex are called respiratory disorders, they underlie the definition of pathology - sleep apnea-hypopia syndrome (SAGS).
To date, there are no clearly defined criteria for determining sleep apnea syndrome. Initially, its definition was based solely on taking into account the number of respiratory events (apnea and hypopnea) per 1 hour of sleep time (apnea-hypopnea index). Snoring is one of the most characteristic and necessary symptoms of obstructive sleep apnea and a major risk factor, predictor of sleep apnea. Not all snoring people have sleep apnea, but the risk of developing it is much higher for snoring than snoring.
In the classification of Lugaresi, there are 4 stages:
- Stage 0 - preclinical - snoring with / without sporadic apnea, apnea-hypopnea index <10.
- Stage 1 - initial - recurring apnea, intensifying in separate conditions (lying on your back when the possibility of collapse of the oropharyngeal muscles increases; with superficial sleep and in the REM phase of sleep, when physiological oscillations occur in the respiratory center, apnea-hypopne index is approximately = 30) .
- Stage 2 - the height of the disease - repeated apnea throughout the night, apnea-hypopne index> 60.
- Stage 3 - complicated disease - when alveolar hypoventilation joins, even in the daytime, the fall of SaO2 in the REM phase of sleep.
There is another classification of SOAGS - according to severity, the criteria for which are the number and duration of apnea and hypopne attacks per 1 hour of nighttime sleep. It is customary to distinguish three degrees of severity of SOAGS:
- mild course (from 5 to 20 attacks);
- moderate course (from 20 to 40 attacks);
- severe course (more than 40 attacks).
In addition, the severity of SOAGS is affected by the severity and duration of a decrease in blood oxygen saturation, as well as the duration of the seizures themselves and the degree of disturbance in sleep structure.
Additional criteria for assessing the severity of SOAGS can be indicators of a decrease in blood oxygen saturation (desaturation) during apnea / hypopnea episodes, the degree of night sleep disruption, cardiovascular complications associated with respiratory disorders (myocardial ischemia, rhythm and conduction disturbances, arterial hypertension).
In the future, we will focus on obstructive sleepy apnea-hypopia syndrome. S. GuiJIeminault gave the most complete definition of SOAGS: obstructive sleepy apnea-hypopia syndrome can be defined as a condition when a patient experiences multiple repeated respiratory arrests due to complete (apnea) or partial (hypopnea) ) narrowing (falling) of the airways during sleep at the level of the pharynx and cessation of pulmonary ventilation with persistent respiratory effort, characterized by the presence of snoring, a decrease in the level of blood oxygen gross fragmentation of sleep, frequent awakenings and excessive daytime sleepiness. For the diagnosis of apnea, it is necessary that apnea episodes last at least 10 seconds and occur at least 15 times per hour.
In severe cases, up to 500 respiratory arrests with a total duration of up to 3-4 hours can occur during the night, which leads to both acute and chronic nocturnal hypoxemia, which, in turn, significantly increases the risk of developing hypertension, heart rhythm disturbances, heart attack myocardium, stroke and sudden death in a dream. During the working day, such patients experience attacks of drowsiness, irritability, decreased attention, memory, potency, and headache.
Especially dangerous are bouts of acute drowsiness while driving because of the risk of traffic accidents. Men have nighttime apnea 20 times more often than women, usually aged 40-65 years. About 2/3 of these patients are obese or obese.
The manifestations of apnea were first described in 1919 by Osier in overweight young people who complained of daytime sleepiness. Although, probably, the first description of sleep apnea syndrome in the medical literature should be considered an article by W. H. Braoadbent, published in the English journal Lancet in 1877, on the problem of chain-Stokes breathing in hemorrhagic strokes. This is the first description of the sleepy apnea episode itself.
Later, in 1956, Burwell et al. described a similar condition in which the following easily recognizable symptoms are observed: obesity, nocturnal snoring, arterial hypertension and polycythemia with hyperemia of the face and called it Pickwick Syndrome. In 1962, J. Seve-ringhaus and R. Mitchell described Undine's Curse Syndrome, a rare form of central sleep apnea. They observed a patient with severe damage to the conduction pathways of the brain, in whom automatic control of ventilation was lost, and only voluntary was preserved. The patient could only breathe while awake, when he fell asleep he had apnea.
Gastaut et al. cases of frequent respiratory failure during sleep in obese patients. In 1967, R. Young and V. Kuhl first identified an independent pathological symptom complex from Pickwick syndrome, the main manifestation of which is regular episodes of nocturnal asphyxical states - nocturnal apnea. Scientists have found that apnea is accompanied by severe hypoxia, hypercapnia and changes in the electrical activity of the brain, which lead to frequent awakenings, and attempted to correct it using tracheotomy. In 1968, A. Rechtschaffen and A. Kales first performed a multiple night registration of biological signals - night polysomnography.
In the future, data appeared about the possibility of apnea in people with normal body weight and against the background of a lack of daytime sleepiness. In the early 70s of the last century Guilleminault and colleagues described sleep apnea as a syndrome associated with insomnia. In 1988, Gould proposed the term “hypopnea syndrome during sleep” to describe a subset of patients with apnea symptoms who have experienced episodes of airflow restriction. Since the physiological effects of apnea and hypnosis are similar, the term “apnea-hypnosis syndrome” was proposed to reflect these disorders.
Snoring is a sound phenomenon that occurs when the soft structures of the pharynx beat against each other as the air stream passes through the narrowed airways.
The causes of snoring are:
- Anatomical disorders leading to narrowing of the airways:
- Nasal septum curvature
- Congenital narrowness of the nasal passages and / or pharynx
- Polyps in the nose
- Elongated palatine tongue
- Small posterior lower jaw (malocclusion)
- Tonsil enlargement
Functional factors and diseases that reduce the tone of the muscles of the pharynx:
- Actually sleep (decreased muscle tone)
- Sleep deficiency and fatigue
- Alcohol intake
- Taking medication
- Decreased thyroid function
- Menopause in women
How to distinguish "normal" snoring from pathological?
Snoring can occur in any person at any age, however, the frequency of its detection progressively increases with aging. During his life, every person, at least once, peacefully snored. But, many do not know about it. However, is it worth worrying if your neighbor began to talk about your nightly tunes in the morning?
The main criterion that defines the boundary between “normal” and pathological snoring is how snoring affects your health. If snoring is just a trivial phenomenon without pathological consequences and does not prevent you from enjoying life, then there is no need to treat it. However, if the snoring is loud, then this can spoil the life not for you, but for your partner.
It is known that every fifth person after 30 years constantly snores in his sleep. It is well known that the severity of snoring increases with age. So, at the age of 30-35 years, 20% of men and 5% of women snore, and at the age of 60 - 60% and 40%, respectively. According to foreign studies, the prevalence of CAS is quite high and amounts to 5-7% in a population older than 30 years, with approximately a third of these patients having moderate severity or a severe degree of disease.
From the problems associated with snoring, 38,000 people die annually in the United States, and the total damage caused to the state by various manifestations of this syndrome amounted to $ 150 billion in 1994. Thus, this disease is very common, and, no doubt, every doctor has encountered these patients. Snoring, which affects one in five, is really harmful to health. Excessive relaxation of the muscles of the pharynx during sleep literally paralyzes the respiratory apparatus, and a special activation of the brain is needed for the next breath. After the resumption of breathing, the normal oxygen content is restored in the body, the brain calms down, the person falls asleep, and ... everything repeats, that is, the bedroom again shakes with snoring.
During short-term respiratory arrests, pressure can jump up to 200-250 mmHg. But there is one more nuisance accompanying snoring: the production of the hormone responsible for the metabolism of fats is reduced in the body. As a result, they no longer turn into energy, and a person, stocking up with it, becomes voracious and gains excess weight. These excesses are deposited in the most inappropriate places - for example, in the neck. Fat deposits here narrow the airways, which in itself triggers the mechanism of snoring, provoking the further development of the disease.
Snores are usually irritable, distracted, and complain of drowsiness. The desire to "have fun" may arise at their most crucial moment - during a business meeting or (much worse) at the wheel. It is better to be treated for snoring by a doctor. But there are some simple recommendations, following which you can avoid a visit to the therapist. The easiest way to stop snoring is to gently turn the sleeping person to the other side. Do not be angry with your loved ones for this, on the contrary, give thanks: after all, snoring only disturbs them, and it is really harmful to you.
Almost the majority of people suffering from snoring do not even suspect that they have breathed more than once or even twice during the night. Thank God that not for very long. Families and relatives know about this, who, with some observation, can see this and experience fear. Frequent awakenings of a snoring person, necessary for restoring breathing, make it impossible for them to sleep, nor for those who sleep nearby in bed or even in the next room.
Snoring in children
Snoring is observed not only in adults, but also in children. The most common cause of snoring in children is an increase in tonsils and adenoids. Other causes may be acute and chronic nasal congestion, various abnormalities in the structure of the bones of the facial part of the skull. Curvature of the nasal septum with blockade of nasal breathing also contributes to the development of snoring.
In more severe cases, the child may experience respiratory arrest in a dream. In this case, you must urgently consult a doctor to assess the severity of respiratory disorders and determine the treatment method. The presence of respiratory disorders during sleep can lead to various symptoms that, at first glance, seemingly unrelated to snoring and respiratory arrest.
The behavior of children changes, they become moody, less obedient, often can complain of fatigue, school performance decreases, their sleep becomes restless, they can often wake up, sometimes night enuresis is observed. There may also be growth retardation, which is associated in this case with insufficient production of growth hormone. This hormone, mainly determines the growth of children and is produced mainly at night. If the structure of sleep is disturbed, as is the case with snoring and respiratory arrest in a dream, then its production decreases.
Why do people snore in their sleep?
Normally, breathing air during sleep, we create a negative pressure in the chest cavity, which has a suction effect on the soft tissues of the upper respiratory tract. The walls of the pharynx and larynx are retracted inward, but the muscular frame prevents their complete subsidence. The sound of snoring is heard when the root of the tongue, soft palate and pharyngeal wall oscillate due to excessive relaxation of their muscles in a dream.
The main causes of snoring are: diseases of the nose, pharynx, larynx, enlarged palatine tongue, enlarged and sagging soft palate, enlarged tongue, decreased tone of the muscular skeleton. Decreased tone is associated with age, obesity, alcohol, sleeping pills, and smoking.
Is snoring harmful?
During snoring, air, on the way to the lungs, is forced to pass through an obstruction in the form of blocked airways, which complicates ventilation and creates a deficiency of oxygen in the blood.
Body tissues, primarily the brain and heart, suffer from oxygen deficiency. Therefore, "snoring" is subject to several rather unpleasant diseases and conditions.
First of all, these are:
- The ineffectiveness of night sleep (it is impossible to get enough sleep), and therefore - the deterioration of well-being during the day and a decrease in working capacity, memory, attention, reaction;
- Decreased sexual function for the same reasons;
- Increased blood pressure;
- Overload of the heart and its disease, first of all - violation of the heart rhythm and "pulmonary heart";
- Frequent short respiratory arrest in a dream or "Sleep Apnea Syndrome".
10 tips to spend the night quietly
There are several degrees of snoring. "If your wife leaves the bedroom, you snore sparingly, but if your neighbors leave, you have severe snoring," says Dr. Philip Westbrook, director of the Mayo Clinic for Sleep Disorders in Rochester, Minnesota.
Men snore more often than women. Sleep researchers Dr. Earl W. Dunn and Dr. Peter Norton, when examining more than 2,000 people in Toronto, found that 71% of men and only 51% of women snored. In another study, the difference was almost two to one in favor of men.
"From a clinical point of view," says Dr. Westbrook, "moderate snores are those that snore every night, but perhaps only lying on their backs and only part of the night."
Snoring may not sound like a musical sound to your ears, but the sound is orchestrated by a wind instrument located on the back of your throat. “The tissue in the upper airways on the back of the throat is relaxing during sleep,” says Dr. Philip Smith, director of the Johns Hopkins Sleep Disorders Center in Baltimore, Maryland. “When you breathe in, the tissue on the back of the throat vibrates, and this effect very similar to a wind instrument. "
For those whose sleep partners are not talking about twin beds, but about separate bedrooms, here are ways to help stop this music.
1. Go on a diet. As a rule, most snorers are middle-aged people, overweight men. Most snoring women are in menopause. Losing weight leads to stopping snoring. “Snoring is often associated with being overweight,” says Dr. Dunn of the Sleep Laboratory at the University of Toronto Medical Center. “We found that if moderate snoring loses weight, snoring becomes less loud and actually disappears in some people.” “You don’t need to have a weight of 2 tons to develop snoring. Just a small excess of weight can cause this problem,” he says. “Men whose weight is 20% higher than ideal can also develop snoring. Women should usually be 30- 40% heavier than your ideal weight. But the more weight you have, the more likely your airway is weakening. "
2. Ignore the glass for NIGHT. “Alcohol at bedtime enhances snoring,” says Dr. Dunn. Do not drink before going to bed and sleep.
3. Refrain from drowsy. Sleeping pills can make you sleep, but your partner will be kept awake. “Everything that relaxes the tissues of the head and neck tends to worsen snoring. Even antihistamines work this way,” says Dunn.
4. Extinguish the cigarette. Kill snoring by destroying cigarettes. “Smokers usually become snovers,” says Dr. Dunn. “So stop smoking.”
5. Do not sleep on your back. Lie down on your side while sleeping. "Strong snores snore in almost any position," says Dr. Dunn, "but moderate snores snore only when they sleep on their backs."
6. Substitute the ball. This refers to a tennis ball. “Sew a tennis ball into your pajamas on your back,” Dr. Dunn suggests. “So, when you turn on your back, you will stumble on this solid object and involuntarily turn on your side.”
7. Fight the pillow, then dispose of it. From pillows, the strength of your snoring only increases. “Anything that causes a kink in the neck, such as a large pillow, makes you snore harder,” says Dr. Dunn.
8. Raise your bed. Raising the bed can help reduce snoring to a minimum. “Lift your upper torso, not just your head,” says Dr. Westbrook. "Put a couple of bricks under the legs of the head of the bed."
9. Blame it on allergies. Sneezing and snoring go side by side. "Snoring can develop due to an allergy or a cold," Dr. Westbrook says. "Use a nasal decongestant, especially if your snoring is intermittent and occurs during the hay fever season."
10. Insert earplugs in your ears. “When it's all in vain,” says Dr. Westbrook, “someone who suffers from snoring by another person should put earplugs on their ears overnight. They are inexpensive and can be bought at any pharmacy.”
There are a variety of methods for conservative and surgical treatment of snoring.
Conservative methods are aimed at expanding the airways. Patients should choose the correct sleeping position. There are also special intraoral devices that prevent snoring. Patients can do special exercises to reduce snoring.
Surgical correction of snoring includes a complex of operations that improve nasal breathing, increase the lumen of the pharynx, and reduce the size of the soft palate and lymphoid formations of the pharynx. These operations are usually performed using a laser, ultrasound, or mechanical scalpel.
Inpatient treatment with positive airway pressure is also possible.
Stress and sleep
Stress is a physiological neurohormonal reaction to external and internal influences aimed at eliminating the effects of "damaging" factors, leading to disruption of the integrative activity of the brain and other body systems, and as a result, to a decrease in certain functional capabilities of a person. It follows from this definition that stress has both positive and negative manifestations. The activity of antistress systems is aimed at solving the negative effects of stress, is carried out in a sleep-wake cycle, and determines the individual's resistance to stress.
The mechanisms for the implementation of the antistress system can be divided into neurophysiological, humoral and psychological, which have their own characteristics, both during wakefulness and sleep. An important role in antistress mechanisms is given to sleep, as a multifunctional, self-regulating and multi-stage process of preparing the brain for subsequent wakefulness, having certain external and internal manifestations, actively participating in adaptation in acute and chronic stress of various modalities. Adaptation (antistress) sleep system (ACC) - a set of cerebral mechanisms, providing a single process of alternating appearance, course and end of sleep stages, leading to the restoration of human functionality. Its capabilities make it possible to optimize the organism’s adaptation to the environment during sleep and partly determine stress resistance in general. A feature of this system is that it actively works during the whole time of sleep, namely, even in the absence of the action of a stressor. The main properties of ACC are based on biological (gender, age, constitution, etc.) factors and are determined by the participation of various neurophysiological, biochemical, and psychological mechanisms in the implementation of the adaptive function of sleep.
Dwelling on the neurophysiological aspects of stress reactivity, it is necessary to note the important role in the development of sleep of both systems forming separate stages of sleep and integrative processes that ensure the work of the whole ACC mutually coordinated in sleep time. A change in the activity of ACC is an essential component of stress, which is expressed in a change in the functioning of various neurophysiological systems and is characterized by both focus and severity. Stressful reaction begins in wakefulness and continues during the whole night's sleep, and during chronic stress during several sleep-wake cycles. It is important to note that the sleep reaction has both general and particular neurophysiological patterns. The strength and direction of stress during wakefulness is determined by a combination of both a stressor (its strength, modality and duration) and individual characteristics of a person (biological and psychological factors).
A nonspecific manifestation of stress is characterized by an increase in the activity of ascending activating systems and is manifested in an increase in the representation of wakefulness during sleep and a violation of stability in maintaining the functional states of sleep. A variety of specific sleep changes depend on the type of exposure and initial stress tolerance of the individual. At the same time, various dubious systems are included in different ways in stress reactions.
All of the above changes in sleep can be detected not only at the intrastress, but also at the post-stress stage (a few days after the end of the stress), which may cause the development of insomnia (disturbances of night sleep) in the future. I would like to pay special attention to the principle of the correspondence of sleep to subsequent wakefulness, which is of independent importance. This principle is based on different functions and mechanisms of sleep and wakefulness. The lack of implementation of the target function of sleep can lead to a decrease in the functional capabilities of a person during wakefulness. During wakefulness, on the contrary, a person is able to actively influence existing functional states, changing the program of behavior in accordance with the internal feeling of his abilities.
Wakefulness, in which a person does not take into account the features of previous sleep, can be completely maladaptive. Thus, if the functional meaning of "sleep" does not match the possibilities of subsequent "wakefulness", an adaptive dissonance (HELL) of the sleep-wake cycle arises, which can cause non-adaptive reactions during wakefulness. The close interaction of antistress mechanisms of wakefulness and sleep determines the adaptive capabilities of the body. Prevention at the stressful and post-stressful stage should take into account not only the characteristics of ACC, but also all manifestations of wakefulness as factors capable of supporting and even exacerbating chronic stress.
Sleep Disorders in Children
These disorders are diverse and in structure differ significantly from adult sleep disorders. Their prevalence is 25% at the age of 1-5 years. Most often, PARASOMNIA (various phenomena that occur during sleep) and INSOMNIA (disorders of the initiation and maintenance of sleep) are detected in children. The most interesting and more common parasomnia.
Convergence. It is the pronunciation of words or sounds during sleep in the absence of subjective awareness of the episode. Episodes of phrases occur at any stage of sleep, more often during shallow slow sleep (stages 1 and 2). It is known that they are a benign phenomenon that occurs in most people throughout life, but in childhood it is much more common than in adulthood. So, in the category of “often or every night”, the overlap took place in 5-20% of children and in 1-5% of adults in the general population. Special treatment is not carried out.
Bruxism. Bruxism refers to episodes of gnashing of teeth during sleep. Teeth grinding usually occurs once per second and lasts 5 seconds. or longer. Then these episodes are repeated throughout the night. They can take place at any stage of sleep; typical motor artifacts are recorded on the EEG and EMG at this time. The causes of gnashing of teeth are unknown. The family nature of the inheritance of this disorder is noted - according to our data, 18% of patients' relatives had in childhood or have similar episodes at present. As in the case of phrases, more often this phenomenon was noted in boys. The association of the frequency of episodes of gnashing of teeth with daytime emotional situations is also traced. There was no association of bruxism and the presence of helminthic invasion in a child (a common myth). In children, bruxism very rarely leads to damage (toothbrushing), therefore, special treatment is usually not carried out. Nootropic and sedatives are used. Sometimes you have to pick up a special tire.
Enuresis at night. A disorder characterized by frequent (for boys after 5 years of age more than 2, for girls - 1 episode per month) cases of involuntary urination during sleep. The prevalence of NE at the age of 12 reaches 3%, more often it is boys. Children with this disorder often have very deep sleep (increased delta sleep), but episodes of NE occur in all stages. The primary (enuresis from birth without "bright gaps") and secondary (interrupted for 3-6 months) forms of the disease are distinguished. It is assumed that congenital or acquired dysfunction of the autonomic apparatus controlling the bladder plays a large role in the development of this condition. A fairly close hereditary predisposition is noted. The genes of family forms of NE - enur1 and enur2 - were isolated. The treatment uses behavioral techniques (limiting fluid intake, promoting, training the bladder), psychotherapy, physiotherapy, nootropic drugs, antidepressants (melipramine) and pituitary hormones (adiuretin).
Sleepwalking. Sleepwalking is a series of episodes of complex behavior that occur during sleep and are manifested by the performance of various actions, most often - walking. During such episodes, the child may get out of bed and take any action. Most often it’s just a “trip” to the corridor, to the kitchen or to the parents bedroom. More complex motor acts that mimic the usual actions can be carried out: search for toys, an attempt to open the door with a key. Actions are performed with open eyes, with an expressionless look. The child does not respond to questions addressed to him. A similar episode lasts from a few seconds to several minutes, on average - about 6 minutes. Amnesia of the incident in the morning is characteristic. The prevalence of sleepwalking in the child population is 10-30%. Most often they occur in the first third of the night, when the representation of "delta sleep" is greatest. Heredity for these parasomnias was noted in 20% of patients. . The plan of therapeutic measures includes a conversation with parents on the organization of sleep patterns and behavior during an attack, courses of sedative and nootropic therapy, psychotherapy. According to the literature, 5-7% of cases of dreaming are epileptic in nature, however, most likely, these data are greatly overstated.
Nightly fears. These include episodes of awakenings with a loud cry and behavioral and vegetative manifestations of fright. Parents' attention can be attracted by the cry of a child, when they come up they find him sitting in bed with an expression of fear or confusion on his face. Breathing and palpitations are frequent, profuse sweating may be noted. At the same time, the child does not respond to the words addressed to him, and attempts to calm him down can lead to increased fear or resistance. In the morning amnesia of what is happening is observed. Nightly fears are less common than dreams, their prevalence in children is 1-4%, reaching a peak at the age of 4-12 years. More common in boys. Provoke these episodes can daytime emotional situations, fever and prolonged lack of sleep. Polysomnographic research does not reveal a specific pathology. Therapeutic measures include psychotherapy, nootropic and sedative therapy.
Nightmares. Nightmares are terrifying dreams. The content of dreams frightens the child, he dreams that he is being threatened, hurt, persecuted or attacked. From this he wakes up in excitement, cries or calls for his parents. Unlike nightly fears, nightmares more often occur in the morning and are confined to the REM phase. Nightmares differ from nightly fears in that the night awakening is complete, the child is available for contact, says that he was scared and continues to remember this in the morning. The prevalence of nightmares in the child population is 5-30%. The appearance of nightmares in a child can be triggered by stressful situations, feverish conditions, and the use of psychotropic drugs. The increase in nightmares may be a testament to the child’s troubles in the psycho-emotional sphere, a manifestation of his internal conflict. Among the therapeutic measures, the main role is played by psychotherapy with the possible addition of sedative and nootropic drugs.
Rhythmic motor disorder. Manifested by stereotypical, repetitive movements involving large muscles, usually the neck and head. The pattern of these movements can be quite varied: a child can “butt” with his head a pillow or headboard or, standing on his hands and knees, swing back and forth rhythmically. The prevalence of this phenomenon in children under 4 years of age according to the literature is 6-10%. It is believed that in this way, through a rhythmic effect on the structures of the vestibular apparatus, children "calm" and "rock" themselves. Indeed, the development of such episodes can be triggered by emotional overexcitation.
Restless Leg Syndrome (RLS)
Ekbom K. - 1945 - a clinical description. RLS is a condition characterized by "unpleasant" sensations in the legs, completely or partially disappearing only at the moment of movement. The need for movement is irresistible. “Unpleasant” sensations are described by patients as “discomfort”, “pain”, “stretching”, “twitching”, “tingling”, “tingling”, “pinching”, “itching”, “shuddering”.
- 5% to 15%
- Among children under 10 years old - 18%
- The peak incidence occurs in middle age.
In the clinical picture, it is noted (according to the international RLS group - Walter et. All .1995):
- The need to move limbs, accompanied by unpleasant sensations in the legs.
- Motor anxiety.
- Worsening of symptoms in a dream, with periods of increased motor activity.
- Worse symptoms in the evening or at night.
- Sleep disorders and their consequences in wakefulness (difficulty falling asleep, shallow sleep, daytime drowsiness, increased fatigue).
- Involuntary periodic movements of the limbs in sleep and wakefulness considered in the framework of the syndrome of periodic movements of the limbs.
- Light - episodic disorders.
- Medium - less than two times a week, falling asleep, waking daytime worsening.
- Severe - three or more episodes per week with nighttime sleep disorders and a significant deterioration in daytime conditions.
Duration of violations:
- Acute - less than two weeks.
- Subacute - from two weeks to three months.
- Chronic - from three months or more.
Relationship with gender:
- women suffer more.
Reasons for secondary RLS:
- Rheumatoid arthritis, Acute and chronic renal failure, Parkinsonism, Uremia, Pregnancy, Narcolepsy, Sleep Apnea Syndrome, Polyneuropathy, Anemia, Depression, Anxiety, Fibromyalgia Syndrome, Caffeineism, Iatrogenic effects.
RLS leads to the development of:
- Anxiety, Depression, Insomnia, Social maladaptation.
Periodic Limb Movement Syndrome (SPDK)
SPDK is a condition characterized by episodes of repeated, stereotypical movements in the legs, consisting of extension of the thumb in combination with flexion of the knee, and sometimes the thigh, usually during a night’s sleep.
In the clinical picture of SPDK are noted:
- Complaints of sleep disturbances and daily salinity.
- Repeated stereotypical movements in the legs, usually not noticed by patients.
Prevalence of SPDK:
- Among people over 60 years old - 34%
- Among patients with insomnia - from 1 to 15%
- Etiology: unknown.
To clarify the diagnosis of motor disorders in a dream, night polysomnography is necessary.
Epilepsy and sleep
The connection of epileptic seizures with sleep was noted more than a century ago. 40% of patients had daytime seizures (in wakefulness), 25% of patients had night-time forms of seizures. In other cases, attacks occurred regardless of sleep or wakefulness. The connection between the course of epilepsy and the movement of the lunar phases is noted. In some patients with epilepsy, the largest number of seizures occurs on the first day after the new moon and full moon. A number of authors described "sleepy" epilepsy with seizures that occur exclusively during sleep.
Sleep epilepsy is manifested more often in partial generalized seizures, sensory phenomena are noted in the seizure, foci located in the right hemisphere dominate. The prognosis of the disease with seizures that occur in a dream is more favorable in the case of generalized tonic-clonic seizures than in the case of partial ones.
Wakefulness epilepsy is equally common in boys and girls, while sleep-wakefulness epilepsy is 1.5 times more likely to occur in males.
There are a number of epileptic syndromes associated with a period of sleep. These include: idiopathic generalized epilepsy with tonic-clonic seizures, absences, juvenile myoclonic epilepsy, infantile cramps, benign partial E with centrothermal adhesions, benign partial E of childhood with occipital paroxysms. Recently, interest in autosomal dominant frontal frontal epilepsy with nocturnal paroxysms and Landau-Kleffner syndrome has increased.
Epilepsy significantly affects the structure of sleep. Sleep disorders can be in the structure of prodromal epileptic symptoms. Deep sleep after a generalized seizure is probably a defense mechanism. Paroxysmal, sometimes unexplained awakenings during sleep may be the only manifestation of nocturnal seizures. As a result, the patient is mistakenly diagnosed with sleep disorders. These paroxysmal awakenings can occur in the presence of deep epileptic focus, especially with frontal epilepsy.
Drugs such as barbiturates and benzodiazepines, diphenin and carbamazepine can cause a decrease in the presence of the REM phase. However, some of them can positively affect the structure of sleep. Concerning valproic acid, there is no unambiguous data: in one work there was no significant effect on sleep structure, in another, an increase in the representation of delta sleep was shown, in the third, a reduction in the phase of REM sleep was revealed.
In 1937, just 9 years after the discovery of electroencephalography (EEG), Gibbs F.A., Gibbs E.L. and Lenoex W.G. wrote that "recording an EEG within one minute of superficial sleep provides more information for diagnosing epilepsy than an hour of wakefulness research." This is due to the fact that epilepsy as a disease uses the same morphological and biochemical substrates for its development as the physiological sleep of a healthy person. Therefore, the study of sleep allows you to look much deeper into the essence of the epileptic process.
The study of night sleep has a special role in situations where the cause of the disease is unclear. For example, a person regularly loses consciousness and cramps occur. There are many cardiovascular and neurogenic diseases that can give such symptoms. The study of night sleep allows us to resolve the emerging dilemma: epileptic or non-epileptic are seizures. The prognosis, treatment and social relationships of the patient depend on this.
Narcolepsy is a central nervous system disease characterized by complex sleep disorders, which have 4 main manifestations:
- Sudden daytime drowsiness and bouts of sudden falling asleep
- Cataplexy (bouts of sudden weakness)
- Sleep paralysis
- Hypnagogic (upon falling asleep) and hypnapompic (upon awakening) hallucinations
The prevalence of narcolepsy is 5-7 per 10,000 people. Narcolepsy usually develops between the ages of 20-50, more often in men. The hereditary nature of the disease is assumed.
Narcolepsy can occur (especially at the onset of the disease) with only one of the above symptoms. Over time, the picture of the disease may change due to the addition of other symptoms of narcolepsy.
Ниже мы подробно остановимся на характерных проявлениях нарколепсии:
Sharp daytime drowsiness and bouts of sudden falling asleep during the daytime are usually the first symptoms of narcolepsy. Drowsiness is so severe that patients fall asleep despite the extreme reluctance of this or a completely inappropriate environment. This is especially dangerous if a person is associated with professions that require increased attention. Daytime falling asleep can be repeated several times a day and last from a few seconds to several minutes. In episodes of daytime sleep, at first a gradual slowdown of speech occurs, then a "fall" of the head and a complete turn off of consciousness. At the same time, patients, as a rule, still manage to take a pose that is comfortable for sleeping. After awakening, patients feel alert and energized. However, after a few hours, pronounced drowsiness develops again.
Cataplexy is an attack of sudden weakness amid strong positive or negative emotions (laughter, surprise, sexual intercourse, crying, anger). Weakness is due to loss of muscle tone. An attack can develop so quickly that the patient can fall and get injured. The duration of the attack ranges from a few seconds to several minutes. This may be followed by falling asleep.
Hypnagogic (during the period of falling asleep) and hypnapompic (during the period of awakening) hallucinations are vivid acoustic or visual visions that resemble a dream arising during falling asleep or awakening. They are also called “waking dreams”, as a person realizes that he is not sleeping yet, but is already starting to see a dream. At the same time, visions are introduced into the environment: people or fabulous creatures can walk around the bedroom. A person can hear voices, music or see flashes of light. Usually these visions are accompanied by fear and anxiety.
Carotid paralysis is a condition characterized by complete immobility after waking up. A person is fully conscious and adequately assesses the situation, but cannot move. Saved only the ability to blink and move your eyes. Carotid paralysis is more often observed in the morning, but can occur in the evening and at night. This situation can be very frightening, especially in the case of frightening hallucinations against a background of stillness. The attack can last from a few seconds to several minutes and ends with a gradual restoration of control over movements.
he disease can be suspected by passing a self-test to detect excessive daytime sleepiness and narcolepsy.
An accurate diagnosis is possible only on the basis of a consultation with a specialist in sleep medicine and a number of complex diagnostic tests (polysomnography, multiple sleep latency test, encephalography and several others). To do this, contact a sleep laboratory.
Unfortunately, narcolepsy is incurable. However, supportive care can significantly improve the patient's quality of life. Drug therapy consists in the appointment of stimulants that reduce daytime sleepiness, as well as the appointment of drugs that alleviate the symptoms of cataplexy or sleep paralysis. The use of these funds should be carried out under strict medical supervision.
Particular attention should be paid to sleep hygiene. Adequate night sleep is required, as well as daytime sleep 1-2-3 times for 30-60 minutes. It is necessary to solve the question of choosing a profession that allows you not to adhere to a tight schedule of sleep and wakefulness, and is also not associated with the use of tools or mechanisms that require increased attention.