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1. Sleep
2. Anxiety Disorders
3. Substance Abuse

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SLEEP STAGES:

• STAGE I
• STAGE II: EEG in theta range.
• K-complexes may occur: high amplitude negative deflections followed by a positive wave.
• STAGE III: DEEP SLEEP -- required for restful sleep.
• Delta waves
• STAGE IV: DEEP SLEEP -- required for restful sleep. No thought is occurring.
• REM:
• Symptoms:
• Waking EEG pattern (alpha waves)
• Flaccid paralysis; active inhibition of skeletal muscle.
• Penile erection
• Conjugate quick eye movements (saccades) similar to waking state.
• Dreaming
• REM Deprivation: Occurs as a result of total-sleep deprivation, or by using REM-Suppressing Drugs like sedative hypnotics.
• ICU Psychosis: Delirium resulting from REM deprivation in the ICU due to overall sleep deprivation.
• REM Rebound: Prolonged and more frequent REM episodes following REM deprivation.

DREAMS: No evidence that they have psychological import, other than to show the thoughts of the previous day.

• Early REM cycles: Preoccupied thought from short-term (last 24 hrs) memory.
• Late REM cycles: Long term memory is integrated into dreams.

SLEEP ARCHITECTURE:

• Old age ------> shorter and shallower sleep cycles.
• REM is 25% of total sleep time.
• REM latency
• Sleep cycle becomes shallower as the night progresses.

PARASOMNIAS:

• Nightmares: Dreams with heightened emotional content.
• PGO COMPLEXES: EEG activity found with aversive emotions in dreams. Similar activity found with response to frightening stimuli when awake.
• P = Pons
• G = Geniculate Bodies
• O = Occipital lobe
• Night Terror (Pavor Nocturnus): Sudden arousal from deep sleep, not during dreaming, without passing through Stages I and II.
• Sign of sympathetic activation, but the EEG pattern remains in slow wave sleep.
• Little kid does not remember the episode -- delirium episode.
• Somniloquy: Associated with stage II sleep.
• Somnambulism: Sleep-walking. Can be dangerous. Occurs during REM sleep.
• Hypnagogic / Hypnopompic Hallucinations: Hallucinations during the period of going to sleep (hypnagogic) or arousing from sleep (hypnopompic).
• Sleep Paralysis: Skeletal muscle paralysis (resembling REM sleep) continuing into wake-fulness.

Disorders of Excessive Daytime Somnolence (DOES):

• NARCOLEPSY: Disorder of excessive REM sleep.
• Symptom-Complex
• Sleep onset REM -- REM occurs during the first cycle of sleep.
• Sleep Attacks during the day -- blasts of REM sleep during the day.
• Cataplexy: Loss of skeletal muscle tone (collapse) following heightened emotions, during wakefulness.
• Skeletal muscle tone resembles REM sleep.
• Sleep Paralysis: Again resembling REM sleep.
• Hypnagogic / Hypnopompic Hallucinations: Excessive hallucinations is characteristic of narcolepsy. Occasional mild hallucinations is normal.
• Treatment: Amphetamines successful supress daytime sleep attacks.
• Epidemiology: Rare and predominantly males 10-20 at onset.
• SLEEP APNEA: Inability to remain in deep sleep due to constantly jolting out of deep sleep (not awake, but back to shallow sleep) in order to breathe.
• Peripheral Sleep Apnea: Problem with patency of upper airways.
• Central Sleep Apnea: COPD. Insensitivity to hypercapnia (high CO₂) in the medullary respiratory centers.
• Treatment: Continuous Positive Airway Pressure (CPAP)

Disorders of Initiation and Maintenance of Sleep (DIMS):

• Simple Insomnia: Increased sleep latency -- period it takes to fall asleep.
• Treat it with behavioral therapy to improve sleep hygiene.
• Only use sleeping pills (sedative hypnotics) for the short-term (less than two weeks) for situational insomnia.
• Long-term misuse can result in tolerance, dependence, and rebound insomnia.
• Transient Insomnia: Anticipation or anxiety when sleeping, due to a situation or event. This is the single best use for sedative hypnotics.
• Sleep-Shifting:
• Sleep cycle is less disrupted if the sleep time is advanced (moved up) rather than moved back.
• Thus, traveling from California to New York is less disruptive than going from New York back to California.

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PANIC DISORDER:

• Panic Attacks
• Tachycardia
• Tachypnea (hyperventilation)
• Hypertension
• Sweating
• Tremor
• Abdominal Distress: Butterflies, blood drawn away from splanchnic circulation.
• Light-headedness
• AGORAPHOBIA: Epiphenomenon, resulting from Learned Helplessness in dealing with panic attacks. Fear of having another attack in public.
• TREATMENT:
• Initial treatment: Sedative hypnotics may be used to initially get them to the clinic, but not for long-term use.
• Sedative Hypnotics do not prevent the onset of panic attacks, although they may reduce their severity.
• Long-term: Ironically, treat it with the things that make some sympathetics stick around longer!
• MAO Inhibitors
• Tricyclics: Norepinephrine reuptake inhibitors.
• SSRI's: Probably the best thing to treat it with.
• Therapy:
• Desensitization: Gradual exposure to frightening stimulus.
• Education
• Epidemiology:
• Women
• 30% of patients also have Mitral Valve Prolapse.
• Doctors often mistake other diagnoses for a panic attack: Tachycardia, GI problems, seizures, etc.
• Differential Diagnosis:
• Hyperthyroidism
• Carcinoid Tumor: Serotonin secreting GI tumor.
• Pheochromocytoma: Adrenal medullary tumor
• Paroxysmal Atrial Tachycardia (PAT)
• Atrial Fibrillation
• Somatization Disorder: Similar except it involves multiple organ systems over a long period of time.

OBSESSIVE-COMPULSIVE DISORDER (OCD):

• OBSESSION: Worrying that you always have a boogar on your shirt when in fact you don't.
• Doubt.
• They don't know why they have the worry, contrasted with delirium or schizophrenia, where they do know why.
• COMPULSION: Habitual, compensatory steps taken to avoid, satisfy, or ameliorate the obsession.
• OCD is chronic and may wax and wane, but it is exacerbated by major depression, which often coincides in the same patient.
• TREATMENT: Revolutionary treatment in past five years with SSRI's.
• Clomipramine is the only tricyclic that has shown some efficacy with OCD. Other tricyclics have failed.
• Behavioral Modification:
• Thought Stopping
• Flooding / Implosion / Exposure
• Surgery: Anterior Cingulotomy, not done too often!

TOURETTE'S SYNDROME: Related to OCD; the presence of forced and automatic thoughts and actions.

• People with OCD often show a family history of Tourette's Syndrome.
• Extrapyramidal system is turned on all the time. Tourette's patients are forcefully compelled to mimic the actions and words of people around them. They are "possessed" by their environment.
• TREATMENT: Neuroleptics (Dopamine blockers) are prescribed.

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ABUSE: Persistent use of a pharmacologically active substance despite objective evidence of detrimental effects on the user.

DEPENDENCE: The pharmacological phenomenon of dependence and withdrawal.

• TOLERANCE: Increased dosage required to achieve the same effect
• Metabolic Tolerance: Increased production of metabolic enzymes ------> increased and more rapid metabolism and excretion of drug.
• Neuronal Tolerance: Down or up regulation of neuronal receptors involved in mediating the effect of the drug.
• Alcohol Tolerance ------> overstimulation of GABA (hypnotic) receptors ------> down regulation of GABA receptors.
• WITHDRAWAL: Observable rebound response when the drug is removed.

ADDICTION: Drug seeking behavior. Going to all ends (enduring discomfort, breaking the law) to assure a ready supply of the drug. It quickly follows dependence, although context of drug use does make a difference (medicinal -vs- recreational).

• Factors determining addiction:
• RISK-TAKING behavior (Cluster B personalities) are at increased risk for trying the drug initially, which is a factor in addiction to illicit drugs -- but not to alcohol.
• CONTEXT: Analgesic use of opiates is not associated with increased risk of drug-seeking behavior.
• DRUG PROPERTIES: Highly euphoriant drugs with short-half lives (Heroin, Cocaine) induce the strongest addiction the quickest. They result in almost instantaneous development of tolerance and withdrawal.
• Risks of Dependency: Alcoholics are at increased risk if they can tolerate the adverse effects of alcohol when young.

ALCOHOLISM:

• OPERATIONAL DIAGNOSIS: Alcoholic is one who (1) drinks alcohol, (2) has problems directly attributable to that drinking and, (3) continues to drink in spite of those problems.

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