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Băile Felix, 18-21.09.2019

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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


NIGHT AND SLEEP CONOBIOLOGY AND PSYCHOPATHOLOGY. PSYCHOPROPHYLAXIS OF CHILD AND ADOLESCENT NIGHTDISORDERS

Autor: Constantin Lupu Cătălina Tocea

We present aspects of sleep physiological chronology determined by day – night alternation and the need of darkness for the children and adolescents sleep. The authors provide landmarks in the history of species and ontogenetic history. We enumerate those psychopathological manifestations specific at different ages, such as: insomnia, night pavor, dreams and nightmares, sleepwalking, that are more common. Are also related primary psychoprophylaxis aspects regarding security of sleep and repause, avoiding overdose of sensory stimuli and anxious situations at young ages. We refer to pharmacological landmarks, of night disorders in children and adolescents.

An anthropological vision of sleep is based on historical and current knowledge about sleep stages of fetal development, during the new born, infant, toddler, scholar, puberty, adolescent. For millennia the human body scheduled day -night alternation. This rhythm has made ”clock genes” that exist in our genome. It is known that the infant sleep is different to the 3 -4 years old child or a scholar sleep. Sleep ontogenesis can be followed parallel with other physiological functions that depend on the organic maturation of the brain vascularity and the progression of sensory – motor functions.

Sleep in the uterus it is estimated by fetal hipnograma who established slow sleep distribution at 50% of the time, paradoxical sleep at 40% and wake-up phase at 10% from fetal actogram sequences. These hiponograms also establish the nictemeral polyphasic distribution of sleep in new borns and toddlers. We have enough documentation about fetal hipnograms of new borns and toddlers which specify that maternal emotional disturbances and nictemeral ambient anxious factors which have their action during sleep : noise, physical aggresion, light overdosed stimuli, sudden awakenings, different acute distress disorders, breath deficiency, brutal meteorological factors, induce interruptions and disturbances of sleep phases. These situations induce anxiety, which quickly become constant and have psychosomatic repercussions. All these information can be used by specialists for specific
recommendation regarding the primary mental protection of anxiety in pregnancy and child’s life.

Alterness and sleep are developed progressively, by genetic memory and is carried on by all the other body functions especially by CNS. During ontoge-nesis it is created the general scheme of the alternation between wakefulness and sleep – under the powerful influence of time and environment, information that will be processed by the child sensory- cognitive possibilities. Even with fetal life are recorded periods of calm and anxious (nervous) sleep. Both have distinct EEG: restless sleep has hypovoltate polymorphic routes with different frequencies, and calm sleep is specific to extensive activity with reduced frequency – including electrogenesis phases interrupted for a few seconds. (J. Monod and Dreyfus – Brisac). This alternation also succeed in new born and toddler, which have periods of wakefulness and sleep with anxiety, eye movement, face or body movement, calm and deep breathing followed by hyperpnea, tachycardia and respiratory pause.

Birth produces a major shock in new born’s life. Turning suddenly from intrauterine aquatic environment (in which the fetus had prolonged sleep and absence of light) into the air and light environment he is exposed to a new lifestyle with sudden anxious conditioning. Nictemeral cycle of waking and sleep condition is not constant in the first months: there are many unordered sleep periods. At night the toddler wakes up in several rounds. These rounds depend mainly on hunger sensation that must be resolved to avoid becoming anxieties.

Regulating mechanisms of sleep – wakefulness function have been described by Mauthner who located the control center of this function in the neurons around Sylvius aqeduct. This is where hormones from triangle epiphysis -hypophisis – hypothalamus mainly melatonin are formed and secreted. Reticular substance from brainstem, ponto – midbrain region and subthalamic region contribute by upward beam that pass through intermediate nuclei to cortex, with a constant role in regulation of vital functions during sleep and the sleep-wakefulness cycle, in sleep initiation and development of sleep phases but also in the genesis of dreams.

Physiological stages of sleep are well defined by clinical aspects, EEG, MRI investigations, including studies of emission of directed protons and also by biochemical intracerebral determinations.

Sleep – wakefulness relation depends on genetic quality and the integrity of CNS, age, environment, sex, diseases, etc. At all ages exist a dependence of cosmic nictemeral schedules. Chronobiology researches from Connecticut University showed that melatonin is the “darkness hormone”, it is secreted at night, having hypnotic and antioxidant role, restoring the energy of the organism especially CNS activity.

Night anxiety described by J. Deluneau, is interpreted as evidence of cosmic schedules dependence, the need of light opposed to fear of extinction of the sun and light. This fear of the dark, of entrance in the unseen, is typical to all ancient people and explains primary deification of the sun in ancient times: Horus, Helios, Apollo etc. Infants, children and adults, are afraid of the dark, identifying the night with underground darkness of death. Fear of the night is cultured by archaic concepts that ghost walk in the dark, spirits, fantastic animals, evil spirits, giant monsters, unknown spectra.

In legends, stories even in reality, night is the accomplice of thieves and murderers. Satan uses night to bring evil on earth, to urge the human being to do evil things. Some commit suicide because of the fear of the night, especially in polar night. Even blind people fear of the night. W. Shakespeare poetically describes the night and its cortege of superstitions in “A Midsummer Night’s Dream”.

 

Those who sleep hear far
As an owl sings
Of pain and death
Hour of torture and terror
When ghost from the grave
Unseen they creep
Under the darkness, under the wind

Recently other specialties associated to neuropsychiatry in the study and treatment of sleep: hypnology, sophrology, sleepology etc., each with a partial area of study.

They all agreed that rehabilitation functions of sleep (physically and mentally rest) can be disturbed and may evolve anxiously if falling asleep and waking up of the toddler and child is brutal. Deprivation of correct sleep and waking up, slow and progressive is considered by specialists as anxious distress factor. From birth to age of 2, security behaviour is considered normal. After that, the child will form his own rituals, pressing object with his chin or mouth. Particularly will use a finger as a substitute for mother’s breast, or fabrics or soft toys to secure his sleep, avoiding vesperal anxieties.

True sleep disturbances have many aspects and clinical diversity staring with sleep disorders, insomnia and rarely hypersomnia. We can start from the general finding that children’s sleep is constantly under positive or disturbing influences. Insomnia is common, so generates anxiety and dismay of parents. Toddler nictemeral cycle, sleep – wakefulness alternation is still irregular and can take place in stages, and between these states may appear noisy events. Insomnia is more frequent.

In the second half of the new born and infant’s life, installation of sleep disorders are common and may be due to wrong, inadequate, conditions of the parents and caregivers. So that sleep disorders, insomnia, may become easily and quickly a permanent deficiency. Most common exogenous causes are: separation anxiety, attachment deficit, anxiety and fear of darkness, reports or threats of negative people (thieves, bad or ugly man, the enemy, etc). These situations lead to terrifying dreams and pavor night bouts.

To solve this type of insomnia, we recommend sleep rituals and especially avoidance of negative conditions: noise, disputes, overcrowded rooms, radio or TV programs, unprotected light, etc. Of course some minor illnesses without gravity (nasopharyngitis, common digestive disorders) or dental eruptions can disrupt infant’s sleep. To address chronic insomnia, the doctor may prescribe a sleep inducer according to the child’s age.

In the second period of childhood causes of insomnia become more accurate. Generally, the anxious child has disturbing images taken from adult discussions, from the street, TV or cinema, that don’t allow the transition from wakefulness to unconsciousness of sleep. Before sleep, it is amplified the imagination game, with his cortege of ghosts. Combination between fantasies and fragments of strange dreams leads to nocturnal awakenings and sleep insomnia.

It is known that thirst and hunger are associated with these sleep situations, so that most states of sleep disruption can be resolved with hydration and feeding of infants and children.

Forms of security and repose of infant and child sleep:

a). The adult presence

The best known requirement of children to neutralize anxiety is to avoid sleeping alone. Always this anxiety is doubled by anxiety of mother, father, grandparents, or of other persons who believe they offer safety through their presence and direct contact. Lullaby creates a specific relation of insurance and primary prevention of insomnia and night sleep.

b). Next step to not let him sleep alone is joining a symbolic substitute represented by a human looking doll or a pet that he plays during the day. Most times, triad: doll, lullaby (so the presence of adult), a lamp, sublimates child vesperal anxiety.

c). Suction action of infant and child

For the first impulses triggered by starvation in the presence of mother and in contact with the nipple or teat, new born opens his mouth and makes suction movement so the hunger is solved and he falls asleep. We appreciate that the oral reflect how the child relates to the world. His sensory -motor and psychological behaviour is determined by orofacial area. Renee Spitz believes that these areas and sensory organs play an intermediary role between the peripheral sensor consisting of lips (external oral areas) and other visceral sensory organs (oropharyngeal areas). These mechanisms of transition between external perception and internal reception of ingested food are part of solving anxiety of child fear of loss – separation – of the mother. In evolution, these mechanisms are the bridge between kinesthesia perception and diacritical perception that will be further developed.

Sleep disorder are more complex in puberty and adolescence. According to D. Marcelli and E. Berhaut sleep difficulties are found on average to about 30% of adolescents, actually 21% of boys and 35% girls. Girls often have nightmares, 9% of girls and 5% of boys have anxiety dreams. Nocturnal awakenings are found in 19% of girls and 8% of boys.

Sleep disorders in puberty and adolescence are dominated by specific sexual concerns that are constant and often excessive. They are base on imagination and daily meetings with the opposite sex and it is expressed through fantasy, imaginative experience, masturbation, nymphomania or satiriazis. During sleep, boys have pollutions and girls have sexual dreams.

In the twilight, that is personified in Romanian legends by Murgila (until the advent of Hipnos – god of sleep and Morfeus – god of dreams), young people begin their vesperal fantasies by projecting images on known characters: artists, teachers, familiar and beloved people, etc. At this age we can use WHO codes, that refers to non-organic sleep disorders, Chapter F.51, framed in emotional disorders, although these sleep manifestations form a distinct pathology. F.51.0 code is indicated primary insomnia, where quality and quantity of sleep are not satisfactory. This code applies if insomnia is prolonged and consists of falling asleep difficulties, sleep disorders in obesity: Pickwick syndrome, meaning organic disorders.

F.51.1 code refers to non-organic hypersomnia, and F.51.2 code includes wakefulness/sleep rhythm disorders and absence of synchronization between sleep and wakefulness. It is a framing of reverse sleep / wakefulness rhythm.

Sleep and dreams specialists say that is enough for a scholar and adolescent to sleep 6 -8 hours during the night and 1 -2 hours during the day (midday nap).

Regarding quality of sleep and dreams it is emphasized that the good quality of these two functions will develop a personality with a positive psyche. Also children who dream a lot have good psychic chances in life.

The dreams and nocturnal automatisms are initiated by under tentorial retrieval deposits – from reticular nuclei and cerebellum that start to upper floors. This CNS activity resembles to a film that makes visible images and actions projected from an outbreak at a sensorial – cortical screen. Programs are done “in waves” of specific waves.

Recently it was established that neurons may have frequent short or long sleep states. So the neurons of reticular substance rest during sleep. They sleep at a time as they continue to maintain rhythmic function of vital functions: respiration, circulation, tonus etc. When they have done the rest by groups, they begin to act on the cortex and sense organs. Of these actions dreams are formed, involuntary movements and nocturnal sleep automatisms. During puberty, sleep has already a precise development and features similar to adult. Sleep functions have the following schedule: deep sleep lasts 90 minutes alternating with superficial sleep and short time dreams. These mechanisms are located and conducted by overchiasmatic nucleus who receives installation of the darkness by specific retinal cells (spotted recently) that activates the melatonin secretion. It is understandable that most dreams occur near dawn when reticular mechanism finished his rest period, and begins to function by stimulating retrieval deposits.

Thus sleepwalking (somnambulism or night ambulatory automatism) refers to impairment of sleep with unconscious motor activity. There are many forms of night automatisms. We can say that every child or adult has his own sleepwalking models. It is very important that all the forms should be investigated – especially if we consider an epileptic pathology – and to be treated. We already know about families with dominant autosomal transmission of the sleepwalking. The sleepwalking can be treated and resolved medically, providing vital protection for those who are affected.

WHO code F.51.4: night terror (night pavor) which consists of an episode of terror extreme panic attack expressed by horror pantomime and muscular contractions accompanied by screaming, motor agitation, increased neurovegetative function. The clinical picture is characterized by getting of the bed, running, and total amnesia of the episode.

F.51.5 code includes nighmares consisting of fear and anxiety dreams, accompanied by detailed memories of the dream, with aggression, threats, falling into the abyss. The nightmare can repeat itself the same night or other night.

It is recommended that the dreams should be discussed with the child and reassuring explanations should be given, and the experience to be interpreted as an imaginary story. It is also important not to disturb the dark /light rhythm that is necessary to induce recovery sleep, but also for stimulating growth, recovery of vital organs, of immunity, of nervous functions.

The new concerns of night and sleep pathology include sleep apnea (sleep apnea syndrome) and sleep talking that can be investigated, having many therapeutic benefits.

A special group of night pathology is the crisis and epileptic status. According to statistical findings sleep may induce seizures. These are constant concerns of the epileptologists – this type of seizures benefit from modern treatment. Topics in this material are contemporary and can be still studied by all our experts.

 

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Correspondence to:
Constantin Lupu, Hypocrate Clinic, Street. Dr. Nemoianu, No. 9 – 300011, Timisoara