Unibersidad de Sta.

Isabel City of Naga

Graduate School Master of Arts in Nursing Major in Medical Surgical Nursing

ADVANCE PATHOPHYSIOLOGY

“Concepts in Stress and Sleep”

Prepared by; FREDERICK B. BALDEMORO, RN

Submitted to: Dr. Diana Sarah Buena-Donacao, MD

HOMEOSTASIS AND ADAPTATION Homeostasis   Define as the maintenance of static or constant conditions in the internal environment. “Equilibrium” or “balance”

Adaptation   Define as adjustment of an organism to a changing environment. An adaptive response is a type of negative feedback that maintains the organism in the steady state. Feedback Mechanism Define as the process of self-regulation by which open systems determine and control the amount of input and output of the system Simply, a mechanism or a signal that tends to initiate (or accelerate) – Positive feedback or to inhibit (or slow down) or return to equilibrium– Negative feedback. Example: An example of positive feedback loop is the onset of contractions in childbirth. When contraction begins, the hormone oxytocin is released into the body to stimulate further contractions. As for the negative feedback loop, an example is the regulation of blood glucose levels. If blood glucose levels continue to rise insulin is produced to regulate glucose level. STRESS  Defined as the non specific response of the body to any demand placed on it.  The wear and tear that lie causes on the body (Seyle, 1956)  Stressors are stress-producing factors, these may be physiological or psychological, may be pleasant or unpleasant Physiological Trauma Thermal changes Physical Trauma Atmospheric pressure Biochemical Drugs Organisms Hormones Abnormal secretion Dietary Poisons Environmental Pollutants Organisms

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Deprivation of substances Psychological Emotional pressure Vocational pressure Social pressure Cultural pressure Hans Selye  An endocrinologist identified the physical aspect of stress, which he called General Adaptation Syndrome  He used laboratory animals to assess biologic system changes; the stages of the body’s physical responses to pain, heat, toxins, and restraint. STAGES of the GENERAL ADAPTATION SYNDROME (GAS) 1. Alarm Stage -The hypothalamus is activated, releasing of corticosteroid –releasing hormone, which stimulates the adrenal gland to release Adrenocorticotropic hormone. Glucocorticoids from the adrenal cortex are then released. -The so called- fight or flight mechanism is activated mainly through the sympathetic nervous system, which release to catecholamine, Epinephrine and Norepinephrine. 2. Resistance Stage -the digestive system reduces function to shunt blood to areas needed for defense. -The lungs take in more air and the heart beats harder and faster so it can circulate highly oxygenated and nourished blood to the muscles. -increase level of corticosteroids, thyroid hormones, glucagon, and aldosterone 3. Exhaustion Stage -body stores are depleted or the emotional component are not resolve. -may cause immunodeficiency secondary to stress Local Adaptation Syndrome (LAS)  Localized reaction of stressors which is illustrated by the process of inflammation. PHYSIOLOGIC RESPONSE TO STRESS Psychophysiology is a term to describe the body’s physiological reaction to perceived stressors suggesting that the stress response is a mind-body phenomenon. 1. NEUROLOGIC MECHANISM  Involves autonomic nervous system to stress response Autonomic nervous system A part of the nervous system that regulates key involuntary functions of the body, including the activity of the heart muscle; the smooth muscles, including the muscles of the intestinal tract; and the glands

The involuntary autonomic nervous system is regulated through input from the hypothalamus. -Sympathetic and Parasympathetic response Sympathetic  “fight or flight response”  It originates at the spinal cord’s first thoracic segment and extends to third lumbar segment. This nervous system is considered to have thoracolumbar outflow since the cells of these nerves originates in the lumbar and thoracic regions. The primary function of this nervous system is mobilization of the body’s nervous system due to fight or flight response. Parasympathetic  “rest and digest”  The parasympathetic nervous system is composed of 4 cranial nerves (III, VII, IX and X) that originate from the brainstem. The PNS activity begins in the head to the sacral region this reason why this is called activity that is called cranio-sacral in nature while the SNS is thoraco-lumbar in nature.

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Parasympathetic vs. Sympathetic Response

2. ENDOCRINE MECHANISM Effect of Glucocorticoids Almost all types of stress causes a significant increased in the production of ACTH (Adrenocorticotropic hormone).       ACTH is product by the anterior pituitary gland ACTH causes an increase in synthesis and release of Glucocorticoids from the Adrenal gland. Glucocorticoid has the ability to increase glucose production whereas can alter metabolism of carbohydrates, fat and protein. The result is that more fuel is made available for energy during the stress response. Cortisol, a form of glucocorticode, commonly known as hydrocortisone, is a potent anti-inflammatory hormone that depresses inflammatory response of the body. Increase secretion of Adrenal Cortex I Hypertrophy of the Adrenal cortex I Increase circulating Glucocorticoids I I Thymic Atrophy Decrease Inflammation I I Decrease number T lymphocytes Increase spread of infection

I Decrease Lymphocyte Eosinophils Basophils Decrease activity of Macrophages CIRCARDIAN Secretion

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In individuals with a day-wake/night sleep cycle, the Glucocorticoids are thought to be synchronized by light. Glucocorticoid’s concentration in the blood and urine decreases during sleep and rises to its highest levels in the early morning, this is called circadian rhythm or pattern. Disruption in circadian rhythms is often produced by stress, which disturbs the rhythmic patterns of blood glucose, white blood cells, and temperature regulation.

Stress Effects and Disease Genetic Predisposition  If one has a genetic or hereditary susceptibility to stressors, the alteration may be manifested as disease. Organ Susceptibility  Suggests that certain organs have increased susceptibility in certain individuals. Stress-Induced Disease - According to some research, 90% of the diseases know to men are cause or predisposed by stress, from heart attack to hair lost to insulin resistance. Cardiovascular diseases - Individuals who have hypercholesterolemia have a greater risk of developing atherosclerotic heart disease than those with normal cholesterol level - Mechanism: During stressful periods, the serum cholesterol has been shown to rise, perhaps due to lypolysis (conversion of fat to sugar or energy) induced by the increased levels of circulating catecholamines (epinephrine and norepinephrine) - Emotional stress, esp. anger, can precipitate angina pain and aggravate heart failure - Type A personality behavior pattern includes competitiveness in work, fast work pace, time pressure, inability to relax at work or play and hostility Immune Deficiency - Physiologically or psychologically stressful events precipitate a decrease in lymphocytes and other leukocytes. Digestive Diseases - Duodenal ulcerations are often due to infection of the pylorus with Helicobacter pylori bacteria that may proliferate when the immune system response to organism is decreased - Stress also indicates many diverse digestive conditions, such as constipation, diarrhea, ulcerative colitis, and Crohn’s disease. Cancer - Currently, there is no evidence that stress is a direct cause of cancer. But evidence is accumulating that there is some link between stress and developing certain kinds of cancer, as well as how the disease progresses. - Typically, our immune system recognizes abnormal cells and kills them before they produce a tumor.

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There are 3 important things that can happen to prevent cancer from developing:    The immune system can prevent the agents from invading in the first place DNA can repair the abnormal cells Killer T-cells can kill off cancer cells

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Research has shown that stress can lower the body’s ability to do each of those things

Other stress-related disorders - Eczema - Urticaria - Psoriasis - Acne Anxiety Feeling of unknown fear It is because you don’t know clearly the source of your fear or anxiety that makes you more anxious. Difference between stress and anxiety 1. Anxiety is likelier to affect daily functioning compared to ordinary stress. 2. Anxiety is more of a mental disorder unlike stress which is more of an ordinary state or innate experience. 3. Anxiety usually has vague triggers while stress often has clearly identifiable stressors. Anxiety and Stress-Related Disorders (Symptoms of Anxiety Disorder) PANIC DISORDER Characterized by recurrent or repeated unexpected panic attack Panic attack is the sudden onset of intense apprehension, fearfulness or terror associated with feelings of impending doom

PHOBIAS Is an illogical, intense, persistent fear of a specific object or a social situation that causes extreme distress and interferes with normal functioning

Agoraphobia Avoidance of places or situation from which escape might be difficult or help might be unavailable a condition which develops when a person begins to avoid spaces or situations associated with anxiety Typical "phobic situations" might include driving, shopping, crowded places, traveling, standing in line, being alone, meetings and social gatherings

Specific Phobia Characterized by significant anxiety provoked by specific feared object or situation, which often leads to avoidance behavior

Social Phobia Characterized by anxiety provoked by certain types of social or performance situation

OBSESSIVE-COMPULSIVE DISORDER Involves obsession (thought) that causes marked anxiety and/or compulsion (action) that attempts to neutralize anxiety

GENERALIZED ANXIETY DISORDER Characterized by at least 6 months of persistent and excessive worry

ACUTE STRESS DISORDER Development of anxiety, dissociation, and other symptoms within 1 month of exposure to an extreme traumatic stressor

POSTTRAUMATIC STRESS DISORDER SLEEP    A basic human need on which the physical and emotional health of an individual is being restored, preserved, and stabilized An activity of conserving energy A naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. Characterized by the re-experiencing of an extremely traumatic event

Physiologic Changes during Sleep The brain Activity in the cortex - the surface of the brain - drops by about 40 per cent while we are in the first phases of sleep, the brain remains highly active during later stages of the night, this is when our dreams are formed. A typical night's sleep comprises five different sleep cycles, each lasting about 90 minutes. The first four stages of each cycle are regarded as quiet sleep or non-rapid eye movement (NREM). The final stage is denoted by rapid eye movement (REM).

SLEEP CYLCLE Stage I (Very Light Sleep) During the first stage of sleep, brain waves are small undulation or wave called theta wave. During stage two these intersperse with electrical signals called sleep spindles - small bursts of activity lasting a couple of seconds which keep us in a state of quiet readiness. It only last for 4 minutes or 5% of total sleep    The person is in a relaxed state but still somewhat aware of the surrounding Involuntary muscle jerking may occur and sometimes awakens the person The person can be aroused easily

Stage II (Light Sleep) Stage 2 is the second stage of sleep and lasts for approximately 10-15 minutes or 45% of the total sleep. The brain begins to produce bursts of rapid, rhythmic brain wave activity known as sleep spindles. Body temperature starts to decrease and heart rate begins to slow.    The person detached himself to the surrounding Vitals signs normalizes The person cannot be easily aroused and needs more stimuli to be awake

Stage III (Deep Sleep) As stage two merges into stage three, the emergent of the large slow waves called as delta wave. The larger and slower the brain wave, the deeper the sleep. It composed of 5% of the sleep cycle. Stage 3 is the most relaxing stage.       Arousing the person is more difficult Blood pressure drops Breathing becomes slower Muscles are relaxed Blood supply to muscles increases Tissue growth and repair occurs

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Energy is restored Hormones are released, such as: Growth hormone, essential for growth and development, including muscle development Snoring occurs Salivation may occur

Stage IV (Deepest Sleep) Stage 4 is sometimes referred to as delta sleep because of the slow brain waves known as delta waves that is dominant during this stage. Stage 4 is a deep sleep that lasts for approximately 30 minutes.   The person may experience bed-wetting and sleepwalking or sleep talking Arousal is difficult

Stage V (Rapid Eye Movement) Most dreaming occurs during the fifth stage of sleep, known as rapid eye movement (REM) sleep.    REM sleep is characterized by eye movement, increased respiration rate and increased brain activity. REM sleep is also referred to as paradoxical sleep because while the brain and other body systems become more active, muscles become more relaxed. Dreaming occurs due because of increased brain activity, but voluntary muscles become paralyzed

Melatonin   Secreted by pineal gland has potent regulatory effects on sleep-wake pattern Its secretion is stimulated by dark and suppressed by light

Factors Affecting Sleep Aging    Infants apparently have the highest amount of Stage V (REM) Young adult ages 20-40 years old spend 50% of their sleeping time in stage II (Light Sleep) Old people ages 50 and above spends most of the time in bed but apparent amount of actual sleep is decreased and most of the time Stage IV (deep sleep) is absent

Life-style    Factors that can disrupt sleep are excessive alcohol, tobacco, caffeine before bed time, intense exercise, emotionally upsetting events. Environmental factors such as noise, too warm or cold surrounding, unfamiliar location. Also a habit of naps and day time sleeping

Depression

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People who are depress shows decreased in stage III (deep sleep) and stage IV (deepest sleep) May be caused by neurotransmitter imbalance such as Acetylcholine and Serotonin

SLEEP DISORDERS Divided into 2 basic group Dysomnia Parasomnia Pathologic sleepiness is characterized by the fact that it occurs at inappropriate times and places.

DYSOMNIA  A primary sleep disorder in which the patient suffers from changes in the quantity, quality, or timing of sleep.

1. Insomnia Most adults have experienced insomnia or sleeplessness at one time or another in their lives. An estimated 30%-50% of the general population is affected by insomnia, and 10% have chronic insomnia.    "Difficulty initiating or maintaining sleep, or both" or the perception of poor quality sleep. Insomnia is not defined by a specific number of hours of sleep that one gets, since individuals vary widely in their sleep needs and practices Transient Insomnia (<a week), Short term Insomnia (1-3 weeks) and Chronic (>3 weeks)

Causes
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Jet lag Changes in shift work Excessive or unpleasant noise Uncomfortable room temperature (too hot or too cold) Stressful situations in life (exam preparation, loss of a loved one, unemployment, divorce, or separation) Presence of an acute medical or surgical illness or hospitalization Withdrawal from drug, alcohol, sedative, or stimulant medications Insomnia related to high altitude (mountains)

Treatment The main focus of treatment for insomnia should be directed towards finding the cause. Once a cause is identified, it is important to manage and control the underlying problem, as this alone may eliminate the insomnia all together. Treating the symptoms of insomnia without addressing the main cause is rarely successful.

2. Narcolepsy and Cataplexy     Narcolepsy is a sleep disorder that causes overwhelming and severe daytime sleepiness. Pathologic sleepiness is characterized by the fact that it occurs at inappropriate times and places. The daytime sleep attacks may occur with or without warning, and can occur repeatedly in a single day. Cataplexy is a sudden and temporary loss of muscle tone often triggered by extreme emotions Cause Narcolepsy is believed to result from a genetic predisposition and abnormal neurotransmitter (hypocretin, also known as orexin) functioning and sensitivity. Hypocretin appears to modulate activity in the hypothalamus. The deficiency of hypocretin might produce sleep attacks. Tests

Epworth Sleepiness Scale Questionnaires are used to measure excessive sleepiness. The most commonly used questionnaire is the 8-question Epworth Sleepiness Scale (1991).    Response to each question on a scale from 0 (not at all likely to fall asleep) to 3 (very likely to fall asleep) is obtained. The resulting total score is between 0 and 24. Although what score constitutes abnormal sleepiness is controversial, total scores above 10 generally warrant investigation. Polysomnography For this exam, one needs to come to a sleep laboratory about two hours prior to bedtime without making any changes in the daily habits. Then, the whole night's sleep is monitored and recorded. Health Teaching  Sleep hygiene is very important.

For example, many people have an improvement in their symptoms if they maintain a regular sleep schedule, usually seven to eight hours of sleep per night.  Scheduled naps during the day also help.

One study suggested that the optimal sleep pattern is a combination of scheduled nighttime sleep (such as from 11:00 pm to 7:30 am) and two 15-minute naps.

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Patien's with narcolepsy should also avoid heavy meals and alcohol (as it can interfere with sleep). Driving should be restricted when the patient feels sleepy. Children should be encouraged to participate in after-school activities and sports. A well-designed exercise program can be beneficial and stimulating.

3. Hypersomnia    “Excessive sleeping” Hypersomnia is characterized by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep. Persons with Hypersomnia are compelled to nap repeatedly during the day, often at inappropriate times such as at work, during a meal, or in conversation. These daytime naps usually provide no relief from symptoms. Patients often have difficulty waking from a long sleep, and may feel disoriented. Symptoms:        increased irritation, decreased energy, restlessness, slow thinking, slow speech, loss of appetite, hallucinations

Treatment Changes in behavior (for example avoiding night work and social activities that delay bed time) and diet may offer some relief. Patients should avoid alcohol and caffeine. 4. Sleep Apnea Syndrome    Sleep apnea is a common condition characterized by a periodic reduction in or a complete stop of breathing during sleep. Defined as a cessation or near-cessation of breathing for 10 seconds or more that results in a reduction of airflow to 25% below normal. There are two main types of sleep apnea; obstructive sleep apnea (OSA) and central sleep apnea (CSA). Normally, the brain sends a signal to the respiratory muscles to expand and bring air into the lungs.

Central sleep apnea The brain fails to send this signal appropriately, causing disrupted and unregulated breathing pattern

Obstructive sleep apnea The brain sends appropriate signals and the muscles try to expand to initiate breathing, however, the flow of air into the lungs is obstructed, causing reduced breathing and airflow into the lungs. Causes In general, central sleep apnea stems from an abnormal regulatory mechanism in the brain. Some common causes of central sleep apnea include: strokes, heart failure, certain medications, some congenital abnormalities, or High altitude. Premature infants may also be at risk for central sleep apnea. 5. Periodic Limb Movement Disorder (PLMD) Periodic limb movement disorder (PLMD) is repetitive cramping or jerking of the legs during sleep "Periodic" refers to the fact that the movements are repetitive and rhythmic, Restless legs syndrome is a condition involving strange sensations in the legs (and sometimes arms) while awake and an irresistible urge to move the limbs to relieve the sensations. When PLMD was first described in the 1950s, it was called nocturnal myoclonus. Nocturnal means night and myoclonus is a rapid, rhythmic contraction of a group of muscles similar to that seen in seizures.

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Causes
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Diabetes mellitus Iron deficiency Spinal cord tumor Spinal cord injury Sleep apnea syndrome Narcolepsy Uremia - Build-up of waste products in the blood because of poor kidney function Anemia - Low level of hemoglobin, the substance that carries oxygen in the blood Medication -Neuroleptics and other antidopaminergic agents or tricyclic antidepressants Withdrawal from sedative medications such as barbiturates or benzodiazepines (such as Valium) Test and Exams You may have blood drawn to check your blood cell counts and hemoglobin, chemistry, and thyroid hormone levels.

A urine sample may be collected to check for traces of drugs that can cause sleep problems. Treatment

Benzodiazepines: These drugs suppress muscle contractions. They are also sedatives and help you sleep through the movements sush as Clonazepam Anticonvulsant agents: These medications reduce muscle contractions in some people such as gabapentin (Neurontin). GABA agonists: These agents inhibit release of certain neurotransmitters that stimulate muscle contractions such as baclofen (Lioresal).

PARASOMNIAS Parasomnias are disruptive sleep-related disorders. They are characterized by undesirable physical or verbal behaviors or experiences.

1. Sleepwalking - Patients with sleepwalking disorder show complex automatic behaviors, such as wandering aimlessly, carrying objects without any purpose, going outdoors, and performing other activities of varying complexity and duration (even driving). - Persons affected with the disorder usually have their eyes wide open in a stare. They may mumble; however, communication with a person who is sleepwalking is usually poor or impossible. - This disorder occurs in the slow-wave stages of NREM sleep. Causes Hereditary Fever Sleep deprivation Environment Nightmare Nightmare disorder is also called dream anxiety attack. Most patients with nightmare disorder are children. Nightmares are frightening dreams that occur during REM sleep and are associated with an increase in heart rate (tachycardia), an increase in the rate of breathing (tachypnea), profuse sweating, and arousal. Most of the time, the patient remembers the scary dream in detail and responds to soothing and comforting by a parent or caregiver. Causes: Stress Relationship Difficulties

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3. Sleep terror - Sleep terror disorder is characterized by extreme panic and a sudden, loud, terrified scream during sleep, followed by physical activities such as hitting objects or moving in and out of the bedroom. - Persons with this disorder can injure themselves.

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Sleep terror is a disorder of arousal that primarily occurs during stages III and IV of NREM sleep. Causes:

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Fever Sleep Deprivation

4. Sleep Paralysis - Sleep paralysis consists of a period of inability to perform voluntary movements either at sleep or upon awakening Symptoms A complaint of inability to move the trunk or limbs at sleep onset or upon awakening Presence of brief episodes of partial or complete skeletal muscle paralysis Episodes can be associated with hypnogenic hallucinations or dream-like mentation (act or use of the brain)

5. Sleep Bruxism - “Teeth Grinding” or “Teeth Clenching” - A stereotyped movement disorder characterized by grinding or clenching of the teeth during sleep. Symptoms
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abnormal wear of the teeth Sounds associated with bruxism (It's about as pleasant as fingernails on a chalkboard!) jaw muscle discomfort TREATMENT Self-Care at Home Go to bed at the same time each night. Use the bed only for sleeping and intimacy Avoid napping Avoid stress, fatigue, and sleep deprivation. Avoid vigorous activity prior to bedtime, though a brief period of aerobic activity 4 hours before bedtime may be helpful. - Avoid cigarettes, alcohol, and excessive caffeine. In general, when a person has been diagnosed with sleepwalking, the following precautions need to be taken: Remove potentially dangerous items. Have the person sleep in a bedroom on the ground floor if possible. Lock the doors and windows. Cover glass windows with heavy drapes. Place an alarm or bell on the bedroom door For sleep Bruxism, advise to wear teeth guard before going to sleep

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Behavioral Modification -Void before going to bed -avoid caffeine rich beverages -avoid drinking large amount of fluid before sleeping -if urination is felt, go the bathroom immediately 6. Sleep Enuresis - It is the inability to maintain urinary control during sleep

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