dr. Linny G. M.

Liando, SpKJ
NORMAL SLEEP
REM
NON-REM:
STAGE I
STAGE II
STAGE III
STAGE IV
 EEG EOG EMG
wakefulness Low volt, activity, mixed Eye blinks High tonic act,
freq. act voluntary
NREM 1 Low volt, act, mixed Slow eye movemnt Tone slight
freq. act, vertex sharp decreased
wave
NREM 2 Low volt, sleep spindle, None Low tonic act.
K complex
NREM 3 High amp, slow wave, None Low tonic act.
20-50% epoch
NREM 4 High amp, slow wave, None Low tonic act.
50% epoch
REM Low volt, mixed freq.act, REMs Tonic atonia w/
saw-tooth wv, & slow phasic switches
 Siklus Tidur-Bangun dan SCN

Melatonin
(N-acetyl-
5methoxytryptamine
)

10/5/2009 8
 Fungsi Melatonin

mengatur analgesik,
efek neuroprotektif regulasi
sirkadian
serotonin.

menekan mengontrol
eksitabilitas endokrin
SSP lainnya, mis
Melatonin HPG

menangkap memodulasi
radikal bebas, fungsi imun,
mood, sis. reproduksi
onkostatik antioksidan
kuat
AGOMELATIN: antidepresan dengan mekanisme kerja
10/5/2009 baru 9
CHARACTERISTIC OF REM SLEEP
AUTONOMIC INSTABILITY
TONIC INHIBITION
RAPID EYE MOVEMENTS
DREAMING
REDUCED HYPERCAPNIC RESPIRATORY DRIVE
RELATIVE POIKILOTHERMIA
PENILE TUMESCENCE OR VAGINAL
LUBRICATION
DEAFNESS
RUANG LINGKUP (ICD-10)
1. PRIMARY SLEEP DISORDERS :
Dyssomnia : Insomnia, hipersomnia, (Narcolepsy),
gangguan irama tidur-jaga non organik
Parasomnia : somnambulisme, night terror,
nightmares
2. SLEEP DISORDERS RELATED TO ANOTHER
MEDICAL and MENTAL DISORDER
3. OTHER SLEEP DISORDERS
 Dyssomnia : primary disorders of initiating or
maintaining sleep or of excessive sleepiness and are
characterized by a disturbance in the amount, quality,
or timing of sleep
Parasomnia : disorders characterized by abnormal
behavior or psychological events occurring in
association w/ sleeps, specific sleep stages, or sleep-
wake transitions.
A. DYSSOMNIA
1. Primary Insomnia
- most common type
- cause: Medical conditions, psychiatric, or
environmental conditions
- ICD : adanya kesulitan untuk jatuh tertidur,
mempertahankan tidur atau kualitas tidur yang buruk;
minimal 3x/ minggu selama minimal sebulan; adanya
preokupasi tidak bisa tidur (sleeplessness) dan peduli
berlebihan terhadap akibatnya baik malam atau siang
hari; distress dan disfungsi karenanya.
- Treatment: deconditioning techniques, transcendental
medications, relaxation tapes, sedative-hypnotic drugs,
and nonspecific measures such as sleep hygiene
Sleep Hygiene
Arise at the same time daily.
Limit daily in-bed time to the usual amount present before the
sleep disturbance.
Discontinue CNS-acting drugs.
Avoid daytime naps (xcpt they coz better night sleep)
Establish physical fitness.
Avoid evening stimulation (subst. radio/ relaxed reading for TV
Try very hot, 20mnt, body-temperature-raising bath soak near
bedtime.
Eat at regular times daily; avoid large meals near bedtime
Practice evening relaxation routines, such as progressive muscle
relaxation or meditation.
Maintaining comfortable sleeping condition
A. DYSSOMNIA
2. Primary Hypersomnia
- Rasa kantuk pada siang hari yang berlebihan atau
adanya sleep attack (tidak disebabkan oleh jumlah
tidur yang kurang), dan atau transisi yang
memanjang dari saat mulai bangun tidur sampai
sadar sepenuhnya (sleep drunkeness); gangguan
terjadi setiap hari selama >1 bulan, atau berulang
dalam kurun waktu yang lebih pendek,
menyebabkan distres dan disfungsi; tidak ada
narcolepsy atau sleep apnoe; tidak ada kondisi
medis atau neurologis yang menunjukkan gejala
kantuk pada siang hari.
- Treatment: Stimulant drugs
A. DYSSOMNIA
3. Narcolepsy
a. Characteristic:
- Excessive daytime somnolence (sleep attacks) is the
primary symptom of narcolepsy
- Cataplexy
- Sleep paralysis
- Hypnagogic and hypnopompic hallucinations
- Sleep onset REM periods (SOREMPs)
b. Increased incidence of other clinical findings in narcolepsy:
- periodic leg movement
- sleep apnea
- short sleep latency
- frequent nighttime arousals
- memory problems
- occular symptoms: blurring, diplopia, flickering
- depression
- automatic behaviours can occur for which people have
no memory
c. Onset and clinical course:
full syndrome emerges in late adolescence or early 20s
once established, condition is chronic without major
remissions
a long delay may occur between the earliest symptoms
(excessive somnolence) and the late appearance of
cataplexy
d. Causes
Abnormality of REM inhibiting mechanism
HLA-DR 2 found
Hypocretin deficient
e. Treatment
Regular bedtime
Stimulants (e.g.: modafinil)
Tricyclics and SSRIs for REM-related symptoms,
especially cataplexy.
4. Gangguan jadwal tidur-jaga non-organik (Circadian
Rhythm Sleep Disorders)
- includes a wide range of conditions involving a
misalignment between desired and actual sleep
periods.
- ICD : pola tidur jaga dari individu tidak seirama (out of
synchrony) dengan pola tidur jaga yang normal bagi
masy setempat; insomnia pada waktu orang2 tidur
dan hipersomnia pada waktu kebanyakan orang jaga,
yang dialami hampir setiap hari untuk sedikitnya 1
bulan atau berulang dengan kurun waktu yang lebih
pendek; ketidakpuasan dalam kuantitas, kualitas, dan
waktu tidur yang menyebabkan distres dan disfungsi.
- treatment: regular schedule of bright-light therapy to
entrain the sleep cycle (most effective); Melatonin
B. PARASOMNIAS
Characterized by unusual or undesirable phenomena during sleep or on
threshold of wakefulness.

1. Sleepwalking (Somnabulism)
- complex activity with brief episodes of leaving bed and walking
without full consciousness
- more common in boys
- occurs during NREM sleep (stages III and IV)
- in adults may reflect psychopathology rule out CNS pathology
- ICD : 1 atau lebih episode terbangun dari tidur (biasanya sepertiga
awal tidur malam), dan terus berjalan-jalan (kesadaran berubah);
pasien bengong, tidak merespons bila dipanggil dan sulit
dibangunkan; setelah bangun pagi hari pasien tidak ingat
kejadian selama somnambul.
- drugs that suppress stage IV sleep, such as benzodiazepines, can be
used to treat somnabulism
- treatment includes education and reassurance
2. Teror tidur (Sleep Terror Disorder)
- Sudden awakening, usually sitting up, with
intense anxiety
- occurs during sleep, nREM sleep, ususally stage
II or IV
- Treatment rarely needed in childhood
- Awakening child before night terror for several
days may eliminate terrors for extended
periods.
 Teror tidur (ICD)
- Satu atau lebih episode bangun dari tidur, disertai
kecemasan yang hebat, bisa sampai terjadi serangan
panik (dengan hiperaktivitas otonom)
- lama setiap episode 1-10 menit, biasanya pada sepertiga
tidur malam. Dapat berulang
- tidak bereaksi terhadap usaha membangunkan; setelah
bangun biasanya tidak ingat kejadian saat teror /
disorientasi
3. Nightmare disorder
- Nightmares are vivid dreams in which one awakens
frightened, almost always occur during REM
- ICD : terbangun dari tidur malam atau tidur siang
berkaitan dengan mimpi yang menakutkan yang
diingat kembali dengan rinci dan jelas (biasanya
perihal ancaman kelangsungan hidup, keamanan
atau harga diri); setelah terbangun segera sadar
penuh; distres +
- No specific treatment; benzodiazepines, tricyclic, and
SSRIs may be of help
SLEEP DISORDERS RELATED TO
ANOTHER MENTAL DISORDER
- In 35% of patients who complaints of insomnia,
the underlying cause is a psychiatric disorder. Half
of these patients have major depression. Treated
by sedating antidepressant, such as amitryptiline
(Elavil).
- Hypersomnia is usually found in psychiatric
disorders such as the early stages of mild
depressive disorder, grief, personality disorders,
and somatoform disorders.
 Gangguan Tidur pada Depresi
o Keluhan paling dominan (80% gangguan tidur)

o Abnormalitas arsitektur tidur terkait dengan depresi efisiensi tidur

, total durasi tidur , tidur REM , SWS

o Gangguan tidur bagian depresi atau penyebab depresi

patogenesis depresi perlu diterapi

o Disorganisasi ritmik sirkadian dikaitkan dengan depresi melatonin

berperanan memperbaiki ritmik sirkadian

o Perbaikan klinis depresi didahului perbaikan tidur

o Kualitas tidur indikator utama rasa nyaman subjektif

33
A. SLEEP DISORDER RESULTING FROM A
GENERAL MEDICAL CONDITION
Insomnia, hypersomnia, parasomnia, or a combination
can be caused by such medical conditions:
- sleep-related epileptic seizures
- sleep-related cluster headaches and chronic
paroxysmal hemicrania
- sleep related asthma
- sleep-related cardiovascular symptoms
- sleep-related gastrooesophageal reflux
- sleep-related hemolysis
- painful conditions, e.g., arthritis
Treatment: treated the underlying medical condition
B. SUBSTANCE INDUCED SLEEP DISORDER
Insomnia, hypersomnia, parasomnia, or combination
caused by the use of medication or by intoxication froma
drug abuse.
- Somnolence can be related to withdrawal from CNS
stimulants or to sustained use of CNS depressants
- Insomnia is associated with tolerance or withdrawal from
sedative-hypnotic drugs, with CNS stimulants, & long-term
alcohol consumption.
- Sleep problems may occur a a side effect of many drugs,
such as antimetabolites, thyroid preparations,
anticonvulsant agents, antidepressants.
SLEEP AND AGING
A. SUBJECTIVE REPORTS BY ELDERLY
B. OBJECTIVE EVIDENCE OF AGE-RELATED
CHANGES IN SLEEP CYCLE
C. CERTAIN SLEEP DISORDERS ARE MORE
COMMON IN THE ELDERLY
D. MEDICATIONS AND MEDICAL DISORDERS ALSO
CONTRIBUTE TO THE PROBLEM
dr. Linny G.M Liando, SpKJ
IMPULS-CONTROL DISORDERS
Patients with impulse-control disorders are not able to
resist drives or impulses that may or may not be
harmful to themselves or others
Intermittent Explosive Disorder
Episodes of aggression resulting in harm to others
Men affected more than women
DD: temporal lobe epilepsy, head trauma, bipolar I
disorder, medical condition, schizophrenia,
borderline personality disorder (impulsive type)
Treatment: combined pharmacotherapy and
psychotherapy. May have to try different
medications before result is achieved.
KLEPTOMANIA
Is repeated shoplifting or stealing
Women affected more than man
DD: temporal lobe epilepsy, head trauma, bipolar I
disorder, medical condition, schizophrenia
Treatment: insight-oriented psychotherapy is
helpful in understanding motivation and to
control impulse. Medications such as SSRIs,
tricyclics, trazodone, lithium, and valproate may
be effective.
PYROMANIA
Deliberately setting fires
Affected men more than women
DD: temporal lobe epilepsy, head trauma, bipolar I
disorder, medical condition, schizophrenia
Treatment: insight-oriented therapy, behaviour
therapy. Should include family therapy and closed
supervision
PATHOLOGICAL GAMBLING
Repeated episodes of gambling that result in
socioeconomic disruption, indebtness, and illegal
acivities
Higher in men
DD: temporal lobe epilepsy, head trauma, bipolar I
disorder, medical condition, schizophrenia
Treatment: total abstinence is the goal; insight-
oriented psychotherapy coupled with peer support
groups is recommended
TRICHOTILLOMANIA
Compulsive hair pulling that produces bald spots
(alopecia areata)
Women affected more
DD: temporal lobe epilepsy, head trauma, bipolar I
disorder, medical condition, schizophrenia
Treatment usually involves psychiatrists and
dermatologists in a joint endeavor. Medications
such as benzodiazepines, antidepressants, may be
helpful.
IMPULSE-CONTROL DISORDERS NOT
OTHERWISE SPECIFIED
Compulsive buying
Internet addiction
Compulsive sexual behaviour
TERIMA KASIH

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