Subjective assessment of sleep: statistical analysis in a population of healthy subjects

A principal components analysis was carried out on subjective data obtained from the sleep questionnaire systematically used in our laboratory on the morning following a polysomnographic recording. This technique, based on 70 healthy subjects, revealed three principal axes which explore the questionnaire. The first axis reflects the subjective evaluation of the quality of sleep. The second underlines the importance of dreams and of the brief waking periods which immediately follow. Finally, the third axis brings out the subjective assessment of sleep efficiency. The third axis was the most ambiguous and the only one to show a gender difference. Women tend to better estimate general sleep events, while men tend to evaluate better the more circumstantial events. Finally, given the results, it would be interesting to apply a similar analysis to populations presenting sleep disorders in order to establish the presence of an eventual pattern specific to the disorder.

New variables for defining sleep continuity

One very synthetic way to represent a night's sleep is by way of a hypnogram: a graphical representation of the sleep stages as a function of time. The hypnogram is generally quantified by a series of variables that measure the durations and latencies of the various sleep stages including wake. These variables, however, do not fully account for all the information contained in the hypnogram, in particular information on sleep continuity. A series of variables that measure and localize disruption of this continuity are proposed and their utility validated on three groups of patients presenting sleep disorders. Utility is established if the variable is capable of differentiating between patients and healthy controls. Two sets of variables are examined: those that use the entire sleep period as unit of measurement, and those that are measured within each consecutive NREM-REM sleep cycle. The results show that the variables proposed are able to differentiate between groups and, therefore, are useful measures reflecting the hypnogram more precisely. They also show that fragmentation of REM sleep does not present a systematic trend across the night, but that fragmentation of NREM sleep goes up linearly.

[Classification of sleep disorders]

Abnormal sleep can be insufficient, which constitutes insomnia; it can be excessive or inappropriate, which is hypersomnia, it can be misplaced with respect to the normal sleep-wakefulness rhythm, or it can be accompanied by various phenomena which do not belong to sleep itself (i.e. parasomnia). This is the format of most traditional classifications of sleep disorders. A modern classification has been introduced in 1990 and contains the description of 88 different sleep disturbances. They are classified in the main categories of dyssomnia, parasomnia and sleep disorders associated with psychiatric, neurological or somatic conditions. This classification is an excellent tool for the practice of sleep medicine and for the study of sleep disorders.

Effect of zolpidem on sleep in healthy subjects: a placebo-controlled trial with polysomnographic recordings

The aims of this double-blind, placebo-controlled study, conducted in a group of healthy young adults with normal sleep patterns, were to ascertain the effect of various doses of zolpidem on polysomnographic variables and to determine whether zolpidem disrupts sleep architecture. Of the 15 subjects recruited, 8 were included in the final analysis. Subjects underwent four experimental sessions during three nights, of which the first night was used for adaptation, the second for zolpidem (10, 20, and 40 mg) or placebo administration, and the third for placebo administration. Sleep was assessed by conventional sleep parameters (latency, duration, wakefulness) and by subjective questionnaire. Polysomnographic recordings were analyzed for sleep stage, paradoxical sleep, graphic features, and longitudinally with reference to sleep stage. Zolpidem had little effect on polysomnographic variables, except for a trend toward a hypnotic effect and a slight, transient inhibition of paradoxical sleep at the highest dose. In particular, the clearcut reduction of stage 4 sleep and increase in spindle density often observed with benzodiazepine administration was not observed with zolpidem. Adverse effects were restricted to three reports of daytime drowsiness each after zolpidem 10 and 40 mg and placebo, and one amnesic episode after the highest dose (40 mg). There were no signs of ataxic symptomatology.

Lack of effect of anxiety on total plasma MHPG in depressed patients

This report was undertaken to test the noradrenergic deficiency hypothesis of depression and the postulated increase in noradrenergic activity associated to anxiety states. A possible dual effect of both depression and anxiety on total plasma MHPG levels was hypothesized and assessed in anxious and non-anxious depressed patients. The findings show a decrease in plasma MHPG levels in depressed patients whatever their degree of anxiety. There was no difference in total plasma MHPG levels either between anxious and non-anxious depressed patients or between low and high anxiety to depression ratio (ADR) depressed patients. Following antidepressant drug-treatment, a decrease in plasma MHPG was found. A positive correlation between the drug-induced decrease in NA activity and the severity of depression was observed, and suggested a relationship between the severity of depression and the instability of the NA system. No correlation between the drug-induced decrease in plasma MHPG and the degree of anxiety was found. The results do not suggest out an effect of anxiety on total plasma MHPG levels in depressed patients.

Blood magnesium, potassium, sodium, calcium and cortisol in drug-free depressed patients

Many biochemical variables, including plasma and erythrocyte magnesium, were simultaneously measured in drug-free depressed patients (n = 34), compared to healthy controls (n = 35). Higher plasma and erythrocyte magnesium concentrations were observed in patients than in controls (+12 per cent, P < 0.0001 and 14 per cent, P < 0.0001, respectively). In contrast, patients showed a lower plasma potassium level (-10 per cent; P < 0.007). Cortisol secretion was much higher in patients (+35 per cent; P < 0.02), particularly in females, showing overactivity of the hypothalamo-hypophyseo-adrenal axis in the patients. Except in a few cases, plasma sodium and calcium in patients did not differ from control values. Significant differences in magnesium and cortisol levels were observed between patients classified in diagnostic groups and by sex, whereas little variation in the other biochemical indices was noted. The increase in blood magnesaemia and its possible association with central hypocatecholaminergic deficiency in affective disorders are discussed.

Adrenaline-induced platelet aggregation in depressed patients and control subjects

We measured alpha 2-adrenoceptor-mediated platelet primary aggregation in depressed patients and healthy subjects. Both initial velocity and maximum amplitudes of platelet response to increasing concentrations of adrenaline were decreased in drug-free depressed patients as compared with controls. The EC50 of both initial slope and maximum amplitude were also increased in drug-free depressed patients. The results suggested a lowered platelet alpha 2-adrenoceptor function. Demographic factors (age and sex) and the time between blood collection and start of aggregation monitoring did not influence the results. This report is consistent with postsynaptic receptor desensitization in depressed patients. The precise molecular mechanism for this impairment remains to be elucidated.

Platelet membrane alpha 2-adrenergic receptors in depression

The platelet membrane was used as a model system to examine alpha 2-adrenergic receptors in 30 depressed patients and 30 healthy control subjects. The number of binding sites and their affinity for 3H-UK 14304 (5-bromo-6-(2-imidazoline-2-ylamino)-quinoxaline), a potent, highly selective alpha 2-adrenergic receptor agonist, was measured. Plasma magnesium and free 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations were assayed in the same sample. A decreased agonist-receptor affinity was found in depressed patients, whereas receptor density was not significantly altered compared with that in control subjects. In bipolar depressed and dysthymic patients, there was a tendency toward a higher density of alpha 2-adrenergic receptors. This trend was not apparent in unipolar, recurrent depressed subjects. Moreover, a positive correlation between Bmax and Kd values was observed in patients but not in control subjects--a finding that suggests that a compensatory phenomenon occurs in depression. After the patients were treated with antidepressant drugs, an increased affinity (decrease in Kd) was observed, together with a decrease in binding sites. Plasma magnesium concentrations were higher in drug-free depressed patients than in control subjects. In addition, magnesium concentrations were negatively correlated with the density of alpha 2-adrenergic receptor binding sites in depressed patients, both before and during treatment. Lastly, a trend toward a negative correlation between plasma MHPG concentration and the number of binding sites was also observed. These results suggest a complex multifactorial regulation of alpha 2-adrenergic receptors, which are probably hyposensitive in depressive syndromes.

The EEG of the sleep onset period in insomnia: a discriminant analysis

A period of rapid change in the wave components of the electroencephalogram (EEG) marks the transition from wake to sleep. Twenty-six insomniac and 28 control nights were studied in a discriminant analysis to determine whether this transitional state is modified in any way in subjects diagnosed for psychophysiological insomnia. A discriminant function was derived based on 20 insomniac and 22 normal nights. All 42 nights were correctly classified by this function. The sleep onset period, extending on the average over about 3 minutes, was characterized essentially by the beta and delta components of the EEG signal and by an activity index given by the ratio beta/delta, measured at the temporal lobe sites. Other variables included the subject's age and the magnitude of the changes occurring in the difference between activities in the right and left hemispheres. The variables contributing most to the discrimination were the activity index and beta, especially at the transitions from wake to stage 1 and from stage 1 to stage 2. The contribution of delta to the discrimination was less, but extended further in time to include stage 2 sleep. A test on the remaining six insomniac and six control nights gave a 75% classification accuracy, thus validating the derived discriminant function.

[Sleep disorders in psychiatric diseases. Clinical and polygraphic data]

This article considers first the relationships between sleep disturbances and psychiatry in general. It shows the interest of sleep recordings in psychiatric diseases as a complementary examination, in order to clarify a diagnosis or the selection of a treatment. Sleep disturbances in the main psychiatric disorders are described: brain organic diseases, thymic disorders, schizophrenia. Modifications of sleep are also found in many other psychiatric disturbances such as anxiety or neuroses. Polysomnography is an excellent functional examination of the brain and has an increasing importance in psychiatry.

Decrease in epinephrine-induced attenuation of platelet adenylate cyclase activity in depressed patients: relation with plasma electrolytes

We have measured the alpha 2-adrenoceptor-mediated inhibition of platelet membrane adenylate cyclase in depressed patients and control subjects. The results showed a decrease in the forskolin-stimulated adenylate cyclase inhibition of depressed patients compared to the healthy subjects. This suggests a subsensitivity of alpha 2-adrenoceptor in depression. However, this subsensitivity was not correlated to the severity of depression as both severely and moderately depressed patients exhibited the same percent of adenylate cyclase inhibition. The antidepressant drugs treatment induced an increase in the percent of adenylate cyclase inhibition with a trend towards the control values. However, this increase did not equal control value, and moreover both remitted and unremitted patients presented a similar change in their alpha 2-adrenoceptor-mediated adenylate cyclase inhibition. This result raises the question about a simple and direct relation between the clinical status of depression and the power of alpha 2-adrenoceptor-mediated adenylate cyclase inhibition. Plasma magnesium and sodium yielded correlations to this alpha 2-adrenoceptor-mediated adenylate cyclase inhibition suggesting a relation between the platelet adrenergic function and plasma electrolytes.

Evolution of blood magnesium, sodium and potassium in depressed patients followed for three months

No consensus has been obtained about blood electrolyte status, especially about magnesium, in affective disorders. This is mainly due to the lack of information about the distribution of the patients in clinical subgroups, sex, type of treatment and about the severity of their illnesses. Most of these studies concerned treated patients. We confirmed in this study that drug-free depressed patients have higher erythrocyte and plasma magnesium than controls, as shown in previous reports. Significant differences are observed in as shown in previous reports. Significant differences are observed in patients for sex and between clinical subgroups. Low plasma potassium levels are described in both male and female depressed patients. The erythrocyte magnesium level tends to normalize in parallel with clinical improvement, depending on sex and clinical subgroup, and seems then to be related to the intensity of the depression. Plasma magnesium in male and female patients, except for female unipolars, remains higher than controls in all conditions and might be related to the diagnosis of affective disorders.

A study of the interrupted REM episode

Brief interruptions of REM sleep are considered to be part of the REM episode. The maximum allowable duration of such an interruption, which is used to define the end of the REM episode, is currently a matter of debate. Making measurements on individual REM cycles, inter-REM interval analysis was carried out to determine whether the generally adopted 15 minute empirical rule for this maximum needs to be extended to 25 minutes as suggested by several including Kobayashi et al. Our results show that there is no reason to alter the 15 minute rule and that measurements which do not take into account the time-of-night effect may be misleading. The proportion of interrupted REM episodes observed in our population of healthy adults is high. We have therefore also examined in some detail the phenomenology of the temporal evolution of the structure and content of the interrupted REM episodes. Both showed a definite change over the night: the interruptions in the earlier episodes tend to return the system to slow wave sleep while those in the later episodes tend to return it to wake. It is hypothesized that these interruptions reflect a measure of REM sleep pressure and its interaction with both slow wave sleep and wake pressures.

Hypnotic action of flunitrazepam is reversed by proglumide in rats

1. Caerulein, an analogue of cholecystokinin (CCK-8), like CCK-8, has been shown to produce hypnotic effects similar to those of benzodiazepine (flunitrazepam). 2. Proglumide antagonizes the action of CCK-8 and of its analogue. 3. The aim of the present study was to demonstrate whether proglumide would affect the potent hypnotic action of flunitrazepam in rats. 4. The association of proglumide with flunitrazepam suppress the increase of total sleep time and slow wave sleep seen after flunitrazepam alone. Proglumide alone has no effect on sleep stages. The authors report here for the first time that the hypnotic action of flunitrazepam is antagonized by proglumide in rat.

Effects of moclobemide on sleep in healthy human subjects

Ten healthy, normal subjects (5 male and 5 female) aged 20-28 years participated in this experimental study of the effect of moclobemide on sleep. The design consisted of 2 sessions of 5 nights each, comprising 1 adaptation night, 2 nights on placebo and 2 inputs of moclobemide 4 mg/kg (session B). The 2 sessions were separated by at least 15 days and their order was balanced and randomized. During the last 4 nights of each session, sleep parameters were recorded throughout the night according to standard procedures. Moclobemide at a dose of 4 mg/kg induced moderate changes in the sleep-wake balance: a significant increase in stage 1 on the second drug night, a slight increase in stage 2 and a significant decrease in paradoxical sleep on the 2 drug nights. There was also a moderate reduction in the number of rapid eye movements (REM) during paradoxical sleep, but the number of cycles and latency to paradoxical sleep were unchanged, as well as all other sleep parameters measured. With 6.5 mg/kg, the changes were more pronounced: total sleep time was diminished, but this was significant only on the second and third nights. Transient awakenings increased significantly on the first drug night, and wakening latency decreased. The only modification of orthodox sleep was an increase in the percentage of stage 2 on the first drug night, whereas slow-wave sleep was unchanged. Paradoxical sleep was reduced on the first 2 drug nights, but tolerance appeared on the third night. The decrease in paradoxical sleep was exacerbated in the last part of the night. REM were decreased during paradoxical sleep.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible in vitro decrease of L-tyrosine and L-tryptophan influx across the human erythrocyte membrane induced by cytochalasin B, the specific inhibitor of D-glucose transport

For many years, we have been studying, in psychiatric conditions, the influx of tyrosine (TYR) and tryptophan (TRP), the two amino acid precursors of monoamines, across the membrane of human blood cells. We have also attempted to characterize better the transport mechanisms. In a previous paper, we suggested a close relationship between glucose and the two neuter amino acid transports in vitro. The purpose of the present study is to test the effect of cytochalasin B, the specific and potent inhibitor of glucose transport. Our data show that at high concentrations, the cytochalasin B induces a reversible inhibition of about 70% or more on the temperature-dependent influx of the two amino acids, depending on the medium of incubation. The effect of cytochalasin B was about 200 times less for TYR and TRP transport than for glucose. The cytochalasin E, claimed to be a nonspecific inhibitor, decreased both these transports only when used at very high concentrations, as described for sugar influx in the same structure. In conclusion, we suggest that there is a relationship between the transport of glucose and nucleosides, both carried into the cells by the glycoprotein band 4.5, and the two amino acid precursors of monoamines.

The intrasleep relationship between wake and stage 4 examined by transition probability analysis

The relationship between wake and stage 4 of slow-wave sleep (SWS), in particular the previously observed deficiency in SWS accompanying sleep containing long-wake periods, is examined in this study of 147 health subjects. Stage shift comportment is compared between those NREM/REM cycles with wake periods greater than 3 minutes and those with less, using the method of transition probabilities. It is shown that these long wake interruptions occur preferentially in light sleep, and systematically disrupt the regular normal descent towards SWS, but do not significantly reduce the number of SWS episodes. There is at the same time, however, a reduction in the average duration of stage 4 periods of SWS which accounts for the observed reduction in the total amount of SWS.

The heterogeneity of 3-methoxy-4-hydroxyphenylglycol levels among depressed patients

A previous report by our group and results published by other research groups have indicated a dichotomy in MHPG levels in depressed patients. This study attempted to characterize phenomena associated with this dichotomy in plasma MHPG levels. First, we have noted, at least in female patients, that homogeneity of MHPG levels, as tested by fitting with a normal curve, can be ruled out. In contrast, in the total population, a dichotomy was less evident in this study; the 2 subgroups, high and low levels of MHPG, partially overlap, and this results in a gaussian distribution. However, based on the hypothesis of a bimodal distribution, as shown by others and not excluded here, it was possible to find some factors associated with heterogeneity. Thus, polarity of depression, sex and age of the patients, age of disease onset and depression score affect MHPG levels. On the other hand, other elements suspected to modify MHPG values, such as the different lengths of the washout period (minimum 10 days), or some medication (chloralhydrate or levomepromazine) required during the washout period, did not show any effect. The aim of this study was to better characterize this peripheral index for its possible use in clinical application.

Differential effects of flunitrazepam on human sleep in combination with flumazenil

The experiments reported here were designed to characterize in detail the spectrum of activity of flunitrazepam in human sleep. The direct and residual effects of flunitrazepam, as well as the antagonism by flumazenil, an antagonist of benzodiazepine receptors, were studied in 28 normal subjects recorded in the sleep laboratory. The five categories of variables--sleep-wake balance, sleep organization, orthodox sleep, phasic events in sleep, and sleep waveforms--were all modified by flunitrazepam. Some of these modifications were observed only on the drug night and were antagonized by flumazenil, whereas others persisted in the placebo postdrug night and were not antagonized by flumazenil. A few variables showed changes intermediate between these two types of reactivity. The results do not fit well with the multiple benzodiazepine receptors theory, but instead support the concept of spare receptors. Along these lines, the study of the reactivity of sleep components to ligands of benzodiazepine receptors can contribute to the better understanding of the neuronal systems involved in their control.

Involvement of sulfhydryl groups in the transport of L-tyrosine and L-tryptophan across the human red cell membrane in vitro

In previous papers, we reported a deficit in tyrosine (TYR) and tryptophan (TRP) transport across the erythrocyte membrane in depressed patients. To investigate further the transport mechanism of the two precursors of monoamines, we tested in healthy subjects the role played by sulfhydryl groups (SH). These groups, cysteine residues, are localized on the intrinsic domain such as the transporters of chloride or sugars. We found that all sulfhydryl reagents that inactivated the SH induced a strong inhibition of the transport of amino acid across the red cell membrane when incubated in the plasma as medium. We concluded that a relationship might exist between these neutral amino acids and D-glucose transport.

Hypnotic action of flunitrazepam in the rat: does 5-HT mechanism play a role?

This study examined whether pharmacological manipulation of serotonergic (5-HT) systems would affect the hypnotic action of flunitrazepam in rats. Flunitrazepam, a potent hypnotic, was used alone or combined with parachlorophenylalanine (pCPA), an inhibitor of the synthesis of 5-HT, 8-OH-DPAT, a 5-HT1A receptor agonist and fluvoxamine, an inhibitor of the reuptake of 5-HT. Flunitrazepam increased the amount of orthodox sleep, the latency of rapid eye movement (REM) sleep and decreased the amount of REM sleep. The drug pCPA decreased the total sleep time and the amount of orthodox and REM sleep. Administration of flunitrazepam to pCPA-pretreated rats induced orthodox sleep in an identical way to that found in the controls. The drug 8-OH-DPAT increased wakefulness and the latency of REM sleep. The association of flunitrazepam with 8-OH-DPAT abolished the increase in waking seen after 8-OH-DPAT alone. In contrast, the combined treatment with flunitrazepam and 8-OH-DPAT resulted in a lengthening of the latency of REM sleep significantly greater than that observed with the same dose of each drug alone. Fluvoxamine increased the latency a decrease the amount of REM sleep. The association of fluvoxamine with flunitrazepam induced a decrease in REM sleep, equal to the sum of the effects of the two drugs alone. Fluvoxamine did not modify the other effects of flunitrazepam. The present experiments demonstrate that the association of pCPA, 8-OH-DPAT and fluvoxamine, did not alter the hypnogenic effect of flunitrazepam. The possibility of an involvement of 5-HT mechanisms in the effect of flunitrazepam on the phasic events in sleep is questionable.