PARASOMNIAS

Parasomnias are a category of sleep disorders characterized by abnormal movements, behaviors, emotions, perceptions, or dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. These phenomena can be disruptive and may affect the sleep quality of the individual and sometimes their bed partners.

Types of Parasomnias:

1. Non-REM (NREM) Parasomnias:
   
   • Sleepwalking (somnambulism)
   • Sleep terrors (night terrors)
   • Confusional arousals

1. REM Parasomnias:
   
   • REM Sleep Behavior Disorder (RBD)
   • Nightmares
   • Sleep paralysis

1. Other Parasomnias:
   
   • Bedwetting (enuresis)
   • Sleep-related eating disorder (SRED)
   • Exploding head syndrome

Symptoms: The symptoms of parasomnias can vary widely depending on the type of disorder, but common manifestations include:

• Sleepwalking: Performing complex behaviors like walking, talking, eating, or even driving while asleep.
• Sleep Terrors: Sudden arousal from sleep with intense fear, screaming, and thrashing.
• Confusional Arousals: Confusion upon awakening, often without fully becoming aware.
• REM Sleep Behavior Disorder: Acting out dreams, sometimes violently.
• Nightmares: Vivid, disturbing dreams that often lead to awakening.
• Sleep Paralysis: Temporary inability to move or speak while falling asleep or upon waking.
• Sleep-related Eating Disorder: Eating and drinking during the night with little to no memory of the event.
• Exploding Head Syndrome: Sensation of a loud noise or explosive feeling in the head during the transition to or from sleep.

Causes: Parasomnias can be triggered by various factors, including:

• Genetics: Family history of sleep disorders.
• Stress and Anxiety: High levels of stress or anxiety can precipitate parasomnias.
• Sleep Deprivation: Lack of adequate sleep can increase the likelihood of parasomnias.
• Medications: Certain medications, particularly those affecting the central nervous system, can induce parasomnias.
• Substance Use: Alcohol, drugs, and caffeine can contribute to sleep disturbances.
• Other Sleep Disorders: Conditions like sleep apnea can exacerbate parasomnias.
• Medical Conditions: Neurological disorders, fever, and other medical conditions can trigger parasomnias.

Diagnosis and Tests

• Medical History: Detailed history of symptoms, sleep patterns, and family history of sleep disorders.
• Sleep Diary: Keeping a sleep diary to track sleep patterns, behaviors, and symptoms.
• Polysomnography (Sleep Study): An overnight test that records brain waves, blood oxygen levels, heart rate, breathing, and eye and leg movements during sleep.
• Video Monitoring: Recording sleep behaviors to observe any abnormal movements or activities.
• Multiple Sleep Latency Test (MSLT): Measures how quickly a person falls asleep in a quiet environment during the day.
• Questionnaires: Sleep questionnaires to assess sleep quality, habits, and related symptoms.

From the Cleveland Clinic:

 Overview

A parasomnia is a sleep disorder that involves unusual and undesirable physical events or experiences that disrupt your sleep. A parasomnia can occur before or during sleep or during arousal from sleep. If you have a parasomnia, you might have abnormal movements, talk, express emotions or do unusual things. You are really asleep, although your bed partner might think you’re awake.

Yes. Parasomnias are grouped by the stage of sleep in which they happen. There are two main stages of sleep – non-rapid eye movement (Non-REM) sleep and rapid eye movement (REM) sleep. There are other parasomnias that fall into an “other” category.

Non-rapid eye movement (Non-REM) sleep are the first three stages of sleep – from first falling asleep to about the first half of the night. Non-REM sleep disorders are also called arousal disorders.

Non-REM parasomnias involve physical and verbal activity. You are not completely awake or aware during these events, are not responsive to others’ attempts to interact with you and you usually don’t remember or only partially remember the event the next day. Non-REM parasomnias usually occur in individuals between five and 25 years of age. Non-REM parasomnias often occur in people who have a family history of similar parasomnias.

Parasomnias that happen during Non-REM sleep include:

• Sleep terrors: If you experience this sleep disorder, you wake up suddenly in a terrified state. You may scream or cry in fright. Sleep terrors are usually brief (30 seconds), but can last up to a few minutes. Other features of this disorder are a racing heart rate, open eyes with dilated pupils, fast breathing and sweating.
• Sleepwalking (somnambulism): If you’re a sleepwalker, you get out of bed, move about with your eyes wide open, but you’re actually asleep. You may mumble or talk (sleep talking). You may perform complex activities – such as driving or playing a musical instrument – or do strange things like pee in a closet or move furniture. Sleepwalking can be dangerous and lead to injuries because you’re unaware of your surroundings. You can bump into objects or fall down.
• Confusional arousals: If you have this sleep disorder, you appear to be partially awake, but you are confused and disoriented to time and space. You remain in bed, may sit up, have your eyes open, and may cry. You speak slowly, have trouble understanding questions that are asked or responding in a sensible way. The episode may last from a few minutes to hours. Confusional arousals are common in childhood and tend to decrease in frequency with increasing age.
• Sleep-related eating disorder: If you have this sleep disorder, you eat and drink while you’re partially awake. You may eat foods or food combinations you wouldn’t eat if awake (such as uncooked chicken or slabs of butter). Dangers include eating inedible or toxic foods, eating unhealthy or too much food, or injuries from preparing or cooking foods.
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Rapid eye movement (REM) sleep follows the three non-REM stages of the sleep cycle. During REM sleep, your eyes rapidly move under your eyelids and your heart rate, breathing and blood pressure are all increased. This is a time when vivid dreaming occurs. Your body cycles through and repeats non-REM and REM sleep about every 90 to 110 minutes.

Parasomnias happen during the latter part of the night. If awakened during the event, it’s likely you’d be able to recall part or all of the dream.

Parasomnias that happen during REM sleep include:

• Nightmare disorder: These are vivid dreams that cause feelings of fear, terror and/or anxiety. You may feel a threat to your survival or security. If you are awakened during your nightmare, you’d be able to describe your dream in detail. You often have trouble falling back to sleep. Nightmare disorder is more likely to occur if you’re under stress or experience a traumatic event, illness/fever, extreme tiredness or after alcohol consumption.

• Recurrent isolated sleep paralysis: If you have this sleep disorder, you can’t move your body or limbs during sleep. Scientists think the paralysis might be caused by an extension of REM sleep – a stage in which muscles are already in a relaxed state. This happens either before you fall asleep or as you are waking up. Episodes last seconds to a few minutes and are distressing, usually causing anxiety or fear. Sleep paralysis can be stopped if your bed partner speaks to you or touches you.

• REM sleep behavior disorder (RSBD): If you have this sleep disorder, you act out, vocalize (e.g., talk, swear, laugh, shout), or make aggressive movements (e.g., punching, kicking, grabbing) as a reaction to a violent dream. This sleep disorder is more common among older adults. Many people with this disorder have neurodegenerative disease, such as Parkinson’s disease, Lewy body dementia, multiple system atrophy or stroke.

Other parasomnias include:

• Exploding head syndrome: If you have this sleep disorder, you hear a loud noise or explosive crashing sound in your head as you’re falling asleep or waking up. You may also see an imaginary flash of light or have a sudden muscle jerk.
• Sleep enuresis (bedwetting): This is not the bedwetting that occurs in young children. To be a parasomnia, this bedwetting must happen in children age five and older and must occur at least two times a week for at least three months.
• Sleep-related hallucinations: If you have this sleep disorder, you experience hallucinations as you’re falling asleep or waking up. You may see things, hear things, feel things or feel movement that doesn’t really exist. You may leave your bed to escape what you’re experiencing.
• Sleep-related groaning (catathrenia): With this sleep disorder, you have repeat episodes of groaning noises (long groans followed by sighs or grunts) during sleep.
• Sexsomnia: Persons with this sleep disorder carry out sexual behaviors during their sleep. These may include intercourse, masturbation, sexual assault, fondling your bed partner or sexual vocalizations.
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Nightmares appear to happen more often in females. Sexsomnia is seen more often in males. REM sleep behavior disorder is more commonly reported in males over age 50. Sleep terrors, confusional arousals and sleepwalking occur in a similar number of males and females.

Yes. Parasomnias are more common in children than in adults. Non-REM sleep disorders are more common in children than REM disorders. The most common parasomnias in children under the age of 15 are:

• Confusional arousal.
• Sleepwalking.
• Sleep terror.
• Nightmare.

Parasomnias are seen more often in children who have neurologic or psychiatric health issues including epilepsy, attention-deficit hyperactive disorder (ADHD) or developmental issues.

Causes of parasomnias can be grouped into those that disrupt sleep and other general health issues.

Issues that disrupt sleep:

• Incomplete transition from being awake to the stages of sleep.
• Lack of sleep, irregular sleep-wake schedules (jet lag or shift work).
• Medications including those that cause sleep (benzodiazepines: zolpidem), treat depression (amitriptyline, bupropion, paroxetine, mirtazapine), treat psychotic disorders (quetiapine, olanzapine), treat high blood pressure (propranolol, metoprolol), treat seizures (topiramate), treat asthma/allergy (montelukast) treat infections (fluoroquinolones).
• Medical issues that disrupt sleep, such as restless leg syndrome, obstructive sleep apnea, pain, narcolepsy, sleep deprivation, circadian rhythm disorders, or periodic limb movement disorder.
• Lack of maturity of the sleep-wake cycle (in children with parasomnias).

Each type of parasomnia has many unique features and triggers. However, some of the more common symptoms include:

• Difficulty sleeping through the night.
• Waking up confused or disoriented.
• Being tired during the day.
• Finding cuts and bruises on your body for which you don’t remember the cause.
• Displaying movements, expressions, vocalizations or activities – as told to you by your bed partner – that you don’t remember.

Your sleep medicine specialist will ask you and your sleep partner about your sleep symptoms. You will also be asked about your medical history, family history, alcohol use and any substance abuse. You’ll be asked about your current medications. You may be asked to keep a sleep diary and your bed partner may be asked to keep track of your sleep events.

Other sleep disorders tests include:

• Sleep study (polysomnogram): This is a sleeping laboratory in which you’ll be monitored as you sleep. Your brain waves, heart rate, eye movements and breathing will be recorded as you sleep. Video will record your movements and behavior. While some sleep studies can be done at home, an in-lab study will be recommended if there's concern for parasomnia.
• Video electroencephogram (EEG) or sleep EEG: These tests help your healthcare provider see and record your brain activity during a brain event.
• Neurologic exam, CT or MRI scan to detect degeneration of the brain or other possible neurologic causes of your symptoms.

Treatment starts with identifying and treating other sleep problems and any other health issues as well as reviewing medications that may trigger the parasomnia.

General management strategies for both Non-REM and REM sleep disorders are to:

• Follow good sleep hygiene habits (get 7-9 hours of sleep/night; turn off lights, TV and electronic devices; keep room temperature cool; avoid caffeine and strenuous exercise near bedtime).
• Maintain your regular sleep-wake schedule. Have a consistent bed time and wake up time.
• Limit, or don’t use, alcohol or recreational drugs.
• Take all prescribed medications as directed by your healthcare provider.
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Other treatments for non-REM sleep disorders:

• Medication is not usually prescribed for non-REM parasomnias. However, when they are used, benzodiazepines are the medications of choice for parasomnias that are long lasting or potentially harmful. Tricyclic antidepressants are also sometimes tried. Psychological approaches (such as hypnosis, relaxation therapy or cognitive behavioral therapy, psychotherapy) are also considered.
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Other treatments for REM sleep disorders:

• Clonazepam and melatonin are the medications commonly used to manage REM sleep disorders.

Your healthcare provider will discuss the best treatment options – medications and/or psychologic approaches – for your specific type of parasomnia considering your unique health history and medical issues.

Safety precautions

Another discussion you and your healthcare provider will have are suggestions to keep your sleeping environment safe. Tips include:

• Lock or remove any dangerous or sharp items from the bedroom.
• Secure tableside lights.
• Use floor pads to prevent injuries from falls.
• Pad the edges of bedside furniture.
• Use plastic bottles and cups if water is needed at the bedside.
• Install alarms on windows and doors for sleepwalkers.
• Sleep in separate beds if the person with parasomnia displays aggressive behaviors – like punching or kicking.
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Non-REM parasomnias are most common during childhood and normally end during adolescence. Usually all that’s needed is calming reassurance from the parents that everything is okay. Medications are rarely needed, but if they are, they’re typically only prescribed for three to six weeks. Medications typically tried include benzodiazepines or anti-anxiety drugs.

Although some causes of parasomnias are less likely to be prevented, such as those due to neurological diseases, mental health issues or heredity, others may be prevented by following some of the same management approaches discussed in this article. These include getting seven to nine hours of sleep a night sticking with consistent bedtime and wakeup times, and limiting alcohol and recreational drug use. (See the treatment section for more tips.) Also, ask your healthcare provider to review your current medications. Many can disrupt sleep. If this is the case, perhaps different drugs can be prescribed.

 Disorders of arousal (DOA)

 Disorders of arousal (DOA) is an umbrella term initially covering classical sleepwalking, sleep terrors, and confusional arousals, and now including a wider spectrum of specialised forms of non rapid eye movement (non REM) parasomnias such as sexsomnia, sleep-related eating disorder, and sleep-related choking syndrome. 

You should talk to your doctor if you or your family member experiences any abnormal sleep-related behaviors, especially those associated with injuries or sleep disruption.

Parasomnias are complex sleep disorders that require a comprehensive approach to manage effectively. By understanding the symptoms, causes, and available treatments, individuals can take proactive steps to improve their sleep quality and overall well-being. Regular follow-ups with healthcare providers and support from family and caregivers are crucial in managing these disorders successfully.