Day # 156: Parasomnias
- Marcus Hunt
- Nov 19, 2024
- 7 min read
Today, we will focus on parasomnias, a category of sleep disorders involving abnormal behaviors and perceptions during different sleep stages. These disorders range from occurrences like sleepwalking to conditions such as sleep paralysis or night terrors. Understanding types, causes, and treatments is crucial for managing these disorders and improving sleep quality for our patients.
Today's Content Level: All levels (Beginner, Intermediate, Advanced)
Introduction 1
•Parasomnias are a category of sleep disorders characterized by abnormal movements, behaviors, emotions, perceptions, or dreams that occur during sleep, while falling asleep, or waking up.
•They often occur in two main stages of sleep: non-REM (non-rapid eye movement) and REM (rapid eye movement) sleep. Parasomnias are sometimes described as an abnormal fusion of wakefulness with sleep.
•Isolated episodes are common in childhood and adolescence but typically do not progress to a parasomnia disorder.
•Diagnosis: Description of behaviors from a bed partner is often sufficient to make a diagnosis of parasomnias, however a polysomnography (PSG) can be useful in the evaluation of sleep-related behavioral disorders. An expanded workup is important for REM sleep behavior disorder (see below) due to the differential diagnosis for this condition.
Treatment: Common strategies for managing all sub-types of parasomnias include the following:
Improve sleep hygiene: Sleep deprivation exacerbates all parasomnias. Additionally, reducing alcohol and caffeine intake may improve symptoms.
Reduce stress: Engaging in relaxation techniques like meditation, breathing exercises, or therapy can help alleviate stress, a known trigger for parasomnias.
Medication Adjustments: If medications are a potential cause, switching to alternative treatments may reduce symptoms. Certain medications are known to be associated with parasomnias, such as antidepressants, sedative-hypnotics, antipsychotics, stimulants, antiparkinsonian medications, steroids, and some beta-blockers.
Safety measures: Simple modifications, such as installing safety locks, removing dangerous objects, or placing cushions on the floor, can help protect against injuries during episodes.
•Non-REM sleep disorders involve repeated episodes of incomplete arousals that are brief and typically occur during the first third of the sleep episode. Subtypes include sleepwalking, sleep terrors, and confusional arousals (confusion, slow speech, difficulty responding upon awakening).
In all NREM parasomnias:
Individuals are relatively unresponsive to others trying to communicate with them and can only be awakened with difficulty.
Episodes typically conclude with patients going back to bed or waking up momentarily feeling confused and disoriented.
There is amnesia for the experience.
Typically occurs in the first third of the night in slow wave sleep (N3).
Management:
For most cases, treatment is unnecessary. Benefit can be found through education, reassurance, addressing triggers, creating a safe environment, and maintaining good sleep habits. Parents often need reassurance that sleep terrors are harmless and typically resolve on their own.
If treatment is refractory, low-dose short-acting benzodiazepines may be used. SSRIs and topiramate have been used for managing sleep-related eating.
Sleepwalking
Clinical Features
Repeated occurrences of getting out of bed while asleep and walking around.
Behaviors may include sitting up in bed, walking, eating, and may even "escape" outdoors. May rarely be associated with complex actions (e.g., driving, sex).
Eyes are usually open with a blank, staring face.
Etiology/Epidemiology
Known risk factors include family history of sleepwalking (in ~80% of cases), sleep deprivation, stress, irregular sleep schedules, obstructive sleep apnea, and having a fever.
Approximately 10-30% of children and 1-7% of adults experience sleepwalking, with 2-3% of children being frequent sleepwalkers. In most cases, sleepwalking is harmless and does not need additional assessment or treatment, but severe cases may require a PSG to rule out other conditions.
Sleep Terrors
Clinical Features
Episodes involve sudden terror arousals, often beginning with screaming or crying.
Accompanied by signs of intense anxiety and autonomic arousal such as rapid heartbeat, rapid breathing, sweating, and dilated pupils.
Difficulty waking the person during an episode and individuals typically return to sleep without remembering the episode. Rarely, awakening may lead to aggressive behavior.
Dreams are not remembered, and there is amnesia for the event.
The differential diagnosis includes nocturnal panic attacks, which often occur during the transition between stages N2-N3.
Etiology/Epidemiology
Known risk factors are the same as listed for sleep walking, with a 10-fold increase in first-degree biological relatives of affected patients. There is also a high comorbidity with sleep walking.
Approximately 2% of adults and 20% of young children have sleep terrors.
Nightmare disorder
Clinical Features
Recurrent episodes of vivid, extended, and frightening dreams that typically involve threats to survival, security, or physical integrity.
Occurs during REM sleep, usually in the second half of the sleep period.
Upon awakening, there is no confusion or disorientation and dreams are well-remembered.
May lead to significant distress or impairment in social, occupational, or other areas of functioning.
Frequent awakenings from the nightmares often lead to difficulty returning to sleep.
Etiology/Epidemiology
Risk factors include stressful life events, trauma, anxiety disorders, sleep deprivation, irregular sleep schedules, and certain medications or substance use such as antidepressants or withdrawal from alcohol.
Common in children and peak prevalence is in late adolescence or early adulthood. Prevalence decreases with age; about 1-5% of the adult population experience frequent nightmares.
Nightmares are seen in at least 50-70% of patients with PTSD.
Treatment
Treatment is not always needed. Psychoeducation and reassurance may help in many cases. Addressing stress or trauma through therapy is the priority.
Cognitive-behavioral therapy (CBT) and imagery rehearsal therapy (IRT) are effective.
IRT involves using mental imagery to modify and rehearse an improved outcome of a recurrent nightmare.
Medication, such as prazosin, may be used in some cases to reduce nightmare frequency. Prazosin is an α1-receptor blocker (technically an inverse agonist at α1 adrenergic receptors) that is commonly used to treat nightmares and sleep disturbance in PTSD, despite mixed results in clinical trials.
REM Sleep Behavior Disorder (RBD)
Clinical Features
Characterized by repeated episodes of vocalizations or complex motor behaviors.
These behaviors often correspond to dream enactment and can include talking, yelling, punching, kicking, limb jerking, jumping out of bed, walking and/or running. The presenting complaint is often violent behaviors during sleep resulting in injury to the patient and/or to the bed partner.
Normally, REM sleep is characterized by lack of muscle tone. In RBD, there is an absence of muscle atonia.
Upon awakening, there is no confusion or disorientation, but may be unaware of their movements. Individuals are often able to recall details of their dream.
Episodes typically occur after more than 90 minutes of sleep and are more frequent in the second half of the night.
Etiology/Epidemiology
An expanded assessment is required in RBD, as it is strongly associated with neurodegenerative diseases (alpha synucleinopathies) like Parkinson's disease, Lewy body dementia, and multiple system atrophy.
Prevalence is approximately 0.5% in the general population, but higher in those with neurodegenerative disorders as well as psychiatric disorders. More common in older adults, particularly men > 50 yo.
Certain medications or substance use such as antidepressants or withdrawal from alcohol can also increase the risk of symptoms.
Treatment
Clonazepam, a benzodiazepine, is the most commonly prescribed medication and is effective in reducing symptoms.
Melatonin (high dose, 5-18mg nightly) may also be used first-line, especially in patients where clonazepam is contraindicated. Lower doses are generally not effective.
Other agents such as dopamine agonists (e.g. pramipexole) and acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) have demonstrated benefit, but are generally reserved as second-line treatments.
Ensuring a safe sleep environment to prevent injury from dream enactment behaviors.
Addressing any underlying neurological conditions or discontinuation of any causative medications if possible.
Sleep Paralysis
Clinical Features
Temporary inability to move or speak while falling asleep or upon waking. Conscious awareness of surroundings is maintained, distinguishing it from other sleep disorders.
Episodes can last from a few seconds to a couple of minutes.
May be accompanied by hallucinations, which can be auditory, visual (e.g. seeing a shadowy figure), or sensory (e.g. feel like there is a pressure on their chest, suffocating, or like they are being touched).
These symptoms may cause intense fear or make them feel like they cannot breathe.
While distressing, sleep paralysis is not dangerous and does not require treatment.
Etiology/Epidemiology
Strongly associated with narcolepsy. General risk factors include irregular sleep schedules, sleep deprivation, increased stress, anxiety, other mental health issues, sleeping in a supine position (on the back), and familial patterns suggest a potential genetic component.
Sleep paralysis occurs in ~ two-thirds of patients with narcolepsy. Healthy individuals can have occasional sleep paralysis (and hypnagogic or hypnopompic hallucinations), often due to insufficient sleep and likely high REM "sleep pressure", but the frequency of these events is much higher in patients with narcolepsy. For example, sleep paralysis occurs ≥1 time per month in most people with narcolepsy type 1 and only in approximately 3 percent of the general population.
Affects approximately 7.6% of the general population at least once in their lifetime. More common in adolescents and young adults, with a decrease in frequency as age increases. Equally affects both men and women.
Treatment
Education and reassurance that the condition is not dangerous and is commonly experienced. No medication is indicated for sleep paralysis.
Improving sleep hygiene, such as maintaining a regular sleep schedule and creating a restful sleep environment.
Stress reduction techniques, including mindfulness and relaxation exercises.
CBT may be helpful for those with frequent episodes.
In severe cases, addressing any underlying sleep disorders like narcolepsy.
Conclusion
•Nice work. I hope today's less helped you gain a better understanding of parasomnias. In the upcoming lesson, we will cover Restless Leg Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD).
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