• Parasomnia

    Introduction

    The term "parasomnia" is used in reference to a wide range of disruptive sleep-related events. These behaviors and experiences generally occur during sleep, and in most cases are infrequent and mild. At times, however, they may occur often enough or become so bothersome that medical attention is indicated.

    What Are Disorders of Arousal?

    The most common of the parasomnias are "disorders of arousal," which include confusional arousals, sleepwalking (somnambulism), and sleep terrors. Experts believe that the various arousal disorders are related and share some characteristics. Essentially, these occur when a person is in a mixed state, both asleep and awake, and often emerging from the deepest state of non-dreaming sleep. The sleeper is awake enough to act out complex behaviors, but is still asleep and not aware of or able to remember these activities.

    Parasomnias are very common in young children, and do not usually indicate significant psychiatric or psychological problems such disorders tend to run in families, and can be more severe when a child is overly tired, has a fever, or is taking certain medications. They may occur during periods of stress, and may increase or decrease with "good" and "bad" weeks.

    Confusional Arousals: Confusional arousals are most common in infants and toddlers, but are also seen in adults. These episodes may begin with crying and thrashing around in bed. The sleep appears to be awake, and seems to be confused and upset, but resists attempts to comfort or console. It is difficult to awaken a person in the grips of a parasomnia episode. The confusional arousal can last up to half an hour, and usually ends when the agitation subsides and the sleeper awakens briefly, wanting to return to sleep.

    Sleepwalking: This disorder is commonly seen in older children, and can range from simply getting out of bed and walking around the bedroom to prolonged and complex actions, such as going to another part of the house or even outdoors. A sleepwalker will sometimes speak, but is unlikely to be clearly understood. Sometimes complicated behaviors take place during a sleepwalking episode (such as rearranging furniture), but these activities are usually not purposeful. While injures during sleepwalking are uncommon, sleepwalkers may put themselves in harm's way -- such as walking outside in bedclothes during the winter. Simple precautions enhance safety.

    In most cases, no treatment is necessary. The sleepwalker can family can be assured that these events rarely indicated any serious underlying medical or psychiatric problem. In children, the number of events tends to decrease with age, although they can occasionally persist into adulthood or even originate during the adult years.

    Sleep-related Eating: A rare variation of sleepwalking is "sleep-related eating." This disorder manifests itself as recurrent episodes of eating during sleep, without conscious awareness. Sleep-related eating can occur often enough to result in significant weight gain. Although it can affect both sexes and all ages, it is most common in young women.

    Sleep Terrors: These are the most extreme and dramatic of the arousal disorders, and the most distressing to witness. A sleep terror episode often begins with a "blood-curdling" scream or shout, and can produce signs that suggest extreme terror, such as dilated pupils, rapid breathing, racing heart, sweating, and extreme agitation. During a sleep terror episode, the victim may bolt out of bed and run around the room or house. In the course of the frenzied event, sleepers can hurt themselves or others.

    As disturbing and frightening as these episodes are to an observer, the sleeper usually has no conscious awareness of the event, and generally does not remember it upon awakening.

    Unlike typical nightmares or bad dreams, sleep terror episodes are not usually associated with vivid dream images and are recalled after awakening.

    How Are Arousal Disorders Evaluated?

    In typical childhood occurrences of arousal disorders, medical evaluation is unlikely to be needed. You should, however, contact a healthcare professional if a child's disturbed sleep causes:

    1. Potentially dangerous behavior, such as that which is violent or could cause injury;
    2. Extreme disturbance of other household members;
    3. Excessive sleepiness during the day. In these cases, formal evaluation at a sleep center is warranted.

    Because disorders of arousal are relatively uncommon after childhood, adults suffering from these disorders can be triggered by other conditions, such as sleep apnea, heartburn, or periodic limb movements during sleep. A sleep specialist should evaluate the patient's behaviors and medical history.

    Are There Treatments for Arousal Disorders?

    Clearing of obstructions, securing windows, sleeping on the ground floor, and installing locks or alarms on windows and doors can add a degree of security for the individual and the family.

    In cases severe enough that the sleep disorders leads to injury or involves violence, excessive eating, or disturbance to others, treatment may be warranted. Therapy can include medical intervention with prescription drugs, or behavior modification through hypnosis or relaxation/mental imagery.

    What Are Some Other Parasomnias?

    While the great majority of sleep-related complex behaviors and experiences are due to disorders of arousal, simple precautions should be taken to ensure safety for people with arousal disorders. Clearing the bedroom several other conditions can be frightening or disturbing to those who experience them.

    Hypnagogic Hallucinations and Sleep Paralysis: Hypnagogic hallucinations are episodes of dreaming while awake, usually just before falling asleep. These dreams can be frightening because the setting reflects reality (for example, the bedroom), and the content of the dream is often threatening.

    Sleep paralysis is the experience of waking up -- usually following a dream -- with a feeling that the muscles of the body (except those used to breath and move the eyes) are paralyzed. Hypnagogic hallucinations and sleep paralysis may occur together. They are common in people with narcolepsy, but can also affect others, particularly individuals who are sleep-deprived. While they can be terrifying, these events are not physically harmful.

    Nocturnal Seizures: These seizures, which occur only during sleep, can cause the victim to cry, scream, walk or run about, curse, or fall out of bed. Like other seizures they are usually treated with medication.

    Rapid Eye Movement (REM) Sleep Behavior Disorder: All body muscles -- except those used in breathing -- are normally paralyzed during REM sleep. In some people commonly older men, this paralysis is incomplete or absent, allowing dreams to be: acted out." Such dream-related behavior can be violent and can result in injury to the victim or bed partner. In contrast to those who experience sleep terrors, the victim will recall vivid dreams. REM sleep behavior disorder can be controlled with medication.

    Sleep Starts: Most people experienced the common "motor" sleep start -- a sudden, often violent jerk of the entire body upon falling asleep. Other forms of sleep starts can occur just as sleep begins. A "visual" sleep start is a sensation of blinding light coming from the inside the eyes or head. An "auditory" sleep start is a loud snapping noise that seems to come from inside the head. Such occurrences, while they can be frightening, are harmless.

    Teeth grinding (bruxism): Grinding of teeth during sleep is a very common occurrence, and little evidence suggests that teeth grinding is associated with any significant medical or psychological problems. In severe cases, mouth devices can help reduce the risk of dental injury.

    Rhythmic-movement Disorder: This condition, seen most frequently in young children, can also occur in adults. It takes the form of recurrent head banging, head rolling and body rocking. The individual may also moan or hum. These activities can occur just before sleep begins, or during sleep. Medical or psychological problems are unlikely to be associated with rhythmic movement disorder. Behavioral treatments may be effective in severe cases.

    Sleep Talking (somniloquy): Sleep talking is a normal phenomenon and is of no medical or psychological importance.

    When Do I Ask a Healthcare Professional's Help?

    Since most of these sleep-related behaviors are due to disorders of arousal -- which are not medically significant -- medical evaluation and treatment is often not necessary. Medical attention should be considered however, if the parasomnia behaviors: 1) are violet or may cause injury; 2) are disturbing to other household members; or 3) result in excessive daytime sleepiness.

    Where Do I Seek Assistance?

    Minor sleep problems can be handled by a primary care professional, often with a telephone consultation with a sleep medicine specialist experience with these conditions. Due to the complex nature of some parasomnias, however, proper diagnosis requires expert clinical evaluation and sleep laboratory monitoring of many body functions during sleep. A sleep specialist should direct these evaluations with experience in such cases.

    In most cases of bothersome parasomnias, a specific cause can be identified and effectively treated.

    Courtesy of the American Academy of Sleep Medicine

    (http://www.aasmnet.org)

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