WISCONSIN MEDICAL JOURNAL

Parasomnias
Gary Leo, DO

INTRODUCTION The control mechanisms for the switch from one

Parasomnias represent a wide variety of disorders that state to the other have not been defined.3 There is no
interrupt sleep and cause unusual nocturnal behavior. specific “sleep” and “wake” center that regulates this
These disorders are reported in 1% to 10% of the pop- activity. The control of the state is dependent upon in-
ulation,1 with the highest preponderance in children. teraction from a diverse spectrum of structures, which
These disorders may be classified on the basis of the in turn affect the characteristics and reactivity of the
sleep stage in which they occur, or the age of first oc- rest of the brain. Brain structures will have different
currence in a given patient, or the clinical behavior dur- functions based upon the current state of conscious-
ing the event. Clinical history from the patient and ness. Stimulation of a certain nucleus may have differ-
family members is usually enough to establish a diag- ent effects if the person is awake as compared to being
nosis. Treatment is dependent upon the type of behav- in REM sleep.
ior exhibited, frequency, and disruption to patient and Parasomnias arise due to a disruption in the switch
other family members. The importance of these disor- from one state to another. Most commonly parasom-
ders arises from the potential that they hold for anxiety, nias occur as an incomplete awakening from NREM
sleep disruption, and possible harm. sleep. In these episodes the brain is reacting to both in-
ternal and external stimuli. Characteristic behaviors of
•••
sleep may also invade wakefulness. Cataplexy (abrupt
Human consciousness has three separate states of loss of muscle tone), which is found in 70% of persons
being, each with its own unique characteristics: wake, with narcolepsy, is due to muscle atonia. Here, REM
nonrapid eye movement (NREM) sleep, and rapid eye sleep transgresses abruptly into wakefulness; muscle
movement (REM) sleep.2 During wakefulness, one re- atonia is the accompaniment of REM sleep. Normally
acts to external stimuli. During sleep, the brain reacts to smooth transitions between states can be influenced by
internal stimuli. Sleep is subdivided into different stages genetic and environmental factors. Sleep terrors and
based on EEG activity and other behavior including sleepwalking often have a familial incidence. Environ-
eye movements and muscle tone. During NREM sleep, mental factors such as sleep deprivation, alcohol and
which accounts for 75% of any given night’s sleep in stimulants might increase these episodes, as would
normal adults, brain wave activity slows but muscle emotional stress. These environmental and emotional
tone is preserved. REM sleep is unique in that the EEG factors likely decrease arousal threshold allowing for
frequency is in the “wake” range, with bursts of eye more frequent arousals, or disrupting the normal mech-
movements and muscle atonia. REM episodes appear anism of transition from one stage to another.
cyclically during the night. The first REM episode ap-
pears 90 minutes after the first sleep onset and then re- CLASSIFICATION
occurs every 60 to 90 minutes through the remainder of Parasomnias may be classified according to sleep stage
sleep cycle. These sleep stages are interspersed with (Table 1), type of behavior and age of onset.
periods of wakefulness that also appear periodically
during the night. A systematic arrangement of these NREM Parasomnias
different stages during the course of a typical night Collectively, this group of disorders is the most com-
constitutes what is referred to as sleep architecture. mon parasomnia.4 It includes confusional awakenings,
sleep terrors, and sleepwalking. These disorders differ
Doctor Leo is Medical Director, Sleep Laboratory, St. Joseph in their clinical presentation but often there is a great
Regional Medical Center, Milwaukee, Wis. deal of overlap between them. Most common in child-

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hood, they may persist into adulthood. The episodes Table 1. Sleep-stage based classification of parasomnias
occur as an incomplete arousal from stage 3-4 NREM
sleep; therefore they usually occur within the first one NREM REM Sleep Stage-independent
Parasomnias Parasomnias Parasomnias
third of the night when stage 3-4 sleep is most promi-
nent. Amnesia for the event is a characteristic of Confusional REM behavior Sleep-talking
arousals disorder (RBD)
NREM parasomnias and usually the person cannot be (awakenings)
Teeth grinding
awakened from the episode. Bed rocking
Sleep terrors
NREM parasomnias share common features. All are Periodic Limb Movements
Sleepwalking of Sleep
more common in childhood, but as the brain matures,
Nocturnal panic disorders
the incidence decreases. A positive family history is as-
sociated with all of the disorders. More recent studies,
particularly in children, have refuted a previous notion
of association of parasomnias with psychopathology. from 6% to 40%. As with the other NREM parasom-
The episodes are usually precipitated by environmental nias the incidence declines with age. Sleepwalking oc-
stimuli such as loud noises during sleep, metabolic dis- curs in 2% of the adult population.1 People may be
turbances, infection, and fever. Sleep deprivation or a awakened from sleepwalking and may or may not have
change in the sleep schedule will increase the likelihood amnesia for the episodes. Generally purposeful activity
of an event, especially when other factors are involved. can occur such as walking around the house, having a
Psychoactive drugs such as alcohol and sedatives may conversation, doing household chores, and even oper-
exacerbate the condition. Emotional stress and anxiety ating an automobile.
will also precipitate an event. Treatment depends upon the frequency and severity
Confusional Awakenings are a common feature in of the events. Most children do not require treatment.
young children under age 5. The episodes consist of The episodes are generally infrequent, and education
arousal with confusion, slow speech, and mild agita- and reassurance of the parents are all that is required.
tion. Moaning or crying may signal the episode, which Episodes that are frequent and self-injurious may re-
generally lasts for 5 to 10 minutes, and the child usually quire medication. Benzodiazepines such as clonaz-
cannot be aroused from the episode. Attempts at awak- epam (0.5–1 mg) and zolpidem (Ambien™, 5–10 mg)
ening the child may actually prolong the parasomnia. given at bedtime are the drugs of choice.5 Nightly use
Sleep Terrors are the most dramatic of the NREM of medication may be needed for frequent events.
disorders. Onset is abrupt with a cry followed by auto- Alter-natively, intermittent use may be helpful if a
nomic and behavioral features of intense fear. Pathoge- stressful situation is anticipated, e.g., sleepovers or
nesis is a very abrupt arousal from stage 3-4 NREM summer camp. Scheduled arousals have also been effec-
sleep. The child may sit in bed or begin to run about tive.6 The child is awakened 1 to 2 hours after bedtime,
the room as if trying to escape from an unseen danger. but before the expected arousal. Four weeks of sched-
During the episode the child appears to be awake with uled awakenings will often reduce the incidence of the
eyes open and clumsy purposeful movement. Injury is arousals. Locks on outside doors will prevent excur-
possible in that the child may run into furniture or leave sions outside of the house.
the house. The child, who cannot be awakened, will re- These episodes may persist into adulthood. Med-
turn to sleep in 5 to 15 minutes. As with other NREM ication remains the cornerstone of management. Envi-
parasomnias, attempts at awakening the child will pro- ronmental factors such as alcohol and sleep deprivation
long the episode. Recent studies cite an incidence of become important precipitating factors in adults as well
15% in children between 3 and 10 years. Although the as emotional distress. Attention to sleep hygiene is ef-
disorder generally resolves during the mid-teens, in a mi- fective. Sleep hygiene consists of regular sleep/wake
nority of patients it might persist into adulthood. There is hours, avoidance of caffeine and alcohol after 3 PM, and
often a family history of parasomnias. soothing activities prior to bedtime. Those in whom
Sleepwalking consists of motor behavior, which may emotional stress plays a precipitating role will find
be as simple as standing at the bedside or as complex as stress management and self-hypnosis helpful.
opening doors and walking out of the house. The sleep-
walking may be calm or agitated, but it is without the REM Behavior Disorder
intense fear that is noted in sleep terrors. Onset is be- REM behavior disorder (RBD) was first described in
tween the ages of 4 and 8 years. Incidence rates vary 1985.7 This parasomnia occurs during REM sleep;

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therefore it manifests usually during the second part of ropathy, degenerative arthritis or chronic back pain. It
the night. The episodes, which are generally brief and is more common in the elderly and may have no under-
intense, do not occur during the first several REM lying precipitating factor.
episodes and are not seen when REM is achieved dur-
ing daytime sleep. RBD consists of complex activity Nocturnal Panic Disorder
for which the patient has amnesia, although he may Panic disorders may occur in conjunction with daytime
awaken during or after the event. Activity often con- disorder or be an independent disorder.10 People awaken
sists of lunging out of bed or striking a bed partner. with intense anxiety or fear. In contrast to sleep terrors,
The mechanism of the outburst is due to the lack of the patient awakens easily. Lack of dream recall sepa-
muscle atonia, which usually accompanies REM sleep rates this disorder from nightmares.
and prevents motor movement during REM or dream
Nocturnal Seizures
sleep. In essence, the patient “acts out (the) dream,” al-
Seizures occur frequently during sleep in those with
though the episode generally consists of nonspecific
epilepsy. Of patients with epilepsy, 10% to 20% will
movements.8 Actions may be aggressive against the
have seizures only during sleep. Seizures are most
bed partner such as striking out with leg or arm. The
likely to occur during transitions in NREM sleep. A
patient may become violent if attempts are made to re-
parasomnia, previously known as paroxysmal noctur-
strain him.
nal dystonia, has been found to actually represent a
RBD usually begins in men with onset in the 60s and
nocturnal seizure disorder.11 Nocturnal frontal lobe
70s. Its etiology is uncertain but perhaps related to
seizures may mimic parasomnias. Like a parasomnia,
cerebrovascular disease. It has also been noted that a
the seizure causes a sudden apparent awakening from
number of patients with RBD ultimately develop Par-
sleep. The motor activity of the seizure is highly stereo-
kinson’s Disease.9 Sleep disorders are a common early
typed as compared to the more reactive activity noted
feature of this neurodegenerative disorder.
during parasomnias. A polysomnogram with extended
RBD and NREM parasomnias share the same pre-
EEG and concurrent video recording is often required
cipitating factors. There is some evidence that SSRIs
for diagnosis. As with other forms of epilepsy, anticon-
may aggravate RBD. Benzodiazepines, especially the
vulsants are the treatment of choice.
longer-acting agents such as clonazepam and temaz-
epam, are effective in treatment of RBD.
DIAGNOSIS OF PARASOMNIAS
Sleep Disorders Not Dependent On Sleep Stage Ideally diagnosis would be based upon capturing an
These consist of a number of less dramatic episodes event during a polysomnogram. However, the yield
during sleep. Sleep talking is a common disturbance and cost aspects make this approach impractical. Also,
with many of the same precipitating characteristics of the parasomnias occur sporadically, making it unlikely
NREM parasomnias. Often familial, it is aggravated by that an event will be captured during the one night in
poor sleep hygiene and emotional distress. Teeth grind- the sleep lab. Therefore diagnosis usually depends on
ing and bed rocking are similar problems. While teeth the clinical history obtained from the patient as well as
grinding may require a mouth guard to prevent injury witnesses to the episode. A clinical history is adequate
to the teeth, the other disorders usually do not disturb for diagnosis if the behavior and timing are consistent
sleep to a significant degree, and therefore, often re- with a parasomnia, a strong family history is present,
quire no treatment. the episodes are infrequent and the potential for self-
injury is absent. Investigation with a polysomnogram is
OTHER NOCTURAL ACTIVITIES indicated if there are unusual clinical characteristics; in-
Periodic Limb Movements Of Sleep jurious behavior, frequent (weekly) episodes or the
Periodic limb movements of sleep (PLMS) consist of motor behavior is stereotyped.12 Patient’s complaints of
episodic brief movements of the extremities—usually daytime sleepiness or symptoms of sleep apnea or peri-
the legs—throughout the early stages of sleep. Move- odic limb movements should trigger additional investi-
ments last from 0.5 to 3 seconds and reoccur in a peri- gation with a polysomnogram. The sleep study should
odic pattern every 20 to 40 seconds. The patient is un- be done with extended EEG with the goal of identify-
aware of the movements and the bed partner might ing usual EEG activity as well as sleep apnea and
report disturbed sleep because of the periodic move- PLMS, which may trigger a parasomnia. If there is a
ments. PLMS may be associated with Restless Leg high suspicion for seizures, video-EEG monitoring
Syndrome, iron deficiency anemia, renal disease, neu- would be the preferred diagnostic procedure.

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TREATMENT REFERENCES
In all forms of parasomnia, attention to sleep hygiene is 1. Ohayon MM, Guilleminault C, Priest RG. Night terrors, sleep-
walking and confusional arousals in the general population:
the basis for treatment. Sleep deprivation, irregular their frequency and relationship to other sleep and mental
sleep hours, caffeine, nicotine, and alcohol lead to dis- disorders. J Clin Psychiatry. 1999;60(4):268-276.
turbed sleep and a greater likelihood of nocturnal 2. Schenck CH, Mahowald MW. Parasomnias. Postgraduate
Medicine. 2000;107(3):145-156.
arousals. Clonazepam is the drug of choice when the
3. Jones BE. Basic mechanisms of sleep-wake states. In
episodes are frequent and dangerous for the patient or Kryger MH, Roth T, Dement WC, eds. Principles and prac-
those in the vicinity. Other benzodiazepines such as tice of sleep medicine. 3rd ed. Philadelphia: WB Saunders;
temazepam, diazepam and alprazolam have also been 2000:134-154.
4. Brooks S, Kushida CA. Behavioral parasomnias. Curr
utilized. Tricyclic antidepressants, trazodone, and anti- Psychiatry Rep. 2002;4(5):363-368.
convulsants are used in the unlikely event that the para- 5. Schenck CH, Mahowald MW. Long-term, nightly benzodi-
somnia does not respond to a benzodiazepine. Lack of azepine treatment of injurious parasomnias and other disor-
ders of disrupted nocturnal sleep in 170 adults. Am J Med.
response to a benzodiazepine requires a re-examination 1996;100(3):333-337.
of the diagnosis. 6. Frank NC, Spirito A, Stark L, Owens-Stively J. The use of
scheduled awakenings to eliminate childhood sleepwalking.
SUMMARY J Ped Psychol. 1997;22(3):345-353.
7. Schenck CH, Bundlie SR, Mahowald MW. Human REM
Parasomnias are common in the benign forms such as sleep chronic behavior disorders: a new category of para-
sleepwalking and sleep talking. The more dramatic somnia. Sleep Research. 14:208,1985.
forms such as sleep terrors and confusional awakenings 8. Mahowald MW, Schenck CH. REM sleep parasomnias.
Neurologic Clinics. 1996;14(4): 697-720.
occur frequently in childhood, but attenuate in the teen 9. Schenck CH, Bundlie SR, Mahowald MW. Delayed emer-
years. REM behavior disorder, seen in the elderly, is an gence of a Parkinsonian disorder in 38% of 29 older men ini-
uncommon entity. Generally diagnosis is based upon tially diagnosed with idiopathic rapid eye movement sleep
behavior disorder. Neurology. 1996;46:388-393.
clinical history with sleep studies reserved for unusual 10. Hauri PJ, Friedman M, Ravaris CL. Sleep in patients with
presentation. The focus of treatment is attention to spontaneous panic attacks. Sleep. 1989;12(4):323-337.
sleep hygiene with medication(s) reserved for more se- 11. Scheffer IE, Bhatia KP, Lopes-Cendes I. Autosomal domi-
nant frontal epilepsy misdiagnosed as sleep disorder.
vere and repetitive cases.
Lancet. 1994;343:515-517.
12. Chesson AL, et al. An American Sleep Disorders Association
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procedures. Sleep. 1997;20(6):423-487.

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