Introduction[1]

Parasomnias may be defined as undesirable disorders of behaviour or experience that occur during sleep or its specific stages, or during sleep-wake transitions. Common behavioural problems include unwelcome verbal outbursts or movements.
•Primary parasomnias arise without an underlying physical cause and may be classified by the stage of sleep in which they occur, as rapid eye movement (REM), non-REM (NREM) or miscellaneous (no specific stage affected). They are also classified diagnostically on the basis of their characteristic presentation.
•Secondary parasomnias are disorders caused by accompanying physical/psychiatric disturbance leading to sleep-related symptoms, eg seizures, cardiac dysrhythmia or dysfunction, respiratory dysfunction and gastro-oesophageal reflux.
•Dyssomnias such as insomnia, in contrast, are disorders of the initiation, timing, quality, maintenance or phasing of sleep and are not usually associated with aberrant behaviour or experiences.
•Night terrors and sleepwalking are sometimes called arousal parasomnias.
•Sleep disorders are being reported more often as they become more recognised and deemed as suitable conditions for treatment by the medical profession.[2]
•Two disorders recently described are somnambulistic sexual behaviour, or sexsomnia and sleep-related eating disorder.
•A Turkish survey of pre-adolescent school-aged children found a 14.4% prevalence of parasomnias. About 1 in 6 children had at least one parasomnia. Bruxism (grinding of teeth), nocturnal enuresis (considered by some to be a parasomnia) and night terrors were the most common types.[3]

Risk factors

One study found that arousal parasomnias were associated with sleep apnoea, alcohol intake at bedtime, mental disorders, shiftwork, excessive need for sleep, and stress.[4]

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Nightmare disorder[1]

This is synonymous with dream-anxiety attacks. Bad dreams/nightmares occur in REM sleep, with associated severe anxiety and symptoms of increased sympathetic outflow. There is complete alertness and recall of dreams on waking.The presence and recollection of the dream is what helps to differentiate this condition from night terrors. Sufferers may have experienced previous trauma that is relived. This presentation is a major symptom of post-traumatic stress disorder.

Epidemiology

Prevalence in children aged 3-5 years is estimated at 10-50% with an unknown adult prevalence. Up to 50% of adults report occasional nightmares.

Prognosis

Most children outgrow nightmare disorder but a small proportion may suffer into adulthood, with improvement in later life.

Night terrors[5]

This is synonymous with sleep terror disorder. The condition occurs with increased frequency in some families, suggesting a genetic predisposition. Disordered arousal occurs during NREM sleep, causing extreme panic and loud screams/movement. A sudden arousal from non-dreaming sleep occurs, usually about 90 minutes or so after falling asleep. There is often an accompanying scream or shout. There may be symptoms of increased sympathetic outflow. Initially, the patient may be unresponsive and tends to be confused, disorientated and unable to recall what has caused them to wake up. There may be nonsense or indistinct speech and bed-wetting. The sufferer may hit/throw objects or leave the bedroom. There is little or no subsequent recall of events.

Epidemiology

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) estimates prevalence at 1-6% in children, although recurrent episodes are less common. Adult prevalence is estimated at 65 years.[1][10]

For further details of presentation, associated diseases, management and prognosis, see the separate article Restless Legs Syndrome.

Assess family history of similar problems, recent changes in drug regimen or new over-the-counter/complementary preparations, drug or alcohol misuse, recent life events, nocturnal urinary function or any concerns/worries that may be pressing on the patient, such as debt, relationship difficulties or psychiatric disturbance. A review of prescribed or non-prescribed medicines that the patient is taking may give clues as to the type of disorder in question, or any pharmacological factors that are provoking or worsening parasomnia.

Signs

There are no specific physical signs of any of these conditions. Mental state examination should be predominantly normal. Significant abnormalities in mental state suggest a psychiatric condition causing a secondary parasomnia. REM sleep behaviour disorder patients (or their bed partners) may show signs of injury.

It is important to carry out a full screening physical examination in order to detect any other underlying disease that may be disturbing sleep and causing a secondary parasomnia, or precipitating RLS, eg signs of neuropathy/spinal cord disease.

Differential diagnosis[1]
•Generalised anxiety disorder.
•Panic disorder.
•Obstructive sleep apnoea.
•Post-traumatic stress disorder.
•Undiagnosed or decompensated physical illness, eg heart failure leading to paroxysmal nocturnal dyspnoea, neuropathy/myelopathy causing restless legs.
•Undiagnosed/relapsing psychiatric illness.
•Epileptiform disorders, especially temporal lobe epilepsy.
•Fugue states.
•Hypnagogic or hypnopompic phenomena (abnormal experiences associated with falling asleep or waking up).
•Alcohol or other drug misuse/withdrawal.

Investigations[1]

No specific investigations are needed unless there is reason to suspect an underlying physical condition causing a secondary parasomnia. In such cases, the following may be helpful:
•Electroencephalograph (EEG)/CT/MRI scanning for temporal lobe epilepsy.
•CXR/echocardiography for suspected heart failure.
•Investigations/referral for suspected obstructive sleep apnoea.
•In those with RLS/PLMD, an FBC to exclude iron deficiency anaemia is worthwhile.
•In older patients with RLS/PLMD, or new-onset REM sleep behaviour disorder, screening tests such as U&E, LFTs and TFTs and others may be considered useful to exclude physical diseases common in this age group.
•Patients with atypical or confusing presentations may benefit from referral to a sleep clinic for polysomnography to reach a definitive diagnosis.
•PLMD has a characteristic EMG pattern if recorded during sleep episodes.

Associated diseases[1]

REM sleep behaviour disorder has been associated with Lewy-body and other dementias, Parkinson’s disease,[11] subarachnoid haemorrhage, ischaemic cerebrovascular disease, olivopontocerebellar degeneration, multiple sclerosis and brain stem neoplasms.[1] A recent association with narcolepsy has also been discovered.[8]

There appears to be an association between parasomnias in early life and the later development of vitiligo. This is thought to be related to an abnormality of the serotoninergic neural system.[12]

There is an association between night terrors and sleepwalking and families with a predisposition for one condition also have an increased incidence of the other. There is also a link between both conditions and nocturnal frontal lobe epilepsy.[5]

Night terrors in children are not associated with psychopathology but in adults they can be associated with post-traumatic stress disorder and generalised anxiety . Dependent, schizoid and borderline personality disorders are also more prevalent.

For all parasomnias, medication side-effects, toxicity or withdrawal due to prescribed or non-prescribed medication should always be borne in mind.

Management[1]
•Most parasomnias require no definitive treatment other than explanation, reassurance of the sufferer and their family/bed partner and an offer to follow things up.
•Information leaflets (see Internet and further reading section, below) are a relatively easy and effective way of achieving this.
•Once parents of children with terror disorder have been appropriately informed and reassured, the vast majority can cope with the condition and it will usually resolve. Keeping a sleep diary may help to identify trigger factors.[5]
•Most night terrors resolve with time and without treatment. Treatment of comorbidities such as sleep breathing disorders may be helpful. Promoting a regular sleep pattern in a stable environment is important.There is little evidence that sedative medication is helpful in the long-term management of children with night terrors and other sleep disorders. Tricyclics are occasionally used for severe symptoms or where the condition affects daytime performance (eg at school).[5]
•Patients with underlying physical or psychiatric disease may benefit from adjustment of their treatment or specialist input to help ameliorate sleep-related symptoms.
•REM sleep behaviour disorder is usually treated with nocturnal benzodiazepines such as clonazepam and tricyclic antidepressants, where there is some evidence for their efficacy.[8]
•The successful treatment of sexsomnia with selective serotonin reuptake inhibitors (SSRIs) has been reported.[7]
•Levodopa/carbidopa, gabapentin and clonidine are sometimes used but there is little systematic evidence of benefit. Management in the context of dementia/Parkinson’s disease can be difficult and may require expert elderly medicine/psychogeriatric input.

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Complications[1]
•Accidental injury.
•Overeating during sleepwalking, leading to obesity.
•Relationship difficulties.
•Forensic consequences of behaviour during sleepwalking, particularly if the patient ventures into the outside world or displays sexual behaviour.

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Prevention[1]

Sufferers should avoid precipitants, particularly medications, caffeine, alcohol or sedatives, especially at night. One study suggested that an increase in sleep disorders was more prevalent in children who shared a bed, or a bedroom. Precautions against physical and potential legal consequences of disturbed nocturnal behaviour should be considered.

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