Parasomnia refers to a cluster of disorders that revolve around disruption to the natural sleep cycle. Once considered a variation of psychopathology, parasomnias are now considered a physical response to the transition from being awake through the various sleep cycles.
The term parasomnia actually is an umbrella term that covers a number of known sleep disorders. Some of the most common conditions are sleep-paralysis, sleep walking (somnambulism), night terrors, sleep eating, enuresis (bedwetting), and REM sleep behavior disorder.
Generally, sleep disorders are more likely to affect children. Sleep eating affects roughly 1-5% of American adults and is twice as likely to affect women as men. REM sleep behavior disorder is most frequently observed in older adults.
There are three categories of parasomnias, Non REM (NREM) sleep disorders, REM sleep disorders and other sleep disorders that are not linked to the sleep cycle.
Confusional arousals are characterized by a complete disorientation when the patient is awakened. This confusion can occur when the patient is aroused suddenly by a loud noise or physical change. He or she often will seem to be awake but speaks nonsensically, has no idea of location or time, etc. The patient often does not remember the event.
Night terrors manifest themselves with the patient suddenly screaming or moving violently in bed. They can be brought on by a nightmare, but do not have to be. The patient’s heart rate will be elevated and their eyes will be open. They may kick or bite and often will shout unintelligible words. They may not remember this event. These events often affect bed partners or parents more than the patient.
Sleep walking (somnambulism) is a condition where the patient gets out of bed without regaining sentiency. The patient will often leave the bedroom and walk around the house. He or she may also go outside. The dangers of sleep walking are more physical than many other parasomnias as the patient could fall down stairs, injure themselves, walk to an unsafe location or get lost. It is not uncommon for a patient with somnambulism to wake up in a strange place, to have moved furniture around in the house or to have urinated in an inappropriate place. While sleepwalking, the patient’s eyes will be open and he or she will seem to be awake.
Sleep paralysis occurs when the patient awakens but has several seconds or minutes of being unable to move or speak. It can also happen as the patient is falling asleep. This condition can often be accompanied by hallucinations. While this disorder can be very frightening for the patient, particularly if hallucinations are present, episodes typically are short-lived and end when someone speaks to or touches the patient.
Nightmare disorder is characterized by frequent intense nightmares. While everyone suffers the occasional bad dream, nightmare disorder is diagnosed by order of magnitude. When the nightmares occur with such frequency that the patient is suffering from chronic sleeplessness and a fear of going to sleep, then referral to a sleep specialist may be in order.
REM sleep behavior disorder – of all the parasomnias, this one may be the most dangerous. REM sleep behavior disorder manifests itself by the patient acting out particularly vivid and violent dreams. The patient’s eyes are not open and he or she is not awake, but may kick, slap or punch in response to the images from the dream he or she is having. Episodes of this disorder tend to escalate and grow more frequent, and the patient can represent a danger to himself or to his partner.
The patient typically does not leave the bed as part of the event, but may fall out of the bed as a result of the physical activity corresponding to the dream. Treatment by a sleep specialist is vital in controlling REM sleep behavior disorder as medication may be required. This disorder is also one of the only parasomnias that has a late adult onset, typically presenting itself in the late 50s or early 60s.
Bedwetting (enuresis) is generally not a serious condition. While it can be an indicator of very serious health conditions like diabetes or congestive heart failure, typically this disorder impacts young children that have not yet developed the muscle to prevent bladder contraction or sleep so deeply that they sleep through a full bladder emptying itself.
Exploding head syndrome can be a frightening condition, but it’s not actually dangerous. Symptomatic of this condition is the sensation of a very loud noise – a gun shot, firework exploding, or crashing of cymbals, usually as the patient is falling asleep. The patient can be fearful that he or she is having a stroke or heart attack or some other life threatening event. Getting more rest is essential to addressing this syndrome as that reduces the number of overall incidences for the patient.
Sleep talking disorder manifests itself with the patient talking loudly while he or she is asleep. Unless it is linked to another, more dangerous condition or is impactful on the patient’s quality of sleep, treatment is not necessary. The actual content of the speech is usually unintelligible or unrelated to a dream or situation in the patient’s life.
Sleep eating disorder is not, in and of itself, a dangerous condition. However, the consequences of this disorder can be very dangerous as this condition leads to binge eating and substantial weight gain. There is also a risk that the patient could consume something dangerous or toxic. Patients rarely have any memory of these episodes. Sleep eating disorder can be caused by certain prescribed medications, particularly sedatives such as zolpidem (Ambien) or eszopiclone (Lunesta).
Sleep related groaning (catathrenia) is also not a dangerous condition and is generally more of a disruption to the sleep pattern of the patient’s bed partner. The disorder is exactly what it sounds like – it would be with the patient drawing in a deep breath and then exhaling a long groan that can last anywhere from 15 to 40 seconds.
Parasomnia often runs in families, which would seem to indicate a genetic component. This is particularly true for parasomnias that manifest themselves in childhood and are later outgrown. Parasomnia may also be caused by poor sleep habits such as not getting enough sleep, not maintaining a regular sleep routine, sleeping with the television on or eating right before beginning the sleep cycle. Sleep disorders can also be part of a package of conditions. For example, parasomnia is often a consequence of post-traumatic stress disorder or the onset of Parkinson’s.
There are certain medications that have been shown to cause sleep disorders. Medications such as corticosteroids, statins and beta-blockers can cause sleeplessness. Ironically, some medicines intended to act as sleeping aids, such as zolpidem (Ambien) or eszopiclone (Lunesta), have been linked to sleep walking and sleep eating as well as other parasomnias.
Some antibiotics and antidepressants have been shown to cause night terrors and sleep talking. Medications for diseases like Parkinson’s, such as levodopa, have also been proven to cause very bad dreams and can lead to REM sleep behavior disorder. Counterintuitively, levodopa is also occasionally prescribed as a treatment for night terrors and sleep talking, depending on how the patient responds to other medications.
The first line of treatment for sleep disorders is managing the patient’s sleep hygiene. Maintaining a regular sleep schedule is critical, as well as getting enough sleep. Avoiding electronic devices, television and other stimulating activity before bedtime is recommended as well. Beyond that, if the patient can reduce stress and adjust their diet to avoid caffeine and other stimulants near to bedtime, parasomnia events can be largely eradicated. Putting these regimen in place can be most effective in treating parasomnia disorders in most patients.
It is also very important to make the environment as safe as possible for patients suffering from sleep walking or sleep eating disorders, as their mobility in the night can represent real dangers to the patient and their families. This would include removing sharp objects from proximity to the bed, making sure doors to the outside are locked, perhaps blocking staircases in the evenings and adding an alarm system to warn families if the patient attempts to exit the house.
In situations where the patient’s sleep disorder may lead to injury to the patient or to others, or the symptoms are so severe that improving sleep regimens are not effective, particularly if those events seem to be escalating, a sleep study may be required. Sleep studies generally involve a patient checking into a sleep study center where he or she is monitored overnight.
The actual study may involve monitoring the patient’s breathing, particularly to check for sleep apnea. Sleep apnea is not considered a parasomnia, but is often related to the presence of another condition. Electrocardiogram and encephalograms may also be conducted to provide a fuller picture of the presence and severity of the condition affecting the patient. The results of that study may then lead to a course of treatment involving drug therapy of some sort. Psychotherapy and support groups may also prove helpful in reducing the frequency of sleep disorder events.
In terms of medical intervention for treatment of parasomnia disorders, there are a few medications that are prescribed. Clonazepam and imipramine can be used for arousal disorders like sleep walking and sleep eating as they depress locomotor activity. These medications have been found to work safely, but patients often find their symptoms come back as soon as the course of treatment has been completed. Melatonin can also be described to address general effects of sleeplessness and to increase the quality and depth of sleep, which has been shown to help with the family of parasomnia disorders linked to dreaming, confusion, disorientation and nightmares.
Generally, prevention of sleep disorders follows the same lines of treatment of most parasomnias. The best prevention is good sleeping habits. These habits would include going to bed at roughly the same time every evening and waking up at the same time every morning, getting at least eight hours of sleep on a regular basis, avoiding stimulants prior to bedtime such as television, computers and other electronic devices.
Diet can also play a role in sleep disruption and so controlling caffeine and sugar intake, as well as spicy food, particularly close to bedtime is important. Where children are affected, parents need to ensure that the child’s room is safe and that there are no dangerous or overstimulating objects in the room.