PARASOMNIAS
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura Faculty of Medicine
Two major types of primary sleep disorders are
dyssomnias and parasomnias
• Primary sleep disorder is a malady of sleep that does not
appear to be secondary to a physical or mental illness and is
not substance-induced.
• Dyssomnias are characterized by insomnias and excessive
sleepiness (abnormal sleep quality, including initiation,
maintenance, duration, timing, and amount of sleep)
• parasomnias are distinguished by deviant behavioral and/or
physiologic events
• parasomnias manifest by activation of systems, such as the
autonomic nervous system, or programs, such as cognitive,
behavioral, or motor program stimulation
Parasomnias
Parasomnias are disorders characterized by
abnormal behavioral or physiological events
occurring in association with sleep, specific sleep
stages, or sleep-wake transitions.
parasomnias do not involve abnormalities of the
mechanisms generating sleep-wake states, nor of
the timing of sleep and wakefulness.
Individuals with parasomnias usually present with
complaints of unusual behavior during sleep rather
than complaints of insomnia or excessive daytime
sleepiness
Parasomnias
• Most of the symptoms are manifestations of
central nervous system activation, specifically
motor and autonomic discharge.
• All parasomnias are more common in males than
in females, and persons with one type of
parasomnia are more likely to manifest symptoms
of another.
• Children with sleep terrors usually sleepwalk
when they reach an older age. Positive family
histories of parasomnias are common.
Pathophysiology
• The concept that wakefullness ,NREM and REM sleep can
occur simultaneously or oscillate rapidly is the key to the
understanding of primary sleep parasomnias
• The mixture of wakefullness and NREM sleep would explain
confusional arousals
• THE tonic and phasic REM sleep can become dissociated
,intruding or persisting into wakefullness, explaining
cataplexy ,wakefull dreaming and persistence of motor
activity during REM sleep ( REM sleep behaviour disorder)
Pathogenesis
1- State dissociation (two state of being ovelap or
occur simultaneously )
2- Locomotor centers present in multiple sites in CNS
which represent motor activity that is dissociated from
waking consciosness .
3- Sleep inertia (sleep drunkness) is a period of
impaired performance and reduced vigilance followig
awakening from sleep episode or naps (gradual
disengagment from sleep to wakfullness ).
4- Sleep state instability( cyclic alternating pattern of
NREM sleep which correlte with arousal oscillations )
Types of parasomnias
Primary parasomnias (disorders of the
sleep state per se)
1- NREM sleep
Normal (exploding head syndrome ,exlosive tinnitus)
Abnormal(confusional arousals ,sleep walking ,sleep
terrors)
2- REM sleep
Normal (sleep paralysis,hypnagogic and hypnopompic
hallucinations)
Abnormal REM sleep behavior disorders ,REM
related painfull erections ,nightmares)
Types of parasomnias
Miscellaneous
Nocturnal catathrenia (groaning),bruxism,enuresis,rhthmic
movement disorder,sleep talking(somniloquy),myoclonus
Secondary parasomnias (diorders of other systems that
emerge during sleep )
1-CNS (hypnic headach ,tinnitus ,seizers)
2- Cardiopulmonary (arrhthmias,nocturnal angina
pectoris,nocturnal asthma ,respiratory dyskinesias
,coughing ,hiccup ,choking )
3-Gastrointestinal(GERD,esophageal spasm ,abnormal
swallowing )
4- Medications and substance abuse (Beta adrenergic
blocker,SSRI,TCA,cocaine)
5- Functional (nocturnal panic attacks, PTSD ,maligering )
Epidemiology
• The disorders of arousal are most common of
NREM sleep parasomnias ,commonly in children
,positive family history, febril illness ,sleep
deprivation and emotional stress.
• Numerous sleep disorders that result in arousals
(OSA ,PLMS,nocturnal seizures )can provoke
NREM sleep parasomnias .
• Sleep disordered breathing has been found to be
more prevalent in children and adults with disorders
of arousal ( sleep disorder within sleep
disorder).This explain common improvement of
disorders of arousal following treatment of OSA
NREM sleep parasonias
Disorders of arousals
• Abnormal arousal (motor activity is restored without
an accompanying full consciousness )
• Occur during NREM sleep stage N3
• Predisposing factors (febrile illness ,sleep derivation
irregular sleep wake schedules ,stress,alcohol
,distended bladder ,OSA ,PLMS, minor tranquilizers
,neuroleptics ,hypnotics ,stimulants)
Types of disorders of arousals
1-confusional arousals
2- sleepwalking
3-sleep terrors.
Confusional Arousals
• Episodes of confusion following spontaneous or
forced arousals from sleep, typically from NREM
stages N3
• Disorientation, confusion, (moving around in bed,
crying, or sleep talking), diminished vigilance and
blunted response to questions or external stimuli.
• Signs of fear or autonomic hyperactivity are minimal
or absent. last from several minutes to hours, with
most cases spontaneously resolving within 5 to 15
minutes and amnesia for the event.
Sleep walking (somnambulism)
• Sleepwalking, refers to ambulation that occurs
during sleep.
• Sleepwalking is associated with an altered state of
consciousness, diminished arousability, impaired
judgment and inappropriate behavior (eg, shouting
or climbing out of a window).
• The behavior can either be calm or agitated and
violent
• Each episode varies widely from several minutes to
over an hour
• sleepwalker’s eyes are usually open (described as
a blank stare), but attempts to communicate with
the sleepwalker are generally unsuccessful
Sleep Terrors
• Sleep terrors consist of abrupt awakenings with
profound fear usually from NREM stages N3.
• Sleep terrors suddenly bolt upright from their beds with
a loud cry, or scream, and in rare instances,
sleepwalking or running
• Associated clinical features include misperception of the
environment, confusion, amnesia for the episode,
autonomic and behavioral manifestations of intense fear
(tachycardia, elevated blood pressure, tachypnea,
dilated pupils, and profuse sweating), vocalizations, or
urinary incontinence
• Persons with sleep terrors then spontaneously calm
down and return rapidly to sleep.
REM sleep parasomnias
Rapid Eye Movement Sleep Behavior Disorder
• Abnormal behaviors develop during REM sleep and are
accompanied by loss of REM-related muscle atonia or
hypotonia.
• These dream-enacting behaviors can result in sleep disruption
or injury to the sleeper or bed partner.
• There is often no history of violent or aggressive behavior
during the day while awake.
• Range from simple motions to highly elaborate activities (eg,
screaming, punching, kicking, jumping, or running).
• Affected individuals appear to be “acting out their dreams.
dream content often involving defense of the sleeper against
attack.
• The eyes are usually closed, in contrast to the sleepwalker,
whose eyes are open during the episode.
Rapid Eye Movement Sleep Behavior Disorder
• Episodes end with a rapid awakening and full
alertness.
• Associated features include good dream recall
on awakening.
• Most forms of RBD are idiopathic (approximately 60%
of cases).
• RBD can also be associated with Parkinson disease,
dementia with Lewy bodies,and multiple system
atrophy. during withdrawal from alcohol or REM sleep
suppressants.
Clinical subtypes of rapid eye
movement sleep behavior disorder
• Subclinical RBD Polysomnographic features
consistent with RBD without clinical manifestations
of the disorder
• Parasomnia overlap syndrome Elements of
disorders of arousal (confusional arousals, sleep
terrors, and sleepwalking) and RBD are present.
• Status dissociatus Admixture of the different states
of wakefulness, NREM sleep, and REM
sleep.Abnormal sleep and dream-related behaviors
closely resembling RBD in the absence of identifi
able sleep stages during polysomnography.
Sleep-Related Painful Erections
• Painful penile erections occurring during REM sleep
can give rise to repetitive awakenings, and, in some
cases, insomnia and/or excessive daytime
sleepiness.
• Begin after the fourth decade of life and
progressively worsens with advancing age. It is not
associated with any physical abnormality, or any
penile disorder or pain during sexual erections while
awake.
• Sexual function while awake is generally normal
Nightmares
• Nightmares are frightening dreams, often involving
threats to life or security, that occur during REM
sleep and that commonly abruptly awaken the
sleeper from sleep.
• Once awakened, the person is fully alert and
profoundly fearful and anxious, can recall vividly the
preceding dream, and has difficulty returning to
sleep. Some minor autonomic activation, such as
tachycardia and tachypnea, is evident.
• Nightmares can be precipitated by illness, traumatic
experiences, acute alcohol ingestion,and
medications.
Differences between nightmares and sleep terrors
Characteristics
Nightmares
Time of night
Latter half of night First half of night
Sleep stage
REM sleep
NREM sleep
consciousness
Alert
Confused
Memory of episode Full recall
Subsequent
return to sleep
Delayed
Sleep terrors
Partial or complete amnesia
Rapid
Miscellaneous parasomnias
Sleep-Related Groaning (Catathrenia)
• Catathrenia consists of expiratory groaning during sleep.
• Episodes occur predominantly or exclusively during REM sleep.
• A rare condition that is more common among males. The
individual is asymptomatic with no evident distress and is
unaware of the events.
• Polysomnography demonstrate episodes of bradypnea
associated with loud expiratory groaning sounds that occur in
clusters recurring several times throughout the night mainly
during REM sleep. unusual movements or cardiac arrhythmias
are typically absent. Sleep architecture and oxygen saturation
remain normal.
Sleep Bruxism
– Sleep bruxism is characterized by repetitive grinding of the teeth,
caused by contractions of the masticatory muscles (eg, masseter and
temporalis) during sleep.
– Bruxism during sleep can give rise to arousals, unpleasant noises
that might disrupt the bed partner’s sleep or causing abnormal dental
damage
– chronic bruxism was present in 8% of adults
– can either be isolated and sustained, or repetitive (rhythmic
masticatory muscle activity [RMMA])
– The risk of developing bruxism is increased among smokers, restless
legs syndrome , stress, dental disease such as malocclusion or
mandibular malformation, caffeine, alcohol, primary sleep disorders
(eg, OSA or REM sleep behavior disorder), personality subtypes (eg,
vigilant and highly motivated), and medication use (eg, levodopa or
SSRIs).
Enuresis
– Recurrent involuntary bed-wetting occurring during sleep
after 5 years of age. It can arise throughout the night and
during any stage of sleep, although most tend to occur early
during sleep in the first third of the evening.
– Children with enuresis may report guilt about their problem
– Pathophysiology include failure to arouse in response to a
sensation of bladder fullness, impaired ability to transiently
delay bladder contraction when a need to void develops,
greater urine production during sleep in relation to agerelated nocturnal bladder capacity, or a maturational delay in
bladder development resulting in a smaller bladder capacity.
Enuresis
• Primary if recurrent sleep-related micturition occurring at
least twice a week persists in children older than 5 years of
age who have not been consistently dry during sleep
• Secondary (5-10%)if bed-wetting recurs at least twice a
week for at least 3 months after the child or adult has
maintained dryness for at least six consecutive months
• Increased production of urine due to the use of diuretics,
ingestion of caffeine, or impairment in the ability to
concentrate urine (eg, diabetes mellitus or diabetes
insipidus); urinary tract infection;pelvic abnormalities (eg,
anomalies of the bladder); psychosocial stressors (eg, birth
of a sibling); depression; OSA; congestive heart
failure;dementia; seizures; and chronic constipation.
Enuresis
• Nocturia involves frequent awakenings from sleep to urinate in
the bathroom. ( diuretic therapy, diabetes mellitus,diabetes
insipidus )
• Evaluation includes an extensive medical, neurologic, psychiatric,
and sleep history.
• polysomnography or EEG to rule out the presence of OSA or
seizure disorder, respectively.
• Spontaneous cure rate in children with primary sleep enuresis is
estimated at 15% annually.
• Treatment consists of pharmacotherapy (Desmopressin ,Tricyclic
antidepressants )or behavioral therapy( sleep hygiene). A
secondary cause of enuresis, if identified, should be addressed
and corrected.
• Sleep hygiene ( restricting fluid intake after dinner and voiding
prior to going to bed. Rewards for dry nights are preferable to
punishing the child for bedwetting).
Rhythmic Movement Disorder
• Head banging (jactatio capitis nocturna) repeatedly
lifting and banging the head back onto the bed,
head rolling (lateral movements of the head), body
rolling (side-to-side motions of the body), body
rocking (entire body is rocked while positioned on
hands and knees), leg rolling or banging.
• complications of head banging, in addition to sleeponset insomnia, include eye and cranial injuries,
such as fractures or soft tissue trauma.
• Often affects normal infants younger than 18
months of age. Typically self-limited; spontaneous
resolution before 4 years of age is characteristic.
Sleep Paralysis
Generalized transient inability to move the head,body,
and extremities,with sparing of the ocular and
respiratory muscles. unable to speak during these
episodes. It can occur either at sleep onset
(hypnagogic)or upon awakening (hypnopompic)
• Profound anxiety, and hallucinations (visual,
auditory, or tactile) may accompany these attacks,
but consciousness and recall are typically
unaffected.
• Paralysis spontaneously resolves after several
seconds to several minutes.
Sleep Paralysis
• The frequency of episodes ranges from once in a
lifetime to almost nightly
• Predisposing and precipitating factors include sleep
deprivation, irregular sleep patterns (eg, shift work),
a supine sleep position, use of anxiolytic agents,
and stress.
• Most cases are identified in an isolated form; others
occur in a familial form (autosomal dominant in
some cases) or in persons with narcolepsy.
• Isolated sleep paralysis occurs at least once in a
lifetime in 40% to 50% of normal individuals,
Sleep-Related Hallucinations
• Hallucinations can occur during sleep-wake
transitions, either at sleep onset (hypnagogic
hallucinations)or during awakening (hypnopompic
hallucinations).
• These hallucinatory experiences can take a variety
of forms, visual, auditory, or tactile phenomena, and
can last from several seconds to minutes. Sleep
paralysis may accompany the hallucinations.
• can be encountered in patients with narcolepsy or
in an isolated form in otherwise healthy individuals
in whom they occur more commonly during
adolescence or early adulthood.
Sleep-Related Hallucinations
• Prevalence decreases with aging. Women are
affected more frequently than men.
• Reported during administration of β-adrenergic
blocking agents and in patients with mood
disorders, Parkinson disease, substance or alcohol
use and sleep deprivation.
• Occurring predominantly during sleep-onset REM
periods, but episodes can also arise during NREM
sleep
Diaphragmatic flutter
• Diaphragmatic flutter is a rare disorder characterized by rapid
involuntary contractions of the diaphragm superimposed on
ordinary respiratory excursions
• High frequency bilateral oscillatory movements were observed in
chest and upper abdomen during both inspiration and expiration.
• Involuntary movements were not seen in hands and legs.
• Etiology of this disorder includes abnormal excitation of the
central nervous system including cerebrum and the brainstem,
direct irritation of the phrenic nerve and irritation of the diaphragm
itself. Since the psychosomatic status played a significant role in
the development of diaphragmatic flutter, this may be a disorder in
the behavioral control of breathing.
Palatal myoclonus
• Palatal myoclonus is a rapid spasm of the palatal
muscles, which results in clicking or popping in the
ear.
• Chronic clonus is often due to lesions of the central
tegmental tract .
• Uniquely, the clicking noise does not subside when
the patient sleeps.
Rapid Eye Movement Sleep-Related Sinus Arrest
• Cardiac rhythm disorder is characterized by sinus arrest
developing during REM sleep. Episodes often occur in
clusters, with periods of asystole lasting up to 9 seconds in
duration that usually recur frequently.
• It affects apparently healthy young adults without any
identifiable cardiac pathology.
• Episodes of nocturnal sinus arrest are not accompanied by
arousals, OSA or sleep disruption.
• Most patients are asymptomatic, although palpitations or
vague chest discomfort may occasionally be reported.
• Daytime ECG and angiography are usually unremarkable.
• Underlying pathophysiology involves abnormal vagal activity,
particularly during REM sleep.
Evaluation of PARASOMNIAS
• Diagnosis for most parasomnias is based on its
clinical presentation and seldom requires
polysomnographic documentation.
• Polysomnographic study is recommended for
possible parasomnias associated with very frequent
episodes, complaints of excessive sleepiness,
unusual presentation or significant sleep
disturbance, significant disruption of the bed
partner, an underlying seizure activity is suspected,
or in cases that have medicolegal implications.
• A single normal PSG does not exclude the
presence of parasomnias.
Evaluation of PARASOMNIAS
• Time-synchronized video recording (ie,simultaneous
video and sleep monitoring), performed over several
nights may be required.
• Additional EEG electrodes are required for patients in
whom a seizure disorder is being excluded.
• Evaluation of patients presenting with violent behavior
during sleep should be more comprehensive, and it
may include an extensive neurologic and psychiatric
assessment.