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HowtoapproachParasomniainadult

Dr.Yotin Chinvarun M.D.Ph.D.

CEPandSleepdisorderprogramPMKhospital

Introduction:Normalsleepcycle

• Sleepconsists oftwostrikinglydifferent states:• Rapideyemovementsleep(REM)• Non-rapideyemovementsleep(NREM),alternateincyclicalfashion

• Sleepbeginswitha“shallow”Stage1ofNREMand“deepens”toNREMStages2,3,and4,followed byfirstbriefepisodeofREM~90minutes

• Afterthefirstsleepcycle,NREMandREMsleepcontinue alternatingincyclicalfashion, durationofeachcycle~90minutes

• Stages3and4ofNREMsleeppredominateduring firstthird ofthenight.• REMsleepepisodesbecomelonger,• LongestREMperiodsfoundinlastthirdofthenight

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Introduction: Parasomnia

• Parasomnias,definedundesirablebehavioral,physiological,orexperientialeventsthataccompanysleep

• Commoningeneralpopulation

• OccurmorefrequentlyinchildrenthaninadultswithexceptionofREMsleepbehaviordisorder(RBD),morecommoninmenover50

Introduction: Parasomnia

• Parasomniascanarisefromanystateofsleep(REMandNREM)aswellassleep-waketransitions

• Classifiedintodistinctsyndromeson thisbasis

• Disordersofarousal,forexample,mostprevalentoftheNREMparasomnias• Typically,disorders ofarousaloccur duringfirstthird ofthenight,during deepsleepismostabundant

• REMsleepparasomniasmorelikelytoemergeduringlaterportionofsleepperiod,whenREMsleepabundant

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Parasomnia

• NREM– related• Sleepwalking/talking• Sleepterrors• Rhythmic movementdisorder

• REM• REMbehaviordisorder• Nightmaredisorder

• Other• Sleep-relateddissociative disorders e.gSleepbingeeating,Sleepenuresis, sexsomnia• Headbanging• SleepGroaning

NREMParasomnias

• Youngadults• +vehistoryofchildhood sleepwalking• Re-emergenceinadulthood

• Psychologicalorphysicaltrauma• Sleeprestriction• Sleephistory

• First1– 1.5hours• Difficult toarouse• Poor, ornodreamrecall

• Specialcases• Complex dissociativebehaviors

• Sleepsex,sleepeating

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DifferentialDiagnosisofParasomnias

• Nocturnalepilepsy• Nocturnal FrontalLobeEpilepsy• TemporalLobeEpilepsy/Complex Partial

• Seizures• Severesleepapnea• Malingering

Sleepterrors Sleepwalking Nightmares REM-SleepBehaviorDisorder

SleepStage UsuallyIII, IV III, IV REM REM

Mostlikelytimeofnight Firstthirdofsleepperiod

Firstthirdofsleepperiod

Finalthirdofsleepperiod

Finalthirdofsleepperiod

Agegroup Children Children 20-40%ofchildren Oldermen

Familyhistory Yes Yes No No

Violence Ifattempt toarousesleeper

Possible,e.g.homicidalsomnambulism

Possible

Amnesiaforevent Yes Yes No No

Confusion Yes Yes No No

Mayprogresstosleepwalking

Yes No

Terminatedby Returningtosleep Returningtobed/sleep

Usuallyawaken thesleeper

Parasomnias and sleep stages

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Confusional arousal

• Subjectawakenpartiallyexhibiting markedconfusion, slowmentation, disorientation andperceptual impairment, erroroflogic

• Commoninchildren <5yrs

• Prevalenceinthe15to24-year-oldpopulation 6%,ageof65is1%

• Resultfrompartial orincomplete arousalfromdeepsleep,typicallyduringfirstthird ofthenight

• Typicallylastfrom1- 10minutes, andarefollowed byretrogradeamnesiafortheevent

• Precipitating factorsi.e.fever,CNSdepressants, recoveryfromsleepdeprivation

Confusional arousal

• Pathophysiology• Incompleteawakening fromsleep, leading toprolongationofnormalperiodofsleepinertia

• DDx• Sleepwalking• Sleep terrors• RBD• Nocturnalseizures

• Treatment:• Benignandrequirenotreatment• Interruptionmaylead toincreasedagitationandpossibleinjury

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Sleepwalking(somnambulism)

• Seriesofcomplex behaviorsthatareinitiated duringslow-wavesleepandresults inwalkingduring sleepArousal fromdeepsleep(1st third)

• Without awakening:exhibition ofwiderange,complex autonomicbehaviors

• Typically,sitsupinbedduringfirstthird ofthenight,looksaroundwithablankstare,andexhibitssomerepetitive motor automatisms,suchaspickingatclothes orlinens, getsupandwalksaroundthebedroom, entersother rooms,andmayevenleavethehouse

• Maycauseinjury

• Duration 1-5minutes, >1hr whenbehaviorsaremorecomplex

Sleepwalking(somnambulism)

• Sleepwalkingepisodes typicallylastlessthan15minutes;• Episodeslastingmorethanonehourhavebeenreported

• Attemptstoawakenasleepwalkerusuallyfailtoproducearousalandmayleadtoaggressiveandviolentresponses• Casesofsleepwalkingviolence, including homicidal somnambulism, havebeendescribed

• 40percent ofchildren experience atleastonesleepwalkingepisodeduring childhood• 2- 3percentofchildrensleepwalkmorethanoncepermonth.• 2- 3percentofadultsingeneralpopulationsleepwalk

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Sleepwalking

• Hybridattack:sleepterror precedesandevolvesintosleepwalking

• Uponawakeningpatientmayexhibit mentalconfusionandamnesia

• Mostcommoninchildren 4-5yrs,associatedwith strongfamilyhistory

Sleepwalking

• Precipitatingfactors• Sleepdeprivation, stress,pain,OSA,distendedbladder• Alcohol– SWSinc--- Incsleepwalking

• DDX• RBD• Confusionalarousal• Sleeprelatedseizureswithambulatoryautomatisms

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Sleepwalking

• Treatment• Safety• Avoidprecipitatingfactors• Medication

• Benzodiazepines

Sleepterror(Parvor nocturnus,incubusattacks)

• Suddenarousalsfromdeepsleep

• Scream/terror/confusion

• Extremeautonomicarousal

• Variablemotoractivity• Includeextremeagitation/escapebehavior• Mayresultininjuryduringtheepisode

• Clinical• Patientwakesup,sits,emits,screaminastateofterror,difficultiesbreathing,palpitationsandamnesia

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Sleepterror(Parvor nocturnus,incubusattacks)

• Prevalence3%ofchildren, 1%ofadults,Male>Female

• DDX• Nightmare(REMsleep)• Nocturnal seizures(frontallobeepilepsy)

• Treatment• Oftenunnecessaryifepisodesarerare• DZP,Clonazepam, TCA• Psychotherapy,stressreduction, hypnosis

Sleep-relatedeatingdisorder(SRED)

• Featuresofparasomnia (sleepwalking,partialarousals)combinedwithcharacteristicsofbingeeatingdisorder

• Duringtheseepisodes,individualsconfused,notfullyawake,anddisplayvariabilityindegreeofawarenessoftheirbehavior

• Accuraterecollectionofeventisabsent,andindividualsreport“half-asleep.”

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Sleep-relatedeatingdisorder(SRED)

• SREDfrequentlyhavepriorhistoriesofsleepwalkingwithlateronsetofeatingatnight

• Sleep-relatedeatingdisorderdifferentiatedfromconditionnighteatingsyndrome• Individualswithnighteatingsyndromeconsumemealsduringnighthours whilebeingfullyawake

• PrevalenceofSREDestimated1- 5%inadultpopulation,womenaffected2to4timesmorefrequently thanmen

Sleep-relatedeatingdisorder(SRED)

• Treatmentofsleep-relatedeatingdisorder

• Mitigatingprecipitatingsleepdisorders,suchas• Obstructivesleepapneasyndrome,periodic limbmovementdisorder, orrestlesslegssyndrome

• Combinationsofdopaminergicagents,opiates,andtrazodone,aswellastopiramate havebeenusedwithsomesuccess

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Sexsomnia

• Patientsexhibitingcomplexsexualbehaviorsduringsleep

• itisunclearwhethersexsomnia isdistinctparasomniaoravariantofsleepwalking

• Somefeaturesofthisparasomniadistinctfromsleepwalking:• Behaviorsinvolvesexualpartners, individuals exhibitsexualarousal, andmoreprominentautonomic activation, andsomeformofdreammentationispresent

REMSleepParasomnia

• REM-SLEEPBEHAVIORDISORDER

• NIGHTMARES

• HYPNOGOGIC/HYPNOPOMPIC HALLUCINATIONS

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REMBehaviorDisorder

• REM-sleepbehaviordisorder (RBD)isbeststudied REMsleepparasomnia

• Prevalenceofviolentbehaviorassociatedwith RBDis0.5percentinthegeneral

• REMsleepbehaviordisorder morecommoninelderly• Ageofonsetistypicallybetween50- 60yearsold

• Menaffectedmorefrequentlythanwomen,manyindividualstheremaybeasubclinicalprodromalstate

• Mechanismresponsible fornormalskeletalmuscleatonia isnot functioning properly andindividuals actout theirdreams• Lesions andmalfunctions inbrainstemarebelievedtoberesponsibleforthelackofskeletalmuscleatonia during

REMsleep

REMBehaviorDisorder

• Injurious ordisruptive behaviour duringsleep

• Easilyaroused;Dreamrecallprominent

• Two-thirds ofpatients developParkinson’s disease• Meanlatencyof13years;associatedwithsynucleinopathies (PD,LBD,MSA)

• Polysomnographydiagnosticallyhelpful

• HighlyresponsivetoClonazepam

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RBDinParkinson’sdisease

• RBDmaybeheralding manifestationofPDbymanyyears

• RBDoccur 15-50%ofpatient withPD

REMSleepbehaviordisorder

• Characterized bycomplexvigorousmotor activitiesandinjurious behaviorsrepresentingattemptsofvivid,action filledviolentdreams

• Occuratleast90minutes aftersleeponsetandpredominantly inthe2nd halfofthenight

• Riskforinjury-self andbedpartner

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REMSleepbehaviordisorder

• Widerangeofbehaviors• Verbalizations• Singing• Yelling, shouting, screaming• Walking,running• Punching, kicking,jumping• Violent/agitatedbehaviors

REMSleepbehaviordisorder

• Clinical feature(OlsonEJetalBrain2000)• 93cases,M87%:F13%• Meanageofonset61yrs• Meanageofdiagnosis64yrs• Injuriestoself/bedpartner 32%/16%

• Diagnosis:• suspectedclinically, confirmed byPSG

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AcutereversibleRBD

• AcuteRBDmostcommonlyassociatedwith• Withdrawalfromalcohol,benzodiazepines,andbarbiturates,

• Administrationofsomepsychiatricmedications• Tricyclic antidepressants• Selectiveserotonin reuptakeinhibitors• Cholinergic agents• Monoamineoxidaseinhibitors

• BehaviorsinindividualswithacuteRBDincludelimbandbody jerking,kickingthebed,shouting,andstrikingbedpartners

REMBehaviorDisorder

NORMALREM

REMBehaviorDisorder

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REMBehaviorDisorder

Arms

Legs

REMSleepbehaviordisorder

• DDX• Sleepwalking• Sleepterrors• Nocturnal seizures• Sleeptalking• PLM

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REMSleepbehaviordisorder

• Treatment• AvoidpotentialaggravatedRx

• SSRI,Selegiline, Clomipramine, Anticholinergic ,TCA,MAOIs• PrescribedClonazepam0.25-1mghs (90%effective)• BupropionshouldbetheantidepressantofchoiceinpatientswithRBD,• Melatonin• Levodopa,dopamineagonists• AEDs

Nightmares

• Frighteningdreams ordisturbingmentalexperiences,usuallyawakensleeperfromREMsleep

• Dreamcontentmostfrequentlyinvolvesimminentdanger;attacksorpursuitarecommonthemes

• Fearand/oranxietymostfrequentemotionsassociatedwithnightmares;sadness,anger,anddysphoriaalsofrequently reported

• Nightmaresnotassociatedwithconfusionordisorientation

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Nightmares

• Moreprevalentinchildhood;• Prevalenceinchildren is20to40percent• 5to30percent ofchildren report havingoftennightmares“oftenoralways.”• Inadults, prevalencehavingoneormorenightmarespermonthrangesfrom8to30percent

• Multipleclassesofdrugsmaytriggernightmares

• WithdrawalfromREM-suppressingmedications,suchas• Selectiveserotonin reuptakeinhibitors, tricyclic antidepressants, hypnotics, andalcohol, betablockersanddopaminergic agonistsmayprecipitate nightmaresorincreasetheseverityofnightmares

Nightmares

• Treatmentincludes• Psychotherapy,• Minimizingoravoidingstress,• Minimizingtheuseofdrugsthatmayprecipitate nightmares

• Inindividuals withpoor sleephygiene,instituting aregular sleep-wakepattern

• Pharmacotherapy• Cyproheptadine 4to16mg• Prazosin5to10mghelpful inRxnightmares

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Hypnogogic andhypnopompichallucinations

• Hypnogogicandhypnopompichallucinationsarevividperceptualexperiences

• Occurringattheonset(hypnogogic)ofsleeporuponawakening(hypnopompic)

• ThoughttoresultfromintrusionofREMsleepprocessintothewakingstate.

• Hallucinationsmostfrequentlyvisual,butcanbeauditory,tactile,orcenesthopathic (abnormalsensations)

Hypnogogic andhypnopompichallucinations

• Visualhallucinationsrangefrompoorly formedshadows,shapes,orcolorstowellformedcompleximages

• Individualsreport seeingcircles,shadows,faces,persons,andanimalsintheroom

• Imagesmaybeconstantorchanginginsize,blackandwhite,or incolor

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Hypnogogic andhypnopompichallucinations

• Auditoryhallucinationsmayincludeindistinctsounds,threateningsentences,orcomplexmelodies

• Cenesthopathic hallucinations includechangesinbodypartlocationandextracorporealexperiences

• Hallucinationscanbepleasingorfrightening;eventuallyindividualslearnthatimagesnotrealanddisappearafterafewminutes

• Occasionally,individualswithhypnagogicorhypnopompichallucinationsmisdiagnosedashavingpsychoticdisorders

Somniliquy

• Speechduringsleep

• Notcomplex

• Notassociatedwith subjectiveawarenessoftalking

• Notsleepstagespecific

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Hypnicjerks

• Briefbodyjerksinisolation /succession• Exclusivelyduringsleeponset• Leg>arm&head• Sensorysymptoms:flashinglights, feelingoffalling,hypnagogichallucinations

• Etiology• Nicotine, caffeine,stress,exercise

Bruxism

• Prevalence5-10%

• Uncertainrelationshiptostress

• Associatedwithanysleepstage

• Consequenceprimarydentalpathology

• PSG• Phasicincreaseinmassetermuscletone,rhyhtmicEMGartifactsintheEEG,freq0.5-1.5HzoccurringinburstsatstageI,II,REM

• Treatment• Stressreduction,mouthguard,BZD

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PeriodicLimbMovementsofSleep

Insummary:ApproachtopatientswithParasomnia• Itisessentialtointerviewboththepatientandpatient’sbedpartner

• Becauseoftenpatientswith NREMparasomniamaybeunawareoftheir activitiesatnight

• Askaboutchildhood andfamilyhistoryofparasomnias

• Askabouttimeofnightwhensymptomsoccur andwhetherthepatient recallsassociateddreams

• Neurologic examisadvisable

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Insummary:ApproachtopatientswithParasomnia• Allpatientswithadultonsetparasomnias(NREMandREM)needtobereferredtosleepspecialistforanevaluation

• Theevaluationincludenocturnal polysomnographic study,andsleepspecialistwilldeterminewhetherpatientneedsMRIbrainorneurologicworkup

• Whenparasomniasleadtoinjuryorpsychologicaldistresstopatientorbedpartner,resultinlawbreaking,impairfunctioningdue toexcessivedaytimesleepiness,causeweightgain,referraltosleepspecialistforevaluationandtreatment

Insummary:Parasomnia

• Parasomniascommoningeneralpopulation

• ClinicalphenomenaariseasbraintransitionsbetweenREMsleep,NREMsleep,andwakefulness

• Parasomniascanbeaccuratelydiagnosedandeffectivelytreated

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Insummary:Parasomnia

• Certainparasomniasmaysignalonsetofseriousmedicaldisorders

• Inmostcases,adheringtogoodsleephygienemeasures,• Avoidingsleepdeprivation, treating primarysleepdisorders, reducing stress,andensuringpatientsafety

• Whenepisodesfrequent, causedistress, and/orimposedangertopatientortheir bedpartner• Effectivepharmacotherapeutic measures