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PARASOMNIAS

By; TEMESGEN REGASA

TEMESGEN REGASA(SMS)

outline

• Definition• Classification• Discussion of important Parasomnias• Management

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Definition

• Parasomnias are abnormal experiences , movements, behaviors, emotions, perceptions, and dreams that occur during sleep

• not abnormalities of the processes responsible for sleep and awake states

• are disorders of arousal, partial arousal, and sleep-stage transition

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ICSD Classification of Parasomnias

• Non–Rapid Eye Movement Sleep Arousal Disorders Sleepwalking Sleep Terrors confusional arousals• Rapid Eye Movement Sleep Behavior Disorder REM Sleep Behavior Disorder (RBD) sleep-related groaning (catathrenia) Nightmare Disorder• Other parasomnias;

Sleep-Related Dissociative Disorder Sleep Enuresis Sleep-Related Eating Disorder (SRED) Parasomnias Related to Drug or Substance Use Sleep paralysis Sleep talking Sleep bruxism etc

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International Classification of Sleep Disorders (ICSD)A. Arousal Disorders B. Sleep-Wake Transition D/o 1. Confusional Arousals 1. Rhythmic movement D/o 2. Sleepwalking 2. Sleep Starts 3. Sleep Terrors 3. Sleep Talking 4. Nocturnal Leg Cramps C. Parasomnias Usually Associated with REM 1. Nightmares D. Other Parasomnias 2. Sleep Paralysis 1. Sleep Bruxism 3. Impaired Sleep-Related Penile Erections 2. Sleep Enuresis 4. Sleep-Related Painful Erections 3. Primary Snoring 5. REM Sleep-Related Sinus Arrest 4. Infant Sleep Apnea 6. REM Sleep Behavior Diso 5. Sleep-Related Abnormal Swallowing Syndrome 6.Nocturnal Paroxysmal Dystonia 7. Sudden Unexplained Nocturnal Death Syndrome 8. Congenital Central Hypoventilation Syndrome 9. Sudden Infant Death Syndrome 10. Benign Neonatal Sleep Myoclonus 11. Other Parasomnia NOS

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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,neuroleptics ,hypnotics ,stimulants)

Types of disorders of arousals 1-confusional arousals 2- sleepwalking 3-sleep terrors.

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Diagnostic CriteriaA. Recurrent episodes of incomplete awakening from sleep, usually occurring during the

first third of the major sleep episode, accompanied by either one of the following: 1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about.

While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.

2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

B. No or little (e.g., only a single visual scene) dream imagery is recalled.C. Amnesia for the episodes is present.D. The episodes cause clinically significant distress or impairment in social, occupational, or

other important areas of functioning.E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug

of abuse, a medication).F. Coexisting mental and medical disorders do not explain the episodes of sleepwalking or

sleep terrors.

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Sleep walking (somnambulism)• refers to ambulation that occurs during sleep.• associated with an altered LOC, ↓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 minutes to over an hour• eyes are usually open (described as a blank stare), but

attempts to communicate with the sleepwalker are generally unsuccessful

• Risk factors• Environmental; Sedative use, sleep deprivation, sleep-

wake schedule disruptions, fatigue, Fever and stress• Genetic; +ve family history in up to 80%

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Sleep Terrors• Recurrent abrupt awakenings with profound fear usually from

NREM stages III. • suddenly bolt upright from their beds with a loud cry, or

scream, and in rare instances, sleepwalking or running • Associated with misperception of the environment, confusion,

amnesia for the episode, autonomic and behavioral manifestations of intense fear

• Persons with sleep terrors then spontaneously calm down and return rapidly to sleep.

• Risk factors• Environmental; Sedative use, sleep deprivation, sleep-wake

schedule disruptions, fatigue, Fever and stress• Genetic; more in monozygotic, 10-fold increase

among first-degree biological relatives

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Rapid Eye Movement Sleep Behavior Disorder

• develop during REM sleep and are accompanied by loss of REM-related muscle atonia or hypotonia.

• 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. • good dream recall on awakening.

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DSM-5Diagnostic Criteria of RSBD

A. Repeated episodes of arousal during sleep associated with vocalization and/or complex motor behaviors.

B. These behaviors arise during rapid eye movement (REM) sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.

C. Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.

D. Either of the following: 1. REM sleep without atonia on polysomnographic recording. 2. A history suggestive of REM sleep behavior disorder and an established

synucleinopathy diagnosis (e.g., Parkinson’s disease, multiple system atrophy).E. The behaviors cause clinically significant distress or impairment in social,

occupational, or other important areas of functioning (which may include injury to self or the bed partner).

F. The disturbance is not attributable to the physiological effects of a substance

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Nightmare Disorder• Nightmares are typically lengthy, elaborate, story like sequences of dream

imagery that seem real and that incite anxiety, fear, or other dysphoric emotions.

• terminate with awakening and rapid return of full alertness• dysphoric emotions may persist into wakefulness• Associated with sweating, tachycardia, and tachypnea• often begin between ages 3 and 6 years• Risk Factors Sleep deprivation or fragmentation personality disturbances or psychiatric diagnosis. medications, Gender

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…CONT DSM-5 Diagnostic CriteriaA. Repeated occurrences of extended, extremely dysphoric, and well-

remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.

B. On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

D. The nightmare symptoms are not attributable to the physiological effects of asubstance e.g., a drug of abuse, a medication).

E. Coexisting mental and medical disorders do not adequately explain the predominant complaint of dysphoric dreams

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…cont Specify if: Acute: Duration of period of nightmares is ≤1 months Subacute: ≥ 1 month but less than 6 months. Persistent: Duration of 6 months or more. Specify current severity(by the frequency ): Mild: Less than one episode per week on average. Moderate: ≥ 1 episodes/week but less than nightly.

Severe: Episodes nightly.

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Differences between nightmares and sleep terrors

Characteristics Nightmares Sleep terrors

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 Partial/complete amnesia

Subsequent Delayed Rapid return to sleep

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Sleeptalking (Somniloquy)

• found in all stages of sleep. • involves a few words that are difficult to

distinguish. • involve the sleeper's life and concerns, • Don’t ( relate their dreams or reveal deep

secrets) • accompany night terrors and

sleepwalking. • Sleeptalking alone requires no treatment.• can be induced by fever, stress, or

conversing with the sleeper.

I don’t love u anymore! U r sucking the

living life outta me!!!!

Sayyy whaaat

!!!!

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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 can give rise 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), and medication use (eg, levodopa or SSRIs).

– rule out nocturnal seizures.– oral appliance to protect the teeth during sleep. – Relaxation, biofeedback, hypnosis, and stress management

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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 individual is partial conscious and aware of the surroundings

• Paralysis spontaneously resolves after several seconds to several minutes.

• Improved sleep hygiene and assurance of sufficient sleep.

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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; sleep-onset 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.

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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 age-related nocturnal bladder capacity, or a maturational delay in bladder development resulting in a smaller bladder capacity. 8/19/2015


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; depression; OSA; congestive heart failure;dementia; seizures; and chronic constipation.

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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 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.

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Evaluation of PARASOMNIAS

• Time-synchronized video recording (ie,simultaneous video and sleep monitoring), performed over several nights may be required.

• 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.

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MANAGEMENT OF SELECTED PARASOMNIAS

• SLEEP WALKING; Reassurance is the mainstay of treatment; identify and eliminate any environmental or predisposing factors lock windows and doors, remove obstacles & sharp objects from room Medication isn't usually used to treat sleepwalking. sedative-hypnotics or antidepressants reduced the incidence in some pts.

• SLEEP TERROR; reassurance and education. scheduled awakenings Behavioral therapy keep affected individuals from harming themselves or others. TCA, benzodiazepam if severe symptoms that affect waking behavior (eg,

school performance and peer or family relations) and only after behavioral interventions have failed.

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….cont

• NIGHTMARE; Daytime stressors should be identified and resolved cognitive behavioral techniques REM sleep suppressants( TCA, BDZ) nefazodone & prazosin-----PTSD related Universal sleep hygiene stimulus control therapy

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Enuresis• 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 ;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).

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references

• DSM-V• Kaplan and sadock • Wikipedia

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MERCI!!!

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