Parasomnias

Parasomnias
Zenobia Zaiwalla
John Radcliffe Hospital
Oxford
Definition of Parasomnias (ICSD 2)
• Undesirable physical events or experiences that
occur during entry into sleep, within sleep or
during arousals from sleep
• Encompass abnormal sleep related movements,
behaviours, emotions, perceptions, dreaming
and autonomic nervous system functioning
• “Basic drive states” can emerge with
parasomnias such as sleep related aggression,
locomotion, eating , sexual behaviours
• Parasomnia spectrum and when to
investigate
• Pseudo/ pretend parasomnia behaviours
• Parasomnia vs Epilepsy
Classification of parasomnias:ICSD 2
• Disorders of arousal from
NREM sleep
-confusional arousals
-sleep walking
-sleep terrors
- sleep sex
- sleep related eating disorder
• Parasomnia associated with
REM sleep
-REM sleep behaviour disorder
- recurrent isolated sleep
paralysis
- nightmares
- hypnagogic / hypnopompic
hallucinations
• Other parasomnias
- sleep related dissociate
disorder
- sleep related abnormal
swallowing/choking/laryngeal
spasm
- sleep enuresis
- sleep related groaning
- exploding head syndrome
- sleep related hallucinations
- (sleep related eating disorder)
- parasomnia unspecified
- parasomnia due to drugs,
substance abuse or medical
condition
Classification of sleep related
movement disorders: ICSD 2
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Restless leg syndrome
Periodic limb movement disorder
Sleep related leg cramps
Sleep related bruxism
Sleep related rhythmic movement disorder
Sleep related movement disorder unspecified
Sleep related movement disorder unspecified
Sleep related movement disorder due to drug /
substance use or medical condition
Rhythmic movement Disorder
• Sleep related movement disorder characterised by
repetitive, stereotype and rhythmic motor behaviours that
occur predominantly in drowsiness and sleep
• Disorder only if behaviours interfere with normal sleep,
cause impairment in daytime function or result in bodily
injury
• Common in infants and young children; rarely continues
into adult life
Management of Rhythmic
Movement Disorder
• Diagnosis and reassurance
• Sleep onset movements or movements in
consciousness- behavioural intervention
• Movements may occur as conditioned response
to arousals
• Try encouraging alternate less intrusive
rhythmic movements
• Polysomnography/actigraphy to look for sleep
disturbance due to OSA/PLM/sleep wake cycle
disorder
• Sleep restriction+/- short period on medication
Sleep related choking/ panic
attacks from sleep
• Frequent abrupt awakening from sleep with
feeling of choking; can last a couple of minutes
but not noted by bed partners
• Associated features include rapid heart rate,
anxiety and feeling of impending death
• Underlying psychogenic basis with emotional
stress
Eleanor age 52
Onset of parasomnias age 21; on maternity ward startled by night
staff approaching her as drifting off to sleep; sat up with a scream
Episodes :
1. Within 30 secs of sleep onset, leaps up with a gasp, heart
pounding; recurs up to 10 times; scared to sleep
2. Wake an hour after sleep onset with eyes bulging , choking,
whistling sound as if unable to breathe out
3. Episodes middle third of night, “ I know I have died and claw
my way back to life screaming; feeling of getting stuck or
locked in; effort to get away”
4. Vivid dreams with vicious content “ with other people`s
thoughts intruding, thoughts changing as if flicking a card”; one
occasion choking while having argument in dream , woke up
coughing and struggling to breathe
Disorders of arousal from NREM sleep
*Characteristics:
• Onset during NREM sleep
• Lack of conscious awareness or memory
of event
• Event characterised by automatic
behaviours
*American academy of sleep Medicine. International Classification of Sleep Disorders.
2nd ed: diagnostic and coding manual. Westcheister, IL: Academy of Sleep Medicine
2005
• Common occurrence; 20% children; 4% adults
Arousal Disorders characteristics cont.
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Usually occur on arousal from non REM
stages 3 and 4 sleep (slow wave sleep)
•
Tend to occur early in the night but can occur
later if deep sleep occurs later in the night, as
following sleep deprivation
•
Usually once a night but more than one
episode can occur
•
Strong genetic predisposition; common in
children
• Adults can have varying degree of memory of
preceding mentation or may remember with a
prompt the next day
• Complex visual hallucinations from NREM
sleep: sudden waking often with terror, without
memory of preceding dream; see images of
people or animals in the room; visual
hallucinations disappear if room illumination is
increased
Late onset may need investigation for
symptomatic complex visual hallucinations eg
narcolepsy, mid brain pathology, dementia with
Lewis bodies etc
Factors that predispose, prime and precipitate NREM arousal
Parasomnias in adults… Mark Pressman in Sleep Medicine Review
2007
• Predispose : genetic tendency; HLA DQB1 in 35% vs
13.3% in controls; increase chance of developing
arousal parasomnia episodes in first degree relatives by
factor of 10
• Prime: factors that deepen sleep ( maturation, sleep
deprivation, medication), fragment sleep (fever, stress)
and or make arousal from sleep more difficult (alcohol),
increases chance of episode
• Precipitants: Sleep disordered breathing, PLMS, noise,
touch, full bladder, touch, sound
• Overlap between prime and precipitants when primers
associated with lowering arousal threshold from slow
wave sleep
Spectrum of NREM arousal
parasomnias
• Confusional arousals
• Night terrors
• Sleep walking
• Sleep sex
• Sleep related eating disorder
Sleep Walking
• Usually occur in the first third of the night
• Repetitive confused movements may precede the
walking
• Confused , complex behaviours initiated on arousal
from slow wave sleep culminating in walking or
bolting / running from perceived threat
• Limited capacity to respond to environmental
stimuli and negotiate objects; walk with eyes
open
• Dangerous activities and directed violent behaviour
can occur
• May wake up confused or return returns to bed /
sleep; no memory but sometimes fragmentary or
detail dream recall
• Duration – minutes to hour
Sleep walking cont
• Behaviours maybe routine though inappropriately timed
or inappropriate behaviours like urinating in the
cupboard, moving furniture, climbing out of windows,
driving, eating etc.
• Reported forensic cases - violence including homicide;
driving accidents; sexual behaviour
• Personality (adult sleep walkers)- inhibited aggression,
controlled, highly developed mental defence against
anxiety
• Can appear anytime after the child starts walking but
can emerge even up to seventh decade; childhood
sleep walking tends to stop in adolescence
Mechanism of NREM arousal parasomnias
• Disturbance in maintainance of stable NREM sleep
• Breakdown of boundaries between wake and NREM
sleep states
• Global vs ‘local awakening’
• Single SPECT study during sleep walking, showed
increase in regional blood flow in posterior cingulate
cortex with decrease in blood flow in fronto-parietal
associated cortices
(Bassetti et al, Lancet 2000)
• Single case of confusional arousal occurring during a
depth electrode study for epilepsy
Assessment of NREM arousal
Parasomnias
• History: childhood and family history of parasomnias and
bed wetting; psychosocial history; personality traits;
medication/ alcohol
• Be aware of pretend attacks
• Polysomnography to exclude OSA/PLM triggers
• Forensic cases – 3 nights of sleep recordings, with one
night preceded by 36 hours of sleep deprivation
( R Cartwright 2004); alcohol induced sleep studies
controversial
Pilon et al (2008) suggest combining sleep deprivation
with forced arousals by auditory stimulation
• Video-telemetry if epileptic seizures suspected
Management of NREM
parasomnias
• Address potential triggers (OSA/PLM); touch,
sound etc
• Address psychological issues; strategies to
create closure and decrease high emotion
processing in sleep
• Small data on efficacy of hypnosis
• Medication - clonazepam; SSRI; imipramine
• Explore non drug strategies to stay safe,
including movement sensors, room illumination
etc
REM Sleep Behaviour Disorder
(Schenk et al 1986)
• Age of onset – after 50 years; earlier with
neurological disorders
• Characterised by acting-out of dream content
• Violent motor activity – kicking, thrashing,
running limb movements
• Complete dream recall; violent dreams
• Injury in sleep
….RSBD continued
• 60% (?100%) associated with or harbinger of neurodegenerative
diseases – Synucleinopathies such as Parkinson’s disease,
dementia with Lewy bodies and multi system atrophy (90%)
• Also in other neurological disorders associated with
interruption of the REM atonia pathways (pedinculo-pontine
nucleus) and or disinhibition of brainstem motor pattern
generation; common in narcolepsy; also Moebius syndrome
• Transient RSBD associated with drugs (tricyclics etc) or
withdrawal of alcohol, barbiturates, benzodiazepines
• Antidepressants associated with asymptomatic
polysomnographic features of RSBD
• Overlap NREM arousal / RSBD parasomnia
• Exclude OSA
Epilepsy and NREM arousal
Parasomnias
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Occur from sleep; 19-24% only from sleep
Occur from NREM sleep
NREM sleep unstable with increase in arousals
Family history positive
Stress can be a trigger
Interictal EEG/ ictal EEG not helpful
Normal MRI
May co-exist
Complex Partial Seizures Originating in the Frontal
Lobe
(cingulate cortex/supplementary motor area)
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Abrupt onset and termination
Short duration
Frequent occurrence
Dystonic posturing/focal tonic or fencing posture
Complicated motor/gestural automatisms; hypermotor
seizures
Vocalisations
Stereotyped movements
No ictal/postictal confusional automatisms
Prone to complex partial status epilepticus
Frequently misdiagnosed as a parasomnia/pseudoseizure
The Frontal Lobe Epilepsy & Parasomnias (FLEP) Scale
Derry, C.P. et al. Arch Neurol 2006;63:705-709
Age at onset of first clinical event
<55 y
>55 y
0
-1
Duration of typical event
<2 min
2 - 10 min
>10 min
+1
0
-2
Clustering: typical number in single night
1 or 2
3–5
>5
0
+1
+2
Time of night events most commonly occur
Within 30 min of sleep onset
Other times ( including no clear
pattern identified)
0
+1
Yes
No
Yes
No (or uncertain)
Yes
No (or uncertain)
Yes
No (or uncertain)
+2
0
-2
0
-2
0
+1
0
Symptoms
Association of aura
Wandering outside the bedroom in event
Perform complex directed behaviours
Clear history of dystonic posturing, tonic limb
extension or cramping during events
The Frontal Lobe Epilepsy & Parasomnias (FLEP) Scale
cont Derry, C.P. et al. Arch Neurol 2006;63:705-709
Stereotypy of events
Highly stereotyped
Some variability/uncertain
Highly variable
+1
0
-1
Recall of events
Yes, lucid recall
No or vague recollection
+1
0
Vocalisation: does the patient speak during event, and
if so is there subsequent recollection of this speech
No
Yes, sounds only or single words
Yes, coherent speech with incomplete
or no recall
Yes, coherent speech with recall
0
0
-2
+2
FLEP scale cont
Score of 0 or less – parasomnias
Score 0-3 - overlap
Score 3 or more – epilepsy
The Frontal Lobe Epilepsy & Parasomnias (FLEP) Scale
Derry, C.P. et al. Arch Neurol 2006;63:705-709
NREM arousal parasomnias vs NFLE Derry et al 2009
Strongly favour
parasomnia
Moderately favour
parasomnia
Do not discriminate
between parasomnias
and NFLE
•Yawning
•Scratching, nose
rubbing
•Rolling over in bed
•Int. or ext. trigger
•Waxing and waning n
•Physical or verbal
interaction
•Sobbing, sad,
emotional behaviour
•Duration>2mins
•Discrepancy between
severity of reported vs
recorded behaviours
•Tremor/trembling
•Myoclonic jerks
•Coughing
•Semipurposeful
fumbling, manipulation
of nearby objects
•Variability, absence of
stereotype
•No events recorded
on first night of
monitoring
•Few events recorded
in total (less than 3)
•Brevity
•Sitting
•Standing and walking
•Preceding normal
arousal
•Brief arousal up to
10secs. without
semiological features
of epilepsy
•Fearful emotional
behaviour
Conclusions
• Familiarity with range of behaviours that can
occur from sleep important
• Detail history usually sufficient
• Polysomnography in parasomnias indicated to
exclude co-morbid sleep disorders and for
forensic cases; essential for diagnosis of REM
sleep behaviour disorder
• Look out for psychogenic/pseudo parasomnias
• Video-telemetry if episodes frequent, brief and
occur all through the night to exclude epileptic
seizures