Parasomnias

Overview

Parasomnias are a collection of sleep disorders involving abnormal movements, behaviours, emotions or perceptions that occur within a sleep state, or on the transition from one state to another.

Parasomnias are common. In some cases, may produce physical injuries, disturb sleep and cause psychological distress to both the patient and their bed partners.

Non-rapid eye movement (NREM) related parasomnias

NREM related parasomnias are more common in children, and often settle as the brain matures. They are observed during stage 3, deep sleep and reflect a discoordination of sleep and wake physiology.

They are typically made more frequent or severe by sleep deprivation, alcohol, CNS acting medication, stress and noisy or uncomfortable sleeping environments.

• Confusional arousals – a person wakes (is aware of themselves and their environment) but is in a disoriented state. Episodes in children can be alarming, with a child staring through an observer with a confused expression. This can happen after forced awakenings. They can last for up to 20 minutes.
• Sleepwalking - Sleepwalkers may sit up and appear awake when they are actually asleep, they can walk around and get undressed. Generally, behaviour is in or around the bed and semi purposeful.
• Night terrors – most common in children but reported in 2.2% of adults. The person sits up in bed with a loud scream and expression of terror. Adults may get up and run, or lash out, with the potential to cause injury. The person is usually confused and disorientated and any attempts to console the individual may actually prolong the episode. There is characteristically no recollection of the event, or if woken the person may recall non-narrative dream content e.g. ‘I thought the room was on fire’ or ‘I thought I had to escape’.
• Sexsomnia – may involve any kind of sexual act occurring during sleep with the individual appearing to be awake. Can involve behaviours quite different to those done during wakefulness. May have medical, social, and legal implications, and parents with this problem should not sleep in bed with their children.
• Sleep Related Eating Disorders - where binge eating may occur during a state of sleep and the person feels dissociated from their behaviour as well as having no recollection of it afterwards.

Rapid eye movement related parasomnias

• REM sleep behavioural disorder (RBD) - is a condition where the usual muscle atonia that occurs during REM sleep which prevents an individual acting out their dreams, is not consistently applied. This results in a person acting out their dreams which can lead to sometimes serious injuries including fractures to the individual or their bed partner. Vocalisation, screaming and swearing may occur along with aggressive motor activity. It is most common in males over 50 years old and can precede the development of conditions like Parkinson’s disease or Lewy Body dementia, by 10-20 years. It may also occur as a side effect of antidepressant medication, during substance withdrawal, or as a symptom of narcolepsy.
• Nightmare disorder – this is when a person has recurrent nightmares that produce arousals and may prevent them returning to sleep, and which cause ongoing stress during the day. Nightmare disorders are common in the context of PTSD, where 85% of sufferers report nightmares, and patients may wake up from nightmares in a dissociated state.
• Recurrent isolated sleep paralysis – is the inability to produce voluntary motor activity at either sleep onset or on waking (usually the latter), despite being conscious. It is thought to be caused by either the prolongation, or early application, of REM atonia. It self-terminates after a few seconds usually but can cause significant anxiety as patients feel as if there is a great weight bearing upon them, or that they are unable to voluntarily use their respiratory muscles. It is more common during periods of sleep deprivation and irregular sleep-wake cycles, as with shift work.

Other parasomnias

• Sleep-related dissociative disorders
• Sleep-related enuresis
• Sleep-related groaning (catathrenia)
• Exploding head syndrome
• Sleep-related hallucinations

Who to refer

Not all parasomnias need referral. Referral is only required if the episodes are frequent, causing harm to the individual or their bed partner or are causing daytime somnolence.

Adult patients (aged 18 years and over) can be referred as detailed in the Services section below.

Paediatric patients (aged under 18 years) -please consider the following service for advice: The neuropsychiatry team have established a drop-in consultation service for all local and community colleagues that occurs on the 1st Tuesday of each month at 15:00 p.m. They are happy to discuss patients aged under 18 who are being considered for referral in this forum. If a clinician would like to attend the drop in to discuss a patient then they can contact the team on 01173428168 or email them at paediatric.neuropsy@uhbw.nhs.uk

What to do before referral

Parasomnias are usually diagnosed with history, a sleep diary and occasionally polysomnography. As sleep deprivation is such a common precipitant, the general treatment of all parasomnias is to ensure good quality sleep.

Ensure that the following are ruled out prior to consideration of referral:

• Sleep deprivation
• Intoxication or withdrawal
• Other sleep disorders
• Medical or psychiatric causes for sleep disturbance
• Confirm childhood history or family history of parasomnias

Management in primary care

As sleep deprivation is such a common precipitant, the general treatment of all parasomnias is to ensure good quality sleep. This should include

• Good sleep hygiene
• Diagnosing and treating underlying sleep disorders including obstructive sleep apnoea, insomnia and restless leg syndrome
• Management of chronic pain
• Limiting the use of alcohol and recreational drugs

Drug treatment for parasomnias should not be initiated in primary care.

Services

• Neuropsychiatry Sleep Disorders clinic - NBT

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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