Parasomnias (A Sleep-Related Disorder) - Types, Causes, and Treatment

Introduction:

A parasomnia refers to a sleep disorder that includes unusual and undesirable behaviors during sleep. Sleep disturbances are one of the most common complaints by patients. A parasomnia can occur before or during sleep or also arousal from sleep. Parasomnia patients have abnormal movements, emotions, talk, or do unusual movements during sleep.

What Are the Different Types of Parasomnias?

Parasomnias are grouped under the stages of sleep in which they happen. There are two main stages of sleep, and they are:

• Rapid eye movement (REM).

• Non-rapid eye movement (NREM).

Both rapid and non-rapid eye movement changes in a cycle that lasts about 120 minutes. Non-rapid eye movement stages are further sub-classified into four stages, stage 0, stage 1, stage 2, and stage 3. The initial stages of rapid eye movement last around five to ten minutes, followed by frequent periods. Disturbances in both cycles during continuous sleep or upon transitions to wakefulness are grouped under the term ‘parasomnias.’

What Is the Etiology of Parasomnia?

Recent studies suggest that disturbances in stage 3 slow-wave sleep can increase the probability of this condition. These include:

• Restless leg syndrome (condition refers to an irresistible urge to move the legs).

• Obstructive sleep apnea.

• Narcolepsy (uncontrollable daytime sleepiness).

• Circadian rhythm disorders (physical, mental, and behavioral changes that follow a 24 hours cycle).

• Lack of maturity of the sleep-wake cycle.

• Sleep deprivation.

• Genetics.

• Alcohol.

• Periodic limb movements.

• Stress.

• Fever.

• Pregnancy or menstruation.

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• Inflammatory disease (for example, encephalitis).

• Psychiatric illnesses, such as depression, post-traumatic stress disorder, and anxiety.

• Neurological diseases such as multiple system atrophy, stroke, multiple sclerosis, migraines, brain tumors, and spinocerebellar ataxia type 3.

• Medications involved in treating -

  • Depression (Amitriptyline, Paroxetine, Mirtazapine, Bupropion).

  • Causing sleep (Benzodiazepines: Zolpidem).

  • Seizures (Topiramate).

  • Asthma or allergy (Montelukast).

  • Infections (Fluoroquinolones).

  • High blood pressure (Propranolol, Metoprolol).

  • Psychotic disorders (Quetiapine, Olanzapine).

What Are the Symptoms of Parasomnias?

Common Symptoms of Parasomnias Include:

• Movements, verbal activity, or expressions during sleep.

• Confused or disoriented.

• Difficulty sleeping.

• Fatigue.

• Sometimes finding cuts and bruises on the body, for which the cause cannot be remembered.

How Parasomnias Occur in Children?

• This condition is more commonly seen in children than in adults.

• Non-rapid eye movement eye disorders occur more commonly in children compared with rapid eye movement disorders.

• This disorder occurs in children who are associated with neurologic or psychiatric health issues such as attention-deficit hyperactivity disorder, epilepsy (disorder in which the nerve cell activity of the brain is disturbed), and also in certain developmental issues.

• The common features of parasomnia that occurs in children are:

  • Sleepwalking.

  • Sleep terror.

  • Nightmare.

  • Confusional arousal.

What Are the Effects of Parasomnias in Non-rapid Eye Movement (NREM) Sleep Arousal Disorders?

• Non-rapid eye movement (NREM) sleep is the first three stages of sleep, from initially falling asleep to about the first half of the night.

• Non-rapid eye movement sleep disorders are also known as arousal disorders.

• It usually occurs between five and 25 years of age and often occurs in people with a family history of a similar condition.

• Various manifestations of non-rapid eye movement are as follows-

Sleep Terrors:

Patients with this sleep disorder wake up suddenly in a terrified state. It usually occurs for about 30 seconds but lasts up to a few minutes. Other features are-

• Open eyes with dilated pupils.

• Fast breathing.

• Sweating.

• Rapid heart rate.

• Screaming or crying in fright after waking up suddenly.

• Confusional Arousals:

In this disorder, the individual appears to be partially awake but seems to be confused or disoriented to time and place. The duration of this episode may last from a few minutes to hours. It is more common in childhood and may decrease in frequency with increasing age. Other features of this disorder include:

• Slow speech.

• Trouble in understanding questions.

• Difficulty in responding.

• During the episode, the patient may remain in bed in a sitting posture with eyes open and may cry or scream.

• Somnambulism (Sleep Walking):

In this disorder, the sleepwalker gets out of the bed and moves with eyes wide open, but actually, the person will be asleep. Patients may talk or mumble (sleep talking) and perform various complex activities such as playing musical instruments or driving or moving furniture. It is too dangerous as a person is unaware of the surroundings and can fall or get hurt by objects on the way.

• Sleep-Related Eating Disorder:

In this disorder, a person may eat or drink while partially awake. This condition is also dangerous as the patient has chances of eating inedible or toxic foods, which cannot be taken when awake. In addition, there is a possibility of getting injured.

What Are the Effects of Parasomnias in Rapid Eye Movement Disorder?

Rapid eye movement disorder sleep disorders are manifested with eyes moving rapidly under the eyelids, and there is an increase in heart rate, blood pressure, and breathing. During this duration, vivid dreaming occurs. The sleeping cycle repeats between non-rapid eye movement and rapid eye movements; sleep for about every 90 to 110 minutes. Parasomnias mostly occur in the late part of the night, and hence the person can recall the overall or part of the memory. Parasomnia manifestations include-

• Rapid Eye Movement Sleep Behavior Disorder (RSBD): This sleep disorder is most commonly seen in older adults. Some people with this disorder are associated with neurodegenerative diseases, such as multiple system atrophy, Lewy body dementia, Parkinson's disease, and stroke. It is associated with aggressive movements such as punching, kicking, and grabbing, and verbal activities such as laughing, shouting, and talking loudly as a result of violent dreams.

• Nightmare Disorder: In this disorder, vivid dreams happen, which causes a feeling of anxiety, fear, and terror. Patients develop a feeling of insecurity or fear of survival and have trouble falling back to sleep. It is caused due to stress, fever, traumatic event or illness, alcohol consumption, and extreme tiredness.

• Recurrent Isolated Sleep Paralysis: In this disorder, the patient cannot move the body or limbs during sleep since the muscles are already in a relaxed state. The duration of this episode occurs for about a second to a few minutes. It usually results in anxiety or fear. It can be stopped immediately once the bed partner starts the conversation.

• Sleep Enuresis (Bedwetting): It is different from the bedwetting that occurs in children. In parasomnia patients, this bedwetting happens in children of age five and older and occurs twice a week for at least three months.

• Sleep-Related Groaning: Individuals with this type of disorder have repeat episodes of groaning noises during sleep.

What Are the Investigation Procedures for Parasomnia?

The medical history, family history, alcohol use, and drug history are clearly evaluated.

Various sleep disorder tests are carried out and are as follows-

• Polysomnogram (Sleep Study): This refers to a sleeping laboratory where the patient is monitored while sleeping. The patient’s heart rate, brain waves, eye movements, and breathing are recorded. Video is recorded to observe any movements or behavior.

• Computed Tomography (CT) And Magnetic Resonance Imaging (MRI): Neurologic examinations determine the degeneration of the brain or other possible causes of the symptoms.

• Video Electroencephalogram (EEG): This test helps to record brain activity during a brain event.

How Are Parasomnias Treated?

Treatments for Non-rapid Eye Movement Sleep Disorders:

• Follow good sleep habits - Seven to nine hours of sleep at night, turn off lights and other electronic gadgets, avoid caffeine, and strenuous exercise before bedtime.

• Maintain a regular sleep-wake schedule.

• Avoid alcohol or recreational drugs.

• Regular intake of prescribed medications.

• Medications are not usually prescribed for non-rapid eye movement disorder. However, certain drugs are recommended. Benzodiazepines are the long-lasting drugs used for this disorder. Tricyclic antidepressants are also tried sometimes.

• Psychological approaches such as hypnosis and cognitive behavioral therapy are also recommended.

Treatments for Rapid Eye Movement Sleep Disorders:

• Clonazepam and Melatonin are commonly used to manage this disorder.

• Other safety measures are followed. These include-

  • Use floor pads to prevent injuries from falls.

  • Cover the sharp edges of the furniture.

  • Install alarms on windows and doors for sleepwalkers.

  • Lock or remove any dangerous or sharp items from the bedroom.

Conclusion:

Some causes of parasomnia can be easily managed, whereas parasomnia caused due to neurologic conditions, heredity, and mental illness are managed through various treatment approaches, as discussed. Lifestyle modifications, including sleep routines, are highly focused on getting a better improvement of this disorder.