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A.W.A.K.E GROUP PARASOMNIAS. Dr. Joe Malli Stanford Sleep Disorders Center 3/2/11. Parasomnias. Unpleasant or undesirable behavioral or experiential phenomena occur almost exclusively during sleep Originally thought to be due to psychiatric disorders.

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a w a k e group parasomnias


Dr. Joe Malli

Stanford Sleep Disorders Center


  • Unpleasant or undesirable behavioral or experiential phenomena occur almost exclusively during sleep
  • Originally thought to be due to psychiatric disorders.
  • Actually due to a large number of different conditions, most not psychiatric and most treatable.
  • Primary Parasomnias (disorders of the sleep state).
    • REM
    • NREM
  • Secondary Parasomnias
    • Due to underlying medical condition or medications.
nrem parasomnias
NREM Parasomnias
  • State Dissociation:
    • Brain partially awake and partially in NREM.
    • Awake enough to perform very complex motor or verbal actions
    • Sleep enough not to have conscious awareness or responsibility for these actions.
  • BRAIN: Three primary states of being:
    • Wakefulness
    • NREM sleep
    • REM sleep
  • Much of the brain is active across all three states at any one time, but activity stimulation.
  • Activity in one phase can inhibit activity in another phase.
  • Does mean that there is the potential for interaction between the different states of being especially during transition periods between states.
nrem parasomnias6
  • Tend to arise from Slow Wave Sleep (but can occur in other stages)
  • First 1/3rd of night(rare in naps)
  • Common in childhood – decrease frequency with increasing age
  • Possible genetic link with sleepwalking – can have strong family history
nrem parasomnias7
NREM Parasomnias
  • Triggers
    • Febrile illness
    • Alcohol
    • Sleep deprivation
    • Physical activity or emotional stress
    • Medications (sedative-hypnotics, neuroleptics, stimulants, antihistamines)
    • Nocturnal seizures
    • Periodic limb movements
nrem parasomnias8
  • Not caused by psychopathology.
    • Sleepwalking experimentally induced by standing children up during SWS
    • Sleep terrors experimentally induced by sounding a buzzer during SWS.
nrem parasomnias pathogenesis
NREM ParasomniasPathogenesis
  • Sleep State Instability
    • Predominance of cyclic alternating patterns (arousal oscillations) in patients with disorders of arousals
nrem parasomnias pathogenesis10
NREM ParasomniasPathogenesis
  • Locomotor Centers
    • Multiple centers in the brain that allow dissociated complex motor activity from waking consciousness


  • Arousals Disorders
    • Confusional Arousals
    • Sleep Terrors
    • Sleep Walking
  • Usually only one episode during the night
  • Precipitating factors include:
  • Fever, systemic illness, medication or other substances, internal or external sleep interrupting stimuli (such as a full bladder, sleeping in an unfamiliar environment, child being woken forcefully
nrem parasomnias14
NREM Parasomnias
  • Confusional Arousals
    • Mainly occur in infants and toddlers.
    • Prevalence: 17% age 3 to 13. Older then 15 yo (3% to 4%)
    • Episode may begin with movements and moaning, progress to agitated and confused behavior…
    • Crying (perhaps intense), calling out, or thrashing about.
    • Parents often times are alarmed, consoling attempts not successful, or require significant effort.
nrem parasomnias15
NREM Parasomnias
  • Confusional Arousals
    • Episodes last 5–15 minutes (sometimes much longer) before child calms down/falls back asleep spontaneously or with parental intervention.
    • Easily precipitated by forced awakenings (esp. early in sleep cycle)
    • Can occur during naps
nrem parasomnias pathogenesis16
NREM ParasomniasPathogenesis
  • Sleep Inertia (Sleep Drunkenness)
    • Adolescent / adult variant of confusional arousals.
    • Occurs during light NREM sleep.
    • Impaired performance and reduced vigilance following awakening from a regular sleep episode or nap
    • Minutes (usually) to hours
    • PSG proven microsleep
    • Waking up  stumbling to shower  in shower retrograde amnesia
    • Probably plays a role in susceptibility to disorders of arousal.
nrem parasomnias18
NREM Parasomnias
  • Sleepwalking (Somnambulism)
    • Childhood Prevalence (20% to 40%)
    • Peak age 11 to 12 years
    • Adults 4%
    • Arise out of SWS
    • Episodes last up to 10 minutes (usually)
    • Event usually not as dramatic as other arousal disorders
    • Usually walk calmly around house (or out)
      • Falling down stairs is a real risk
    • Partial awareness/responsiveness – blank or glossy stare
    • Habitual behaviors (automatism)
nrem parasomnias19
NREM Parasomnias
  • Sleepwalking
    • If awoken during an event subject usually confused, may react violently.
    • Agitated, violent or belligerent behaviors can occur.
    • May spontaneously awaken before returning to bed, or may lie down and continue sleeping in different location.
    • Inappropriate behaviors (urinating in waste basket, rearranging furniture, climbing out a window)
    • Agitated sleepwalking difficult to distinguish from adolescent / adult sleep terrors.
nrem parasomnias21
NREM Parasomnias
  • Sleep Terrors (Pavor Nocturnas)
    • Age 4 – 12 yo
    • Prevalence in adults up to 5%
    • Occur 1st third of night
    • Significant autonomic discharge (tachycardia, tachypnea, flushing, diaphoresis)
nrem parasomnias22
NREM Parasomnias
  • Sleep Terrors
    • Initiated by loud, blood-curdling scream, extreme panic state, followed by motor activity (hitting the wall, running around room or out of house can result in injury)
    • Inconsolability (universal feature)
    • Amnesia typical (complete or partial)
sleep eating
Sleep Eating
  • Specialized form of DOA
  • Frequent episodes of nocturnal eating
    • Frozen pizzas, raw bacon, buttered cigarettes, cat food, coffee grounds, ammonia cleaning solutions…
  • Partial to no recall
  • Occur any time in sleep cycle
  • Female predominance
  • Mean age of onset 22 to 29 years
  • Usually due to primary sleep disorder and psychotropic medications
  • Strongly associated with other parasomnias
nrem parasomnias25
NREM Parasomnias
  • Diagnosis:
    • Not all cases warrant medical attention
    • General indications for formal evaluation:
      • Potentially violent or injurious behavior (always a first time)
      • Extremely disruptive to other household members
      • Result in complaint of excessive daytime sleepiness
      • Associated with medical psychiatric or neurologic symptoms or findings
nrem parasomnias26
NREM Parasomnias
  • Diagnosis
    • Formal, appropriately formed polysomnography may provide direct or indirect diagnostic information.
    • Expanded EEG montage (nocturnal seizures) – not always diagnostic.
    • Continuous audiovisual monitoring
    • Sleep deprivation prior to formal PSG may increase likelihood of capturing an in-lab event.
nrem parasomnias27
NREM Parasomnias
  • Treatment
    • Not always necessary (be wary if progressive)
    • Benzodiazepines may be effective (never seen in my experience at Stanford - OSA)
    • Paroxetine/Trazodone – improvement in some cases
    • Psychotherapy, progressive relaxation, hypnosis (? Role if no underlying psychological disorder)
    • Anticipatory awakenings for sleepwalking/terrors: (15-30 minutes before usual episode time) May result in sleep deprivation and paradoxical worsening.
    • Avoidance of precipitants: drugs, alcohol, sleep deprivation
  • Safe environment (removal of obstructions in the bedroom, secure windows, install locks or alarms on outside doors, or cover windows with heavy curtains)
rem parasomnia
REM Parasomnia
  • REM Sleep Behavior Disorder (RBD)
    • Abnormal behaviors during REM sleep
    • Usually result in injury to self or partner and sleep disruption
    • Excess phasic muscle tone activity
    • Awareness of dream/nightmare (attacked or chased)
    • End of episode there is rapid awareness, dream recall (corresponds to action of subject - isomorphism)
rem parasomnia30
REM Parasomnia
  • RBD
    • Behaviors include: talking, laughing, shouting, swearing, gesturing, reaching, grabbing, arm flailing, slapping, punching, kicking, sitting up, leaping from bed, crawling, running, walking (rare)
    • Eyes usually remain closed (higher risk of injury)
    • Behaviors do not include: chewing, feeding, dinking, sexual behaviors, urination, defecation
    • http://www.youtube.com/watch?v=rFXYRQ9xPUA&feature=player_detailpage
rem parasomnia31
REM Parasomnia
  • RBD
    • Male predominant (usually after age 50)
    • .38% prevalence in general population
    • .5% prevalence in elderly population.
    • Sleep violence 2.8% prevalence:
      • 38% associated with dream enactment.
    • 33% prevalence of RBD in newly diagnosed Parkinson’s disease.
    • 90% prevalence in multiple system atrophy.
rem parasomnia32
REM Parasomnia
  • Precipitating factors
    • Male sex
    • Age ≥ 50
    • Underlying neurological disorder (esp. Parkinson’s, dementia w/ Lewy bodies, narcolepsy, stroke)
    • Medication use (SSRIs, Venlafaxine, Mirtazapine, other anti-depressants)
rem parasomnia33
REM Parasomnia
  • Subclinical or preclinical RBD (“REM without Atonia”
    • Minor subclinical REM sleep behaviors (limb twitching/jerking/talking) no complex behaviors.
    • Eventual emergence of clinical RBD in at least 25% of cases.
rem parasomnia34
REM Parasomnia
  • Treatment:
    • Limited: Klonopin; Melatonin.