The Clinical Spectrum of the Parasomnias.

Parasomnias are defined as abnormal movements or behaviors that occur in sleep or during arousals from sleep. Parasomnias vary in frequency from episodic events that arise from incomplete sleep state transition. The framework by which parasomnias are categorized and diagnosed is based on the International Classification of Sleep Disorders-Third Edition, Text Revision (ICSD-3-TR), published by the American Academy of Sleep Medicine. The recent Third Edition, Text Revision (ICSD-3-TR) of the ICSD provides an expert consensus of the diagnostic requirements for sleep disorders, including parasomnias, based on an extensive review of the current literature.

Nocturnal agitation: From sleep state dissociation to sleep-related dissociative state.

Nocturnal agitation refers to a broad spectrum of symptoms from simple movements to aggressive behaviors with partial or complete loss of awareness. An accurate identification of its etiology is critical for appropriate therapeutic intervention. In children and young adults, distinguishing between non-rapid eye movement (NREM) sleep parasomnias and psychogenic non-parasomniac manifestations, a condition known as sleep-related dissociative disorder (SRDD), can be challenging. This review aims to summarize current clinical, neurophysiological, and epidemiological knowledge on NREM parasomnia and SRDD, and to present the pathophysiological hypotheses underlying these nocturnal manifestations. Sleepwalking, sleep terror and confusional arousals are the three main presentations of NREM parasomnias and share common clinical characteristics. Parasomniac episodes generally occur 30minutes to three hours after sleep-onset, they are usually short, lasting no more than few minutes and involve non-stereotyped, clumsy behaviors with frequent amnesia. The prevalence of NREM parasomnia decreases from 15-30% in children to 2-4% in adults. Parasomniac episodes are incomplete awakening from the deepest NREM sleep and are characterized by a dissociated brain activity, with a wake-like activation in motor and limbic structures and a preserved sleep in the fronto-parietal regions. SRDD is a less known condition characterized by dramatic, often very long episodes with frequent aggressive and potentially dangerous behaviors. SRDD episodes frequently occur in quiet wakefulness before falling asleep. These dissociative manifestations are frequently observed in the context of psychological trauma. The pathophysiology of SRDD is poorly understood but could involve transient changes in brain connectivity due to labile sleep-wake boundaries in predisposed individuals. We hypothesize that SRDD and NREM parasomnia are forms of sleep-related dissociative states favored by a sleep-wake state dissociation during sleep-onset and awakening process, respectively.

Parasomnias in Pregnancy.

OBJECTIVES: Pregnancy is often associated with reduced sleep quality and an increase in sleep disorders, such as restless leg syndrome, obstructive sleep apnea, and insomnia. There are few studies investigating the prevalence of parasomnias in pregnancy, although they may be expected to be a significant problem, as disturbed sleep in this time period in addition to these sleep disorders may trigger parasomnia episodes. METHODS: We conducted a survey using an online questionnaire focusing on a comparison of the prevalence of parasomnias in three time periods: 3 months before pregnancy, during pregnancy, and 3 months after delivery. We also inquired about psychiatric and neurological comorbidities, current anxiety and depression symptoms, and pregnancy complications. RESULTS: A total of 325 women (mean age 30.3 ± 5.3 years) participated in the online survey. The overall number of reported parasomnias increased during pregnancy compared to the 3 months before pregnancy (p < 0.001) and decreased after childbirth (p < 0.001). Specifically, we found a significant increase in sleepwalking (p = 0.02) and night terrors (p < 0.001), as well as in vivid dreams (p < 0.001) and nightmares (p < 0.001) during pregnancy. A similar significant increase during pregnancy was reported for head explosion (p < 0.011). In contrast, the number of episodes of sleep paralysis increased after delivery (p = 0.008). At the individual level, an increase in the severity/frequency of individual parasomnia episodes was also observed during pregnancy. Participants whose vivid dreams/nightmares persisted after delivery had higher BDI-II and STAI-T scores. Our data also suggest a significant impact of migraines and other chronic pain, as well as complications during pregnancy, on the presence of parasomnia episodes in our cohort. CONCLUSIONS: We have shown that the prevalence of parasomnias increases during pregnancy and needs to be targeted, especially by non-pharmacological approaches. At the same time, it is necessary to inquire about psychiatric and neurological comorbidities and keep in mind that more sleep disorders may be experienced by mothers who have medical complications during pregnancy.

Parasomnias related to shift work disorder among medical residents during the first year of training in Mexico.

Shift work disorder (SWD) may affect medical residents because their workload, academic demands and extended work hours. This condition set residents at risk of more sleep disorders. The study compared parasomnias among residents with and without shift work disorder (SWD) and weighed their relative risk (RR) for each parasomnia. One hundred twenty-six residents participated in the study. The Munich Parasomnia Screening questionnaire and the Barger Questionnaire for SWD were used for the screening of parasomnias and SWD, respectively. Means and percentages of studied variables were compared between groups. Relative risk (RR) was calculated for each type of parasomnia. The more frequent parasomnias in residents with SWD the RR (and 95% confidence intervals) were: sleep terrors, 5.60 (1.84-17.01); confusional arousals, 3.73 (1.84-7.56); sleep paralysis, 3.27 (1.53-6.93); hypnagogic/hypnopompic hallucinations, 2.55 (1.03-6.28); somniloquies, 2.45 (1.21-4.92); and nightmares, 2.01 (1.54-2.62). Our data suggest that residents who experience SWD may be at risk of having lower threshold for the occurrence of rapid eye movement (REM) and non-REM (NREM) sleep parasomnias. Additional research is needed to confirm these results, and to further identify the contribution to this association.

Parasomnias in patients with addictions-a systematic review.

Parasomnias are involuntary behaviors or subjective experiences during sleep. Our objective was to review existing information on the presence of parasomnias in patients with addictions or during treatment for addictions. Information about parasomnias related to rapid-eye-movement (REM) and non-REM sleep in patients with addictions, while using substances or in abstinence, was reviewed. A systematic search of published articles reporting parasomnias as a consequence of drug use or abuse was conducted in the PubMed and SciELO databases. The search for the studies was performed in three phases: (1) by title, (2) by abstract, and (3) by complete text. The search was performed independently by two researchers, who then compared their results from each screening phase. Seventeen articles were found. The consumption of alcohol was reported in association with arousal disorders, such as sexsomnia and sleep-related eating disorder; and REM sleep behavior disorder was reported during alcohol withdrawal. Cocaine abuse was associated with REM sleep behavior disorder with drug consumption dream content. Overall, we found that several types of parasomnias were very frequent in patients with addictions. To avoid accidents in bedroom, legal problems, and improve evolution and prognosis; must be mandatory to include security measures related to sleep period; avoid pharmacological therapy described as potential trigger factor; improve sleep hygiene; and give pharmacological and behavioral treatments for patients with these comorbid sleep disorders.

Sleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported cases.

STUDY OBJECTIVES: To update the literature on the diagnostic category of sleep-related dissociative disorders (SRDDs), involving psychogenic dissociation, since the time of their inclusion in the parasomnias section of the International Classification of Sleep Disorders, second edition, in 2005; to summarize the most salient clinical and video-polysomnographic (vPSG) findings and typical clinical profile from all reported cases; and to provide the rationale for the re-inclusion of the group of SRDDs in future editions of the International Classification of Sleep Disorders. METHODS: A systematic computerized literature search was conducted searching for SRDDs, nocturnal dissociative disorders, and nocturnal dissociation. RESULTS: Nine additional cases were identified, with sufficient clinical history and vPSG findings to justify the diagnosis of SRDDs, supplementing the 11 cases cited in the International Classification of Sleep Disorders, second edition, for a total of 20 cases. Twenty-six other cases with vPSG testing were found, with 18 cases reported in abstracts and 8 cases reported in a publication with compelling histories of SRDDs and 2 consecutive vPSG studies, but without the vPSG findings explicitly reported for any case. In more than half of all reported cases, there was objective diagnostic confirmation for SRDDs consisting of the hallmark finding of abnormal nocturnal behaviors arising from sustained electroencephalography wakefulness, or during wake-sleep transitions, without epileptiform activity. These nocturnal behaviors often replicated daytime psychogenic dissociative behaviors. A history of trauma (physical, sexual, emotional) was an almost universal finding, along with major psychopathology. All patients, except for one, had prominent histories of daytime dissociative disorders. Many of the patients were referred on account of a presumed parasomnia. CONCLUSIONS: Cases of SRDDs continue to be reported, often as a "parasomnia mimic," with psychogenic dissociation being clearly distinguished from physiologic sleep-wake dissociation as found in primary sleep disorders such as narcolepsy, rapid eye movement sleep behavior disorder, etc. Eleven reasons are provided for why the category of SRDDs should be re-included in future editions of the International Classification of Sleep Disorders, and in the parasomnias section.

Parasomnias: A Comprehensive Review.

Parasomnias are a group of sleep disorders characterized by abnormal, unpleasant motor verbal or behavioral events that occur during sleep or wake to sleep transitions. Parasomnias can occur during non-rapid eye movement (NREM) and rapid eye movement (REM) stages of sleep and are more commonly seen in children than the adult population. Parasomnias can be distressful for the patient and their bed partners and most of the time, these complaints are brought up by their bed partners because of the possible disruption in their quality of sleep. As clinicians, it is crucial to understand the characteristics of various parasomnias and address them with detailed sleep history and essential diagnostic approach for proper evaluation. The review aims to highlight the epidemiology, pathophysiology and clinical features of various types of parasomnias along with the appropriate diagnostic and pharmacological approach.

Parasomnias and antidepressant therapy: a review of the literature.

There exists a varying level of evidence linking the use of antidepressant medication to the parasomnias, ranging from larger, more comprehensive studies in the area of REM sleep behavior disorder to primarily case reports in the NREM parasomnias. As such, practice guidelines are lacking regarding specific direction to the clinician who may be faced with a patient who has developed a parasomnia that appears to be temporally related to use of an antidepressant. In general, knowledge of the mechanisms of action of the medications, particularly with regard to the impact on sleep architecture, can provide some guidance. There is a potential for selective serotonin reuptake inhibitors, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors to suppress REM, as well as the anticholinergic properties of the individual drugs to further disturb normal sleep architecture.