Somnambulism.

Somnambulism, also called sleepwalking, classified as a non-rapid eye movement sleep parasomnia, encompasses a range of abnormal paroxysmal behaviors, leading to sleepwalking in dissociated sleep in an altered state of consciousness with impaired judgment and configuring a kind of hierarchical continuum with confusional arousal and night terror. Despite being generally regarded as a benign condition, its potential severity entails social, personal, and even forensic consequences. This comprehensive review provides an overview on the current state of knowledge, elucidating the phenomenon of somnambulism and encompassing its clinical manifestations and diagnostic approaches.

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.

NonREM Disorders of Arousal and Related Parasomnias: an Updated Review.

Parasomnias are abnormal behaviors and/or experiences emanating from or associated with sleep typically manifesting as motor movements of varying semiology. We discuss mainly nonrapid eye movement sleep and related parasomnias in this article. Sleepwalking (SW), sleep terrors (ST), confusional arousals, and related disorders result from an incomplete dissociation of wakefulness from nonrapid eye movement (NREM) sleep. Conditions that provoke repeated cortical arousals, and/or promote sleep inertia, lead to NREM parasomnias by impairing normal arousal mechanisms. Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders. Sleep-related eating disorder (SRED) is characterized by a disruption of the nocturnal fast with episodes of feeding after arousal from sleep. SRED is often associated with the use of sedative-hypnotic medications, in particular the widely prescribed benzodiazepine receptor agonists. Compelling evidence suggests that nocturnal eating may in some cases be another nonmotor manifestation of Restless Legs Syndrome (RLS). Initial management should focus upon decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders and eliminating incriminating drugs. Sexsomnia is a subtype of disorders of arousal, where sexual behavior emerges from partial arousal from nonREM sleep. Overlap parasomnia disorders consist of abnormal sleep-related behavior both in nonREM and REM sleep. Status dissociatus is referred to as a breakdown of the sleep architecture where an admixture of various sleep state markers is seen without any specific demarcation. Benzodiazepine therapy can be effective in controlling SW, ST, and sexsomnia, but not SRED. Paroxetine has been reported to provide benefit in some cases of ST. Topiramate, pramipexole, and sertraline can be effective in SRED. Pharmacotherapy for other parasomnias continues to be less certain, necessitating further investigation. NREM parasomnias may resolve spontaneously but require a review of priming and predisposing factors.

The Arousal Disorders Questionnaire: a new and effective screening tool for confusional arousals, Sleepwalking and Sleep Terrors in epilepsy and sleep disorders units.

BACKGROUND: Arousal Disorders (DoA) include Confusional Arousals, Sleepwalking and Sleep Terrors. DoA diagnosis is mainly clinical but no validated questionnaires exist for DoA screening according to the criteria of the International Classification of Sleep Disorders, Third Edition. Recently our group proposed the Arousal Disorders Questionnaire (ADQ) as a new diagnostic tool for DoA diagnosis. The objective of this study was to evaluate the diagnostic accuracy of the ADQ in a sleep and epilepsy center. METHODS: One interviewer blinded to clinical and video-polysomnographic (VPSG) data administered the ADQ to 150 patients consecutively admitted to our Sleep and Epilepsy Centers for a follow-up visit. The final diagnosis, according to VPSG recordings of at least one major episode, classified patients either with DoA (DoA group) or with other sleep-related motor behaviors confounding for DoA (nDoA group). RESULTS: 47 patients (31%) composed the DoA group; 56 patients with REM sleep behavior disorder, 39 with sleep-hypermotor epilepsy, six with night eating syndrome, and two with drug-induced DoA composed the nDoA group. The ADQ had a sensitivity of 72% (95% CI: 60-82) and a specificity of 96% (95% CI: 89-98) for DoA diagnosis; excluding the items regarding consciousness and episode recall, sensitivity was 83% (95% CI: 71-90) and specificity 93% (95% CI: 86-97). CONCLUSIONS: The ADQ showed good accuracy in screening patients with DoA in a sleep and epilepsy center setting. Diagnostic criteria related to cognition and episode recall reduced ADQ sensitivity, therefore a better definition of these criteria is required, especially in adults.

Video-Polysomnographic Assessment for the Diagnosis of Disorders of Arousal in Children.

OBJECTIVES: To highlight the slow-wave sleep (SWS) fragmentation and validate the video-polysomnographic (vPSG) criteria and cutoffs for the diagnosis of disorders of arousal (DOA) in children, as already reported in adults. METHODS: One hundred children (66 boys, 11.0 ± 3.3 years) with frequent episodes of DOA and 50 nonparasomniac children (32 boys, 10.9 ± 3.9 years) underwent vPSG recording to quantify SWS characteristics (number of N3 sleep interruptions, fragmentation index, slow/mixed and fast arousal ratios, and indexes per hour) and associated behaviors. We compared SWS characteristics in the 2 groups and defined the optimal cutoff values for the diagnosis of DOA using receiver operating characteristic curves. RESULTS: Patients with DOA had higher amounts of N3 and REM sleep, number of N3 interruptions, SWS fragmentation, and slow/mixed arousal indexes than controls. The highest area under the curve (AUC) values were obtained for SWS fragmentation and slow/mixed arousal indexes with satisfactory classification performances (AUC 0.80, 95% confidence interval [CI] 0.73-0.87; AUC 0.82, 95% CI 0.75-0.89). SWS fragmentation index cutoff value of 4.1/h reached a sensitivity of 65.0% and a specificity of 84.0%. Slow/mixed arousal index cutoff of 3.8/h reached a sensitivity of 69.0% and a specificity of 82.0%. At least one parasomniac episode was recorded in 63.0% of patients and none of the controls. Combining behavioral component by vPSG increased sensitivity of both biomarkers to 83% and 89%, respectively. CONCLUSIONS: We confirmed that SWS fragmentation and slow/mixed arousal indexes are 2 relevant biomarkers for the diagnosis of DOA in children, with different cutoffs obtained than those validated in adults. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that SWS fragmentation and slow/mixed arousal indexes on vPSG accurately identify children with DOA.

Interobserver reliability of ICSD-3 diagnostic criteria for disorders of arousal in adults.

PURPOSE: Disorders of arousal include confusional arousals, sleepwalking and sleep terrors. The diagnosis of disorders of arousal is based on the clinical criteria established in the International Classification of Sleep Disorders, third edition, although the interobserver reliability of these criteria has never been investigated. The aim of this study was to estimate the inter-rater reliability of the diagnostic criteria for disorders of arousal throughout the whole life in order to understand their feasibility in clinical daily activity and in multicenter observational studies. METHODS: Three raters interviewed 126 subjects (patients complaining of sleep disorders, headache, and healthy subjects), aged 18-80 years, with a standardized questionnaire created by applying the International Diagnostic Criteria for Disorders of Arousal. RESULTS: An "almost perfect" inter-rater reliability for disorders of arousal criteria and the final diagnosis was found among the raters (kappa 0.89 for confusional arousals, 0.87 for sleepwalking, and 0.87 for sleep terrors). CONCLUSIONS: The International Classification of Sleep Disorders, Third Edition criteria are adequate for a reliable diagnosis of disorders of arousal. Further validation studies, confirming DOA diagnosis with video polysomnography, are needed to investigate the predictive value of ICSD-3 criteria.

Neurocognitive performance in insomnia disorder: The impact of hyperarousal and short sleep duration.

Given the recent evidence on the association between hyperarousal in insomnia disorder and neurocognitive deficits, we aimed to examine the effect of short sleep duration on neurocognitive reaction time tests in insomnia disorder sufferers. We recruited subjects with insomnia disorder (n = 35, mean age = 40.6 years) who scored ≥29 on a Hyperarousal Scale, and a group of controls (n = 54, mean age = 31.5 years) who had no sleep disorders and scored <26 on the Hyperarousal Scale. Participants completed two in-home polysomnograms and four daytime trials of neurocognitive tests, including simple reaction time, choice reaction time, big circle-little circle, rapid visual information processing, attention switching task, and spatial working memory tests. Total sleep time divided study cohorts into subgroups of short (total sleep time <6 hr) and normal (total sleep time ≥6 hr) sleepers. ANCOVA showed a significant interaction between participant type (insomnia disorder versus controls) and sleep duration (short versus normal) for spatial working memory-latency (p = 0.020) and spatial working memory-errors (p = 0.025). The short-sleeping insomnia disorder group had longer spatial working memory-latencies and more spatial working memory-errors than did normal-sleeping controls. Regardless of sleep duration, those with insomnia disorder had more attentional deficits with longer attention switching task-latency (p = 0.011) and more attention switching task-incorrect trials (p = 0.015) than the control group. Normal-sleepers only had longer attention switching task-latency than short-sleepers (p = 0.004). A phenotype of insomnia disorder with hyperarousal and short sleep duration is associated with daytime cognitive deficits in complex attentional and spatial working memory tasks.

Confusional arousals during non-rapid eye movement sleep: evidence from intracerebral recordings.

Study Objectives: Confusional arousals (CA) are characterized by the association of behavioral awakening with persistent slow-wave electroencephalographic (EEG) activity during non-rapid eye movement (NREM) sleep-suggesting that sensorimotor areas are "awake" while non-sensorimotor areas are still "asleep." In the present work, we aimed to study the precise temporo-spatial dynamics of EEG changes in cortical areas during CA using intracerebral recordings. Methods: Nineteen episodes of CA were selected in five drug-resistant epileptic patients suffering incidentally from arousal disorders. Spectral power of EEG signal recorded in 30 non-lesioned, non-epileptogenic cortical areas and thalamus was compared between CA and baseline slow-wave sleep. Results: Clear sequential modifications in EEG activity were observed in almost all studied areas. In the last few seconds before behavior onset, an increase in delta activity occurred predominantly in frontal regions. Behavioral arousal was associated with an increase of signal power in the whole studied frequency band in the frontal lobes, cingulate cortex, insular cortex, and precuneus. Afterwards, a diffuse cessation of very low frequencies (<1 Hz) occurred. Simultaneously, a hypersynchronous delta activity (HSDA) (1-1.5 Hz) arose in a broad network involving medial and lateral frontoparietal cortices, whereas higher frequency activities increased in sensorimotor, orbitofrontal, and temporal lateral cortices. This HSDA was predominantly observed in the inferior frontal gyrus. Conclusions: During CA, the level of activity changed in almost all the studied areas. The embedding of a broad frontoparietal network, especially the inferior frontal gyrus, in an HSDA might explain the participants' altered state of consciousness.

An interprofessional approach to managing children with treatment-resistant enuresis: an educational review.

Enuresis (intermittent urinary incontinence during sleep in a child aged ≥ 5 years) is commonly seen in paediatric practice. Despite the availability of effective interventions, treatment resistance is encountered in up to 50% of children. In this educational review we attempt to provide insight into the causes of treatment resistance, and offer practical suggestions for addressing this condition using an interprofessional approach. We explore the pathophysiology of and standard treatments for enuresis and discuss why standard treatments may fail. An interprofessional approach to treatment resistance is proposed which utilises the expertise of professionals from different disciplines to address the problems and barriers to treatment. The two interprofessional approaches include a multidisciplinary approach that involves the patient being sent to experts in different disciplines at different times to address their treatment resistance utilising the skills of the respective experts, and an interdisciplinary approach that involves a patient being managed by members of interdisciplinary team who integrate their separate discipline perspectives into a single treatment plan. Although an interdisciplinary approach is ideal, interdisciplinary teams may not be available in all circumstances. Understanding the roles of other disciplines and engaging clinicians from other disciplines when appropriate can still be helpful when treatment resistance is encountered.

Non-Rapid Eye Movement Sleep and Overlap Parasomnias.

PURPOSE OF REVIEW: This article reviews the spectrum of non-rapid eye movement (non-REM) sleep parasomnias, including sleepwalking, confusional arousals, and sleep terrors, which represent the range of phenotypic disorders of arousal from non-REM sleep that occurs in children and adults. RECENT FINDINGS: The International Classification of Sleep Disorders, Third Edition (ICSD-3) classifies parasomnias according to the sleep stage they emerge from: REM, non-REM, or other. Demographics, clinical features, and diagnosis of non-REM parasomnias are reviewed in this article, and an up-to-date synopsis of guidelines for management strategies to assist in the treatment of these sleep disorders is provided. SUMMARY: The non-REM parasomnias are most common in children and adolescents but may persist into adulthood. They can be distinguishable from REM parasomnias and nocturnal epilepsies, and, importantly, may lead to injury. Additionally, other parasomnias in this spectrum include sleep-related eating disorder and sexsomnia. Overlap parasomnia disorder includes one or more manifestations of a non-REM parasomnia seen in combination with REM sleep behavior disorder, representing an apparent erosion of the normally distinct stages of non-REM and REM sleep. A similar yet much more extreme dissociation of states underlies agrypnia excitata and status dissociatus, which represent rare, severe dissociations between non-REM, REM, and wake states resulting clinically in oneiric behaviors and severe derangement of normal polysomnographic wake and sleep stage characteristics. Management of non-REM and overlap parasomnias and state dissociation disorders include ensuring bedroom safety and prescription of clonazepam or hypnosis, in select cases, although in children and adolescents with noninjurious behaviors, non-REM parasomnias are often age-limited developmental disorders, which may ultimately remit by adulthood, and, in these cases, counseling and education alone may suffice. Timely and accurate recognition of the non-REM and overlap parasomnias is crucial to limiting potential patient injury.

Debating the Role of Arousal in Delirium Diagnosis: Should Delirium Diagnosis Be Inclusive or Restrictive?

Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.

Obstructive sleep apnea exaggerates cognitive dysfunction in stroke patients.

BACKGROUND: Obstructive sleep apnea (OSA) is very common in stroke survivors. It potentially worsens the cognitive dysfunction and inhibits their functional recovery. However, whether OSA independently damages the cognitive function in stroke patients is unclear. A simple method for evaluating OSA-induced cognitive impairment is also missing. METHODS: Forty-four stroke patients six weeks after onset and 24 non-stroke patients with snoring were recruited for the polysomnographic study of OSA and sleep architecture. Their cognitive status was evaluated with a validated Chinese version of Cambridge Prospective Memory Test. The relationship between memory deficits and respiratory, sleeping, and dementia-related clinical variables were analyzed with correlation and multiple linear regression tests. RESULTS: OSA significantly and independently damaged time- and event-based prospective memory in stroke patients, although it had less power than the stroke itself. The impairment of prospective memory was correlated with increased apnea-hypopnea index, decreased minimal and mean levels of peripheral oxygen saturation, and disrupted sleeping continuity (reduced sleep efficiency and increased microarousal index). The further regression analysis identified minimal levels of peripheral oxygen saturation and sleep efficiency to be the two most important predictors for the decreased time-based prospective memory in stroke patients. CONCLUSIONS: OSA independently contributes to the cognitive dysfunction in stroke patients, potentially through OSA-caused hypoxemia and sleeping discontinuity. The prospective memory test is a simple but sensitive method to detect OSA-induced cognitive impairment in stroke patients. Proper therapies of OSA might improve the cognitive function and increase the life quality of stroke patients.

Nocturnal agitation in Huntington disease is caused by arousal-related abnormal movements rather than by rapid eye movement sleep behavior disorder.

BACKGROUND: Patients with Huntington disease (HD) and their spouses often complain of agitation during sleep, but the causes are mostly unknown. OBJECTIVE: To evaluate sleep and nocturnal movements in patients with various HD stages and CAG repeats length. METHODS: The clinical features and sleep studies of 29 patients with HD were retrospectively collected (11 referred for genotype-phenotype correlations and 18 for agitation during sleep) and compared with those of 29 age- and sex-matched healthy controls. All patients had videopolysomnography, but the movements during arousals were re-analyzed in six patients with HD with stored video. RESULTS: The patients had a longer total sleep period and REM sleep onset latency, but no other differences in sleep than controls. There was no correlation between CAG repeat length and sleep measures, but total sleep time and sleep efficiency were lower in the subgroup with moderate than milder form of HD. Periodic limb movements and REM sleep behavior disorders were excluded, although 2/29 patients had abnormal REM sleep without atonia. In contrast, they had clumsy and opisthotonos-like movements during arousals from non-REM or REM sleep. Some movements were violent and harmful. They might consist of voluntary movements inappropriately involving the proximal part of the limbs on a background of exaggerated hypotonia. Giant (>65 mcV) sleep spindles were observed in seven (24%) patients with HD and one control. CONCLUSION: The nocturnal agitation in patients with HD seems related to anosognostic voluntary movements on arousals, rather than to REM sleep behavior disorder and other sleep problems.

Sexsomnia: sleep sex research and its legal implications.

"Sleep sex," also known as sexsomnia, is a sleep disorder characterized by sexual behaviors committed while asleep. There has recently been increased interest in sexsomnia due to controversies arising in legal trials that have been widely publicized in the social and public media. This article attempts to marshal the current information about sexsomnia from the forensic literature and provides an overview of sexsomnia including common features, precipitating factors, prevalence rates, diagnostic procedures, and treatment. As sexsomnia represents a condition in which sexual acts are committed without awareness or intention, this paper also reviews the development of sexsomnia as a legal defense and summarizes Canadian case law on the topic. It provides an overview of the hurdles presented to defense attorneys attempting to utilize the defense and examines popular public notions surrounding the legitimacy of sexsomnia and the possibility of malingering. We conclude that sexsomnia is a legitimate sleep disorder for which case law now exists to support its use in legal defenses based on automatism. The question of whether it is an example of "sane" or "insane" automatism remains to be determined by the courts. Regardless of whether or not sexsomnia is determined to be a mental disorder by the courts, it is now a recognized and well-described sleep disorder that can be safely treated and managed by knowledgeable clinicians.

Sleep-related cortical arousals in adult subjects with negative polysomnography.

PURPOSE: The arousal index (AI) quantifies cortical arousal relative to total sleep time and is widely used to determine the severity of sleep fragmentation. It usually includes arousals secondary to respiratory events, limb movements, and spontaneous arousals. No systematic studies have been undertaken to determine AI cutoff in subjects with negative polysomnography. METHODS: Three hundred fifty polysomnograms of subjects ≥18 years of age with no sleep disorders (apnea-hypopnea index (AHI) <5, periodic limb movement index (PLMI) <10, no upper airway resistance syndrome) or minimum oxygen saturation > 90 % and no comorbid health problems were reviewed. RESULTS: Basic sleep architecture appears within normal range, except for increased stage N2 and decreased stage N3. AI significantly correlated with age (r = 0.7), sleep efficiency (r =-0.16), sleep latency (r = 0.14), rapid eye movement (REM) latency (r = 0.12), stage N1 (r = 0.15), stage N2 (r = 0.12), stage N3 (r = -0.27), AHI (r = 0.24), PLMI (r = 0.18), and nadir oxygen saturation (r = -0.17) [p < 0.05 for all]. A significant correlation was noted between age and sleep efficiency (r = -0.19), REM latency (r = 0.13), stage N1 (r = 0.16), stage N2 (r = 0.21), stage N3 (r = -0.39), and nadir oxygen saturation (r = -0.16) [p < 0.05 for all]. Multiple linear regression analysis showed that age is only the independent predictor of AI (R (2) = 0.70, p < 0.01). The prediction equation for the arousal index in subject with negative polysomnography is AI = 0.276 × age (year) + 8.018. CONCLUSIONS: Age is the most important independent factor in predicting increasing AI in subjects with negative polysomnography.

The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is safer.

BACKGROUND: Delirium is a common and serious problem among acutely unwell persons. Although linked to higher rates of mortality, institutionalisation and dementia, it remains underdiagnosed. Careful consideration of its phenomenology is warranted to improve detection and therefore mitigate some of its clinical impact. The publication of the fifth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-5) provides an opportunity to examine the constructs underlying delirium as a clinical entity. DISCUSSION: Altered consciousness has been regarded as a core feature of delirium; the fact that consciousness itself should be physiologically disrupted due to acute illness attests to its clinical urgency. DSM-5 now operationalises 'consciousness' as 'changes in attention'. It should be recognised that attention relates to content of consciousness, but arousal corresponds to level of consciousness. Reduced arousal is also associated with adverse outcomes. Attention and arousal are hierarchically related; level of arousal must be sufficient before attention can be reasonably tested. SUMMARY: Our conceptualisation of delirium must extend beyond what can be assessed through cognitive testing (attention) and accept that altered arousal is fundamental. Understanding the DSM-5 criteria explicitly in this way offers the most inclusive and clinically safe interpretation.

[Confusional arousal: a rare cause of self-injurious behaviour]. / Confusional arousal als zeldzame oorzaak van zelfverwonding.

Non-rapid eye movement (NREM) arousal sleep disorders (confusional arousal, somnambulism and sleep terror) are self-limiting and temporary phenomena which cannot be attributed to medical or psychiatric factors. However, very occasionally they can be the cause of unintentional injury to self or others. We describe the case of an 18-year-old who engaged in self-injurious behaviour while asleep. This behaviour could be attributed to confusional arousal.