Home nocturnal infrared video to record non-rapid eye movement sleep parasomnias.

To assess the feasibility, the acceptability and the usefulness of home nocturnal infrared video in recording the frequency and the complexity of non-rapid eye movement sleep parasomnias in adults, and in monitoring the treatment response. Twenty adult patients (10 males, median age 27.5 years) with a diagnosis of non-rapid eye movement parasomnia were consecutively enrolled. They had a face-to-face interview, completed self-reported questionnaires to assess clinical characteristics and performed a video-polysomnography in the Sleep Unit. Patients were then monitored at home during at least five consecutive nights using infrared-triggered cameras. They completed a sleep diary and questionnaires to evaluate the number of parasomniac episodes at home and the acceptability of the home nocturnal infrared video recording. Behavioural analyses were performed on home nocturnal infrared video and video-polysomnography recordings. Eight patients treated by clonazepam underwent a second home nocturnal infrared video recording during five consecutive days. All patients had at least one parasomniac episode during the home nocturnal infrared video monitoring, compared with 75% during the video-polysomnography. A minimum of three consecutive nights with home nocturnal infrared video was required to record at least one parasomniac episode. Most patients underestimated the frequency of episodes on the sleep diary compared with home nocturnal infrared video. Episodes recorded at home were often more complex than those recorded during the video-polysomnography. The user-perceived acceptability of the home nocturnal infrared video assessment was excellent. The frequency and the complexity of the parasomniac episodes decreased with clonazepam. Home nocturnal infrared video has good feasibility and acceptability, and may improve the evaluation of the phenotype and severity of the non-rapid eye movement parasomnias and of the treatment response in an ecological setting.

The use and misuse of exogenous melatonin in the treatment of sleep disorders.

PURPOSE OF REVIEW: To explore the evidence for using exogenous melatonin in the treatment of sleep disorders, both primary and secondary, in children and adults. RECENT FINDINGS: A number of recently published meta-analyses have shown that there is evidence for the efficacy of exogenously administered melatonin in a number of sleep disorders. However, melatonin is likely to be prescribed largely for reasons of perceived minimal side-effect profile and very low cost in situations in which high-quality evidence for its usefulness is not forthcoming. SUMMARY: There is evidence for the efficacy of melatonin in the management of insomnia and some intrinsic disorders of circadian rhythm in adults and children as well as in reducing sleep onset latency in jet-lag and shift work disorder in adults. Melatonin is used routinely in the treatment of rapid-eye movement sleep-behaviour disorder despite limited trial evidence. Increasingly, dual melatonin receptor agonists are being trialled in a variety of sleep disorders. Long-term adverse effects are currently not fully identified.

Sleep related rhythmic movement disorder: phenotypic characteristics and treatment response in a paediatric cohort.

OBJECTIVE: To describe phenotypic, polysomnographic characteristics, impact, and treatment response in children with sleep related rhythmic movement disorder (SR-RMD). BACKGROUND: There is limited research on SR-RMD. We have developed a systematic clinical evaluation of children with SR-RMD to improve understanding and treatment. METHODS: A retrospective chart review of 66 children at a UK tertiary hospital. Baseline assessment included validated screening questionnaires to study autism spectrum characteristics, general behaviour and sensory profile. A standardised questionnaire assessed impact on sleep quality and daytime wellbeing of child and family. Polysomnography data were collated. RESULTS: Children were aged 0.9-16.3 years (78.8% male). 51.5% had a neurodevelopmental disorder, most commonly autism spectrum disorder. High rates of behavioural disturbance and sensory processing differences were reported, not confined to children with neurodevelopmental disorders. Parents reported concerns about risk of injury, loss of sleep and persistence into adulthood. Daytime wellbeing was affected in 72% of children and 75% of other family members. Only 31/48 children demonstrated rhythmic movements during video-polysomnography, occupying on average 6.1% of time in bed. Most clusters occurred in the settling period but also arose from N1, N2 and REM sleep and wake after sleep onset. Melatonin was prescribed to 52 children, all but one were extended-release preparations. 24/27 children with available data were reported to improve with melatonin. CONCLUSIONS: SR-RMD places a significant burden on child and family wellbeing. Our novel findings of sensory processing differences in this population and parent reported therapeutic response to extended-release melatonin offer potential avenues for future research.

Drug-induced sleep: theoretical and practical considerations.

Faithful replication of normal sleep through medications--can it be achieved? Departure from normal sleep with the use of drugs--when is it desired? Answers to these questions depend on accurate understanding of sleep and on concrete criteria upon which to define it. Since these elements are evolving sciences, as yet incompletely known, one might take a nihilistic approach that we simply cannot judge whether we have successfully replicated sleep, since we do not fully grasp what sleep is or what it does. To address these potential obstacles, our article is written in two sections. The first addresses theoretical considerations for how medications might be seen in the larger framework of sleep. The purpose of this section is to inform readers about key issues in evaluating whether a drug has sufficient data to persuasively argue it is re-creating sleep. (We hope that researchers interested in conducting studies, or critical readers of the drug-study literature, might find this section particularly useful.) The second section of this article approaches exemplary, current concepts of pharmacologic manipulation of sleep, organized by disorders as articulated by the International Classification of Sleep Disorders (2005). This second section will combine practical knowledge of clinical sleep medicine, with emphasis on contemporary knowledge about molecular mechanisms that are felt to underlie some of these phenomena. We recognize that our collective knowledge about sleep will advance in the coming years. We hope that this article serves to facilitate that advance.

Effective Treatment of Adult Parasomnias with Keishikaryukotsuboreito in Four Cases.

Parasomnias are undesirable behaviors or experiences during sleep that manifest clinically as abnormal behavior, emotions, and nightmares. We herein report four elderly parasomnia patients who were successfully treated for abnormal nocturnal behaviors, including rapid eye movement (REM) sleep behavior disorders, with Keishikaryukotsuboreito (KRB), a Japanese traditional herbal medicine. KRB resolved nocturnal violent behaviors and sleep walking without any adverse effects. In one patient, occipital dominant spike-wave complexes induced by 3-Hz photic stimulation were reduced after KRB treatment, suggesting that KRB has inhibitory effects on brain irritability. KRB may represent a safe therapeutic option for treating parasomnias in the elderly.

Epilepsy and sleep.

PURPOSE OF REVIEW: There is a complex relationship between epilepsy, sleep and sleep disorders. Recent studies have provided new insights into the links between the disorders that may facilitate differential diagnosis and treatment but may also improve our understanding of underlying pathophysiological mechanisms. RECENT FINDINGS: Sleep and sleep deprivation have long been recognized to influence interictal epileptiform discharges and seizures. More recent studies have shown that primary sleep disorders such as obstructive sleep apnoea may worsen epilepsy and treatment of these sleep disorders can lead to improved seizure control. Seizures may interfere with night-time sleep structure and cause excessive day-time somnolence (EDS). Antiepileptic drugs may also cause EDS or influence sleep. Despite more frequent use of video-electroencephalographic telemetry and polysomnography, the differential diagnostic challenges between nonrapid eye movement parasomnia and nocturnal frontal lobe epilepsy remain. There is also ongoing debate regarding the possibility of a common pathogenic background for parasomnias and nocturnal seizures that is summarized in the review. SUMMARY: Accurate identification and diagnosis of sleep disorders as well as epilepsy is clinically important to ensure optimal treatment of both epilepsy and sleep disorders. Further studies of these nocturnal events may advance our understanding of underlying pathological mechanisms and the complex relationship between sleep and epilepsy.

Kambakutaisoto Treatment for Children With Night Crying and Arousal Parasomnias Developed During Prolonged Hospitalization for Hematological and Oncological Diseases.

OBJECTIVE: The lack of an established treatment standard prompted an examination of whether kambakutaisoto, an herbal formula, is effective for non-rapid eye movement (NREM)-related parasomnias and night crying (provisionally defined as an infantile form of arousal parasomnia). METHODS: This study included 137 children aged median 4.1 years (range, 0.02-18.5) who were admitted for hematological and oncological diseases. RESULTS: Of 137, 3 children developed recurrent episodes of NREM-related parasomnias, and 3 developed night crying. The proportion of children with night-crying/parasomnia receiving invasive procedures was significantly higher than those without (100% vs. 47%, P = .013). All 6 children with night crying/parasomnia received kambakutaisoto at a dose of 0.13-0.22 g/kg per os and responded from the start of administration with a significant reduction in the number of episodes. No adverse effects were observed. CONCLUSION: Kambakutaisoto may be a safe and promising therapy for night crying and NREM-related parasomnias in children.

Resolution of sexsomnia with paroxetine.

None: Sexsomnia is a parasomnia consisting of sexual behavior during non-rapid eye movement sleep. To date, there have been 116 clinical cases of sexsomnia reported and most were treated with clonazepam. We present a case of an adult male with sexsomnia that started during his college days. He presented to us because of problems in his current marriage arising from sexual behavior during sleep. Polysomnography revealed no significant sleep-disordered breathing, electroencephalography abnormality, or abnormal movement during non-rapid eye movement and rapid eye movement (REM) sleep. Alcohol consumption was reported to worsen his sexsomnia. To avoid the neuro-depressant effects of benzodiazepines, paroxetine was administered and resulted in complete resolution of sexsomnia.

Drugs Used in Parasomnia.

Patient education and behavioral management represent the first treatment approaches to the patient with parasomnia, especially in case of disorders of arousal (DOA). A pharmacologic treatment of DOA may be useful when episodes are frequent and persist despite resolution of predisposing factors, are associated with a high risk of injury, or cause significant impairment, such as excessive sleepiness. Approved drugs for DOA are still lacking. The most commonly used medications are benzodiazepines and antidepressants. The pharmacologic treatment of rapid eye movement sleep behavior disorder is symptomatic, and the most commonly used drugs are clonazepam and melatonin.

Encephalopathy related to status epilepticus during sleep due to a de novo KCNA1 variant in the Kv-specific Pro-Val-Pro motif: phenotypic description and remarkable electroclinical response to ACTH.

Although the classic phenotype of episodic ataxia type 1 (EA1) caused by variants in KCNA1 includes episodic ataxia and myokymia, further genotype-phenotype correlations are difficult to establish due to highly heterogeneous clinical presentations associated with KCNA1 pathogenic variants. De novo variants in the paralogous Pro-Val-Pro motif (PVP) of KCNA2, an essential region for channel gating, have been reported to be associated with severe epilepsy phenotypes, including developmental and epileptic encephalopathies (DEE). Here, we describe the first patient with a DEE who developed an encephalopathy related to status epilepticus during sleep (ESES) and cerebellar signs, harbouring a variant in the Kv-specific PVP motif of the KCNA1 gene. Interestingly, he showed a remarkable long-term electroclinical response to IM ACTH therapy. This report extends the range of phenotypes associated with KCNA1 variants to include that of ESES, and suggests that ACTH therapy is likely to have a positive effect in patients with these variants.

NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients.

BACKGROUND: Non-REM parasomnias are not uncommon conditions in the general population. Current treatment options are based on small case series and reports. In this study, we aimed to present the clinical experience from a large cohort of patients. PATIENTS: Five hundred and twelve patients with Non-REM parasomnia or parasomnia overlap disorder (POD), who had undergone a video polysomnography and were exposed to treatment, were retrospectively identified. Treatment outcome was assessed based on patients' reports, and treatment approach on a locally accepted hierarchy of interventions. RESULTS: Forty percent of patients were diagnosed with sleepwalking, 23.8% with mixed-phenotype and 10% with POD. Ultimately, 97.2% reported adequate control of their symptoms. Moreover, 60.1% were treated with pharmacotherapy and 32.0% without, consistent across all phenotypes (p = 0.09). Benzodiazepines were the most common drugs prescribed (47.1%, p < 0.05). In the end, 37.7% of our patients were receiving a benzodiazepine as part of their successful treatment, 11.7% an antidepressant, 9.2% a z-drug, and 10.7% melatonin. Finally, 13.2%, 12.1%, and 5.8% of our patients reported good control of their symptoms with sleep hygiene, management of sleep-disordered breathing, and psychological interventions (cognitive behavioral therapy [CBT] or mindfulness-based stress reduction [MBSR]), as monotherapy, respectively. CONCLUSION: The treatment approach to effective treatment of the patients with Non-REM parasomnias or POD offering first sleep hygiene advice, next treatment of concurrent sleep disorders and management of other priming factors like stress and anxiety, and lastly pharmacotherapy for Non-REM parasomnia is supported by our results. Non pharmacological interventions were effective in one third of our patients, and CBT/MBSR and melatonin appeared promising new treatments.

British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update.

This British Association for Psychopharmacology guideline replaces the original version published in 2010, and contains updated information and recommendations. A consensus meeting was held in London in October 2017 attended by recognised experts and advocates in the field. They were asked to provide a review of the literature and identification of the standard of evidence in their area, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. Each presentation was followed by discussion, aiming to reach consensus where the evidence and/or clinical experience was considered adequate, or otherwise to flag the area as a direction for future research. A draft of the proceedings was circulated to all speakers for comments, which were incorporated into the final statement.

A Case of Buspirone Demonstrating Immediate and Sustained Benefit in a Man With Lifelong Non-Rapid-Eye-Movement Parasomnias.

BACKGROUND: Non-rapid-eye-movement (NREM) parasomnias are disorders of sleep ranging from confusional arousals to sleepwalking and sleep-related eating disorders. Historically, antidepressants and benzodiazepines were recommended in treatment of NREM parasomnias. In this case report, we are reporting the use of buspirone in a patient with NREM parasomnias, which produced substantial resolution of symptoms. CASE PRESENTATION: A 38-year-old man presented with confusional arousals and somnambulism. In addition, the patient had significant anxiety with work-related stress. Given the patient's concerns of side effect profile of other medications indicated in NREM parasomnias and the patient's history of anxiety, we started the patient on buspirone. The patient had significant improvement in his symptoms immediately after starting the medication with sustained relief from symptoms. CONCLUSION: Buspirone can be considered an effective alternate treatment option for NREM parasomnias when other medications are not preferred or cannot be prescribed.

Improvement of Parasomnias After Treatment of Restless Leg Syndrome/ Periodic Limb Movement Disorder in Children.

STUDY OBJECTIVES: Previous studies have shown that non-rapid eye movement (NREM) sleep parasomnias commonly coexist with restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) in children, leading to speculation that RLS/PLMD may precipitate or worsen parasomnias. However, there are limited data about the effect of the treatment of RLS/PLMD on parasomnias in children. Hence, we performed this study to determine whether the treatment of RLS/PLMD with oral iron therapy is associated with improvement of parasomnias in children. METHODS: A retrospective database was created for children with RLS/PLMD who were treated with iron therapy. These participants were followed for at least 1 year at Cincinnati Children's Hospital Medical Center. All participants had ferritin level testing and were treated with iron therapy. In addition, all participants underwent polysomnography before starting iron therapy for RLS/PLMD except for one participant who was already on iron but required a higher dose. Most participants underwent polysomnography after iron therapy. RESULTS: A total of 226 participants were identified with the diagnosis of RLS/PLMD. Of these, 50 had parasomnias and 30 of them were treated with iron therapy. Of the 30 participants, RLS symptoms improved in 15 participants (50%) and resolution of parasomnias was noted in 12 participants (40%) participants after iron therapy. Repeat polysomnography after iron therapy was performed in 21 participants (70%). After iron therapy, there was a significant decrease in periodic limb movement index (17.2 ± 8.8 [before] versus 6.7 ± 7.3 [after] events/h, P < .001). In addition, there were significant decreases in PLMS (24.52 ± 9.42 [before] versus 7.50 ± 7.18 [after] events/h, P < .0001), PLMS-related arousals (4.71 ± 1.81 [before] versus 1.35 ± 1.43 [after] events/h, P < .0001), and total arousals (11.65 ± 5.49 [before] versus 8.94 ± 3.65 [after] events/h, P < .01) after iron therapy. CONCLUSIONS: Parasomnias are common in our cohort of children with RLS/PLMD. Iron therapy was associated with a significant improvement in periodic limb movement index, RLS symptoms, and resolution of a significant proportion of NREM sleep parasomnias, suggesting that RLS/PLMD may precipitate NREM sleep parasomnia.

Sleep-Related Orgasms in a 57-Year-Old Woman: A Case Report.

ABSTRACT: We report a case of problematic spontaneous orgasms during sleep in a 57-year-old woman who also complained of hypnic jerks and symptoms of exploding head syndrome. To our knowledge, this is the first case report in the English language literature of problematic spontaneous orgasms during sleep. She had a complex medical and psychiatric history, and was taking oxycontin, venlafaxine, amitriptyline, and lurasidone. Prolonged video electroencephalogram monitoring did not record any ictal or interictal electroencephalogram discharges, and nocturnal video polysomnography monitoring did not record any behavioral or orgasmic event. Periodic limb movement index was zero events/h. Severe central sleep apnea was detected with apnea-hypopnea index = 130 events/h, but she could not tolerate positive airway pressure titration. Sleep architecture was disturbed, with 96.4% of sleep spent in stage N2 sleep. Bedtime clonazepam therapy (1.5 mg) was effective in suppressing the sleep-related orgasms and hypnic jerks.

Two Cases of Sleep-Related Eating Disorder Responding Promptly to Low-Dose Sertraline Therapy.

ABSTRACT: We report two cases of adult males with sleep-related eating disorder (SRED), with durations of 3 and 7 years, and without associated psychiatric history. In both cases, the use of low-dose (25 mg) sertraline taken at bedtime resulted in immediate, full and sustained resolution of symptoms at the latest follow-ups. The sertraline efficacy was of particular benefit for the patient reported on in case 2 who was a commercial airline pilot subjected to a highly restricted list of Federal Aviation Administration-approved medications. Risk factors for SRED included smoking cessation and work-related stress in case 1, and a history of sleepwalking and work-related circadian disruptions and partial sleep deprivations in case 2. Sertraline therapy of SRED is considered within a review of all current pharmacologic therapies of SRED.

Drugs Used in Parasomnia.

Patient education and behavioral management represent the first treatment approaches to the patient with parasomnia, especially in case of disorders of arousal (DOA). A pharmacologic treatment of DOA may be useful when episodes are frequent and persist despite resolution of predisposing factors, are associated with a high risk of injury, or cause significant impairment, such as excessive sleepiness. Approved drugs for DOA are still lacking. The most commonly used medications are benzodiazepines and antidepressants. The pharmacologic treatment of rapid eye movement sleep behavior disorder is symptomatic, and the most commonly used drugs are clonazepam and melatonin.

L-Tryptophan As Treatment for Pediatric Non-Rapid Eye Movement Parasomnia.

OBJECTIVE: Parasomnias are common in childhood but there is no established treatment for parasomnias. The aim of this study was to (1) report on the outcome of using L-tryptophan to manage parasomnias in children and (2) examine sleep architecture and subjective psychological/sleep symptoms in children with parasomnia. METHOD: A retrospective analysis was conducted of charts of children (3-18 years old) who underwent polysomnographic testing and were diagnosed with primary parasomnia. Study patients were either prescribed L-tryptophan (daily dose range: 500-4500 mg, mean dose of 2400 mg) to manage their parasomnias or administered no treatment whereby parents/guardians declined treatment. Questionnaires assessing sleep and psychosocial symptoms were administered at the initial clinical consultation and a follow-up parasomnia outcome questionnaire was administered over the phone to parents/guardians. RESULTS: One hundred and sixty-five children (106 boys, 59 girls) received a sleep diagnosis of primary parasomnia. A significantly (p < 0.001) higher proportion (84%) of children taking L-tryptophan experienced improvements in their parasomnia symptoms compared with those (47%) who chose not to use L-tryptophan. Polysomnography revealed that children with parasomnias had an altered sleep architecture based on age-related normative values. Children with a diagnosis of parasomnia were also subjectively more fatigued and endorsed more depressive symptoms. CONCLUSIONS: This study finds that parasomnias in children are not benign and that treatment with L-tryptophan provides a favorable outcome. Children diagnosed with parasomnia had altered sleep architecture, were more fatigued, and endorsed depressive symptoms. This study supports the need to diagnose and treat parasomnias in children.