PARASOMNIAS

CHAIR PERSON : DR. V.K.BHAT PRESENTER : DR. CAROLINE

SLEEP DISORDERS

Dyssomnias: primarily psychogenic conditions in which the predominant disturbance is in the amount, quality, or timing of sleep insomnia, hypersomnia, disorders of sleep-wake schedule

PARASOMNIAS
Also referred to as disorders of partial arousal Diverse collection of sleep disorders char by physiological or behavioral phenomena that occur during or are potentiated by sleep Activation of physiological systems ANS, motor system, cognitive process at inappropriate times during sleep or sleepwake transition

DEFINITION

DSM IV TR Abnormal behavioral or physiological events occurring in association with sleep, specific sleep stages, or sleep wake transitions

ICD 10 Abnormal episodic events occurring during sleep; in childhood these are related mainly to development, while in adulthood they are predominantly psycho genic, i.e., sleep walking, sleep terrors and nightmares.

STATE BOUNDARY VIOLATIONS SEEN IN PARASOMNIAS

Overlaps or intrusions of one basic sleep-wake state into another Wakefulness, NREM sleep and REM sleep can be char as three basic states that differ in their neurological organization Wakefulness: body and brain- active NREM sleep: much less active REM sleep: pairs atonic body with an active

AROUSAL DISORDERS: momentary or partial wakeful behaviors suddenly occurring in NREM( slow wave) sleep. E.g., confusional arousal, sleep walk, sleep terror TRANSITION DISORDERS: Isolated sleep paralysis is persistence of REM atonia into wakefulness transition REM behavior disorder: failure of mechanism of REM atonia, where individuals literally act out their dream.

TYPES OF PARASOMNIAS: ICSD 2 CLASSIFICATION:

DISORDERS OF AROUSAL FROM NREM SLEEP 1. Sleepwalking 2. Sleep terrors 3. Confusional arousals

PARASOMNIAS USUALLY ASSOCIATED WITH REM SLEEP 1. REM Sleep behavior disorder 2. Recurrent isolated sleep paralysis 3. Nightmare disorder

OTHER PARASOMNIAS
Sleep -related dissociative disorder Sleep- enuresis Sleep -related groaning (catathrenia) Exploding head syndrome Sleep- related hallucinations Sleep- related eating disorders Parasomnia , unspecified Parasomnia due to drug or substance use Parasomnia due to medical condition

EVALUATION OF PARASOMNIAS

Clinical sleepwake interview, with review of medical records, and review of a patient questionnaire that covers sleepwake, medical, psychiatric, and alcohol/chemical use and abuse history, review of systems, family history, and past or current physical, sexual, and emotional abuse. Psychiatric and neurological interviews and examinations, including psychometric testing.

DIAGNOSTIC WORKUP

Diagnostic workup for the primary or comorbid condition causing sleep disturbance. Laboratory tests for the diagnosis and monitoring of sleep disorders. Overnight polysomnography (PSG) Multiple sleep latency tests (MSLT) Maintenance of wakefulness test Video-PSG Standard electroencephalography (EEG) and video-EEG monitoring for suspected seizure disorders

ICD 10: NON ORGANIC SLEEP DISORDERS (F51)

SLEEP WALKINGSOMNABULISM (F51.3) SLEEP TERRORS ( F51.4) NIGHTMARES (F51.5)

DSM IV TR CLASSIFICATION

NIGHTMARE DISORDER SLEEP TERRORS SLEEP WALKING PARASOMNIA NOS SLEEP DISORDER DUE TO SUBSTANCEPARASOMNIA TYPE SLEEP DISORDER DUE TO GMCPARASOMNIA TYPE

PARASOMNIA NOS
REM sleep behaviour disorder Sleep paralysis Parasomnia is present but unable to determine whether it is primary, due to a general medical condition, or substance induced

CONFUSIONAL AROUSALS
Mildest form Very common in young children Child will typically partially awaken and sit up Episodes are marked by confusion , but usually the child backs down and resumes sleep Confusional arousals sleepwalking sleep terrors lie on a continuum

SLEEP TERROR DISORDER

Repeated abrupt awakenings from sleep characterized by intense fear, panicky screams, autonomic arousal (tachycardia, rapid breathing, and sweating), absence of detailed dream recall, amnesia for the episode, and relative unresponsiveness to attempts to comfort the person.

A. Recurrent episodes of abrupt awakening from sleep, usually occurring during the first third of the major sleep episode and beginning with a panicky scream. B. Intense fear and signs of autonomic arousal, such as tachycardia, rapid breathing, and sweating, during each episode. C. Relative unresponsiveness to efforts of others to comfort the person during the episode.

DSM IV TR: SLEEP TERRORS

DSM IV TR: SLEEP TERRORS

D. No detailed dream is recalled and there is amnesia for the episode. E. The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

ICD 10 : SLEEP TERRORS

(A) The predominant symptom is that one or more episodes of awakening from sleep begin with a panicky scream, and are characterized by intense anxiety, body motility, and autonomic hyperactivity, such as tachycardia, rapid breathing, dilated pupils, and sweating. (B) These repeated episodes typically last 1 to 10 minutes and usually occur during the first third of nocturnal sleep.

ICD 10 : SLEEP TERRORS

(C)There is relative unresponsiveness of efforts of others to influence the sleep terror event and such efforts are almost invariably followed by atleast several minutes of disorientation and perseverative movements. (D) Recall of the event, if any, is minimal ( usually limited to one or two fragmentary mental images) (E) There is no evidence of a physical disorder, such as brain tumor or epilepsy.

CLINICAL FEATURES

occur primarily during delta sleep usually take place during the first third of the night Sleep terrors may also be called night terrors, pavor nocturnus , or incubus. Incidence in children 1-6%, adults 1% 4-12yrs, resolves on its own. Boys > girls Strong genetic component, with high probability that one or both parents will have a history of sleep terrors, sleepwalking, or another parasomnia.

SLEEP TERROR

NIGHTMARES

STAGE OF SLEEP RECALL CONTENT

NREM POOR MAY BE DEVOID OF IMAGES, OR FRAGMENTS OF VIVID FRIGHTENING IMAGES DISORIENTED

REM GOOD ELABORATE, INCREASINGLY FRIGHTENING DREAM

AFTER EPISODE

USUALLY ORIENTED

TREATMENT OF SLEEP TERROR

Sleep hygiene Maintaining a safe sleep environment (i.e., removing sharp or pointed objects that the sleeper could run into, having these individuals sleep in ground-floor bedrooms) BZD s supress delta sleep, and decrease arousal.

SLEEPWALKING (SOMNAMBULISM)

Repeated episodes of motor behavior initiated in sleep, usually during delta sleep in the first third of the night.

DSM IV TR: SLEEP WALKING

A. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. B. While sleepwalking, the person has a blank, staring face, is relatively unresponsive to the efforts of others to communicate with him or her, and can be awakened only with great difficulty. C. On awakening (either from the sleepwalking episode or the next morning), the person has amnesia for the

DSM IV TR: SLEEP WALKING

D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior (although there may initially be a short period of confusion or disorientation). E. The sleepwalking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. F. The disturbance is not due to the direct physiological effects of a substance (e.g.,

ICD 10 : SLEEPWALKING
(A) The predominant symptom is one or more episode of rising from bed, usually during the first third of nocturnal sleep, and walking about. (B) During the episode, individual has a blank, staring face, is relatively unresponsive to the efforts of others to influence the event or to communicate with him or her, and can be awakened only with considerable difficulty. (C) Upon awakening( either from an episode or the next morning) the

ICD 10 : SLEEPWALKING
(D) Within several minutes of awakening from the episode, there is no impairment of mental activity or behavior, although there may be a short period of some confusion and disorientation. (E) There is no evidence of an organic mental disorder such as dementia, or a physical disorder such as epilepsy.

CLINICAL FEATURES
Individual arises from bed and ambulates without fully awakening. Engage in a variety of complex behaviors while unconscious. Begin toward the end of 1st or 2nd slow wave sleep cycle. Sleep deprivation and interruption exacerbate, or provoke episodes. Pt can successfully interact with the environment.

CLINICAL FEATURES
Once awake, person will appear confused. Better not to grab or shake the person to wake up. May react violently if forced to wake up. Has a familial pattern in adults, is rare. Common in children, age 4-8 yrs. In adolescence, it disappears completely.

POLYSOMNOGRAPHIC FINDINGS
Sleep architecture usually normal Micro-structure of NREM Sleep in adults can be perturbed, with increased micro-arousals and increased rate of the cyclic alternating EEG Pattern

TREATMENT OF SLEEP WALKING

No specific treatment Some patients may respond to BZDs and antidepressants. Prevent injuries to sleep walker.

NIGHTMARE DISORDER
DSM IV TR: A. Repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security, or self-esteem. The awakenings generally occur during the second half of the sleep period B. On awakening from the frightening dreams, the person rapidly becomes oriented and alert (in contrast to the confusion and disorientation seen in sleep terror disorder and some forms of epilepsy)

C. The dream experience, or the sleep disturbance resulting from the awakening, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The nightmares do not occur exclusively during the course of another mental disorder (e.g., a delirium, posttraumatic stress disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition

ICD10: NIGHTMARE DISORDER

(A) Awakening from nocturnal sleep or naps with detailed and vivid recall of intensely frightening dreams, usually involving threats to survival, security, self esteem; the awakening may occur at any time during the sleep period, but typically during the second half. (B) Upon awakening from the frightening dream, the individual becomes rapidly oriented and alert. (C) The dream experience itself, and the resulting disturbance of sleep, causes marked distress to individual.

CLINICAL FEATURES

Frightening or terrifying dreams Dream anxiety attacks Sympathetic activation, ultimately awaken pt. Occur in REM sleep. Person remembers dream Long complicated dream which increasingly becomes frightening Common in children 3-6 yrs. Individuals predisposed: schizotypal, borderline, schizoid personalities, schizophrenia thin boundaries individuals who are

Produce fear of sleeping type of insomnia Insomnia exacerbates nightmares L-DOPA, beta blockers, withdrawal from REM supressant medications

TREATMENT
Self limited in children Cognitive and behavioral interventions, including systematic desensitization, relaxation techniques as methods effective in reducing the frequency and severity of nightmares. Although SSRIs do suppress REM activity, they also tend to lighten and fragment sleep Sedative hypnotic/anxiolytic agents do not suppress REM, but may prevent

REM SLEEP BEHAVIOUR DISORDER

Involves a failure of atony during REM stage sleep. Pt enacts her or his own dreams. Punching, kicking, leaping, running from bed during attempted dream enactment occur. Individual is unaware of natural environment, and acts on dream sensorium. Can sustain serious injury, unlike sleep walking. Memory for dream content is good upon awakening.

NEUROLOGIC CONDITIONS CAUSING RBD

Bilateral peri locus coeruleus lesions Diffuse hemispheric lesions Bilateral thalamic abnormalities Brainstem lesions Pre motor stage of Parkinsons Lewy body dementia Multiple system atrophy Narcolepsy Progressive supranucler palsy

SUBSTANCE WITHDRAWAL CAUSING RBD

Alcohol Meprobamate Pentazocine Nitrazepam

TREATMENT OF RBD
Clonazepam 0.5- 1 mg is effective. Educate family about possibility of injury. Educate that it could be a precursor of a neurodegenerative disorder.

RECURRENT ISOLATED SLEEP PARALYSIS

Inability to make voluntary movements during sleep During sleep onset and awakening: when individual is partially conscious and aware of surroundings Distress increases when pt also has hypnogogic or hypnopompic hallucination One of the tetrad of symptoms of narcolepsy May or may not be accompanied by hypnogogia May lead to experiences such as feeling a presence near them, ghost or creature attacking them, etc.,

Irregular sleep, sleep deprivation, psychological stress, shift work exacerbate sleep paralysis episodes. Occurs in 7-8% of young adults. If individual makes voluntary rapid eye blinking or is touched by anther person, episode terminates. Sleep hygiene and reassurance- first line therapies.

OTHER PARASOMNIAS
SLEEP RELATED DISSOCIATIVE DISORDERS: Dis Identity dis, Dis fugue, Dis NOS. Individuals experiencing these at wakefulness may also experience at sleep. History of violence, trauma, and/ or psychiatric illness.

SLEEP ENURESIS: Bed wetting individual urinates during sleep while in bed Primary and secondary Parental primary enuresislikelihood of children having enuresis Secondary assc. With nocturnal seizures, sleep deprivation, urological abnormalities Treatment: oxybutinin, vasopressin,imipramine Behavioural therapy, fluid restriction

SLEEP-RELATED GROANING (CATATHRENIA): Prolonged frequently loud groans during sleep Can occur at any stage during the sleep cycle Begins in childhood Not related to any psychiatric or physiologic abnormalities No known treatment does not improve with CPAP

EXPLODING HEAD SYNDROME: hear a loud imagined noise or a sense of a violent explosion in the head just as they are about to fall asleep or during a nocturnal awakening Can occur once or recurrently Can trigger severe insomnia No known neurological consequences

SLEEP- RELATED HALLUCINATIONS: Typically visual images occurring at sleep onset or awakening Difficult to differentiate from dreams Images tend to be vivid and immobile persisting for several minutes Can be frightening

SLEEP RELATED EATING DISORDER: Inability to get back to sleep after awakening unless the individual has something to eat or drink Predominantly affects infants and children Mainly assc with breast feeding or bottle feeding In adults, nocturnal feeding can be conditioned to awakening Eating may become obsessional several small meals

PARASOMNIA DUE TO SUBSTANCE USE

Alcohol Drugs worsening parasomnias: biperiden, TCAs, MAOIs, caffeine , venlafaxine , selegiline, serotonin agonists.

SLEEP DISORDERS DUE TO GMC

Degenerative neurologic diseases Cardiovascular disease Endocrine ( hypo or hyperthyroidism) Viral and bacterial infections Respiratory disorders Pain from musculoskeletal disease

OTHER PARASOMNIAS
Sexual parasomnias: sleep sex, sexsomnia Nocturnal panic attacks Sleep- related trichotillomania Rhythmic disorders or NREM and REM sleep head banging, body rocking Parasomnia pseudo suicide

DIFFERENTIAL DIAGNOSIS
Seizures Breathing related sleep disorder Narcolepsy Panic attacks during sleep Medications: L-DOPA, beta blockers, antihypertensive medications, amphetamine, cocaine Withdrawal of REM suppressants: antidepressants, alcohol Malingering

As a part of other psychiatric conditions: post traumatic stress disorder schizophrenia mood disorders anxiety disorders Adjustment disorder Personality disorders

PARASOMNIA AGE OF ONSET USUALLY LESS THAN 10 YR

NFLE VARIABLE; USUALLY CHILDHOOD AND ADOLESCENCE 40% 3 or more 2040 Often stable with increasing age 20 yr Seconds to 3 min (often <2 min) Highly stereotyped on video monitoring, often vigorous movements.

Family history Attacks per night (mean) Episode frequency/mo Clinical course (over years)

6090% 1 or 2 <1 to 4 Tends to disappear by adolescence 7 yr Seconds to 30 min

Disease duration (mean) Episode duration

Semiology of movements

Variable complexity; not highly stereotyped (on video)

PARASOMNIAS

NFLE

Trigger factors

Sleep deprivation, febrile illness, alcohol, stress

Obstructive sleep apnea Slow waves, no epileptiform features

Often none identified

Associated conditions Ictal EEG

Often none identified Often normal, or obscured by movement. Frankly epileptiform ictal rhythms in <10%

Time of episodes during sleep

First third of night, but usually after 90 min of sleep NREM stage 3 or 4

Any time, but may occur in first 3060 min

PSG sleep stages when events occur

Usually stage 2 NREM, occasionally stage 3 or 4

IMPORTANCE IN PSYCHIATRY: Parasomnias can be misdiagnosed and inappropriately treated as a psychiatric disorder. Parasomnias can be a direct manifestation of a psychiatric disorder, e.g. dissociative disorder. The emergence and/or recurrence of a parasomnia can be triggered by stress. Psychotropic medications can induce the initial emergence of a parasomnia, or aggravate a pre-existing parasomnia.

Parasomnias can cause psychological distress or can induce or reactivate a psychiatric disorder in the patient or bed partner on account of repeated loss of self-control during sleep and sleeprelated injuries. Familiarity with the parasomnias will allow psychiatrists to be more fully aware of the various medical and neurological disorders that can be associated with disturbed (sleep-related) behaviour and disturbed dreaming.

Parasomnias present a special opportunity for interlinking animal basic science research (including parasomnia animal models) with human (sleep) behavioural disorders. Parasomnias carry forensic implications. Psychiatrists are often asked to render an expert opinion in medicolegal cases pertaining to sleep-related violence.

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