Awareness about parasomnias within the sleep community and among the general public is, without question, on the rise. As sleep center staffs and physicians prepare for monitoring and treating these patients, there are some fundamental approaches to consider, as well as some safety precautions that should be planned. Good communication by the sleep technologist about observations made during the polysomnogram (PSG) to the diagnosing physician is a critical component of any sleep study, but never more essential than when one encounters a patient with a parasomnia.
Parasomnias are defined as unpleasant or undesirable behavioral or experiential phenomena that occur predominantly or exclusively during the sleep period.1 The International Classification of Sleep Disorders, second edition, characterizes parasomnias as undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep. According to Carlos H. Schenck, MD, one of the pioneering researchers in this area, parasomnias encompass abnormal sleep-related movements, behaviors, emotions, perceptions, dreaming, and autonomic nervous system functioning.
Instinctual behaviors often emerge pathologically with parasomnias, as seen with sleep-related aggression (eg, REM sleep behavior disorder [RBD]), locomotion (eg, somnambulism), eating (eg, sleep-related eating disorder [SRED]), and sex (often described with terms like “abnormal sleep-related sexual behavior,” “sleepsex,” “atypical sexual behavior during sleep,” and “sexsomnia”).
Parasomnias result in injuries, sleep disruption, and adverse health and psychosocial effects. They often involve complex, seemingly purposeful, and goal-directed behaviors that are disconnected from conscious awareness or control, are devoid of sound judgment, and are classified as sleep automatisms. One way to understand parasomnias is from the perspective of “state dissociation,” with components of one state of being inappropriately intruding into another. It is not uncommon for someone to display multiple parasomnias.2
Treating the Parasomnia Patient
By the time patients suffering from parasomnias present to a sleep disorders center, they have often encountered a number of negative reactions from family members, friends, and even their physicians, Schenck says. Disbelief, incredulity, and the automatic mislabeling of a psychological problem are common. There is no consideration of a primary sleep disorder, and people make statements to parasomnia patients such as:
- “No one does these things, and if they do, then they must be psycho.”
- “You’re just exaggerating; we all move around a bit in bed when we sleep, but that is normal.”
- “It’s just one of those things that happens.”
- “You’ll outgrow it.” (Regardless of the age of the person.)
- “It must be your diet.”
- “Do you drink too much alcohol or consume too much caffeine?”
- “It must be stress, so change your job or wait until you can retire—or do you have marriage problems?”
As a consequence of these negative, judgmental, and derogatory attitudes, many parasomniacs are reluctant to seek help out of fear of being minimized, ridiculed, and mislabeled. “Often there are major self-doubts—‘Am I really weird or becoming a psycho with the first signs coming out in sleep, and it is a matter of time before I become crazy while being awake?’ ” Schenck says. “Therefore, when [parasomniacs] do present to a sleep disorders center, they, first of all, want to be ‘validated’ in regard to what they actually do in bed at night.”
A Dose of Empathy
Parasomniacs want to be believed, as do their bed partners and roommates. “People can actually fly out of bed at night, or walk to the kitchen and binge-eat, or act out wild and violent dreams while still being asleep,” Schenck says. Sufferers can demonstrate superhuman strength that they cannot equally demonstrate while awake; or act like animals. Those with parasomnias often say and shout profanities that they would never say while awake. This nighttime behavior even can include repeatedly injuring oneself and one’s bed partner.
“The clinician must first say, ‘Yes, I believe what you are saying is true; now let’s try to find the cause,’ ” Schenck says.
He advises that, when patients are being prepared for overnight PSGs— periods when they spend a lot of time with sleep technologists—it is important that the technologists show understanding and consideration, and encourage the patients to describe what they have been going through. “The message all-around is that there is a medical sleep disorder basis for the vast majority of parasomnia complaints,” he says.
The PSG study is an important component of the diagnostic and therapeutic process for parasomnia patients, Schenck adds. Therefore, it is important for sleep technologists to be empathetic toward these patients and ask questions that can prepare them for the night ahead in the laboratory. Encouraging dream-enacting behaviors also can help.
After a parasomnia episode, sleep technicians should assess for any dreaming associated with the behaviors, along with the patient’s level of consciousness during the behaviors. The patient’s primary concern is to be believed and validated, and then properly diagnosed and effectively treated, Schenck says.
In addition, screening for psychological problems should be part of the evaluation. However, patients should not be made to feel defensive about these tests, and should be told that this is a standard part of the evaluation process. Also, even if some depression and anxiety are detected through the psychological testing, these symptoms may be the consequence of suffering from a long-standing parasomnia with repeated loss of self-control during sleep, injuries, embarrassment, etc, and not necessarily the result of an underlying psychological illness.
Parasomnias in single people who are dating can be a source of great embarrassment and apprehension, which, in turn, may be the precipitating reason for coming to a sleep center for help.
“When about to start an intimate relationship, the fear of having your new mate witness strange sleep behaviors on your part can be enormous, and quite legitimately it can be a ‘deal-breaker,’ ” Schenck says.
Making Sense of the Strange
Schenck has been a faculty member of the Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, and University of Minnesota Medical School in Minneapolis since 1982, and is the author of Paradox Lost: Midnight in the Battleground of Sleep and Dreams.3 He also has coproduced a documentary called Sleep Runners: The Stories Behind Everyday Parasomnias.
The book and documentary were intended largely to inform sleep technologists about the range of parasomnias, and thereby help them be more empathetic with these patients. For sleep medicine professionals, Schenck’s book includes the relevant clinical and scientific information, and proposes that an assessment tool called the “Mental Status Exam of Sleep” should be a clinical foundation of sleep medicine, similar to the Mental State Examination used in neurology and psychiatry assessments. Schenck says that the Mental Status Exam of Sleep provides a framework for assessing all that can go wrong with the parasomnias and facilitating the formulation of “target symptoms” to be controlled with treatment.
With RBD, for example, the target symptoms that need to be controlled include the RBD abnormal dreaming, as well as the violent sleep behaviors, Schenck says. RBD was first recognized as a distinct parasomnia in 1985,4 and was named in 1987 at Hennepin by Schenck and his colleagues, including the parasomnia expert Mark Mahowald, MD, and the sleep technologist Andrea Patterson, RPSGT, R.EEG.T.
“When our center first identified RBD, the reaction in the sleep medicine community was that it was a ‘Minnesota disease,’ but, of course, we now know that it is a universal condition,” Schenck says. “Moreover, what I am now emphasizing in my lectures is that parasomnias can shadow most other sleep disorders and their therapies. Therefore, contrary to popular opinion in the sleep field—in which parasomnias are considered to be ‘exotic conditions’ of little relevance to most sleep clinicians—we now know that parasomnias can emerge with virtually all other sleep disorders.”
A good example, Schenck says, is parasomnia associated with OSA, one of the most common disorders seen in sleep laboratories. “Many parasomnias can emerge with obstructive sleep apnea and its treatment,” he says. “Pseudo-RBD can emerge with OSA-induced REM sleep awakenings and violent dream enactment occurring in the immediate post [REM] awakening interval.” In a study published in 2005 in the journal Sleep, researchers from the University of Barcelona found that in elderly men—the prime RBD group—treatment with CPAP controlled both the OSA and the pseudo-RBD.5
“Also, with OSA, there can be intense slow-wave sleep rebound during CPAP initiation, triggering episodes of sleepwalking and sleep terrors,” Schenck says and adds that OSA can trigger confusional arousals with sexsomnia. Bed partners in at least four cases have reported loud snoring during the sleepsex as proof that the afflicted men were indeed asleep, he says. OSA also can trigger sleepwalking-like episodes with eating and violence.
Other sleep disorders also seem to be linked to parasomnias. “In RBD, we now know that around half of narcoleptic patients have comorbid RBD, with the RBD being triggered by narcolepsy itself and/or the treatment of cataplexy with venlafaxine (Effexor), fluoxetine (Prozac), and tricyclic antidepressants,” Schenck says. “Turning to RLS, sleep-related eating disorder is a risk factor. In fact, at our center, 20% of our patients with sleep-related eating disorder have comorbid RLS. Therefore, parasomnias are lurking around various other sleep disorders and their therapies.”
The RBD treatment that currently shows the most promise, according to Schenck, is having patients take clonazepam (Klonopin) at bedtime. It has been reported to be 80% to 90% effective in the worldwide literature. More newly recognized alternative and adjunctive therapies consist of melatonin at bedtime (3 to 15 mg) and the dopaminergic pramipexole (Mirapex and Sifrol) (0.25 to 1 mg), he says.
For sleep-related eating disorder, the anticonvulsant medication topiramate (Topamax) had about two thirds efficacy in two published series. Also, in two separate series, researchers reported that topiramate was effective in controlling SRED in two thirds of treated patients, presumably on the basis of suppressing the urge to eat rather than on the basis of its direct effects on convulsions and sleep. Schenck advises prescribing a starting dose of 25 mg at bedtime, with increases by 25-mg increments every 5 days up to the typical therapeutic range of 50 mg to 150 mg (which can be extended to 200 mg to 400 mg).
At times topiramate will control the nocturnal eating but not the awakenings. In these cases, the addition of low-dose trazodone (Desyrel, Trittico, Thombran, and Trialodine) or clonazepam at bedtime can be effective. Paresthesias (abnormal touch sensations, such as burning or prickling, that occur without an outside stimulus) and various other side effects have been reported, which at times can result in cessation of therapy.6,7
For sleepwalking and sleep terrors in children and adults, there is growing recognition that comorbid OSA and upper-airway resistance syndrome may be triggering factors in patients who are genetically predisposed to these conditions. Therefore, by controlling the SDB, the comorbid parasomnia also may be controlled. In this scenario, treat the SDB first and then assess to what extent the parasomnia is controlled, Schenck says.
Living With Parasomnia
Certain preparations can help the person afflicted with parasomnias cope with disturbing symptoms that may not resolve completely with treatment. Maximizing the safety of the sleeping environment should always be emphasized, even when specific therapies are initiated. “This is especially true if symptoms are not fully controlled with therapy,” Schenck says. “Also, the ongoing effort to identify, and then minimize or eliminate, triggering factors—stress, diet, sleep deprivation, etc—should be maintained. In general, the classic non-REM parasomnias (confusional arousals, sleepwalking, sleep terrors) have many more triggering factors that can be modified than is the case with RBD or SRED.”
Schenck recommends equipping the bedroom with a door alarm that can awaken a person who is sleepwalking or has sleep terrors, and alert others in the household that a parasomnia episode is occurring. Covering windows and moving harmful objects away from the bedside also are helpful in some cases.
Safety Measures for Laboratories
Regarding issues arising from patients becoming a danger to themselves or the sleep center staff when sleepwalking, there are a few steps Schenck advises facilities to take when monitoring these patients. “When entering the room while a parasomnia episode is taking place, the sleep tech should talk gently to the patient to try to wake that person up, but they should not touch the patient, who may react with agitation or violence,” he says. “Certainly, bed rails should be used or else the patient could roll out of bed, or leap out of bed and land on the floor, hurting him- or herself.”
Because parasomnias can show up in patients who may originally present to a sleep center with a more common sleep disorder, even facilities that do not focus on parasomnias should be prepared to monitor a possible parasomniac in a way that is safe for both the patient and the staff. Treating these patients with empathy and communicating symptoms clearly to the diagnosing physician is key.
Theresa Shumard is a longtime sleep technician and medical columnist, and the founder of REMgazer Sleep Communications. She is the host of the “Let’s Talk Sleep with Theresa Shumard” radio program. She is a member of the Sleep Review Editorial Advisory Board and can be reached at .
- Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Saunders; 2005:889.
- The British Neuropsychiatry Association Conference 2006. The Institute of Child Health page. Available at: . Accessed January 9, 2007.
- Schenck CH. Paradox Lost: Midnight in the Battleground of Sleep and Dreams. Violent Moving Nightmares page. Available at: http://www.parasomnias-rbd.com/. Accessed January 3, 2006.
- Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep. 1986;9:293-308.
- Iranzo A, Santamaria J. Severe obstructive sleep apnea/hypopnea mimicking REM sleep behavior disorder. Sleep. 2005;28:203-206.
- Schenck CH, Mahowald MW. Topiramate therapy of sleep related eating disorder. Sleep. 2006;29:A268.
- Winkelman JW. Efficacy and tolerability of topiramate in the treatment of sleep related eating disorders: an open-label, retrospective case series. J Clin Psychiatry. In press.