Sleep Quality and Parasomnia: Types, Causes, Diagnosis, and Treatments
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Sleep disorders are not a rarity anymore. Over 40 million people suffer from a milieu of sleep disorders in the US. About 60 million Americans experience difficulty falling asleep or staying asleep at least once a week. Sleepwalking, talking while asleep, sleep eating and partial arousal in the middle of the night are all parasomnia related disorders. These are manifestations of unwanted sleep disturbances that can occur irrespective of age or lifestyle.
People over the age of 65 years are more likely to experience an episode of parasomnia in their lifetime. However, it is more common among children. This term refers to every strange thing that can happen during sleep, except incidents of sleep apnea. Sleep paralysis, sleep aggression, as well as sleep sex, are cases of parasomnia that occur in the general population.
Parasomnias are usually more likely to occur when a person is falling asleep or during any particular sleep cycle. The kind that happens while a person is falling asleep usually accompanies hallucinations. It can be quite disturbing and scary. Sleep paralysis is quite common for this type of disturbance. If you frequently have trouble falling asleep due to recurring incidents of immobility and hallucinations, you might be suffering from a form of parasomnia.
All kinds of abnormal movements, perceptions, emotions, and behaviors can be a manifestation of the sleep disorder. The result of almost all symptoms of parasomnia is the lack of proper restorative sleep. While a person may not be able to remember what they did or said during their episode of parasomnia, they feel tired from the activity and the lack of enough rest.
Since parasomnia can occur at all ages, it is difficult to diagnose it without proper tests conclusively. The epidemiology of this sleep disorder is diverse, and there are hundreds of different symptoms that can point towards it. The sign and symptom of parasomnia can be different for each. Here are some of the most common symptoms that characterize this disorder.
As you can see, different signs can all signify the incidence of parasomnia among children and adults alike. Therefore, it is essential to classify the cases of parasomnia according to the causes, times of occurrence and types of activities.
Primary parasomnia defines the undesirable actions that can result in sudden arousal from sleep. It can occur during any sleep stage or while transitioning from an awake to sleep stage. All REM sleep disorders are cases of primary parasomnia. The sleep-wake transition issues include night leg cramps, restless leg syndrome and sleep paralysis. These are all classic examples of the primary type of the sleep-wake disorder.
It can occur among children and in infants as well. There have been several documented cases of children suffering from parasomnia due to rapid oscillation of the non-REM and REM sleep stages. Therefore, experts classify the primary instances as per the stages of sleep they affect (non-REM or REM) or as per their symptomatic presentation.
Secondary parasomnia is usually the manifestation of an existing psychological problem or an issue of an organ system during sleep. This form is quite common in adults. Since this kind of sleeping disorder is usually a result of some other pre-existing problem, experts refer to it as secondary. Experts typically classify the secondary forms of the disease according to the organ systems involved.
Some of the symptoms of primary and secondary parasomnias do overlap, but it does not mean they have the same causes or deserve the same treatment. Bed wetting among growing children and adults is a classic example of secondary parasomnia. Seizures, gastro-esophageal reflux, cardiac arrhythmia and respiratory dysfunction can all give rise to secondary sleep-related disorders in the adults.
The most common classification system of parasomnias depends on the sleep stages during which they occur. As a result, there are two broad classifications, non-REM or NREM parasomnia, and REM parasomnia. During sleep, our brain goes through 4 stages of the REM cycle and 1 phase of the non-REM cycle. As a result, sleep progresses from one step to another throughout the night as the duration of the REM stages increases. Ideally, we go through 4 to 5 sleep cycles per night for full restorative sleep.
People suffering from sleep disorders that cause them to wake up frequently throughout the night are unable to complete the REM and non-REM stage cycles. The lack of 4 or 5 cycles of sleep compromises the restorative power of the brain and body. That can lead to excessive daytime sleepiness (EDS) and lowered productivity. Sleep disorders like parasomnia can jolt an individual awake from any of the five stages of NREM or REM sleep.
The non-REM related parasomnias can occur during any of the four phases of non-REM sleep phases 1, 2, 3 and 4. They are more common during the early parts of the night than in the early mornings. NREM parasomnias have further classifications that help sleep experts and doctors diagnose and treat a patient more effectively.
Doctors and sleep experts often refer to it as somnambulism or noctambulism. Irrespective of the number of syllables in the name, they all mean the same thing – getting out of bed while asleep and moving around. People with somnambulism usually walk around with their eyes open, but they are unaware of their movement or whereabouts.
People often find out about their sleepwalking problem when they wake up outside their bedroom or somewhere else in the house. It can be quite dangerous as people can open doors and windows, walk in the middle of the street, or start driving. People often complete complex tasks during this phase. Strangely, sleep-walkers have no memory of the activity after waking up.
Night terrors or sleep terrors are very different from nightmares. They usually happen during the first phase of the night. In the event of experiencing nightmares, people often wake up from sleep gasping for breath, crying or screaming. They have full recollection of the unpleasant dream and their reaction the next morning.
During episodes of night terrors, people seem to wake up scared, screaming, crying, or even pointing towards imaginary people. However, they have no recollection of the events the next morning. Night terrors are terrifying for the family members, sleeping partners, or roommates of the individuals.
Waking up in the middle of the night and saying strange things might seem comical. You will find elaborate sub-Reddits on people “waking up,” saying funny or meaningless things and going right back to sleep. However, this is a severe disorder.
During the state of confusional arousal from slumber, people can respond to questions, but the answers can vary from somewhat funny to utterly absurd. While these people seem to be awake, their thinking is confused. This phase can last from a few seconds to a few hours. Just like the other types of parasomnia, the affected individual has no recollection of the event.
We find it hilarious when Peter Griffin sleep eats. After all, eating while sleeping does sound funny, but it can happen to anyone. Just like sleepwalking, people can wake up partially to binge on junk food or drink.
The sleep eating diet usually consists of items that they would never consume when fully awake. It can include a whole bag of chips, chocolate syrup, frosting, peanut butter, and any other high-calorie food you can imagine. These binges can last for as long as 10 minutes, but people with this disorder do not remember these incidents at all. It is very dangerous since binging does not involve edible items only. They can consume toxic substances.
In some cases, people suffering from sleep-related eating disorders have also tried to start a fire to cook while asleep. It is a bizarre but genuine sleep disorder that commands immediate attention.
These are more common during the later hours of the night than when the person is falling asleep. The REM sleep disorders only affect the REM phase of sleep or the stage where people are more likely to dream.
Sleep paralysis can affect you while you fall asleep, but that does not mean this disorder cannot alter your REM sleep. If you have found yourself awake and aware of your surroundings at night, but unable to move or speak, you might have this particular REM-related parasomnia.
In most of the cases, the experience is terrifying due to the presence of an accompanying hallucination. These episodes can last for only a few seconds or longer. These episodes usually end on their own or when someone touches the sleeping person. Sleep paralysis is undoubtedly scary, but it is not necessarily dangerous for everyone. It can disrupt sleeping habits since a scared person is more likely to stay awake for a long time after an episode due to the fear of a recurrence.
Everyone has one or two nightmares once in a while. However, imagine experiencing one or two scary dreams every night for weeks on end. If you do not have to picture it, because you are living it, then you might have what experts refer to as a nightmare disorder.
Since it only occurs during the REM phase of sleep, it is a primary REM parasomnia. It can prevent the individual from falling asleep due to increased anxiety levels or physical discomforts like rapid heartbeats, dry throat, and excessive sweating.
REM Sleep Behavior Disorder (RBD) encompasses all kinds of in-dream actions that people carry out while they are asleep. For example, you may experience a violent dream where you are thrashing goons. During this dream, if you thrash around in bed or act out the movements, it is likely that you have a case of RBD.
An increasing number of physicians and sleep experts now consider RBD to be a severe brain disorder. While people suffering from this parasomnia have higher risks of hurting themselves while thrashing around, they also have a high chance of hitting their sleep partner in their sleep. If you recognize the symptoms, you should visit a sleep specialist immediately for proper diagnosis and treatment.
Researchers, sleep specialists, and doctors have observed and classified the parasomnias as mentioned earlier over the last couple of decades. Documentation of cases, observation in sleep clinics and thorough checkups of the individuals affected have given them the chance to learn about these types of disorder over time.
There are several other lesser studied instances and types of parasomnias. These include sleep talking, bruxism, exploding head syndrome, and sleep sex. Some of them occur during REM as well as Non-REM sleep. Hence, completing the full list of unusual sleep-related behaviors is quite impossible due to the heterogeneity of the risk groups and symptoms.
Parasomnia can be of various types, and it can have myriads of symptoms on people depending on their age, psychology, and physical conditions. It points towards a plethora of causes for abnormal sleep-related behavior. Different preexisting medical disorders and diseases can also contribute to the beginning of parasomnia in people. The roots of secondary parasomnia can be an infection of the urinary tract or the kidneys. People with heart problems, respiratory tract blockages and diabetes experience frequent incidence of parasomnia.
People with alcoholism or history of drug abuse usually suffer from nightmare disorders, night terrors, bruxism, sleep talking, and RBD more frequently. Adults who take psychoactive medications for mood disorders and other psychological disorders experience recurring episodes of sleep disorders. However, that is not enough reason to call any parasomnia a lifestyle disorder.
According to recent research, parasomnia in a family can be hereditary. The effects of genetics can vary between the types of parasomnia in families. Scientists have finally located the genetic factors responsible for enuresis. Sleepwalking has a strong association with the HLA system. As per the recent findings, the incidence of parasomnia in family depends on the environmental factors and the genetic environment to a significant degree.
Several REM parasomnias and NREM disorders have a genetic predisposition. Hublin and Kaprio, the sleep researcher duo showed that sleep talking has a high reliance on multiple inheritable genetic components in 2003.
Anyone can experience sleep-wake disorders during his or her lifetime. Although adults are more likely to seek treatment for any form of sleeping disorders, children suffer from parasomnia more frequently. Since it can happen to anyone, it is imperative for you to find out your chances of experiencing a REM or non-REM sleep disorder.
Children. Interestingly, the developing minds of children are more prone to sleep disorders during the REM phase. Bedwetting, sleep talking, sleepwalking, and night terrors are very common among children. More often than not, children naturally grow out of this phase, and they are more likely to forget the traumatic experiences if they occur early in their lives.
Sleepwalking is common among children between 5 and 12 years of age. Sleepwalking and sleep talking go away in the early teenage years. Night terrors are the real menace since they can disrupt REM sleep and Non-REM sleep. Night terrors affect only 6% of the children. Causes of parasomnias can be genetic, or they can be a result of some medication.
Adults. There are several cases, where the parasomnias continue well into adulthood. Several adults experience night terrors, frequent nightmares, sleepwalking, sleep eating, painful erections during sleep and RBD. Periods of excessive stress at work often exacerbates the cases of parasomnia. Unaddressed trauma including untreated PTSD can cause chronic nightmare disorder in adults. It is very common among veterans in the USA.
More frequently than not, parasomnias in adults occur as a result of genetic mutations they have inherited from one or both of their parents. However, the symptoms of different kinds of sleep-wake disorders can be results of other underlying health conditions like Parkinson’s, Alzheimer’s or Huntington’s. Therefore, if you are experiencing unexplainable episodes of sleep disorders, book a sleep specialist’s appointment immediately. Parasomnias occur in about 4% of the adults.
The elderly. The elderly are more likely to experience age-related changes in sleep-wake patterns. Aside from advanced sleep phase syndrome and insomnia, they show sure signs of several REM sleep disorders and non-REM parasomnias. In subjects older than 50 years of age, REM sleep-awake disorders like RBD are more common.
The prevalence of parasomnia in the elderly community is around 5% to 7% in the USA. Early-onset of RBD has an association with antidepressant use in the test subjects. Members of the elderly community with a history of alcohol abuse, smoking, and drug abuse have more chances of suffering from early onset REM sleep disorder, as compared to the healthier 50-year-olds.
The differential diagnoses for REM and non-REM sleep disorders consist of nocturnal seizures, panic attacks, dissociative disorders, confusional arousals and medication-induced complex behavior. Clinical history is vital for decisively diagnosing parasomnia. It includes careful timing assessment and expression. There are a few things a physician or a sleep specialist should do for proper diagnosis of the disorder.
Polysomnography is not very cost effective in the diagnosis of non-REM parasomnias. It can only rule out cases of additional physiological problems including narcolepsy, restless leg syndrome, and sleep apnea.
The diagnostic criteria for REM parasomnia require polysomnography to establish the presence of REM without atonia. This test can rule out obstructive sleep apnea and other co-morbid sleep disorders that can interfere with sleep quality.
Sometimes, parasomnias are not curable but manageable. Non-REM sleep disorders are very different from REM sleep disorders in symptoms, but there are a few standard treatments that work for both.
Confusional arousals, sleep terrors and sleepwalking are the three main types of NREM parasomnias.
Treatment of confusional arousals. Control and management of confusional arousals involve improving sleep hygiene, maximizing the understanding of sleep, management of stress and anxiety. Research shows that scheduling regular awakening during sleep can also be helpful. For any form of confusional arousal among adults, it is of paramount importance to maximize sleep stability.
Treatment of sleepwalking. This is one of the most well-known forms of NREM parasomnia among children and adults. Children usually grow out of their occasional episodes, but it is a severe problem for adults. Some people have a genetic predisposition towards somnambulism.
The patient should speak with their family members about the threats of sleepwalking. Avoidance of sleep deprivation and agitation of co-morbid disorders in patients often reduce the instances. Psychotherapy, hypnosis, and relaxation exercises can be helpful depending on the other factors that might be triggering the unrest.
Treatment of sleep terror. Although common in children, it can persist in adulthood as well. Sleep terror is often prevalent in people with chronic depression, obsessive-compulsive traits, and predominant phobias.
There is a robust correlation between sleep terror and psychiatric disorders. Benzodiazepine and tricyclic antidepressants are useful in the treatment of night terrors. There are three parasomnias under the REM category, and some of their management is very similar to those of NREM sleep disorders.
RBD. REM sleep behavior disorder can be acute or chronic. Polysomnography and electromyography are necessary to establish the occurrence of RBD. It is also a sign of several neurodegenerative diseases. People with RBD have a good 60% chance of developing a neurodegenerative disease in the next ten years. A long history of research shows that clonazepam can be useful for the treatment of RBD. Melatonin is a clonazepam alternative that works wonderfully to stabilize sleep quality as well.
Sleep paralysis. The pathophysiology of sleep paralysis is still mostly unknown. Irregular sleep-wake schedules, jet lag, sleep deprivation and high levels of stress can contribute to sleep paralysis. Other secondary causes include narcolepsy and neuropsychiatric diseases. Selective serotonin uptake inhibitors (SSRIs) can be useful for the treatment of sleep paralysis since they can suppress REM sleep. People can also opt for psychotherapy for the control of sleep paralysis episodes.
Nightmare disorders. Nightmares can evoke feelings of fear, anger, and disgust that can prolong periods of awakening in people. Nightmare disorders can be results of PTSD, depression and other psychological disorders. They can be part of REM or NREM sleep. Therefore, both psychological and pharmacologic approaches are necessary for the management and treatment of nightmare disorders.
Other parasomnias including exploding hear syndrome, sleep talking and sleep eating are often difficult to categorize, diagnose and treat. While sleep experts often consider sleep-talking and sleep eating as forms of sleepwalking, their treatments require extensive psychological counseling and psychotherapy.
The only way to be helpful to a person suffering from any form of parasomnia is by gaining more knowledge about the particular type of disorder they might have. For example, people living with someone with sleepwalking disorder might want to turn the main valve of the gas off and lock all doors and windows before hitting the hay. They might want to make sure that all knives and guns are out of reach from the patient while they sleepwalk through the house. They should also try to keep the car keys away from plain sight to prevent the person from starting the car or driving during one of their episodes.
It is not always helpful to jostle the person awake while they are having an episode of sleepwalking, sleep talking, confusional arousal, or night terror. It often helps to touch their arms or legs gently. Using force can be counterintuitive since the person can move their limbs forcefully without control. Waking people up from sleepwalking or night terrors can be harmful to both the patient as well as the co-sleeper.
You can always help your family or friend by addressing their sleep hygiene issues. Encourage people suffering from parasomnias to stay away from substance abuse. In case of frequent, intense episodes you should always suggest medical care, therapy and medication for promoting sleep quality. The improvement of sleep quality and continuity can prevent the instances of all forms of parasomnia in adults.
Parasomnias are more common than most people believe. They often do not have any association with psychiatric disorders, especially in children. Most children under the age of 12 suffer from night terrors, sleep talking, sleep movements and even sleepwalking. Most parasomnias that occur in children are NREM like night terrors, confusional arousal, and sleepwalking. Although there is a genetic factor that can contribute to one’s predisposition towards noctambulism, there is no clear pathophysiology of the disorder.
In most cases, parasomnias have a long history since it goes on for years without a confirmative diagnosis. In the younger risk group, researchers often find a link between ongoing medications and REM sleep behavior disorder. RBD in the younger population can also be an effect of a disease of the central nervous system. REM sleep disorders in younger patients might dissolve as they grow up.
Certain parasomnias like sleepwalking in an adult can be potentially harmful. There have been cases of adults handling loaded firearms during a sleepwalking phase or that of adults walking on highways in one of their stupors. These are severe cases of sleepwalking, where psychologic and pharmacologic interventions are mandatory. Evaluation of the disorder and its treatment is a must when parasomnias are potentially deleterious to the patient and others.
Any unusual or undesirable movements and actions during sleep can be a symptom or a result of parasomnia. Several cases also include unwanted emotions that keep a person from falling asleep night after night. However, most parasomnias include dissociative stages of sleep that can result in partial arousal during the transition between sleep and wakefulness. These disorders can occur during REM sleep or non-REM sleep. Some people experience only one parasomnia, while there are multiple cases where doctors have diagnosed people with several distinct parasomnias that occur together.
Since REM and NREM disorders are often premature signs and symptoms of neurodegenerative diseases like Alzheimer’s, Huntington’s and Parkinson’s, sleep experts always recommend a thorough checkup to highlight the possible causes of the parasomnias. It is especially true for adults around the age of 40. People above the age of 50 often suffer from at least one instance of parasomnia per week.
Timely diagnosis and treatment can prevent psychological harm and physical injury that several sleep-wake disorders can cause. Some of the parasomnias require medication, while others often respond to regular psychotherapy. Depending on the severity of the disease, you might find simple improvements in sleeping habits, like when you switch off the bright LED light in your room, which can be helpful for experiencing sound sleep without episodes of parasomnia.
Co-founder of Counting Sheep and Sleepaholic