A.W.A.K.E GROUP PARASOMNIAS

1. A.W.A.K.E GROUPPARASOMNIAS Dr. Joe Malli Stanford Sleep Disorders Center 3/2/11

2. Parasomnias • Unpleasant or undesirable behavioral or experiential phenomena occur almost exclusively during sleep • Originally thought to be due to psychiatric disorders. • Actually due to a large number of different conditions, most not psychiatric and most treatable.

3. Parasomnias • Primary Parasomnias (disorders of the sleep state). • REM • NREM • Secondary Parasomnias • Due to underlying medical condition or medications.

4. NREM Parasomnias • State Dissociation: • Brain partially awake and partially in NREM. • Awake enough to perform very complex motor or verbal actions • Sleep enough not to have conscious awareness or responsibility for these actions.

5. Parasomnias • BRAIN: Three primary states of being: • Wakefulness • NREM sleep • REM sleep • Much of the brain is active across all three states at any one time, but activity stimulation. • Activity in one phase can inhibit activity in another phase. • Does mean that there is the potential for interaction between the different states of being especially during transition periods between states.

6. NREM-Parasomnias • Tend to arise from Slow Wave Sleep (but can occur in other stages) • First 1/3rd of night(rare in naps) • Common in childhood – decrease frequency with increasing age • Possible genetic link with sleepwalking – can have strong family history

7. NREM Parasomnias • Triggers • Febrile illness • Alcohol • Sleep deprivation • Physical activity or emotional stress • Medications (sedative-hypnotics, neuroleptics, stimulants, antihistamines) • Nocturnal seizures • Periodic limb movements

8. NREM PARASOMNIAS • Not caused by psychopathology. • Sleepwalking experimentally induced by standing children up during SWS • Sleep terrors experimentally induced by sounding a buzzer during SWS.

9. NREM ParasomniasPathogenesis • Sleep State Instability • Predominance of cyclic alternating patterns (arousal oscillations) in patients with disorders of arousals

10. NREM ParasomniasPathogenesis • Locomotor Centers • Multiple centers in the brain that allow dissociated complex motor activity from waking consciousness

11. http://www.youtube.com/watch?v=5jIYBatQyCM&feature=player_detailpagehttp://www.youtube.com/watch?v=5jIYBatQyCM&feature=player_detailpage

13. PARASOMNIAS • Arousals Disorders • Confusional Arousals • Sleep Terrors • Sleep Walking • Usually only one episode during the night • Precipitating factors include: • Fever, systemic illness, medication or other substances, internal or external sleep interrupting stimuli (such as a full bladder, sleeping in an unfamiliar environment, child being woken forcefully

14. NREM Parasomnias • Confusional Arousals • Mainly occur in infants and toddlers. • Prevalence: 17% age 3 to 13. Older then 15 yo (3% to 4%) • Episode may begin with movements and moaning, progress to agitated and confused behavior… • Crying (perhaps intense), calling out, or thrashing about. • Parents often times are alarmed, consoling attempts not successful, or require significant effort.

15. NREM Parasomnias • Confusional Arousals • Episodes last 5–15 minutes (sometimes much longer) before child calms down/falls back asleep spontaneously or with parental intervention. • Easily precipitated by forced awakenings (esp. early in sleep cycle) • Can occur during naps

16. NREM ParasomniasPathogenesis • Sleep Inertia (Sleep Drunkenness) • Adolescent / adult variant of confusional arousals. • Occurs during light NREM sleep. • Impaired performance and reduced vigilance following awakening from a regular sleep episode or nap • Minutes (usually) to hours • PSG proven microsleep • Waking up  stumbling to shower  in shower retrograde amnesia • Probably plays a role in susceptibility to disorders of arousal.

18. NREM Parasomnias • Sleepwalking (Somnambulism) • Childhood Prevalence (20% to 40%) • Peak age 11 to 12 years • Adults 4% • Arise out of SWS • Episodes last up to 10 minutes (usually) • Event usually not as dramatic as other arousal disorders • Usually walk calmly around house (or out) • Falling down stairs is a real risk • Partial awareness/responsiveness – blank or glossy stare • Habitual behaviors (automatism)

19. NREM Parasomnias • Sleepwalking • If awoken during an event subject usually confused, may react violently. • Agitated, violent or belligerent behaviors can occur. • May spontaneously awaken before returning to bed, or may lie down and continue sleeping in different location. • Inappropriate behaviors (urinating in waste basket, rearranging furniture, climbing out a window) • Agitated sleepwalking difficult to distinguish from adolescent / adult sleep terrors.

21. NREM Parasomnias • Sleep Terrors (Pavor Nocturnas) • Age 4 – 12 yo • Prevalence in adults up to 5% • Occur 1st third of night • Significant autonomic discharge (tachycardia, tachypnea, flushing, diaphoresis)

22. NREM Parasomnias • Sleep Terrors • Initiated by loud, blood-curdling scream, extreme panic state, followed by motor activity (hitting the wall, running around room or out of house can result in injury) • Inconsolability (universal feature) • Amnesia typical (complete or partial)

23. NREM ParasomniasSleep Eating

24. Sleep Eating • Specialized form of DOA • Frequent episodes of nocturnal eating • Frozen pizzas, raw bacon, buttered cigarettes, cat food, coffee grounds, ammonia cleaning solutions… • Partial to no recall • Occur any time in sleep cycle • Female predominance • Mean age of onset 22 to 29 years • Usually due to primary sleep disorder and psychotropic medications • Strongly associated with other parasomnias

25. NREM Parasomnias • Diagnosis: • Not all cases warrant medical attention • General indications for formal evaluation: • Potentially violent or injurious behavior (always a first time) • Extremely disruptive to other household members • Result in complaint of excessive daytime sleepiness • Associated with medical psychiatric or neurologic symptoms or findings

26. NREM Parasomnias • Diagnosis • Formal, appropriately formed polysomnography may provide direct or indirect diagnostic information. • Expanded EEG montage (nocturnal seizures) – not always diagnostic. • Continuous audiovisual monitoring • Sleep deprivation prior to formal PSG may increase likelihood of capturing an in-lab event.

27. NREM Parasomnias • Treatment • Not always necessary (be wary if progressive) • Benzodiazepines may be effective (never seen in my experience at Stanford - OSA) • Paroxetine/Trazodone – improvement in some cases • Psychotherapy, progressive relaxation, hypnosis (? Role if no underlying psychological disorder) • Anticipatory awakenings for sleepwalking/terrors: (15-30 minutes before usual episode time) May result in sleep deprivation and paradoxical worsening. • Avoidance of precipitants: drugs, alcohol, sleep deprivation • Safe environment (removal of obstructions in the bedroom, secure windows, install locks or alarms on outside doors, or cover windows with heavy curtains)

29. REM Parasomnia • REM Sleep Behavior Disorder (RBD) • Abnormal behaviors during REM sleep • Usually result in injury to self or partner and sleep disruption • Excess phasic muscle tone activity • Awareness of dream/nightmare (attacked or chased) • End of episode there is rapid awareness, dream recall (corresponds to action of subject - isomorphism)

30. REM Parasomnia • RBD • Behaviors include: talking, laughing, shouting, swearing, gesturing, reaching, grabbing, arm flailing, slapping, punching, kicking, sitting up, leaping from bed, crawling, running, walking (rare) • Eyes usually remain closed (higher risk of injury) • Behaviors do not include: chewing, feeding, dinking, sexual behaviors, urination, defecation • http://www.youtube.com/watch?v=rFXYRQ9xPUA&feature=player_detailpage

31. REM Parasomnia • RBD • Male predominant (usually after age 50) • .38% prevalence in general population • .5% prevalence in elderly population. • Sleep violence 2.8% prevalence: • 38% associated with dream enactment. • 33% prevalence of RBD in newly diagnosed Parkinson’s disease. • 90% prevalence in multiple system atrophy.

32. REM Parasomnia • Precipitating factors • Male sex • Age ≥ 50 • Underlying neurological disorder (esp. Parkinson’s, dementia w/ Lewy bodies, narcolepsy, stroke) • Medication use (SSRIs, Venlafaxine, Mirtazapine, other anti-depressants)

33. REM Parasomnia • Subclinical or preclinical RBD (“REM without Atonia” • Minor subclinical REM sleep behaviors (limb twitching/jerking/talking) no complex behaviors. • Eventual emergence of clinical RBD in at least 25% of cases.

34. REM Parasomnia • Treatment: • Limited: Klonopin; Melatonin.

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