Parasomnias

1. Parasomnias Wahba W. Wahba, M.D. Director of Sleep-Wake Disorder Center Daytona Beach, FL Family Medicine Spring Forum Hollywood, Florida

2. Objectives • Definition of Parasomnias • Classification of Parasomnias • Pathophysiology of Parasomnias • Diagnosis of Parasomnias • Medicolegal Implications of Parasomnias • Treatment of Parasomnias

3. What are Parasomnias? • A group of disorders exclusive to sleep and wake-to-sleep transition • They encompass arousals with abnormal motor, behavioral or sensory experiences • Sensory experiences often involve perceptions, dream-like hallucinatory experiences, and autonomic symptoms • When excessive motor-activity is present, can be disruptive to patient and patient’s bed partner

4. Classification of Parasomnias

5. Nocturnal Spells: Overlapping States • RBD • Hypnagogic Hallucinations • Sleep Paralysis • Confusional Arousal • Sleepwalking • Sleep Terrors Wake REM Non-REM • Dissociative Disorders • PTSD NFLE

6. Pathophysiology • Abnormal brain electro-chemical activity during sleep • Disordered arousals from sleep • Over-activation and release (disinhibition) phenomena • Mixed states of sleep and wakefulness

7. PATHOPHYSIOLOGY • De-afferentiation of the locomotor centers from the generator of the different sleep states • Locomotor sensors are present at spinal and supraspinal levels and explain motor activity or ambulation

8. Pathophysiology • NOT caused by psychiatric disorders • Stress, Sleep Deprivation and OSA/SDB can trigger sleep aggression and violence in a person already predisposed to certain sleep disorders

9. Confusional Arousal Including sleep-related abnormal sexual behaviors Sleepwalking Sleep Terrors Increased predilection in children Decreased predilection with age Occur in the first half of the night (typically first two hours of sleep) Non-REM Parasomnias

10. Confusional Arousal • Confusion during and following arousals from sleep • Patient is disoriented in time and space • Slow of speech and mentation • Responds poorly to commands or questions • Major memory impairment both retrograde and anterograde • Behavior may last for several minutes to hours • May be precipitated by forced awakening or OSA

11. 56-year-old man history of traumatic brain injury and OSA poor compliance with CPAP complains of night spells Described as sudden arousal with confusion and singing PSG Multiple spells of arousal and confusion with arm flapping and talking from NREM sleep In one event, technician reported quacking like a duck 20 episodes recorded with and without preceding respiratory effort No seizure activity Case History – Confusional Arousal Diagnosis: Confusional Arousal, Resolved with CPAP therapy

12. Criminal Cases – Confusional Arousal • A sleeping person stabbed a friend to death after the friend tried to awaken him • A boy tried to pick up an object next to a sleeping person • Person was aroused by the noise, grabbed a knife and stabbed the boy • Person was awakened by a noise at midnight • Person grabbed an axe and attacked a “stranger in the room,” killing his wife Sleep 2007; 30: 1039-1947

13. Night shift supervisor fell asleep in his office and 30 minutes later an employee entered the office to wake the supervisor • Supervisor immediately pulled out his gun in confusion and fired the gun, killing the employee • A porter entered a darkened hotel room unannounced and awakened the defendant • Defendant shot the porter 3 times, killing the porter

15. Sleepwalking: Non-REM Sleep Parasomnia • A series of complex behaviors that emerge abruptly during sudden arousals from slow-wave sleep • Walking around with an altered state of consciousness and impaired judgment • Eyes are open • Inappropriate interaction with the environment

16. Sleepwalking: Diagnostic Criteria • Ambulation that occurs in sleep • Onset typically in prepubertal children • Associated features • Difficulty arousing patient during an episode • Amnesia following an episode • Typically in first third of sleep episode • PSG onset of episode during N3

17. Sleepwalking & Confusional Arousal • Major Predisposing Factor: Genetic • 22% - neither parent has the disorder • 45% - one parent has the disorder • 60% - both parents have the disorder • Major Precipitating Factors: • Sleep Deprivation • Stress • Sleep Disordered Breathing • Alcohol Use (?) • Thioridazine, Chloral Hydrate, Lithium, Prolixin, Perphenazine & Desiparmine

18. Case – Canada v. Parks • 24-year-old Parks arose from couch where he fell asleep watching TV, put on his shoes, took car keys, left front door and garage door open, and drove 23 km in Toronto to his in-laws home • Parks unlocked the door, walked to in-laws bedroom, strangled father-in-law, beat mother-in-law with tire iron, stabbed both with knife from the kitchen • Parks cut his own flexor tendons in both hands and felt no pain then, or later when he was observed in a sleepwalking-like state

19. Canada v. Parks • Parks picked-up kitchen phone and took it off the hook, ran upstairs to children's’ bedrooms • Children described hearing screaming and animal-like grunting • Grunting stopped, after which Parks left • Parks turned himself in to police stating: • “I killed someone with my bare hands.” • Distressed and shaking, Parks asked policeman: • “What happened? I was sleeping on the couch. I just woke up. I had a dream. I had a knife in my hand. I was killing them. I choked them, then I went to the police station…How could I drive there and not know?”

20. Canada v. Parks • According to police, Parks did not appear to be in pain despite his severed tendons • Striking example of dissociative analgesia (i.e. profound blunting of pain) found in sleepwalking • This observation by police provides compelling evidence supporting a grossly impaired state of consciousness

21. Sleep Talking – 7 family members Excessive Sleepiness – 3 Sleepwalking – 5 Sleep Terror – 3 Sleep Cooking – 2 Sleep Driving – 1 Sleep Running – 2 Bedwetting – 5 Leaving stove on after sleep cooking – 2 Sleep-related injury – 2 Going out a window – 1 Total – 20 Parasomnias affecting 10 1st and 2nd degree family members Parks Family History

22. Violent OSA-Triggered Confusional Arousal & Sleepwalking Baron J. Auckley. Sleep and Breathing 2005 • 55-year old morbidly obese man, • Known OSA • Progressive cognitive and psychological deterioration due to suboptimal treatment of OSA • On night of admission, patient reached for bi-pap mask accidently picking up pistol with the mask and straps • Unaware of gun in his hand, patient fired the pistol attempting to pull the straps of the mask • Result: tangential scalp wound

23. Parasomnia & OSA Lateef O, Wyatt J, Cartwright R. Chest 2005 • 54-year-old female • No childhood parasomnia, • 5 year history of parasomnias, • Sleep-driving from naps 5 times per month, • Sleepwalking barefoot in the snow • Found by police wandering in nearby town • Chopped up her cat on cutting board in kitchen • Awoke at 6 AM, hands covered in blood, cats remains next to trash can • Sleep History: load snoring, EDS, weight gain • PSG: severe OSA w/ marked hypoxia • 4 month follow-up on CPAP: No Parasomnia

24. Sexsomnia • Other Terms: • Sleepsex • Atypical sexual behavior during sleep • Abnormal sleep-related sexual behaviors (ICSD-2) • Problematic sexual behaviors emerging during sleep • Two Most Common Causes: • Non-REM Parasomnias • Confusional Arousal and Sleepwalking • OSA

25. Sexsomnia in NREM Parasomnias • Usually a history of Parasomnias • Often childhood onset: • sleepwalking, • sleep terrors, • Confusional arousals, • sleep-related eating disorder, • sleep talking • etc.

26. Sexsomnia in OSA • “Snorgasm” “Sexapnea” • Typical History: • Onset or Increase of Snoring occurs with the onset of Sexsomnia

27. Sexsomnia: 31 Published Cases • Gender • Males 80.6% • Females 19.4% • Age • 31.9 ± 8.0 years • Duration • 9.5 ± 6.1 years • Behaviors may include: • masturbation 22.6% • Sexual vocal/verbal 19.3% • Fondling 45.2% • Sexual Intercourse 41.9 %

28. Sexsomnia: 31 Published Cases • Amnesia of Sleepsex 100% • Assaultive Sleepsex behaviors 45.2% • Sleepsex with Minors 29.0% • Legal Repercussions 35.5% • Polysomnography performed 83.9% • Total # of Parasomnias 71 • Mean # of Parasomnias/Pt 2.2±1.0

29. Sexsomnia: Forensic Cases • A case of Sexsomnia where there is no current documented OSA, and no past history of (observed) Parasomnias should be considered with skepticism • A 1st time Sexsomnia episode resulting in legal consequences should be considered doubtful

30. REM SLEEP BEHAVIOR DISORDER • Complex and elaborate motor activity • Associated with agitated and violent dream mentation • Wide range of activity: • Verbalization • Shouting • Screaming • Walking • Running • PSG with elevation of limb or chin EMG during REM sleep • The injury associated with these spells is often what triggers the patient to seek help • Singing • Yelling • Kicking • Punching • Violent Agitated Behaviors

31. RBD: DIAGNOSTIC CRITERIA(ISCD 2) • POLYSOMNOGRAPHIC • Excessive chin tone during REM sleep and/or • Excessive limb twitching during REM sleep • Absence of EEG epileptiform activity during REM sleep • BEHAVIORAL CRITERIA • History of problematic sleep related behaviors (Often, but not necessarily, dream enacting behaviors) that are injurious, potentially injurious, or disruptive of sleep And/Or • Documented REM sleep behaviors during PSG

32. CAUSES ASSOCIATED WITH CHRONIC RBD • Idiopathic • Neurologic disorders • Medication induced • SSRIs,Venlafaxine,mitazepine,TCAs, • MAOIs,(not bupropion) • B-Blockers • ACE inhibitors • Selegeline • Caffiene, chocolate: excessive consumption

33. RBD: Sleep-Related Injury • Bruises • Subdural hematomas • Lacerations • Fractures • Dislocations & Sprains • Abrasions • Tooth Chipping • Hair Pulling

34. RBD • The only parasomnia in ICSD-2 requiring PSG confirmation. • 3 Reasons: • PSG findings are present every night • RBD is NOT the only dream-enacting disorder • DOA, OSA, Nocturnal Seizures • RBD is strongly linked to future Parkinson’s Disease making objective diagnosis crucial

35. POTETILY LETHAL BEHAVIORS ASSOCIATED WITH RBD Review of the Literature and Forensic Implications Journal of Forensic Sciences 2009; 54: 6

36. Published Cases of RBD Associated with Potentially Lethal Behaviors (Usually during Dream-Enactment) • Choking/Headlock n=22-24 • Punching a pregnant bed partner n=2 • Defenestration n=1 • Near-Defenestration n=6 • Diving from Bed n=10 • Total: n= 41-43

37. RBD & PARKINSONS DISEASE • Reviewed medical records from 2002-2006 • Entry Criteria • Idiopathic RBD at time of RBD onset • ≥ 15 yrs between RBD onset and onset of a neurodegenerative disorder (NDD) • Results • 27 patients satisfied entry criteria • 23 yrs median interval between RBD onset and NDD • 50 yrs greatest interval • Conclusion • The pathologic process may start decades before the first symptom of PD • Long period has important implications for furture epidemiologic studies and interventions to slow or halt the NDD process

38. RBD Protects Against Obstructive Sleep Apnea (OSA)!!! • Correlation study • 71 RBD patients • Loss of REM atonia and severity of OSA in RBD patients • Case control study: • 28 RBD/OSA patients; 27 OSA patients • Compare sleep related respiratory events between RBD/OSA patients and OSA patients

39. RBD Protects Against (OSA)RESULTS • Correlation Study: increased REM sleep EMG activity was significantly associated with lower severity of OSA in RBD patients • Total AHI • NREM AHI • Obstructive AHI • Mean apnea duration • Case Control Study: RBD/OSA patients had significantly lesser severity of sleep apnea parameters than OSA controls • O2 saturation (86% vs 81%) • Shorter max hypopnia duration (54 vs 60 sec) • Mean apnea duration (22 vs 26 sec)

40. Sleep-Related Eating Disorder (SRED)

41. SRED: Essential Features • Recurrent episodes of involuntary eating and drinking during arousals from sleep with problematic consequences • Episodes of eating always occur in an involuntary manner after an interval of sleep and usually during partial arousals with partial recall • Some patients cannot be awakened (as in classic sleepwalking) • Some patients have considerable alertness and substantial recall

42. SRED: Predominant Associations • Sleepwalking • RLS/PLMD • OSA • Medication: Zolpidem, Olanzapine, Risperidone, Mitrazapine, Lithium, Anticholinergics • Idiopathic, Indeterminate • Onset childhood adolescents • early-mid adulthood

43. SRED • Appears to be a “final common pathway” disorder that can emerge from a broad range of clinical conditions • Once SRED emerges, regardless of origin, SRED demonstrates a rather stereotypical course • Classifies as a parasomnia (ICSD-2)

44. SRED: Diagnostic Criteria (ICSD-2) • Recurrent episodes of involuntary eating and drinking during the main sleep period • One of the following must be present: • Consumption of peculiar forms or combination of food or inedible or toxic substances (frozen pizza, buttered cigarettes, raw bacon, cat food or salt/sugar peanut butter sandwich, amonia) • Insomnia related to sleep disruption from repeated episodes of eating with a complaint of non-restorative sleep, daytime fatigue or somnolence • Sleep-related injury: • laceration from careless use of kitchen utensils, • internal or external burns from consuming or spilling hot foods or beverages, • poisoning and internal injuries from ingesting toxic substances

45. SRED: Diagnostic Criteria • Dangerous behaviors performed while in pursuit of food or while cooking food • e.g. Driving, kitchen fires • Morning Anorexia often with abdominal distention • Adverse health consequences from recurrent binge eating of high caloric foods • Excessive weight gain • Destabilization or precipitation of Diabetes Mellitus • Hyperlipidemia • Overnight fasting before next day surgery can be compromised • Consuming foods to which one is allergic • Dental complication: tooth chipping and caries

46. SRED (ICSD-2) • Female predominant disorder (60-83%) • Mean age of onset: 22 – 40 years In reported series • Nightly frequency of nocturnal eating very common • > 50% in reported cases

47. ASSOCIATION BETWEEN RLS & SRED • 100 RLS patients in Northern Italy and 100 matched controls • Two phone interviews about nocturnal eating, EDS, sleep quality, social demographics, health status, psychopathological traits

48. RESULTS • SRED: 33% in RLS versus 1% in controls (P=0.001) • Medication Use, Obsessive Compulsive Inventory more prevalent in RLS/SRED patients compared to RLS patients with out SRED • Use of dopaminergic or hyptnotic medications in RLS patients did not corrolate with the presence of SRED

49. CONCLUSION • A strong association of RLS with SRED was demonstrated in the aforementioned study • Prospective studies are needed to establish the mechanisms underlying such association and whether it is causal Movement Disorders 2009 24 (6: 871-877) Provini F. et al and Brotherhood (Univ. Of Bologna Italy)

50. COMMENTS • SRED patients should be carefully questioned about RLS (including family history) • RLS patients should be questioned about SRED (initially and longitudinally)