JRSM >
Volume 94, Number 4 >
Pp. 173-176
University Section, Park Hospital for Children, Old Road, Headington, Oxford OX3 7LQ, UK
Email: gregory.stores{at}psych.ox.ac.uk
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 TOP INTRODUCTION TYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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| TYPES OF PARASOMNIA |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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Clinical manifestations in the parasomnias vary from subtle—readily overlooked without special observation—to complex. At any age the obvious, complex and dramatic parasomnias are likely to cause most concern to sufferers and relatives, and also to clinicians uncertain about what they are and what they mean. The present account is confined to the clinical manifestations of the more dramatic forms of parasomnia which give rise to such anxiety and uncertainty, and which are generally less well known than other parasomnias. More comprehensive reviews, including the evidence for the various recommended treatments, can be found elsewhere4,5.
| AROUSAL DISORDERS |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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Often there is a strong family history of an arousal disorder. In predisposed individuals, the arousal may be precipitated by such factors as a febrile illness, central nervous system depressant medication sometimes combined with alcohol, sleep loss or disruption in which SWS is increased (as in some other sleep disorders such as obstructive sleep apnoea) or psychological stress.
Three types
The three basic types of arousal disorders recognized in the ICSD are
confusional arousals, sleepwalking and sleep terrors (although episodes can
involve elements of all three). They vary somewhat in clinical features and
age of occurrence, but in all of them the patient seems to be simultaneously
awake and asleep, with apparent awareness or even distress but little if any
awareness of the environment (and therefore limited or no recall of the
episode) because he remains asleep (`he' is used for simplicity). Dramatic
behaviour can occur in all three types of arousal disorder.
Confusional arousals
This type of arousal disorder occurs mainly in infants and toddlers,
perhaps most of whom have such episodes to some degree. An episode may begin
with movements and moaning and then progress to agitated and confused
behaviour with crying, calling out or thrashing about. Although appearing
alert, the child typically does not respond when spoken to, and more forceful
attempts to intervene may meet with resistance and increased agitation.
In this and the other types of arousal, parents are often very alarmed and, wanting to console, may make vigorous attempts to waken the child, without success or only with great difficulty. Such efforts may actually prolong the arousal and, if the child is woken to some extent, he is likely to be confused and frightened. Each episode usually lasts 5-15 minutes (though it can be much longer) before the child calms down spontaneously and returns to restful sleep.
Confusional arousals in adults (`sleep drunkenness') can occur on waking from particularly deep sleep. Causes of such deep sleep include medication effects, recovery from sleep deprivation and other sleep disorders characterized by excessive sleepiness or abnormal circadian sleep—wake patterns.
Sleepwalking
Sleepwalking is said to occur in up to 17% of children, mainly between 4
and 8 years of age. The condition usually ceases spontaneously by adolescence.
Episodes, which seldom last more than 10 minutes, tend to be less dramatic
than confusional arousals. The young child may crawl or walk about in his cot.
At a later age he may calmly walk around his room or into other parts of the
house such as to the toilet, towards a light or to his parents' bedroom. The
child may appear downstairs or may be found standing on the landing or
elsewhere in the house, looking vague with eyes open but with a glassy stare.
At most he will be partially responsive. Some children are found asleep in
various parts of the house. Quite complicated routes may be followed if well
known to the child, or other complex habitual behaviour may occur. Urinating
in inappropriate places is not uncommon.
Accidental injury in sleepwalking (e.g. from falling downstairs) is a substantial risk. In later childhood, adolescence or adult life, the wandering may extend further within the house or outside. The sleepwalking can then take an agitated form, again sometimes worsened by attempts to intervene and with an even greater risk of injury from crashing through windows or glass doors, for example.
Sleep terrors
This term is preferred to night terrors since the episodes are associated
with sleep whatever its timing. They are said to occur in about 3% of
children, mainly in late childhood and adolescence, and in something under 1%
of adults. The natural histories of this and other arousal disorders have been
little studied. Preliminary reports suggest that sleep terrors starting before
and about 7 years of age continue on average for about 4 years and that those
of later onset tend to last much longer.
Typically, parents are woken up by their child's piercing scream, which marks the very sudden onset of the partial arousal. Whatever the age, the patient seems terrified with staring eyes, intense sweating and rapid pulse, with cries or other vocalizations suggesting intense distress. He may jump out of bed and rush about frantically, as if trying to escape from something. Injury from running into furniture or jumping through windows is again a serious risk, and other people may be injured in the process. The episode usually lasts no more than a few minutes, ending abruptly with the patient settling back to sleep. If the patient wakes up at the end (as may happen in older children and adults), he may describe a feeling of primitive threat or danger, but does not offer the extended narrative that characterizes a nightmare.
Importance
Arousal disorders are important for several reasons. They can be
embarrassing for sufferers themselves, especially if they occur away from
home. They carry a risk of accidental injury. They are often confused with
other primary or secondary parasomnias, including nocturnal epilepsy. In
addition, the more dramatic forms cause parents to worry that the child is
psychologically disturbed. Professionals may share this concern. In fact, as
with other common childhood parasomnias, arousal disorders seem only
occasionally to be a feature of an underlying psychiatric condition. The
clinical impression is that such exceptions to the rule are characterized by
parasomnias which are very frequent, later than usual in onset, recurrent
after having stopped, persistent well beyond the age at which they usually
cease or preceded by a dramatic event (although the occurrence of the trauma
may not be immediately apparent, as in some cases of child sexual abuse).
Examples are described (mainly in adults) in which antisocial acts, including injury to others, have occurred during a sleepwalking episode. In such circumstances various possibilities, including other sleep disorders, have to be considered6.
A single type of arousal disorder may have different implications according to age. A general rule, again based on clinical impression, is that in children arousal disorders are `developmental' and not in themselves caused by any serious underlying condition, whereas in adults there is greater likelihood of psychological disorder. In the elderly, an organic cause should be considered.
Treatment
The principles are as follows. First, reassure the parents (where this is
justified) that these often frightening events do not mean that the child is
ill or disorded, and that he can be expected to grow out of them. Second,
ensure regular and adequate sleep routines, to prevent sleep loss or
disruption. Third, make the environment as safe as possible, to reduce the
risk of injury (e.g. remove obstructions in the bedroom, secure windows,
install locks or alarms on outside doors, cover windows with heavy curtains).
Fourth, advise parents not to try to waken or restrain the child during the
episode: waking the child is difficult, counter-productive and unnecessary. It
is much better to wait until the episode subsides and calmly help him back to
quiet sleep (the same applies to adults). Fifth, if the patient has no recall
of the episodes, there is little point in recounting them since this may
become a source of anxiety. Sixth, if sleepwalking or sleep terrors are
frequent and consistent in the time they occur, `scheduled waking' can be
helpful. This consists of gently and briefly waking the patient 15-30 minutes
before the episode is due. The procedure is repeated nightly for up to a
month. Preliminary reports suggest that improvement can be maintained for
several months. Seventh, medication (e.g. low-dose clonazepam) should be
reserved for particularly worrying, embarrassing or dangerous arousals where
other measures have failed. Last, if there is evidence of an underlying
psychological or physical disorder, special enquiries and help will be
needed.
| REM SLEEP BEHAVIOUR DISORDER |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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| NOCTURNAL EPILEPSIES |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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Seizures closely related to the sleep—wake cycle occur in several types of epilepsy of both children and adults. Some seizures are subtle and may go undetected at night; in others the manifestations are dramatic, with greater risk of diagnostic confusion.
Mesial frontal seizures illustrate the difficulty well. This not uncommon form of epilepsy tends to be misdiagnosed mainly because of the complex motor manifestations (e.g. kicking, hitting, rocking, thrashing and cycling or scissor movements of the legs) and vocalizations ranging from grunting, coughing, muttering or moaning to shouting, screaming or roaring8. The abrupt onset and termination, short duration of the attacks (different from seizures of temporal lobe origin) and sometimes preservation of consciousness can also suggest a non-epileptic basis. Diagnosis rests mainly on clinical features. Electroencephalography, even during the episodes, is of limited diagnostic value. The underlying cerebral disorder varies and no structural abnormality may be found. One form is clearly genetic in origin, with an autosomal dominant pattern. The brief type of `nocturnal paroxysmal dystonia' is within this category of epilepsy. Response to treatment is unpredictable.
Other epilepsies involving dramatic manifestations that may well occur in relation to sleep are benign centrotemporal (Rolandic) epilepsy in children, some seizures of temporal lobe origin with prominent affective symptoms especially fear, benign epilepsy with affective symptoms and benign occipital epilepsy. Episodic nocturnal wandering is a sleep-related condition of adults that may be epileptic in nature.
In most cases, epilepsy should be distinguishable from the primary parasomnias by careful clinical evaluation combined with special investigations such as sleep studies and long-term electroencephalographic (EEG) monitoring in hospital or at home. The occurrence of attacks both at night and during the day favours epilepsy.
| OTHER DRAMATIC PARASOMNIAS |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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Patients may have combinations of each of these and other parasomnias. `Overlap parasomnias' combine arousal disorder and RSBD episodes.
Recognition of all the parasomnias depends on an awareness of their existence and careful assessment of the clinical features of the nocturnal episodes, together with special investigations where necessary.
| REFERENCES |
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TOPINTRODUCTIONTYPES OF PARASOMNIAAROUSAL DISORDERSREM SLEEP BEHAVIOUR DISORDERNOCTURNAL EPILEPSIESOTHER DRAMATIC PARASOMNIASREFERENCES |
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