Parasomnias

Arousal Disorders (NREM parasomnias)
Confusional Arousals
Sleep Walking
Sleep Terrors
Sleep Wake Transition Disorders

NREM PARASOMNIAS

Confusional arousals are characterized by episodes of arousal from deep sleep with associated mental confusion and these tend to occur in the first third of the night usually from stage 3/4 sleep. Typically the patient sits up in bed or acts confused or inappropriately however the subject does not show any expression of terror or leave the bed. These episodes tend to occur more commonly in children less than 5 years of age. Typically it is less common in older children and adults. Episodes can be precipitated by events that predispose the patient to excessive tiredness/fatigue such as inadequate sleep or sleep deprivation. Differential diagnosis include sleep terrors, complex partial seizures, and nocturnal paroxysmal dystonia.
ICSD diagnostic criteria:
• Subject or observer noted recurrent mental confusion upon arousal or awakening in the subject.
• Spontaneous confusional episodes can be induced by forced arousal
• An absence of fear, walking behaviour or intense hallucinations with events
• DPSG showing arousals from SWS
• The symptoms are not associated with any other medical condition
• The symptoms do not meet the diagnostic criteria for other sleep disorders

SLEEP TERRORS

Sleep terrors are characterized by episodes of sitting up during sleep associated with the emitting of a piercing scream and showing both autonomic and behavioral manifestations of intense fear. Usually occurs in the first third of the nights like confusional arousals and occurs from stage 3/4 sleep.
During the event the patient is unresponsive to stimuli and if aroused becomes confused. The typical age of presentation is between ages 4-12 years. Sleep terrors, unlike confusional arousals, do occur in adults and typically they occur between ages 20-30 years. The differential diagnosis include: nightmares, confusional arousals, complex partial seizures, nocturnal choking events and panic attacks.
ICSD diagnostic criteria:
• The patient complains of sudden episode of intense terror during sleep
• The episodes usually occur in the first third of the night
• Partial or total amnesia occurs for the events during the episodes
• DPSG showing arousals from SWS. Also tachycardia
• Other medical disorders are not the cause
• Other sleep disorders are not the cause though they may also exist such as nightmares.

MANAGEMENT

NREM parasomnias should be allowed to self terminate. Interference can lead to prolongation of the episodes. If events are rare and do not affect family dynamics, treatment is not required. Treatment should include avoidance of precipitating factors such as sleep deprivation and stress. Stress reduction and relaxation therapy, hypnosis can be used. Pharmacological management includes use of the benzodiazepines, and occasionally tricyclic antidepressants. Safety issues must be emphasized especially with sleep walkers.