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Sleepwalking – Sleep Terrors – Somniloquy – Sleep Starts – Exploding Head Syndrome – Rhythmic Movement Disorder – Bruxism – Enuresis
Parasomnias are undesirable phenomena associated with sleep, which normally do not adversely affect the quality of sleep. Their classification is based on the time of appearance in relation to the sleep phases. Most parasomnias are not considered pathological. Non-REM parasomnias appear in Non-REM sleep.
Arousal Disorders (impaired arousal from sleep)
Sleepwalking occurs upon arousal from deep (slow wave) sleep. It occurs in 17% of children and in 4% of adults. Sleepwalking peaks between ages 8 and 12 years. It is believed to be caused by immature sleep structure. Fever and insufficient sleep may trigger sleepwalking.
Behavior during sleepwalking episodes may be very complex but the judgment is impaired. This combination may lead to dangerous consequences. Sleepwalkers are able to communicate. It is easily noticeable, however, that something is going wrong.
A sleepwalking individual has one’s eyes open, walks around quietly and slowly, appears confused but the activity usually appears goal directed. An agitated or aggressive behavior is not typical but it has been reported, especially in response to forced arousal.
A sleepwalking episode normally terminates by returning to bed. Any recollection about sleepwalking is usually absent upon arousal.
Sleepwalking has a strong genetic predisposition. Having a first degree sleepwalking relative increases the chance of sleepwalking 10-fold.
Sleep terrors tend to happen in somewhat younger kids. This phenomenon also tends to run in families. The very first sleep terror attack is a horrifying experience for parents, but the kid remembers nothing.
Sudden awakening is followed by horrible screaming lasting for a few minutes. Any attempts to calm the child down are unsuccessful until the attack runs its course. An electroencephalogram during sleep terror attack is consistent with deep sleep. Sleep terrors classically occur during the first sleep cycle about 1 to 1.5 hours after falling asleep. Sleep terrors are very common and experienced by 40% of children.
Confusional arousals tend to occur in children under 5 years of age. During a confusional arousal the child sits up in bed while asleep. There is no screaming but the child appears distressed, whimpers, and has a negative attitude. Soothing produces no calming effect. Confusional arousals occur in the first third of the night and last for up to half an hour. In the morning, upon arousal, the child appears just fine. Parent’s distress is the only complication of this sleep phenomenon.
Treatment of Arousal Disorders
Infrequent sleepwalking and sleep terrors do not require any treatment. The only reason for the treatment is a safety concern due to frequent attacks.
A small dose of Clonazepam at bedtime may prevent the episodes. Scheduled awakenings 15 minutes prior to usual time of the attacks each night is another alternative. Some anecdotal evidence suggests that it might even speed up the remission of sleepwalking.
Sleep-wake Transition Disorders
Sleep Starts (Benign Hypnic Myoclonus)
Sudden jerky movements of a body part or the whole body while falling asleep have been experienced by everyone. This phenomenon is a feature of stage I of Non-REM sleep. It is often associated with a sensation of falling.
Benign hypnic myoclonus is a totally benign condition. Sometimes sleep starts look pretty violent, which may raise concerns about epilepsy. As long as sleep starts are limited to the first stage of sleep, they are very unlikely to be pathological. No treatment is required.
Another possible version of sleep starts is an “exploding head syndrome”. It presents with a sudden arousal with sensation of bursting of the head (but not a headache). Exploding head syndrome is a benign condition, which may sometimes be mimicked by an epileptic seizure.
Sleep Talking (Somniloquy)
Sleep-talking is very common. It occurs in both REM and NREM sleep. Somniloquy has no medical or psychological significance besides disturbance to the bed partner. It may have genetic predisposition and is provoked by stress.
Nocturnal Leg Cramps
Muscle cramping at night is a very common but poorly understood phenomenon. It runs in families. Potentially effective medications are Quinine (I avoid this one due to unfavorable side effects), Verapamil and Gabapentin.
Rhythmic Movement Disorder
Rhythmic movement disorder is characterized by stereotyped head or whole body rolling side-to-side or banging with the head, usually, while falling or staying asleep. The rhythm of movements is maintained with a specific oscillation frequency.
This condition occurs almost exclusively in stage II NREM sleep. Rhythmic movement disorder is common in infants and is very uncommon on older children and adults.
There are multiple theories explaining this phenomenon. I don’t agree with a stigma of association between rhythmic movement disorder and mental retardation. This phenomenon is a sleep phenomenon and has nothing to do with stereotypical behavior of mentally retarded people. The idea that rhythmic movements promote deeper sleep stages sounds very logical to me, but it is not the most popular opinion.
Sleep Bruxism (teeth grinding)
An intermittent grinding or clenching of teeth during sleep is common in children (88%). About 20% of adults have bruxism. This phenomenon is not attached to any particular sleep stage. The force applied to the teeth is substantial, which may lead to the teeth and TMJ damage.
There is no single acceptable theory explaining this sleep disorder. Available treatment options, such as a splint, occlusional adjustments, psychotherapy, anti-inflammatory medications, hypnosis e.t.c., lack scientific proof of any significant benefit.
Enuresis may occur in any sleep stage. Frequent in children, it may be present in 2% of adolescents and in 0.5% of adults.
In spite of multiple studies, the cause of enuresis remains elusive. Urological conditions are found in only 3% of children with enuresis. There is no proof that psychological problems have any causative relationship to enuresis.
Psychotherapy is ineffective. Some medications (Imipramine, Desipramine and Desmopressin) do offer symptomatic improvement but they are not recommended for long term use. Bell-and pad device may offer a temporary relief. No radical treatment is available.