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Parasomnias
are undesirable behaviors that occur during entry into sleep, during
sleep, or during arousal from sleep. Diagnosis is clinical. Treatment
may include drugs and psychotherapy.
For many of these disorders, history and physical examination can confirm the diagnosis.
Somnambulism
:
: Sitting, walking, or other complex behavior occurs during sleep, usually with the eyes open but without evidence of recognition. Somnambulism is most common during late childhood and adolescence and occurs after and during arousal from nonrapid eye movement (NREM) stage 3 or 4 sleep. Prior sleep deprivation and poor sleep hygiene increase the likelihood of these episodes, and risk is higher for 1st-degree relatives of patients with the disorder. Patients may mumble repetitiously, and some injure themselves on obstacles or stairs. There is no accompanying dream. Usually, patients do not remember the episode.
Treatment is directed at protecting patients from injury. It includes using electronic alarms to awaken patients when they leave the bed, using a low bed, and removing obstacles from the bedroom. Benzodiazepines, particularly clonazepam 0.5 to 2 mg po, at bedtime may help.
Sleep (night)
terrors:
During the night, patients have episodes of fear, screaming, and flailing, often with sleepwalking. Patients are difficult to awaken. Sleep terrors are more common among children and occur after arousal from NREM stages 3 or 4 sleep; thus, they do not represent nightmares. In adults, sleep terrors can be associated with mental difficulties or alcoholism. If daily activities are affected (eg, if school work deteriorates), intermediate- or long-acting oral benzodiazepines (eg, clonazepam 1 to 2 mg, diazepam 2 to 5 mg) at bedtime may help.
Nightmares:
Children are more likely to have nightmares than adults. Nightmares occur during REM sleep, more commonly when fever is present or after alcohol has been ingested. Treatment is directed at any underlying mental distress.
REM
sleep behavior disorder:
Verbalization (sometimes profane) and often violent movements (eg, waving the arms, punching, kicking) occur during REM sleep. These behaviors may represent acting out dreams by patients who, for unknown reasons, do not have the atonia normally present during REM sleep.
This disorder is more common among the elderly, particularly those with CNS degenerative disorders (eg, Parkinson's or Alzheimer's disease, vascular dementia, olivopontocerebellar degeneration, multiple system atrophy, progressive supranuclear palsy). It can also occur in patients who have narcolepsy and with use of norepinephrine reuptake inhibitors (eg, atomoxetine , reboxetine, venlafaxine ). Cause is usually unknown.
Diagnosis may be suspected based on symptoms reported by patients or the bed partner. Polysomnography can usually confirm the diagnosis. It may detect excessive motor activity during REM; audiovisual monitoring may document abnormal body movements and vocalizations. A neurologic examination is done to rule out neurodegenerative disorders. If an abnormality is detected, CT or MRI may be done.
Treatment is with clonazepam 0.5 to 2 mg po at bedtime. Most patients need to take the drug indefinitely to prevent recurrences; potential for tolerance or abuse is low. Bed partners should be warned about the possibility of harm and may wish to sleep in another bed until symptoms resolve. Sharp objects should be removed from the bedside.
Sleep-related
leg cramps:
Muscles of the calf or foot muscles often cramp during sleep in otherwise healthy middle-aged and elderly patients. Diagnosis is based on the history and lack of physical signs or disability.
Prevention includes stretching the affected muscles for several minutes before sleep. Stretching as soon as cramps occur relieves symptoms promptly and is preferable to drug treatment. Numerous drugs (eg, quinine , Ca and Mg supplements, diphenhydramine , benzodiazepines, mexiletine ) have been used; none is likely to be effective, and adverse effects may be significant (particularly with quinine and mexiletine ). Avoiding caffeine and other sympathetic stimulants may help.
Last full review/revision April 2008 by Karl Doghramji, MD
Content last modified April 2008
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