Parasomnia: Everything you need to know

Those frantic awakenings from nightmares, nighttime treks to the fridge, even bed-wetting—did you know there is a diagnosis for that? Parasomnias are a group of sleep disorders impacting approximately 10% of Americans. Read more to become familiar with the various types of parasomnia, effective parasomnia treatments, and safety concerns that can improve the lives of you and your loved one with parasomnia.

What is Parasomnia?

Parasomnia: the suffix (–somnia) means “relating to a condition of sleep.”
Thus, it is no surprise to learn that parasomnia is an umbrella term describing a group of sleep disorders characterized by abnormal behaviors during sleep. Brief examples include sleepwalking, nightmares, and even bed wetting. Depending on the type, parasomnia can occur in both REM or non-REM stages of sleep. Irregular activity of the central nervous system tends to provoke the disorders.

Basic Symptoms of Parasomnia

While there are various types of parasomnia, each classification does have a set of common, general symptoms.

• Nightmares
• Confusion
• Fatigue
• Grinding of teeth
• Sudden or partial awakening
• Hallucinations
• Sleepwalking
• Sleep-talking
• Sleep-eating

Causes of Parasomnia

The causes of parasomnia are not fully understood. It is thought to be genetic. Parasomnia conditions are frequently seen in families. However, REM parasomnias are associated with neurological disorders such as Parkinson’s Disease and Lewy Body Dementia.

Who is at risk for Parasomnia?

There are certain risk factors that increase one’s chances of having various types of parasomnias. Children are more susceptible to displaying parasomnia behaviors like night terrors, bedwetting, and talking during sleep. Adults are often seen with REM sleep behavior disorder and catathrenia.

Stress exacerbates parasomnias. Those with Post Traumatic Stress Disorder (PTSD) are likely to have severe nightmares. Lifestyle factors also contribute. Substance abuse alters the chemical balance in the brain, which triggers the symptoms of a parasomnia diagnosis. Additionally, parasomnia is often a side effect of medications that treat other medical conditions.

Non-REM Parasomnias

The first three phases of sleep are the non-REM stages: N1, N2, and N3. In non-REM sleep, the body is transitioning into unconsciousness. The nervous system is less stimulated by external stimuli as its senses begin to dull. People experiencing non-REM parasomnias are thought to be partially awake. Parasomnias typically present in the last phase of non-REM sleep (N3), which is referred to as “slow-wave” or “delta” sleep. That phase is important for feeling refreshed upon waking. Daily functioning is impacted when sleep is interrupted by the non-REM parasomnias.

Sleep Walking

Sleepwalking is the act of walking around while asleep. The zombified look portrayed on cartoons is somewhat accurate, as sufferers are usually unaware. A sleepwalking episode is not restricted to solely walking. Behaviors can consist of reorganizing furniture, urinating, or potential dangers like driving a car or leaving their house with impaired judgment.

Sleepwalkers are prone to anger and violence when awakening from an episode. They are confused because they have no recollection of the events. However, waking someone who is sleepwalking should not cause harm to the sleepwalker.

Night Terrors

After a bad dream, your eyes quickly dart open. You orient yourself with your surroundings—remembering that the disturbing images of your subconscious mind are only nightmares. Night terrors exceed the traditional nightmare. In many ways, the two parasomnias are similar, but those with night terrors are inconsolable. The dramatic response is not necessarily provoked by scary mental images. They sit upright in bed, thrash around, and shout out of fear. Excessive sweating, a racing pulse, and increased respirations are physical symptoms that come with the disorder. These episodes are not remembered upon awakening because it is a fear response by a malfunction of the nervous system.

Confusional Arousal

Confusional arousals are described as unusual or strange behaviors when a person appears to be fully awake but is actually asleep. The odd behaviors manifest from a state of confusion shortly after waking. The episodes span from lasting minutes to hours. Slow speech, disoriented thinking, poor memory, and inappropriate responses are classic traits of confusional arousal. Agitation and aggression are also common.

The episodes are sensitive to disrupted sleep schedules, travel, and health problems like a fever or migraines. Sleep-disordered breathing and restless leg syndrome influence confusional arousal too.

Sleep Related Eating Disorder

We have all roused from a deep sleep hankering for a midnight snack. Sleep-related eating disorder is more serious than the average, occasional nighttime craving. The condition involves frequent eating and drinking behaviors in a state of sleep. Out-of-control eating episodes fall within any of the three stages of non-REM sleep.

Food is prepared and consumed with little to no awareness. Sleep related eating disorder does pose dangers. For instance, preparing food while asleep and using sharp objects like knives is not safe. Weight gain, high blood pressure, vitamin deficiencies, and health complications from eating food prepared improperly might arise. Patients with the diagnosis are liable to eat toxic substances found in the same area as food—cleaning chemicals, coffee grounds, etc.

A few tell-tale signs of sleep related eating disorders are:

• No appetite at breakfast
• Eating most of daily intake after dinner
• Awakenings that require food to fall back to sleep

Bed Wetting (Enuresis)

Enuresis, or bed wetting, is another childhood parasomnia resulting from a lack of bladder control and causing urination while asleep. According to the organization of sleep education, children should have full control of their bladders by age 5. Nighttime accidents are not classified as a sleep disorder until the child has surpassed the prime developmental stage for learning to delay urination. Bed wetting at least twice a week after age 5 warrants an enuresis diagnosis.

Bed wetting does not cause negative health effects. Still, children with the condition have poor self-esteem and are embarrassed over their “accidents.”

Exploding Head Syndrome

As the name suggests, exploding head syndrome mimics a detonating explosion in one’s head. The parasomnia is distinguished by loud noises imagined just before falling asleep or soon after waking up. Sounds range from fireworks to the clashing of cymbals. While exploding head syndrome is not painful, it is startling for those experiencing the sensations. Many assume they are having a stroke or a heart attack.

Muscle twitches or visual disturbances such as a flashing light accompany the noise in some cases. Professionals are uncertain as to the cause of the exploding head phenomena. Current hypotheses are that the condition is from stress, seizure activity in the brain, or changes in the anatomy of the middle ear.

Sleep Talking

Sleep talking is a sleep disorder consisting of talking during sleep. The disorder is an isolated symptom. The speech can be mumbled or clear, loud or subtle, and inappropriate or innocent. Aside from embarrassment over unconsciously spilling deep dark secrets, sleep talking is physically harmless and only disrupts the sleeping partner.

REM Parasomnias

REM stands for the stage of sleep with rapid eye movement, increased dreaming, and elevated pulse and breathing rates. It is the deepest stage of sleep, making up 25% of the sleep cycle with the brain at its peak of activity. The majority of unwanted behaviors associated with REM parasomnias are performed while fully asleep, which differs from non-REM parasomnias that occur when partially awake.

Sleep Paralysis

Sleep paralysis is REM parasomnia that inhibits involuntary muscle movement. Lasting only a few minutes, those with sleep paralysis are unable to move or speak. Unlike the other forms of REM parasomnias, sleep paralysis stems from unwanted arousals. There is full awareness during an episode. Movement and speech usually return with a touch or sound. Poor sleep quality or narcolepsy exacerbates the episodes of sleep paralysis. Although they do not exceed a two to three minutes, the inability to move is frightening to those with the disorder. The diagnosis relies solely on symptom presentation.

REM Sleep Behavior Disorder (RBD)

REM sleep behavior disorder is similar to a nightmare in the fact of dreaming. However, this parasomnia takes it a step further. Those with RBD do not have a flair for the dramatics, but the serious disorder involves physically acting out violent nightmares in REM sleep. Limbs repeatedly move in a state of dreaming, despite the paralysis (atonia) that generally hallmarks REM sleep in someone without the disorder. A sleep study aids in diagnosing RBD. Males around the age of 50 are most frequently diagnosed, but it can occur in women and children.

Nightmares 

Nearly all of us are familiar with the occasional nightmare. However, having “bad dreams” more than once a week are considered to be a sleep disorder. Nightmares are intense, frightening images that occur during sleep. The details of these dreams are easily recalled upon waking. Difficulty falling back to sleep is common. Nightmares are triggered by stressful life events, trauma, or as medication side effects.

Catathrenia

Catathrenia is classified as a parasomnia, as well as a sleep-related breathing disorder. The unwanted behavior displayed in catathrenia is a moaning or groaning sound produced from bradypnea breathing patterns. The person experiencing the disorder is unaware. Unless a sleeping partner witnesses the groaning, there is little evidence of its occurrence. Symptoms unique to this disorder are hoarseness of voice and a sore throat.

Safety Precautions for Parasomnia

Parasomnia does not typically cause permanent physical impairment. Yet, the lack of awareness and control during a parasomnia episode is potentially dangerous if proper precautions are not implemented to prevent injury. Whether sleepwalking or REM sleep behavior disorder, below are preventative measures to ensure all remain safe:

• Avoid drugs and alcohol
• Sleep on first floor to avoid stairs or put gates by the stairwells
• Move bed away from windows
• Remove sharp objects near the bedroom
• Do not use bunkbeds
• Do not restrain someone during the episode
• Speak to the parasomniac in gentle tones
• Install locks on doors, cabinets, windows, and the fridge
• Consider a surveillance camera for severe cases

Parasomnia Treatment

Treatment for parasomnia is determined on the exact diagnosis. If you are battling a parasomnia disorder, do not lose hope. There are a variety of treatment options available to target the general symptoms.

Sleep Hygiene

You are probably wondering what hygiene has to do with sleep. Hygiene, as it pertains to sleep, is not used in the traditional sense of the word. Interferences in the sleep-wake cycle worsen every type of parasomnia. Creating and abiding by a strict sleep schedule drastically improves symptoms.

An important aspect of sleep hygiene is following a strict sleep schedule and forming consistent habits. Other ways to practice healthy sleep hygiene are to limit naps to 30 minutes or less, getting sufficient exercise, refraining from caffeine and stimulants, and not consuming heavy meals before bed.

Behavior Therapy and Psychotherapy

A combination of psychological therapies treats parasomnia conditions. Behavior therapy focuses on changing reactions to stimuli, which then has an influenced behavior. Part of behavioral therapy entails seeing a sleep psychologist. Studies including patients with childhood sleep terrors have proven that behavioral interventions like hypnosis and waking a child 30 minutes before an expected episode was successful at reducing their frequency.

Additionally, psychotherapy is an asset to parasomnia treatment because it has the goal of resolving stressful issues that trigger or exacerbate the sleep disorder. For example, talking with a psychologist about a childhood trauma can lessen the number of parasomnia episodes.

Experts explain, “Minimizing children’s exposure to potentially traumatic experiences, such as terrifying movies and television programs or frightening bedtime stories, can help reduce the frequency of nightmares” (Vgontzas & Kales, 1999).

Medications

Some cases of parasomnia do not respond to controlling outside influences like sleep hygiene and therapy techniques. Non-medical treatments are applied with pharmaceutical options as a last resort.

Melatonin

Melatonin is a hormone naturally produced by the body’s pineal gland. The pineal gland is located in the brain and is inactive in daylight hours. The pineal gland is stimulated by darkness to release melatonin. Levels increase about two hours prior to bedtime and regulate the circadian rhythm sleep-wake cycle. Melatonin is offered in supplement form. Stabilizing the sleep cycle improve parasomnia disorders. Discuss with your physician before melatonin supplementation.

Benzodiazepines

Benzodiazepines are a class of drugs that alter tranquilizing chemicals in the brain. They are commonly prescribed to treat anxiety disorders and insomnia, but they are effective for parasomnia too.

Parasomnias either occur while waking from sleep or during REM sleep. Benzodiazepines treat parasomnias by suppressing REM sleep, as well as preventing frequent wakening. Sleepwalking and night terrors respond favorably to this class.

Familiar examples of benzodiazepines include clonazepam (Klonopin), diazepam (valium), and alprazolam (Xanax). Sleepwalking and night terrors are particularly responsive to this class of drugs.

Tricyclic Antidepressants

When benzodiazepines are not tolerated, tricyclic antidepressants are preferred. Aside from REM sleep behavior disorder, tricyclic antidepressants work to treat parasomnia conditions by suppressing REM sleep. Patients with REM sleep behavior disorder are advised to avoid this class of medications because they can cause the condition.

Antiparkinson Agonists

Antiparkinson drugs are a group of medications intended to treat Parkinson’s Disease. Examples of antiparkinson medications include dopamine agonists and anticholinergics that influence the neurotransmitter, dopamine.

CPAP Therapy

CPAP stands for continuous positive airway pressure. The device is a hose and mask that delivers steady air pressure to counteract irregular breathing while asleep. CPAP therapy is the first line treatment for sleep-related breathing disorders. While it does not treat parasomnia directly, diagnosis and treating any contributing sleep-related breathing disorder adding to parasomnia symptoms is helpful.

With so many treatment options, parasomnia does not have to rule your life. You are bound to find what works for you! Managing symptoms is a possibility.

References

Vgontzas AN, Kales A. Sleep and Its Disorders. Annual Review of Medicine. 1999;50(1):387. https://search.ebscohost.com.ezproxy.ngu.edu/login.aspx?direct=true&db=pbh&AN=5365351&site=ehost-live. Accessed November 16, 2018.
H. Attarian, “Treatment options for parasomnias,” Neurologic Clinics, vol. 28, no. 4, pp. 1089–1106, 2010.

Cheyanne Perry

Cheyanne is currently studying psychology at North Greenville University. As an avid patient advocate living with Ehlers Danlos Syndrome, she is interested in the biological processes that connect physical illness and mental health. In her spare time, she enjoys immersing herself in a good book, creating for her Etsy shop, or writing for her own blog.