Parasomnias

Introduction & Background Scenario Activities Resources & Clinical Tools CME Certification for Module

There's an increase in sleepwalking or night terrors in children with obstructive sleep apnea.

17 %
of children will regularly sleepwalk

Boys are

3 x
more likely to experience bed-wetting than girls

By the end of this module, you will be able to:

Describe the triggers for sleepwalking and possible treatment options.
Recognize the differences of NREM parasomnias.
Recognize the differences between night terrors and sleepwalking versus nightmares versus nocturnal seizures.
Create an evaluation and treatment plan for a child with bedwetting / nocturnal enuresis.

Parasomnias are “undesirable” physical events or experiences that occur during sleep, while falling asleep, or when awakening from sleep. Parasomnias can occur during any stage of sleep and are usually divided into non-REM related parasomnias, REM-related parasomnias, and other parasomnias, as well as normal variants, including sleep-talking.

NREM
Parasomnias that occur during non-REM (NREM or non-rapid eye movement) sleep include: confusional arousals, night or sleep terrors, and sleepwalking.
REM
REM related parasomnias include nightmares and sleep paralysis.
Other
Finally, other parasomnias not associated with a particular stage of sleep include nocturnal enuresis (bedwetting), bruxism, and sleep-talking.

Parasomnias are an example of how the different states of human consciousness, including wake, REM sleep, and NREM sleep, may become dissociated and unstable leading to these “undesirable” effects. For example, sleepwalking and night terrors and confusional arousals are a mixture of NREM sleep and wakefulness. Nightmares, which are a combination or overlap of REM sleep and wakefulness, represent how our dream imagery enters into our wakefulness.

Figure 1
Schema of typical night sleep pattern of sleep states and stages

Nightmares tend to occur more often in the 2nd half of the night due to more REM sleep

Non REM parasomnias, like Night Terrors and Sleepwalking, occur in the first thrid of the night when Non-REM sleep is more prevalent

1 Non-REM Parasomnias

NREM parasomnias, also referred to as “disorders of arousal” have many common features, including an association with NREM deep sleep (i.e. slow wave sleep, N3 sleep). These events usually occur in the first half of the night when there is the highest proportion of N3, or NREM deep sleep. A child may awaken, appear confused or dazed, and not respond to routine interventions from parents or caregivers. The child usually does not remember the events the next day. Depending on what happens during the event - walking, screaming, or just sitting up - further classifies the disorder of arousal into the following categories. Also, at times, a child may have a combination of sleep terror and sleepwalking events such as screaming and running around in the night.

Description	Preschool Age	School Age	Teenage
Confusional arousals: Often occurring in young children, these events can include a child thrashing around in bed, sitting up, disoriented, which can be somewhat longer than the usual night terror events lasting from minutes up to 30 minutes. They also may be observed if a caregiver tries to force them awake for some reason (such as a nap or in the middle of the night) and children can act confused and partially unresponsive.
Night terrors or sleep terrors: These are sudden arousals from sleep characterized by high autonomic response - heart racing, sweating, tachypnea. They often occur in the preschool and elementary years. The differential of night terrors can include nocturnal panic attacks, nocturnal seizures, nightmares, and cluster headaches.
Sleepwalking: This may initially start as a confusional arousal and then progress to the child getting out of bed and performing an activity. Someone who is sleepwalking is usually more clumsy and may perform unusual or bizarre things (such as trying to urinate in a trash can or closet).

2 REM Parasomnias

Parasomnias are “undesirable” physical events or experiences that occur during sleep, while falling asleep, or when awakening from sleep. REM sleep related parasomnias are those that are more classically associated with REM sleep.

Nightmares: dreams that cause someone to awaken causing distress and making it difficult to go back to sleep.

Isolated sleep paralysis: A recurrent inability to move while falling asleep or upon awakening which usually last seconds to minutes and is causing distress / anxiety. There is also an inability to speak but consciousness and awareness of the event is preserved. Hallucinatory experiences can accompany this. Onset is usually in adolescence. If not associated with narcolepsy, substance use, or a mental disorder, it can be a normal phenomenon without complications. Sleep deprivation or an irregular sleep pattern are precipitating factors. (ICSD, 3rd edition)

3 Other Parasomnias

Nocturnal enuresis (bedwetting): Recurrent involuntary voiding during sleep that occurs at least twice a week for at least 3 months past the age of 5 years. There is Primary enuresis in which a child has never had a dry period for more than 6 months or Secondary enuresis in which the child had a dry period of greater than 6 months.

Sleep-talking: Talking or verbalization during sleep. The lifetime prevalence of sleep talking is very high - over 50%. Sleep-talking can be isolated or can also be associated with other parasomnias / sleep disorders such as confusional arousals or night terrors.

Due to the wide variety of parasomnias, the content in this parasomnia module will focus on three common types: sleepwalking and night terrors, nightmares, and bedwetting.

Professionals in a variety of roles may connect with families and children regarding sleep issues. Consider these diverse roles when evaluating parasomnias and how they all can work within an interdisciplinary framework.

Medicine	Medical providers (MD, PA, APNP) will perform a history and exam to determine next course of action including testing needed and possible treatment. Many of the parasomnias can initially be managed with a complete history and physical exam.
Nursing	Obtain additional information about medications (antihistamines, SSRIs), activities and adherence to therapies that may affect outcome and course as well as potential for follow up. Follow up phone calls after a clinic evaluation may be used as a way to determine treatment response from recommended interventions. School nurses or other school personnel should include sleep issues when asked to consult around issues of disruptive behavior, falling asleep in class, obesity or poor academic performance.
Nutrition	Review general dietary practices that can impact sleep including caffeine intake, late night or middle of the night eating, poor nutrition or over nutrition. Additionally, in children with special health care needs, assessment of bedtime or overnight G tube feedings may be pertinent to sleep history.
Pharmacy	Determine what medications patient is taking that may worsen the underlying disorder and what alternatives are available. Medications such as stimulants or SSRI’s have impact on routine sleep architecture that can contribute to difficulty falling asleep, vivid dreaming or daytime sleep/wake pattern.
Respiratory Therapy	Respiratory therapists play a role in educating patients and families on proper techniques for using respiratory equipment such as nebulizers, PAP (positive airway pressure) devices, ventilators, and many others. Respiratory health can play a role in overall sleep quality which could influence findings of other parasomnias such as night terrors or nightmares.
Social Work and Mental Health	Social workers can assess for overall new stressors in the home which could be exacerbating sleep disturbances and parasomnias. They also can evaluate the ability of the family to follow through on treatment recommendations.
Family Perspective and Leadership	Family representative's as well as caregivers, help determine if family’s concerns are being appreciated by the entire team and if recommendations are unrealistic for families to follow. For recommendations to be instituted, there may be additional family issues exacerbating the sleep disorder and the barriers to the execution of the treatment plan.