Parasomnia

Parasomnia is a sleeping disorder characterized by abnormal behaviour while sleeping. This can include abnormal movements, behaviours, perceptions, emotions, or dreams such as night terrors, screaming, crying, or waking up afraid.

What Is Parasomnia?

Parasomnias refer to a group of sleep disorders which involve abnormal and unwanted behaviors, movements and experiences while sleeping. These mostly occur while a person is falling asleep, sleeping or waking up. Even though their complex behavior may indicate that the sufferer is awake and acting deliberately, they actually remain asleep during the occurrences. They may even have no memory of the events. People with a parasomnia often have trouble sleeping properly during the night.

Parasomnias can occur at different stages of sleep. These are dissociated sleep states which include partial arousals. According to a 2018 scientific review ¹, Parasomnia is defined as “a group of sleep disorders characterized by abnormal, unpleasant motor or verbal behaviour events that occur during sleep or wake to sleep transitions”. Studies ² have identified this condition as a clinical phenomenon that arises from brain transitions during REM sleep. Generally, Parasomnias tend to include common sleep problems, like :

Nightmares
Night Terrors
Sleepwalking
Sleep Talking
Confusional Arousals
Nocturnal Leg Cramps
Sleep Paralysis
Irregular Heart Rhythms
REM Sleep Behavior Disorder (RBD)

This disorder may occur in a person independently or in a setting of trauma, psychiatric illness, other sleep-related disorders, Parkinson’s disease, and spinocerebellar ataxia. It is often seen more in children than in adults.

How Parasomnia Affects Us

According to Mind Help, parasomnia refers to “a sleep disorder marked by abnormal, physiological and intrusive behaviour, experiences & physiological events occurring during the transition between sleep & waking or while sleeping.” The condition usually involves unusual and unwanted perceptions, emotions, behaviours, movements and dreams or nightmares. Parasomnia is a Greek term, derived from the Greek prefix Para meaning “alongside of” and the Latin noun Somnus meaning “sleep”. This disorder encompasses several abnormal events that include abnormal motor behaviours, or unusual behaviour during sleep. Excess motor activity or abnormal behaviour can affect an individual negatively or the bed partner that results in sleep fragmentation, psychosocial effects, and even injuries.

An individual experiencing night terrors, sleepwalking, sleep talking or other abnormal behaviors can be a sign of this disorder. It can also occur if a person is suffering from an underlying mental health condition, such as depression or anxiety. If you are experiencing any unusual behavior during sleep then it is important to seek medical attention to diagnose it. Sometimes it has been found that this disorder occurs due to a side effect of any drugs or medications. So it is important to address such issues with the health professional in order to devise a treatment plan. It is a common form of sleep disorder. But it may disrupt the sleep of other people around you.

The condition can be seen in both Non-Rapid Eye Movement (NREM) and Rapid Eye Movement (REM) sleep states and is classified separately by the DSM-5 and International Classification of Sleep Disorders- 3 (ICSD-3). In children, the NREM parasomnia is more common than REM parasomnia. Studies ³ have found that the prevalence rate is 17.3 per cent for the age group 3 to 13 and 6.9 per cent for more than 15 years. The prevalence rate in the adult population is reported to be approximately 4%.

Non-Rapid Eye Movement Related Parasomnia

NREM sleep parasomnia is caused by a psychological activation in which the individual’s brain exits slow-wave sleep (SWS) and is caught between a sleeping and waking state. These disorders involve activation of the autonomic nervous system, motor system, or cognitive processes during sleep or sleep-wake transitions. These are common during childhood but they tend to decrease in adulthood. It can be triggered in individuals by alcohol, sleep deprivation, physical activity, emotional stress, depression, medication, or illness. This kind of disorder can include confusional arousals, somnambulism, or night terrors.

Rapid Eye Movement Related Parasomnias

In this case, muscle atonia is absent and is more common in older adults. This usually makes the individual act out of their dreams and may result due to repeated injury, bruises, lacerations, and fractures. The clinical features of REM sleep behavior disorder are:

Male gender prediction
Age of onset is around 50-65 years
Vocalization, screaming, swearing that are associated with dreams
Motor activity, simple or complex that may result in injury to patient or bed partner
Occurs in the latter half of the sleep period
It can be associated with neurodegenerative diseases

Parasomnia In Children

This disorder affects more children than adults. Studies ⁴ have found that sleep disorders may affect between 20 per cent to 30 per cent of young children. It is found in children with neurological or psychiatric conditions like epilepsy or ADHD. Stress and sleep deprivation can also become a contributing cause of developing this disorder. It usually occurs because the sleep-wake cycle of children is still immature. Hence the boundaries between wakefulness and sleep are still underdeveloped which ultimately results in a mixed state of consciousness. Most children are found to completely recover from this disorder during their adolescence as their sleep-wake cycle matures. Children with parasomnia may experience more crying and fear than adults.

According to one 2009 study ⁵, children and adolescents with parasomnias can experience movement disorders which may “arise from a variety of etiologic factors.” Another 2007 study ⁶, most pediatric parasomnias are self-limited and benign. These usually may not persist during adolescence or late childhood. Moreover, childhood parasomnias are characteristically different from parasomnias in adults. According to research, pediatric parasomnias can be categorized as:

Disorders of arousal from NREM sleep
Parasomnias associated with REM sleep
Other parasomnias

If your child is having abnormal sleep behaviors it is important to understand and support them. It is always wise to seek professional help in such circumstances to manage the situation in an organized manner. Keep in mind that you shouldn’t punish them for having abnormal sleep patterns. Instead, show the support they need and comfort them when they are scared. For instance, if they wet the bed, tell them to use the bathroom before going to sleep.

Types Of Parasomnia

Some types of parasomnia occur in the first half of the night during NREM sleep while others happen later in the night. The different types of parasomnia are as follows:

1. Sleepwalking

This type is characterized by walking while being asleep. It is also known as somnambulism. It is a common form of parasomnia. Sleepwalking occurs early in the night and usually involves moving around the house. It can happen during daytime naps as well.

2. Sleep Talking

Sleep talking is when a person talks while sleeping. It is also known as somniloquy. This can involve a wide range of talking which includes mumbling to full conversations while sleeping. It can occur at any time during the night. It is usually easier to understand the talking in the later stages of sleep.

3. Sleep-related groaning (Catathrenia)

This involves making loud noises or humming while sleeping. It happens when an individual slowly exhales and deeply inhales. The groaning can include different noises such as :

Roaring while asleep
Loud humming
High pitched cracking noise

This condition is often mistaken for snoring. But groaning is usually related to breathing issues.

4. Nightmares

This type of parasomnia involves troubling intense dreams that trigger anger, anxiety, or fear. If it occurs frequently it is called nightmare disorder. This kind can make it difficult for an individual to fall back to sleep. In severe cases, multiple nightmares can happen in one night. Nightmares often occur during REM sleep.

Read More About Nightmares Here

5. Night terrors

Night terrors cause an individual to suddenly wake up in a terrified state. This terror can last from 30 seconds to 5 minutes. Night terrors are also related to:

Crying
Screaming
Rapid heart rate
Excess sweating
Skin flushing

Night terrors usually involve no dream activity. This typically occurs in Non-REM sleep.

6. Bedwetting (Enuresis)

This involves involuntary urinating while sleeping. This is also known as nocturnal enuresis. It is more common in children especially kids younger than 6 years of age. Usually, it occurs when the bladder has more urine than it can hold. There may be an underlying cause in some cases. However, in other cases, it can occur due to urinary tract infections.

7. Confusional arousal

This happens when you wake up in a confused state. The individual might have trouble understanding what they are doing or where they are. Other related behaviors include:

Slow speech
Poor memory
Crying
Reacting slowly

8. Teeth Grinding

In this case, the individual clenches or grinds their teeth while sleeping. Such behaviors can cause:

Toothache or sensitivity
Sore jaw, face, or neck
Earache

9. Sleep-related eating disorders

This condition is characterized by binge eating and drinking during Non-REM sleep. It can happen that the individual may be partly or fully conscious. Binge eating episodes happen repeatedly. The specific behaviors include:

Eating unusual foods or food combinations such as a stick of butter
Eating or drinking quickly
Consuming food that’s toxic like uncooked meat

10. REM sleep behavior disorder

In REM sleep behaviour disorder, the individual has troubling dreams that cause them to act out during REM sleep. It is completely different from sleepwalking or sleep terrors where the person is often confused. In this case, the individual usually wakes up easily and remembers the dream.

The behaviors related to this disorder are:

Grabbing
Punching
Shouting
Kicking
Jumping

11. Rhythmic Movement Disorder

This occurs mostly in children under the age of 1 right before they fall asleep. The child may lie flat, lift their head or upper body, and then forcefully hit their head on the pillow. This is often referred to as headbanging. It can also involve movements such as rocking on hands and knees.

12. Nocturnal Leg Cramps

This condition is characterized by sudden uncontrollable muscle contractions while sleeping. This isn’t dangerous but can disturb bed partners or family members. It usually happens in the calf muscles in the legs. The cramping feeling may last for a few seconds or ten minutes but the pain may linger. It often occurs in middle-aged or older people but anyone can have them.

13. Sleep Paralysis

This occurs when you can’t move while falling asleep or while waking up. This can be partial or total paralysis. It usually runs in families but the exact cause is still unknown. This type of parasomnia isn’t dangerous but it can get scary if the individual doesn’t realize what is happening. A touch or a sound may pull out the individual from the trance.

14. Impaired Sleep-Related Erections

It isn’t unusual for men to have erections as a part of their REM sleep. This happens when the man can’t keep an erect penis rigid enough to have sex while they sleep. This can also mean that they have erectile dysfunction.

15. Irregular heart rhythms

The medical term for irregular heart rhythms is cardiac arrhythmia. People who have coronary artery disease and who have lower blood oxygen because of sleep-related breathing problems are more likely to have arrhythmias. Continuous positive airway pressure treatment may lower the risk.

16. Nocturnal Paroxysmal Dystonia

This parasomnia might be a form of epilepsy. It can cause seizure-like episodes during non-REM sleep. It can sometimes occur several times a night.

17. Other parasomnias

These are less common than the others. They include:

Sleep texting: This happens when an individual sends text messages when they are asleep.
Sexsomnia: In this case, the individuals act out sexual behaviours while sleeping.
Exploding head syndrome: This happens when the individual imagines a loud or sudden noise during wake-sleep transitions. Some think they are having a stroke while sleeping.
Sleep-related hallucinations– This type involves hallucinations in which you can see, feel, or hear. It can occur when falling asleep or waking up.
Sleep-related scratching- This occurs during sleep when the individual scratches their body continuously. They might wake up with scratches, bleeding, and cuts.
Sleep driving- It is an extremely rare condition where it’s possible to drive while sleeping. This is a form of sleepwalking and it can be very dangerous.

Signs And Symptoms Of Parasomnia

There can be several symptoms that trigger abnormal behaviour. The following are the symptoms of parasomnia:

Waking up confused or disoriented
Waking up wondering where they are
Not remembering doing certain things after waking up
Finding unfamiliar cuts on their body
Difficulty sleeping throughout the night
Daytime sleepiness or fatigue
Screaming, crying or waking up afraid

Causes For Parasomnia

There can be several reasons why Parasomnia can occur. Studies ⁷ have found that medical conditions, activities, and substances that increase slow-wave sleep or that lead to increased arousals can trigger this condition among others. Some of the most common causes are as follows:

Stress
Anxiety
Depression
Post Traumatic Stress Disorder (PTSD)
Substance Abuse
Side effects of certain medications
Irregular sleep schedules like night shifts at the workplace
Other sleep disorders such as insomnia
Sleep deprivation
Neurological conditions such as Parkinson’s disease

Diagnosis Of Parasomnia

The doctor can help diagnose this disorder. The diagnosis ⁸ is based on the following criteria:

The basis of stage of sleep from which they occur
The presence of predisposing, priming, or provoking factors
The type of sleep behaviours that occur during the stages of sleep

A healthcare professional can also recommend having a sleep specialist in order to further analyze the patient’s sleeping behaviour. This diagnosis often includes:

Evaluation of the patient’s medical history to detect any underlying medical conditions.
The doctor will also evaluate the family history and lifestyle
The sleep specialist will recommend maintaining a sleep diary to track the sleeping patterns and behaviour of the patient
The diagnosis will also involve a Polysomnography ⁹ or sleep study. The patient will sleep in a lab overnight so a specialist can evaluate the sleeping behaviour. They will record and track the brain waves, breathing patterns, and heart rate to make a diagnosis.

The doctor might also include a questionnaire in order to detect the disorder. The questionnaire may include the following questions that –

Rule out sleep deprivation
Rule out the adverse effects of intoxication or withdrawal
Rule out other sleep disorders that cause sleep instability
Rule out medical disorders or treatments that are associated with sleep instability
Confirm the presence of NREM parasomnias in other family members and during the patient’s childhood
Determine the timing of such events
Determine the morphology of the event

Treatment For Parasomnia

The treatment depends on the type and severity of this disorder. Usually, therapy and medication can help ease the symptoms. Case studies ¹⁰ have found that pharmacological interventions can improve this disorder but can have side effects from excess usage.

Here are some of the most common and effective treatment options available for parasomnia:

1. Medication

If the disorder is frequent and recurring, certain medications can be used to manage the symptoms. The examples of medications used are:

Topiramate
Antidepressants
Dopamine antagonists
Melatonin
Levodopa
Benzodiazepines like clonazepam

In case the symptoms get triggered due to some medication, the doctor may recommend alternative medications. However, it is important to keep in mind to not stop the medication without the doctor’s permission.

Read More About Antidepressants Here

2. Psychotherapy

This therapy involves talking to a psychiatrist in order to get to the root of the problem. During this therapy, the mental health expert assesses the patient’s moods and behaviours and helps to channelize it to their advantage. According to a 2016 study ¹¹, psychotherapy and counselling have proven effective in the case of sleepwalking.

3. Cognitive behavioral therapy (CBT)

This is a common form of treatment for parasomnia since this disorder is often related to underlying mental health conditions such as stress or anxiety. Studies ¹² have found CBT effective in treating patients suffering from this disorder when compared with medications. Cognitive Behavioral Therapy is used to evaluate the thought and patterns that trigger unwanted behaviour. The negative thought patterns are then replaced with the positive factors in order to reach the desired outcome. This therapy often helps to devise a coping mechanism in order to deal with the symptoms.

Read More About Cognitive Behavioral Therapy Here.

4. Relaxation therapy

This therapy uses a number of relaxation techniques that are designed to teach someone how to relax on their own. These techniques can include breathing exercises, meditation, or progressive muscle relaxation exercises to reduce physical and mental tension. This therapy helps the person to relax and have a night of normal and sound sleep.

5. Home treatment methods

There are several ways in which the treatment can be done at home. The doctor may suggest the following methods for home treatment of parasomnia:

Scheduled Awakenings – This is used when you wake up your child 15 to 30 mins before they suddenly wake up.
Safe sleep environment- If an individual sleepwalks or has REM sleep behaviour disorder (RBD) they might need to sleep alone or remove objects that are dangerous from their way. They can also lock the windows and doors and place the mattress on the floor and sleep with extra padding.

Can Parasomnia Be Prevented?

Usually, sleep disorders like parasomnia are related to some underlying mental health conditions. So it is important to address the concerns that are triggering abnormal sleep behaviour. Prevention is possible if the individual seeks help from a professional who helps them to understand their behaviour and what to do in order to manage it.

Recovery Is Possible

The causes of developing parasomnia are still unclear. However, it often occurs due to its association with other mental health disorders or it can be a side effect of certain drugs and medications. It is important to consult a doctor in order to understand what is causing the condition. With therapy and medication, it is possible to recuperate from this disorder and lead a healthy life.

Parasomnia At A Glance

Parasomnias refer to a group of sleep disorders which involve abnormal and unwanted behaviors, movements and experiences while sleeping.
Parasomnia refers to “a sleep disorder marked by abnormal, physiological and intrusive behavior, experiences & physiological events occurring during the transition between sleep & waking or while sleeping.”
NREM sleep parasomnia is caused by a psychological activation in which the individual’s brain exits slow-wave sleep (SWS) and is caught between a sleeping and waking state.
Some types of parasomnia occur in the first half of the night during NREM sleep while others happen later in the night.
The causes of developing parasomnia are still unclear.

👇 References:

Singh, S., Kaur, H., Singh, S., & Khawaja, I. (2018). Parasomnias: A Comprehensive Review. Cureus, 10(12), e3807. https://doi.org/10.7759/cureus.3807 [↩]
Markov, D., Jaffe, F., & Doghramji, K. (2006). Update on parasomnias: a review for psychiatric practice. Psychiatry (Edgmont (Pa. : Township, 3(7), 69–76.[↩]
Singh, S., Kaur, H., Singh, S., & Khawaja, I. (2018). Parasomnias: A Comprehensive Review. Cureus, 10(12), e3807. https://doi.org/10.7759/cureus.3807 [↩]
Bruni, O., & Novelli, L. (2010). Sleep disorders in children. BMJ clinical evidence, 2010, 2304. [↩]
Bloomfield ER, Shatkin JP. Parasomnias and movement disorders in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2009 Oct;18(4):947-65. doi: 10.1016/j.chc.2009.04.010. PMID: 19836698. [↩]
Mason TB 2nd, Pack AI. Pediatric parasomnias. Sleep. 2007 Feb;30(2):141-51. doi: 10.1093/sleep/30.2.141. PMID: 17326539. [↩]
Said Alkaabi, Meyerovich MD, Yakubov B and Shapiro CM (2018) Triggers of Parasomnias – What Sleep Experts Think?. J Neurol Psychiatr Disord 1(1): 101 [↩]
Pressman, M. (2013). Classification of Parasomnias and diagnostic criteria. Encyclopedia of Sleep, 194-198. https://doi.org/10.1016/b978-0-12-378610-4.00423-x [↩]
Rundo JV, Downey R 3rd. Polysomnography. Handb Clin Neurol. 2019;160:381-392. doi: 10.1016/B978-0-444-64032-1.00025-4. PMID: 31277862. [↩]
Fleetham, J. A., & Fleming, J. A. (2014). Parasomnias. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne, 186(8), E273–E280. https://doi.org/10.1503/cmaj.120808 [↩]
Owens, J., Mohan, M. Behavioral Interventions for Parasomnias. Curr Sleep Medicine Rep 2, 81–86 (2016). https://doi.org/10.1007/s40675-016-0046-z [↩]
Mitchell, M. D., Gehrman, P., Perlis, M., & Umscheid, C. A. (2012). Comparative effectiveness of cognitive-behavioral therapy for insomnia: a systematic review. BMC family practice, 13, 40. https://doi.org/10.1186/1471-2296-13-40 [↩]