Parasomnia

Parasomnia refers to a wide variety of disruptive, sleep-related events or, “disorders of arousal.” These behaviors and experiences occur usually while sleeping, and most are often infrequent and mild. They may however happen often enough to become so bothersome that medical attention should be sought out. “Parasomnias are disorders characterized by abnormal behavior or physiological events occurring in association with sleep stages, or sleep-wake transitions.”(DSM pg. 435)

Arousal disorders are the most common type of parasomnia. These disorders include: confusional arousals, sleepwalking, sleep terrors and nightmares. Experts believe that each is related and share some symptoms. Essentially, they occur because a person is in a mixed state of being both asleep and awake, generally coming from the deepest stage of non-dreaming sleep. The individual is awake enough to act out complex behaviors, but asleep enough not to be aware of or remember them.

Arousal disorders (parasomnia) are common in young children but may occur in adults as well. These disorders tend to run in families and might be made worse when overly tired or stressed, a high fever, or when taking certain medications.

Confusional Arousals can occur at any age. “Confusional arousals consist of confusion during and following arousals from deep sleep in the first part of the night” Stanford (1972). This disorder often occurs in infants and toddlers, but may also be seen in adults. These episodes may begin with a person crying and thrashing around in bed. The individual may appear to be awake, even confused and upset, yet resists all attempts by others to comfort them. It’s also very difficult to wake someone up when they are in this state. The episode may last up to thirty minutes to an hour and it usually ends with the person calming, waking briefly and then wanting to go back to bed. The individual usually will have no recollection of this event in the morning so it would be either the parents, or the spouses’ responsibility to bring this to the individuals attention.

Sleepwalking is commonly seen in older children. It ranges from getting out of bed to prolonged and complex actions. “Sleepwalking occurs relatively often among children; one can even cause it intentionally simply by picking up a child or adult in deep sleep and standing them on their feet” Borbely (1986). In adults, sleepwalking could indicate a personality disturbance. For instance, a good amount of adults that sleepwalk are suffering from depression. It is thought that this condition is hereditary and can be brought on by stress, also by not getting enough sleep or a high fever.

The typical sleepwalking episode begins about three hours after the individual has fallen deeply asleep and it will usually last about five to twenty minutes. During one of these episodes the sleepwalker’s eyes are generally open. However, we don’t think they can see their surroundings because they always seem to be completely unaware of the environment around them. They manage to show keen ability to navigate through their surroundings without serious harm. Less often than not you can expectt a sleepwalker to dress themselves, open doors, make a sandwich, or go to the bathroom without any problems. Unfortunately there is always the extreme tragedies, for example. “A fourteen-year- old boy got up, walked to the refrigerator, and then stepped out the door—-of the family camper, which was going fifty miles per hour down the San Diego freeway” Fritz (1993).

“The etiology of sleepwalking is not clear. It does however seem to be concentrated in families and to be characterized by the presence of bursts of high voltage delta activity in delta sleep” Borbely (1986). There is no known drug yet for sleepwalking however doctors have been prescribing Valium, which suppresses stage four sleep. The down side to this though is it will only work for a short while and shouldn’t be taken for more than six months. It can be pretty difficult to distinguish sleepwalking disorder from sleep terror disorder. In both disorders, the individual shows movement, difficulty awakening, and amnesia of the entire event.

Sleep Terrors are the most extreme form of arousal disorders and are horrible to witness. Broughton (1970), Fisher, Byrne, Edwards and Kahn (1970) have each suggested that night terrors are precipitated by the sudden release of emotional conflicts when the defenses are at their lowest, in the deepest stages of sleep.” Like sleepwalking sleep terrors begin during deep sleep, NREM, that is characterized by slow-frequency EEG activity. “The onset of sleep terror episodes is typically heralded by very high voltage EEG delta activity, an increase in muscle tone, and a twofold to fourfold increase in heart rate, often to over 120 beats a minute” (DSM pg. 435). These episodes usually begin with a scream or shout and cause behavior simulating terror or fear, an increased heart rate, rapid breathing, sweating and agitation. Some sleep terror cases report that the terror is attached to a single scene, like being trapped in a cave, or being burned alive. By themselves, sleep terrors are not dangerous, but what happens during one can be. A person may jump out of bed and do something he might not normally do. Then of course there are always the extreme cases that usually result in injury, violence, excessive eating, or disturbances to others in and around the bed.

Among children, sleep terror disorder is more common in males than in females ands among adults the sex ratio is equal. Instead of waking and moving into another stage of sleep, the child or adult get “stuck” in between stages of sleep. “This can occur in as many as 15% of young children and can be caused by being overly tired, of having an interrupted sleep cycle, having a high fever can also produce an increase in frequency of episodes” Borbely (1986). Attacks of this sleeping disorder usually occur during the first third of the night. Just like sleepwalking disorder the individual has no recollection of the episode when he wakes up in the morning. Which is probably why the individual rarely complains, it’s usually always the frightened parents or lover who speak up. The good thing is that these attacks usually go away with maturation of the nervous system.

Classically sleep terror, has been thought of as being a disorder of the young, but it’s so closely related to incubus which is a NREM nightmare. “MAO inhibitors will suppress these attacks, but, such drugs are somewhat dangerous as long term treatment for young children” Cartwright (1978). In a synopsis chaired by Kales (1972), suggested, “that the muscle relaxant Valium be used. He has found that this reduces the number of arousals from deep sleep.”

Nightmares are a frightening dream that usually awakens a person from the dreaming stage of sleep. The nightmare is normally a complicated dream that gets more terrifying towards the end. Upon awakening, the person may be breathing rapidly and notice an increased heart rate. The dream content will also be vividly recalled. Nightmares are very common in children and generally do not require treatment. In adults, emotional stress and traumatic events are often the cause of nightmares. “They are dream experiences of a frightening nature, occurring usually in the second half of the night, in a REM sleep stage, and ending with our waking up with a start” Borbely, (1986 ). Usually when a person awakens from this type of REM nightmare they are oriented and aware of their surroundings. This could be related to the fact that REM sleep is not as deep of a sleep than NREM.

Now we must ask ourselves what causes nightmares to occur. We mainly relate nightmares to kids and their waking up crying in the middle of the night. “Dream anxiety attacks are quite common during childhood, apparently, reflecting normal development, conflicts and concerns during childhood” Anch (1988). This relates to children as well as adults. “The general adult themes involve fears, such as being chased or attacked. The person experiencing the nightmare often has physical sensations” Anch (1988). There is a theme suggested here where what we dream is related to our surrounding environment and what events are occurring in our lives. “In particular, nightmares occur following significant real events in life that are psychologically painful, such as death in the family or being a victim of an assault. “Nightmares are also involved with physical illness, which includes high fever” Anch (1988). It also suggests that we can sense physically what is happening during this parasomnia sleep.

“The lesser intensity of the REM anxiety dream may be at least partially explained by the fact that during REM the physiological activation provides a buffer, which prevents extreme terror” Anch (1988). This physical movement also helps the body awaken to avoid the nightmare altogether and awaken the dreamer. “The nightmare provokes a retaliatory response, both in dream content and in actual physical movement. The resulting body movement is usually sufficient to cause an awakening” Anch (1988). Therefore it seems that even though our mind is putting us through a nightmare the dreaming is helping us fight against the scary situation by giving us physical movement to wake ourselves up.

The sleep related disorders referred to as parasomnias encompass a fascinating array of peculiar, distressing, and dangerous nocturnal experiences and behaviors. “These disorders are scientifically explainable and usually treatable. They also can have forensic implications in cases involving accidents, homicide, or presumed suicide” Ohayon (1997). An experienced sleep disorder center is a valuable resource for the evaluation and treatment of unusual or injurious parasomnias.

Arousal disorders (parasomnias) in children rarely need medical evaluation. However, you should contact a physician if they are causing potentially injurious behavior, are disrupting household members or if the individual is excessively sleepy during the day.

Adults, however, should seek evaluation from a sleep specialist. In some cases, these disorders are triggered by other sleep disorders such as sleep apnea, gastroesophageal reflux or periodic limb movements during sleep.

Treatment is usually only recommended in severe cases involving injury, violence, excessive eating or disruption to others. Treatment may include medical intervention with prescription drugs and or psychological or behavioral intervention.

Bibliography

American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th ed.)

Washington, DC:Author

Anch, A.M., & Browman, C.P., & Mitler, M.M., & Walsh, J.K. (1998)

Sleep: A scientific perspective. New Jersey : Prentiss Hall, Inc.

Arkin, A.M., & Antrobus, J.S., & Ellman, S.J. (1978)

The mind in sleep : Psychology and parapsychology. New Jersey : Lawrence Earlbaum Associates, Publishers

Borbely, A (1986) Secrets of Sleep. New York : Basic Books, Inc., Publishers

Broughton, R. (1970) Sleep and Dreaming. Boston : Little Brown

Cartwright, R.D. (1978) A primer on Sleep and Dreaming. Massachusetts : Addison – Wesley, Publishing, Company

Fisher, C.J., Byrne, A., Edwards, and Kahn, E. (1970) REM and NREM nightmares. In E. Hartman (ed), Sleep and Dreaming. Boston : Little Brown

Fritz, R. (1993) Sleep Disorders: America’s Hidden Nightmare Michigan : Publishers Distribution service

Kales, A. (1972). The evaluation and treatment of sleep disorders : Pharmacological and psychological studies. In M. Chase (ed.)The Sleeping Brain. Los Angeles : Brain Information Service.

Ohayon, M.M., Caulet, M., Priest, R.G. (1997) Violent Behavior During Sleep New Jersey: J Clin Psychiatry