Parasomnias

Case 3. FT is a 62-year-old man who comes to your office concerned about acting out his nightmares. His wife reports that several times in the past 3 months, FT has begun violently thrashing around in bed and yelling in the middle of the night. Once, he jumped out of bed and bruised his forehead on the nightstand but had no memory of the episode the following morning. FT takes for hypertension and sertraline for depression. He reports no prior difficulty sleeping.

The American Academy of Sleep Medicine International Classification of Sleep Disorders, 3rd ed., text revision, defines parasomnias as undesirable physical events or experiences occurring during sleep onset, while sleeping, or on arousal. These events can occur in non–rapid eye movement (NREM) sleep, in REM sleep, or during transitions between sleep and wakefulness.¹ Parasomnias are prevalent across all ages, with certain types more common in specific populations.

Early detection of and intervention for parasomnias are crucial to reducing their health effects as they are linked to underlying conditions such as sleep-related breathing disorders, including obstructive sleep apnea (OSA).² Recognizing this connection is essential because parasomnias frequently resolve with treatment, such as continuous positive airway pressure therapy in the case of OSA.³

Parasomnias are classified by the sleep stage in which they occur—NREM or REM.¹ Table 1 provides a list of parasomnias classified by sleep stage.^2,4–6

NREM parasomnias include confusional arousals, sleep-related eating disorders and sexual behaviors, sleep terrors, and sleepwalking. (Clinicians should note that sleep-related eating disorders, though less common, can be an adverse effect of Z-drugs that requires careful monitoring during therapy.^1,2,4) NREM parasomnias typically arise from partial arousals during deep sleep and are influenced by sleep deprivation, stress, and external stimuli.¹ They are more common in children but can persist into adulthood.^1,5

Behavioral and psychological therapies for NREM parasomnias, including hypnosis, psychotherapy, sleep hygiene, education, relaxation techniques, scheduled awakenings, and mindfulness, are the first-line treatments.⁷ Hypnosis and psychotherapy are the most commonly discussed approaches, with evidence supporting their potential to reduce episodes by addressing stress and sleep deprivation.⁷ Multicomponent cognitive behavior therapy (CBT), sleep hygiene, and scheduled awakenings also show promise.^8,9 However, the evidence is limited because of retrospective study designs and inconsistent outcome measures.⁷ Pharmacologic treatment is reserved for severe cases.⁷