**5.3 Sleepwalking**

Among arousal parasomnias, sleepwalking (somnambulism) is the most common. Sleepwalking (somnambulism) includes ambulation or other intricate behaviors while still asleep, with amnesia for the event. Sleepwalking is a complex behavior that ranges from limited and noninjurious activities to dangerous activities associated with injuries to self or others. Up to 40% of normal children have experienced at least one episode of sleepwalking and 2% to 3% of children experience it at least once a month (Klackenberg, 1971).

It affects mostly children aged 6-12 years, and episodes occur during stage 3 or stage 4 sleep in the first third of the night and in REM sleep in the later sleep hours. Despite widespread prevalence of these disorders and the recognition that they may arise from incomplete arousal, their pathophysiology is not well understood. Evidence for a strong genetic background of sleepwalking was shown in epidemiological surveys as in twin studies. Further evidence for heredity of sleepwalking is documented by the 10-fold increased prevalence of sleepwalking in relatives of patients suffering from sleepwalking. Sleepwalking in elderly people may be a feature of dementia. Idiosyncratic reactions to drugs (eg, marijuana, alcohol) and medical conditions (eg, partial complex seizures) may be causative factors in adults. During an episode of sleepwalking, a person may appear agitated or calm and behaviour may range from simple ambulation with a "glassy stare" to more complex activities such as driving. Sleepwalking may be preceded by confusional arousals or sleep terrors.

Depending on the degree of confusion, bedroom location, furniture, and strength of the subject, sleepwalking may lead to accidents and self-injury. Safety precautions should be taken for sleepwalking. These include removing dangerous objects, placing heavy drapes on glass doors and windows, and special locks on doors. Sleepwalking episodes occur in slowwave sleep, during which time the individual is not easily arousable. Family members may gently guide the person back to the bed; strong stimuli to awaken the patient may cause resistance or aggression and are not recommended. Sleep terror and sleepwalking episodes are disturbing to parents but prepubertal sleepwalking is usually self-limited. Adult-onset sleepwalking with complicated patterns of sleepwalking, however, may contain a psychiatric component. These patients may benefit from psychotherapy, relaxation, or hypnosis (Farid et al, 2004).

#### **5.4 Nightmares**

Nightmares are vivid nocturnal events that cause feelings of fear and terror, with or without feeling anxiety. In most cases, a person having a nightmare will be abruptly awakened from REM sleep and is able to give a detailed account of what he dreamt about. Also, the person having a nightmare has difficulty returning to sleep. Episodes typically occur in the latter half of the night. Following the awakening, the individual becomes fully alert and profoundly anxious. There is vivid recall of the preceding dream as well as difficulty returning to sleep. Compared to sleep terrors, there is less autonomic activation, and tachycardia and tachypnea, if present, are not as severe. Episodes can be precipitated by

Parasomnias 155

REM sleep behavior disorder can be controlled with medication. Clonazepam is the mainstay in the treatment of REM sleep behavior disorder and leads to either a complete or partial response in approximately 90% of cases. Before it is prescribed, the potential benefits of treatment should be weighed against the possible side effects. Other medications have been tried when clonazepam is not effective or is poorly tolerated. Discussions related to safety are very important, because precautionary measures may prevent serious injury to

Ten disorders are classified under this category (Table 1). The most common are sleep

Sleep bruxism is the third most common parasomnia and it can be bothersome to the bed partner. Bruxism is not a dangerous disorder. However, it can cause permanent damage to the teeth and uncomfortable jaw pain, headaches, or ear pain. Approximately 8.2% of people experience it at least once a week. Sleep apnea and anxiety disorders are the most prominent risk factors for bruxism. Bruxism could be a reflex to open the airway after an apneic or hypopneic event. Bruxism may improve with treatment of sleep apnea with continuous positive airway pressure. Sleep bruxism does not have a definite cure. The goals of treatment are to reduce pain, prevent permanent damage to the teeth, and reduce clenching as much as possible. Stress reduction, relaxation, biofeedback, hypnosis and improvement of sleep hygiene have been tried with no persistent or significant improvement. To prevent damage to the teeth, mouth guards or appliances (splints) have been used since the 1930s to treat teeth grinding, clenching, and TMJ disorders. A splint may help protect the teeth from the pressure of clenching. Pharmacologic interventions are indicated for short-term management of patients who experience complications of sleep bruxism, including pain in the temporomandibular joint. Benzodiazepines could be effective because of their muscle-relaxing and anti-anxiety properties. Additionally, they increase the

Sleep enuresis, more commonly known as bedwetting, refers to the lack of ability to maintain urinary control during sleep. This recurrent involuntary urination is also called nocturnal enuresis, which is characterized by at least two occurrences per month in 3 to 6 years old infants and at least one occurrence per month for older children. Sleep enuresis is observed in 10% of children at the age of 6. The prevalence decreases with age. Approximately 77% of children had enuresis when their parents were enuretic, whereas 44% of children with one parent who was enuretic developed enuresis. Simple behavior modifications can be very effective treatments for children with enuretic episodes. For example, intake of liquids and dietary bladder irritants such as citrus products should be discouraged before bedtime. Taking note of when the enuresis actually occurs, and waking and taking the child to toilet before that hour, can also be very helpful Matthias et

Psychological treatments such as encouragement of self-reliance, participation in management, inculcation of self-respect and responsibility are also recommended by many experts. Physical punishments and coercion, on the other hand, are considered to be the

arousal threshold that could precede teeth grinding. (Farid et al., 2004)

most counterproductive measures and should be avoided at all costs.

the patient or family members (Schenck et al., 2002).

bruxism, sleep enuresis, and primary snoring.

**5.6 Other parasomnias** 

al., 2002).

illness, traumatic experiences, and alcohol and medication use, such as antidepressants and beta-antagonist antihypertensive agents.

Nightmares affect 20 to 39 percent of children between five and 12 years of age. Contrary to popular belief, frequent nightmares in children do not suggest underlying psychopathology. Nightmares and night terrors in children are usually disturbing to parents and family members; therefore, proper diagnosis and education of family members are important components of management. It is essential to control the environment by removing dangerous objects and providing barriers to prevent escape from a safe sleeping environment. Reassurance and support are often the only therapy required because these disorders rarely, if ever, reflect underlying illness and usually disappear with maturity. Pharmacologic intervention is not usually indicated; in fact, it should be discouraged because it may contribute to further sleep disruption. Behavioral methods for treatment of frequent nightmares are effective in older children.

#### **5.5 Rapid Eye Movement (REM) sleep behavior disorder**

REM sleep is characterized by a paucity of muscle activity with near complete somatic muscular atonia. REM sleep behaviour disorder is characterized by the intermittent loss of REM atonia due to disinhibition of normally inhibitory mid-brain projections to spinal motor neurons. This, in conjunction with an active dream state, results in behavioural release and the apparent "acting out of dreams". Abnormal behaviours include sleep talking, yelling, limb movement, and complex motor activities. Patients with REM sleep behaviour disorder arouse from sleep to full alertness often with complete recall of fearful dream content, which may involve being chased or attacked. The motor behaviour exhibited tends to correlate with dream content. REM sleep periods typically occur in the latter half of the night. The most common symptom at time of presentation is injury of the patient or bed partner. As a result of the behaviors, bed partners often simply move to another bed or room. Also, patients and families may have a sense of guilt or shame regarding the behaviors, even though the behaviors may not be consistent with patients' personalities. This is particularly true when sexual behaviors are involved. Sleep disruption and daytime sleepiness are often part of the history. REM sleep behaviour disorder tends to be a disease that occurs in older men, although women and people of all ages may be affected. The reason for the strong predominance toward men, with an approximately nine-to-one mento-women ratio, is not clearly known. The average age of onset is between 52.4 years to 60.9 years. Unlike those who experience sleep terrors, the victim will recall vivid dreams. The frequency of these episodes varies from once every few weeks to several times a night. Episodes tend to occur 90 min or more after sleep onset, when the first REM period typically begins. (Mahowald et al., 2005).

REM sleep behavior disorder has been linked to a number of other neurological conditions; thus, a careful review of systems and a physical examination are crucial. Polysomnographic monitoring in patients with REM sleep behavior disorder reveals increased tonic and/or phasic electromyographic activity, often accompanied by muscle twitching, extremity flailing, or vocalization during REM sleep. REM sleep behavior disorder is often associated with a growing number of underlying neurologic disorders, and may be induced by numerous medications, particularly selective serotonin reuptake inhibitors (Boeve et al., 2004).

illness, traumatic experiences, and alcohol and medication use, such as antidepressants and

Nightmares affect 20 to 39 percent of children between five and 12 years of age. Contrary to popular belief, frequent nightmares in children do not suggest underlying psychopathology. Nightmares and night terrors in children are usually disturbing to parents and family members; therefore, proper diagnosis and education of family members are important components of management. It is essential to control the environment by removing dangerous objects and providing barriers to prevent escape from a safe sleeping environment. Reassurance and support are often the only therapy required because these disorders rarely, if ever, reflect underlying illness and usually disappear with maturity. Pharmacologic intervention is not usually indicated; in fact, it should be discouraged because it may contribute to further sleep disruption. Behavioral methods for treatment of

REM sleep is characterized by a paucity of muscle activity with near complete somatic muscular atonia. REM sleep behaviour disorder is characterized by the intermittent loss of REM atonia due to disinhibition of normally inhibitory mid-brain projections to spinal motor neurons. This, in conjunction with an active dream state, results in behavioural release and the apparent "acting out of dreams". Abnormal behaviours include sleep talking, yelling, limb movement, and complex motor activities. Patients with REM sleep behaviour disorder arouse from sleep to full alertness often with complete recall of fearful dream content, which may involve being chased or attacked. The motor behaviour exhibited tends to correlate with dream content. REM sleep periods typically occur in the latter half of the night. The most common symptom at time of presentation is injury of the patient or bed partner. As a result of the behaviors, bed partners often simply move to another bed or room. Also, patients and families may have a sense of guilt or shame regarding the behaviors, even though the behaviors may not be consistent with patients' personalities. This is particularly true when sexual behaviors are involved. Sleep disruption and daytime sleepiness are often part of the history. REM sleep behaviour disorder tends to be a disease that occurs in older men, although women and people of all ages may be affected. The reason for the strong predominance toward men, with an approximately nine-to-one mento-women ratio, is not clearly known. The average age of onset is between 52.4 years to 60.9 years. Unlike those who experience sleep terrors, the victim will recall vivid dreams. The frequency of these episodes varies from once every few weeks to several times a night. Episodes tend to occur 90 min or more after sleep onset, when the first REM period typically

REM sleep behavior disorder has been linked to a number of other neurological conditions; thus, a careful review of systems and a physical examination are crucial. Polysomnographic monitoring in patients with REM sleep behavior disorder reveals increased tonic and/or phasic electromyographic activity, often accompanied by muscle twitching, extremity flailing, or vocalization during REM sleep. REM sleep behavior disorder is often associated with a growing number of underlying neurologic disorders, and may be induced by numerous medications, particularly selective serotonin reuptake inhibitors (Boeve et al.,

beta-antagonist antihypertensive agents.

frequent nightmares are effective in older children.

begins. (Mahowald et al., 2005).

2004).

**5.5 Rapid Eye Movement (REM) sleep behavior disorder** 

REM sleep behavior disorder can be controlled with medication. Clonazepam is the mainstay in the treatment of REM sleep behavior disorder and leads to either a complete or partial response in approximately 90% of cases. Before it is prescribed, the potential benefits of treatment should be weighed against the possible side effects. Other medications have been tried when clonazepam is not effective or is poorly tolerated. Discussions related to safety are very important, because precautionary measures may prevent serious injury to the patient or family members (Schenck et al., 2002).

#### **5.6 Other parasomnias**

Ten disorders are classified under this category (Table 1). The most common are sleep bruxism, sleep enuresis, and primary snoring.

Sleep bruxism is the third most common parasomnia and it can be bothersome to the bed partner. Bruxism is not a dangerous disorder. However, it can cause permanent damage to the teeth and uncomfortable jaw pain, headaches, or ear pain. Approximately 8.2% of people experience it at least once a week. Sleep apnea and anxiety disorders are the most prominent risk factors for bruxism. Bruxism could be a reflex to open the airway after an apneic or hypopneic event. Bruxism may improve with treatment of sleep apnea with continuous positive airway pressure. Sleep bruxism does not have a definite cure. The goals of treatment are to reduce pain, prevent permanent damage to the teeth, and reduce clenching as much as possible. Stress reduction, relaxation, biofeedback, hypnosis and improvement of sleep hygiene have been tried with no persistent or significant improvement. To prevent damage to the teeth, mouth guards or appliances (splints) have been used since the 1930s to treat teeth grinding, clenching, and TMJ disorders. A splint may help protect the teeth from the pressure of clenching. Pharmacologic interventions are indicated for short-term management of patients who experience complications of sleep bruxism, including pain in the temporomandibular joint. Benzodiazepines could be effective because of their muscle-relaxing and anti-anxiety properties. Additionally, they increase the arousal threshold that could precede teeth grinding. (Farid et al., 2004)

Sleep enuresis, more commonly known as bedwetting, refers to the lack of ability to maintain urinary control during sleep. This recurrent involuntary urination is also called nocturnal enuresis, which is characterized by at least two occurrences per month in 3 to 6 years old infants and at least one occurrence per month for older children. Sleep enuresis is observed in 10% of children at the age of 6. The prevalence decreases with age. Approximately 77% of children had enuresis when their parents were enuretic, whereas 44% of children with one parent who was enuretic developed enuresis. Simple behavior modifications can be very effective treatments for children with enuretic episodes. For example, intake of liquids and dietary bladder irritants such as citrus products should be discouraged before bedtime. Taking note of when the enuresis actually occurs, and waking and taking the child to toilet before that hour, can also be very helpful Matthias et al., 2002).

Psychological treatments such as encouragement of self-reliance, participation in management, inculcation of self-respect and responsibility are also recommended by many experts. Physical punishments and coercion, on the other hand, are considered to be the most counterproductive measures and should be avoided at all costs.

Parasomnias 157

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Using devices such as bedwetting alarms and moisture alarms, combined with bladder muscle exercises, dietary changes, retention control training etc can also be helpful remedies in treating sleep enuresis. Education, encouragement, and patience are prudent approaches for younger children. For older children who may be embarrassed by the occurrences, and who may be affected by the emotional concerns, more aggressive treatment is recommended. Biofeedback, including enuresis alarms, arousal training and desmopressin have been tried with prominent success rates, although they are associated with high relapse rates. Hypnotherapy and imipramine have been somewhat helpful in the management Schenck et al., 1996).

Primary snoring is reported in 40% to 50% of people over the age of 65 and approximately 25% of the middle-age group. Snoring is usually a symptom of sleep disordered breathing. Oral appliances and otolaryngologic procedures, including velopharyngeal surgery, can effectively resolve snoring. Most of the studies on oral appliances are conducted for treatment of obstructive sleep apnea syndrome, with no clear data on primary snoring. They have decreased the frequency of snoring by 50%.
