how to approach parasomnia in adult · • it is unclear whether sexsomniais distinct parasomnia or...
TRANSCRIPT
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HowtoapproachParasomniainadult
Dr.Yotin Chinvarun M.D.Ph.D.
CEPandSleepdisorderprogramPMKhospital
Introduction:Normalsleepcycle
• Sleepconsists oftwostrikinglydifferent states:• Rapideyemovementsleep(REM)• Non-rapideyemovementsleep(NREM),alternateincyclicalfashion
• Sleepbeginswitha“shallow”Stage1ofNREMand“deepens”toNREMStages2,3,and4,followed byfirstbriefepisodeofREM~90minutes
• Afterthefirstsleepcycle,NREMandREMsleepcontinue alternatingincyclicalfashion, durationofeachcycle~90minutes
• Stages3and4ofNREMsleeppredominateduring firstthird ofthenight.• REMsleepepisodesbecomelonger,• LongestREMperiodsfoundinlastthirdofthenight
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Introduction: Parasomnia
• Parasomnias,definedundesirablebehavioral,physiological,orexperientialeventsthataccompanysleep
• Commoningeneralpopulation
• OccurmorefrequentlyinchildrenthaninadultswithexceptionofREMsleepbehaviordisorder(RBD),morecommoninmenover50
Introduction: Parasomnia
• Parasomniascanarisefromanystateofsleep(REMandNREM)aswellassleep-waketransitions
• Classifiedintodistinctsyndromeson thisbasis
• Disordersofarousal,forexample,mostprevalentoftheNREMparasomnias• Typically,disorders ofarousaloccur duringfirstthird ofthenight,during deepsleepismostabundant
• REMsleepparasomniasmorelikelytoemergeduringlaterportionofsleepperiod,whenREMsleepabundant
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Parasomnia
• NREM– related• Sleepwalking/talking• Sleepterrors• Rhythmic movementdisorder
• REM• REMbehaviordisorder• Nightmaredisorder
• Other• Sleep-relateddissociative disorders e.gSleepbingeeating,Sleepenuresis, sexsomnia• Headbanging• SleepGroaning
NREMParasomnias
• Youngadults• +vehistoryofchildhood sleepwalking• Re-emergenceinadulthood
• Psychologicalorphysicaltrauma• Sleeprestriction• Sleephistory
• First1– 1.5hours• Difficult toarouse• Poor, ornodreamrecall
• Specialcases• Complex dissociativebehaviors
• Sleepsex,sleepeating
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DifferentialDiagnosisofParasomnias
• Nocturnalepilepsy• Nocturnal FrontalLobeEpilepsy• TemporalLobeEpilepsy/Complex Partial
• Seizures• Severesleepapnea• Malingering
Sleepterrors Sleepwalking Nightmares REM-SleepBehaviorDisorder
SleepStage UsuallyIII, IV III, IV REM REM
Mostlikelytimeofnight Firstthirdofsleepperiod
Firstthirdofsleepperiod
Finalthirdofsleepperiod
Finalthirdofsleepperiod
Agegroup Children Children 20-40%ofchildren Oldermen
Familyhistory Yes Yes No No
Violence Ifattempt toarousesleeper
Possible,e.g.homicidalsomnambulism
Possible
Amnesiaforevent Yes Yes No No
Confusion Yes Yes No No
Mayprogresstosleepwalking
Yes No
Terminatedby Returningtosleep Returningtobed/sleep
Usuallyawaken thesleeper
Parasomnias and sleep stages
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Confusional arousal
• Subjectawakenpartiallyexhibiting markedconfusion, slowmentation, disorientation andperceptual impairment, erroroflogic
• Commoninchildren <5yrs
• Prevalenceinthe15to24-year-oldpopulation 6%,ageof65is1%
• Resultfrompartial orincomplete arousalfromdeepsleep,typicallyduringfirstthird ofthenight
• Typicallylastfrom1- 10minutes, andarefollowed byretrogradeamnesiafortheevent
• Precipitating factorsi.e.fever,CNSdepressants, recoveryfromsleepdeprivation
Confusional arousal
• Pathophysiology• Incompleteawakening fromsleep, leading toprolongationofnormalperiodofsleepinertia
• DDx• Sleepwalking• Sleep terrors• RBD• Nocturnalseizures
• Treatment:• Benignandrequirenotreatment• Interruptionmaylead toincreasedagitationandpossibleinjury
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Sleepwalking(somnambulism)
• Seriesofcomplex behaviorsthatareinitiated duringslow-wavesleepandresults inwalkingduring sleepArousal fromdeepsleep(1st third)
• Without awakening:exhibition ofwiderange,complex autonomicbehaviors
• Typically,sitsupinbedduringfirstthird ofthenight,looksaroundwithablankstare,andexhibitssomerepetitive motor automatisms,suchaspickingatclothes orlinens, getsupandwalksaroundthebedroom, entersother rooms,andmayevenleavethehouse
• Maycauseinjury
• Duration 1-5minutes, >1hr whenbehaviorsaremorecomplex
Sleepwalking(somnambulism)
• Sleepwalkingepisodes typicallylastlessthan15minutes;• Episodeslastingmorethanonehourhavebeenreported
• Attemptstoawakenasleepwalkerusuallyfailtoproducearousalandmayleadtoaggressiveandviolentresponses• Casesofsleepwalkingviolence, including homicidal somnambulism, havebeendescribed
• 40percent ofchildren experience atleastonesleepwalkingepisodeduring childhood• 2- 3percentofchildrensleepwalkmorethanoncepermonth.• 2- 3percentofadultsingeneralpopulationsleepwalk
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Sleepwalking
• Hybridattack:sleepterror precedesandevolvesintosleepwalking
• Uponawakeningpatientmayexhibit mentalconfusionandamnesia
• Mostcommoninchildren 4-5yrs,associatedwith strongfamilyhistory
Sleepwalking
• Precipitatingfactors• Sleepdeprivation, stress,pain,OSA,distendedbladder• Alcohol– SWSinc--- Incsleepwalking
• DDX• RBD• Confusionalarousal• Sleeprelatedseizureswithambulatoryautomatisms
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Sleepwalking
• Treatment• Safety• Avoidprecipitatingfactors• Medication
• Benzodiazepines
Sleepterror(Parvor nocturnus,incubusattacks)
• Suddenarousalsfromdeepsleep
• Scream/terror/confusion
• Extremeautonomicarousal
• Variablemotoractivity• Includeextremeagitation/escapebehavior• Mayresultininjuryduringtheepisode
• Clinical• Patientwakesup,sits,emits,screaminastateofterror,difficultiesbreathing,palpitationsandamnesia
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Sleepterror(Parvor nocturnus,incubusattacks)
• Prevalence3%ofchildren, 1%ofadults,Male>Female
• DDX• Nightmare(REMsleep)• Nocturnal seizures(frontallobeepilepsy)
• Treatment• Oftenunnecessaryifepisodesarerare• DZP,Clonazepam, TCA• Psychotherapy,stressreduction, hypnosis
Sleep-relatedeatingdisorder(SRED)
• Featuresofparasomnia (sleepwalking,partialarousals)combinedwithcharacteristicsofbingeeatingdisorder
• Duringtheseepisodes,individualsconfused,notfullyawake,anddisplayvariabilityindegreeofawarenessoftheirbehavior
• Accuraterecollectionofeventisabsent,andindividualsreport“half-asleep.”
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Sleep-relatedeatingdisorder(SRED)
• SREDfrequentlyhavepriorhistoriesofsleepwalkingwithlateronsetofeatingatnight
• Sleep-relatedeatingdisorderdifferentiatedfromconditionnighteatingsyndrome• Individualswithnighteatingsyndromeconsumemealsduringnighthours whilebeingfullyawake
• PrevalenceofSREDestimated1- 5%inadultpopulation,womenaffected2to4timesmorefrequently thanmen
Sleep-relatedeatingdisorder(SRED)
• Treatmentofsleep-relatedeatingdisorder
• Mitigatingprecipitatingsleepdisorders,suchas• Obstructivesleepapneasyndrome,periodic limbmovementdisorder, orrestlesslegssyndrome
• Combinationsofdopaminergicagents,opiates,andtrazodone,aswellastopiramate havebeenusedwithsomesuccess
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Sexsomnia
• Patientsexhibitingcomplexsexualbehaviorsduringsleep
• itisunclearwhethersexsomnia isdistinctparasomniaoravariantofsleepwalking
• Somefeaturesofthisparasomniadistinctfromsleepwalking:• Behaviorsinvolvesexualpartners, individuals exhibitsexualarousal, andmoreprominentautonomic activation, andsomeformofdreammentationispresent
REMSleepParasomnia
• REM-SLEEPBEHAVIORDISORDER
• NIGHTMARES
• HYPNOGOGIC/HYPNOPOMPIC HALLUCINATIONS
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REMBehaviorDisorder
• REM-sleepbehaviordisorder (RBD)isbeststudied REMsleepparasomnia
• Prevalenceofviolentbehaviorassociatedwith RBDis0.5percentinthegeneral
• REMsleepbehaviordisorder morecommoninelderly• Ageofonsetistypicallybetween50- 60yearsold
• Menaffectedmorefrequentlythanwomen,manyindividualstheremaybeasubclinicalprodromalstate
• Mechanismresponsible fornormalskeletalmuscleatonia isnot functioning properly andindividuals actout theirdreams• Lesions andmalfunctions inbrainstemarebelievedtoberesponsibleforthelackofskeletalmuscleatonia during
REMsleep
REMBehaviorDisorder
• Injurious ordisruptive behaviour duringsleep
• Easilyaroused;Dreamrecallprominent
• Two-thirds ofpatients developParkinson’s disease• Meanlatencyof13years;associatedwithsynucleinopathies (PD,LBD,MSA)
• Polysomnographydiagnosticallyhelpful
• HighlyresponsivetoClonazepam
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RBDinParkinson’sdisease
• RBDmaybeheralding manifestationofPDbymanyyears
• RBDoccur 15-50%ofpatient withPD
REMSleepbehaviordisorder
• Characterized bycomplexvigorousmotor activitiesandinjurious behaviorsrepresentingattemptsofvivid,action filledviolentdreams
• Occuratleast90minutes aftersleeponsetandpredominantly inthe2nd halfofthenight
• Riskforinjury-self andbedpartner
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REMSleepbehaviordisorder
• Widerangeofbehaviors• Verbalizations• Singing• Yelling, shouting, screaming• Walking,running• Punching, kicking,jumping• Violent/agitatedbehaviors
REMSleepbehaviordisorder
• Clinical feature(OlsonEJetalBrain2000)• 93cases,M87%:F13%• Meanageofonset61yrs• Meanageofdiagnosis64yrs• Injuriestoself/bedpartner 32%/16%
• Diagnosis:• suspectedclinically, confirmed byPSG
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AcutereversibleRBD
• AcuteRBDmostcommonlyassociatedwith• Withdrawalfromalcohol,benzodiazepines,andbarbiturates,
• Administrationofsomepsychiatricmedications• Tricyclic antidepressants• Selectiveserotonin reuptakeinhibitors• Cholinergic agents• Monoamineoxidaseinhibitors
• BehaviorsinindividualswithacuteRBDincludelimbandbody jerking,kickingthebed,shouting,andstrikingbedpartners
REMBehaviorDisorder
NORMALREM
REMBehaviorDisorder
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REMBehaviorDisorder
Arms
Legs
REMSleepbehaviordisorder
• DDX• Sleepwalking• Sleepterrors• Nocturnal seizures• Sleeptalking• PLM
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REMSleepbehaviordisorder
• Treatment• AvoidpotentialaggravatedRx
• SSRI,Selegiline, Clomipramine, Anticholinergic ,TCA,MAOIs• PrescribedClonazepam0.25-1mghs (90%effective)• BupropionshouldbetheantidepressantofchoiceinpatientswithRBD,• Melatonin• Levodopa,dopamineagonists• AEDs
Nightmares
• Frighteningdreams ordisturbingmentalexperiences,usuallyawakensleeperfromREMsleep
• Dreamcontentmostfrequentlyinvolvesimminentdanger;attacksorpursuitarecommonthemes
• Fearand/oranxietymostfrequentemotionsassociatedwithnightmares;sadness,anger,anddysphoriaalsofrequently reported
• Nightmaresnotassociatedwithconfusionordisorientation
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Nightmares
• Moreprevalentinchildhood;• Prevalenceinchildren is20to40percent• 5to30percent ofchildren report havingoftennightmares“oftenoralways.”• Inadults, prevalencehavingoneormorenightmarespermonthrangesfrom8to30percent
• Multipleclassesofdrugsmaytriggernightmares
• WithdrawalfromREM-suppressingmedications,suchas• Selectiveserotonin reuptakeinhibitors, tricyclic antidepressants, hypnotics, andalcohol, betablockersanddopaminergic agonistsmayprecipitate nightmaresorincreasetheseverityofnightmares
Nightmares
• Treatmentincludes• Psychotherapy,• Minimizingoravoidingstress,• Minimizingtheuseofdrugsthatmayprecipitate nightmares
• Inindividuals withpoor sleephygiene,instituting aregular sleep-wakepattern
• Pharmacotherapy• Cyproheptadine 4to16mg• Prazosin5to10mghelpful inRxnightmares
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Hypnogogic andhypnopompichallucinations
• Hypnogogicandhypnopompichallucinationsarevividperceptualexperiences
• Occurringattheonset(hypnogogic)ofsleeporuponawakening(hypnopompic)
• ThoughttoresultfromintrusionofREMsleepprocessintothewakingstate.
• Hallucinationsmostfrequentlyvisual,butcanbeauditory,tactile,orcenesthopathic (abnormalsensations)
Hypnogogic andhypnopompichallucinations
• Visualhallucinationsrangefrompoorly formedshadows,shapes,orcolorstowellformedcompleximages
• Individualsreport seeingcircles,shadows,faces,persons,andanimalsintheroom
• Imagesmaybeconstantorchanginginsize,blackandwhite,or incolor
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Hypnogogic andhypnopompichallucinations
• Auditoryhallucinationsmayincludeindistinctsounds,threateningsentences,orcomplexmelodies
• Cenesthopathic hallucinations includechangesinbodypartlocationandextracorporealexperiences
• Hallucinationscanbepleasingorfrightening;eventuallyindividualslearnthatimagesnotrealanddisappearafterafewminutes
• Occasionally,individualswithhypnagogicorhypnopompichallucinationsmisdiagnosedashavingpsychoticdisorders
Somniliquy
• Speechduringsleep
• Notcomplex
• Notassociatedwith subjectiveawarenessoftalking
• Notsleepstagespecific
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Hypnicjerks
• Briefbodyjerksinisolation /succession• Exclusivelyduringsleeponset• Leg>arm&head• Sensorysymptoms:flashinglights, feelingoffalling,hypnagogichallucinations
• Etiology• Nicotine, caffeine,stress,exercise
Bruxism
• Prevalence5-10%
• Uncertainrelationshiptostress
• Associatedwithanysleepstage
• Consequenceprimarydentalpathology
• PSG• Phasicincreaseinmassetermuscletone,rhyhtmicEMGartifactsintheEEG,freq0.5-1.5HzoccurringinburstsatstageI,II,REM
• Treatment• Stressreduction,mouthguard,BZD
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PeriodicLimbMovementsofSleep
Insummary:ApproachtopatientswithParasomnia• Itisessentialtointerviewboththepatientandpatient’sbedpartner
• Becauseoftenpatientswith NREMparasomniamaybeunawareoftheir activitiesatnight
• Askaboutchildhood andfamilyhistoryofparasomnias
• Askabouttimeofnightwhensymptomsoccur andwhetherthepatient recallsassociateddreams
• Neurologic examisadvisable
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Insummary:ApproachtopatientswithParasomnia• Allpatientswithadultonsetparasomnias(NREMandREM)needtobereferredtosleepspecialistforanevaluation
• Theevaluationincludenocturnal polysomnographic study,andsleepspecialistwilldeterminewhetherpatientneedsMRIbrainorneurologicworkup
• Whenparasomniasleadtoinjuryorpsychologicaldistresstopatientorbedpartner,resultinlawbreaking,impairfunctioningdue toexcessivedaytimesleepiness,causeweightgain,referraltosleepspecialistforevaluationandtreatment
Insummary:Parasomnia
• Parasomniascommoningeneralpopulation
• ClinicalphenomenaariseasbraintransitionsbetweenREMsleep,NREMsleep,andwakefulness
• Parasomniascanbeaccuratelydiagnosedandeffectivelytreated
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Insummary:Parasomnia
• Certainparasomniasmaysignalonsetofseriousmedicaldisorders
• Inmostcases,adheringtogoodsleephygienemeasures,• Avoidingsleepdeprivation, treating primarysleepdisorders, reducing stress,andensuringpatientsafety
• Whenepisodesfrequent, causedistress, and/orimposedangertopatientortheir bedpartner• Effectivepharmacotherapeutic measures