Shyam is a 27 year old combat war veteran from India. He successfully completed many dangerous missions during his tenure in India and killed many enemies. But in one of the last missions, many of his colleagues were ambushed and were killed though Shyam escaped safely. But since then he was haunted by their memories and often used to have nightmares sometimes suddenly waking up from sleep. These episodes became more and more frequent since he came back home one year ago to join his wife and family. It happened six months ago. One night he dreamt about the mission he had and in the nightmare he also remembered to have smothered the enemies. But to his dismay when he got up from sleep next morning, he found his wife strangled by him lying down beside, dead.
Later, he was diagnosed to be suffering from parasomnia.
Types of parasomnias and prevalence
Sleep can be defined as the dynamic cycle of rest. Sleep is of types- Non rapid eye movement (REM) sleep consisting of four stages-1 to 2, 3, 4- and REM sleep. Complete sleep cycle takes about 90 to 110 minutes. 50% of our sleep is spent in stage 2 sleep, 20% in REM sleep and 30% in the remaining stages.
Parasomnias are sleep abnormalities manifested by undesirable behavioral or physiological actions occurring at various stages of sleep. The parasomnias are categorized into disorders of arousal, sleep-wake transition disorders, REM sleep disorders, and other parasomnias.
Sleep terrors, sleep walking and confusional arousals are grouped under this category because all these abnormalities postulated to stem from improper arousal from sleep.
These normally occur during childhood and cease by adolescence.
- Sleep terrors (Night terrors): Sleep terrors are manifested by abrupt arousal from slow-wave sleep with a sharp cry or shriek, characterized by panic and strong fear. Prevalence rate among children is 3% and among adults is less than 1%.
- Sleep walking (Somnambulism): Sleep walking may involve from simple sitting up in bed to walking in the sleep and even to frenzied attempts to “run away.” The person may not remember about the event and most of the times confused. 1% to 15% of the population exhibits this disorder and more common among children than among the adults.
- Confusional arousals (Sleep drunkenness): Confusional arousals are manifested by confusion during and or immediately after arousals from sleep. Confusional arousals occur commonly among the children of less than 5 years of age and uncommon among adults.
REM sleep disorders
The disorders essentially occurring during REM sleep are nightmares, recurrent isolated sleep paralysis and REM sleep behavior disorder (RBD).
- Nightmares: Nightmares are scary dreams that normally awaken the sleeper from
- REM sleep. 10 to 50% of children of the age of 3 to 5 years experience nightmares. 50% of adults admit to have occasional nightmares.
- Sleep paralysis: People with sleep paralysis are not able to move the body or limbs when falling asleep or waking up. Brief episodes of partial or complete skeletal muscle paralysis can occur during sleep paralysis.
- REM sleep behavior disorder (RBD): People with rapid eye movement (REM) sleep behavior disorder act out dramatic and/or violent dreams during REM sleep. REM sleep usually involves a state of paralysis (atonia), but people with this condition move the body or limbs while dreaming. RBD occurrence is rare and in most of the cased may be exhibited as other parasomnias.
Sleep enuresis: In this condition, also called bedwetting, the affected person is unable to maintain urinary control when asleep. In children of the age of 4-5 years, the prevalence is estimated to be between 20 and 30%. In children of the age of 7 years it is about 10%, and further reduced to around 3% in 12 year children. In adults the occurrence of primary sleep enuresis is rare or around 2%.
Diagnosis of parasomnia
Your doctor can diagnose parasomnia based on your signs and symptoms, history of the family, physical exam and results of the tests. Your symptoms can be well defined so that your doctor can diagnose parasomnia. Besides, your doctor may recommend you to a sleep specialist who will conduct specific tests to confirm parasomnia. You may need to visit a sleep center and stay overnight for testing and evaluation.
The Sleep Specialist can confirm the diagnosis of a parasomnia or diagnose for another sleep disorder, or exclude a specific sleep disorder as the cause of your symptoms, based on symptoms, recorded diary of your sleep habits and the results of polysomnogram (sleep study).
Are parasomnias dangerous?
Some of the disorders of parasomnias such as sleep walking can be dangerous as the person affected by parasomnia can hurt or kill. Relatively few parasomnias may result in dangerous or capable of causing violent injury. These parasomnias include disorders of arousal, rapid eye movement (REM) sleep behavior disorder and night time seizures. A survey conducted over telephone indicated the prevalence of harmful behavior during sleep to an extent of 2%, and approximately 25% of these people suffer from REM sleep disorder.
Treatment of parasomnias
The main aim of treating parasomnias is to reduce the frequency of occurrence and also minimize the intensity. Medication treatments are given to prevent arousal out of sleep and suppress REM sleep. All the present medications used for these disorders are used off-label and there are no medications available which are indicated for these disorders.
The most common drugs used to treat these disorders are benzodiazepines (sedatives and hypnotics) and anticonvulsants (anti-seizure) medications. The treatment of rapid eye movement behavior disorder is treated with clonezapam which has been shown to be effective over long periods. Discontinuation results in the relapse of the disorder. Tricyclic anti-depressants are also used occasionally for REM behavior disorder. Though Imipramine is used for its serotonergic (chemical which functions to enhance the effects mediated by serotonin in the central nervous system) effects in the treatment of REM behavioral disorder, the results cannot be predicted. Though anecdotal (doubt about veracity) reports on levodopa/carbidopa, gabapentin, and clonidine have been published, their benefits have not yet been evaluated.
Precautions in parasomnia
In general, the disorder does not bring about or cause any changes to your present life. But certain precautions are needed to be taken during the treatment of parasomnia. These include:
- Keep away all the potentially harmful items.
- If possible accommodate the person with parasomnia disorder in the ground floor. Avoid accommodation in upper floors.
- Clear the path where the person is sleeping from any obstacles.
- Keep the doors and windows locked and bolted.
- Use heavy grapes to cover the glass windows.
- Keep an alarm or bell within reach for the person to call for help in case of parasomnia attack or episode.
- Ensure going to bed at the same time every day.
- Avoid any factors that cause stress, fatigue and deprive you from sleep.
- Avoid alcohol, smoking, and excessive consumption of beverages that contain caffeine.
- Keep your family informed about the disorder and the necessary course of action they should take in case of attack of parasomnias.
Sleep is a dynamic activity that occurs in cycles consisting of non REM sleep and REM sleep. Parasomnias are abnormal sleep disorders associated with various sleep stages, sleep-transition stages and sleep arousal. Parasomnias are subdivided into disorders of arousal, disorders of REM sleep and miscellaneous parasomnias. Parasomnias can be diagnosed by your doctor through physical exam, tests and specific tests such as polysomnogram. Parasomnias can be treated through medications. As some of the parasomnias can be harmful and dangerous, precautions need to be taken.