The Parasomnias: Epidemiology, Clinical Features, and Diagnostic Approach

The Clinical Spectrum of the Parasomnias

Parasomnias are defined as abnormal movements or behaviors that occur in sleep or during arousals from sleep. Parasomnias vary in frequency from episodic events that arise from incomplete sleep state transition. The framework by which parasomnias are categorized and diagnosed is based on the International Classification of Sleep Disorders-Third Edition, Text Revision (ICSD-3-TR), published by the American Academy of Sleep Medicine. The recent Third Edition, Text Revision (ICSD-3-TR) of the ICSD provides an expert consensus of the diagnostic requirements for sleep disorders, including parasomnias, based on an extensive review of the current literature.

Common Childhood Sleep Problems and Disorders

BACKGROUND

Sleep insufficiency and disturbances affect the physical, cognitive, and emotional well-being of children.

OBJECTIVE

To perform a narrative review on common sleep problems and disorders encountered in primary care for children and adolescents.

METHODS

A search of English literature in the Pubmed and Google Scholar databases published from 1 January 2000 till 31 October 2021 was conducted with the keywords "sleep problem" or "sleep disorder" and "child" or "adolescent". Findings in the relevant articles and cross-references were compiled.

RESULTS

Sleep duration and habits of children vary widely across countries with different cultural backgrounds. There is robust evidence to support the promotion of positive bedtime routines and sleep hygiene as prevention and management of sleep problems. 15-70% of parents reported their children having sleep problems or disturbances. Common sleep complaints include difficulty in initiation or maintenance of sleep, abnormal behaviors or movements, snoring or abnormal breathing, and excessive daytime sleepiness. Comprehensive sleep history and a sleep diary are the first steps for evaluation. Home video and actigraphy may be used as preliminary tools to confirm the history. Referrals to a sleep specialist for polysomnography and other tests are needed, if suspecting specific sleep disorders, such as obstructive sleep apnea and narcolepsy, needs timely intervention. Common sleep disorders in different age groups encountered in primary care are reviewed with clinical features, indications for evaluation, and treatment options summarized.

CONCLUSION

Screening for sleep problems shall be an integral part of each child's health care visit. It is important to evaluate the impact of common sleep problems and identify specific sleep disorders for early intervention to prevent long-term adverse outcomes.

A case report of atypical sleep in an ischemic stroke patient with psychiatric symptoms caused by olanzapine

Antipsychotics, tricyclic and 5-hydroxytryptamine reuptake inhibitors (SSRI) and 5-hydroxytryptamine and norepinephrine reuptake inhibitor (SNRI) antidepressants, and monoamine oxidase inhibitors can produce dream-rendering behaviors and/or dystonic deregulation during REM sleep. Acute episodes are also seen with withdrawal from alcohol or sedative-hypnotics, and the use of tricyclic and SSRI antidepressants. In this article, we present a case of olanzapine treatment of a patient with cerebrovascular disease with psychobehavioural symptoms. The patient was an elderly patient who developed psychobehavioural symptoms after a sudden cerebral infarction. Initially, his symptoms improved when he took olanzapine (5 mg orally once/night). However, the patient subsequently developed symptoms of hypersomnia when he continued to take olanzapine, and the symptoms of hypersomnia gradually worsened as the dose of olanzapine was gradually increased. Benzodiazepines are often used to treat anomalous sleep, and clonazepam is one of the commonly prescribed drugs. In this case, the patient's abnormal sleep behavior was alleviated after treatment with clonazepam. As an atypical antipsychotic drug, olanzapine has been reported to cause abnormal sleep behavior during clinical use, and only one case has been reported in China. Clinicians should be aware that heteromorphic sleep can occur in patients treated with olanzapine.

Cognitive Disengagement Syndrome and Child Sleep Problems in ADHD, Anxiety and Depression

The main objective of this study was to analyse the relationship and differential contribution of Cognitive Disengagement Syndrome (CDS) and sleep problems in children in different psychopathological measures. A total of 1133 participants (612 fathers/mothers and 521 children aged 7-13 years in Years 3-6 of Primary Education) completed the scales on CDS, sleep problems, depression (DEP), anxiety (ANX) and attention deficit and hyperactivity disorder (ADHD). Similar and significant correlations were identified in the measures of CDS and sleep problems between fathers and mothers, obtaining a high coefficient between the two parents. However, weak correlations were found between fathers/mothers and children. The scores of CDS and the sleep disturbance scale for children (SDSC) significantly predicted the internalising measures and ADHD, especially between SDSC and DEP. It was confirmed that sleep problems had a greater presence in the group of children with the highest ADHD scores, and especially in CDS and ADHD jointly. To conclude, the data indicate the importance of sleep problems in understanding CDS and its relationship with other psychopathological measures, especially ADHD, although to a greater extent with internalising symptoms, especially DEP.

The Sleep Disturbance Scale for Children: psychometric properties and prevalence of sleep disorders in Spanish children aged 6-16 years

The present research aimed to investigate, for the first time, the validity and reliability of the Sleep Disturbance Scale for Children (SDSC) in a sample of 2733 Spanish children aged 6-16 years. We also described the prevalence and sociodemographic correlates of sleep disorder symptoms among young people, which had never been studied in Spain. Confirmatory factor analysis supported the original six-factor model and Cronbach's alpha for the total questionnaire was 0.82, which indicated good reliability. Moreover, all the SDSC subscales correlated positively and significantly with the total score (range = 0.41-0.70), thus showing convergent validity. Considering T-scores >70 as pathological, we identified at least one sleep disorder in 116 participants (4.24%), including disorders of excessive somnolence (DOES; 5.82%), sleep-wake transition disorders (SWTD; 5.27%), and disorders of initiating and maintaining sleep (DIMS; 5.09%) among the most common problems. Students in secondary education and those from families with a low socioeconomic status were more likely to have DIMS, disorders of arousal, and DOES. Subjects with clinically elevated levels of sleep breathing disorders were more frequently of foreign origin and from disadvantaged families. Boys and primary school students were more prone to sleep hyperhidrosis, while SWTD were overrepresented among children with a low socioeconomic status. According to our results, the Spanish version of the SDSC seems to be a good instrument for assessing sleep disturbances in school-age children and adolescents, which is essential to prevent the significant implications of poor sleeping on the overall welfare of young people.

Sleep terrors-A parental nightmare

Sleep terrors (STs) are sleep disorders characterized by abrupt arousal from sleep with autonomic hyperactivity and inappropriate behavior. Though a common condition in childhood that usually affects children between 4 and 12 years of age, STs, however, may be present even in adulthood. The exact etiology of STs is not known yet, however, several hypotheses have been proposed over the years, identifying some potential genetic, neurodevelopmental, or other causes. Nevertheless, a useful pathophysiological model identified a common cascade of predisposing, priming, and precipitating factors, which could help to explain and sometimes prevent STs. Establishing a correct diagnosis is mandatory for appropriate management, as several conditions (such as other parasomnias or nocturnal seizures) may mimic STs. Furthermore, we also described some conditions which can be comorbid to STs, like some medical or psychological disorders. A number of treatment options have been proposed, ranging from only sleep hygiene practices to pharmacological therapies; we reviewed some of the most prominent ones. In spite of the fact that STs have long been considered benign disorders, which tend to reduce spontaneously over the years, they may have unexpected consequences on the child but also on the caregivers.

Sleep Complaints Among School Children

Sleep complaints are common among children. These include both night-time and daytime symptoms, such as trouble falling asleep, problems in maintaining sleep, snoring, and unusual events during sleep and daytime functioning impairment. However, sleep complaints in children are often overlooked and undertreated in clinical practice. Untreated sleep problems may further impact on children's development and will persist into adulthood in some cases. This review summarizes the common sleep complaints and disorders in school children, and provides an overview of the epidemiology, clinical features, consequences, and treatment of the sleep problems.

Olanzapine-Related Somnambulism: A Systematic Review of Literature and a Case Report of Anorexia Nervosa

BACKGROUND

Somnambulism, or sleepwalking (SW), is one of the most common forms of arousal parasomnias. It is characterized by different complex motor behaviors leading to unwanted movements in bed or walking during sleep. It can be the consequence of psychological stress, abnormal breathing during sleep, high fever, or drug adverse effects. There is evidence of an association between antipsychotic treatment, including olanzapine, and SW.

METHODS

We present the case of a patient experiencing treatment-resistant anorexia nervosa whose somnambulism re-exacerbated after the addition of a low dose of olanzapine, following the CARE (CAse REport) Statement and Checklist. We also conducted a systematic review of the literature on olanzapine-induced somnambulism following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, PsychINFO, and the Cochrane Library databases were independently reviewed up to January 2021 for articles reporting olanzapine-related somnambulism cases, without language or time restriction.

RESULTS

We describe a case of somnambulism in a patient initially admitted to our hospital for anorexia nervosa and treated with a low dose of olanzapine. This is the first case of SW induced by olanzapine in eating disorders to be reported. Up-to-date olanzapine-related somnambulism was described in 8 patients experiencing psychiatric disorders (ie, schizophrenia and bipolar disorder).

CONCLUSIONS

To provide a reliable estimate of incidence and prevalence for olanzapine-related somnambulism, large-scale, pharmacovigilance studies are required, to allow for comparisons of overall clinical characteristics, outcomes, including time to recovery, between different treatment options. Clinician awareness should be enhanced, and attention should be given to such infrequent adverse effects associated with antipsychotics.

A rare presentation of sexsomnia in a military service member

NONE

Sexsomnias are unconscious sexual behaviors during sleep (parasomnias) that are garnering more attention as they become increasingly evident in forensic cases. Presentations of sexsomnia in active duty service members are seldom described, and often evaluation is clouded by intoxication with substances such as alcohol, sleep deprivation, untreated sleep disturbances, or criminal behavior masquerading as a medical disorder. We present a case of a 40-year-old male soldier evaluated in our sleep clinic for multiple episodes of sleep masturbation occurring over a period of 2 years. The patient was concerned about his suitability for deployment to a combat zone and participation in field training exercises (both require sleeping in groups in an open environment). Video polysomnography confirmed moderate obstructive sleep apnea, and the patient showed improvement with continuous positive airway pressure therapy. The authors also discuss the relevance of this case compared with previously reported sexsomnia cases and expand on parasomnia topics that are more common in military populations.

Sleep-related disorders and sleep quality among adults living in Parakou, a sub-Saharan African city

PURPOSE

To determine the prevalence of sleep-related disorders, poor sleeping, and factors associated with poor sleep quality among inhabitants of Parakou, Benin.

METHODS

This was a cross-sectional study conducted from April-August 2018 on 930 randomly selected adults (age ≥ 18 years). Using the Pittsburg Sleep Quality Index, the Insomnia Severity Index, and the Epworth Sleepiness Scale, subjects were questioned on their sleep, on parasomnias, and on movement-related sleep disorders.

RESULTS

Overall, the prevalence of insomnia was 22% (95% CI, 19.1-24.4) and severe insomnia was 0.8%. The prevalence of excessive daytime sleepiness was 15% (95% CI, 12.5-17.0). Daily nightmares (2%) and rhythmic movements (6%) were those most commonly reported among parasomnias and movement-related sleep disorders. No major differences were found between men and women. The prevalence of poor sleeping (PSQI > 5) was 39% (95%CI, 36.3-42.5). Adjusted analyses showed a higher risk of poor sleeping in those aged 45-54 years (aOR = 1.78, p = 0.032) or ≥ 55 years (aOR = 3.61, p < 0.001), those overweight or obese (aOR = 1.53, p = 0.007), those underweight (aOR = 2.90, p = 0.030), and among females (aOR = 1.84, p < 0.001). Being divorced was associated with a lower risk of poor sleeping (aOR = 0.18, p = 0.036). Poor sleepers were more commonly found among those who had excessive daytime sleepiness (65% versus 36%, p < 0.001) and insomnia (86% versus 27%, p < 0.001).

CONCLUSION

Sleep-related disorders were common in Parakou city, Benin, with four out of ten persons having poor sleep quality. There is a need to improve the management of sleep-related disorders and promote better sleep practices for the community.

Sleep-Related Hypermotor Epilepsy vs Disorders of Arousal in Adults: A Step-Wise Approach to Diagnosis

Disorders of arousal (DoA) and sleep-related hypermotor epilepsy (SHE) are sleep-related events characterized by complex, often bizarre, and violent behaviors. DoA are involuntary motor manifestations of various complexities occurring during incomplete awakening from non-rapid eye movement sleep. SHE is a focal epilepsy characterized by stereotyped hyperkinetic or/and asymmetric tonic/dystonic seizures usually arising from non-rapid eye movement sleep. Even if many aspects regarding DoA and SHE have been clarified, the differential diagnosis remains challenging, because DoA and SHE share some semiologic features and genetic background. The clinical history, collected from the patient and his/her witness, represents the first and common milestone in the diagnosis. Validated questionnaires constitute suitable screening tools that could guide further analysis. The worldwide availability of homemade video recordings has increased the possibility of adding more objective information to the clinical history alone. The confirmed diagnosis relies on video-polysomnographic recording although it requires time, economic resources, and specific skills for the analysis. In this review we propose a simple diagnostic algorithm for the differential diagnosis between DoA and SHE in adults, based on the most updated knowledge, from the simpler tool to the most specific and tailored one.

Prevalence of sleep disorders in chronic obstructive pulmonary disease and utility of global sleep assessment questionnaire: An observational case-control study

INTRODUCTION:

Although sleep disorders in chronic obstructive pulmonary disease (COPD) are common, no study has comprehensively evaluated sleep disorders in COPD, and there are no screening tools available for COPD patients. Global sleep assessment questionnaire (GSAQ) is one of the best screening tools for the general population.

AIMS AND OBJECTIVES:

The aims and objectives of the study were to find (i) the prevalence of sleep disorders in COPD based on GSAQ score; (ii) if the GSAQ score in COPD is high compared to healthy adult population; (iii) the prevalence of insomnia, obstructive sleep apnea (OSA), restless leg syndrome (RLS), and depression in COPD patients; and (iv) the sensitivity and specificity of GSAQ.

METHODS:

This was a prospective case–control study where GSAQ is administered to 100 stable COPD and 50 healthy individuals. The presence of sleep disorder in COPD was further confirmed based on the diagnostic criteria and polysomnography.

RESULTS:

GSAQ was positive in 68% of the COPD patients compared to 16% of the matched healthy adults (P < 0.001). The sleep disturbance was confirmed in 66 COPD patients. Insomnia, OSA, RLS, depression/anxiety, and overlap of two or more disorder were seen in 39, 13, 30, 22, and 31 patients, respectively. The overall sensitivity/specificity of GSAQ for sleep disturbances in COPD was 90.9%/70.58%, respectively. The sensitivity/specificity of GSAQ for insomnia, OSA, RLS, and anxiety/depression was 87/75%, 77/67%, 90/80%, and 91/65%, respectively.

CONCLUSION:

Sleep disorders in COPD patients are significantly high. GSAQ is a good screening tool for detecting the presence of disturbed sleep in COPD. Overlap of two or more sleep disorders is common in COPD.

Association of sleep terror, walking or talking and tinnitus

BACKGROUND/PURPOSE

Sleep disturbances are associated with chronic tinnitus in humans. However, whether parasomnias are associated with chronic tinnitus is unclear. This study aims to investigate this issue.

METHODS

Clinical data for 2907 subjects who had visited the Sleep Center of a community hospital in Taiwan during November 2011 to June 2017 were collected retrospectively. The association of chronic tinnitus with sleep terror, sleep walking, and sleep talking was analyzed using Pearson's Chi-Square test and multivariate logistic regression.

RESULTS

The cohort age ranged from 7 to 91 years old, with a mean age of 49.8 years (standard deviation, 14.3 years). The cohort included 1937 patients without and 970 patients with chronic tinnitus. The percentage of patients who experienced sleep terror was significantly higher among those with tinnitus than those without (p < 0.001). The percentage of patients reporting sleep walking was slightly higher in subjects with tinnitus than in those without, with borderline significance (p = 0.063). The percentage of patients experiencing sleep talking did not differ significantly between the groups. Multivariate logistic regression also showed that sleep terror but not sleep walking was significantly associated with tinnitus after adjusting for age, sex, hearing loss, and insomnia. After adjusting for other factors, subgroup analysis by age showed that sleep terror was significantly positively associated with chronic tinnitus in patients aged 20-44 years but not in those aged 7-19 or >45 years.

CONCLUSION

Sleep terror is positively associated with chronic tinnitus, especially in young adults.

Sleep Terrors: An Updated Review

BACKGROUND

Sleep terrors are common, frightening, but fortunately benign events. Familiarity with this condition is important so that an accurate diagnosis can be made.

OBJECTIVE

To familiarize physicians with the clinical manifestations, diagnosis, and management of children with sleep terrors.

METHODS

A PubMed search was completed in Clinical Queries using the key terms "sleep terrors" OR "night terrors". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

It is estimated that sleep terrors occur in 1 to 6.5% of children 1 to 12 years of age. Sleep terrors typically occur in children between 4 and 12 years of age, with a peak between 5 and 7 years of age. The exact etiology is not known. Developmental, environmental, organic, psychological, and genetic factors have been identified as a potential cause of sleep terrors. Sleep terrors tend to occur within the first three hours of the major sleep episode, during arousal from stage three or four non-rapid eye movement (NREM) sleep. In a typical attack, the child awakens abruptly from sleep, sits upright in bed or jumps out of bed, screams in terror and intense fear, is panicky, and has a frightened expression. The child is confused and incoherent: verbalization is generally present but disorganized. Autonomic hyperactivity is manifested by tachycardia, tachypnea, diaphoresis, flushed face, dilated pupils, agitation, tremulousness, and increased muscle tone. The child is difficult to arouse and console and may express feelings of anxiety or doom. In the majority of cases, the patient does not awaken fully and settles back to quiet and deep sleep. There is retrograde amnesia for the attack the following morning. Attempts to interrupt a sleep terror episode should be avoided. As sleep deprivation can predispose to sleep terrors, it is important that the child has good sleep hygiene and an appropriate sleeping environment. Medical intervention is usually not necessary, but clonazepam may be considered on a short-term basis at bedtime if sleep terrors are frequent and severe or are associated with functional impairment, such as fatigue, daytime sleepiness, and distress. Anticipatory awakening, performed approximately half an hour before the child is most likely to experience a sleep terror episode, is often effective for the treatment of frequently occurring sleep terrors.

CONCLUSION

Most children outgrow the disorder by late adolescence. In the majority of cases, there is no specific treatment other than reassurance and parental education. Underlying conditions, however, should be treated if possible and precipitating factors should be avoided.

Update on nonpharmacological interventions in parasomnias

Parasomnias are abnormal behaviors that occur during sleep and can be associated, in particular during adulthood, with impaired sleep quality, daytime dysfunction, and occasionally with violent and harmful nocturnal behaviors. In these cases, therapies are often considered. Longterm pharmacological treatments are not always well tolerated and often have limited efficacy. Therefore, behavioral approaches remain an important treatment option for several types of parasomnias. However, the evidence-based approaches are limited. In the current review, we highlight results from various nonpharmacological techniques on different types of parasomnias and provide a glimpse into the future of nonpharmacological treatments in this field.

Rapid Eye Movement (REM) Sleep Behavior Disorder and REM Sleep with Atonia in the Young

BACKGROUND

Rapid eye movement (REM) sleep behavior disorder (RBD) and REM sleep without atonia (RWA) have assumed much clinical importance with long-term data showing progression into neurodegenerative conditions among older adults. However, much less is known about RBD and RWA in younger populations. This study aims at comparing clinical and polysomnographic (PSG) characteristics of young patients presenting with RBD, young patients with other neurological conditions, and normal age-matched subjects.

METHODS

A retrospective chart review was carried out for consecutive young patients (<25 years) presenting with clinical features of RBD; and data were compared to data from patients with epilepsy, attention deficit hyperactivity disorder (ADHD), and autism, as well as normal subjects who underwent PSG during a 2-year-period.

RESULTS

Twelve patients fulfilling RBD diagnostic criteria, 22 autism patients, 10 with ADHD, 30 with epilepsy, and 14 normal subjects were included. Eight patients with autism (30%), three with ADHD (30%), one with epilepsy (3.3%), and six patients who had presented with RBD like symptoms (50%) had abnormal movements and behaviors during REM sleep. Excessive transient muscle activity and/or sustained muscle activity during REM epochs was found in all patients who had presented with RBD, in 16/22 (72%) autistic patients, 6/10 (60%) ADHD patients compared to only 6/30 (20%) patients with epilepsy and in none of the normal subjects.

CONCLUSION

We observed that a large percentage of young patients with autism and ADHD and some with epilepsy demonstrate loss of REM-associated atonia and some RBD-like behaviors on polysomnography similar to young patients presenting with RBD.

Sleep talking: A viable access to mental processes during sleep

Sleep talking is one of the most common altered nocturnal behaviours in the whole population. It does not represent a pathological condition and consists in the unaware production of vocalisations during sleep. Although in the last few decades we have experienced a remarkable increase in knowledge about cognitive processes and behavioural manifestations during sleep, the literature regarding sleep talking remains dated and fragmentary. We first provide an overview of historical and recent findings regarding sleep talking, and we then discuss the phenomenon in the context of mental activity during sleep. It is shown that verbal utterances, reflecting the ongoing dream content, may represent the unique possibility to access the dreamlike mental experience directly. Furthermore, we discuss such phenomena within a cognitive theoretical framework, considering both the atypical activation of psycholinguistic circuits during sleep and the implications of verbal 'replay' of recent learning in memory consolidation. Despite current knowledge on such a common experience being far from complete, an in-depth analysis of sleep talking episodes could offer interesting opportunities to address fundamental questions on dreaming or information processing during sleep. Further systematic polysomnographic and neuroimaging investigations are expected to shed new light on the manifestation of the phenomenon and related aspects.

Absenteeism and Delay to Work Due to Sleep Disorders in the Turkish Adult Population: A Questionnaire-Based National Survey

Sleep problems may have negative effects on work-life balance, overall health, and safety. We aimed to investigate the association between sleep disorders and absenteeism and delay to work (being late or tardy) among the working adult population. The study was conducted by using data from a large survey of working adults who participated in the Turkish Adult Population Epidemiology of Sleep Study (TAPES) managed by Turkish Sleep Medicine Society (TSMS). Secondary analyses was employed to examine absenteeism and delay to work and their associations with sleep problems, including sleepiness by Epworth Sleepiness Scale (ESS), parasomnias, sleep apnea (by Berlin Questionnaire), sleep quality (by Pittsburgh Sleep Quality Index), and restless leg. History of any absenteeism and delay to work was observed in 276 (18%) and 443 (29%) out of 1,533 working adults, respectively. In the multivariate analyses, absenteeism was associated with younger age, female gender and poor sleep quality, while delay to work was associated with younger age, poor sleep quality, parasomnia, and sleepiness. In the presence of absenteeism and delay to work, sleep disorders including sleepiness, poor sleep quality, and parasomnia should be considered. Such evaluation may improve worker well-being and provide some additional benefits in terms of increasing productivity and lowering work-related costs.

Prevalencia de Trastornos de Sueño en Relación con Factores Sociodemográficos y Depresión en Adultos Mayores de Monterrey, México

<p>La prevalencia de síntomas de trastornos, calidad de sueño y depresión se evaluó en 313 adultos mayores en la ciudad de Monterrey, México con el Cuestionario de Trastornos de Sueño Monterrey, el Índice de Calidad del Sueño de Pittsburgh y la Escala de Depresión Geriátrica de Yesavage. Los resultados indicaron que los adultos mayores presentaron 50% ronquido, 24% piernas inquietas e insomnio, 44.1% mala calidad de sueño, y 62% síntomas de depresión. Los trastornos de sueño son los que más afectan la calidad de sueño en esta población, por lo que es importante la detección y tratamiento de estos trastornos en los adultos mayores.</p>

Treatment Approach to Sleep Terror: Two Case Reports

Parasomnias are a group of disorders characterized by abnormal behaviors, physical activities, and autonomic arousal symptoms while transition to sleep or continuation of sleep. Sleep terror (ST) is classified under parasomnias characterized by sudden fear attacks beginning with crying attacks or high-frequency screams and continuing with increased autonomic symptoms. ST occurs in the first few hours of sleep during the delta phase. Further, the lifetime prevalence of ST in adults is less than 1%. It is important to obtain; anamnesis from patients' bed partner for a clinical evaluation of ST. Methods, such as evaluating sleep diaries and video recordings, can help ST diagnosis. It is also important to evaluate patients' medical history, history of substance or alcohol abuse, psychological traumatic experiences, primary or secondary incomes, and detailed neurological aspects. Physician can select some serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCADs) as medical treatment if patients have a high frequency of attacks. Because of addiction and relapse of ST episodes, benzodiazepines are not preferred as the first-line treatment. In this study, we will discuss ST, which is rare in adulthood, and use of long-acting benzodiazepine based on two cases.

Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder

The clinical spectrum of sleep disorders in children is broad, ranging from primary snoring and obstructive sleep apnea (OSA) syndrome to complex sleep-related behaviors and movement disorders. Although snoring and OSA typically receive significant attention and discussion, other biologically based sleep disorders are as common, if not more common, in children. A general pediatrician is frequently presented with the complaint of sleep talking, sleep walking, or abnormal movements during sleep. Even more alarming is the presentation of the child suddenly and explosively screaming during sleep. Such complaints fall under the category of parasomnias. Exclusive to sleep and wake-to-sleep transitions, these parasomnias include arousals with abnormal motor, behavioral, autonomic, or sensory symptoms. Parasomnias can be noticeably dissimilar in clinical manifestations, but most share biologic characteristics. Three parasomnias associated with loud vocalizations associated with sleep that can present to general practitioners include sleep terrors, nightmares, and rapid eye movement sleep behavior disorder (RBD). Although usually benign, these sleep disorders can be disruptive and even potentially dangerous to the patient and can often be threatening to quality of life. In this article, we describe the clinical features of some of these disorders and how to differentiate between their alarming presentations.

Risperidone for Night Terrors and Sleepwalking in an Adult: A Case Report

Objective:

To report the successful treatment of a case of night terrors and sleepwalking in an adult using low-dose risperidone.

Case Summary:

A 30-year-old female with a history of nightmares as a teen, but with no prior psychiatric history, presented with new-onset night terrors and sleepwalking related to psychosocial stressors. She recalled images of being chased by monsters and of people trying to hurt her. Sleepwalking sometimes involved self-injurious behavior, as she ran through the house screaming. Intake diagnoses included general anxiety disorder (GAD), obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). She reported compulsive counting since childhood and episodes of compulsive eating. Risperidone 1 mg was started and eventually titrated to 2 mg at night for night terror and sleepwalking suppression. For GAD, OCD, and OCPD, paroxetine 10 mg was started and titrated to 50 mg. Temazepam 30 mg was added to prolong sleep and cyproheptadine 4 mg was prescribed for anorgasmia. Symptoms were well controlled with the medications for about 8 months. The patient chose to stop the paroxetine and temazepam on day 655, but continued to take risperidone 2 mg for approximately 45 days. When she discontinued the risperidone, the night terrors and sleepwalking returned within 3 days.

Discussion:

Low-dose risperidone has been shown to modulate combat posttraumatic stress disorder nightmares. Its effectiveness for night terrors and sleepwalking has not been reported. In this case, risperidone was the sole medication suppressing night terrors and sleepwalking for a month and a half. As found in previous studies, 2 mg of risperidone seemed to be the optimal dose.

Conclusions:

Risperidone dosed at 1–2 mg at night may be a pharmacologic alternative for the symptoms of sleep terrors with sleepwalking.

Sleep medicine pharmacotherapeutics overview: today, tomorrow, and the future (part 2: hypersomnia, parasomnia, and movement disorders)

Over the past 10 years, significant strides have been made in therapeutics for sleep disorders. In this second installment of a two-part review series, we discuss the current evidence surrounding the mechanisms of actions, indications, efficacy, and adverse side effects associated with the current over-the-counter and pharmacotherapeutics for hypersomnia, parasomnias, and movement disorders of sleep.