Treatment options for parasomnias

Parasomnias During the COVID-19 Pandemic

COVID-19 had a massive impact on sleep, resulting in overall increase of sleep disturbances. During lockdown many factors contributed to sleep disturbances, in particular changes in sleep-wake habits and stress. This article will describe the frequency and features of the principal parasomnias and the impact of the pandemic and the government restriction measures on sleep. Among different pathophysiological hypotheses, we will discuss the role of stress, considered as an expression of the allostatic load. Finally, during the pandemic, parasomnias were mainly investigated by questionnaires, with controversial results; video-polysomnographic studies are crucial to obtain a definitive diagnosis, even in critical conditions.

Somnambulism

Somnambulism, also called sleepwalking, classified as a non-rapid eye movement sleep parasomnia, encompasses a range of abnormal paroxysmal behaviors, leading to sleepwalking in dissociated sleep in an altered state of consciousness with impaired judgment and configuring a kind of hierarchical continuum with confusional arousal and night terror. Despite being generally regarded as a benign condition, its potential severity entails social, personal, and even forensic consequences. This comprehensive review provides an overview on the current state of knowledge, elucidating the phenomenon of somnambulism and encompassing its clinical manifestations and diagnostic approaches.

Diagnosis and Management of NREM Sleep Parasomnias in Children and Adults

Non-rapid eye movement (NREM) sleep parasomnias are recurrent abnormal behaviors emerging as incomplete arousals out of NREM sleep. Mounting evidence on NREM sleep parasomnias calls for an update of clinical and therapeutical strategies. In the current review, we summarize the state of the art and provide the necessary background to stimulate a critical revision of diagnostic criteria of disorders of arousal (DoA), the most common NREM sleep parasomnia. In particular, we highlight the poor sensitivity of the diagnostic items related to amnesia and absence of conscious experiences during DoA episodes, encourage the role of video-polysomnography and home-video recordings in the diagnostic and treatment work-up, and suggest three levels of diagnostic certainty based on clinical and objective findings. Furthermore, we highlight current gaps of knowledge that prevent the definition of standard guidelines and future research avenues.

Drugs Used in Parasomnia

Parasomnias, especially disorders of arousal during childhood, are often relatively benign and transitory and do not usually require a pharmacologic therapy. A relevant aspect in both nonrapid eye movement and rapid eye movement parasomnia treatment is to prevent sleep-related injuries by maintaining a safe environment. Physicians should always evaluate the possible presence of favoring and precipitating factors (sleep disorders and drugs). A pharmacologic treatment may be indicated in case of frequent, troublesome, or particularly dangerous events. The aim of this article is to review current available evidence on pharmacologic treatment of different forms of parasomnia.

Relative frequency of drug-induced sleep disorders for 32 antidepressants in a large set of Internet user reviews

STUDY OBJECTIVES

It is known that antidepressant drugs can induce sleep disorders in patients, but little data exist about high or low-risk molecules. The aim was to study the frequency of antidepressant drugs-induced sleep disorders (DISD) by molecule.

METHODS

77,391 patient comments for 32 antidepressant drugs were collected from drug review websites and screened for DISD. Association between drugs and nightmare disorder, restless legs syndrome, sleep paralysis, sleep terrors, sleep-related hallucinations or sleep walking was expressed as relative proportion [proportional reporting ratio (PRR)]. A detailed analysis of the dreams content was also carried out.

RESULTS

Amitriptyline, doxepin, fluvoxamine, mirtazapine, nortriptyline, trazodone, venlafaxine and vilazodone were associated with a greater frequency of DISD compared to other antidepressants. Vilazodone heavily increased the probability of developing 5 of the 6 studied DISD (PRR 3.3 to 19.3) and mirtazapine increased the probability for developing 4 DISD (PRR 2.4 to 6.4). Bupropion and citalopram were associated with lower probabilities for 5 DISD (PRR 0.2 to 0.7). Sentiment analysis showed that patients described disturbing dreams for vilazodone or mirtazapine and strange but less negative dreams for bupropion, citalopram or duloxetine.

CONCLUSIONS

Relative frequencies of sleep disorders were obtained for a vast panel of antidepressant drugs through an original analysis of user's drug reviews on drug rating websites. Our results could guide clinicians in appropriate choice of antidepressant drug for high DISD-risk patients in need of such treatment. These results may however be cautiously taken, considering the uncertain reliability and generalisability of web-based data.

Drugs Used in Parasomnia

Patient education and behavioral management represent the first treatment approaches to the patient with parasomnia, especially in case of disorders of arousal (DOA). A pharmacologic treatment of DOA may be useful when episodes are frequent and persist despite resolution of predisposing factors, are associated with a high risk of injury, or cause significant impairment, such as excessive sleepiness. Approved drugs for DOA are still lacking. The most commonly used medications are benzodiazepines and antidepressants. The pharmacologic treatment of rapid eye movement sleep behavior disorder is symptomatic, and the most commonly used drugs are clonazepam and melatonin.

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.

Behavioural and Cognitive-Behavioural Treatments of Parasomnias

Parasomnias are unpleasant or undesirable behaviours or experiences that occur predominantly during or within close proximity to sleep. Pharmacological treatments of parasomnias are available, but their efficacy is established only for few disorders. Furthermore, most of these disorders tend spontaneously to remit with development. Nonpharmacological treatments therefore represent valid therapeutic choices. This paper reviews behavioural and cognitive-behavioural managements employed for parasomnias. Referring to the ICSD-3 nosology we consider, respectively, NREM parasomnias, REM parasomnias, and other parasomnias. Although the efficacy of some of these treatments is proved, in other cases their clinical evidence cannot be provided because of the small size of the samples. Due to the rarity of some parasomnias, further multicentric researches are needed in order to offer a more complete account of behavioural and cognitive-behavioural treatments efficacy.

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.

Use of topiramate in pregnancy and risk of oral clefts

OBJECTIVE

The objective of this study was to evaluate the association between the use of monotherapy topiramate in pregnancy and cleft lip with or without cleft palate (CL/P) in the offspring.

STUDY DESIGN

Data from the Slone Epidemiology Center Birth Defects Study (BDS) from 1997 to 2009 and the National Birth Defects Prevention Study (NBDPS) from 1997 to 2007 were analyzed. Conditional logistic regression was used to compare the first-trimester use of topiramate monotherapy to no antiepileptic drug use during the periconceptional period between the mothers of infants with CL/P and the mothers of controls for each study separately and in pooled data.

RESULTS

The BDS contained 785 CL/P cases and 6986 controls; the NBDPS contained 2283 CL/P cases and 8494 controls. The odds ratios (exact 95% confidence intervals) for the association between topiramate use and CL/P were 10.1 (1.1-129.2) in the BDS, 3.6 (0.7-20.0) in the NBDPS, and 5.4 (1.5-20.1) in the pooled data.

CONCLUSION

First-trimester use of topiramate may be associated with CL/P.

Management of post-traumatic nightmares: a review of pharmacologic and nonpharmacologic treatments since 2010

Nightmares are a universal and timeless phenomenon. They occur in most healthy adults as well as a significant portion of clinical populations, especially those exposed to trauma. Considerable advances in the pharmacological and psychological treatment of post-traumatic nightmares have occurred over the last decade with continuing advances in psychological interventions over the last few years. Pharmacologically, the medication prazosin is showing robust clinical effects with minimal side effects. Psychologically, imagery rehearsal therapy commands the greater portion of the nightmare literature due to its established efficacy. These issues are reviewed in the following paper along with recommendations for future studies.

Pediatric sleep pharmacology

This article reviews common sleep disorders in children and pharmacologic options for them. Discussions of pediatric sleep pharmacology typically focus on treatment of insomnia. Although insomnia is a major concern in this population, other conditions of concern in children are presented, such as narcolepsy, parasomnias, restless legs syndrome, and sleep apnea.

Differentiation of subgroups of monosymptomatic enuresis according to prepulse inhibition of the startle reflex

AIM

Monosymptomatic enuresis (ME) is a common disorder in children with serious social and psychological consequences. Treatment is usually initiated with desamino-arginine vasopressin (dDAVP) and/or alarm therapy as first-line treatment and imipramine as second-line. All treatments have proven efficacy, but are not successful with all patients. Therefore, a differentiation into subgroups according to treatment efficacy would be beneficial.

METHODS

A group of patients resistant to first-line treatment was treated with imipramine and compared with matched controls successfully treated with dDAVP and/or alarm therapy. Prepulse inhibition (PPI) to acoustic startle reflexes was measured in all patients.

RESULTS

In a group of 23 nonresponders, the median PPI was 72% (range 43-94%) compared with the matched dDAVP/alarm - responders with a median PPI of 26% (range 0-61%) (p < 0.0001). The response rate to imipramine was 87%.

CONCLUSION

The presented data provide evidence that PPI allows to identify two subgroups of ME. The results offer further insight into (at least) two different pathomechanisms involved in ME: (i) a maturational delay of reflex inhibition with reduced PPI and (ii) a normal PPI, possibly with abnormal sleep patterns, that can be influenced by imipramine.