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Mundt JM, Schuiling MD, Warlick C, Dietch JR, Wescott AB, Hagenaars M, Furst A, Khorramdel K, Baron KG. Behavioral and psychological treatments for NREM parasomnias: A systematic review. Sleep Med 2023; 111:36-53. [PMID: 37716336 PMCID: PMC10591847 DOI: 10.1016/j.sleep.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/01/2023] [Accepted: 09/04/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Non-rapid eye movement (NREM) parasomnias are often benign and transient, requiring no formal treatment. However, parasomnias can also be chronic, disrupt sleep quality, and pose a significant risk of harm to the patient or others. Numerous behavioral strategies have been described for the management of NREM parasomnias, but there have been no published comprehensive reviews. This systematic review was conducted to summarize the range of behavioral and psychological interventions and their efficacy. METHODS We conducted a systematic search of the literature to identify all reports of behavioral and psychological treatments for NREM parasomnias (confusional arousals, sexsomnia, sleepwalking, sleep terrors, sleep-related eating disorder, parasomnia overlap disorder). This review was conducted in line with PRISMA guidelines. The protocol was registered with PROSPERO (CRD42021230360). The search was conducted in the following databases (initially on March 10, 2021 and updated February 24, 2023): Ovid (MEDLINE), Cochrane Library databases (Wiley), CINAHL (EBSCO), PsycINFO (EBSCO), and Web of Science (Clarivate). Given a lack of standardized quantitative outcome measures, a narrative synthesis approach was used. Risk of bias assessment used tools from Joanna Briggs Institute. RESULTS A total of 72 publications in four languages were included, most of which were case reports (68%) or case series (21%). Children were included in 32 publications and adults in 44. The most common treatment was hypnosis (33 publications) followed by various types of psychotherapy (31), sleep hygiene (19), education/reassurance (15), relaxation (10), scheduled awakenings (9), sleep extension/scheduled naps (9), and mindfulness (5). Study designs and inconsistent outcome measures limited the evidence for specific treatments, but some evidence supports multicomponent CBT, sleep hygiene, scheduled awakenings, and hypnosis. CONCLUSIONS This review highlights the wide breadth of behavioral and psychological interventions for managing NREM parasomnias. Evidence for the efficacy of these treatments is limited by the retrospective and uncontrolled nature of most research as well as the infrequent use of validated quantitative outcome measures. Behavioral and psychological treatments have been studied alone and in various combinations, and recent publications suggest a trend toward preference for multicomponent cognitive behavioral therapies designed to specifically target priming and precipitating factors of NREM parasomnias.
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Affiliation(s)
- Jennifer M Mundt
- Department of Neurology, Northwestern University Feinberg School of Medicine, Abbott Hall 11th Floor, 710 N Lake Shore Drive, Chicago, IL, 60611, USA; Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, USA.
| | - Matthew D Schuiling
- Department of Psychology, Indiana University-Purdue University Indianapolis, 402 N. Blackford St., LD 119, Indianapolis, IN, 46202, USA.
| | - Chloe Warlick
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 710 N Lake Shore Drive, Chicago, IL, 60611, USA.
| | - Jessica R Dietch
- School of Psychological Science, Oregon State University, 2950 SW Jefferson Way, Corvallis, OR, 97331, USA.
| | - Annie B Wescott
- Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL, 60611, USA.
| | - Muriel Hagenaars
- Department of Clinical Psychology, Utrecht University, Heidelberglaan 1, 3584 CS, Utrecht, Netherlands.
| | - Ansgar Furst
- War Related Illness and Injury Study Center, VA Palo Alto Health Care System, 3801 Miranda Ave, Mailcode 151Y, Palo Alto, CA, 94304, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, USA; Department of Neurology and Neurological Sciences, Stanford University School of Medicine, USA; Polytrauma System of Care, VA Palo Alto Health Care System, USA.
| | - Kazem Khorramdel
- Department of Psychology and Education Science, Shiraz University, Shiraz, Fars, 71345, Iran.
| | - Kelly G Baron
- Department of Family and Preventive Medicine, University of Utah, 375 Chipeta Way Suite A, Room 142, Salt Lake City, UT, 84108, USA.
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Mainieri G, Loddo G, Provini F, Nobili L, Manconi M, Castelnovo A. Diagnosis and Management of NREM Sleep Parasomnias in Children and Adults. Diagnostics (Basel) 2023; 13:diagnostics13071261. [PMID: 37046480 PMCID: PMC10093221 DOI: 10.3390/diagnostics13071261] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
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.
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Walsh C, Mitchell L, Hrozanova M, Kotoulas SC, Derry C, Morrison I, Riha RL. NREM Sleep Parasomnias Commencing in Childhood: Trauma and Atopy as Perpetuating Factors. Clocks Sleep 2022; 4:549-560. [PMID: 36278536 PMCID: PMC9624320 DOI: 10.3390/clockssleep4040043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 12/03/2022] Open
Abstract
Objective/Background: Phenotyping of non-rapid-eye-movement (NREM) parasomnias is currently poorly undertaken. This study aimed to determine whether there are differences phenotypically among childhood-, adolescent-, and adult-onset NREM parasomnias continuing into and presenting in adulthood. Patients/Methods: A retrospective, cohort study of patients presenting with NREM parasomnia between 2008 and 2019 (n = 307) was conducted. Disorders included sleepwalking (n = 231), night terrors (n = 150), sexualised behaviour in sleep (n = 50), and sleep-related eating disorder (n = 28). Results: Compared to the adult-onset NREM behaviours group, the childhood- and adolescent-onset groups were more likely to have a family history of NREM behaviours (p < 0.001), experience a greater spectrum of NREM disorders (p = 0.001), and report a history of sleep-talking significantly more frequently (p = 0.014). Atopy was most prevalent in the childhood-onset group (p = 0.001). Those with childhood-onset NREM parasomnias were significantly more likely to arouse from N3 sleep on video polysomnography (p = 0.0003). Psychiatric disorders were more likely to be comorbid in the adult-onset group (p = 0.012). A history of trauma coinciding with onset of NREM behaviours was significantly more common in the childhood- and adolescent-onset groups (p < 0.001). Conclusions: Significant differences exist across childhood-, adolescent-, and adult-onset NREM parasomnia presenting in adulthood. This study suggests that adult-onset slow-wave sleep disorders may be confounded by psychiatric disorders resulting in nocturnal sleep disruption and that unresolved traumatic life experiences perpetuate NREM disorders arising in childhood and comprise one of the strongest external risk factors for triggering and perpetuating these disorders in adolescence.
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Affiliation(s)
- Cara Walsh
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
| | - Lee Mitchell
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
| | - Maria Hrozanova
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
| | - Serafeim-Chrysovalantis Kotoulas
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
| | - Christopher Derry
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
| | - Ian Morrison
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
- Department of Neurology, Ninewells Hospital, Dundee DD1 9SY, Scotland, UK
| | - Renata L. Riha
- Sleep Research Unit, Department of Sleep Medicine, The University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, UK
- Correspondence: ; Tel.: +131-242-3872
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Ntafouli M, Galbiati A, Gazea M, Bassetti CLA, Bargiotas P. Update on nonpharmacological interventions in parasomnias. Postgrad Med 2019; 132:72-79. [PMID: 31760836 DOI: 10.1080/00325481.2019.1697119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Maria Ntafouli
- Sleep Wake Epilepsy Center and Department of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Andrea Galbiati
- Faculty of Psychology, "Vita-Salute" San Raffaele University, Milan, Italy.,Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mary Gazea
- Centre for experimental Neurology, Dept. of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland.,Department of Biomedical Research (DBMR), Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Claudio L A Bassetti
- Sleep Wake Epilepsy Center and Department of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland
| | - Panagiotis Bargiotas
- Sleep Wake Epilepsy Center and Department of Neurology, Inselspital University Hospital, University of Bern, Bern, Switzerland.,Department of Neurology, Medical School, University of Cyprus, Nicosia, Cyprus
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Castelnovo A, Lopez R, Proserpio P, Nobili L, Dauvilliers Y. NREM sleep parasomnias as disorders of sleep-state dissociation. Nat Rev Neurol 2019; 14:470-481. [PMID: 29959394 DOI: 10.1038/s41582-018-0030-y] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Non-rapid eye movement (NREM) sleep parasomnias (or NREM parasomnias) are fascinating disorders with mysterious neurobiological substrates. These conditions are common and often severe, with social, personal and forensic implications. The NREM parasomnias include sleepwalking, sleep terrors and confusional arousals - collectively termed disorders of arousal (DOAs) - as well as less well-known entities such as sleep-related sexual behaviours and eating disorders. Affected patients can exhibit waking behaviours arising abruptly out of NREM sleep. Although the individual remains largely unresponsive to the external environment, their EEG shows both typical sleep-like and wake-like features, and they occasionally report dreaming afterwards. Therefore, these disorders offer a unique natural model to explore the abnormal coexistence of local sleep and wake brain activity and the dissociation between behaviour and various aspects of consciousness. In this article, we critically review major findings and updates on DOAs, focusing on neurophysiological studies, and offer an overview of new clinical frontiers and promising future research areas. We advocate a joint effort to inform clinicians and the general public about the management and follow-up of these conditions. We also strongly encourage collaborative multicentre studies to add more objective polysomnographic criteria to the current official diagnostic definitions and to develop clinical practice guidelines, multidisciplinary research approaches and evidence-based medical care.
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Affiliation(s)
- Anna Castelnovo
- Center for Sleep and Consciousness, Department of Psychiatry, University of Wisconsin-Madison, Madison, WI, USA.,Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - Régis Lopez
- Reference National Center for Narcolepsy-Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France
| | - Paola Proserpio
- Claudio Munari Center for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Lino Nobili
- Claudio Munari Center for Epilepsy Surgery, Niguarda Hospital, Milan, Italy. .,Department of Neuroscience, DINOGMI, University of Genoa, Genoa, Italy.
| | - Yves Dauvilliers
- Reference National Center for Narcolepsy-Hypersomnia, Sleep Unit, Department of Neurology, Gui-de-Chauliac Hospital, CHU Montpellier, Montpellier, France.
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[Psychoanalytic therapy for a child with somnambulism: a case report]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2019; 39:505-507. [PMID: 31140411 PMCID: PMC6743939 DOI: 10.12122/j.issn.1673-4254.2019.05.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Somnambulism is defined as a state of dissociated consciousness triggered by impaired arousal, which results in partial wakefulness and partial sleep. No effective therapy or medication has been available for treating children with somnambulism. Herein we present a case in a 4.5-year-old girl, who presented with somnambulism associated with separation anxiety disorder every night in a week. The girl received formal assessment and appropriate interventions, and the symptoms disappeared within a week. The treatment was carried out in 5 stages: diagnosis of the disease, establishment of trust, information collection, supervision, and individualized psychotherapy. Although dreams in childhood can be difficult to interpret, close observation of the behaviors in sleepwalking, as a special form of dream, in addition to the more precise description by the guardians, still provides useful clues to understand those dreams. For children with somnambulism, early intervention with psychotherapy can significantly decrease the false revival of the unconscious desires, and thus may serve as a treatment option other than medications.
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McRae L. Blaming rape on sleep: A psychoanalytic intervention. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2019; 62:135-147. [PMID: 30616848 DOI: 10.1016/j.ijlp.2018.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 06/09/2023]
Abstract
The governance of sleep sex (or sexsomnia) in the criminal law is a nightmare. Press reports of sleeping, often drunk, men acquitted as automatons of raping adults and children suggest cases are rising. The use of automatism, rather than insanity, in these cases is strong evidence of the immemorial struggle faced by legal psychiatry in appropriately construing unconscious defendants. This paper responds by drawing on well-established psychoanalytic conceptions of unconsciousness to present sexsomnia as dispositional to the defendant. Taking the Freudian concepts of eros and death instinct, it asserts that sexsomniacs are acting on repressed sadistic desires. Accordingly, those on notice of their sexsomnia, who fail to mitigate the risk of further attacks, should be guilty of rape. Reliance on (a reformed) insanity defence - being a denial of responsibility at the time of the offence - undermines the scope of the criminal law to self-responsibilise sexsomniacs against perpetrating unwanted sex.
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Affiliation(s)
- Leon McRae
- School of Law, Keele University, Staffordshire ST5 5GB, United Kingdom.
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Abstract
Our understanding of non-rapid eye movement (NREM) parasomnias has improved considerably over the last two decades, with research that characterises and explores the causes of these disorders. However, our understanding is far from complete. The aim of this paper is to provide an updated review focusing on adult NREM parasomnias and highlighting new areas in NREM parasomnia research from the recent literature. We outline the prevalence, clinical characteristics, role of onset, pathophysiology, role of predisposing, priming and precipitating factors, diagnostic criteria, treatment options and medico-legal implications of adult NREM parasomnias.
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Frange C, Banzoli CV, Colombo AE, Siegler M, Coelho G, Bezerra AG, Csermak M, Naufel MF, Cesar-Netto C, Andersen ML, Girão MJBC, Tufik S, Hachul H. Women's Sleep Disorders: Integrative Care. ACTA ACUST UNITED AC 2017; 10:174-180. [PMID: 29410750 PMCID: PMC5760052 DOI: 10.5935/1984-0063.20170030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The integrative care model is rooted in a biopsychosocial approach. Integrative
is a term which refers to increasing the harmony and coherence of your whole
being, and integrative care is therefore focused on the person, not on either
the disease or a therapy. It is provided collaboratively by a health team
comprising physicians, psychologists, physiotherapists, acupuncturists, and
meditation, nutrition, and floral therapy. Previous studies have demonstrated
that interventions based on the integrative care model improved womens lifestyle
and quality of life. Our aim was to describe the use of complementary and
alternative medicine (CAM) alongside traditional medicine among women with sleep
conditions in our Womens Sleep Disorders Integrative Treatment Outpatient
Clinic. We are sharing our experiences and clinical practice as the model we
developed seems to have both physical and psychological benefits for women with
sleep problems. We discuss the wide range of benefits that result from this type
of complex intervention, and the contextual factors that may influence these
benefits. This will inform future practitioners and we hope to contribute to
quantitative research in the clinical setting. The study highlights the
importance of treating sleep complaints with a caring relationship and a CAM
approach, alongside conventional medicine. Exploration of the lived experience
of CAM and its meaning enables healthcare professionals to gain insights into
the patients needs, preferences, and values. Gynecologists, clinicians, and
health care providers should support and guide patients in their decision to use
CAM by providing evidence-based and comprehensive advice on the potential
benefits, risks and related safety issues of this approach.
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Affiliation(s)
- Cristina Frange
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | | | - Ana Elisa Colombo
- Universidade Federal de São Paulo, Department Gynecology - São Paulo - SP - Brazil
| | - Marcele Siegler
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | - Glaury Coelho
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | - Andréia Gomes Bezerra
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | - Marcelo Csermak
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | | | - Cristiana Cesar-Netto
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | - Monica Levy Andersen
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | | | - Sergio Tufik
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil
| | - Helena Hachul
- Universidade Federal de São Paulo, Departament Psychobiology - São Paulo - SP - Brazil.,Universidade Federal de São Paulo, Department Gynecology - São Paulo - SP - Brazil
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Behavioural and Cognitive-Behavioural Treatments of Parasomnias. Behav Neurol 2015; 2015:786928. [PMID: 26101458 PMCID: PMC4458546 DOI: 10.1155/2015/786928] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/12/2015] [Indexed: 11/17/2022] Open
Abstract
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.
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Bušková J, Sonka K. Adult NREM parasomnia associated with lancinating throat pain. J Clin Sleep Med 2014; 10:925-6. [PMID: 25126041 DOI: 10.5664/jcsm.3974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We report the case of a 30-year-old woman presenting with dangerous nocturnal NREM episodes with the clinical feature of lancinating throat pain. We hypothesize that the pain may have represented sensory hallucination analogous to commonly recognized visual images associated with NREM parasomnias. This case is also unusual for probable psychological triggers that could play a role in the pathogenesis of the disease, as evidenced by successful psychotherapy.
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Affiliation(s)
- Jitka Bušková
- Sleep Disorders Center, Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Karel Sonka
- Sleep Disorders Center, Department of Neurology and Center of Clinical Neuroscience, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
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