A scale for assessing the severity of arousal disorders

Treating narcolepsy-related nightmares with cognitive behavioural therapy and targeted lucidity reactivation: A pilot study

Nightmares are a common symptom in narcolepsy that has not been targeted in prior clinical trials. This study investigated the efficacy of Cognitive Behavioural Therapy for Nightmares (CBT-N), adapted for narcolepsy, in a small group of adults. Given the high prevalence of lucid dreaming in narcolepsy, we added a promising adjuvant component, targeted lucidity reactivation (TLR), a procedure designed to enhance lucid dreaming and dream control. Using a multiple baseline single-case experimental design, adults with narcolepsy and frequent nightmares (≥3/week, N = 6) were randomised to a 2 or 4 week baseline and received seven treatment sessions (CBT-N or CBT-N + TLR). Across the groups, there was a large effect size (between-case standardised mean difference [BC-SMD] = -0.97, 95% CI -1.79 to -0.14, p < 0.05) for reduced nightmare frequency from baseline (M = 8.38/week, SD = 7.08) to posttreatment (M = 2.25/week, SD = 1.78). Nightmare severity improved significantly with large effect sizes on sleep diaries (BC-SMD = -1.14, 95% CI -2.03 to -0.25, p < 0.05) and the Disturbing Dream and Nightmare Severity Index (z = -2.20, p = 0.03, r = -0.64). Treatment was associated with a reduction for some participants in sleep paralysis, sleep-related hallucinations, and dream enactment. NREM parasomnia symptoms (z = -2.20, p = 0.03, r = -0.64) and self-efficacy for managing symptoms (z = -2.02, p = 0.04, r = -0.58) improved significantly with large effect sizes. Participants who underwent TLR (n = 3) all recalled dreams pertaining to their rescripted nightmare. In interviews, participants noted reduced shame and anxiety about sleep/nightmares. This study provides a proof of concept for the application of TLR as a therapeutic strategy with clinical populations, as well as preliminary evidence for the efficacy of CBT-N in treating narcolepsy-related nightmares.

Conscious experiences during non-rapid eye movement sleep parasomnias

Disorders of Arousal (DOA) are non-rapid eye movement (NREM) parasomnias traditionally regarded as unconscious states. However, recent research challenges this assumption. This narrative review aims to explore the presence and qualitative features of conscious experiences in patients with DOA during their episodes. The literature indicates a higher recall of conscious experiences during DOA episodes than previously believed, estimated at about 50-60 % in adults (immediately post-episode). Data on children are limited but suggest a lower recall rate (<30 % when interviewed retrospectively). Patient reports range from brief scenic fragments to elaborate scenarios with plot development, often fraught with negative emotions and misfortunes and with considerable correspondence between subjective experiences and observed behaviors. In many of the described cases, patients appear to enact their dreams, entering a hallucinatory state where internally generated images overlay external percepts. The potential implications for clinical management, research endeavors, and legal considerations regarding nocturnal violence, along with existing limitations and controversial points, are discussed.

Latency to N3 interruption in arousal disorders

STUDY OBJECTIVES

To help expert witnesses in criminal cases using the "sleepwalking defense," we studied the time of first and last interruptions from stage N3 in patients with arousal disorders, including sexsomnia, as well as their determinants.

METHODS

The epochs of lights off, sleep onset, first N3 interruption (with and without behaviors), and last N3 interruption were determined by videopolysomnography on two consecutive nights in 163 adults with disorders of arousal, including 46 with and 117 without sexsomnia.

RESULTS

The first N3 interruption (independently of concomitant behavior) occurred as early as 8 minutes after sleep onset and within 100 minutes of falling asleep in 95% of cases. The first motor arousal from N3 occurred as early as 25 minutes after lights off time, a timing more variable between participants (between 30 and 60 minutes after lights off time in 25% of participants and within 60 minutes of falling asleep in 50%). These latencies did not differ between the groups with and without sexsomnia. No correlation was found between these latencies and the young age, sex, or clinical severity. The latency of motor arousals was shorter when they were associated with a fast-wave EEG profile and were not preceded by another type of N3 arousal.

CONCLUSIONS

The first motor arousal may occur early in the night in patients with arousal disorders, with or without sexsomnia, suggesting that abnormal behaviors occurring as early as 25 minutes after lights off time in clinical and criminal cases can be a parasomnia manifestation.

Brief Psychoeducational and Cognitive Therapy for Nightmare Disorder (BPCT-ND)

In adults, nightmare disorder is related to sleep deprivation, drug consumption or abuse, or other comorbid sleep disorders such as insomnia or insufficient sleep syndrome. Behavioral treatment has solid scientific evidence in disorders such as insomnia and, more recently, parasomnias. The aim of the present study was to investigate the clinical effectiveness of a Brief Behavioral Telemedicine Therapy in Nightmare Disorder in a 23-year-old female patient. The procedure consisted of the case study, with pre and posttreatment measures as well as follow-up after 1 month; and the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Paris Arousal Disorders Severity Scale, and a sleep diary were applied. In parallel with changes recorded in the sleep diary, a decrease in nightmares, sleepiness, and insomnia symptoms was observed when the intervention was finished. The behavioral intervention was clinically effective; therefore, the present case report provides information on behavioral treatments for nightmare disorder.

Current evidence and future perspectives in the exploration of sleep-related eating disorder-a systematic literature review

Sleep-related eating disorder (SRED) is a non-REM parasomnia with potentially significant negative effects on general health (dangerous activities during night eating episodes, obesity, or metabolic syndrome, for example). Although the history of SRED encompasses more than six decades, public awareness and even the awareness of the mental health specialists of this disorder is very limited, a phenomenon that hinders the development of research in this field. Therefore, a systematic review based on PRISMA 2020 guidelines explored the available evidence for SRED found in four electronic databases (PubMed, Cochrane Collaboration, Google Scholar, and Clarivate/Web of Science). A number of 94 primary and secondary reports were retrieved, investigating aspects regarding the risk factors, epidemiology, clinical data and differential diagnosis, epidemiology, structured evaluation, and treatment of SRED. Based on the results of these reports, Z-drugs, but also certain benzodiazepines, antidepressants, antipsychotics, and psychostimulants may trigger the onset of SRED. Psychiatric and neurologic disorders have also been associated with SRED, either as risk factors or comorbid conditions. Cerebral glucose metabolism dysfunctions, neurotransmitter dysfunctions, and genetic factors have been invoked as pathogenetic contributors. Structured assessment of SRED is possible, but there is a dearth of instruments dedicated to this purpose. Data on the prevalence and treatment of SRED exist, but good-quality epidemiological studies and clinical trials are still missing. In conclusion, future research is expected to address the shortcomings of SRED exploration by creating the conditions for better quality and larger group clinical research. The need for such investigation is granted by the importance of this pathology and its negative functional consequences.

Temporal dynamics of awakenings from slow-wave sleep in non-rapid eye movement parasomnia

Non-rapid eye movement parasomnia disorders, also called disorders of arousal, are characterized by abnormal nocturnal behaviours, such as confusional arousals or sleep walking. Their pathophysiology is not yet fully understood, and objective diagnostic criteria are lacking. It is known, however, that behavioural episodes occur mostly in the beginning of the night, after an increase in slow-wave activity during slow-wave sleep. A better understanding of the prospect of such episodes may lead to new insights in the underlying mechanisms and eventually facilitate objective diagnosis. We investigated temporal dynamics of transitions from slow-wave sleep of 52 patients and 79 controls. Within the patient group, behavioural and non-behavioural N3 awakenings were distinguished. Patients showed a higher probability to wake up after an N3 bout ended than controls, and this probability increased with N3 bout duration. Bouts longer than 15 min resulted in an awakening in 73% and 34% of the time in patients and controls, respectively. Behavioural episodes reduced over sleep cycles due to a reduction in N3 sleep and a reducing ratio between behavioural and non-behavioural awakenings. In the first two cycles, N3 bouts prior to non-behavioural awakenings were significantly shorter than N3 bouts advancing behavioural awakenings in patients, and N3 awakenings in controls. Our findings provide insights in the timing and prospect of both behavioural and non-behavioural awakenings from N3, which may result in prediction and potentially prevention of behavioural episodes. This work, moreover, leads to a more complete characterization of a prototypical hypnogram of parasomnias, which could facilitate diagnosis.

Parasomnias manifest different phenotypes of sleep-related behaviors in age and sex groups. A YouTube-based video research highlighting the age slope of sleepwalking

STUDY OBJECTIVE

Finding typical patterns - phenotypes - of sleep behaviors characterizing parasomnias in different age and sex groups.

METHODS

We analyzed YouTube videos on sleep-related behaviors likely representing parasomnias. We applied the search terms "sleepwalking", "somnambulism", "sleep eating" "sleep sex", "sleep talking" and "aggression in sleep" in six languages. We classified those persons shown on the videos into estimated biological sex and age (child, adult, elderly) groups. We scored the activity types by a self-made scale and applied binary logistic regression to analyze the association between sleep behaviors versus sex and age groups by the STATA package, providing a 95 % confidence interval and the probability of statistical significance.

RESULTS

224 videos (102 women; 68 children, 116 adults, and 40 elderly people) were scored. Elderly people had significantly (P < 0.012) less odds of ambulation in sleep likely consistent with somnambulism compared to adults and children. Adult females performed complex manual activities during sleepwalking more often, than males (P < 0.012). Elderly males had 40-fold odds compared to adults and children, to perform aggressive movements and 70-fold odds of complex movements in bed, compared to adults. Elderly people presented emotional behaviors less frequently than adults (P < 0.004), and females showed them twice as often as males. Adults sleep-talked full sentences more often than children and elderly people (P < 0.001).

CONCLUSION

Our results support the existence of age- and sex-specific parasomnia phenotypes, denoting possible safety measures. The remarkably low odds of sleepwalking in the elderly highlight the possibility of different pathomechanisms in higher age groups compared to children.

Understanding Sexual Parasomnias: A Review of the Current Literature on Their Nature, Diagnosis, Impacts, and Management

Sexual behavior during sleep, known as sexual parasomnias, has captured the interest of researchers and clinicians. These parasomnias involve various sexual activities that occur unconsciously during sleep. Although relatively rare, they can profoundly affect well-being and relationships and can carry legal consequences. Understanding their nature, prevalence, and causes is crucial for advancing knowledge in this field. This article revisits the topic of sexsomnia, presenting new data and discussing cases published from 2007 to 2023. By analyzing these cases, we aim to enhance recognition, diagnosis, and management of sexsomnia, reducing stigma and providing better support for affected individuals.

Sleep Terrors

Sleep terrors, categorized under disorders of arousal, more prevalent in pediatric population, generally are self-limited but sometimes can persist or occur in adulthood. These are primed by factors enhancing homeostatic drive on backdrop of developmental predisposition and are precipitated by factors increasing sleep fragmentation resulting in dissociated state of sleep with some cerebral regions showing abnormal slow wave activity and others fast activity. This phenotypically evolves into abrupt partial arousal with individual arousing from N3 or N2 sleep with behaviors representing intense fear such as crying with autonomic hyperactivity. There is no recollection of the event, and lack of vivid dream mentation although fragmented imagery may be noted. Behavioral management is of prime importance including addressing precipitating factors, family reassurance, safety measures, and scheduled awakenings. Pharmacologic agents such as clonazepam and antidepressants are used infrequently in case of disruptive episodes.

Challenges in diagnosing NREM parasomnias: Implications for future diagnostic classifications

NREM parasomnias are frequent and potentially disabling sleep disorders characterized by recurrent abnormal behaviors emerging from NREM sleep. Recently, several studies provided more detailed clinical and polysomnographic characterization of NREM parasomnia which may enhance the diagnostic process. Several revisions of the diagnostic criteria have been proposed in the classification of sleep disorders, the latest being ICSD-3-TR in 2023 with no changes on NREM parasomnias since ICSD-3 published in 2014. We performed an extensive literature review to assess the evidence on the procedure of its diagnosis. We dissected the inconsistencies and shortcomings in the ICSD-3-TR to propose a revision of the current diagnostic criteria. We highlighted the limits of several clinical criteria which should rather be supportive features than mandatory criteria. Infrared cameras with video-recordings with are promising tools to precisely characterize home episodes. Sensitive and specific polysomnographic markers of NREM parasomnias have been identified and should be considered in future revisions. We also suggest the use of diagnostic specifiers (clinical subtypes, clinical significance, levels of severity, age effect, levels of certainty) to define homogeneous subgroups of patients for therapeutic intervention and research purposes. In conclusion, we advocate for significant changes in the current diagnostic criteria of NREM parasomnias for future classification.

Behavioral and psychological treatments for NREM parasomnias: A systematic review

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.

Home nocturnal infrared video to record non-rapid eye movement sleep parasomnias

To assess the feasibility, the acceptability and the usefulness of home nocturnal infrared video in recording the frequency and the complexity of non-rapid eye movement sleep parasomnias in adults, and in monitoring the treatment response. Twenty adult patients (10 males, median age 27.5 years) with a diagnosis of non-rapid eye movement parasomnia were consecutively enrolled. They had a face-to-face interview, completed self-reported questionnaires to assess clinical characteristics and performed a video-polysomnography in the Sleep Unit. Patients were then monitored at home during at least five consecutive nights using infrared-triggered cameras. They completed a sleep diary and questionnaires to evaluate the number of parasomniac episodes at home and the acceptability of the home nocturnal infrared video recording. Behavioural analyses were performed on home nocturnal infrared video and video-polysomnography recordings. Eight patients treated by clonazepam underwent a second home nocturnal infrared video recording during five consecutive days. All patients had at least one parasomniac episode during the home nocturnal infrared video monitoring, compared with 75% during the video-polysomnography. A minimum of three consecutive nights with home nocturnal infrared video was required to record at least one parasomniac episode. Most patients underestimated the frequency of episodes on the sleep diary compared with home nocturnal infrared video. Episodes recorded at home were often more complex than those recorded during the video-polysomnography. The user-perceived acceptability of the home nocturnal infrared video assessment was excellent. The frequency and the complexity of the parasomniac episodes decreased with clonazepam. Home nocturnal infrared video has good feasibility and acceptability, and may improve the evaluation of the phenotype and severity of the non-rapid eye movement parasomnias and of the treatment response in an ecological setting.

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.

Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias

STUDY OBJECTIVES

This pilot study determined whether transdiagnostic cognitive behavioral therapy for parasomnias (CBTp) reduces parasomnia and activity levels during sleep in a sample of adult sleep clinic outpatients. A secondary objective was to assess whether treatment produces improvements in daytime fatigue/sleepiness, perceived cognition, mood, and depression/anxiety/stress, as well as functional impairment in work and leisure activities.

METHODS

This was a randomized controlled trial with CBTp and self-monitoring control conditions. Participants were 19 adults with a DSM 5 parasomnia disorder who received individual CBTp virtually from their homes. CBTp consisted of psychoeducation, sleep hygiene and safety instructions, relaxation training, parasomnia techniques, and relapse prevention in a 6-week manualized, structured program.

RESULTS

Using a repeated measures analysis of variance model, and relative to a self-monitoring control condition, results showed that CBTp produced statistically significant improvements in parasomnia frequency, severity, nocturnal activity, and sleep efficiency. There was a trend toward reduced sleep-onset latency and improved work and social adjustment. Of treated participants, 100% rated themselves as improved at study conclusion.

CONCLUSIONS

Implications of these findings are that cognitive behavioral interventions for parasomnias are effective in lessening parasomnias. More investigation into this type of treatment is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Impact of Cognitive Behavioral Therapy on Parasomnias; URL: https://clinicaltrials.gov/ct2/show/NCT04633668; Identifier: NCT04633668.

CITATION

Vincent N, Dirkse D, Giannouli E, McQuarrie A. Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias. J Clin Sleep Med. 2023;19(3):499-509.

Group Cognitive Behavioural Therapy for Non-Rapid Eye Movement Parasomnias: Long-Term Outcomes and Impact of COVID-19 Lockdown

Prior to the COVID-19 pandemic, we demonstrated the efficacy of a novel Cognitive Behavioural Therapy programme for the treatment of Non-Rapid Eye Movement Parasomnias (CBT-NREMP) in reducing NREM parasomnia events, insomnia and associated mood severities. Given the increased prevalence and worsening of sleep and affective disorders during the pandemic, we examined the sustainability of CBT-NREMP following the U.K.'s longest COVID-19 lockdown (6 January 2021-19 July 2021) by repeating the investigations via a mail survey in the same 46 patient cohort, of which 12 responded. The survey included validated clinical questionnaires relating to NREM parasomnia (Paris Arousal Disorder Severity Scale), insomnia (Insomnia Severity Index) and anxiety and depression (Hospital Anxiety and Depression Scale). Patients also completed a targeted questionnaire (i.e., Impact of COVID-19 Lockdown Questionnaire, ICLQ) to assess the impact of COVID-19 lockdown on NREM parasomnia severity, mental health, general well-being and lifestyle. Clinical measures of NREM parasomnia, insomnia, anxiety and depression remained stable, with no significant changes demonstrated in questionnaire scores by comparison to the previous investigatory period prior to the COVID-19 pandemic: p (ISI) = 1.0; p (HADS) = 0.816; p (PADSS) = 0.194. These findings support the longitudinal effectiveness of CBT-NREMP for up to three years following the clinical intervention, and despite of the COVID-19 pandemic.

Psychobiological personality traits of children and adolescents with disorders of arousal

INTRODUCTION

Disorders of arousal (DOA) are parasomnias that emerge from incomplete arousal out of Non-Rem Sleep (NREM) and lead to a broad variety of emotional and motor behaviours. Increasing evidence supports the hypothesis that specific psychopathological traits contribute to the multifactorial origin of these phenomena. The aim of the current multicenter study was to compare the personality profile of children and adolescents with and without DOA using the Junior Temperament and Character Inventory (JTCI).

METHODS

We enrolled 36 patients with a diagnosis of DOA (mean age of 11 ± 3 years, 64% males), and 36 healthy age and gender matched control subjects (mean age of 11.2 ± 3.6, years, 67% males). Their parents completed the Paris Arousal Disorder Severity Scale (PADSS), the Sleep Disturbance Scale for Children (SDSC) and the JTCI.

RESULTS

Patients with DOA reached significantly higher levels compared to their control group in total PADSS (p < 0.0001) and in total SDSC (p < 0.0001). They also displayed higher scores in novelty seeking (p = 0.005), harm avoidance (p = 0.01), self-transcendence (p = 0.006) JTCI subscales, and lower scores on the self-directedness subscale (p = 0.004).

CONCLUSION

Our pediatric sample with DOA exhibited specific psychobiological personality traits compared to age and gender matched subjects without DOA. These results shed light on new possible etiopathogenetic mechanisms, as TCI traits have been linked to specific genetic variants and brain circuits, like the reward system. Prospective studies are required to assess the effect of targeted psychological/psychiatric treatment on DOA symptomatology.

Violent and Complex Behaviors and Non-Restorative Sleep Are the Main Features of Disorders of Arousal in Adulthood: Real Picture or a More Severe Phenotype?

Disorders of arousal (DoA) are NREM parasomnias characterized by motor and emotional behaviors emerging from incomplete arousals from deep sleep. DoA are largely present in pediatric populations, a period during which they are labeled as self-limited manifestations. However, an extensive literature has shown that DoA can persist in adulthood, with different characteristics from childhood DoA. Adult DoA patients usually report excessive daily sleepiness, sleep-related violence during DoA episodes or potentially harmful behaviors, which are rare in childhood. The semeiological features of DoA episodes in adulthood may complicate differential diagnoses with other motor manifestations during sleep, in particular sleep-related hypermotor epilepsy. However, it cannot be excluded that adults with DoA attending sleep centers constitute a more severe phenotype, thus not being representative of adult DoA in the general population. Video-polysomnographic studies of DoA document a spectrum of motor patterns of different complexities, the simplest of which may often go unnoticed. Despite the different complexities of the episodes, neurophysiologic studies showed the co-existence of deep sleep and wakefulness during DoA episodes or even before their onset. These aspects make DoA an ideal model to investigate the mechanisms regulating local sleep, sleep arousal and cognitive functions including spatial and temporal orientation, attention or memory.

Sleep terrors in early childhood and associated emotional-behavioral problems

STUDY OBJECTIVES

While sleep terrors are associated with emotional-behavioral problems in school-aged children and adults, little is known about these associations in early childhood, when sleep terrors prevalence is at its highest. Moreover, studies using a longitudinal design and controlling for confounding variables are scarce. This study's objective was to determine whether the frequency of sleep terrors in toddlers predicts emotional-behavioral problems during the preschool years.

METHODS

Participants (n = 324) were enrolled in the prospective Maternal Adversity Vulnerability and Neurodevelopment cohort study. The frequency of sleep terrors in children was assessed at 12, 18, 24, and 36 months using maternal reports. Children's emotional-behavioral problems were measured at 48 and 60 months using the Child Behavior Checklist. Relevant confounders linked to the child, mother, and environment were also taken into consideration.

RESULTS

The frequency of sleep terrors was relatively stable across early childhood (16.7-20.5%). A generalized estimating equation revealed that the frequency of sleep terrors in early childhood was associated with increased emotional-behavioral problems at 4 and 5 years of age, more specifically with internalizing problems (P < .001), after controlling for child's sex, time point, family socioeconomic status, maternal depressive symptoms, and nighttime sleep duration. The frequency of sleep terrors was further associated with the emotionally reactive, anxious/depressed, and somatic complaints scales (P < .01).

CONCLUSIONS

This longitudinal study provides further support for a high prevalence of sleep terrors in early childhood. Our findings show meaningful associations between higher frequency of sleep terrors and emotional-behavioral problems as early as toddlerhood, especially internalizing problems.

CITATION

Laganière C, Gaudreau H, Pokhvisneva I, et al. Sleep terrors in early childhood and associated emotional-behavioral problems. J Clin Sleep Med. 2022;18(9):2253-2260.

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.

Sleepwalking, sleep terrors, sexsomnia and other disorders of arousal: the old and the new

Disorders of arousal (DOA) is an umbrella term initially covering classical sleepwalking, sleep terrors, and confusional arousals, and now including a wider spectrum of specialised forms of non rapid eye movement (non REM) parasomnias such as sexsomnia, sleep-related eating disorder, and sleep-related choking syndrome. Growing evidence has shown that DOA are not restricted to children but are also prevalent in adults (2%-4% of the adult population). While DOA run in family, genetics studies remain scarce and inconclusive. In addition to the risk of injury on themselves and others (including sexual assaults in sexsomnia), adults with DOA frequently suffer from excessive daytime sleepiness, pain, and altered quality of life. The widespread view of DOA as automatic and amnesiac behaviours has now been challenged by subjective (dream reports) and objective (dream-enacting behaviours documented on video-polysomnography) observations, suggesting that sleepwalkers are 'dream walking' during their episodes. Behavioural, experiential, cognitive, and brain (scalp electroencephalography [EEG], stereo-EEG, high density-EEG, functional brain imaging) data converge in showing a dissociated pattern during the episodes. This dissociated pattern resembles the new concept of local arousal with a wake-like activation in motor and limbic regions and a preserved (or even increased) sleep intensity over a frontoparietal network. EEG and behavioural criteria supporting the DOA diagnosis with high sensitivity and specificity are now available. However, treatment is still based on controlling priming and precipitating factors, as well as on clinicians' personal experience with sedative drugs. Placebo-controlled trials are needed to improve patients' treatment. DOA deserve more attention from sleep researchers and clinicians.

Validation of the Dutch translation of the Paris Arousal Disorders Severity Scale for non-REM parasomnias in a 1-year and 1-month version

STUDY OBJECTIVES

We created a Dutch version of the Paris Arousal Disorders Severity Scale (PADSS), which assesses non-rapid eye movement (NREM) parasomnia symptoms over the past year (PADSS-year). This questionnaire was previously validated in patients with sleep walking and/or sleep terrors (SW/ST). We validated the questionnaire in SW/ST patients, and in a broader population, including patients with confusional arousals, comorbidities, and medication users ("other NREM parasomnias"). Furthermore, we introduced a version covering the past month (PADSS-month), with the potential purpose of evaluating symptom evolution and treatment response.

METHODS

We compared PADSS scores among 54 SW/ST patients, 34 age-matched controls, and 23 patients with other NREM parasomnias. We evaluated discriminative capacity, internal consistency, and construct validity. Furthermore, we assessed the test-retest reliability and treatment response of PADSS-month.

RESULTS

Healthy controls scored significantly lower than both patient groups. We found an excellent diagnostic accuracy (area under the curve PADSS-year 0.990, PADSS-month 0.987) and an acceptable internal consistency. Exploratory factor analysis identified 3 components: "behaviors outside the bed," "behaviors in/around the bed," and "violent behaviors," with the former 2 factors reflecting the distinction between SW and ST. PADSS-month showed an acceptable test-retest reliability (0.75). Additionally, PADSS-month significantly decreased after pharmaceutical and/or behavioral treatment. This change was correlated with the clinical impression of the caregiver, implying that PADSS-month is sensitive to treatment effects.

CONCLUSIONS

The Dutch PADSS questionnaire can be used as a screening tool in a broad population of patients with NREM parasomnia, not only SW/ST. Furthermore, we validated a PADSS-month version to assess the evolution of symptoms and treatment effect.

CITATION

van Mierlo P, Hermans L, Arnulf I, Pijpers A, Overeem S, van Gilst M. Validation of the Dutch translation of the Paris Arousal Disorders Severity Scale for non-REM parasomnias in a 1-year and 1-month version. J Clin Sleep Med. 2022;18(4):1135-1143.

From burlesque to horror: a century of sleepwalking on the silver screen

BACKGROUND

Long before being described as a disorder, sleepwalking was considered as a mysterious phenomenon inspiring artwork. From the early beginning of cinema, sleepwalkers were shown to populations, playing a crucial role in storytelling and collective knowledge.

OBJECTIVE

We characterized how sleepwalking has been portrayed in a large number of movies from the origins of cinema to recent years.

METHODS

Movies containing the words "sleepwalking" or "somnambulism" were searched for in International Movie Databases. Types of movies, sleepwalking characters, postures and behaviors during episodes, triggers, and suggested treatments were collected.

RESULTS

Production of 87 movies and 22 cartoons portraying sleepwalkers was clustered around two peaks, in the 1910s and 2010s. Comedies predominated before 1960, and thriller/horror movies as a dominant genre after 1960. In contrast with real-life sleepwalking epidemiology, sleepwalkers are more often portrayed as women than men (and often wearing a transparent white nightgown), as adults more than children on-screen, and 23% suffered psychiatric comorbidities. The unrealistic posture of outstretched arms and eyes closed was found in 20% of movies and 79% of cartoons. Night terrors, sexsomnias (kissing, having sex, initiated pregnancy), sleep-related eating and sleep driving were also featured. Homicides and falls while sleepwalking were recurrent fear-inducing topics. The first sleep EEG was featured in a sleepwalking movie in 1985, and a sleep specialist gave his first advice in 1997.

DISCUSSION

The representation of sleepwalking on the screen seems to have evolved from popular, unrealistic stereotypes of somnambulism towards a medical condition, paralleling the development of sleep medicine.

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.

The Arousal Disorders Questionnaire: a new and effective screening tool for confusional arousals, Sleepwalking and Sleep Terrors in epilepsy and sleep disorders units

BACKGROUND

Arousal Disorders (DoA) include Confusional Arousals, Sleepwalking and Sleep Terrors. DoA diagnosis is mainly clinical but no validated questionnaires exist for DoA screening according to the criteria of the International Classification of Sleep Disorders, Third Edition. Recently our group proposed the Arousal Disorders Questionnaire (ADQ) as a new diagnostic tool for DoA diagnosis. The objective of this study was to evaluate the diagnostic accuracy of the ADQ in a sleep and epilepsy center.

METHODS

One interviewer blinded to clinical and video-polysomnographic (VPSG) data administered the ADQ to 150 patients consecutively admitted to our Sleep and Epilepsy Centers for a follow-up visit. The final diagnosis, according to VPSG recordings of at least one major episode, classified patients either with DoA (DoA group) or with other sleep-related motor behaviors confounding for DoA (nDoA group).

RESULTS

47 patients (31%) composed the DoA group; 56 patients with REM sleep behavior disorder, 39 with sleep-hypermotor epilepsy, six with night eating syndrome, and two with drug-induced DoA composed the nDoA group. The ADQ had a sensitivity of 72% (95% CI: 60-82) and a specificity of 96% (95% CI: 89-98) for DoA diagnosis; excluding the items regarding consciousness and episode recall, sensitivity was 83% (95% CI: 71-90) and specificity 93% (95% CI: 86-97).

CONCLUSIONS

The ADQ showed good accuracy in screening patients with DoA in a sleep and epilepsy center setting. Diagnostic criteria related to cognition and episode recall reduced ADQ sensitivity, therefore a better definition of these criteria is required, especially in adults.

A Novel Group Cognitive Behavioral Therapy Approach to Adult Non-rapid Eye Movement Parasomnias

Background: Following the success of Cognitive Behavioral Therapy (CBT) for insomnia, there has been a growing recognition that similar treatment approaches might be equally beneficial for other major sleep disorders, including non-rapid eye movement (NREM) parasomnias. We have developed a novel, group-based, CBT-program for NREM parasomnias (CBT-NREMP), with the primary aim of reducing NREM parasomnia severity with relatively few treatment sessions. Methods: We investigated the effectiveness of CBT-NREMP in 46 retrospectively-identified patients, who completed five outpatient therapy sessions. The outcomes pre- and post- CBT-NREMP treatment on clinical measures of insomnia (Insomnia Severity Index), NREM parasomnias (Paris Arousal Disorders Severity Scale) and anxiety and depression (Hospital Anxiety and Depression Scale), were retrospectively collected and analyzed. In order to investigate the temporal stability of CBT-NREMP, we also assessed a subgroup of 8 patients during the 3 to 6 months follow-up period. Results: CBT-NREMP led to a reduction in clinical measures of NREM parasomnia, insomnia, and anxiety and depression severities [pre- vs. post-CBT-NREMP scores: P (Insomnia Severity Index) = 0.000054; P (Paris Arousal Disorders Severity Scale) = 0.00032; P (Hospital Anxiety and Depression Scale) = 0.037]. Improvements in clinical measures of NREM parasomnia and insomnia severities were similarly recorded for a subgroup of eight patients at follow-up, demonstrating that patients continued to improve post CBT-NREMP. Conclusion: Our findings suggest that group CBT-NREMP intervention is a safe, effective and promising treatment for NREM parasomnia, especially when precipitating and perpetuating factors are behaviorally and psychologically driven. Future randomized controlled trials are now required to robustly confirm these findings.

Mental Activity During Episodes of Sleepwalking, Night Terrors or Confusional Arousals: Differences Between Children and Adults

OBJECTIVE/BACKGROUND

Night terrors, sleepwalking and confusional arousals are behavioral manifestations of incomplete awakenings from sleep. According to international diagnostic criteria, these behaviors occur in the absence of any mental experience, or in the presence of very limited cognition or dream imagery (eg, a single visual scene). The aim of this study was to systematically and retrospectively investigate the mental content associated with sleep terrors and/or sleepwalking in both children and adults.

PATIENTS AND METHODS

Forty-five consecutive patients referred for a diagnosis of disorders of arousal (DOA) of all subtypes (sleepwalking/sleep terrors/confusional arousals) (25 adults: 30 ± 6 y, 15 females; 20 children: 10 ± 3 y, 6 females) underwent a detailed semi-structured interview about the mental content associated with their nocturnal episodes. The interview was comprehensive of specific questions about their subjective recall rate, several content details (characters, emotions, actions and setting/context), and hallucinatory or dissociative experiences during clinical episodes. Patients' reports were classified for complexity (Orlinsky scale) and content (Hall and Van de Castle categories).

RESULTS

More than two-third of the children (n = 14) could not recall any mental activity associated with their episodes, whereas more than two-third (n = 16) of the adults recalled at least one mental experience. Half of the adult patients (n = 8) estimated that a specific mental content was subjectively present around 50% or more of the times. Seven adults and one child described clear and vivid hallucinatory experiences of "dreamed" objects or characters projected onto their real home environment, in the absence of any reality testing. Five adults and two children described one or more dissociative experiences. The content of the collected reports was dominated by dynamic actions acted out from a self-perspective, often with apprehension and in response to misfortune and danger, in a home-setting environment.

CONCLUSION

These results suggest that current diagnostic criteria are tailored around the typical presentation of DOA in children, and do not always fit to adult patients with DOA. Furthermore, they support the concept that consciousness may reemerge in DOA patients during clinical episodes, in a peculiar dissociated, psychotic-like form.

Behavioural and emotional profiles of children and adolescents with disorders of arousal

Disorders of arousals are common sleep disorders characterized by complex motor behaviours that arise episodically out of slow-wave sleep. Psychological distress has long been associated with disorders of arousal, but this link remains controversial, especially in children and adolescents. The aim of this multi-centre study was to characterize behavioural and emotional problems in a sample of children/adolescents with disorders of arousal, and to explore their relationship with the severity of nocturnal episodes. The parents of 41 children/adolescents with a diagnosis of disorders of arousal (11.5 ± 3.3 years old, 61% males) and of a group of 41 age- and gender-matched control participants filled in the Child Behavior Checklist, along with the Sleep Disturbance Scale for Children and the Paris Arousal Disorders Severity Scale. Multilevel t-tests revealed significantly higher total scores and sub-scores of the Child Behavior Checklist for the patient group compared with the control group. Thirty-four percent of the patients obtained pathological total scores, and 12% of them borderline scores. The severity of emotional/behavioural problems in the patient group was positively correlated with the severity of the nocturnal episodes. Interestingly, children/adolescents with disorders of arousal also obtained higher excessive daytime sleepiness and insomnia symptoms sub-scores at the Sleep Disturbance Scale for Children. These results confirmed the hypothesis that behavioural/emotional problems are surprisingly common in children/adolescents with disorders of arousal. Further studies are warranted to investigate the causal relationship between pathological manifestations, subtler sleep abnormalities, and diurnal emotional/behavioural problems in children/adolescents with disorders of arousal.

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.

Pediatric Sleep Tools: An Updated Literature Review

Since a thorough review in 2011 by Spruyt, into the integral pitfalls of pediatric questionnaires in sleep, sleep researchers worldwide have further evaluated many existing tools. This systematic review aims to comprehensively evaluate and summarize the tools currently in circulation and provide recommendations for potential evolving avenues of pediatric sleep interest. 144 "tool"-studies (70 tools) have been published aiming at investigating sleep in primarily 6-18 years old per parental report. Although 27 new tools were discovered, most of the studies translated or evaluated the psychometric properties of existing tools. Some form of normative values has been established in 18 studies. More than half of the tools queried general sleep problems. Extra efforts in tool development are still needed for tools that assess children outside the 6-to-12-year-old age range, as well as for tools examining sleep-related aspects beyond sleep problems/disorders. Especially assessing the validity of tools has been pursued vis-à-vis fulfillment of psychometric criteria. While the Spruyt et al. review provided a rigorous step-by-step guide into the development and validation of such tools, a pattern of steps continue to be overlooked. As these instruments are potentially valuable in assisting in the development of a clinical diagnosis into pediatric sleep pathologies, it is required that while they are primary subjective measures, they behave as objective measures. More tools for specific populations (e.g., in terms of ages, developmental disabilities, and sleep pathologies) are still needed.

Simple behavioral criteria for the diagnosis of disorders of arousal

STUDY OBJECTIVES

This case-control study aimed to identify and validate behavioral markers supporting the diagnosis of disorders of arousal (DOA) with video polysomnography.

METHODS

All behaviors associated with 1,335 episodes of N3 interruptions were compared in 52 adult patients with DOA versus 52 participants without DOA (healthy control patients and patients with insomnia, hypersomnia, or sleep apnea syndrome).

RESULTS

Patients with DOA had more frequent (5.1 ± 2.4 versus 3.4 ± 1.9 interruptions/N3 time) and longer (35.8 ± 33 versus 23.1 ± 21.4 sec) arousals and awakenings from N3 than control patients. In the DOA group, the onset of behaviors was more abrupt, and behaviors including eye opening (69% versus 16%), head raising (41% versus 9%), visually exploring the environment (27% versus 1%), expression of fear/surprise (21% versus zero), speaking (18% versus 0.3%), trunk raising (13% versus 0.3%), and interacting with the environment (13% versus 0.5%), were (unlike quiet, comfort behaviors) more frequent than in control patients. A cutoff of two or more N3 interruptions containing eye opening yielded a sensitivity of 94.2% and a specificity of 76.9% for a DOA diagnosis. This accuracy was confirmed in a second set of data (second night of monitoring). Behaviors including an expression of fear/surprise (67.3%), sitting (32.7%), screaming, and standing up were specific to patients with DOA.

CONCLUSIONS

A simple, behavioral video marker of behavioral reactions during N3 interruption (ie, opening the eyes at least two times in the same night) was sensitive, specific, and reproducible for discriminating patients with DOA from sleep laboratory control patients.

CLINICAL TRIAL REGISTRATION

This study is a surrogate study of NCT02648568 and NCT03074578 on ClinicalTrials.gov.

Protocol of the SOMNIA project: an observational study to create a neurophysiological database for advanced clinical sleep monitoring

INTRODUCTION

Polysomnography (PSG) is the primary tool for sleep monitoring and the diagnosis of sleep disorders. Recent advances in signal analysis make it possible to reveal more information from this rich data source. Furthermore, many innovative sleep monitoring techniques are being developed that are less obtrusive, easier to use over long time periods and in the home situation. Here, we describe the methods of the Sleep and Obstructive Sleep Apnoea Monitoring with Non-Invasive Applications (SOMNIA) project, yielding a database combining clinical PSG with advanced unobtrusive sleep monitoring modalities in a large cohort of patients with various sleep disorders. The SOMNIA database will facilitate the validation and assessment of the diagnostic value of the new techniques, as well as the development of additional indices and biomarkers derived from new and/or traditional sleep monitoring methods.

METHODS AND ANALYSIS

We aim to include at least 2100 subjects (both adults and children) with a variety of sleep disorders who undergo a PSG as part of standard clinical care in a dedicated sleep centre. Full-video PSG will be performed according to the standards of the American Academy of Sleep Medicine. Each recording will be supplemented with one or more new monitoring systems, including wrist-worn photoplethysmography and actigraphy, pressure sensing mattresses, multimicrophone recording of respiratory sounds including snoring, suprasternal pressure monitoring and multielectrode electromyography of the diaphragm.

ETHICS AND DISSEMINATION

The study was reviewed by the medical ethical committee of the Maxima Medical Center (Eindhoven, the Netherlands, File no: N16.074). All subjects provide informed consent before participation.The SOMNIA database is built to facilitate future research in sleep medicine. Data from the completed SOMNIA database will be made available for collaboration with researchers outside the institute.

Adrenergic reactions during N3 sleep arousals in sleepwalking and sleep terrors: The chicken or the egg?

To understand the mechanisms of N3 sleep interruptions in patients with sleepwalking episodes and/or sleep terrors (SW/ST), we evaluated whether autonomic reactions preceded or accompanied behavioural arousals from NREM sleep stage N3. In 20 adult patients with SW/ST and 20 matched controls without parasomnia, heart rate and pulse wave amplitude were measured beat-to-beat during the 10 beats preceding and during the 15 beats succeeding a motor arousal from N3 sleep. Respiratory rate and amplitude were measured during the same 25 successive beats. In patients with SW/ST, the N3 arousals were associated with a 33% increase in heart rate, a 57% decrease in pulse wave amplitude (indicating a major vasoconstriction), a 24% increase in respiratory rate and a doubling of respiratory amplitude. Notably, tachycardia and vasoconstriction started 4 s before motor arousals. A similar profile (tachycardia and vasoconstriction gradually increasing from the 4 s preceding arousal and post-arousal increase of respiratory amplitude, but no polypnea) was also observed, with a lower amplitude, during the less frequent 38 quiet N3 arousals in control subjects. Parasomniac arousals were associated with greater tachycardia, vasoconstriction and polypnea than quiet arousals, with the same pre-arousal gradual increases in heart rate and vasoconstriction. Autonomic arousal occurs 4 s before motor arousal from N3 sleep in patients with SW/ST (with a higher adrenergic reaction than in controls), suggesting that an alarming event during sleep (possibly a worrying sleep mentation or a local subcortical arousal) causes the motor arousal.

Disorders of Arousal in adults: new diagnostic tools for clinical practice

Disorders of Arousal  (DOA) are mental and motor behaviors arising from NREM sleep. They comprise a spectrum of manifestations of increasing intensity from confusional arousals to sleep terrors to sleepwalking.

Although DOA in childhood are usually harmless, in adulthood they are often associated with injurious or violent behaviors to the patient or others. Driving motor vehicles, suspected suicide, and even homicide or attempted homicide have been described during sleepwalking in adults. Furthermore, adult DOA need to be differentiated from other sleep disorders such as Sleep-related Hypermotor Epilepsy or REM Sleep Behavior Disorder.

Although many aspects of DOA have been clarified in the last two decades there is still a lack of objective and quantitative diagnostic criteria for DOA.

Recent advances in EEG analysis and in the semiological characterization of DOA motor patterns have provided a better definition of DOA diagnosis.

Our article focuses on the DOA diagnostic process describing accurately the newest DOA clinical, EEG and video-polysomnographic tools in order to aid clinicians in DOA assessment.

Adult NREM Parasomnias: An Update

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.

[Life-threatening sleepwalking (Elpenor's syndrome) in a 10-year-old child]

Though benign in the majority of cases, sleepwalking sometimes causes injuries due, among other causes, to falls. Such accidents can be life-threatening - a situation that has been termed Elpenor syndrome (in reference to an accident experienced by a character in Homer's epic The Odyssey) - in particular when entailing defenestration. This syndrome has been described in adults and adolescents; we report here a case in a child.

OBSERVATION

This 10-year-old girl was admitted at night to our hospital after a 3-m fall at home. She was alert (Glasgow score, 15) at admission; a frontal wound and a deformation of the right wrist were noted. Brain CT scans showed a frontal skull fracture and frontal lobe contusion, wrist x-rays showed a displaced right fracture. The patient underwent urgent neurosurgery (wound excision and suture after reduction of skull fracture) and closed reduction and immobilization of the wrist fracture, both under general anesthesia. She underwent a psychiatric assessment in the intensive care unit 3 days after her fall. She was alert, well-oriented in time and space, and spoke fluently. She had no memory of her fall, only remembering going to bed in the evening before the accident and waking up in the ambulance on the way to the hospital. She displayed no sign of a concurrent mental illness and no suicidal ideas. Her parents reported that the evening of the accident she and her two brothers had all fallen asleep about 11:00 pm while watching TV, in the double bed of the guest room, placed just beside its window. At approximately 1:00 am, her father, who was going to bed and had just made noise in the hall, heard a cry from the guest room. He entered the room immediately and saw the opened window and his daughter lying on the outside ground; the brothers only awakened after the fall. The family had returned 2 days before from a 6-month stay in the United States, with jet-lag, sleep deprivation, and a disorganized sleep/wake rhythm in the patient. There was no medication before the accident, no substance use (including caffeine), and no concurrent medical problem. Over the 2 preceding years, the patient had undergone two witnessed episodes of early-nighttime arousal with altered consciousness and calm wandering (including going downstairs on one occasion), both strongly suggesting sleepwalking. There was a history of sleepwalking in her father and her older brother. Life-threatening sleepwalking (Elpenor syndrome) was diagnosed. The child and her parents were educated about sleepwalking; regularization of sleep schedules and sleep extension (avoidance of sleep deprivation, short napping when possible) were prescribed. We also recommended securing the home (bed, windows, and stairways). No pharmacological treatment was instituted. During the following 18 months, the child manifested only one noted sleepwalking episode, without risk-taking. She had no neurological or psychopathological sequela from her accident, of which she never had a memory.

CONCLUSION

Elpenor syndrome can occur in a child; consequently, it is important to inform parents of children with sleepwalking about the necessity of always securing the night-time environment.

Scalp and Source Power Topography in Sleepwalking and Sleep Terrors: A High-Density EEG Study

STUDY OBJECTIVES

To examine scalp and source power topography in sleep arousals disorders (SADs) using high-density EEG (hdEEG).

METHODS

Fifteen adult subjects with sleep arousal disorders (SADs) and 15 age- and gender-matched good sleeping healthy controls were recorded in a sleep laboratory setting using a 256 channel EEG system.

RESULTS

Scalp EEG analysis of all night NREM sleep revealed a localized decrease in slow wave activity (SWA) power (1-4 Hz) over centro-parietal regions relative to the rest of the brain in SADs compared to good sleeping healthy controls. Source modelling analysis of 5-minute segments taken from N3 during the first half of the night revealed that the local decrease in SWA power was prominent at the level of the cingulate, motor, and sensori-motor associative cortices. Similar patterns were also evident during REM sleep and wake. These differences in local sleep were present in the absence of any detectable clinical or electrophysiological sign of arousal.

CONCLUSIONS

Overall, results suggest the presence of local sleep differences in the brain of SADs patients during nights without clinical episodes. The persistence of similar topographical changes in local EEG power during REM sleep and wakefulness points to trait-like functional changes that cross the boundaries of NREM sleep. The regions identified by source imaging are consistent with the current neurophysiological understanding of SADs as a disorder caused by local arousals in motor and cingulate cortices. Persistent localized changes in neuronal excitability may predispose affected subjects to clinical episodes.