Parasomnias

Parasomnias are a pattern of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders marked by unusual actions, activities, or physiological events that occur during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep or sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake transitions. Parasomnias are divided into which sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep phase the symptoms occur, either rapid eye movement (REM) or non-REM (NREM). Symptoms may include simple or complex abnormal movements, such as sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep talking, sleepwalking, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep terrors, and dream enactment, or emotions, dreams, and autonomic activity. Diagnosis involves a thorough history taking from the patient and the partner. In some cases, polysomnography is required, especially if comorbid sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders are suspected. Some conditions resolve over time without any treatment. For those that require intervention, options include lifestyle or risk modifications, different forms of therapy, and medications. Choice of management is affected by patient preferences.

Last update:

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

Share this concept:

Share on facebook
Share on twitter
Share on linkedin
Share on reddit
Share on email
Share on whatsapp

Overview

Definition

Parasomnias are abnormal behaviors, actions, or activities occurring during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep.

Classification

Sleep disorders are generally divided into the following groups:

  • Parasomnias, which have subtypes according to each sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep stage:
    • Non-rapid eye movement (NREM) sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep arousal disorders: 
      • Sleepwalking (somnambulism)
      • Sleep terrors
      • Sleep-related eating disorders 
      • Confusional arousals
      • Sleep-related abnormal sexual behavior
    • Rapid eye movement (REM) sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep arousal disorders:
      • REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep behavior disorder (RBD) 
      • Nightmare disorder
  • Dyssomnias, which are abnormalities in the amount, quality, or timing of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep; the subtypes are:
    • Insomnia Insomnia Insomnia is a sleep disorder characterized by difficulty in the initiation, maintenance, and consolidation of sleep, leading to impairment of function. Patients may exhibit symptoms such as difficulty falling asleep, disrupted sleep, trouble going back to sleep, early awakenings, and feeling tired upon waking. Insomnia disorder
    • Narcolepsy Narcolepsy Narcolepsy is a neurological sleep disorder marked by daytime sleepiness and associated with cataplexy, hypnagogic hallucinations, and sleep paralysis. There are 2 types of narcolepsy: type 1 is associated with cataplexy and type 2 has no association with cataplexy. Narcolepsy
    • Circadian rhythm sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-wake disorders
    • Sleep apnea

Etiology and Epidemiology

Etiology

  • Theory on dissociation of states of consciousness consisting of wakefulness, NREM, REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep: combinations of these states → parasomnias
  • NREM-related disorders:
    • NREM generally exhibits instinctive actions, which would normally be inhibited in wakefulness. 
    • In NREM subtypes, there is an admixture of wakefulness and NREM.
    • Increased slow-wave sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep in NREM (difficult to arouse) noted, but there is potential for motor capacity
    • Factors:
      • Genetic predisposition
      • Conditions (stress, sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep deprivation, fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever
      • Substances (alcohol, medications such as zolpidem are associated with sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-related eating disorder) 
  • REM-related disorders:
    • Mix of wakefulness and elements of REM
    • Believed to have degeneration of cells involved in the normal REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep pathway 

Epidemiology

  • NREM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders are more common in a younger demographic whereas REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders are more common in an older demographic.
  • REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder is more common among men, especially in the older demographic.
  • Sleep-related eating disorder mostly occurs among women.
  • High prevalence of RBD in those with Parkinson disease

Clinical Presentation and Diagnosis

Clinical features of NREM-related parasomnias

  • Sleepwalking:
    • Episodes of simple to complex movements
    • May include sitting in bed, walking, eating, going outdoors, and, in rare cases, violent behaviors
    • Difficult to arouse during episode (eyes might be open with a blank stare)
    • Failure to recall the episode (amnesia)
    • Episodes might end with patients returning to bed or briefly awakening (confused and disoriented).
  • Sleep terrors:
    • Marked by sudden arousals, beginning with screaming or crying
    • Associated with autonomic changes (tachycardia, tachypnea, diaphoresis, mydriasis)
    • Difficult to arouse during episode (not responsive)
    • Amnesia or partial dream recollection afterwards
    • Episodes end with patients returning to sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep.
    • Most common in children
  • Sleep-related eating disorder:
    • Recurring episodes of involuntary eating after being aroused from sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
    • Possible partial awareness during the event
    • May have partial recollection of event
    • Criteria specify that episodes have to include the following:
      • Consuming toxic food, or
      • Engaging in potentially injurious behaviors while obtaining food, or 
      • Adverse health effects from chronic nighttime eating
  • Confusional arousals:
    • Mental confusion or disorientation on awakening (from slow-wave sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep), usually lasting < 15 minutes
    • Awake patient but with reduced responsiveness
    • Typically without recall of event
  • Sleep-related abnormal sexual behavior (sexsomnia):
    • Can occur with obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea
    • Abnormal sexual behaviors (without awareness and typically without recall) can include:
      • Masturbation 
      • Sexual intercourse with partner
      • Sexual assault

Clinical features of REM-related parasomnias

  • RBD:
    • Dream-enacting behaviors include:
      • Sleep talking or yelling
      • Limb jerking
      • Walking and/or running
      • Punching and/or other violent behaviors
    • Episodes of arousal during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep
    • Characterized by a lack of muscle atonia during REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep 
    • With recollection of dream content 
    • Upon awakening, often alert but can be briefly disoriented
    • Presenting complaint is often made by the patient’s partner (reporting violent behaviors during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep resulting in injury to the partner).
    • Commonly seen in:
      • Elderly patients 
      • Patients taking certain medications (serotonergic antidepressants and beta-blockers)
      • Those with neurodegenerative disorders (Parkinson disease, multiple system atrophy, and neurocognitive disorder with Lewy bodies)
  • Nightmare disorder:
    • Recurrent episodes of vivid dreams (with scary, negative themes)
    • Not associated with motor activity or sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep injury
    • Episodes end with patients awakening and recalling the unpleasant dream. 
    • Patient is fully alert upon awakening (no confusion or disorientation).
    • Causes significant distress or impaired functioning
    • Not associated with medication or substance use

Diagnostic approach

  • NREM parasomnias can often be diagnosed from history taking from the patient or their partner. 
  • Nightmare disorder is also a clinical diagnosis.
  • In conditions above, suspicion of comorbid sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorder (e.g., obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea ( OSA OSA Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea)) requires polysomnography.
  • In RBD, detailed history is helpful, but video polysomnography is required for a definitive diagnosis.

Management

  • Non-REM parasomnias:
    • Patients with mild symptoms may benefit from behavioral therapy:
      • Sleep hygiene
      • Education (patient and partner) and reassurance
    • Risk factor modification (e.g., discontinue medication)
    • Ensure environmental safety (e.g., secure locks, remove dangerous objects)
    • Treat coexisting sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disorders.
    • Refractory cases (frequent, persistent, and distressing) might benefit from a short course of benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines such as clonazepam. 
    • In addition, the following pharmacotherapy are options:
      • Selective serotonin reuptake inhibitors Serotonin Reuptake Inhibitors Antidepressants encompass several drug classes and are used to treat individuals with depression, anxiety, and psychiatric conditions, as well as those with chronic pain and symptoms of menopause. Antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and many other drugs in a class of their own. Serotonin Reuptake Inhibitors and Similar Antidepressant Medications (SSRIs): sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-related abnormal sexual behavior and sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-related eating disorder
      • Topiramate: sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep-related eating disorder
  • REM sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep behavior disorder:
    • Risk factor modification
    • Ensure environmental safety around the patient (remove any dangerous objects near place of sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep).
    • Medications that might be helpful: 
      • Clonazepam is efficacious in 90% of patients.
      • Melatonin 
  • Nightmare disorder:
    • Reassurance might be enough.
    • Desensitization/imagery rehearsal therapy (IRT) involves:
      • Use of mental representation to modify the result of a recurrent nightmare
      • Writing down the improved outcome
      • Mentally repeating it in a relaxed state
    • Medications (e.g., prazosin, antidepressants) may be indicated if nightmare disorder is associated with PTSD PTSD Posttraumatic stress disorder is a psychiatric illness characterized by overwhelming stress and anxiety experienced after exposure to a life-threatening event. Symptoms last more than 1 month and involve re-experiencing the event as flashbacks or nightmares, avoiding reminders of the event, irritability, hyperarousal, and poor memory and concentration. Posttraumatic Stress Disorder (PTSD) or other psychiatric disorder(s).

Differential Diagnosis

  • Restless legs syndrome Restless legs syndrome Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is marked by a severe urge to move the legs, and an unpleasant sensation only relieved by movement. Restless legs syndrome occurs after inactivity, especially during the evening and night, and is associated with sleep disturbance. Restless Legs Syndrome: marked by an overwhelming urge to move the legs, accompanied by unpleasant sensations, which are relieved by movement. Symptoms usually occur during the evening and cause sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep disturbance. Patients are aware of restless legs causing distress, while they are not usually aware of parasomnias.
  • OSA OSA Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea: episodic apnea, or cessation of breathing during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep, in which the period of apnea lasts for more than 10 seconds. Obstructive sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep apnea is usually due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, daytime headache, and somnolence. Obstructive sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep apnea is much more prevalent than parasomnias and must be ruled out. 
  • Nocturnal seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures: should be excluded in patients with suspected parasomnias. Symptoms of nocturnal seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures include repetitive stereotypical movements (tonic or dystonic), occurring at any time during sleep Sleep Sleep is a reversible phase of diminished responsiveness, motor activity, and metabolism. This process is a complex and dynamic phenomenon, occurring in 4-5 cycles a night, and generally divided into non-rapid eye movement (NREM) sleep and REM sleep stages. Physiology of Sleep. Episodes are usually short in duration (≤ 30 seconds).

References

  1. Fariba, K., Tadi, P. (2021). Parasomnias. StatPearls. Treasure Island (FL): StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK560524/
  2. Foldvary-Schaefer, N. (2020). Disorders of arousal from non-rapid eye movement sleep in adults. UpToDate. Retrieved June 5, 2021, from https://www.uptodate.com/contents/disorders-of-arousal-from-non-rapid-eye-movement-sleep-in-adults
  3. Ganti, L., Kaufman, M., Blitzstein, S. (2016). Sleep-wake disorders. First Aid for the Psychiatry Clerkship, (4th ed.), pages 166–168. McGraw-Hill.
  4. Judd, B. (2020). Classification of sleep disorders. UpToDate. Retrieved March 28, 2021, from https://www.uptodate.com/contents/classification-of-sleep-disorders?search=Parasomnias
  5. Kotagal, S. (2021). Parasomnias of childhood, including sleepwalking. UpToDate. Retrieved June 4, 2021, from https://www.uptodate.com/contents/parasomnias-of-childhood-including-sleepwalking
  6. Kazaglis, L., Bornemann, M.A.C. (2006). Classification of Parasomnias. Curr Sleep Medicine Rep2, 45–52. https://doi.org/10.1007/s40675-016-0039-y
  7. Markov, D., Jaffe, F., & Doghramji, K. (2006). Update on parasomnias: a review for psychiatric practice. Psychiatry (Edgmont (Pa.: Township), 3(7), 69–76.
  8. Pressman, M.R. (2007). Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications. Sleep Med Rev. 11(1): 5–30; discussion 31–3. https://pubmed.ncbi.nlm.nih.gov/17208473/
  9. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 16, Sleep-wake disorders, pages 533–563. Philadelphia, PA: Lippincott Williams and Wilkins.

USMLE™ is a joint program of the Federation of State Medical Boards (FSMB®) and National Board of Medical Examiners (NBME®). MCAT is a registered trademark of the Association of American Medical Colleges (AAMC). NCLEX®, NCLEX-RN®, and NCLEX-PN® are registered trademarks of the National Council of State Boards of Nursing, Inc (NCSBN®). None of the trademark holders are endorsed by nor affiliated with Lecturio.

Study on the Go

Lecturio Medical complements your studies with evidence-based learning strategies, video lectures, quiz questions, and more – all combined in one easy-to-use resource.

Learn even more with Lecturio:

Complement your med school studies with Lecturio’s all-in-one study companion, delivered with evidence-based learning strategies.

User Reviews

0.0

()

¡Hola!

Esta página está disponible en Español.

🍪 Lecturio is using cookies to improve your user experience. By continuing use of our service you agree upon our Data Privacy Statement.

Details