NREM-related Parasomnias

by Roy Strowd, MD

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    00:00 Let's walk through some of the non-REM parasomnias and understand the typical presentation given the importance of the history in making this diagnosis.

    00:10 Let's start with sleep walking disorder. Typically, the event will begin with simple to complex movements. Patients may sit up in the bed. They may walk and ambulate around their room or other areas inside or outside the home. There may be eating associated with this. They may go outdoors and this presents a concern for their safety and we can also see violent behaviors but that is rare. Typically, patients are walking around as they typically would but during sleep. This is a dissociation between sleep and wakefulness. Patients wake up and are able to move and ambulate and move around in a coordinated fashion, but they're asleep during this event. They have no conscious recollection of what is happening. This is a non-REM parasomnia. So during the episode, patients are very difficult to arouse.

    01:01 Their eyes may be open but they have a blank stare. They're not fully conscious during this event. They're not lying down to new memories and they're in that deep slow wave period of sleep and as a result very difficult to arouse out of the episode. Trying to arouse the patient to wake them up and get them out of it is often unsuccessful and we want to move patients in to the bed back in to sleep.

    01:25 The end of the episode typically occurs as the patient returns to bed or briefly may wake up confused and disoriented in some of these episodes. And the next morning, the patients will usually have amnesia or lack of recollection of the event, failing to recall the episode that has occurred. What about sleep terror non-REM parasomnia? This is more common in children but we can see in rare episodes this extend into adulthood. These episodes tend to start with sudden arousals beginning with screaming or crying or yelling loudly. There can be autonomic changes, tachycardia, tachypnea, diaphoresis, mydriasis, change in pupillary size during the event. Again, this is a non-REM parasomnia so patients often are very difficult to arouse or wake up during the episode. They're not responsive during these episodes. Sleep terrors are often much shorter than sleep walking parasomnias but can occur for extended period in some cases. As the event ends, patients return to sleep and go back to bed and then the following morning most patients are amnestic to the event or may have partial recollection. What about sleep-related eating disorder? How does this present and what do we hear from patients. Well, to make a diagnosis of sleep-related eating disorder, we tend to see that episodes vary in frequency from once a week to more than 5 times in the same night, so this can become quite significant and frequent. These episodes tend to start with out-of- control or involuntary eating during arousals from sleep. Patients may be partially or completely unconscious during this event.

    03:16 Eating but unaware of what is happening around them. Patients again are often very difficult to arouse owing it that this is a non-REM parasomnia and it ends with the patient returning to sleep. Importantly, there is some variation in the patient's ability to recall these episodes. Many patients will retain complete amnesia, they will not remember the episodes that have occurred, but some may have partial recollection of the events. So what differentiates just eating at night someone who is hungry at night versus a sleep-related eating disorder.

    03:52 Well, in general, one or more of the following must be present with recurrent episodes to make a diagnosis of sleep-related eating disorder. Number 1, consumption of toxic foods, cigarette butts, preservatives, patients are eating things that they wouldn't normally eat if they were conscious and aware of what was going on. Two, engaging in potentially injurious behaviors while obtaining food.

    04:17 We see that patients may fall or burn themselves or sustain cuts and not recall that and that would be supportive of a diagnosis of sleep-related eating disorder.

    04:27 And then lastly, these patients need to have adverse health consequences from recurrent nocturnal eating either weight gain or daytime fatigue or other indication that this is negatively impacting their health. And then let's talk about confusional arousals. This is another non-REM parasomnia, a mental confusion or disorientation that occurs on awakening during slow wave sleep. Typically, these episodes are short lasting less than 15 minutes. Patients may awaken in a semi-conscious state with reduced responsiveness and typically there is not recall of the event the following morning. And then lastly, let's talk about sleep-related abnormal sexual behaviors. These can occur in patients with obstructive sleep apnea or as a result of a true non-REM parasomnia. We see abnormal sexual behaviors without awareness and typically without recall and this can include masturbation, sexual intercourse with a partner, or sexual assault in some cases.

    About the Lecture

    The lecture NREM-related Parasomnias by Roy Strowd, MD is from the course Sleep Disorders​.

    Included Quiz Questions

    1. Patients with NREM sleep behavior disorders often do not remember the events.
    2. Patients with REM sleep behavior disorders often do not remember the events.
    3. Patients with NREM sleep behavior disorders are atonic.
    4. Patients with REM sleep behavior disorders are atonic.
    5. It is difficult to distinguish between the two disorders clinically, and a polysomnogram is required.
    1. Sleepwalking
    2. Sleep terrors
    3. Sleep-related eating disorder
    4. Confusional arousals
    5. REM sleep behavior disorder
    1. Sleep terror disorder
    2. Nightmare disorders
    3. Confusional arousals
    4. REM sleep behavior disorder
    5. Insomnia
    1. Ensuring environmental safety by securing locks and removing nearby dangerous objects
    2. Placing small obstacles around the bed to wake the patient up if they wander out of bed
    3. Installing bed alarms
    4. Installing a home security system
    5. Ensuring the patient sleeps with a helmet and knee/elbow pads until the disorder resolves

    Author of lecture NREM-related Parasomnias

     Roy Strowd, MD

    Roy Strowd, MD

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