Parasomnia: What Is It, Types and Treatment Options

Ever woken up from a terrifying dream that felt realistic? Have you ever experienced talking in your sleep or sleepwalking? If you’ve ever experienced any of these, chances are you’ve just had parasomnia.

Parasomnia is a mysterious sleep disorder that can be quite unpredictable, affecting not just you but also your loved ones. What causes these strange events and how can they be managed? Keep reading to find out!

What is Parasomnia?

Parasomnia is defined as an undesirable behavioral or physiological event that happens during sleep. These events involve either abnormal movements, behaviors, reactions, perceptions, or dreams [1].

Parasomnias typically occur during REM (rapid eye movement) sleep and non-REM (non-rapid eye movement) sleep. However, it can also occur while falling asleep, between sleep stages or transitioning from sleep to wakefulness [2].

Causes of Parasomnia

At the present moment, it is still not clear what causes parasomnia. However, some cases of parasomnia can be attributed to factors like sleep deprivation, genetics, neurological disorders, psychological disorders, post-traumatic stress disorder (PTSD), or side effects from a prescribed medication [3], [4].

Types of Parasomnia

There are four stages of sleep that our body would cycle through, throughout the night. These stages are separated into two main categories which are: non-REM (non-rapid eye movement) sleep and REM (rapid eye movement) sleep.

Stage 1 to 3 fall into the Non-REM sleep category while Stage 4 falls into the REM sleep category. There are two main types of parasomnia that fall under these categories, known as REM-related parasomnias and non-REM-related parasomnias [5].

Non-REM-related parasomnias usually involve doing a physical or verbal activity unconsciously. You are likely to not remember it the next day.

REM-related parasomnias occur during REM sleep when your eyes move rapidly under the eyelids and you have an increased heart rate, breathing, and blood pressure.

How to wake someone with parasomnia?

If it’s a child with sleepwalking and you have addressed the safety issues in the environment then the best treatment is just to safely walk them back to their bed and tuck them in. Similarly, with sleep terror, it is supportive behavior and returning them to sleep so they don’t need to be awakened from the deep sleep that these parasomnias often arise in.

Dr. Dan Rifkin

MD, MPH, FAASM Sleep Medicine Expert Physician & Neurologist

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Non-REM related Parasomnias

Here are the common traits associated with non-REM-related parasomnias:

• Sleepwalking (somnambulism): Sleepwalking is an act that involves getting up and walking around while still in a state of sleep.
• Sleep Terrors (Night terrors): Sleep terrors are a sleep disorder in which a person wakes up with intense fear. This fear may be accompanied by screaming, kicking, crying, or thrashing [6].
• Sleep Talking (somniloquy): Sleep talking is a sleep disorder in which a person talks while they are still in a state of sleep. It could be simple murmurs or complex sentences.
• Confusional Arousal: Confusional arousal or sleep drunkenness is characterized by unusual behaviors when a person appears to be awake from a deep sleep. They may seem disoriented, unresponsive, or confused [7].
• Sleep-related Eating Disorder: This is a sleep disorder that involves eating while asleep. Oftentimes, those who sleep eat have no memory of doing it [8]. It is unrelated to night eating syndrome [9].

REM related Parasomnias

Similarly, for REM-related parasomnias, the common traits are:

• REM Sleep Behavior Disorder: REM sleep behavior disorder is a type of parasomnia in which you physically act out or vocalize your dream. It happens during the REM sleep stage.
• Nightmare Disorder: Nightmare disorder is a sleep-wake disorder that causes a person to wake up frequently with memories of a terrifying dream [10].
• Recurrent Isolated Sleep Paralysis (RISP): Recurrent isolated sleep paralysis is when multiple episodes of sleep paralysis without being caused by any other sleep disorders [11].

Other Types of Parasomnia

Aside from non-REM-related parasomnias and REM-related parasomnias, other parasomnias occur regardless of the stage of sleep that it is in. It can basically happen anytime during the sleep cycle.

Exploding Head Syndrome (EHS)

Exploding Head Syndrome (EHS) is a non-harmful parasomnia in which a person experiences hearing a sudden loud noise while asleep, causing abrupt awakenings. Flashes of light and feelings of distress would usually accompany these events.

The sounds are commonly described to be the sounds of explosions, gunshots, or thunder but it can also be any other kind of loud noise. These events do not cause harm or pain.

There are no tests available to properly diagnose exploding head syndrome as well as to determine the cause of it. However, potential triggers are thought to be stress, uncontrolled anxiety, and insomnia [12].

Sleep-Related Hallucinations

Sleep-related hallucinations or hypnagogic hallucinations are a type of sleep disorder where a person experiences vivid and realistic imagined events upon sleep onset. They are visual hallucinations that may sometimes involve your senses of sound, touch, taste, and smell [13].

It is easily confused with being in a dream as you would be unsure of whether you are awake or asleep. Hallucinations could also be a sign of narcolepsy if it occurs during the day.

Sleep Bruxism

Sleep bruxism, also known as teeth grinding, is the involuntary clenching of your jaw and grinding of your teeth while asleep.

It affects an estimated 15 to 40% of children and 8-10% of adults. The causes of sleep bruxism could be due to stress, anxiety, lifestyle factors, and medical or psychological conditions. Teeth grinding also commonly co-occur with obstructive sleep apnea (OSA) and snoring [14].

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Diagnosis

Parasomnias can be diagnosed by carefully obtaining a thorough clinical history and assessing for characteristics such as time, expression, and present behavior in the individual’s home environment.

Some of the clinical questions asked include questions to rule out sleep deprivation, intoxication or withdrawal, sleep disorders or medical disorders that cause sleep instability, timing of events, and symptoms.

Additionally, a sleep diary or a partner’s account of the events may also help form a diagnosis. If it is a REM-related parasomnia that might cause harm or danger to others, seeing a sleep specialist or doing polysomnography may be necessary.

Treatment Options

In most cases, parasomnias would typically resolve on their own by making lifestyle changes such as improving sleep hygiene or sleep habits. Good sleep hygiene and habits include having a consistent sleep schedule, managing stress and anxiety, and getting enough sleep.

However, in some cases, a sleep medicine specialist may recommend a specific treatment based on the diagnosis and severity of the parasomnia.

Here are the common treatment options [15]:

Cognitive Behavioral Therapy (CBT)

Cognitive Behavioral Therapy (CBT) is a form of psychological treatment that is often used to address sleep disorders, such as parasomnia. It is carried out based on the principles of changing unhealthy thinking or behavioral patterns [16].

An example of cognitive behavioral therapy is image rehearsal therapy. This technique commonly used for nightmare disorder, involves changing the content of the parasomnia into new sets of images. This helps to reduce fear [17].

The primary objective of CBT is to help individuals realize that they are in control of the situation and problems that they are facing.

CBT can be used for nightmare disorder, sleep paralysis, insomnia, confusional arousal, sleepwalking, or night terrors.

Hypnotherapy

Hypnotherapy is defined as a form of psychological therapy that uses hypnosis as a way to change habits.

Based on a long-term study, it was found that hypnosis was most effective at treating parasomnias like nightmares and sleepwalking [18]. Upon completion of 1 to 2 sessions of hypnotherapy and three stages of follow-up post-hypnotherapy, it was found that roughly 40% of the subjects had reported positive changes.

The subjects had either no recurrent episodes of parasomnia or their symptoms were “much improved.” Thus, showing the efficacy of hypnotherapy for specifically nightmare disorder and sleepwalking [19].

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Scheduled Awakenings

Scheduled awakenings are commonly used as a treatment option for young children who deal with frequent parasomnia events [20].

Approximately 40% of children would suffer from sleep problems at some point in their childhood. One of the most common being sleepwalking. As a child transitions from slow-wave sleep to the next sleep cycle, they may become caught between sleep and wakefulness.

This partial arousal state causes sleepwalking to occur. Scheduled awakening is thought to help by waking a child at least 1.5 hours before they would experience the partial arousal parasomnia, as a way of disrupting sleep staging.

How do you treat parasomnia in kids?

It would depend upon the type of parasomnia. Children can have nightmares or night terrors or sleep talking and these can all be treated with reassurance and make sure the sleep environment is safe. Nocturnal anuresis can be treated with behavioral techniques or medication.

Dr. Dan Rifkin

MD, MPH, FAASM Sleep Medicine Expert Physician & Neurologist

Medications

The use of medications may be considered when parasomnia occurs frequently, causes extreme anxiety, or has the potential to put someone else at risk.

Common medications prescribed for adults dealing with parasomnia are benzodiazepines, tricyclic antidepressants, or melatonin supplements to reduce episodes.

Melatonin is an alternative first-treatment option for REM-related parasomnia compared to benzodiazepines or antidepressants. It is rarely a recommended treatment option for children. Like all other medications, it’s important to consult with a sleep specialist before using any supplements in case of contraindications or improper use [22].

Conclusion

Therefore, it can be understood that parasomnia is an abnormal behavior or movement that happens during sleep. Severe cases may require polysomnography and prescribed medications. In most cases, it is not harmful and can be easily treated by making changes to your sleep habits or using psychotherapy methods.

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