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Parasomnias are a group of sleep disorders that affect people as they fall asleep, while sleeping, or right when they’re waking up.
A common parasomnia you’ve likely heard of is sleepwalking. Other parasomnias aren’t as common, like exploding head syndrome, where a person hears loud, crashing sounds just as they awake.
Children experience parasomnias more often than adults. In children, sleep disorders can be connected to neurological conditions like epilepsy or ADHD. In adults, parasomnias can be related to an underlying mental health condition, dementia, or Parkinson’s disease. Parasomnias can also occur on their own.
We spend about a third of our lives sleeping, and we need good sleep in order to function. Disruptions to our sleep can easily impact daily life and relationships. Sleep disorders are especially difficult to diagnose, monitor, and treat because someone with parasomnia is often not fully aware of their nocturnal behaviors (Singh, 2018).
What happens when we sleep?
Researchers aren’t exactly sure why we sleep, but it’s clear the process is crucial for allowing brains and bodies to rest, restore, and reorganize. And while sleep is your body’s time to rest, your brain is still active once your eyes are shut.
During sleep, we cycle through five different stages. Each stage corresponds to different electrical patterns of brain waves that can be monitored to help diagnose sleep problems.
Sleep can be divided into REM (rapid eye movement) sleep and NREM (non-rapid eye movement) sleep.
- NREM sleep makes up 75-80% of our sleep each night. As the name suggests, your eyes don’t move in this phase and you might be more easily woken. NREM encompasses the first four stages of sleep.
- REM sleep makes up 20-25% of our nightly sleep. REM is the fifth stage of sleep. This is a period of deep sleep where dreaming occurs.
Your brain cycles through these phases 4-5 times every night, with REM sleep generally lasting longer with each cycle (Brinkman, 2021). Some parasomnias occur during NREM sleep, while others take place in REM sleep.
Parasomnia symptoms occur as you transition from one stage of sleep to the next. Symptoms can also happen in the transition between sleep and wakefulness, presenting as verbalizations or physical behaviors (Fleetham, 2014).
Insomnia: what is it, symptoms, causes, treatments
Parasomnia signs and symptoms
NREM parasomnias that occur during the first four stages of sleep are seen mostly between ages five and 25. This parasomnia behavior typically occurs in the first third of the night, and many people have their eyes open during the episodes, even though they’re still asleep.
People with NREM parasomnias usually don’t remember anything they said or did during the episode when they wake up the next day. They may only learn about it when someone else tells them, or they see items have moved during the night. Some common parasomnias include (Fleetham, 2014; Singh, 2018):
- Sleepwalking: Sitting up or walking with one’s eyes open during NREM sleep can be caused by genetic predisposition, sleep deprivation, alcohol, medication, or triggered by noise or touch.
- Confusional arousal: Disoriented or confused behavior during a sleep interruption is called confusional arousal. This can also be triggered by medications or alcohol, usually lasting up to a few hours, and people typically don’t remember it the next day.
- Sleep terrors: Researchers don’t know why sleep terrors (or night terrors) occur. Episodes can last up to five minutes and are characterized by intense fear shown by screaming, flailing, or running away.
- Sleep-related eating disorder: Sometimes diagnosed as a type of sleepwalking, sleep-related eating disorder occurs when someone eats or drinks during sleep, typically hurriedly, frantically, and with a focus on high-calorie foods.
- Sexsomnia: More common in males than females, sexsomnia involves sexual behavior, such as intercourse, masterbation, or sexual vocalizations, that happen during sleep.
REM parasomnias typically show up later in life and occur during the last third of the night when REM stages are the longest. People with REM parasomnias tend to remember their dreams (or parts of them) and have their eyes closed during episodes. REM parasomnias include (Fleetham, 2014; Singh, 2018):
- REM sleep behavior disorder: Also called RBD, this disorder is more common in men over the age of 50, and is strongly associated with neurological conditions. Someone with RBD verbally or physically acts out portions of their dreams during sleep.
- Recurrent isolated sleep paralysis: During normal REM sleep, your muscles succumb to temporary paralysis. When this paralysis extends into wakefulness, it’s called sleep paralysis, rendering a person unable to use their muscles or move directly after waking up.
- Nightmare disorder: Most people have had a nightmare or two, but recurring, intense, consistent nightmares that require clinical attention constitute a disorder. They can be triggered by certain medications (such as antidepressants and blood pressure medications), acute stress disorder, and post-traumatic stress disorder (PTSD).
Some people can have both NREM and REM parasomnias. When this happens it’s called parasomnia overlap syndrome. Sleeptalking, or somniloquy, is a common sleep issue that can occur during any stage of sleep.
Cognitive-behavioral therapy (CBT): what is it and what does it work for?
How are parasomnias diagnosed?
Healthcare providers will try to get a whole picture of your health before making a parasomnia diagnosis.
They’ll take into account your medical history, family history, and any history of substance use or abuse. Certain medications may also trigger problems or make existing ones worse. If you share a bed with someone, their input can be helpful in this process, too.
Other conditions, like PTSD, can affect sleep as well. A healthcare provider will work with you to rule out other conditions that might be contributing to your symptoms.
You can also have a sleep study (called a polysomnography), which involves multiple tests done overnight as you sleep, typically performed at a hospital or out-patient clinic. A sleep study typically includes the following tests (Rundo, 2019; Brinkman, 2021):
- Electrocardiogram (ECG): This test monitors electric currents in the heart.
- Electroencephalography (EEG): An EEG tests electrical activity in the brain.
- Electrooculography (EOG): This test assesses eye muscle function during sleep to determine if symptoms occur during NREM or REM sleep.
- Electromyography (EMG): An EMG monitors muscle activity or tension.
- Oxygen saturation: To evaluate the presence of breathing problems during sleep.
PTSD: understanding post-traumatic stress disorder
What is the treatment for parasomnia conditions?
If you have parasomnias or any sleep problems that cause you to get up, walk around, or do other activities, make sure your home is a safe place for you during sleep. Lock windows and doors, secure firearms or other weapons, or add extra padding around your bed––whatever is appropriate for your situation.
Treatment for parasomnias depends on the type but usually involves a combination of reassessing sleep hygiene, managing breathing during sleep, psychotherapy, and medication.
Reviewing good sleep hygiene, such as avoiding screens and alcohol before bedtime, will likely be a part of any treatment.
Therapies like cognitive behavioral therapy (CBT) and mindfulness-based stress reduction programs can be effective for most NREM disorders. One study found that one third of patients with an NREM sleep disorder were treated successfully without medication (Drakatos, 2019).
Some parasomnias can be treated by stopping drugs that affect sleep. Others are treated with medications––typically a benzodiazepine (like clonazepam) or z-drugs, a group of medications used to treat insomnia (Brandt, 2017).
Melatonin supplements can also be used to boost melatonin levels (the sleep-inducing hormone) and improve sleep in some people with sleep disorders (Fatemeh, 2021).
8 common sleep disorders: symptoms, causes, treatment
For REM behavior disorders, the combination of a benzodiazepine and melatonin supplements can be highly effective (Singh, 2018; Jawabri, 2021).
Most children who experience parasomnias outgrow them—either they resolve completely or they continue only sporadically (Fariba, 2021; Singh, 2018).
In adults, following good sleep habits––like sleeping in a dark room, avoiding screens and large meals in the hours before sleep, and having a consistent daily sleep and wake time––therapy, and medications tend to be most effective at managing parasomnias. Many healthcare facilities have sleep clinics with dedicated specialists who can help.
- Brandt, J., & Leong, C. (2017). Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research. Drugs in R&D, 17(4), 493–507. doi: 10.1007/s40268-017-0207-7. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5694420/
- Brinkman, J.E., Reddy, V., Sharma, S. Physiology of Sleep (Updated 2021, April 19). StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482512/
- Drakatos, P., Marples, L., Muza, R., Higgins, S., Gildeh, N., Macavei, R., et al. (2019). NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients. Sleep Medicine, 53, 181–188. doi: 10.1016/j.sleep.2018.03.021. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29753639/
- Fariba, K., Tadi, P. Parasomnias (Updated 2021, January 31). StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560524/
- Fatemeh, G., Sajjad, M., Niloufar, R., Neda, S., Leila, S., & Khadijeh, M. (2021). Effect of melatonin supplementation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Journal of Neurology, 10.1007/s00415-020-10381-w. Advance online publication. doi: 10.1007/s00415-020-10381-w. Retrieved from https://pubmed.ncbi.nlm.nih.gov/33417003/
- Fleetham, J. A., & Fleming, J. A. (2014). Parasomnias. CMAJ : Canadian Medical Association Journal, 186(8), E273–E280. doi: 10.1503/cmaj.120808. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4016090/
- Jawabri, K. H., Raja, A. Physiology, Sleep Patterns (Updated 2021 May 9). StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK551680/
- Kaur, H., Spurling, B.C., Bollu, P.C. Chronic Insomnia (Updated 2020, November 19). StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526136/
- Rundo, J. V., & Downey, R., 3rd (2019). Polysomnography. Handbook of Clinical Neurology, 160, 381–392. doi: 10.1016/B978-0-444-64032-1.00025-4. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31277862/
- Singh, S., Kaur, H., Singh, S., & Khawaja, I. (2018). Parasomnias: A Comprehensive Review. Cureus, 10(12), e3807. doi: 10.7759/cureus.3807. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402728/
- Van Horn, N. L., Street, M. Night Terrors (Updated 2020, July 10). StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK493222/
Yael Cooperman is a physician and works as a Senior Manager, Medical Content & Education at Ro.