Last reviewed: 17 Aug 2021
Last updated: 04 Feb 2021

Summary

Definition

History and exam

Key diagnostic factors

  • known condition causing sleep fragmentation/deprivation
  • normal physical examination between episodes
  • cognitive disturbance during event (confusional arousals, sleep terrors, and sleepwalking)
  • cognitive disturbances in between episodes (rapid eye movement sleep behaviour disorder)
  • sensation of a sudden loud noise in the head (exploding head syndrome)
  • vigorous or violent behaviour during episode (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behaviour disorder)
  • episodes of inability to move during episode (recurrent isolated sleep paralysis)
  • eating behaviour during the night (sleep-related eating disorder)
  • evidence of external injuries (rapid eye movement sleep behaviour disorder)
  • evidence of fear during episode demonstrated by autonomic hyperactivity (sleep terrors, nightmare disorder)

Other diagnostic factors

  • abnormal facial expression during episode (confusional arousals, sleepwalking, sleep terrors, rapid eye movement sleep behaviour disorder)
  • parkinsonian signs (rapid eye movement sleep behaviour disorder)

Risk factors

  • history of childhood parasomnias (non-rapid eye movement parasomnias)
  • age >60 years (rapid eye movement sleep behaviour disorder)
  • male sex (rapid eye movement sleep behaviour disorder)
  • female sex (nightmare disorder, isolated recurrent sleep paralysis)
  • family history (confusional arousals, sleepwalking, sleep terrors)
  • presence of human leukocyte antigen gene DQB1 (sleepwalking)
  • obstructive and central sleep apnoea (mainly non-rapid eye movement sleep parasomnias)
  • enuresis
  • periodic limb movement disorder (mainly non-rapid eye movement sleep parasomnias)
  • sleep deprivation (sleepwalking and sleep paralysis)
  • stress (nightmare disorder)
  • psychiatric disorders (nightmare disorder, sleep paralysis)
  • neurological disorders (rapid eye movement sleep behaviour disorder)
  • medicines such as venlafaxine, SSRIs (rapid eye movement sleep behaviour disorder, nightmare disorder)
  • forced awakenings
  • eating disorder (sleep-related eating disorder)
  • history of sleepwalking, sleeptalking, and periodic limb movements of sleep (sleep-related eating disorder)

Diagnostic investigations

1st investigations to order

  • polysomnography (PSG) (in rapid eye movement sleep behaviour disorder [RBD])

Investigations to consider

  • PSG (in confusional arousals)
  • PSG (in sleepwalking)
  • PSG (in nightmare disorder)
  • PSG (in sleep terrors)
  • PSG (in all other parasomnias)
  • electroencephalogram (EEG)
  • urine drug screen

Treatment algorithm

Contributors

Authors

Hrayr Attarian, MD

Professor

Director of the Center for Sleep Disorders

Neurology Department

Northwestern University

Chicago

IL

Disclosures

HA is an author of a number of references cited in this topic.

Acknowledgements

Dr Hrayr Attarian would like to gratefully acknowledge Dr Pierre Giglio, a previous contributor to this topic.

Disclosures

PG declares that he has no competing interests.

Peer reviewers

Bobbi Hopkins, MD

Baylor College of Medicine

Texas Children's Hospital

Clinical Care Center

Houston

TX

Disclosures

BH declares that she has no competing interests.

Mark Mahowald, MD

Professor and Chairman

Department of Neurology

Hennepin County Medical Center

Minneapolis

MN

Disclosures

MM is an author of a number of references cited in this topic.

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