Parasomnias in adults

Last reviewed: 26 Apr 2022
Last updated: 04 Feb 2021

Summary

Definition

History and exam

Key diagnostic factors

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

Other diagnostic factors

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

Risk factors

  • history of childhood parasomnias (nonrapid eye movement parasomnias)
  • age >60 years (rapid eye movement sleep behavior disorder)
  • male sex (rapid eye movement sleep behavior 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 apnea (mainly nonrapid eye movement sleep parasomnias)
  • enuresis
  • periodic limb movement disorder (mainly nonrapid eye movement sleep parasomnias)
  • sleep deprivation (sleepwalking and sleep paralysis)
  • stress (nightmare disorder)
  • psychiatric disorders (nightmare disorder, sleep paralysis)
  • neurologic disorders (rapid eye movement sleep behavior disorder)
  • medications such as venlafaxine, SSRIs (rapid eye movement sleep behavior 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)
More risk factors

Diagnostic investigations

1st investigations to order

  • polysomnography (PSG) (in rapid eye movement sleep behavior disorder [RBD])
More 1st investigations to order

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
More investigations to consider

Treatment algorithm

ONGOING

nonrapid eye movement (NREM) parasomnia

rapid eye movement (REM) parasomnia

other parasomnias

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.

  • Differentials

    • seizures (sleep related)
    • narcolepsy
    • nocturnal dissociative disorder
    More Differentials
  • Guidelines

    • Position paper for the treatment of nightmare disorder in adults
    • Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea
    More Guidelines
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