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
non-rapid eye movement (NREM) parasomnia
rapid eye movement (REM) parasomnia
other parasomnias
Contributors
Authors
Roneil Malkani, MD
Associate Professor
Department of Neurology (Sleep Medicine)
Northwestern University
Chicago
IL
Physician
Jesse Brown Veterans Affairs Medical Center
Chicago
IL
Disclosures
RM serves on the board of the Illinois Sleep Society. He receives no payment for this role. RM has prepared manuscripts for which he received compensation.
Acknowledgements
Dr Roneil Malkani would like to gratefully acknowledge Dr Hrayr Attarian and Dr Pierre Giglio, previous contributors to this topic.
Disclosures
PG declares that he has no competing interests. HA has carried out consultancy work for Harmony Bioscience, and received royalties from Springer. HA is also an author of a number of references cited in this topic.
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 DifferentialsGuidelines
- The AASM manual for the scoring of sleep and associated events
- Clinical practice guideline for the management of rapid eye movement sleep behavior disorder
More GuidelinesLog in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer