Delayed sleep phase type G47.21 327.31 Advanced sleep phase type G47.22 Irregular sleep-wake type G47.23 Non-entrained type (free running) G47.24 Circadian rhythm sleep disorder due to a medical condition G47.20 Other circadian rhythm sleep disorder G47.20 Jet lag type F51.21 327.35 Shift work type F51.22 327.36 Circadian rhythm sleep disorder due to a drug or substance F11 \200\22319.x 292.85 Circadian rhythm sleep disorder due to alcohol F10.x 291.82 Delayed sleep phase syndrome (DSPS) The late appearance of sleep (typically around 02.00hr) , but normal total sleep time and architecture, which may lead to complaints of sleep-onset insomnia and dif \201 culty awakening at the desired time in the morning. Cause is unknow n, although some cases are related to head injury, psychiatric disorder, or personality tra its (e.g. schizoid, avoidant). Usually presents in adolescence, running a continuing course until old age. Individuals may adapt to the condition by taking evening or night jobs. Advanced sleep phase syndrome (ASPS) The opposite of DSPS, this syndrome leads to complaint s of evening sleep- iness, early sleep onset (e.g. 18.00 \200\22320.00hr), and early mornin g wakening. May be confused with depression (due to early morning wakening), partic- ularly in elderly patients in whom the syndrome occurs more frequently. Irregular sleep \200\223wake pattern Sleep occurrence and waking behavior are very variable , leading to con- siderable disturbance of the normal sleep \200\223wake cycle and complain ts of 11_Semple_Chap11.indd 436 12/10/2012 6:28:59 PM CIRCADIAN RHYTHM SLEEP DISORDERS 1: OVERVIEW 437 insomnia (inadequate nocturnal sleep and daytime somnolence/frequent napping). The idiopath ic form is rare, and it is associated with Alzheimer \200\231s disease, head injury, develo pmental disorders, and hypothalamic tumors. Non-entrained type (free running) Rare occurrence of a greater than 24-hr sleep \200\223wak e period, leading to a chronic pattern of 1 \200\2232hr daily delays in sleep onset and wak e times, with an \200\230in-phase \200\231 period every few weeks (free of symptoms). Asso ciated with schizoid personality traits and may occur more frequently in blind individuals. Jet lag type Sleep disorder secondary to moving between time zones. Symptoms include varyin g degrees of dif \201 culty in initiating or maintaining sleep, day- time fatigue, decreme nts in subjective daytime alertness and performance, feelings of apathy, malaise or depress ion, and somatic symptoms (GI upset, muscle aches, or headaches). Shift work type Symptoms of insomnia or excessive sleepiness occur as transient phe- nomena in most people working shifts. Adaptation to a change in shift- work schedule usually take s 1 \200\2232wks; however, rotating day/night shifts may present particular dif \201 culti es. Often sufferers consult with somatic complaints (general malaise, GI upset), rather tha n the underlying disorder of sleep. Investigations \200 \200 \200 \200 Comprehensive history. Use of a 14-day sleep \200\223wake chart. Actigraphy \200\224objecti ve measurement of the rest \200\223activity cycle. Polysomnography is rarely needed. Differential diagnosis \200 Poor sleep hygiene. \200 Depressive disorder. \200 Misuse of drugs (particularly stimulants or sedatives) and alcohol. ICSD-2 codes this as \200 \230CRSD due to drug or substance/alcohol \200\231. Note: lifestyle factors are also clearl y important. Physical conditions such as: dementia, head injury, other causes of brain dama ge or injury, and recovery from coma. ICSD-2 also codes this separately as \200\230CRSD du e to medical condition \200\231. 11_Semple_Chap11.indd 437 12/10/2012 6:29:00 PM CHAPTER 11 Sleep disorders 438 Circadian rhythm sleep disorders 2: management General measures These include education abo ut the nature of sleep and establishing good sleep habits. This is particularly important f or shift work sleep disorder in which alcohol, nicotine, and caffeine may be used to self-m edicate symp- toms. Other advice for shift-workers should emphasize maintenance of regular sleep and mealtimes whenever possible, use of naps to limit sleep loss, and minimization of environmental factors (noise, light, other inter- ruptions) when sleeping during the day. Chronotherapy DSPS \200 Establishing a regular waking time, with only 1hr variability at weekends and holidays, may help initially. If unsuccessful, \200\230 phase shift of the sleep \200\223wake cycle. Th is involves: \200 phase-delay \200\2311 methods may be employed to achieve a Establishing a 27-hr day to allow progressive delay of the usual onset of sleep by about 3h rs in each sleep cycle. Sleep should only be permitted for 7 \200\2238hrs, with no napping. The disruption to the person \200\231s normal routine caused by undergoing this regime (wh ich may take 5 \200\2237 days to complete) requires appropriate measures to be taken to ens ure other family and work commitments are attended to. \200 An alternative strategy is to advise the individual to remain awake at the weekend for one full night, and to go to bed the next evening 90mins earlier than usual. \200 \200 Sleep periods should again be limited to 7 \200\2238hrs, with no napping. The procedure can then be repeated each weekend until a normal bedtime is achieved. ASPS \200 \200 Delaying sleep onset by increments of 15mins may be effective. Alternatively \200\230 \200 phase-advance \200\2312 methods may be used: The patient goes to bed 3hrs earlier each night until the sleep cycle is advanced back to a normal bedtime. May be dif \201 cult to implement, particularly with elderly patients. Light therapy3 This includes both the use of bright light (2500 \200\22310000lux) with UV r ays \201 ltered out, and light restriction. Bright light is assumed to suppress mela- ton in (which is sleep-promoting). DSPS Exposure to bright light is scheduled on waking to prevent morning leth- argy, usually for 2hrs daily for 1wk, often with adjunctive light restriction after 16.00hr. 11_Semple_Chap11.indd 438 12/10/2012 6:29:00 PM CIRCADIAN RHYTHM SLEEP DISORDERS 2: MANAGEMENT 439 ASPS Exposure to bright light is recommended 2hrs before scheduled bedtime, to delay this t o a more sociable time. Note: evidence for the effectiveness of light therapy in other intr insic circadian rhythm disorders of sleep (e.g. shift-work sleep disorders, jet lag) is lac king. Medication \200 The entrainment of circadian rhythms through the use of appropriately timed short-acting BD Zs4 (e.g. lormetazepam) has been advocated, particularly for the treatment of jet lag. 5 (0 .5 \200\2235mg) also appears capable of advancing the sleep Melatonin phase and resetting t he circadian rhythm in travelers with jet lag syndrome \202 ying across \201 ve or more time zones, particularly in an easterly direction, and especially if they have experienced jet lag on previous journeys. 1 Czeisler CA, Richardson GS, Coleman RM, et al. (1981) Chronotherapy: resetting the circad ian- clocks of patients with delayed sleep phase insomnia. Sleep 4: 1 \200\22321. 2 Moldofs ky H, Musisi S, and Phillipson EA (1986) Treatment of a case of advanced sleep phase syndro me by phase advance chronotherapy. Sleep 9: 61 \200\2235. 3 Terman M, Lewy AJ, Dijk DJ, et al. (1995) Light treatment for sleep disorders: consensus report. IV. Sleep phase and durat ion disturbances. J Biol Rhythms 10(135): 47. 4 Buxton OM, Copinschi G, Van Onderbergen A, et al. (2000) A benzodiazepine hypnotic facilitates adaptation of circadian rhythms and sle ep \200\223wake homeostasis to an eight-hour delay shift simulating westward jet lag. Sleep 23(915): 27. 5 Herxheimer A and Petrie KJ (2002) Melatonin for the prevention and treatmen t of jet lag. Cochrane Database Syst Rev CD001520. 11_Semple_Chap11.indd 439 12/10/2012 6:29:00 PM CHAPTER 11 Sleep disorders 440 Parasomnias 1: overview Essence Parasomnias may be de \201 ned as undesirable physical and /or experiential phenomena accompanying sleep. They include unusual behaviors and motor act s, autonomic changes, and/or emotional-perceptual events. Sometimes these events occur when arousal is incomplete, or they are associated with REM sleep. Other episodes may arise dur ing the transition from sleep to wakefulness, from wakefulness to sleep, or in transitions between sleep stages. They can usually be objectively diagnosed using PSG and successfully treated. Parasomnias are of academic interest as they may provide insights into the biologi cal underpinnings of species-speci \201 c behaviors such as locomotion, exploratory behavi or, appetitive states (hunger, sexual arousal), fear and aggression, that may be released f rom control during sleep, itself a biological imperative. Points to note \200 The often \200\230bizarre \200\231 nature of the parasomnias frequently leads them to bein g misdiagnosed as psychiatric disorders, particularly if they appear temporally related to stressful situations. This may, in turn, lead to inappropriate treatment, with associated p roblems, including exacerbation of the parasomnia. Often there will be associated psycholog ical distress or psychiatric problems secondary to the parasomnia. Rarely there may also be forensic implications, e.g. due to sleep- related violence (b p. 448), sexual activity (b p. 445) or even driving (b p. 445). Classi \201 cation of parasomnias Parasomnias may be classi \201 ed according to the slee p stages they occupy. ICSD-2 only classi \201 es conditions under \200\230parasomnia \200 \231 that are not included in other sections (see Table 11.7). Here, we list the differenti al according to sleep stages but discuss in detail those disorders included in ICSD-2. \200 confusional arousals, sleepwalking, Disorders of arousal/NREM sleep: sleep terrors, nocturnal panic attacks. Disorders associat ed with REM sleep: (RSBD), recurrent isolated sleep paralysis, nightmare disorder, impaired sleep-related penile erections, sleep-related painful erections, REM sleep-related sinus a rrest. Sleep \200\223wake transition disorders: (see b p. 448), exploding head syndrome (lo ud imaged noise or sense of violent explosion in the head on falling asleep or waking), sle ep- related (hypnic) hallucinations, rhythmic movement disorder, sleep starts, sleep-talkin g, sleep-related leg cramps. Miscellaneous (may occur in any sleep stage): disorder, sexsom nia, restless legs syndrome, periodic limb movements of sleep, sleep-related bruxism, sleep -related rhythmic movement disorder, sleep enuresis, sleep-related groaning. REM sleep behavior disorder sleep-related dissociative disorders sleep-related eating 11_Semple_Chap11.indd 440 12/10/2012 6:29:00 PM PARASOMNIAS 1: OVERVIEW 441 Parasomnia overlap disorder1 Sometimes disorders of non-REM sleep (e.g. sleep walking, slee p terrors) may occur along with REM sleep behavior disorder. 70% of cases are in young men (mean age 34yrs). Idiopathic cases, occurring at a younger age, are associated with other m edical (brain injury, nocturnal paroxysmal atrial \201 brillation), psychiatric (PTSD, de pression, schizophrenia), or sub- stance abuse (alcohol, amfetamine) disorders. There is no increased risk of psychiatric disorder. Management Clonazepam (0.5 \200\2232mg nocte). Table 11.7 Classi \201 cation of parasomnias with diagnostic codes ICSD-2 ICD-10 DSM-IV-TR Confusional arousals G47.51 Sleepwalking F51.3 307.46 Sleep terrors F51.4 307.46 REM sleep behavior disorder G47.52 307.47 Recurrent isolated sleep paralysis G47.53 Nightmare disorder F51.5 307.47 Sleep-related dissociative disorders F44.9 300.15 Sleep enuresis N39.44 307.6 Catathrenia (sleep-related groaning) G47.59 Exploding head syndrome G47.59 Sleep-related hallucinations R29.81 Sleep-related eating disorder G47.59 307.50 Parasomnia, unspeci \201 ed G47.50 307.47 Parasomnia due to a drug or substance F10 \200\22319.x 292.85 1 Schenck CH, Boyd JL, and Mahowald MW (1997) A parasomnia overlap disorder involving sleep - walking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically con \201 rmed cases. Sleep 20: 972 \200\22381. 11_Semple_Chap11.indd 441 12/10/2012 6:29:00 PM CHAPTER 11 Sleep disorders 442 Parasomnias 2: disorders of arousal/ NREM sleep Confusional arousals ( \200\230sleep drunke nness \200\231) \200 Clinical features: most typically from deep sleep in the \201 rst part of the night. Indi viduals appear disorientated, incoherent, hesitant and slow, but may walk about, get dresse d, and even perform complex motor behaviors. Violence, assault, and even homicide may occur (rare: planning or premeditation is not possible). Polysomnography: night. Prevalence: les s common in older childhood. Fairly rare in adulthood, usually occurring in the context of sleep deprivation, exacerbated by alcohol or other depressant drugs. Associated disorders: idiopathic hypersomnia, encephalopathy. Differential diagnosis: autonomic arousal), sleepwa lking (usually docile, not aggressive when challenged), and RSBD (evident dream enactment, see b p. 446). Management: \200 confusion during and following arousals from sleep, arousal from NREM sleep, usually in \201 rst third of the almost universal in young children (under 5yrs), becomes sleep-related breathing disorders, narcolepsy, acute confusional states, sleep terrors (evident Prevent the patient from falling into deep, prolonged NREM sleep: avoid sleep deprivation. Restrict use of alcohol and other sedative drugs (illicit and prescribed). Sleep hygiene me asures ( b p. 426). Sleep terrors (parvor nocturnes, incubus) \200 Clinical features: sudden awakening with loud terri \201 ed screaming (the person may sit up rapidly) with marked autonomic arousal (tachycardia, tachypnoea, diaphoresis, mydriasis) . Sometimes frenzied activity occurs \200\224may lead to injury. Episodes usually last for 10 \200\22315min, with increase in muscle tone and resistance to physical contact. If waken ed, individual appears confused and incoherent, but soon falls asleep, wakening next mornin g with no memory of the event. In children, usually occurs in the \201 rst third of the n ight. In adults, can occur at any time of night. Polysomnography : abrupt wakening out of N 3 sleep is seen on EEG, with generation of alpha activity, usually in the \201 rst third of the night. Partial arousals out of N3, occurring up to 10 \200\22315 times in one night, are also seen even when a full episode is not recorded. Prevalence : children \200\2243%, adults \200\2241% (may be more common in males), evidence for heritability. Deep and prolon ged N3 is a predisposing factor, precipitated by fever, sleep deprivation, and depressant m edication. Associated disorders: Differential diagnosis: attacks. \200 as for sleepwalking. nightmares, nocturnal epilepsy, nocturnal panic 11_Semple_Chap11.indd 442 12/10/2012 6:29:00 PM PARASOMNIAS 2: DISORDERS OF AROUSAL/NREM SLEEP 443 reassure individual (and partner/parents) of the benign Management: character of the disord er. If episodes are frequent (more than once a week), use similar methods as for sleepwalki ng. Nocturnal panic attacks (NP) \200 Clinical features: waking from sleep with no obvious trigger in a state of intense fear or discomfort, accompanied by cognitive and physical (autonomic) symptoms of arousal. Symptoms as for panic disorder (see b p. 358). Avoidance of sleep may lead to delayed sleep onset a nd chronic sleep deprivation. Polysomnography: (particularly during the transition). Preval ence: NP is common among patients with panic disorder (44 \200\22371%). Risk factors: drugs (esp. BDZs, antidepressants); mitral valve prolapse; stimulant use (including caffeine). E tiology: \200 usually occurs in late N2 or early N3 sleep lifetime prevalence may be 3 \200\2235% in non-clinical populations. periods of sleep deprivation, withdrawal from alcohol/ respiratory drive dysregulation possibly due to Physiological \200\224 extreme hypercapnia or chronic hyperventilation; heart rate variability during NREM sleep. Psychological \200 \224 and \200\230letting go \200\231 (possible fear of loss of vigilance); low-level somat ic sensations of arousal or anxiety act like conditioned stimuli during sleep to elicit fea r response and panic. increased discomfort related to relaxation, fatigue, Associated disorders: anxiety and related disorders, alcohol and substance misuse. Differen tial diagnosis: (during REM sleep), withdrawal syndromes (esp. BDZs), sleep terrors, sleep- related breathing disorders, sleep paralysis (see b p. 447), nocturnal seizures, PTSD night mares, anxiety due to nocturnal hallucinations. Assessment: other anxiety disorders), use o f alcohol and drugs. Rating of severity using speci \201 c scales, e.g. Nocturnal Panic Sc reen1 and self-monitoring using sleep diary. Additional formal assessment may be necessary for dif \201 cult cases and to exclude other treatable sleep disorders (e.g. sleep apnoea, nocturnal seizures). Management: \200 panic disorder, PTSD, depressive disorder, other panic attacks (after awakening), nightmares full history, with an emphasis on possible comorbidity (i.e. Cognitive behavioral therapy (see b p. 362) including modi \201 cation of maladaptive beha viors (e.g. sleeping with lights or TV on). Pharmacological \200\224little speci \201 c e vidence (not systematically studied yet). Case reports support alprazolam or TCAs. Rational approach to prescribing as for daytime panic (b p. 362) and/or short-term use of hypnotics to help with s sleep avoidance. \200\224most evidence as for panic disorder 1 Craske MG and Tsao JC (2005) Assessment and treatment of nocturnal panic attacks. Sleep M ed Rev 9: 173 \200\22384. 11_Semple_Chap11.indd 443 12/10/2012 6:29:01 PM CHAPTER 11 Sleep disorders 444 Parasomnias 3: sleepwalking and associated disorders of NREM sleep Sleepwalking (somnambuli sm) \200 Clinical features: complex, automatic behaviors (automatisms) (e.g. aimless wandering, atte mpting to dress or undress, carrying objects, eating [see b p. 448], urinating in unusual p laces, and, rarely, driving a car [see Box 11.3] or sexual behavior [see Box 11.4]). Episod es often follow a period of sleep deprivation or increased stress. There is often a persona l and/or family history of sleepwalking or other related disorders. Behaviors of variable d uration usually occur 15 \200\223120min following sleep onset, but may occur at other times . Eyes usually wide open, glassy, and talk is incoherent with communication usually impossi ble. Injury may occur (e.g. falling down the stairs, exiting through a window). Activity ne ver appears intentional or planned, and only rarely aggressive behavior occurs. The person is usually easily returned to bed, falls back into normal sleep, and has no recollection of the episode the following morning. If awakened during the episode \200\224confused and dis orientated. Dream content (if present) is fragmented, without speci \201 c themes. Polysom nography: preceded by hypersynchrony of generalized (non-epileptic) high- voltage delta wav es. Prevalence: Familial forms do occur. Precipitants similar to confusional arousals. Asso ciated disorders: seizures, medical/neurological disorders, febrile illness, alcohol use/ a buse, pregnancy, menstruation, psychiatric medication (lithium, anticholinergics), stress ( no speci \201 c psychiatric illness). Differential diagnosis: sleep, second half of the ni ght), epileptic fugue states, and REM sleep behavior disorder in the elderly. Management: \200 \200 light, NREM sleep, with episodes sometimes up to 17% in childhood (peak age 4 \200\2238yrs); 4 \200\22310% in adults. sleep-related breathing disorders, PLMS, nocturnal confusional arousals, episodic wandering (N2 Reassurance. Protect the patient from coming to harm (e.g. closing windows, locking doors, sleeping downstairs). Relaxation techniques and minimization of stressors. Sleep hygiene me asures ( Avoidance of sleep deprivation. Medication (for patients with frequent episodes/hi gh-risk behaviors: small night-time doses of a BDZ (e.g. diazepam 2 \200\22310mg, clonazepa m 1 \200\2234mg), or low-dose sedating antidepressant at night. \200 \200 \200 b p. 426). Note: treatment of any concurrent psychiatric disorder does not control the parasomnia. 11_Semple_Chap11.indd 444 12/10/2012 6:29:01 PM PARASOMNIAS 3: SLEEPWALKING AND DISORDERS OF NREM SLEEP 445 Box 11.3 Sleep Driving and the Z-drugs1 Sleep driving is regarded as a highly unusual variant of sleepwalking but may be confused w ith impaired driving due to misuse or abuse of sedative/hypnotic drugs when the driver may appear \200\230asleep \200\231. The majority of case reports relate to the Z-drugs \200 \224especially zolpidem and zopiclone \200\224and drivers have excessively high blood level s of z-drugs, failed to take the medication at the correct time or remain in bed for suf \201 cient time and/or combined z-drugs with other CNS depressants/ alcohol. True sleep dri ving can be distinguished by the fact that sleep- walkers are completely unable to understa nd or interact with the police but can stand and walk unaided. In contrast, drivers under t he in \202 uence of sedative drugs are still able to respond to the police but are unable to stand up or maintain balance. If in doubt, sleep studies may be indicated, especially if there are signi \201 cant legal proceedings. Treatment of sleep driving is as for sleepwa lking (see b p. 444). 1 Pressman MR (2011) Sleep driving: sleepwalking variant or misuse of z-drugs? Sleep Medicine Reviews 15: 285 \200\22392. Box 11.4 The curious case of sexsomnia, \200\230sleepsex \200\231, or somnambulistic sexua l behavior1 Another rare sleepwalking variant, the sorts of sexual behavior seen during sleep can inclu de: explicit vocalizations (with sexual content), violent masturbation, and complex sexual activities including oral sex, and vaginal or anal intercourse. Sexual behavior during slee p may be associated with injury to the subject or his/her bed partner, when it is a special form of sleep-related violence (see b p. 448). Sexsomnia appears more common in men. There are sex differences in presenta- tion with women almost exclusively engaging in masturbati on and sexual vocalizations, whereas men are more likely to engage in sexual fondling and i ntercourse. It can be quite challenging to distinguish between typi- cal sleepwalking and s exsomnia, but uniquely there is often involvement of a partner who is usually more than a w itness. Most people with this disorder have a previous and/or family history of sleepwalkin g. PSG is necessary to con \201 rm diagnosis and diagnoses associated with sexual behavior during sleep include not only NREM sleep somnambulism but also RSBD and frontal lobe seizu res. Treatment involves general meas- ures of good sleep hygiene and addressing precipitati ng factors such as sleep deprivation, drug misuse, alcohol, stress, RLS, and OSA. If medica - tion is being considered, evidence supports use of clonazepam (0.5 \200\2232mg nocte), se rtraline, valproic acid and lamotrigine. 1 Anderson ML, Poyares D, Alves RSC, et al. (2007) Sexsomnia: abnormal sexual behavior duri ng sleep. Brain Research Reviews 56: 271 \200\22382. 11_Semple_Chap11.indd 445 12/10/2012 6:29:01 PM CHAPTER 11 Sleep disorders 446 Parasomnias 4: disorders associated with REM sleep REM sleep behavior disorder (RSBD)1 \200 Clinical features: vivid, intense, action-packed, violent dreams (reported as \200\230nigh tmares \200\231), dream-enacting behaviors (verbal and motor), sleep injury (ecchymoses, la cerations, fractures \200\224of self and bed partner), general sleep disruption. Polysomnog raphy: phasic submental/limb EMG twitching during REM sleep, in the absence of EEG epilepti form activity. a rare sleep disorder, more common in older males. Prevalence: Associated di sorders: 50% of cases associated with neurological disorders, usually degenerative (e.g. Pa rkinson \200\231s disease), and narcolepsy (may be an early sign of neurological disease th at manifests fully several years later \200\224full neurological examination should be perf ormed). Rarely associated with other psychiatric disorders, but may be induced or aggravate d by psychiatric drugs (e.g. TCAs, MAOIs, high-dose SSRIs, SNRIs), cessation/misuse of REM- suppressing agents (e.g. alcohol, amfetamine, cocaine), or severe stress related to traumat ic experiences. Differential diagnosis: disorders, nocturnal epilepsy, obstructive sleep ap noea (where arousals from REM sleep associated with aggressive behavior and vivid REM-relat ed dreams), states of intoxication, malingering. Management: \200 elevated submental EMG tone and/or excessive \200 sleepwalking, sleep terrors, nocturnal dissociative Ensure a safe sleeping environment (for patient and sleeping partner). Eliminate any factor s that might be inducing or aggravating the condition (including treatment of any primary n eurological, medical, or psychiatric disorder). If symptoms persist and are problematic, cl onazepam (0.5 \200\2231.0mg nocte) is the treatment of choice, effectively controlling both behaviors and dreams, with good evidence of long-term safety and sustained bene \201 t. A lternatives include carbamazepine, melatonin, levodopa (L-dopa), and imipramine. Nightmare disorder \200 Clinical features: from REM sleep, without associated confusion. May be preceded by a frigh tening or intense real-life traumatic event. Polysomnography: terminated by an awakening, u sually in the second half of the night. Prevalence: Frequent nightmares (one or more a week ) occur in about 1% of adults. Differential diagnosis: nocturnal panic attacks. frightening dreams that usually awaken the sleeper increased REM density, lasting about 10min, common (occasional occurrence in 750% of adults). sleep terrors, REM sleep behavior disorder, 11_Semple_Chap11.indd 446 12/10/2012 6:29:01 PM PARASOMNIAS 4: DISORDERS ASSOCIATED WITH REM SLEEP 447 Treatment usually unnecessary. If episodes are frequent, Management: distressing, or causin g a major disturbance to the individual \200\231s carers or bed partner: \200 General measures may potentially promote nightmares (see Box 11.5), principles of sleep hyg iene (b p. 426), Medication: REM-suppressing drugs (e.g. antidepressants). sudden discontin uation may lead to exacerbation of the problem with REM-rebound. \200\224avoidance of stress, discontinuation of drugs that Note: Recurrent isolated sleep paralysis \200 Clinical features: voluntary movements either at sleep onset (hypnagogic or pre- dormital f orm) or awakening (hypnopompic or post-dormital form), either during the night or in the mo rning. Polysomnography: despite desynchronized EEG with eye movements and blinking (i.e. aw ake). H-re \202 ex activity is also abolished during an episode (as in REM sleep). Prevale nce: as an isolated phenomenon, reported to occur at least once in the lifetime of 40 \200 \22350% of normal individuals (usually due to sleep deprivation). As a chronic complaint, h owever, it is much less common. Familial sleep paralysis (without sleep attacks or cataplex y) is exceptionally rare. Differential diagnosis: periodic hypokalaemia (in adolescents, fo llowing a high carbohydrate meal, and with low-serum potassium during the attack). Manageme nt: \200 the frightening experience of being unable to perform atonia in peripheral muscles (as in REM sleep) narcolepsy (occurs in up to 40% of cases), b p. 426), esp. avoidance of sleep deprivation, may Sleep hygiene ( help to prevent episodes. Persistent problems may respond to REM-suppressan t medication (e.g. clomipramine 25mg or an SSRI). Box 11.5 Drugs associated with vivid dreams or nightmares \200 \200 \200 \200 \200 \200 \200 Nalbumetone Nicotine patches Pergolide Reserpine Stanozolol Verapamil Withdrawal (alcohol, BDZs, opiates, and other hypnotics) Baclofen Beta-blockers (atenolol, propranolol) Clonidine Digoxin toxicity Famotidine Indome tacin Methyldopa \200 \200 \200 \200 1 Schenck CH and Mahowald MW (2002) REM sleep behavior disorder: clinical, developmental, a nd neuroscience perspectives 16 years after its formal identi \201 cation in Sleep. Sleep 25: 120 \200\22338. 11_Semple_Chap11.indd 447 12/10/2012 6:29:02 PM CHAPTER 11 Sleep disorders 448 Parasomnias 5: other presentations Sleep-related eating disorder (SRED)1 First reported 1955; received very little attention until more recently. Sleep-related eati ng disorder is usually described in 20 \200\22330-yr-old women. Consists of recurrent episo des of involuntary eating and drinking during partial arousals from sleep. \200 Clinical features: consumption of inedible (pica) or even toxic substances such as raw meat , frozen pizza, or pet food. Sleep is disrupted and patients report often signi \201 cant (sometimes unexplained) weight gain. reports show multiple confusional arousals with Polyso mnography: or without eating, arising predominantly from N3 sleep, but also occasionally fr om N1, N2, and REM sleep. Differential diagnosis: other sleep disorders, e.g. sleepwalking, RLS-PLMS, OSA, narcolepsy, circadian rhythm disorders. Various medications associated with SRED, e.g. triazolam, zolpidem, olanzapine, and risperidone. Management: disorder and cess ation of provoking medication. If pharmacotherapy is indicated, case reports suggest use of : topiramate, dopaminergics, clonazepam, and \202 uoxetine. sometimes there may be particularly unusual can be either idiopathic or comorbid with treatment is best directed at any comorbid sleep Sleep-related dissociative disorders2 First reported in 1976,3, there is usually a history of repeated physical and/ or sexual abuse in childhood and/or adulthood. Usually, there are also daytime states of dissociation too with self-harm behaviors. \200 Polysomnography: re-enactments of previous abuse, occur during wakefulness after an episode of sleep. Management: disorder which may require inpatient assessment. Night-time benzodia zepines may exacerbate the problem and are best avoided. complex and lengthy behaviors; appear to be treatment involves long-term therapy for the dissociative Sleep-related violence Violence and sleep are commonly thought to be mutually exclusive, but in fact can co-exist (see Table 11.8). Key aspects of determining role of an underlying sleep disorder include:4 \200 Presence of underlying sleep disorder: history of previous episodes. Characteristics of act : duration, impulsive, senseless, without motivation, lack of awareness during event, victi m was coincidentally present or was a possible arousal stimulus. On return to consciousness : amnesia for the event. Presence of precipitating factors: intake of sedative/hypnotic dru gs, prior sleep deprivation, not due to voluntary alcohol or drug intoxication. solid evidence on PSG/video, on awakening or falling asleep, abrupt onset, brief perplexity, horror, no attempt to escape, attempts to awaken the subject, 11_Semple_Chap11.indd 448 12/10/2012 6:29:02 PM PARASOMNIAS 5: OTHER PRESENTATIONS 449 Table 11.8 Disorders associated with sleep-related violence1 Disorder State of occurrence Clinical features Circumstances of violence When being forced to wake from sleep Confusional arousal Wake/ NREM Incomplete awakening, reduced vigilance, impaired cognition, amnesia Sleepwalking Wake/ NREM Like confusional arousals with complex motor activity Incidental encounter or when approached Sleep terror Wake/ NREM Incomplete fearful awakening from NREM sleep Linked to frightening dream RSBD Wake/REM Acting out of dreams Linked to dream content Nocturnal paroxysmal dystonia All sleep stages (esp. N2) Bipedal automatisms, twisting of trunk/pelvis, vocalizations, posturing of head/limbs Accidental or related to hyperkinetic features Epileptic nocturnal wandering All sleep stages (esp. N2) Like sleepwalking, but more directed violence possible Accidental or when approached/ restrained Confusional states Awake Variable Variable Dissociative disorder Awake or wake/sleep Variable, frequently wandering, amnesia Self-harm, thrashing, assaults Malingering Awake Variable (evident primary or secondary gain) Variable 1 Mahowald MW, Bundlie SR, Hurwitz TD, et al. (1990) Sleep violence \200\224forensic scienc e impli- cations: polygraphic and video documentation. J Forensic Sci 35: 413 \200\22332. 1 Howell MJ, Schenck CH, and Crow SJ (2009) A review of nighttime eating disorders. Sleep M ed Rev 13: 23 \200\22334. 2 Schenck CH, Milner DM, Hurwitz TD, et al. (1989) Dissociative d isorders presenting as som- nambulism: polysomnographic, video and clinical documentation ( 8 cases). Dissociation 2: 194 \200\223204. 3 Rice E and Fisher C (1976) Fugue states in sle ep and wakefulness: a psychophysiological study. J Nerv Ment Dis 163: 79 \200\22387. 4 Sicl ari F, Khatami R, Urbaniok F, et al. (2010) Violence in sleep. Brain 133: 3494 \200\223509. 11_Semple_Chap11.indd 449 12/10/2012 6:29:02 PM CHAPTER 11 Sleep disorders 450 Sleep-related movement disorders Essence Usually relatively simple, stereotyped movements disturbing sleep, and causing inso mnia and EDS (see Table 11.9). Can also be a cause of sleep-related violence (see b p. 449) and lead to harm to self or others. Restless legs syndrome (Ekbom \200\231s syndrome)1 Unpleasant, often painful sensations in the legs, particularly on sleep onset. Signi \201 cantly interferes with the ability to ge t to sleep. Usually idiopathic or familial. Exacerbated by caffeine, fatigue, or stress. \200 \200 10% general population, 4 = 5, greater in the elderly. PLMS, pregnancy, uraemia, rheumatoi d arthritis, iron Prevalence: Associations: de \201 ciency anemia, folate de \201 ciency, hypothyroidism, p oliomyelitis, peripheral neuropathy (e.g. diabetes), chronic myelopathy, Parkinson \200\231 s disease, drug-related (e.g. antidepressants; phenothiazines; lithium; Ca2+ channel blocke rs; withdrawal from barbiturates, other sedatives and opiates). Differential diagnosis: Inv estigations: (polysomnography rarely needed). Management: General \200 or stimulation of the legs (rubbing, squeezing, hot showers, hot packs, ointments). Medication \200\224possi ble agents include: clonazepam, cabergoline, levodopa, ropinirole, rotigotine (patch), pram ipexole, opiates (oxycodone), clonidine, gabapentin (possibly other anti-epileptics), eithe r alone or in combination. \200 antipsychotic-induced akathisia, ADHD. full history, examination, routine blood tests \200\224treat any secondary causes. Movement (walking, stamping) Periodic limb movement (in sleep) disorder (PLMS)1 Periodic episodes of repetitive, stereot yped limb movements. Rare in children, common in over 60s (734%). May be a feature in up to 15% of patients with insomnia. Movements usually reported by bed partner. Associated dayti me somnolence. Polysomnography may aid diagnosis. \200 sleep starts (b p. 452), drug-related exacerbation Differential diagnosis: (e.g. TCAs, lithium). Management: levodopa. reassurance, remove exacerbating factors, clonazepam, Sleep-related leg cramps Sensations of painful muscular tightness or tension, in the calf ( or the foot), occurring during sleep, which awaken the sufferer. \200 Prevalence: elderly. Associated problems: arthritis, pregnancy, and Parkinson \200\231s dis ease. Differential diagnosis: following stroke, other neurological causes of muscle spastic ity. up to 16% of healthy individuals, more common in the excessive muscular activity, dehydration, diabetes, PLMS (painless), muscle spasm due to spasticity 11_Semple_Chap11.indd 450 12/10/2012 6:29:02 PM SLEEP-RELATED MOVEMENT DISORDERS 451 Management: muscle stretching; quinine sulfate (300mg nocte). only for severe, recurrent symptoms \200\224heat, massage, Sleep-related bruxism Clenching and grinding of the teeth during sleep that can result in a rousals. The activity may be severe or frequent enough to result in symptoms of temporomand ibular joint pain, wearing down of the teeth, or severe injury to the tongue and mouth. \200 Management factors, occlusal splints/night-time bite guard, use of clonazepam. General sleep hygiene measures, removal of exacerbating Sleep-related rhythmic movement disorder Stereotyped, repetitive movements involving large muscles, usually head and neck, typically immediately prior to sleep, sustained into light sleep. Common forms: head banging (jactatio capitis nocturna), head rolling, body rocking \200\224 movements may result in head injury. \200 Polysomnography: sleep, without evidence of epileptiform activity. Prevalence: (25% at 18mt hs, 8% at 4yrs). More frequent in boys. Associated problems: children). Management: in the majority of infants the disorder will resolve by around the age of 18 months. If injury or social disruption occurs, medication may be used (e.g. low-dose BDZ or antidepressant). rhythmic movement artifacts during light non-REM common in young children (60% at 9mths), decline with age developmental problems/psychopathology (older unnecessary in most cases. Parents can be reassured that Table 11.9 Classi \201 cation of sleep-related movement disorders with diagnostic codes ICSD-2 ICD-10 DSM-IV-TR Restless legs syndrome G25.81 Periodic limb movement disorder G47.61 Sleep-related leg cramps G47.62 Sleep-related bruxism G47.63 Sleep-related rhythmic movement disorder G47.69 Other sleep-related movement disorder, unspeci \201 ed G47.60 Sleep-related rhythmic movement disorder due to a drug or substance F10 \200\22319 292.85 Sleep-related rhythmic movement disorder due to a medical condition 1 Vignatelli L, Billiard M, Clarenbach P, et al. (2006) EFNS guidelines on management of re stless legs syndrome and periodic limb movement disorder in sleep. Eur J Neurol 13: 1049 \200\22365. 11_Semple_Chap11.indd 451 12/10/2012 6:29:02 PM CHAPTER 11 Sleep disorders 452 Isolated symptoms, apparently normal variants, and unresolved issues Essence Conditions that sit on the borderline between normal and abnormal sleep (see Table 11.10). Rarely pathological, they may nonetheless become a focus of anxiety and a reason fo r consultation. Long sleeper Sleep is normal in architecture and quality, but lasts longer than normal (i.e . >10hrs). The person may complain of EDS if they do not get their usual amount of sleep. Short sleeper Someone who requires 5hrs or less of sleep/day. In children, short sleepers n eed 73hrs less than the norm for their age. Snoring Respiratory sounds that are disturbing to the patient, bed partner, or others, but not associated with either insomnia, EDS, or other sleep disorder (e.g. OSA). Sleep-talking (somniloquy) The common uttering of words or sounds during sleep, without sub jective awareness, and speech generally devoid of meaning. Rarely, emotionally charged long \200\230tirades \200\231 occur with content related to the person \200\231s occupa- tion or preoccupation. \200 brief partial arousal during non-REM sleep is usually Polysomnogra phy: seen on EEG in about 60% of cases. Less commonly, somniloquy may occur during REM slee p, if related to dream content or in association with another disorder of REM sleep. Associ ated disorders: related eating disorder. unless the problem is leading to disruption of sle ep in Management: a bed partner, or is a secondary symptom of other sleep pathology, treatm ent is rarely necessary.