Approach to abnormal movements and behaviors during sleep
- Bradley V Vaughn, MD
Bradley V Vaughn, MD
- Professor of Neurology, Biomedical Engineering and Allied Health
- University of North Carolina
Abnormal movements and behaviors during sleep are part of a larger group of nocturnal events that may occur during sleep, wake, or the transitions into or out of sleep. These events are most common early in life, affecting approximately 15 to 20 percent of children and 4 percent of adults [1-4].
Nocturnal events are typically divided into simple behaviors (eg, single movements, repetitive or periodic movements, rhythmical movements) and complex behaviors (eg, sleep talking, sleepwalking, sleep terrors, dream enactment) (table 1). Most simple movements occur during the transition from wake to sleep or sleep to wake or during light, non-rapid eye movement (NREM) sleep (figure 1). Complex behaviors can result from disruption of the control mechanisms of the three normal states of being: wake, NREM sleep, and rapid eye movement (REM) sleep.
Occasionally, simple or complex motor patterns during sleep are a manifestation of seizures, dissociative psychiatric events, or even physiological states such as hypoglycemia. Therefore, clinicians should be aware that nocturnal events may be a manifestation of specific neurologic, medical, psychiatric, or sleep disorders. On the other hand, some of these behaviors, specifically the disorders of arousal and nightmares, may be normal in childhood.
A detailed history, including a clear description from the patient and ideally a bed partner or family witness, is the cornerstone of establishing clues about the underlying etiology. The challenge for the clinician is to recognize when certain nocturnal events signal an underlying, treatable disorder, an emerging neurological abnormality, or a benign age-appropriate episode.
An approach to the evaluation and diagnosis of abnormal movements and behaviors during sleep is presented here. Additional topics on the diagnosis and treatment of specific parasomnias and sleep-related movement disorders in both children and adults can be found elsewhere. (See "Sleepwalking and other parasomnias in children" and "Disorders of arousal from non-rapid eye movement sleep in adults" and "Rapid eye movement sleep behavior disorder" and "Clinical features and diagnosis of restless legs syndrome/Willis-Ekbom disease and periodic limb movement disorder in adults" and "Restless legs syndrome/Willis-Ekbom disease and periodic limb movement disorder in children".)
- International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Ohayon MM, Mahowald MW, Dauvilliers Y, et al. Prevalence and comorbidity of nocturnal wandering in the U.S. adult general population. Neurology 2012; 78:1583.
- Ohayon MM, Guilleminault C, Priest RG. Night terrors, sleepwalking, and confusional arousals in the general population: their frequency and relationship to other sleep and mental disorders. J Clin Psychiatry 1999; 60:268.
- Kales A, Soldatos CR, Bixler EO, et al. Hereditary factors in sleepwalking and night terrors. Br J Psychiatry 1980; 137:111.
- Sharpless BA. Exploding head syndrome. Sleep Med Rev 2014; 18:489.
- Ohayon MM. Prevalence of hallucinations and their pathological associations in the general population. Psychiatry Res 2000; 97:153.
- Silber MH, Hansen MR, Girish M. Complex nocturnal visual hallucinations. Sleep Med 2005; 6:363.
- Wichniak A, Tracik F, Geisler P, et al. Rhythmic feet movements while falling asleep. Mov Disord 2001; 16:1164.
- Bassetti C, Vella S, Donati F, et al. SPECT during sleepwalking. Lancet 2000; 356:484.
- Oliviero A, Della Marca G, Tonali PA, et al. Functional involvement of cerebral cortex in adult sleepwalking. J Neurol 2007; 254:1066.
- Sharpless BA, McCarthy KS, Chambless DL, et al. Isolated sleep paralysis and fearful isolated sleep paralysis in outpatients with panic attacks. J Clin Psychol 2010; 66:1292.
- Germain A, Nielsen TA. Sleep pathophysiology in posttraumatic stress disorder and idiopathic nightmare sufferers. Biol Psychiatry 2003; 54:1092.
- Hobson JA. REM sleep and dreaming: towards a theory of protoconsciousness. Nat Rev Neurosci 2009; 10:803.
- Schenck CH, Milner DM, Hurwitz TD, et al. A polysomnographic and clinical report on sleep-related injury in 100 adult patients. Am J Psychiatry 1989; 146:1166.
- Schenck CH, Mahowald MW. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep 2002; 25:120.
- Vaughn BV, Ali I. Sleep and epilepsy: opportunities for diagnosis and treatment. Neurol Clin 2012; 30:1249.
- D'Cruz OF, Vaughn BV. Nocturnal seizures mimic REM behavior disorder. Am J Electroneurodiagnostic Technol 1997; 37:258.
- Brassington GS, King AC, Bliwise DL. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years. J Am Geriatr Soc 2000; 48:1234.
- Papadimitriou GN, Linkowski P. Sleep disturbance in anxiety disorders. Int Rev Psychiatry 2005; 17:229.
- Levin R, Nielsen TA. Disturbed dreaming, posttraumatic stress disorder, and affect distress: a review and neurocognitive model. Psychol Bull 2007; 133:482.
- Rice E, Fisher C. Fugue states in sleep and wakefulness: a psychophysiological study. J Nerv Ment Dis 1976; 163:79.
- Merckelbach H, Dekkers T, Wessel I, Roefs A. Amnesia, flashbacks, nightmares, and dissociation in aging concentration camp survivors. Behav Res Ther 2003; 41:351.
- Boeve BF, Molano JR, Ferman TJ, et al. Validation of the Mayo Sleep Questionnaire to screen for REM sleep behavior disorder in a community-based sample. J Clin Sleep Med 2013; 9:475.
- Manni R, Terzaghi M, Repetto A. The FLEP scale in diagnosing nocturnal frontal lobe epilepsy, NREM and REM parasomnias: data from a tertiary sleep and epilepsy unit. Epilepsia 2008; 49:1581.
- Chen LF, Lin CE, Chou YC, et al. A comparison of complex sleep behaviors with two short-acting Z-hypnosedative drugs in nonpsychotic patients. Neuropsychiatr Dis Treat 2013; 9:1159.
- Pressman MR, Mahowald MW, Schenck CH, Bornemann MC. Alcohol-induced sleepwalking or confusional arousal as a defense to criminal behavior: a review of scientific evidence, methods and forensic considerations. J Sleep Res 2007; 16:198.
- Dyken ME, Afifi AK, Lin-Dyken DC. Sleep-related problems in neurologic diseases. Chest 2012; 141:528.
- Prashad PS, Marcus CL, Brown LW, et al. Brain tumor presenting as somnambulism in an adolescent. Pediatr Neurol 2013; 49:209.
- Bell DS. Nocturnal hypoglycaemia presenting as somnambulism. Diabetologia 2010; 53:2066.
- Foldvary-Schaefer N, Alsheikhtaha Z. Complex nocturnal behaviors: nocturnal seizures and parasomnias. Continuum (Minneap Minn) 2013; 19:104.
- Postuma RB, Aarsland D, Barone P, et al. Identifying prodromal Parkinson's disease: pre-motor disorders in Parkinson's disease. Mov Disord 2012; 27:617.
- Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005; 28:499.
- Pilon M, Montplaisir J, Zadra A. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology 2008; 70:2284.
- Pilon M, Zadra A, Joncas S, Montplaisir J. Hypersynchronous delta waves and somnambulism: brain topography and effect of sleep deprivation. Sleep 2006; 29:77.
- TYPES OF NOCTURNAL EVENTS
- Simple or single movements
- Periodic or rhythmic movements
- Complex movements and behaviors (parasomnias)
- - During NREM sleep
- - During REM sleep
- Nocturnal epilepsy
- Panic or dissociative events
- - Event description
- - Provocative factors
- - Symptoms of other sleep disorders
- Physical examination
- Overnight video polysomnography
- Other testing