Disorders of arousal from non-rapid eye movement sleep in adults
- Nancy Foldvary-Schaefer, DO, MS
Nancy Foldvary-Schaefer, DO, MS
- Professor of Neurology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
- Director, Cleveland Clinic Sleep Disorders Center
Disorders of arousal from non-rapid eye movement (NREM) sleep are parasomnias that include confusional arousals, sleepwalking, sleep terrors, and their variants. They are classified as distinct entities, but in reality, they represent a spectrum of sleep-related behaviors that occur as a result of incomplete transition out of deep NREM sleep.
While disorders of arousal typically present in childhood, they may continue into adulthood, remit and recur in adulthood, or present de novo in adults. NREM disorders of arousal must be distinguished from other sleep-related conditions that occur in adults, including rapid eye movement (REM) sleep behavior disorder (RBD), movement disorders of sleep, and nocturnal seizures.
Disorders of arousal are an important cause of sleep-related injury in adults. Management consists primarily of education, environmental and behavioral modifications to promote safety, and identification of predisposing and triggering factors to minimize the number of episodes.
The clinical features, diagnosis, and management of disorders of arousal in adults will be reviewed here. A more general approach to abnormal movements and behaviors during sleep is presented elsewhere. Other parasomnias in adults and disorders of arousal and other parasomnias in children are also reviewed separately. (See "Approach to abnormal movements and behaviors during sleep" and "Rapid eye movement sleep behavior disorder" and "Sleepwalking and other parasomnias in children".)
Disorders of arousal are more prevalent in children than adults, and estimates in adults are largely drawn from survey studies.
- 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.
- Laberge L, Tremblay RE, Vitaro F, Montplaisir J. Development of parasomnias from childhood to early adolescence. Pediatrics 2000; 106:67.
- Ohayon MM, Mahowald MW, Leger D. Are confusional arousals pathological? Neurology 2014; 83:834.
- Hublin C, Kaprio J, Partinen M, et al. Prevalence and genetics of sleepwalking: a population-based twin study. Neurology 1997; 48:177.
- Lopez R, Jaussent I, Scholz S, et al. Functional impairment in adult sleepwalkers: a case-control study. Sleep 2013; 36:345.
- Guilleminault C, Kirisoglu C, da Rosa AC, et al. Sleepwalking, a disorder of NREM sleep instability. Sleep Med 2006; 7:163.
- Tassinari CA, Gardella E, Cantalupo G, et al. Central pattern generators relationships to parasomnias and sleep-related epileptic seizures. Sleep Med Clin 2012; 7:125.
- Licis AK, Desruisseau DM, Yamada KA, et al. Novel genetic findings in an extended family pedigree with sleepwalking. Neurology 2011; 76:49.
- Tinuper P, Bisulli F, Cross JH, et al. Definition and diagnostic criteria of sleep-related hypermotor epilepsy. Neurology 2016; 86:1834.
- Hoda JC, Gu W, Friedli M, et al. Human nocturnal frontal lobe epilepsy: pharmocogenomic profiles of pathogenic nicotinic acetylcholine receptor beta-subunit mutations outside the ion channel pore. Mol Pharmacol 2008; 74:379.
- Combi R, Dalprà L, Ferini-Strambi L, Tenchini ML. Frontal lobe epilepsy and mutations of the corticotropin-releasing hormone gene. Ann Neurol 2005; 58:899.
- Bisulli F, Vignatelli L, Naldi I, et al. Increased frequency of arousal parasomnias in families with nocturnal frontal lobe epilepsy: a common mechanism? Epilepsia 2010; 51:1852.
- Provini F, Plazzi G, Tinuper P, et al. Nocturnal frontal lobe epilepsy. A clinical and polygraphic overview of 100 consecutive cases. Brain 1999; 122 ( Pt 6):1017.
- Tinuper P, Bisulli F, Provini F. The parasomnias: mechanisms and treatment. Epilepsia 2012; 53 Suppl 7:12.
- Chung SA, Yegneswaran B, Natarajan A, et al. Frequency of sexsomnia in sleep clinic patients. Sleep 2010; 33:A226.
- Ingravallo F, Poli F, Gilmore EV, et al. Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports. J Clin Sleep Med 2014; 10:927.
- Bušková J, Piško J, Pastorek L, Šonka K. The course and character of sleepwalking in adulthood: a clinical and polysomnographic study. Behav Sleep Med 2015; 13:169.
- American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Brion A, Flamand M, Oudiette D, et al. Sleep-related eating disorder versus sleepwalking: a controlled study. Sleep Med 2012; 13:1094.
- Chiaro G, Caletti MT, Provini F. Treatment of sleep-related eating disorder. Curr Treat Options Neurol 2015; 17:361.
- US Food and Drug Administration (FDA) requests label change for all sleep disorder drug products. Available at: www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108868.htm (Accessed on September 23, 2015).
- Howell MJ, Schenck CH. Restless nocturnal eating: a common feature of Willis-Ekbom Syndrome (RLS). J Clin Sleep Med 2012; 8:413.
- Hwang TJ, Ni HC, Chen HC, et al. Risk predictors for hypnosedative-related complex sleep behaviors: a retrospective, cross-sectional pilot study. J Clin Psychiatry 2010; 71:1331.
- Dolder CR, Nelson MH. Hypnosedative-induced complex behaviours : incidence, mechanisms and management. CNS Drugs 2008; 22:1021.
- Schenck CH, Pareja JA, Patterson AL, Mahowald MW. Analysis of polysomnographic events surrounding 252 slow-wave sleep arousals in thirty-eight adults with injurious sleepwalking and sleep terrors. J Clin Neurophysiol 1998; 15:159.
- Derry CP, Harvey AS, Walker MC, et al. NREM arousal parasomnias and their distinction from nocturnal frontal lobe epilepsy: a video EEG analysis. Sleep 2009; 32:1637.
- Perrault R, Carrier J, Desautels A, et al. Electroencephalographic slow waves prior to sleepwalking episodes. Sleep Med 2014; 15:1468.
- Fois C, Wright MA, Sechi G, et al. The utility of polysomnography for the diagnosis of NREM parasomnias: an observational study over 4 years of clinical practice. J Neurol 2015; 262:385.
- 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.
- Pilon M, Montplaisir J, Zadra A. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology 2008; 70:2284.
- Proserpio P, Cossu M, Francione S, et al. Epileptic motor behaviors during sleep: anatomo-electro-clinical features. Sleep Med 2011; 12 Suppl 2:S33.
- Unnwongse K, Wehner T, Foldvary-Schaefer N. Mesial frontal lobe epilepsy. J Clin Neurophysiol 2012; 29:371.
- Rheims S, Ryvlin P, Scherer C, et al. Analysis of clinical patterns and underlying epileptogenic zones of hypermotor seizures. Epilepsia 2008; 49:2030.
- Pedley TA, Guilleminault C. Episodic nocturnal wanderings responsive to anticonvulsant drug therapy. Ann Neurol 1977; 2:30.
- Derry CP, Davey M, Johns M, et al. Distinguishing sleep disorders from seizures: diagnosing bumps in the night. Arch Neurol 2006; 63:705.
- 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.
- 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.
- Schenck CH, Boyd JL, Mahowald MW. A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases. Sleep 1997; 20:972.
- Schenck CH, Howell MJ. Spectrum of rapid eye movement sleep behavior disorder (overlap between rapid eye movement sleep behavior disorder and other parasomnias). Sleep and Biological Rhythms 2013; 11:27.
- Dumitrascu O, Schenck CH, Applebee G, Attarian H. Parasomnia overlap disorder: a distinct pathophysiologic entity or a variant of rapid eye movement sleep behavior disorder? A case series. Sleep Med 2013; 14:1217.
- Provini F. Agrypnia excitata. Curr Neurol Neurosci Rep 2013; 13:341.
- Devinsky O, Gazzola D, LaFrance WC Jr. Differentiating between nonepileptic and epileptic seizures. Nat Rev Neurol 2011; 7:210.
- Duncan R, Oto M, Russell AJ, Conway P. Pseudosleep events in patients with psychogenic non-epileptic seizures: prevalence and associations. J Neurol Neurosurg Psychiatry 2004; 75:1009.
- Marchand L, Marchand A, Landry P, et al. Efficacy of two cognitive-behavioral treatment modalities for panic disorder with nocturnal panic attacks. Behav Modif 2013; 37:680.
- Terzaghi M, Sartori I, Rustioni V, Manni R. Sleep disorders and acute nocturnal delirium in the elderly: a comorbidity not to be overlooked. Eur J Intern Med 2014; 25:350.
- Guilleminault C, Kirisoglu C, Bao G, et al. Adult chronic sleepwalking and its treatment based on polysomnography. Brain 2005; 128:1062.
- Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and sleep terrors in prepubertal children: what triggers them? Pediatrics 2003; 111:e17.
- Arnulf I, Rico TJ, Mignot E. Diagnosis, disease course, and management of patients with Kleine-Levin syndrome. Lancet Neurol 2012; 11:918.
- Mukaddes NM, Alyanak B, Kora ME, Polvan O. The psychiatric symptomatology in Kleine-Levin syndrome. Child Psychiatry Hum Dev 1999; 29:253.
- Wills L, Garcia J. Parasomnias: epidemiology and management. CNS Drugs 2002; 16:803.
- Hurwitz TD, Mahowald MW, Schenck CH, et al. A retrospective outcome study and review of hypnosis as treatment of adults with sleepwalking and sleep terror. J Nerv Ment Dis 1991; 179:228.
- Attarian H, Zhu L. Treatment options for disorders of arousal: a case series. Int J Neurosci 2013; 123:623.
- Schenck CH, Mahowald MW. Long-term, nightly benzodiazepine treatment of injurious parasomnias and other disorders of disrupted nocturnal sleep in 170 adults. Am J Med 1996; 100:333.
- Schenck CH, Hurwitz TD, O'Connor KA, Mahowald MW. Additional categories of sleep-related eating disorders and the current status of treatment. Sleep 1993; 16:457.
- Béjot Y, Juenet N, Garrouty R, et al. Sexsomnia: an uncommon variety of parasomnia. Clin Neurol Neurosurg 2010; 112:72.
- Miyaoka T, Yasukawa R, Tsubouchi K, et al. Successful treatment of nocturnal eating/drinking syndrome with selective serotonin reuptake inhibitors. Int Clin Psychopharmacol 2003; 18:175.
- Shapira NA, Goldsmith TD, McElroy SL. Treatment of binge-eating disorder with topiramate: a clinical case series. J Clin Psychiatry 2000; 61:368.
- Winkelman JW. Efficacy and tolerability of open-label topiramate in the treatment of sleep-related eating disorder: a retrospective case series. J Clin Psychiatry 2006; 67:1729.
- Schenck CH, Hurwitz TD, Bundlie SR, Mahowald MW. Sleep-related eating disorders: polysomnographic correlates of a heterogeneous syndrome distinct from daytime eating disorders. Sleep 1991; 14:419.
- Provini F, Albani F, Vetrugno R, et al. A pilot double-blind placebo-controlled trial of low-dose pramipexole in sleep-related eating disorder. Eur J Neurol 2005; 12:432.
- PATHOPHYSIOLOGY AND GENETICS
- Association with nocturnal frontal lobe epilepsy
- CLINICAL FEATURES
- Clinical manifestations
- - Confusional arousals
- Sleep-related abnormal sexual behavior
- - Sleep terrors
- - Sleepwalking
- Sleep-related eating disorder
- Common precipitating factors
- Polysomnographic features
- DIFFERENTIAL DIAGNOSIS
- Nocturnal seizures
- REM sleep behavior disorder
- Parasomnia overlap disorder
- SUMMARY AND RECOMMENDATIONS