Parasomnias

What is parasomnia?

Parasomnias are a type of sleep disorder that causes abnormal experiences or behaviors during sleep. These can happen as you’re falling asleep, during sleep or right before you wake up.

If you have a parasomnia, you might:

• Talk in your sleep
• Sleepwalk
• Have nightmares
• Wake up confused
• Not remember what you did during the night

When these events occur, others may think you’re awake, but you’re actually asleep. In the morning, you might not remember what you did while you were sleeping.

What are the types of parasomnias?

There are three main groupings of parasomnias based on the stage of sleep in which they happen.

• Non-rapid eye movement (non-REM) sleep. Non-REM sleep is the first three stages of sleep — from first falling asleep to about the first half of the night. Non-REM sleep parasomnias involve physical and verbal activity.
• Rapid eye movement (REM) sleep. REM sleep follows the three non-REM stages of the sleep cycle. During REM sleep, your eyes rapidly move under your eyelids and your heart rate, breathing and blood pressure increase. This is a time when vivid dreaming occurs. Parasomnias happen during the latter part of the night.
• Other. Some parasomnias fall into this category because they don’t fit into either a non-REM or an REM sleep phase.

Non-REM sleep parasomnias

The types of non-REM sleep parasomnias include:

• Sleep terrors. Sleep terrors happen when you wake up suddenly scared. You may scream or cry in fright. Sleep terrors are usually brief (30 seconds), but can last up to a few minutes. You may also experience a racing heart rate, dilated pupils, fast breathing and sweating.
• Sleepwalking (somnambulism). With sleepwalking, you get out of bed and move about with your eyes wide open, but you’re asleep. You may perform complex activities — such as driving or playing a musical instrument — or do things you wouldn’t normally do, like pee in an area without a toilet.
• Confusional arousals. Like its name, when you wake up, you feel confused and disoriented. You may sit up, have your eyes open or express emotions like crying. You may speak slowly or not understand what others are saying to you. The episode may last for a few minutes to hours. Confusional arousal is common in childhood and tends to decrease with age.

REM sleep parasomnias

The types of REM sleep parasomnias include:

• Nightmare disorder. Nightmares are vivid dreams that cause feelings of fear, terror and/or anxiety. If you wake up during your nightmare, you’ll be able to describe your dream in detail. It can be difficult to fall back asleep after you wake up.
• Recurrent isolated sleep paralysis. Sleep paralysis causes you to wake up and you can’t move your body. It usually happens when your muscles are already relaxed, like before you fall asleep or as you wake up. Episodes may last seconds to a few minutes. These can be stressful and cause fear and panic. You may jolt out of sleep paralysis if someone speaks or touches you.
• REM sleep behavior disorder (RSBD). With RSBD, you act out, vocalize (talk, swear, laugh, shout) or make aggressive movements (punching, kicking, grabbing) as a reaction to a violent dream. This sleep disorder is more common among adults and people with neurodegenerative diseases like Parkinson’s disease, Lewy body dementia or multiple system atrophy.

Other parasomnias

Parasomnia types that don’t fit into non-REM and REM sleep categories include:

• Sleep enuresis (bedwetting). This is the accidental release of pee during sleep. Parasomnia bedwetting usually happens after age 5. It occurs at least two times a week for at least three months.
• Sleep-related groaning (catathrenia). This causes you to make repeated moaning or groaning noises (long groans followed by sighs or grunts) during sleep.
• Exploding head syndrome. This sleep disorder causes you to hear a loud noise or explosive crashing sound in your head as you’re falling asleep or waking up. You may also see an imaginary flash of light or have a sudden muscle jerk.
• Sleep-related hallucinations. Sleep-related hallucinations cause you to experience false perceptions as you’re falling asleep or waking up. You may see, hear or feel things that don’t really exist.
• Sleep-related eating disorder. This sleep disorder causes you to eat and drink while you’re sleeping. You may eat foods or food combinations you wouldn’t eat if you were awake (such as uncooked chicken or a stick of butter). Dangers include eating inedible or toxic foods, choking or injuries (like cuts or burns) from preparing or cooking foods.
• Sexsomnia. You may carry out sexual behaviors during your sleep. These could include intercourse, masturbation, sexual assault, touching your bed partner or sexual vocalizations.

How common are parasomnias?

Some parasomnias are more common than others. Since there are a variety of types, one study estimated that 4% to 67% of adults around the world experienced parasomnia in their lifetime.

What are the symptoms of parasomnia?

Parasomnia symptoms vary based on the type but could include:

• Difficulty sleeping through the night
• Doing things you wouldn’t typically do when you’re awake while sleeping
• Feeling strong emotions when waking up (fear, stress, anxiety)
• Feeling tired during the day
• Having bad dreams
• Making wakeful movements during sleep (grabbing objects, walking)
• Making vocalizations (talking, yelling) while sleeping
• Waking up confused or disoriented

What causes parasomnia?

There are several possible causes of parasomnias. Your symptoms may be the result of something interfering with your ability to sleep through the night, like:

• An irregular sleep-wake schedule (from jet lag or shift work, for example)
• Difficulty for your body to transition from being awake to falling asleep
• Your genes (genetic predisposition)
• Lack of sleep-wake cycle maturity (in children)

Medications that cause parasomnia

Certain medications can disrupt your sleep cycle and lead to parasomnia including:

• Antibiotics (fluoroquinolones)
• Antidepressants (amitriptyline, bupropion, paroxetine, mirtazapine)
• Antiseizure medications (topiramate)
• Antipsychotics (quetiapine, olanzapine)
• Asthma/allergy medications (montelukast)
• High blood pressure medications (propranolol, metoprolol)
• Sedatives (benzodiazepines, zolpidem)

Underlying health conditions that cause parasomnia

There are several medical conditions that can cause parasomnia symptoms. Common conditions include:

• Chronic pain
• Circadian rhythm disorders
• Narcolepsy
• Obstructive sleep apnea
• Periodic limb movement disorder
• Restless legs syndrome

Other common conditions or events that can cause parasomnia include:

• Alcohol or substance abuse disorder
• Inflammatory disease (encephalitis)
• Mental health conditions (depression, anxiety, post-traumatic stress disorder)
• Neurological conditions (Parkinson’s disease, Lewy body dementia, stroke, multiple system atrophy, multiple sclerosis, brain tumors, migraines, and spinocerebellar ataxia type three)
• Pregnancy
• Traumatic brain injury (TBI)

What triggers parasomnia?

Triggers are things that cause symptoms to happen. Triggers for parasomnia are different for each person but may include:

• Certain medications
• Drinking alcohol before bed
• Fever
• Hearing certain noises
• Not getting enough sleep (sleep deprivation)
• Physical touch
• Stress

What are the risk factors for parasomnia?

Parasomnias can affect anyone at any age. Children and young adults between ages 5 and 25 are more likely to develop non-REM parasomnias. Parasomnias in children usually happen with neurologic or psychiatric health conditions like epilepsy, attention-deficit/hyperactivity disorder (ADHD) or developmental challenges.

REM parasomnias most often affect people during adulthood. They usually appear alongside an underlying neurological or degenerative brain condition.

You may be more at risk of non-REM parasomnias if someone in your biological family has one.

What are the complications of parasomnia?

Complications of parasomnia may include:

• Depression
• Physical injury to yourself and others
• Poor performance at work or school
• Sleep anxiety
• Stress

It’s very rare for parasomnias to cause fatal physical injuries.

How is parasomnia diagnosed?

A healthcare provider, usually a sleep specialist (somnologist), will diagnose parasomnia after a physical exam, neurological exam and testing.

During the exam, your provider will learn more about your symptoms. They may ask your bed partner or others who observed your behavior while you sleep to describe what they noticed. They’ll take a complete medical history and your family medical history, and they’ll learn more about what medications or supplements you currently take. Your provider will also ask you if you use alcohol or any non-prescribed drugs or substances, since those can affect your sleep.

Your provider will likely ask you to keep a sleep diary for at least one week. This is a record of when you go to bed, when you fall asleep, when you wake up and if you experienced any events or symptoms. A sleep diary is helpful for your provider to learn more about your sleep patterns.

What tests diagnose parasomnia?

Testing can help your provider rule out conditions with similar symptoms and narrow down the cause. Tests for parasomnias could include:

• Sleep study (polysomnogram). During a sleep study, providers will monitor as you sleep. They’ll record your brain waves, heart rate, eye movements and breathing.
• Video electroencephalogram (EEG) or sleep EEG. These tests help your healthcare provider see and record your brain activity during a brain event while sleeping.
• Imaging tests. CT or MRI scans can detect brain degeneration or other possible causes.

Is there a cure for parasomnia?

There isn’t a single cure for all parasomnias. Treatment is available to help you manage symptoms throughout your life. Many children notice parasomnias reduce or go away as they get older.

How is parasomnia treated?

Treatment can vary based on each type of parasomnia. But all parasomnias can benefit from the following:

• Follow good sleep hygiene habits (get seven to nine hours of sleep per night, turn off lights and electronic devices, keep room temperature cool, avoid caffeine and strenuous exercise near bedtime, etc.).
• Maintain a regular sleep-wake schedule with a consistent bedtime and wake-up time.
• Limit alcohol intake and don’t use non-prescribed drugs or substances.
• Take all prescribed medications as directed by your healthcare provider.
• Participate in cognitive behavioral therapy (CBT).

Your healthcare provider will discuss the best treatment options for your specific type of parasomnia considering your unique health history and any underlying medical conditions.

What medications treat parasomnia?

Medications that treat parasomnias include:

• Benzodiazepines
• Selective serotonin reuptake inhibitors (SSRIs)
• Tricyclic antidepressants
• Clonazepam
• Melatonin

Your provider might prescribe medications for REM parasomnias but most likely not for non-REM parasomnias unless they’re long-lasting or potentially harmful. Medications aren’t the first line of treatment for parasomnias but they can be effective if proper sleep hygiene and bedtime habits don’t resolve your symptoms.

How are parasomnias in children treated?

Some childhood parasomnias don’t need treatment since they resolve on their own as your child gets older.

Children who experience parasomnias may wake up scared, confused or anxious. Offering calming reassurance and reminding your child that everything is OK may help manage occasional parasomnias. But let their pediatrician know if parasomnias happen frequently and affect your child’s ability to function during the daytime.

Medications are rarely necessary, but if they are, they’re typically only prescribed for three to six weeks. Common medications include benzodiazepines or anti-anxiety medications.

Can parasomnia be prevented?

You can’t prevent all causes of parasomnias, such as those from neurological diseases, mental health conditions or genetics. The best way to reduce your risk of parasomnias is to practice good sleep hygiene. Also, ask your healthcare provider to review your current medications. Many can disrupt sleep. If this is the case, your provider may offer an alternative medication to avoid side effects.

How can I prevent parasomnia injuries?

Your healthcare provider may offer tips to keep you safe if you experience parasomnias, like sleepwalking or REM sleep behavior disorder, where injury during sleep is possible. Tips may include:

• Sleep on the first floor.
• Avoid sleeping in bunk beds or lofted beds; keep your mattress close to the floor.
• Avoid co-sleeping (sharing the bed with someone else).
• Move furniture or lamps away from beside the bed or use padding on potentially hazardous areas in your bedroom.
• Use plastic cups instead of glass if you prefer to keep a cup of water in your room.
• Use childproof doorknobs.
• Remove or lock up any weapons or dangerous items in your home.
• Install alarms on windows and doors.

What can I expect if I have a parasomnia?

It’s normal to experience occasional parasomnias like nightmares throughout your life. Sometimes, sleep disturbances happen frequently and interfere with your ability to stay awake during the daytime and function as expected.

Each person’s experience with parasomnia is different. A child may outgrow certain nighttime behaviors or natural aging could bring on more sleep disturbances. No matter what situation you’re in, if you’re not getting the rest you need to feel well during the daytime, a healthcare provider can help you.

Treatment options are available and range from changing your sleep routine to taking medications regularly. Your provider may modify the medications you take if parasomnia is a side effect.

When should I see a healthcare provider?

Visit a healthcare provider if:

• You’re not getting enough sleep
• The quality of your sleep is poor
• You have frequent sleep disturbances
• You wake up confused
• You feel like you can’t move when you wake up
• You’re toilet trained and wet the bed often

If anything about your sleep routine is concerning, let a provider know. They can help you get the sleep your body needs.

What questions should I ask my healthcare provider?

You may want to ask your provider:

• What type of parasomnia do I have?
• How can I improve my sleep hygiene?
• What type of treatment do you recommend?
• Are there side effects of treatment?
• How can I improve my sleep safety?
• How soon after treatment will my symptoms go away?