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Parasomnias: Unusual and Undesirable - The Apeiron Life Perspective



What is is:

Parasomnias are sleep disorders in which one or more unusual behaviors occur during sleep. The most well-known of these are teeth-grinding (bruxism) and sleepwalking, which are quite common during childhood but can appear at any age. However, there are several other parasomnias to be aware of, as these can disrupt quality of life and even indicate potential underlying health conditions.



The purported claims:

  • Different parasomnias are associated with different sleep stages 

  • A family history of similar parasomnias increases the risk 

  • Many parasomnias can be managed with behavioral or pharmacologic interventions



What the science says:

By and large, the most common sleep disorders are insomnia and obstructive sleep apnea. Highly effective treatments are available for these conditions, including cognitive behavioral therapy for insomnia (CBTi) and continuous positive airway pressure (CPAP) for individuals who need assistance keeping airways open during the night. Thankfully, these disorders and their treatments are becoming better recognized by primary care physicians, and research into new therapies is advancing.


Less discussed, however, are a handful of other sleep disorders that can present across the lifespan. Depending on the disorder, it may or may not seriously affect the sleeper. They can, however, be concerning for bed partners or other household members.



NREM Parasomnias


As a rule of thumb, parasomnias that occur during non-rapid eye movement (NREM) sleep tend to manifest in early life, and many individuals grow out of the disorder sometime in early adulthood. However, some individuals experience symptoms well past this. NREM parasomnias include bruxism, sleepwalking, confusional arousals, sexsomnia, sleep-eating, and night terrors.


Bruxism

Jaw-clenching or teeth-grinding during sleep may affect up to a third of the population at some point in their lives. Chronic stress is accepted as the most significant risk factor for bruxism. Excess arousal of the sympathetic (“fight or flight”) nervous system, triggered by stress, can induce micro-awakenings from sleep, accompanied by clenching or jaw bracing. Treatment typically involves a combination of stress management, relaxation techniques, and an oral appliance such as a mouthguard. 


Sleepwalking

Sleepwalking occurs during deep/slow-wave sleep (NREM stage 3), which is typically most prevalent during the first half of the night. During an episode, sleepwalkers may or may not actually get out of bed and walk around (sometimes they will just sit up in bed), but their eyes are typically open, and they may or may not speak in a slurred voice. 


Up to 80% of children are thought to sleepwalk, while the prevalence in adulthood is estimated at just 1-4%. During an episode, adults may attempt routine tasks such as walking around the bedroom, opening the blinds, looking in the fridge, or going to the restroom. Individuals rarely recall these episodes. 


If awoken while sleepwalking, individuals tend to feel very confused and groggy. Instead, it’s better to let the person safely return to bed and continue with their sleep episode. Bed partners or roommates who witness these events can assist by gently removing any hazards from the sleepwalker’s path.


A family history of sleepwalking is the leading risk factor for an individual. However, risk can be exacerbated by periods of sleep deprivation, stress, fever, or with the use of certain medications. Treatment generally includes scheduled awakenings prior to when episodes usually occur, as well as medication in some instances.


Confusional Arousals

These episodes can include talking or simple movements when NREM sleep is disrupted and are not remembered by the sleeper. Confusional arousals often accompany other sleep disorders, such as narcolepsy and obstructive sleep apnea, and may also worsen if individuals take sleep-disrupting medications. Treatment typically includes a consistent sleep schedule and occasionally medications that stabilize sleep.


Sexsomnia 

As the name suggests, this disorder is characterized by sexual behavior during sleep that the sleeper does not remember. It is categorized as a confusional arousal subtype and can include masturbation, vocalizations, or full sexual intercourse with a bed partner. This disorder is poorly researched due to embarrassment, which prevents many people from seeking help. However, the condition can be serious if it leads to sexual assault. 


Many health professionals are not aware that this is a sleep disorder, so a referral to a sleep medicine specialist is essential. Sometimes, psychotherapy alone can be an effective intervention. However, sexsomnia can also be a secondary disorder to conditions such as sleep apnea, so treatment may be multifaceted. 


Sleep-eating

Some sleepwalkers occasionally eat during their sleep, which isn’t always harmful, but some sleep-eaters put themselves at risk of illness by consuming raw foods or large quantities of unusual foods such as slabs of butter or whole jars of peanut butter. 


Treatment typically involves screening out other underlying sleep disorders and normalizing the person’s sleep and meal schedule. Medications may also be used in some cases.


Night Terrors

These episodes typically involve sleepers sitting up in bed with intense fear and screaming or shouting. The terror might not be remembered by the sleeper, but these episodes can be very distressing for bed partners. Any attempts to get out of bed and run away from the apparent harm can also result in injuries for the sleeper. There is an association between night terrors and psychiatric disorders, including anxiety and depression, and certain psychiatric medications can alleviate symptoms.



REM Parasomnias


During REM sleep, the brain sends signals to the rest of the body to paralyze skeletal muscles. This is important so that dreams cannot be enacted, which would put the sleeper at risk of injury. However, three REM-related disorders can occur during this stage of sleep and are worth knowing about. These include REM-behavior disorder, sleep paralysis, and nightmare disorder.


REM-Behavior Disorder 

Some individuals experience abnormal muscle tone during REM sleep, thus allowing for dream enactment and potential injury to themselves or others. Episodes usually occur about once per week but can occur several times per night, several times per week in some instances. In contrast to NREM parasomnias, sleepers with this disorder wake rapidly, without confusion, and can recall their dreams with striking clarity. 


REM sleep is more likely to occur during the second half of a sleep episode, in the time between sleep-midpoint and the morning awakening. Therefore, these dream enactment episodes are more likely to occur during this time of the night. However, in cases where individuals have been chronically REM sleep-deprived (such as during cannabis withdrawal or early morning shiftwork), REM sleep can manifest earlier in the night. People with narcolepsy can also experience REM behavior disorder earlier in the night.


This disorder can indicate an underlying neurological disorder, including Parkinson’s disease and Lewy body dementia. Approximately 40% to 65% of patients with this disorder go on to develop a neurodegenerative condition within the subsequent 10 years. Interestingly, post-traumatic stress is also associated with REM behavior disorder.


Sleep Paralysis

These episodes occur when muscle paralysis lingers into waking consciousness and can be quite frightening for individuals who experience them. Many people with sleep paralysis report feeling as though they cannot breathe, and some Individuals also experience hallucinations of an ominous presence in the room. 


Sleep deprivation, stress, and other disorders, such as narcolepsy, are all risk factors for sleep paralysis. Treatment typically includes a prescribed regular sleep schedule, stress management, and occasionally an appropriate medication.


Nightmare Disorder 

Nightmares are distinct from bad dreams in that they wake the sleeper and are accompanied by intense feelings of fear, anger, or disgust that linger into waking consciousness. They may revolve around a similar theme or even be recurring and may follow periods of stress, traumatic events, or chronic sleep deprivation. 


Dream completion therapy is an effective technique for tackling disturbing nightmares. It involves having the dreamer allocate time during wakefulness to rehearse the outcome of a recurring nightmare to make it less distressing. For example, a person who repeatedly dreams of being chased by a lion might rehearse a scenario where they cast a spell that turns the lion into a non-threatening house cat. The idea is that with enough practice, this scenario plays out during sleep, thus resolving the nightmare. Pharmacotherapy and psychotherapy can also help in cases of post-traumatic stress disorder and particularly violent nightmares.



Our take:

Sleep is dynamic. It involves many different physiologic processes, all of which can be influenced by our environment and lifestyles. Importantly, sleep is a time for rejuvenation and repair, offering our minds an opportunity to make sense of waking life. When circumstances become stressful, this can manifest as sleep disturbances and unusual behaviors. 


Sometimes, these behaviors can put a sleeper or bed partner at risk of injury, so it’s important to speak with your doctor if you experience or are notified of any of these conditions. Various treatments are available to improve your quality of life and nighttime sleep.



Will this benefit me:

Sleep health continues to garner mainstream attention, and for good reason. Rest is essential if we wish to perform optimally in waking life. While sleep timing and duration naturally vary between individuals, and a few brief awakenings each night are perfectly normal for most people, any of the behaviors described in this article which cause distress or put sleepers and bed partners at risk are certainly worth discussing with a sleep specialist.



Still curious to try it? If you do, here’s what to keep an eye on:

If you plan on speaking to your doctor about a suspected parasomnia, keep a log (or have a bed partner or roommate keep a log) of when episodes occur. Try to identify trends in which time of the night these episodes tend to occur, and whether they are triggered by any daytime behaviors such as stress or alcohol consumption. This information will be helpful for a sleep medicine specialist.



References and additional materials:

Bruxism - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10895390/

Sexsomnia - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8340885/

Review of parasomnia treatments - https://pubmed.ncbi.nlm.nih.gov/37716336/

Awake or asleep? Sleep-related dissociative states - https://pubmed.ncbi.nlm.nih.gov/37373570/

Sleep-related eating disorders - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945843/

Dream Completion Therapy Handout - https://justinhavens.com/admin/uploads/files/Dream_Completion_Technique_The.pdf

Dream Completion Therapy Tutorial - https://justinhavens.com/page/sleep-nightmares

Sleep paralysis and “sleep demons” - https://www.sleepfoundation.org/parasomnias/sleep-demon

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