Sleepwalking and night terrors: psychopathological and psychophysiological correlates

Sleep terrors-A parental nightmare

Sleep terrors (STs) are sleep disorders characterized by abrupt arousal from sleep with autonomic hyperactivity and inappropriate behavior. Though a common condition in childhood that usually affects children between 4 and 12 years of age, STs, however, may be present even in adulthood. The exact etiology of STs is not known yet, however, several hypotheses have been proposed over the years, identifying some potential genetic, neurodevelopmental, or other causes. Nevertheless, a useful pathophysiological model identified a common cascade of predisposing, priming, and precipitating factors, which could help to explain and sometimes prevent STs. Establishing a correct diagnosis is mandatory for appropriate management, as several conditions (such as other parasomnias or nocturnal seizures) may mimic STs. Furthermore, we also described some conditions which can be comorbid to STs, like some medical or psychological disorders. A number of treatment options have been proposed, ranging from only sleep hygiene practices to pharmacological therapies; we reviewed some of the most prominent ones. In spite of the fact that STs have long been considered benign disorders, which tend to reduce spontaneously over the years, they may have unexpected consequences on the child but also on the caregivers.

Tinnitus: at a crossroad between phantom perception and sleep

Sensory disconnection from the environment is a hallmark of sleep and is crucial for sleep maintenance. It remains unclear, however, whether internally generated percepts—phantom percepts—may overcome such disconnection and, in turn, how sleep and its effect on sensory processing and brain plasticity may affect the function of the specific neural networks underlying such phenomena. A major hurdle in addressing this relationship is the methodological difficulty to study sensory phantoms, due to their subjective nature and lack of control over the parameters or neural activity underlying that percept. Here, we explore the most prevalent phantom percept, subjective tinnitus—or tinnitus for short—as a model to investigate this. Tinnitus is the permanent perception of a sound with no identifiable corresponding acoustic source. This review offers a novel perspective on the functional interaction between brain activity across the sleep–wake cycle and tinnitus. We discuss characteristic features of brain activity during tinnitus in the awake and the sleeping brain and explore its effect on sleep functions and homeostasis. We ask whether local changes in cortical activity in tinnitus may overcome sensory disconnection and prevent the occurrence of global restorative sleep and, in turn, how accumulating sleep pressure may temporarily alleviate the persistence of a phantom sound. Beyond an acute interaction between sleep and neural activity, we discuss how the effects of sleep on brain plasticity may contribute to aberrant neural circuit activity and promote tinnitus consolidation. Tinnitus represents a unique window into understanding the role of sleep in sensory processing. Clarification of the underlying relationship may offer novel insights into therapeutic interventions in tinnitus management.

EEG Patterns Prior to Motor Activations of Parasomnias: A Systematic Review

INTRODUCTION

Non-rapid eye movement (NREM) parasomnias are defined as abnormal nocturnal behaviors that typically arise from the NREM sleep stage 3 during the first sleep cycle. The polysomnographic studies showed an increase in sleep fragmentation and an atypical slow wave activity (SWA) in participants with NREM parasomnias compared to healthy controls. To date, the pathophysiology of NREM parasomnias is still poorly understood. The recent investigation of the EEG patterns immediately before parasomnia events could shed light on the motor activations' processes. This systematic review aims to summarize empirical evidence about these studies and provide an overview of the methodological issues.

METHODS

A systematic literature search was carried out in PubMed, Web of Science, and Scopus, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The documents obtained were evaluated using the Newcastle-Ottawa Scale (NOS).

RESULTS

Nine studies were included in the qualitative synthesis. The major evidence revealed an increased slow frequency EEG activity immediately before the motor activations in frontal and central areas and increased beta activity in the anterior cingulate cortices.

DISCUSSION

The investigation of EEG patterns before parasomniac episodes could provide new insight into the study of NREM parasomnia pathophysiology. The high- and low-frequency EEG increase before the episodes could represent a predictive electrophysiological pattern of the motor activations' onset. Overall, identifying specific sleep markers before parasomnias might also help differentiate between NREM parasomnias and other motor sleep disorders. Different methodological protocols should be integrated for overcoming the lack of consistent empirical findings. Thus, future studies should focus on the topographical examination of canonical EEG frequency bands to better understand spatial and time dynamics before the episodes and identify the networks underlying the onset of activations.

Behavioural and emotional profiles of children and adolescents with disorders of arousal

Disorders of arousals are common sleep disorders characterized by complex motor behaviours that arise episodically out of slow-wave sleep. Psychological distress has long been associated with disorders of arousal, but this link remains controversial, especially in children and adolescents. The aim of this multi-centre study was to characterize behavioural and emotional problems in a sample of children/adolescents with disorders of arousal, and to explore their relationship with the severity of nocturnal episodes. The parents of 41 children/adolescents with a diagnosis of disorders of arousal (11.5 ± 3.3 years old, 61% males) and of a group of 41 age- and gender-matched control participants filled in the Child Behavior Checklist, along with the Sleep Disturbance Scale for Children and the Paris Arousal Disorders Severity Scale. Multilevel t-tests revealed significantly higher total scores and sub-scores of the Child Behavior Checklist for the patient group compared with the control group. Thirty-four percent of the patients obtained pathological total scores, and 12% of them borderline scores. The severity of emotional/behavioural problems in the patient group was positively correlated with the severity of the nocturnal episodes. Interestingly, children/adolescents with disorders of arousal also obtained higher excessive daytime sleepiness and insomnia symptoms sub-scores at the Sleep Disturbance Scale for Children. These results confirmed the hypothesis that behavioural/emotional problems are surprisingly common in children/adolescents with disorders of arousal. Further studies are warranted to investigate the causal relationship between pathological manifestations, subtler sleep abnormalities, and diurnal emotional/behavioural problems in children/adolescents with disorders of arousal.

Association of sleep terror, walking or talking and tinnitus

BACKGROUND/PURPOSE

Sleep disturbances are associated with chronic tinnitus in humans. However, whether parasomnias are associated with chronic tinnitus is unclear. This study aims to investigate this issue.

METHODS

Clinical data for 2907 subjects who had visited the Sleep Center of a community hospital in Taiwan during November 2011 to June 2017 were collected retrospectively. The association of chronic tinnitus with sleep terror, sleep walking, and sleep talking was analyzed using Pearson's Chi-Square test and multivariate logistic regression.

RESULTS

The cohort age ranged from 7 to 91 years old, with a mean age of 49.8 years (standard deviation, 14.3 years). The cohort included 1937 patients without and 970 patients with chronic tinnitus. The percentage of patients who experienced sleep terror was significantly higher among those with tinnitus than those without (p < 0.001). The percentage of patients reporting sleep walking was slightly higher in subjects with tinnitus than in those without, with borderline significance (p = 0.063). The percentage of patients experiencing sleep talking did not differ significantly between the groups. Multivariate logistic regression also showed that sleep terror but not sleep walking was significantly associated with tinnitus after adjusting for age, sex, hearing loss, and insomnia. After adjusting for other factors, subgroup analysis by age showed that sleep terror was significantly positively associated with chronic tinnitus in patients aged 20-44 years but not in those aged 7-19 or >45 years.

CONCLUSION

Sleep terror is positively associated with chronic tinnitus, especially in young adults.

Primary headaches during lifespan

Primary headaches are one of the most prevalent neurological disorders and can occur during a wide range of lifespan. Primary headaches, especially migraine, are cyclic disorders with a complex sequence of symptoms within every headache attack. There is no systematic review of whether these symptoms changes during lifespan. Indeed, the clinical presentation of migraine shows an age-dependent change with a significantly shorter duration of the attacks and occurrence of different paroxysmal symptoms, such as vomiting, abdominal pain or vertigo, in childhood and, in contrast, largely an absence of autonomic signs and a more often bilateral headache in the elderly. The age-dependent differences in the clinical presentation are less distinct in cluster headache and, especially, in tension-type headache. The differences in the clinical presentation are in agreement with the idea that the connectivity of hypothalamic areas with different brainstem areas, especially the central parasympathetic areas, is important for the clinical manifestation of migraine, as well as, the change during lifespan.

Treatment and management of seven children with fractured femurs experiencing night terrors in hospital: a case study

This article reports on seven cases of night terror disorder in children with no previous history of parasomnias, or night time disturbance. All children were admitted to a metropolitan children's hospital with a traumatic fracture of the femur and treated with Thomas' traction splint, a phenomenon not previously reported in the literature. The characteristic presentation of a night terror is described and a strategy for immediate nursing management of a night terror is suggested. Various forms of projective play therapy as a safe short-term treatment are described to assist children with night terror disorder.

Risperidone for Night Terrors and Sleepwalking in an Adult: A Case Report

Objective:

To report the successful treatment of a case of night terrors and sleepwalking in an adult using low-dose risperidone.

Case Summary:

A 30-year-old female with a history of nightmares as a teen, but with no prior psychiatric history, presented with new-onset night terrors and sleepwalking related to psychosocial stressors. She recalled images of being chased by monsters and of people trying to hurt her. Sleepwalking sometimes involved self-injurious behavior, as she ran through the house screaming. Intake diagnoses included general anxiety disorder (GAD), obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). She reported compulsive counting since childhood and episodes of compulsive eating. Risperidone 1 mg was started and eventually titrated to 2 mg at night for night terror and sleepwalking suppression. For GAD, OCD, and OCPD, paroxetine 10 mg was started and titrated to 50 mg. Temazepam 30 mg was added to prolong sleep and cyproheptadine 4 mg was prescribed for anorgasmia. Symptoms were well controlled with the medications for about 8 months. The patient chose to stop the paroxetine and temazepam on day 655, but continued to take risperidone 2 mg for approximately 45 days. When she discontinued the risperidone, the night terrors and sleepwalking returned within 3 days.

Discussion:

Low-dose risperidone has been shown to modulate combat posttraumatic stress disorder nightmares. Its effectiveness for night terrors and sleepwalking has not been reported. In this case, risperidone was the sole medication suppressing night terrors and sleepwalking for a month and a half. As found in previous studies, 2 mg of risperidone seemed to be the optimal dose.

Conclusions:

Risperidone dosed at 1–2 mg at night may be a pharmacologic alternative for the symptoms of sleep terrors with sleepwalking.

Classification of sleep disorders

The classification of sleep disorders is necessary to discriminate between disorders and to facilitate an understanding of symptoms, etiology, and pathophysiology that allows for appropriate treatment. The earliest classification systems, largely organized according to major symptoms (insomnia, excessive sleepiness, and abnormal events that occur during sleep), were unable to be based on pathophysiology because the cause of most sleep disorders was unknown. These 3 symptom-based categories are easily understood by physicians and are therefore useful for developing a differential diagnosis. The International Classification of Sleep Disorders, version 2, published in 2005 and currently undergoing revision, combines a symptomatic presentation (e.g., insomnia) with 1 organized in part on pathophysiology (e.g., circadian rhythms) and in part on body systems (e.g., breathing disorders). This organization of sleep disorders is necessary because of the varied nature and because the pathophysiology for many of the disorders is still unknown. The International Classification of Sleep Disorders, version 2 provides relevant diagnostic and epidemiological information on sleep disorders to more easily differentiate between the disorders.

Prevalence of sleepwalking in an adult population

BACKGROUND

Sleepwalking consists of a series of behavioral activities that occur during sleep. These activities may be simple, complex or aggressive in nature. They include motor activities, confusion, and amnesia for the events. Sleepwalking is a disorder of arousal from non-rapid eye movement (NREM) sleep. In children, episodes of sleepwalking are rarely violent; in adults, however, sleepwalking might include violence, which could endanger the patient or others and might precipitate legal issues. There is inadequate information on the prevalence and demographic correlates of sleepwalking in Nigeria.

OBJECTIVES

One objective of this study was to determine the lifetime prevalence rate of sleepwalking in an adult population in Ile-Ife, in Southwestern Nigeria. Another objective was to determine the age and sex distribution of sleepwalking among those who have experienced it at least once in their lifetime.

MATERIALS AND METHODS

A random sample of 228 healthy individuals aged 18-60 years was obtained and the members were asked to fill out a survey form about lifetime prevalence rate of sleepwalking.

RESULTS

The overall lifetime prevalence rate of sleepwalking was 7% (16 of 228 participants). It was 10.4% in males and 3.5% in females, but the difference was not statistically significant (p=0.07).

CONCLUSION

This study has shown that sleepwalking is common in the population. In view of the psychological effects of sleepwalking and the potential physical and legal problems associated with it, adequate efforts should be made for early detection and prompt management of the condition.

Prevalence of Sleepwalking in an Adult Population

BACKGROUND

Sleepwalking consists of a series of behavioral activities that occur during sleep. These activities may be simple, complex or aggressive in nature. They include motor activities, confusion, and amnesia for the events. Sleepwalking is a disorder of arousal from non-rapid eye movement (NREM) sleep. In children, episodes of sleepwalking are rarely violent; in adults, however, sleepwalking might include violence, which could endanger the patient or others and might precipitate legal issues. There is inadequate information on the prevalence and demographic correlates of sleepwalking in Nigeria.

OBJECTIVES

One objective of this study was to determine the lifetime prevalence rate of sleepwalking in an adult population in Ile-Ife, in Southwestern Nigeria. Another objective was to determine the age and sex distribution of sleepwalking among those who have experienced it at least once in their lifetime.

MATERIALS AND METHODS

A random sample of 228 healthy individuals aged 18-60 years was obtained and the members were asked to fill out a survey form about lifetime prevalence rate of sleepwalking.

RESULTS

The overall lifetime prevalence rate of sleepwalking was 7% (16 of 228 participants). It was 10.4% in males and 3.5% in females, but the difference was not statistically significant (p = 0.07).

CONCLUSION

This study has shown that sleepwalking is common in the population. In view of the psychological effects of sleepwalking and the potential physical and legal problems associated with it, adequate efforts should be made for early detection and prompt management of the condition.

Nonrespiratory sleep disorders found in ICU patients

Intensive care subjects the critically ill patient to a multitude of stressors caused by the severity of illness and the use of invasive treatment modalities and medications. The ICU environment contributes significant stress of its own related to noise, light, 24-hour patient care, and other factors that disturb sleep. Consequently, various sleep pathologies may emerge or worsen in the ICU patient. Some sleep disorder symptomatology may be confused with serious neurologic complications of critical illness and lead to inappropriate testing or treatment, particularly in the patient who has narcolepsy. Given the high prevalence of sleep disorders in the general population, it is essential that the ICU practitioner attain an adequate knowledge of sleep and its disorders.

A review of sleepwalking (somnambulism): the enigma of neurophysiology and polysomnography with differential diagnosis of complex partial seizures

The goal of this report is to review all aspects of sleepwalking (SW), also known as somnambulism. Various factors seem to initiate SW, especially drugs, stress, and sleep deprivation. As an etiology, heredity is important, but other conditions include thyrotoxicosis, stress, and herpes simplex encephalitis. Psychological characteristics of sleepwalkers often include aggression, anxiety, panic disorder, and hysteria. Polysomnographic characteristics emphasize abnormal deep sleep associated with arousal and slow wave sleep fragmentation. In the differential diagnosis, the EEG is important to properly identify a seizure disorder, rather than SW. Associated disorders are Tourette's syndrome, sleep-disordered breathing, and migraine. Various kinds of treatment are discussed, as are legal considerations, especially murder during sleepwalking.

Sexsomnia: abnormal sexual behavior during sleep

This review attempts to assemble the characteristics of a distinct variant of sleepwalking called sexsomnia/sleepsex from the seemingly scarce literature into a coherent theoretical framework. Common features of sexsomnia include sexual arousal with autonomic activation (e.g. nocturnal erection, vaginal lubrication, nocturnal emission, dream orgasms). Somnambulistic sexual behavior and its clinical implications, the role of precipitating factors, diagnostic, treatment, and medico-legal issues are also reviewed. The characteristics of several individuals described in literature including their family/personal history of parasomnia as well as the abnormal behaviors occurring during sleep are reported.