Parasomnias: Things That Go Bump in the Night

What all these people have in common is that, in the morning,none of them remembers a thing.

These stories—all true—are examples of parasomnias, whichare defined as "unusual behavioral or experiential phenomenonduring sleep."

What Is a Parasomnia?

"Anything that goes bump in the night is parasomnia," says Dr.Mark Mahowald, a neurologist at the Minnesota Regional SleepDisorder Center and a leading researcher in this field of sleepdisorders.

Parasomnias include sleepwalking, talking during sleep, andsleep terrors. Bed-wetting, when there's not an underlying urologiccondition, also is considered a parasomnia. Some medical literaturealso include grinding the teeth, called "bruxism," and rhythmicmovement disorders, such as head-banging or rocking and rolling,which is almost always limited to infants.

While they can be frightening to observe, most parasomnias arebenign and require no treatment beyond some simple safety measuresto keep people from injuring themselves during an episode.

Parasomnias are more common in children than in adults becausethe condition most often occurs during deep sleep, which decreases as we age."Our sleep matures," says Dr. Dainis Irbe, a neurologist the EmoryChildren's Center in Atlanta, and director of the Sleep Laboratoryat Children's Healthcare of Atlanta at Egleston. "Kids reach stagesof adult sleep by age six, roughly."

REM vs. Non-REM Disorders

Parasomnias fall into two main categories—REM sleep and non-REMsleep disorders.

REM, short for "rapid eye movement," sleep is the lighter stageof sleep that we have during the second and third phases of thenight. This is when most dreams and nightmares occur.

Because we spend more time in REM sleep, there is "moreopportunity to get those symptoms, usually associated with wakingup after a bad dream," says Dr. Irbe. "[The person] might scream,look around, be confused. You can communicate with him, he'llrespond, he'll remember what he dreamt about, and can tell you indetail."

Normally, REM sleep is accompanied by active muscle paralysis,which is the body's way of protecting itself (and others) duringdreams. "Our brains are going into high gear during REM sleep," Dr.Mahowald explains. "[Without the paralysis] we could act on brainactivity." People with REM sleep behavior disorder, who are almostalways older men, lack that paralysis and act physically on theirdreams. "A good example is the man who thinks he's playing footballand thinks he's making a catch and injures himself falling on thefloor," says Dr. Mahowald.

Non-REM sleep is the deep rest that normally occurs during thefirst phase of sleep. That's when sleepwalking, sleep talking, andconfusional arousals, such as sleep terrors, occur.

Sleepwalking

Sleepwalking, Dr. Mahowald says, is "part of the humancondition. Almost every parent of a young child has found the childsleeping somewhere he's not supposed to be." About 10% of adultswalk in their sleep, and there's evidence that it can behereditary.

There's some wisdom to the folk advice not to wake asleepwalker, or a person with night terrors, for that matter. Dr.Rachel Zak from the NewYork-Presbyterian Hospital Sleep WakeDisorders Center explains that during these times, people aren'trational and could lash out. "You don't know what to expect," shesays. "It's not necessarily that they will cause violence, [but]they're just not fully conscious. What you try to do is help themback to bed." Plus, make sure windows are latched and doors arelocked. A gate across stairs could be helpful, too.

Sleep Terrors

Sleep terrors, which can occur at night or during daytime naps,are the most extreme form of arousal disorders. According to Dr.Mahowald, a person may sit or jump up and there is often, whatfamily members describe as, a blood-curdling scream. The person mayeven be running around or throwing things. He appears to be awake,but clearly is not awake and is very difficult to arouse. He may bebreathing very rapidly, have prominent sweating, and lookabsolutely terrified. "Yet if [he's] not awakened during theepisode, [he's] totally unaware in the morning. That's generallytrue for sleepwalking too. There's almost total amnesia," says Dr.Mahowald.

Another major difference between the nightmares of REM sleep andthe sleep terrors of deep sleep is that nightmares involve acomplex plot that can be recalled in detail, while the imagesinvolved with night terrors are very primitive and simplistic, suchas fire, a monster, or the ceiling falling in.

Bed-wetting

Bed-wetting, also called enuresis, in people up to agefive is not a major concern, Dr. Irbe says. But after that, it'sconsidered a problem, since fewer than 5% of those cases arerelated to a urinary tract problem. "It could be because oftraining problems or it could be family problems," he says. "Also,many times, enuresis is associated with underlying sleepdeprivation, restless sleep, sleep fragmentation, and sleepapnea."

Generally, children grow out of parasomnias, and they require notreatment beyond a physician reassuring their parents that thecondition is not serious.

Treatment

If someone's behavior associated with parasomnias are violent,causing injuries to the patient or others, treatment with a classof medications called benzodiazepines can be very effective.However, most physicans consider medication a last resort. "Thequestion is, do you want to give a medicine every single night thatwe know affects the brain?" Dr. Zak says. "We don't know whateffects it has. We don't want to give a child a psychoactive drugevery night for something that occurs rarely. Part of [thedecision] is how frequently it occurs."

Dr. Mahowald teaches patients to use hypnosis or self-relaxationtechniques before they go to sleep. "It appears the arousal stillhappens, but not the behaviors," he says. "It's quite effective inchildren and adults, and that's the treatment we'd prefer."

Prevention

Here are some tips for preventing parasomnias:

• Keep the same sleep schedule and avoid sleep deprivation. Thatwill prevent the need for deep sleep that can trigger sleepwalking,sleep terrors, and other parasomnias.
• Avoid mind-stimulating activities before bed, such as actionmovies, TV shows, or computer games.
• Engage in calming activities, such as listening to soothingmusic, talking, or reading, and don't have a TV in yourbedroom.
• Avoid big meals close to bedtime; late digestion disrupts yourcontinuity of sleep. Caffeine causes sleep fragmentation, and one study suggeststhat drinking any kind of liquid before bedtime can trigger sleepterrors.
• Parents can keep a diary for a week or two of a child'sparasomnias, which will usually occur about the same time. Oncethat time is established, wake the child up about 30 minutes beforean event, just enough so the child opens his eyes and recognizesyou. Then let him go back to sleep.

Safety

There are some general safety precautions you can take if you orsomeone you know experiences parasomnias:

• Make the bed lower to the floor and pad it with pillows.
• If bedrooms are on a second floor, move the bed to the firstfloor.
• Latch windows and lock doors.
• Put gates across stairwells.
• Put bells or alarms on door knobs.
• If a person is staying in bed during a sleep terror, he won'thurt himself. Don't try to restrain him; it can make him moreagitated.