Parasomnias in adults

Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR) criteria for parasomnias[1]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

Criteria for parasomnias are as follows:

• Non-rapid eye movement (NREM) sleep arousal disorders

  • Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following:

    • Sleepwalking: repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty. When diagnosing it is necessary to specify if sleepwalking is accompanied by:

      • Sleep-related eating

      • Sleep-related sexual behaviour (sexsomnia)

    • Sleep terrors: recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.

  • No or little (e.g., only a single visual scene) dream imagery is recalled

  • Amnesia for the episodes is present

  • The episodes cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication)

  • Co-existing mental disorders and medical conditions do not explain the episodes of sleepwalking or sleep terrors

• Nightmare disorder

  • Repeated occurrences of extended, extremely dysphoric, and well-remembered dreams that usually involve efforts to avoid threats to survival, security, or physical integrity and that generally occur during the second half of the major sleep episode.

  • On awakening from the dysphoric dreams, the individual rapidly becomes oriented and alert.

  • The sleep disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The nightmare symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

  • Co-existing mental disorders and medical conditions do not adequately explain the predominant complaint of dysphoric dreams.

  • When classifying, specify:

    • If occurs during sleep onset

    • If with mental disorder or medical condition

    • If with another sleep disorder

    • Acute (duration of period of nightmares ≤1 month), subacute (>1 month, <6 months), persistent (≥6 months)

    • Severity (based on frequency): severity can be rated by the frequency (e.g., mild [<1 episode per week], moderate [≥1 episode per week, but less than nightly], severe [nightly])

• Rapid eye movement sleep behaviour disorder (RBD)

  • There are recurrent episodes of vocalisations or complex motor behaviours that occur during rapid eye movement (REM) sleep.

  • Upon awakening from these episodes, the individual is completely awake, alert, and not confused or disoriented.

  • These behaviours arise during REM sleep and therefore usually occur more than 90 minutes after sleep onset, are more frequent during the later portions of the sleep period, and uncommonly occur during daytime naps.

  • Either of the following:

    • REM sleep without atonia on polysomnographic recording

    • A history suggestive of REM sleep behaviour disorder and an established synucleinopathy diagnosis (e.g., Parkinson's disease, multiple system atrophy)

  • The behaviours cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (which may include injury to self or the bed partner).

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • Co-existing mental disorders and medical conditions do not explain the episodes.

International classification of sleep disorders, 3rd edition, text revision (ICSD-3-TR)[2]American Academy of Sleep Medicine. The AASM international classification of sleep disorders - third edition, text revision (ICSD-3-TR). Jun 2023 [internet publication]. https://aasm.org/clinical-resources/international-classification-sleep-disorders

The ICSD-3-TR defines parasomnias as sleep-related occurrences that represent undesirable physical or cognitive experiences occurring out of sleep, or during the transition from sleep to the awake state, or from the awake state to sleep. It provides a classification of parasomnias and contains diagnostic criteria and severity criteria for each type of parasomnia.

The ICSD-3 lists unique parasomnias as follows:

• Non-rapid eye movement (NREM)-related parasomnias

  • Disorders of arousal (from NREM sleep)

    • Confusional arousals

    • Sleepwalking

    • Sleep terrors

  • Sleep-related eating disorder

• Rapid eye movement (REM)-related parasomnias

  • Rapid eye movement sleep behaviour disorder (RBD)

  • Recurrent isolated sleep paralysis

  • Nightmare disorder

• Other parasomnias

  • Exploding head syndrome

  • Sleep-related hallucinations

  • Sleep-related urological dysfunction (enuresis)

  • Parasomnia due to a medical disorder

  • Parasomnia due to a medication or substance

  • Parasomnia, unspecified