History and exam
Key diagnostic factors
common
known condition causing sleep fragmentation/deprivation
Individual types of parasomnia have particular risk factors strongly associated with them. Obstructive sleep apnoea (OSA), enuresis, and periodic limb movement disorder have been found to contribute to sleep fragmentation, sleep deprivation, and the occurrence of parasomnias (mostly non-rapid eye movement parasomnias).[1] OSA and narcolepsy are also associated with rapid eye movement sleep behaviour disorder (RBD); narcolepsy usually occurs in younger adults with RBD.[39] Antidepressants such as venlafaxine (or other serotonin- and noradrenaline-reuptake inhibitors) and fluoxetine (or other selective serotinin-reuptake inhibitors [SSRIs]) can also trigger RBD.[40][41]
normal physical examination between episodes
In most parasomnias, the examination in the surgery is normal; however, in rapid eye movement sleep behaviour disorder signs of parkinsonism may exist.
cognitive disturbance during event (confusional arousals, sleep terrors, and sleepwalking)
Mental slowing, disorientation, memory problems, and speech disturbances are noted in confusional arousals, sleep terrors, and sleepwalking.[5]
cognitive disturbances in between episodes (rapid eye movement sleep behaviour disorder)
Impaired cognition noted between episodes (during a clinic visit) is a feature of the neurodegenerative disorders that often accompany rapid eye movement sleep behaviour disorder.
sensation of a sudden loud noise in the head (exploding head syndrome)
vigorous or violent behaviour during episode (confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behaviour disorder)
episodes of inability to move during episode (recurrent isolated sleep paralysis)
Described in recurrent isolated sleep paralysis.
eating behaviour during the night (sleep-related eating disorder)
Patient may recall eating behaviour during the night or the parasomnia may be described by a spouse, bed partner, or other household member.
evidence of external injuries (rapid eye movement sleep behaviour disorder)
Points towards a violent parasomnia such as rapid eye movement sleep behaviour disorder; in such cases, patients may have cognitive problems.
evidence of fear during episode demonstrated by autonomic hyperactivity (sleep terrors, nightmare disorder)
Tachycardia, tachypnoea, and pupillary dilation are noted in sleep terrors.
Tachycardia and tachypnoea are common in nightmare disorder.
Other diagnostic factors
common
abnormal facial expression during episode (confusional arousals, sleepwalking, sleep terrors, rapid eye movement sleep behaviour disorder)
A dazed, confused look is typical in confusional arousals, sleepwalking, and sleep terrors.
Decreased facial expression noted between episodes (during a clinic visit) is a feature of the neurodegenerative disorders that often accompany rapid eye movement sleep behaviour disorder.
Risk factors
strong
history of childhood parasomnias (non-rapid eye movement parasomnias)
In general, non-rapid eye movement parasomnias are more prevalent in children.
age >60 years (rapid eye movement sleep behaviour disorder)
Rapid eye movement sleep behaviour disorder is a disorder of older adults, mainly of men.[32]
male sex (rapid eye movement sleep behaviour disorder)
Men are more commonly affected by rapid eye movement sleep behaviour disorder than women.[32]
female sex (nightmare disorder, isolated recurrent sleep paralysis)
Nightmare disorder occurs more frequently in women than in men, with an overall prevalence of 5% to 8% in adults.[13] It is more prevalent in children.
family history (confusional arousals, sleepwalking, sleep terrors)
A familial tendency is often noted in confusional arousals, sleepwalking (very common), enuresis, isolated recurrent sleep paralysis, and sleep terrors.[2]
presence of human leukocyte antigen gene DQB1 (sleepwalking)
The human leukocyte antigen gene DQB1 has been linked to a sleepwalking tendency.[21]
obstructive and central sleep apnoea (mainly non-rapid eye movement sleep parasomnias)
Contributes to sleep fragmentation, sleep deprivation, and the occurrence of parasomnias.
It is likely that sleep-related breathing disorders facilitate the appearance of all parasomnias, especially in otherwise predisposed people.
Screening and treatment for obstructive sleep apnoea is recommended to decrease the frequency of these parasomnias.
Central sleep apnoea could also be a precipitating factor, although it is much less common. Screening detects this as well.
enuresis
Contributes to sleep fragmentation, sleep deprivation, and the occurrence of parasomnias.
periodic limb movement disorder (mainly non-rapid eye movement sleep parasomnias)
Contributes to sleep fragmentation and the occurrence of parasomnias.
Screening and treatment for periodic limb movement disorder is recommended to decrease the frequency of parasomnias.
sleep deprivation (sleepwalking and sleep paralysis)
Strong risk factor for sleepwalking and sleep paralysis, especially in people who are genetically predisposed to these parasomnias.[33]
stress (nightmare disorder)
People with acute and chronic stress are more likely to develop nightmare disorder.[18]
psychiatric disorders (nightmare disorder, sleep paralysis)
neurological disorders (rapid eye movement sleep behaviour disorder)
People with rapid eye movement sleep behaviour disorder often develop neurodegenerative disorders that are usually synucleinopathies, such as Parkinson's disease.[35][36][37][38] Early-onset rapid eye movement sleep behaviour disorder, occurring prior to age 50, comprises a substantial minority of cases and is typically associated with narcolepsy.[39]
medicines such as venlafaxine, SSRIs (rapid eye movement sleep behaviour disorder, nightmare disorder)
Acute rapid eye movement sleep behaviour disorder may be precipitated by venlafaxine, SSRIs, and other antidepressants.[40][41]
Rapid eye movement sleep behaviour disorder has also been observed with mirtazapine prescribed for insomnia and depression in people with parkinsonism.[42]
Pharmacological agents affecting the neurotransmitters noradrenaline, serotonin, and dopamine are associated with nightmares and other sleep disturbances.[18][43][44]
forced awakenings
Parasomnias are commonly reported to occur after forced awakening from sleep.
eating disorder (sleep-related eating disorder)
People with a known eating disorder are at higher risk than controls of developing sleep-related eating disorder.[7]
history of sleepwalking, sleeptalking, and periodic limb movements of sleep (sleep-related eating disorder)
Associated with sleep-related eating disorder.[45]
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