Approach
Management depends on the type of parasomnia and may include reassurance, sleep environment modification, cognitive therapy, and pharmacotherapy. Active treatment is necessary if the parasomnia may result in injury to patient or bed partner and if there is significant sleep disruption.
Non-rapid eye movement (NREM) parasomnias
During an episode of confusional arousal, sleepwalking, or sleep terror, no restraint or interference should be instituted, but environment modifications may be necessary to ensure patient safety. Reversal of risk factors or precipitating factors is also important. Patients must be advised about sleep deprivation, asked to stop medications that may precipitate sleepwalking such as zolpidem, and reassured. Occasionally, scheduled awakenings just before the anticipated time of the event may eliminate the episode.[5][65][66]
In addition, psychotherapy (especially hypnosis and relaxation) may be used with confusional arousal, sleepwalking, or sleep terrors.[65][67]
There is a lack of drug treatment randomised controlled trials (RCTs). Drug treatment choices should be based on the frequency and severity of events.[5][66] Anticonvulsant therapy with topiramate has been shown to be effective in some patients with sleep-related eating disorder and is a first-line choice if treatment is required.[5][68][69] Topiramate treatment duration is variable (may be long term) and depends on the response, adverse effects, and physician/patient choice.
Refractory NREM parasomnias
In rare cases, confusional arousals, sleepwalking, and sleep terrors may become severe or chronic enough to interfere significantly with sleep health. In such cases benzodiazepines are tried.[65] If benzodiazepines are not effective, selective serotonin-reuptake inhibitors (SSRIs), or even tricyclic antidepressants are occasionally used. However, such drugs should only be used in exceptional cases.[65][70] Given the potential for adverse effects, these drugs should be used only by sleep consultants after exclusion of reversible precipitating factors for confusional arousals.[71]
Dopamine agonists are indicated in cases of sleep-related eating disorder if topiramate therapy fails.[72][73] Pramipexole or ropinirole therapy has been reported to cause sudden sleep in patients even while they are engaged in activities during the day. Patients must be warned about the potential for this adverse effect, especially with regard to driving and operating heavy machinery. Treatment should be withdrawn gradually, as abrupt withdrawal may result in acute worsening of symptoms.
Benzodiazepines and psychotherapy have not been shown to be beneficial for sleep-related eating disorder.[68]
Rapid eye movement (REM) parasomnias
The diagnostic criteria for distinguishing REM parasomnias varies and can overlap. REM parasomnias include rapid eye movement sleep behaviour disorder (RBD), recurrent sleep paralysis, and narcolepsy. RBD can be further subdivided into isolated, secondary due to a medical condition, or drug-induced.[1][2][37]
Rapid eye movement sleep behaviour disorder (RBD) management
Ensuring a safe sleeping environment
It is critically important to help patients maintain a safe sleeping environment to prevent potentially injurious nocturnal behaviours. Patients and bed partners or household members should be advised to alter the environment to minimise risk in case of injuries; falling or jumping out of bed. Furniture, mirrors, and staircases may need to be moved or padded. Bedside weapons or objects that could inflict injury should be removed. Patients may need to sleep separately from the bed partner or put a pillow barrier between them.[37] A bed alarm can be considered.[74]
RBD pharmacological management
Along with sleep environment modification, pharmacological therapy is often instituted in RBD. However, there is not a robust evidence base for symptomatic treatment. RCTs are lacking, and treatment relies on case series evidence.[37][67][74] Melatonin and clonazepam are recommended as first-line pharmacological options.[23][37][74][75][76][77][78]
Melatonin has a favorable adverse-effect profile, especially in patients with a risk of falls, comorbid sleep apnoea, underlying liver disease, and those receiving polypharmacy with other medications.[37][67][74][77]
The benzodiazepine clonazepam is highly effective.[37][67][74][75] Patients receiving clonazepam should be cautioned about the potential for daytime drowsiness.[37] The addition of alcohol or other central nervous system depressant drugs to benzodiazepines increases the risk of drowsiness and sedation, and patients must be cautioned about this potential for interaction. Withdrawal of benzodiazepine treatment is associated with recurrence of symptoms.
Other RBD pharmacological options
Pramipexole (a dopamine agonist) has shown benefits in patients with isolated RBD based on several observational studies.[37][74][79][80][81] It was most effective in patients with periodic limb movements, suggesting that the effect of pramipexole may be through improving ancillary motor activity. Adverse effects may include orthostatic hypotension, daytime sleepiness, nausea, confusion, and impulse control disorder.[37]
Transdermal rivastigmine (a cholinesterase inhibitor) can be used for isolated and secondary RBD based on a randomised controlled clinical trial showing reduced dream enactment behaviours in patients with mild cognitive impairment and in patients with Parkinson's disease.[37][82][83] Adverse effects include skin irritation, nausea, headache, and bradycardia.[37]
Drug-induced REM sleep behaviour disorder
For patients with drug-induced REM sleep behaviour disorder, typically due to SSRIs or serotonin-noradrenaline reuptake inhibitors, discontinuing the offending drug may be helpful, if possible. However, risks of stopping the drug, such as in worsening the underlying mood disorder, needs to be weighed against the potential benefits, particularly given that it may take months to see RBD symptom improvement.[37]
Recurrent isolated sleep paralysis
Office evaluation and reassurance alone may be appropriate as first-line treatment.[5] Since sleep paralysis most commonly occurs in the supine position, strategies to prevent sleeping in the supine position may help.[25] Cognitive behavioural therapy can be tried (e.g., sleep hygiene, relaxation techniques during episodes, coping strategies for frightening hallucinations, disputation of catastrophic thoughts, imaginary rehearsal of successful resolution of episodes).[25]
Escitalopram (an SSRI) has shown benefit in a small number of case reports.[84] In persistent cases, other SSRIs and tricyclic antidepressants can be considered since they have shown benefit in sleep paralysis due to narcolepsy. However, recurrent isolated sleep paralysis drug treatment options lack good quality evidence since there are no RCTs.[25]
Nightmares
Nightmares that recur enough to interfere with sleep health and patient well-being are managed with relaxation and desensitisation.[18] Nightmare-focused cognitive behavioural therapy (exposure and imagery rehearsal therapy) resulted in better treatment outcomes than indirect methods such as relaxation and recording of nightmares.[18][66][85]
The alpha-blocker prazosin, when used in nightmares associated with post-traumatic stress disorder, has shown beneficial efficacy in several studies in civilian and military settings. Although one large clinical trial failed to show improvement, subsequent meta-analyses incorporating it still show net benefit.[18][86]
Other pharmacological treatment options rely on data from anecdotal case reports, case series, and small open-label trials (e.g., atypical antipsychotics, clonidine, cyproheptadine, fluvoxamine, gabapentin, nabilone, phenelzine, topiramate, trazodone, tricyclic antidepressants), and they are not routinely recommended.[18][87]
Refractory rapid eye movement sleep behaviour disorder (RBD)
RBD may be resistant to first-line treatment options and/or secondary due to a medical condition (e.g., Parkinson's disease, dementia with Lewy bodies, narcolepsy).
Some alternative pharmacological treatments may be tried (e.g., memantine, safinamide, sodium oxybate) but there is a lack of robust clinical evidence, and they are not routinely recommended.[37][88][89][90]
Other parasomnias
Sleep-related hallucinations and exploding head syndrome
During an office evaluation, reassurance alone may be all that is required for sleep-related hallucinations and exploding head syndrome.[5] Sleep-related hallucinations management involves eliminating or reducing known triggers (e.g., sleep deprivation, tobacco smoking, drugs [e.g., adrenergic antagonists, sedative hypnotics, antidepressants]).[5]
For exploding head syndrome, it is important to treat underlying comorbid sleep disorders that may be triggering the parasomnia. Tricyclic antidepressants such as amitriptyline or clomipramine may also be beneficial.[5][91]
Enuresis
The treatment of sleep enuresis requires diagnosis (by careful history and examination) and management of potential secondary causes. These include obstructive sleep apnoea, genitourinary and renal problems, seizures, diabetes mellitus, certain medications (some antipsychotics, valproate, and SSRIs), hyperthyroidism, and psychological factors such as history of sexual abuse.[5][17] When secondary causes have been excluded, the treatments of enuresis fall under 3 major categories: behavioural therapy, alarm therapy (used primarily in children), and pharmacotherapy.[5]
Behavioural therapy is supported by clinical and anecdotal data, but no randomised trials are available to validate its efficacy. Nevertheless, it has very few drawbacks and should be attempted as first line. It includes a strict bowel regimen to avoid hard stools or constipation, as this may cause or worsen enuresis; increasing fluid intake during the morning and early afternoon hours, and limiting it during the evening and night time; encouraging the patient to avoid holding urine and to void at least once every 2 hours; and biofeedback to help relax the pelvic floor muscles.[5][17]
Alarm therapy has only been studied in children and has been shown efficacious in multiple trials. It involves using a moisture-sensitive alarm that goes off and awakens the child at the moment of bedwetting.[5][17]
Pharmacotherapy: the drugs that have randomised trial support for efficacy include anticholinergics (e.g., oxybutynin, tolterodine), desmopressin, tricyclic antidepressants (e.g., imipramine), and verapamil. Rarely, medications can be used in combination.[5][17]
Treatment aims for other parasomnias
In parasomnia unspecified, treatment is focused on the underlying psychiatric condition. If parasomnia is related to drug and substance abuse or underlying medical problems, treatment options will be focused on these.[5]
Use of this content is subject to our disclaimer