Parasomnias Require Thorough Evaluations

By MacNeil, Jane Salodof | Clinical Psychiatry News, April 2008 | Go to article overview
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Parasomnias Require Thorough Evaluations

MacNeil, Jane Salodof, Clinical Psychiatry News

SCOTTSDALE, ARIZ. -- Even though sleepwalking, night terrors, and other parasomnias are usually benign and do not call for specific interventions, Dr. Teofilo L. Lee-Chiong Jr. urged that they be thoroughly evaluated in children and adults.

Violent and potentially injurious behavior can endanger the person and/or the person's bed partner, according to Dr. Lee-Chiong, head of the sleep medicine section at National Jewish Medical and Research Center in Denver. A recent patient, for example, walked for 4 hours along a busy interstate highway while fast asleep, Dr. Lee-Chiong said at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Another concern, he added, is that a patient with REM sleep behavior disorder could have undiagnosed Parkinson's disease or another neurological disorder. Characteristics of this condition include abnormal behavior during REM sleep, REM sleep without atonia, and the enactment of altered, unpleasant, or violent dreams.

"I believe assessment should be extensive," Dr. Lee-Chiong said, recommending a comprehensive neurological evaluation with EEG and brain MRI in REM sleep behavior disorder cases.

Even if these tests prove negative, he urged that the patient be closely monitored for years afterward in case a neurological disorder is late in emerging.

Dr. Lee-Chiong defined parasomnias as undesirable physical phenomena or behaviors that appear "alongside sleep," but are not associated with more common complaints such as excess sleepiness or insomnia. "We all seem to know what it is, but deep down we know very little," he said, adding afterward in an interview, "If you take [posttraumatic stress disorder] away, there really is no psychopathology that predicts the development of parasomnias."

A variety of factors make evaluation difficult, according to Dr. Lee-Chiong. Patients are unaware of some parasomnias. Descriptions are often inaccurate or misleading. The clinician rarely sees the parasomnia. If it is not related to sleep architecture, then polysomnography may not be useful. Moreover, a single negative test does not rule out infrequent events.

Polysomnography is indicated when an underlying seizure disorder is suspected, someone has been injured, the case has medical-legal implications, or the person presents with REM sleep behavior disorder, according to Dr. Lee-Chiong. EEG electrodes should be used if seizures are a possibility. In REM sleep behavior disorder cases, he also recommends EMG monitoring of the upper extremities. Often four to six studies are required before a diagnosis can be made, he advised, and technicians need to be trained to recognize subtle features.

Dr. Lee-Chiong characterized sleepwalking, sleep terrors, and confusional arousals as disorders of arousal that usually occur in non-REM sleep during the first third of the night. These are four times as common in childhood, he said, with a prevalence of 16% vs. 4% in adults. Febrile illness in children and medications in the elderly are among the predisposing factors, though sleep terrors are uncommon in older people.

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