1
Q
Parasomnia
- what is it
- Manber
A
- parasomnia is abnormal behavior or perception associated with CNS activation that occurs during sleep or transitions into or out of sleep
- NREM parasomnia occur during partial arousal from SWS (N3)
- REM parasomnia occur during second half of the night
- NREM eyes are open and when awakened reorientation is difficult
2
Q
Parasomnia
- NREM sleep arousal disorder
- Manber
A
- NREM sleep arousal disorder is parasomnia from stage N3
- Not fully awake (partial arousal)
- amnesia for the episode is common
- Sleep walking type
- sleep terror type starts with scream, abruptly sit up in state of high arousal, no recall
- more time in stage N3 avoid awakening
3
Q
Parasomnia
- Nightmare disorder
- Manber
A
- REM sleep disorder during second half of night
- vivid, frightening and well-remembered dream from which a sleep wakes up and is oriented
- loss of muscle tone
- PSG reveals reduced efficiency and longer sleep latency and less SWS
- nightmares occur repeatedl and high distress and impairment in functioning
- difference with nocturnal panic is nightmare is not associated with dream content
- difference sleep paralysis is nightmare is not aware of being fully awake when experiencing frightful imagery
4
Q
Parasomnia
- REM sleep behavior disorder
- Manber
A
- RSBD is characterized by dream enactment during sleep
- loss of muscle atonia
- individuals engage in complex behavioral consequences
- if woken quickly oriented
- latter half of the night
5
Q
Somnambulism
- what is it
- Zadra
A
- defined as a series of complex behaviors during arousals from SWS (N3) and culminate in walking around with an altered state of consciousness and impaired judgement
- episoded last from few seconds to more than 30 min
- more common in childhood
- excessive daytime somnolance (sleepiness) characteristic somnambulism
- 70% recalled short, unpleasant, dreamlike mentations associated with sleepwalking episodes
- eyes usually open to navigate
- first third of the night
6
Q
Somnambulism
- Diagnosis and clinical management
- Zadra
A
- nocturnal frontal lobe epilepsy and RSBD can be confused with somnambulism
- nocturnal N2 sleep, cannot get out of bed
- RSBD last half of night, REM sleep, awakened fully awake and functional, vivid dream recall
- disorders that ease dissociation or induce confusional states can trigger somnambulism
7
Q
Somnambulism
- as a disorder of slow-wave sleep
- Zadra
A
- presence of intrinsic abnormalities in SWS and atypical response that sleepwalkers have to sleep deprivation
- decrease in slow-wave activity
- sleep deprivation results in more awakenings from SWS during recovery sleep
- response to sleep deprivation are highly sensitive and specific
- sleep deprivation increased activation of amygdala and decrease in connectivity with the PFC
8
Q
Somnambulism
- as a disorder of arousal
- Zadra
A
- delta activity recorder in half of all episoded during SWS –>sleepwalkers caught between NREM sleep and full EEG arousal and thus neither awake or asleep
- arousal from SWS can induce sleepwalking episodes
- sleepwalkers have abnormal arousal reactions
9
Q
Homocidal somnambulism
- case report
- broughton
A
- Kenneth Parks 23 difficult relationship (step)father
- married and good relationship parents in law
- bet at horseraces–> severe stress on mariage
- problems getting asleep, completely sleepless nights and daytime headaches
- gamblers anonymous telling grandmother and family
- delay telling grandmother –>argument wife
- no alcohol or drugs
- did not recall seeing marks or blood on her face
10
Q
Homocidal somnambulism
- medical investigation of the patient
- broughton
A
- drug-related received no support
- no suggestion of motivational or personal gain
- severe bedwetter, deep sleeper, rare dream recall, chronic sleep talker and occasional sleepwalker
- state instability, direcht SWS to wake arousals and high amount of SWS
11
Q
Homocidal somnambulism
- diagnosis and legal argument
- broughton
A
- absence of motive, affection, grief, lack of evidence during sleepwalking
- somnambulism represents state of consciousness and sleep, along with organized behaviors
- legal theory of continuing danger; condition with recurrent danger to public should be treated as insanity
- legal theory of internal causes or disease of mind; sleepwalking is not a disease but a disorder of sleep
12
Q
Parsomnias in childhood
- What is parasomnia, wat provokes parasomnia
- Kotagal
A
- Parasomnias are consequence of dissociation between wakefulness, NREM or REM sleep
- Down-regulation of descending GABAergic projections or diminished serotonergic inhibition may play a role in pathogenesis of sleep-wake transition parasomnias and arousal parasomnia
13
Q
Parasomnias in childhood
- Sleep-wake transition parasomnias
- Kotagal
A
- Hypnic starts
- Benign neonatal sleep myclonus
- isolated sleep paralysis (ISP)
- rhythmic movement disorder
14
Q
Parasomnias in childhood
- Hypnic starts
- Kotagal
A
- isolated, quick jerks of the upper or lower extremities that occur at sleep onset
- feeling of falling, dream-like feeling or flashing sensation
- benign and occur in 70% of all ages
15
Q
Parasomnias in childhood
- benign neonatal sleep myclonus
- Kotagal
A
- symmetric or asymmetric, repetitive jerks of extremities during sleep in first month of life
- benign and resolve spontaneously over weeks
16
Q
Parasomnias in childhood
- isolated sleep paralysis ISP
- Kotagal
A
- isolated or recurrent episodes of transient inability to move the body as falling asleep or upon wakening
- consciousness and hallucinations
17
Q
Parasomnias in childhood
- rhythmic movement disorder
- Kotagal
A
- rhythmic movements in infants and toddlers at time of drifting off from wakefulness to sleep
- occur at transition from wakefulness to N1 sleep, during NREM and in REM sleep
- disorder when it leads to consequences
18
Q
Parasomnias in childhood
- Arousal parasomnias (NREM parasomnias)
- Kotagal
A
- occur at transition from SWS (N3) into lighter stages of sleep
- first third of night sleep
- confusion arousals
- sleep terrors
- sleep walking
19
Q
Parasomnias in childhood
- confusion arousals
- Kotagal
A
- common in infants and toddlers
- onset of symptoms within 2-3 hours at time of SWS (N3) to lighter stage
- typically sit up in bed, no sweating, flushing of face or stereotypic motor behavior
- no recollection of event
20
Q
Parasomnias in childhood
- sleep terrors
- Kotagal
A
-awakenes abdruptly from sleep with a scream, appears agitated, flushed over the face, sweating and tachycardia
21
Q
Parasomnias in childhood
- sleep walking
- Kotagal
A
-Sits up and crawls around the crib, or a child walking quietly in sleep
22
Q
Parasomnias in childhood
- REM sleep parasomnias
- Kotagal
A
- nightmares
- REM sleep behavior disorder
- catathrenia
23
Q
Parasomnias in childhood
- nightmares
- Kotagal
A
- recurrent episodes of awakening from sleep with recall of intensely disturbing dream mentation involving fear, anxiety and anger
- full awareness upon awakening
- early hours of the morning
- treatment; avoiding television, rescripting techniques, desensitization techniques
24
Q
Parasomnias in childhood
- REM sleep behavior disorder (RBD)
- Kotagal
A
- aggressive motor behavior during dream eneactment in adults
- predictive of degenerative neurological disorders
25
Parasomnias in childhood
- catathrenia
- Kotagal
- nocturnal groaning or catathrenia
- unaware of expiratory groaning sound
- second half of the night
26
Parasomnias in childhood
- Miscellaneous parasomnias
- Kotagal
- sleep related ensuresis
- bruxism
- status dissociatus
27
Parasomnias in childhood
- sleep related enuresis
- Kotagal
- recurrent bedwetting
- primary enuresis; child has not had dry period of 6 months
- secondary enuresis; period of 6 months dry
28
Parasomnias in childhood
- bruxism
- Kotagal
-involuntary, non-functional and forceful clenching, grinding or rubbing of teeth
29
Parasomnias in childhood
- status dissociatus
- Kotagal
structural brainstem lesions associated with sleep talking, vigorous movements accompanied by vivid dreams, enuresis and daytime sleepiness
30
Breakdown rem sleep in RBD
- what is RBD
- Peever
- parasomnia characterized by elaborate and often violent motor behaviors during REM sleep can result in injury
- more than 80% develop neurodegenerative disease
- link between dream content and motor behavior in RBD
- excessive tonic of phasic chin EMG activity or excessive limb EMG twitching during REM required for RBD diagnosis
31
Breakdown rem sleep in RBD
- idiopathic and secondary RBD
- Peever
- iRBD when none of the conditions listed for secondary RBD or other conditions that mimic nocturnal manifestation of RBD is present
- secondary RBD when there is an associated condition that likely contributes to its etiology
32
breakdown rem sleep in RBD
- treatment
- Peever
- dopaminergic agents (pramipexole) results are mixed
| - melatonin partially restores REM sleep atonia but negligible effects on phasic motor activity
33
breakdown rem sleep in RBD
- mechanisms of REM sleep atonia
- Peever
- GABA- and glycine- mediated inhibition of motoneurons underlies REM sleep atonia
- loss of this inhibitory mechanism is a candidate in RBD pathogenesis
34
breakdown rem sleep in RBD
- REM sleep circuitry
- Peever
- subcouruleus nucleus and subdorsolateral tegmental nucleus (SLD) cells are REM-on --> induce REM atonia by recruiting inhibitory circuits
- REM-on glutamate SLD cells excite GABA- and glycine containing neurons in the gigantocellular reticular nucleus (GiV) --> which trigger atonia by directly inhibiting skeletal motoneurons
- healty REM sleep; the SLD-GiV inhibits motoneurons which prevents pyramidal neurons in motor cortex from producing movement
- SLD neurons generate REM sleep atonia but do not induce phasic motor events of REM sleep
35
breakdown rem sleep in RBD
- models of RBD
- Peever
- pathologies affecting the brainstem circuits that control REM sleep
- lesions of dopamine system
- dysfunction of normal inhibitory neurotransmission
36
breakdown of rem sleep in RBD
- disease mechanisms in RBD
- Peever
- brainstem lesions can trigger RBD
- loss of subcoeruleus neurons
- changes in normal cholinergic system activity
- pathological changes in basal ganglia anatomy
37
SPECT during sleepwalking
| -Bassetti
- decreased cerebral blood flow in frontoparietal cortices during sleepwalking
- sleepwalking is a dissociated state consisting of motor arousal and persisting mind sleep
- increase blood flow in anterior cerebellum and posterior cingulate cortex
