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Home , Dream, Nightmare, Nightmare disorder

2/13/2015

THINGS THAT GO BUMP IN THE NIGHT Detection & Management of Potentially Injurious

Janet E. Tatman, PhD, PA-C Fellow American Academy of Medicine Certified in Behavioral

From ghoulies and ghosties And long‐leggedy beasties And things that go bump in the night, Good Lord, deliver us!

Traditional Scottish Prayer

Patients’ experience embarrassment social isolation injury

1 2/13/2015

PARASOMNIA

• an undesirable physical event or experience that occurs during entry to sleep, within sleep, or during sleep, i.e., NREM sleep, REM sleep, or transitions to and from sleep

• may encompass abnormal, complex movements, behaviors, , , , and/or abnormal ANS activity—and may patient or bedpartner

• as sleep-wake cycle oscillates, the normally distinct states of (NREM, REM, and wake) may devolve into a state that is not fully declared…a temporary unstable state of dissociation, resulting in a “”…an admixture of one or more normal states

International Classification of Sleep Disorders, 3rd Ed American Academy of Sleep Medicine

“Sleep,” from Wikipedia, downloaded 1/5/15

INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3RD ED.

• NREM-Related Parasomnias • Other Parasomnias • Disorders of (from NREM sleep) • • Confusional • Sleep-Related • • Sleep • Sleep Terrors • Parasomnia Due to Medical Disorder • Sleep-Related • Parasomnia Due to Medication or • REM-Related Parasomnias Substance • REM Sleep Behavior Disorder • Parasomnia, Unspecified • Recurrent Isolated • Normal Variant • Disorder • Sleep Talking

American Academy of Sleep Medicine

2 2/13/2015

INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3RD ED.

• NREM-Related Parasomnias • REM-Related Parasomnias • Disorders of Arousal (from NREM sleep) • REM Sleep Behavior Disorder (RBD) • Confusional Arousals • Recurrent Isolated Sleep Paralysis • Sleepwalking • • Sleep Terrors • Sleep-Related Eating Disorder   no discernible neuropathology not 2o psychiatric disease often serious neuropathology (RBD) failed skeletal muscle paralysis → some areas deactivated, others activated enactment disinhibition of basic drive states

American Academy of Sleep Medicine

CASE EXAMPLES

CASE 1

• 42-year old ♀ goes to sleep at 11:30 PM and wakes around 1:30 AM in the middle of her backyard with nursery plants she had bought 2 days ago scattered around.

─ She is standing next to a 2’ deep hole, has garden soil on her legs and hands, and is naked in temperature of 55o.

3 2/13/2015

CASE 2

• 72-year old British ♂ conveys wife’s reports of him yelling, punching, kicking, and “speechifying” during sleep. Her sleep is disturbed 3-4 nights a week and he is sometimes tired during the day.

CASE 3

• 52-year old ♂ vigorously punches or kicks his wife during sleep every 1-2 months. They both are startled awake and frightened. ≈ once a month he leaves the , fumbles in the closet or stumbles along a wall, feeling it with his hands, returning to bed in response to gentle suggestion from his wife.

CASE 4

• 37-year old ♂ police officer was surprised to wake in AM on living room sofa.

− Wife says that during the night he was “charging around the house” with a loaded service revolver, periodically “hiding” behind furniture, yelling, and seeming to “chase the bad guys.”

4 2/13/2015

STAGES OF SLEEP

NREM Sleep REM Sleep – eyes quiet – rapid eye movements – “idling” brain – “alert” brain – relaxed muscle tone – skeletal muscle paralysis – some dreaming – much dreaming

– stable –  variability of HR, BP, RR, ANS –  brain metabolic activity

SLEEP MENTATION

NREM Sleep REM Sleep – single, basic image – complex stories – more realistic – usually bizarre – difficult to awaken – easily awakened – relative – good memory – up to 40% of lab awakenings – 85+% of lab awakenings result in result in dream reports dream reports

THE DISORDERS

5 2/13/2015

DISORDERS OF AROUSAL

 Confusional Arousals

 Sleepwalking

 Sleep Terrors

DISORDERS OF AROUSAL (NREM SLEEP)

• Recurrent episodes of incomplete awakening • Inappropriate or absent response to others’ efforts to intervene or redirect • Limited or no cognitive experience or dream imagery • Partial or complete amnesia • Usually occur during first 1/3 of the sleep period • May be confused or disoriented for several minutes upon awakening

ICSD from AASM

CONFUSIONAL AROUSALS

• Meets criteria for Disorder of Arousal • Mental confusion or confused behavior while still in bed • Absence of terror or departure from bed

• Usually a lack of autonomic arousal (e.g., mydriasis, tachycardia, tachypnea, diaphoresis)

ICSD from AASM

6 2/13/2015

SLEEPWALKING

• Meets criteria for Disorder of Arousal • Ambulation and other complex behaviors out of bed

ICSD from AASM

SLEEP TERRORS

• Meets criteria for Disorder of Arousal • Abrupt terror, typically beginning with vocalization, scream, etc. • Intense fear and signs of autonomic arousal

ICSD from AASM

SLEEP-RELATED EATING DISORDER (SRED)

• Recurrent episodes of dysfunctional eating after arousal from major sleep period

• Presence of at least one of the following:  Eating odd types of combinations of food, inedible or toxic substances  Injurious or potentially injurious behavior while seeking or cooking food  Adverse health consequences • Partial or complete loss of consciousness w/subsequent impaired recall

ICSD from AASM

7 2/13/2015

CLINICAL EVALUATION

• Thorough medical/behavioral history • Include bedpartner or family whenever possible • Assess risk • Screen for history suggestive of other sleep disorders • if risk is significant

TREATMENT

Environmental safety • bedpartner sleeps separately • move & furniture prn Behavioral safety • AVOID ! • reduce whenever possible Clonazepam is usually considered first line • start low & go slow • habituation/tolerance typically not seen Other med options → trial and error

8 2/13/2015

REM RELATED PARASOMNIAS

 REM Sleep Behavior Disorder

 Recurrent Isolated Sleep Paralysis

 Nightmare Disorder

REM SLEEP BEHAVIOR DISORDER (RBD)

• Repeated episodes of vocalization and/or complex motor behaviors

• Documented by PSG to occur during REM or are presumed to occur in REM based on clinical hx of dream enactment

• PSG demonstrates REM sleep without atonia

ICSD from AASM

RBD

• First described in 19861

• Strongly associated w/ neurodegenerative disorders (PD, DLB, MSA)2

• Severe injuries reported3

1Schenck et al. Sleep, 1986 2ICSD from AASM, 2014 3Schenck & Mahowald, Intensive Care Med, 1991

9 2/13/2015

RBD EVALUATION

• Careful history including reports from bedpartner or family (risk, family reports, other sleep disorders)

• Polysomnography is necessary ― sustained muscle activity in chin EMG ― excessive transient muscle activity (bursts) in chin or limb EMG

QUESTIONNAIRE?

• Single question:

• “Have you ever been told, or suspected yourself, that you seem to ‘act out your dreams’ while asleep (for example, punching, flailing your arms in the air, making running movements, etc.”

Postuma et al. 2012 Mov Disord 27(7), 913-916

• Mayo Sleep Questionnaire (10) questions

Boeve et al. 2011 Sleep Med 12(5), 445-453

10 2/13/2015

RBD TREATMENT

• Clonazepam effective in 90% of cases1 (caution in , gait disorders, & OSA) • Melatonin considered a good alternative2 • Pressurized bed alarm?3

1Schenck & Mahowald, Cleve Clin J of Med, 1991 2McGrane et al. Sleep Med, 2015 3Howell et al. J Clin Sleep Med, 2011

RECURRENT ISOLATED SLEEP PARALYSIS

• Recurrent inability to move trunk and all 4 limbs at or on waking

• Episodes last seconds to minutes

• Causes significant distress including or fear of sleep

ICSD from AASM

 Reassurance

NIGHTMARE DISORDER

• Extended, dysphoric dreams that usually involve threats • Rapidly alert and oriented on awakening • Clinically significant distress or impairment in social/occupational/other areas of function evident in at least one of the following  Mood  Sleep resistance  Cognitive impairments  Family functioning  Behavioral problems  Daytime sleepiness  Fatigue/low energy  Impaired occupational/educational/interpersonal/social function ICSD from AASM

 Behavioral treatments highly effective (eg, Seda et al. J Clin Sleep Med, 2015)

11 2/13/2015

“” Johann Heinrich Füssli

EXPLODING HEAD SYNDROME

• Sudden loud noise or of explosion in the head at wake-sleep transition or on waking during sleep period • Sensation is followed by abrupt arousal, often with great sense of fright • Not associated with complaints of pain

ICSD from AASM

SLEEP-RELATED HALLUCINATIONS

• Recurrent hallucinations just prior to sleep onset or nocturnal or morning awakenings

• Hallucinations are predominantly visual

ICSD from AASM

12 2/13/2015

SLEEP ENURESIS

• Patient is older than 5 • Recurrent involuntary voiding during sleep at least twice a week • Present for at least 3 months

Primary Sleep Enuresis Never consistently dry during sleep

Secondary Sleep Enuresis Previously consistently dry for at least 6 months

ICSD from AASM

HYPNOTIC-INDUCED SLEEPWALKING

Businessman Grandma College Student uses zolpidem intermittently zolpidem nightly 1st week of zolpidem

House alarm goes off 3 AM for unknown reason Irregular schedule 2o classes & job International business travel (Europe), zolpidem when crossing many time She does not wake, police arrive & zones cannot reach her by phone. They Wakes spontaneously in AM after break into home, find her safely single night use of zolpidem & finds sleeping & difficult to rouse. They Jack-in-the-Box bag with half-eaten After short sleep is awakened by burger inside (she does not usually jointly call her daughter, much patronize them). Register receipt partner to attend meeting w/ client. discussion, police secure home, and dated 3:36 AM that day from location They discuss, negotiate, sign 3 she returns to sleep. 2 miles away. Lives alone, has no contracts, and he returns to bed to recall for events. complete a full night of sleep. No Talks w/ daughter in AM and says “Did I call you last night?” recall for any events in the AM.

STRATEGIES

― Use your consultant well

― PSG complexities

― Be aware of liability

13 2/13/2015

CASE RESOLUTION

CASE 1

42-year old ♀ goes to sleep at 11:30 PM and wakes around 1:30 AM in the middle of her backyard with nursery plants she had bought 2 days ago scattered around. She is standing next to a 2’ deep hole, has garden soil on her legs and hands, and is naked.

Has no how she got there No dream recall Days later she reflects on pressure she felt to complete the garden task

Sleep Study?

CASE 1

History of benign childhood sleepwalking, stopped ≈ age 9…

until two other recent incidents

 Sleepwalking

14 2/13/2015

CASE 2

72-year old British ♂ conveys wife’s reports of his yelling, punching, kicking, and “speechifying”. Her sleep is disturbed 3-4 nights a week and he is sometimes tired during the day.

Gives complex dream reports upon awakening Behaviors correlate well with recalled dream content Wife has sustained minor bruises; feels she must protect him during episodes

Sleep Study?

CASE 2

Sleep study showed sustained chin EMG for ≈ 50% of time in 2 of 3 REM periods—also large EMG bursts in arms and legs during REM and a single period of loud shouting lasting ≈ 15 seconds

 REM Sleep Behavior Disorder

CASE 3

52-year old ♂ punches or kicks his wife during sleep every 1-2 months. Once a month he leaves the bed, fumbles in the bedroom closet or stumbles along a wall, feeling it with his hands, returning to bed in response to gentle suggestion from his wife.

Recalls dream after vigorous behavior in bed, but has no idea what happened in times when he gets out of bed, no recall for the latter Has bruised wife with former event type, but no injuries with latter type

Sleep Study?

15 2/13/2015

CASE 3

Sleep study shows elevated chin EMG periodically during each of 4 REM periods and excessive EMG bursting in arms during an episode in which patient is seen via videography vigorously flexing his right elbow. Recalls in AM that he dreamed of being attacked from behind and trying to punch attacker in his stomach.

 REM Sleep Behavior Disorder (explains aggressive behavior w/dream recall)  Sleepwalking is also an appropriate dx on clinical grounds = “Parasomnia Overlap Disorder”

CASE 4

• 37-year old ♂ police officer wakes in AM on living room sofa. Wife says that during the night he was “charging around the house” with a loaded service revolver, periodically “hiding” behind furniture, yelling, and seeming to “chase the bad guys.” Vaguely recalls a dream about being in a shoot- out similar to one he actually experienced several months earlier.

Vaguely recalls a dream fragment about being in a shoot-out similar to one he actually experienced several months earlier

Wife says similar episodes start w/patient sitting bolt upright in bed, screaming, and often fleeing bed, running down hallway

Sleep Study?

CASE 4

Sleep study shows moderate OSA with apnea/hypopnea index of 25.8 Lowest SaO2 = 87% CPAP was not applied per order

 Sleep Terrors, likely triggered or aggravated by untreated OSA

16 2/13/2015

THE END

That we are not much sicker and much madder than we are is due exclusively to that most blessed and blessing

of all natural graces, sleep.

Aldous Huxley

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