NREM Related Parasomnias

Clinic

• They are abnormal behaviors arising primarily but not exclusively during non-REM stage three (N3) sleep.

• NREM parasomnias are arousal disorders include activation of
  • Autonomic nervous system
  • Motor system
  • Cognitive processes

Types

• Teeth grinding
• Rhythmic movement disorder
• Somniloquy
• Sleepwalking (Somnambulism)
• Sleep terrors / Night terrors
• Confusional arousal
• Sexsomnia
• Sleep-related eating disorder (SRED)

Pathophysiology

• In the normal transition from light NREM sleep to wakefulness, consciousness emerges quickly within seconds.
• Incomplete dissociation of NREM sleep into wakefulness is the Core pathology of NREM Related Parasomnias
• Impaired arousal mechanisms and the persistence of sleep drive result in a failure of the brain to fully transition into wakefulness.
• Sleep-promoting conditions such as sleep deprivation and sedative–hypnotic medication can lead to NREM parasomnias.
• Two pathological processes:
  1. Phenomena that deepen sleep (Enhance sleep inertia) promote NREM parasomnias by impairing normal arousal mechanisms. Sleep inertia is a temporary disorientation and decline in performance and/or mood after awakening from sleep.
  2. Conditions that cause repeated cortical arousals lead to NREM parasomnias through sleep fragmentation. These abnormal arousals are often associated with the normal alternating arousal microstructure of NREM sleep, the cyclic alternating pattern (CAP). The complex amnestic behaviors that characterize these conditions are related to central pattern generators The isolated activation of these functional groups of motor neurons with a relative paucity of activity in brain regions that control executive function and memory account for the poor judgment and amnesia that characterize NREM parasomnias.

• Conditions that provoke repeated cortical arousals, and/or promote sleep inertia, lead to NREM parasomnias by impairing normal arousal mechanisms.
• Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders.
• Compelling evidence suggests that nocturnal eating may in some cases be another nonmotor manifestation of Restless Legs Syndrome (RLS). Initial management should focus upon decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders and eliminating incriminating drugs.
• Sexsomnia is a subtype of disorders of arousal, where sexual behavior emerges from partial arousal from nonREM sleep.
• Overlap parasomnia disorders consist of abnormal sleep-related behavior both in nonREM and REM sleep. Status dissociatus is referred to as a breakdown of the sleep architecture where an admixture of various sleep state markers is seen without any specific demarcation. Benzodiazepine therapy can be effective in controlling SW, ST, and sexsomnia, but not SRED. Paroxetine has been reported to provide benefit in some cases of ST. Topiramate, pramipexole, and sertraline can be effective in SRED. Pharmacotherapy for other parasomnias continues to be less certain, necessitating further investigation. NREM parasomnias may resolve spontaneously but require a review of priming and predisposing factors.

Relate disease

• Obstructive sleep apnea and other sleep-related respiratory events have been recognized as triggers of disorders of arousal in children.
• Previous studies suggest that parasomnias occur commonly in children with restless legs syndrome (RLS) and can be precipitated by periodic limb movements in sleep (PLMS).
• NREM sleep related Parasomnia is very similar to FLE. Since both unconsciously move their limbs / Face / vocal cords during sleep. The third condition is Automatism which is seen in Supplementary sensory area epilepsy.

Miasmatic Analysis

• Core pathology of NREM is remaining in deep sleep, when he should normally be Aware / Awake / Alert. So the first rubric would be
  • Consciousness altered
  • Confusion
  • Concentration difficult
  • Disorientation
  • Stupefaction

• He acts automatically / Without free will, therefore the most similar rubric is seizure, esp Focal frontal lobe epilepsy because of complex patterns of involuntary movements. Cognition Impaired would be a good rubric as a good agent of frontal lobe disorder.
• By these three rubrics we have JE, PLV, RBS, TBE, INFL, EEE/WEE, VZV, YF, EBV, TBE, NPH.
• NREM Parasomnias meet the charactristics of COD, Since they are cluster of disease which has three features
  1. Consciousness altered, Confusion, Concentration difficult, Disorientation, Stupefaction
  2. Impaired cognition
  3. Seizure
• These are NREM parasomnia miasms. Depending on situation, we could choose one of them, E.G:
  • Sleepwalking: JE
  • Teeth grinding: RBS
  • Sleep terrors: RBS
  • Periodic limb movement disorder
  • Sexsomnia: Peripism leads us to RBS, Chorea leads to JE
  • SRED: Chorea leads to JE

NREM vs REM parasomnias

• It is different from FFI, who is deeply remain in his dreams.
• FFI resembles RBD, since both of them are acting their dreams consciously. They are deciding to react but are their lower motor neuron is paralyzed. Its strong accompaniment with Sleep disturbance would be a good reason for this selection. Other entities would be