NREM Related Parasomnias

Clinic

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

Sign / Symptoms

• NREM parasomnias are arousal disorders that occur during stage 3 (or 4) of NREM sleep
• These disorders involve activation of the autonomic nervous system, motor system, or cognitive processes during sleep or sleep-wake transitions.

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, typically within seconds.
• Core pathology: Incomplete dissociation of NREM sleep into wakefulness.
• Impaired arousal mechanisms and the persistence of sleep drive result in a failure of the brain to fully transition into wakefulness. Indeed, most SW and related disorders arise out of N3 sleep. Thus, sleep-promoting conditions such as sleep deprivation and sedative–hypnotic medication will lead to NREM parasomnias.
• Two pathological processes:
  1. Phenomena that deepen sleep (Enhance sleep inertia) promote NREM parasomnias by impairing otherwise normal arousal mechanisms
  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.

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

• In NREM, the patient remain in deep sleep, when he should normally become aware / Awake. So the first rubric would be Altered consciousness.
• 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. So 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, NPH. These are NREM parasomnia miasms. Degpending on situation, we could choose one of them. E.G
• Sleepwalking: Chorea due to complex pattern of movement is good rubric, so JE is selected
• Sleep terrors: By choosing Fear as a rubric, RBS is selected
• Periodic limb movement disorder: Myoclonous: NPH,
• Sexsomnia: Peripism leads us to RBS.

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