By Erika Manis, MD, Sleep Medicine

Abnormal behaviors during sleep, such as sleepwalking, sleep talking, dream enactment and nightmares, are referred to as parasomnias. They are generally categorized based on their sleep stage, NREM (non-rapid eye movement) versus REM (rapid eye movement) sleep. This may be assumed based on timing since sleep onset, whether eyes are open or closed, recall and orientation. 

NREM parasomnias tend to occur during the first half of the night. They are associated with open eyes without event recall and confusion. REM parasomnias, on the other hand, tend to occur during the second half of the night and are associated with closed eyes, dreams and event recall with relatively quicker reorientation. Enuresis (or bedwetting), sleep paralysis, sleep-related eating and seizure disorders and exploding head syndrome are also considered parasomnias. A sleep study may or may not be recommended.

Sleepwalking, sleep talking and confusional arousals typically occur in NREM sleep. They are more common during childhood and may run in families. They are often triggered by sleep disruption and, therefore, may be more likely to occur with a change in routine or travel. If they persist into adulthood, there may be a secondary reason, such as sleep-disordered breathing or medication/substance use, including alcohol or hypnotics. Pharmacologic treatment with clonazepam is infrequently required.

Nightmare disorder and REM behavior disorder (RBD) typically occur in REM or stage R sleep. 

Nightmares may be trauma-related and reality-based. Prazosin is an alpha blocker used primarily for high blood pressure but has been studied for trauma nightmares. Treatment for any underlying Post-Traumatic Stress Disorder (PSTD) is recommended. Dream rehearsal therapy with behavioral sleep medicine or a sleep psychologist may also be used for nightmares where a different ending than usual is practiced. 

RBD is dream enactment behavior with complex motor behaviors, usually punching or kicking or vocalizations, often profane and correlated with dream content frequently of being attacked or defending oneself, as well as loss of REM atonia on an in-lab sleep study called a polysomnogram. 

RBD can be a precursor of alpha synucleopathies such as Parkinson’s Disease. Melatonin and/or clonazepam are used to treat RBD and general parasomnia precautions are recommended for all parasomnias. Parasomnia precautions aim to improve bedroom safety for those with abnormal sleep behaviors.