Parasomnias

1. Resident: Dr. Amit Chail
Moderator: Dr. AK Dwivedi
Parasomnias

2. Overview
• Introduction
• Historical perspective
• Sleep Physiology
• Classification systems of sleep disorders
• Parasomnias- NREM , REM & other
• Take home message
• References
2

3. Introduction
• Sleep
– State of decreased awareness
– Fundamental
– 1/3 lifespan
– Sleep and Psychiatry
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

4. History of sleep study
• Ancient Gk – Hypnos & Morpheus
• Hippocrates (GK) Blood retreating to internal organs
• 1830- Robert MacNish- temporary metaphysical death
• 1868- Wilhelm Griesinger- eyelids flutter during sleep
(active)
Kaplan and Saddock, Synopsis of Psychiatry,11th edn, 2015
http://healthysleep.med.harvard.edu/interactive/timeline

5. History of sleep study – Modern era
• 1929- Hans Berger – EEG
• 1953- N Kleitman and Eugene Aserinsky
»discovered REM sleep
• 1955-58 - Wilhelm Dement – sleep cycles
• REM sleep – dreams
• 1968 – Allen Rechtschenaffen and Anthony Kales
• Scoring system for sleep stages – EEG/EMG/EOG
http://healthysleep.med.harvard.edu/interactive/timeline

6. Basic Sleep Physiology-
Types, stages and cycle
• Types
– REM / Paradoxical / Active
– NREM / Orthodox / Quiet
• Stages
– NREM- N1, N2 & N3
– REM (components) – Tonic & Phasic
• Sleep Cycle
– Changes in sleep stages over time (night)
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

7. Stages of sleep
EEG EOG EMG
N1
transit
ional
α  θ
N2 K –complexes and Sleep
spindles
-----
N3, Δ
SWS
Δ (20%) ----- Low tonic
activity
REM Low voltage, mixed ν; saw
toothed; θ ; α.
REM Tonic- atonia
Phasic - twitches
Low tonic activity
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

8. The sleep cycle
9

9. 10

10. Classification systems
of sleep disorders
• ICD 10 (1992) / WHO
• DSM 5 (2013) / APA
• ICSD -3 (2014) / AASM

11. ICD 10 Classification of Sleep Disorders
• Organic vs non-organic
• Organic – Diseases of the Nervous system
– Episodic and paroxysmal disorders (G40-G47)
• Sleep disorders (G47)
• G47.5 - Parasomnia
•G47.50 - Parasomnia, unspecified
•G47.51 - Confusional arousals
•G47.52 - REM sleep behavior disorder
•G47.53 - Recurrent isolated sleep paralysis
•G47.54 - Parasomnia in conditions classified elsewhere
•G47.59 - Other parasomnia

12. ICD 10 Classification of Sleep Disorders
• Non-Organic sleep disorders
– F51.0 – Non organic insomnia
– F51.1- Non-organic hypersomnia
– F51.2- Non organic disorder of the sleep-wake schedule
– F51.3- Sleep walking
– F51.4- Sleep terrors
– F51.5- Nightmares
– F51.8- Other non-organic sleep disorders
– F51.9- Non-organic sleep disorder, unspecified

13. ICSD -3 (2014) - AASM
• Insomnia
• Sleep related breathing disorders
• Central disorders of hyper-somnolence
• Circadian rhythm sleep wake disorders
• Parasomnias
• Sleep related movement disorders
• Other sleep disorders
Sateia MJ. International classification of sleep disorders-third edition: highlights and
modifications. Chest 2014; 146:1387.

14. ICSD -3 (2014) – AASM
Parasomnias
• Disorders of arousal (from NREM sleep)
– Confusional arousals
– Sleep walking
– Sleep terrors
– Sleep related eating disorders
Sateia MJ. International classification of sleep disorders-third edition: highlights and
modifications. Chest 2014; 146:1387.

15. ICSD -3 (2014) – AASM
Parasomnias
• Parasomnias usually associated with REM sleep
– REM sleep related behavior disorder
– Recurrent Isolated Sleep paralysis
– Nightmares
Sateia MJ. International classification of sleep disorders-third edition: highlights and
modifications. Chest 2014; 146:1387.

16. ICSD -3 (2014) – AASM
Parasomnias
• Other Parasomnias
– Exploding head Syndrome
– Sleep related hallucinations
– Sleep enuresis
– Parasomnias due to medical condition
– Parasomnias due to substance/drug abuse
– Parasomnias - unspecified
Sateia MJ. International classification of sleep disorders-third edition: highlights and
modifications. Chest 2014; 146:1387.

17. DSM 5
Sleep wake disorders
• Insomnia disorder
• Hyper-somnolence disorder
• Narcolepsy
• Breathing related sleep disorders
• Circadian rhythm sleep wake disorders
• Parasomnias
• Restless leg syndrome
• Substance / medication induced sleep disorder

18. DSM -5
Parasomnias
– NREM sleep arousal disorder
• Sleep walking
• Sleep terror
– REM sleep related parasomnias
• Nightmare disorder
• REM sleep Behavior disorder

19. Parasomnias

20. Definition
• DSM 5-
Disorders characterized by abnormal
behavioral, experiential or physiological
events occurring in assoc with sleep, specific
sleep stages or sleep wake transitions
• Para – along side
• Somnus- sleep
DSM-5, 2013, American Psychiatric Association

21. Parasomnias
• Disorders of partial arousal
• Physiological or behavioral phenomena that occur
during or are potentiated by sleep
• Intrusions of one basic sleep–wake state into another
• State boundary violations
• Clinical significance –
– Consequences /distress > frequency
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

22. NREM sleep arousal disorders

23. Disorders of Arousal (From NREM Sleep)
• Confusional arousals, sleepwalking, and sleep terrors
lie on a continuum
• Confusional arousals
– Mildest
– Children (<5 yrs)
– partially awaken from SWS and sit up
– Confusion
– lies back down and resumes sleep
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

24. Epidemiology
• Sleep walking
•10-30 % children– once
•Sleep walking disorder- 1-5 %
• Sleep terrors
•Sleep terror disorder- Prevalence- Not Known
•Sleep terror episodes
• 18 months- 36.9 %
• 30 months- 19.7 %
• Adults - 2.2 %
DSM-5, 2013, American Psychiatric Association

25. Pathophysiology
• Active: Motor cortex
• Inactive: Prefrontal & Mid-temporal
• SPECT studies- During a Sleep Walking Episode
Increase blood flow:
- Cerebellum
- Posterior Cingulate Cortex
Decrease blood flow:
- Fronto-parietal cortex
Bassetti, Claudio; SPECT during sleepwalking. Lancet. 356(9228):484-485, August 5, 2000

26. Pathophysiology
• Environmental factors (reduced sleep/ disturbed
sleep/ tiredness/ stress)  lack of SWS sleep
• Rebound sleep with prolonged SWS/deep sleep
provides “fertile ground for such partial arousals”
Rutter’s Child and Adolescent Psychiatry, 6th edn, 2015

27. Risk Factors - Environmental
–Drugs (anti-depressants- TCA, Trazodone& Mirtazapine)
(non-BZD sedatives ie Zolpidem & Zopiclone)
–Sleep deprivation
–Sleep wake cycle disruption
–Stress – physiological and psychological
–Fatigue
DSM-5, 2013, American Psychiatric Association
Lara Kierlin, and Michael R. Littner, Parasomnias and antidepressant therapy: a review of the
literature, 2011 Frontiers in psychiatry

28. Risk Factors - Genetic and physiological
• Sleep walking-
– Family history (80 %)
– Risk increases if both parents +
• Sleep Terrors
• Family history (SW/ST)
• First degree relatives- 10x
• Twins - Mz 6x > Dz
• Exact Mechanism ??
--Bakwin H. Sleep-walking in twins. Lancet 1970; 2:446.
--Hublin C, Kaprio J. Genetic aspects and genetic epidemiology of parasomnias. Sleep Med Rev
2003; 7:413
--DSM-5, 2013, American Psychiatric Association
-- Petit D, Pennestri MH, Paquet J, et al. Childhood Sleepwalking and Sleep Terrors: A
Longitudinal -Study of Prevalence and Familial Aggregation. JAMA Pediatr 2015; 169:653

29. DSM-5 criteria
Disorders of Arousal (From NREM Sleep)
A) Recurrent episodes of “incomplete awakenings”
• First 1/3 , accompanied by 1 of following:
–Sleep walking
–Sleep terrors
B) Little or no dream imagery
C) Amnesia
D) Distress and socio-occupational impairment
E) Not d/t effects of a substance/drug
F) Not d/t other medical or mental condition

30. DSM-5 criteria
• Sleep walking:
repeated episodes
– Rising from bed &
walking around
(purposeful movt)
– Blank, staring face
– Relatively
unresponsive to
communication
– Difficult awakening
(deep sleep)

31. DSM-5 criteria
–Specifiers:
A. Sleep related eating
– Recurrent unwanted
episodes of eating
– Amnesia - variable
– Inappropriate foods +
– Evidence – next
morning

32. DSM-5 criteria
–Specifiers:
B. Sleep related sexual behavior (sexsomnia)
– Recurrent - varying degree of sexual activity
– Masturbation, fondling, groping & sexual intercourse
– Amnesia
– M>>F
– Problems : IP issues and Medico-legal

33. DSM-5 criteria
Sleep terrors: repeated
episodes
– Abrupt terror arousals
– Panicky scream
– Intense fear
– Autonomic hyperactivity
– Relatively unresponsive
to efforts to comfort

34. Course (NREM Parasomnias)
• Onset : Childhood
• Max around 4-6 years of age
• Decrease with age
• Fresh onset SW (adults)- Obstructive sleep apnoea
• Nocturnal seizures or
• drug induced
• Sleep terrors – children – no psychopathology
• Adults - h/o traumatic experience
• Psychiatric comorbidity
DSM-5, 2013, American Psychiatric Association

35. Diagnosis
• Video recording + Polysomnography
• PSG: ST and SW
–First 1/3
–Delta Theta/Alpha
DSM-5, 2013, American Psychiatric Association

36. Treatment
• PARENTS –Reassurance
• CHILD- 1. Prevention of further attacks
–Identify & Reduce environmental risk factors
–Sleep hygiene
2. Before the episode- Safety
3. During an episode- Don’t wake; re-direct
4. Long Term- Relaxation techniques
Anticipatory awakenings
Pharmac: Clonazepam & Melatonin
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn
Kap Schenck CH, Long-term, nightly benzodiazepine treatment of injurious parasomnias and
other disorders of disrupted nocturnal sleep in 170 adults. Am J Med. 1996

37. REM Sleep related Parasomnias
• REM Sleep behavior disorder (RBD)
• Nightmare disorder
• Recurrent isolated sleep paralysis
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

38. The sleep cycle
40

39. REM Sleep behavior disorder

40. Essentials
• Sleep paralysis (atonia)
– α and γ – hypo-polarisation
• RBD- Absence of sleep paralysis
– Enactment of dreams- complex behaviors
– Second half of night
– Story like memory
– Unaware of surroundings
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

41. Essentials
• RBD – Dream Enactment Behavior (DEB)
– Complex behaviors
– Running/jumping/leaping/punching/slapping
– Injuries to self or others
– Vocalisation / Somniloquy
• (loud, profane, emotionally charged)
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

42. Epidemiology
• Prevalence - 0.38 – 0.50 %
• M > F
• >50 years
• Onset – gradual / rapid
• Course- progressive
• If assoc with Neuro-degenerative disease :
– RBD precedes by many years
– RBD improves as the disease progresses
DSM-5, 2013, American Psychiatric Association

43. Risk Factors
• Medicines – TCA /SSRI/SNRI/ β blockers
?? Cause or unmask
• REM rebound states assoc with alcohol & barbiturate
withdrawal
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

45. Diagnostic Criteria DSM 5
• Recurrent episodes, arousals from sleep associated
with vocalization and/or complex motor behaviors
• REM sleep/ > 90 min/ later part
• Upon awakening – alert and oriented
• Either – REM sleep+ NO atonia on PSG
–H/s/o RBD + estd synucleinopathy (PD, LBD)
• Distress / dysfunction
• Excl: drug/substance/co-existing mental/medical
DSM-5, American Psychiatric Association,2013

46. Diagnostic markers
• PSG + Video
• PSG - RSWA (REM sleep Without Atonia)
EEG – REM sleep
EMG – normal to increased tone
• Sub-mental
• B/L Extensor digitorum
• B/L Tibialis anterior
DSM-5, American Psychiatric Association,2013

47. Treatment - RBD
• Identify & remove the offending agent
• Modification of sleep environment Safety of Self and bed
partner -- Level A
– Mattresses on floor
– Window protection
– Padding corners of furniture
– Remove sharps
• Preventive - Customized pressurized bed alarm
--Aurora RN; Zak RS; Maganti RK Best Practice Guide for the Treatment of REM Sleep Behavior
Disorder (RBD). J Clin Sleep Med 2010;6 (http://www.aasmnet.org/resources)
--Devnani P, Fernandes R. Management of REM sleep behavior disorder : An evidence based
review. Ann Indian Acad Neurology. 2015 Jan-Mar; 18 (1): 1-5

48. Treatment - RBD
• Pharmacological
– BZD- Clonazepam (.25-2) mg QHS Level B
–MoA – suppression of phasic ms activity
• Melatonin - 3 to 12 mg QHS - Level B
restores atonia and improves symptoms
--Aurora RN; Zak RS; Maganti RK Best Practice Guide for the Treatment of rem sleep
behavior disorder (rbd). J Clin Sleep Med 2010;6
--Devnani P, Fernandes R. Management of REM sleep behavior disorder : An evidence
based review. Ann Indian Acad Neurology. 2015 Jan-Mar; 18 (1): 1-5

49. RBD and Neurodegenerative Disorders
• Risk of alpha synucleinopathies later in life (? prodrome) :
- Parkinson’s Disease
- Dementia with Lewy Bodies
-Multiple system atrophy
• Thought to be related to the pathological involvement of
common brainstem structures including nigrostriatal
complex, locus coeruleus and raphe nucleus*
Iranzo A, Ferna´ndez-Arcos A, Tolosa E, Serradell M, Molinuevo JL, et al. (2014)
Neurodegenerative Disorder Risk in Idiopathic REM Sleep Behavior Disorder: Study in 174
Patients. PLoS ONE 9(2): e89741. doi:10.1371/journal.pone.0089741
* Iranzo A, Santamaria J, Tolosa E. The clinical and pathophysiological relevance of REM sleep
behavior disorder in neurodegenerative diseases. Sleep Med Rev 2009;13(6):385Y401.

50. Nightmare disorder

51. Epidemiology
• Life time prevalence – 10-50%
• Content : F : sexual harassment / dying /disappearing
M: Aggression / war /terror
0
1
2
3
4
5
6
7
Childhood Adolescence Adulthood Elderly
Males
Female

52. Cause -Psycho-analytical perspective
• Emotionally charged dream –
– Process to de-fuse
– By disguising – symbol
– Preserves sleep
• Failure of this preventive dream process
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

53. Risk factors
• Temperament & personality
– Difficult temperament
– Schizoid/ Schizotypal /Borderline
• Environmental
– Traumatic events
– Sleep deprivation/ fragmentation
– Sleep-wake cycle disruption
– Drugs (L-DOPA, β-adrenergic blockers and alcohol)
• Genetic and Physiological
– Twin studies Mz>Dz, No candidate genes
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

54. Diagnostic Criteria – DSM 5
• Repeated extended, extremely dysphoric and well
remembered dreams- efforts to avoid threats to
security/survival/physical integrity
• 2nd half
• Awakening – alert & oriented
• Clinically significant distress /impairment
• Excl: substance / mental / medical disorder
DSM-5, 2013, American Psychiatric Association

55. Diagnostic Criteria – DSM 5
• Specify – based on onset and presentation
– Acute : < 1 month
– Sub-acute: 1-6 months
– Persistent: > 6 months
• Severity (frequency)
– Mild < 1/ wk
– Moderate >1 /wk - < 1 / night
– Severe Nightly
DSM-5, 2013, American Psychiatric Association

56. Associated Features
• Autonomic arousals – HR/RR/ sweating
• Body movts
• Vocalizations – PTSD, emotional stress, fragmented
sleep
• Frequent nightmares increase risk of suicide
• Idiopathic / secondary (PTSD, anxiety, substance etc)
• Replicative Nightmares- PTSD
DSM-5, 2013, American Psychiatric Association

57. Nightmare disorder- Vicious cycle
Nightmares
Increased
Frequency and
distress
Fear of
sleeping
Insomnia
Sleep
deprivation
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

58. Diagnostic markers
PSG: abrupt awakening from REM sleep in 2nd
half of night
+
Reporting of nightmares
DSM-5, 2013, American Psychiatric Association

59. Treatment
• Identify risk factors- reduce / remove
• Psychological
– Sleep hygiene
– Lucid dream therapy
– Cognitive therapy (Image Rehearsal Therapy) Level A
– Systematic Desensitization and Progressive Muscle
Relaxation training - Level B
• Pharmacological
– Nefazodone
– Prazosin (PTSD associated Nightmares) - Level A
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn
Aurora RN; Best Practice Guide for the Treatment of Nightmare Disorder in Adults. J Clin Sleep
Med 2010;6(4) (http://www.aasmnet.org/resources)

60. Sleep hygiene
Dos Don'ts
Regular hrs -bedtime & arising Watch the clock to check insomnia
If hungry, take a light snack Exercise just before going to bed
Regular exercise Watch TV in bed before going to sleep
Cool, dark and quiet bedroom Take heavy meal before bedtime
Take coffee / tea/ cigarette in the
evening
If pre-occupied or worried –
write it down- deal with it next
morning
Use alcohol to sleep
Eat/ read/ exercise in bed, if cannot
sleep
Talk on phone/surf internet in bed

61. Recurrent Isolated Sleep Paralysis

62. Recurrent Isolated Sleep Paralysis
• Sleep paralysis
• Parasomnia – sleep wake transitions
• Isolated sleep paralysis
• Recurrent isolated sleep paralysis
• Partially conscious and aware
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

63. Recurrent Isolated Sleep Paralysis
• Sleep wake transitions
– While falling asleep
– Awakening
• Partially conscious and aware
• 1-10 minutes
• Subjectively – attacked/ not a able to move / breathe
– Hypnogogic hallucinations – sits/talks – vanishes
– Old hag, night hag, ghost oppression, Kanashbari
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

64. Recurrent Isolated Sleep Paralysis
• Risk factors
– Sleep deprivation
– Stress – psychological
– Shift work – disruption of sleep-wake cycle
•Prevalence - ISP – 25-50 %
•RISP : Not known
•Treatment –
•Identify and reduce/remove the risk factors
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

65. • Differentials

66. Nightmares Sleep terrors
Confusion Arousal with fear & autonomic
hyperactivity- may mimic Nightmares
Diff points-
Timing Later part First 1/3 of night
Imagery Vivid dream No / minimal
Awakening Complete,
oriented & aware
Partial; confused and partially
responsive to awakening, calming
Amnesia Not present +
Autonomic
activation
+ before
awakening
Sudden onset with the episode of
shouting/screaming
PSG REM NREM (N3)
DSM-5, 2013, American Psychiatric Association

67. RBD NREM parasomnias
Confusion Sleep walking and sleep
terrors may mimic RBD
Diff points-
Age Older, Males Younger
Timing Late Early, N3, difficult to awake
(deep sleep)
Awakening Easy, fully oriented &
aware
Difficult, confused,
disoriented
Recall + / story like Nil / minimal
PSG RSWA NREM, REM atonia
DSM-5, 2013, American Psychiatric Association

68. RBD Nocturnal seizures
(NFLE)
Confusion Vocalizations & automatism
may mimic RBD
Diff points-
Behavior Random, DEB,
varied
Stereotyped behavior
FLEP score < 0 >3
PSG+ full EEG
seizure
montage
RSWA REM sleep – atonia+
Focal Seizure +
DSM-5, 2013, American Psychiatric Association

70. Other Parasomnias

71. Exploding Head Syndrome
• Paroxysmal sensory parasomnia
•“Hear” loud noise (? Auditory
hallucination) or
• Sense of a violent explosion in
the head
• About to fall asleep / nocturnal
awakening
•Sudden onset, brief
•No pain
•Autonomic
•Fear -- ?stroke or something is
very wrong

72. Exploding Head Syndrome
• Cause (?)
– Auditory hallucination assoc with RISP
– Assoc with Temporal lobe epilepsy??
• Gender: F>M,
• Age : >50 years
• Consequence insomnia +
• No known neurological consequences (benign)
• Treatment : Reassurance
–TCA
Frese A, Exploding head syndrome: six new cases and review of the literature, Cephalgia,
2014, Sep

73. Sleep Enuresis
• Bed-wetting
• Primary / secondary
• Primary : Prevalence
30% (4), 10 % (6), 3% (12)
»F/H/O +
• Secondary – stress :
• Birth of sibling /
cry for attention
• Sleep deprivation
• Nocturnal seizures
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

74. Sleep Enuresis
• Consequences:
– Embarrassment, shame & guilt
• Treatment
• Pharmacological : Imipramine (TCA)
– oxybutynin (anticholinergic)
–synthetic vasopressin (desmopressin)
• Behavioral :
–Anticipatory awakening
–Bladder training using bell
–Fluid restriction (?)
Kaplan and Saddock, Comprehensive Textbook of Psychiatry, 9 edn

75. Sleep Related Hallucinations
• Visual images
• Hypnagogic or hypnopompic
• Common in patients with
narcolepsy
• D/D dreams
• Abrupt awakening & without
remembrance dreaming
• Vivid and immobile and persists
for several minutes

76. Sleep-Related Groaning (Catathrenia)
• Prolonged, frequently loud groans
• Any sleep stage (up to 30 seconds)
• Begin during childhood (occult)
• Not related to psychiatric or physiologic abnormalities
• D/D snoring (inhalation); groaning (exhalation)
• No specific treatment

77. Parasomnias – Medical conditions
• Seizure disorder
– D/D sleep terror, sleepwalking, RBD, nightmares
• Sleep-related breathing disorders
– Can trigger - sleepwalking, enuresis, sleep terrors,
confusional arousal, and nightmares
• RBD is assoc with
Parkinson's disease, dementia, narcolepsy, MSA

78. Parasomnias –Drugs/substances
• Sleepwalking – Alcohol
• RBD provoked or worsened by
–REM sleep suppressants- TCA, MAOIs, caffeine,
SNRI (venlafaxine) and SSRI
–withdrawal from alcohol, pentazocine (opioid) and
nitrazepam (BZD)
• Nightmares- L-DOPA and β-blockers.
– Drug-induced REM sleep rebound (e.g., withdrawal
from REM-suppressing drugs -methamphetamine)
– Alcohol abuse or withdrawal

79. Class Pharmacology Effects on sleep
TCA
5HT and NE
Re-uptake inhibition & H1 #
Decreased sleep latency
REM suppression
Increased REM latency
SSRI 5HT Re-uptake inhibition
REM suppression
Increased REM latency
SNRI
5HT and NE
Re-uptake inhibition
REM suppression
Increased REM latency
Trazodone
Nefazodone
5 HT-2 antagonism
Decreased sleep latency
Increased SWS
Mirtazapine 5 HT-2 and H1 antagonism
Decreased sleep latency
Increased SWS
Bupropion NE & DA reuptake inhibition Increased REM sleep

80. Take Home Message
• Parasomnias are boundary transgressions involving
abnormal behavioral, experiential and physiological
phenomena
• NREM parasomnias occur in N3- early/deep
sleep/childhood/ benign
• REM parasomnias –R-W boundary- absence or
extension of physiological phenomenon
– Late sleep / Adulthood - elderly/ May be harmful
• Psychotropic drugs can alter the sleep physiology

81. References
• Kaplan and Saddock, Comprehensive Textbook of Psychiatry,
9 edn, 2009
• DSM-5, American Psychiatric Association, 2013
• Sateia MJ. International classification of sleep disorders-
third edition: highlights and modifications. Chest 2014;
146:1387.
• Devnani P, Fernandes R. Management of REM sleep
behavior disorder : An evidence based review. Ann Indian
Acad Neurology. 2015 Jan-Mar; 18 (1): 1-5
• Kaplan and Saddock, Synopsis of Psychiatry,11th edn, 2015

82. Thank you