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What respiratory physicians should know about parasomnias

Imran Johan Meurling, Guy Leschziner, Panagis Drakatos
Breathe 2022 18: 220067; DOI: 10.1183/20734735.0067-2022
Imran Johan Meurling
1Sleep Disorders Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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  • For correspondence: johan.meurling@gstt.nhs.uk
Guy Leschziner
1Sleep Disorders Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
2Plasticity Centre, Dept of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, London, UK
3Dept of Neurology, Guy's and St Thomas’ NHS Foundation Trust, London, UK
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Panagis Drakatos
1Sleep Disorders Centre, Guy's and St Thomas’ NHS Foundation Trust, London, UK
4Faculty of Life Sciences and Medicine, King's College London, London, UK
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    FIGURE 1

    A pathophysiological model of disorders of arousal.

Tables

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  • TABLE 1

    International Classification of Sleep Disorders, third edition (ICSD-3) classification of parasomnias

    NREM parasomniasDisorders of arousal
     Confusional arousals
     Sexsomnia
     Sleepwalking
     Sleep terrors
     Sleep-related eating disorder
    REM parasomniasREM sleep behaviour disorder
    Recurrent isolated sleep paralysis
    Nightmare disorder
    Other parasomniasExploding head syndrome
    Sleep-related hallucinations
    Sleep enuresis
    Parasomnia due to a medical disorder
    Parasomnia due to a medication or substance
    Parasomnia, unspecified
    Isolated symptoms and normal variantsSleep talking

    Information from [1].

    • TABLE 2

      ICSD-3 criteria for NREM parasomnias

      Disorders of arousal#Recurrent episodes of incomplete arousal from sleep:
       Usually occurring during the first third of the major sleep period
       The individual may appear confused or disorientated for several minutes after the episode
      Inappropriate or absent responsiveness
      Limited or no associated dream imagery
      Partial or complete amnesia for the episode
      The episode is not better explained by another sleep disorder, mental disorder, medical disorder, or substance or medication use

      #: confusional arousals, sleepwalking, sleep terrors. Information from [1].

      • TABLE 3

        ICSD-3 criteria for RBD

        Repeated episodes of sleep vocalisation and/or complex motor behaviours
        Behaviours are documented by polysomnography to occur during REM sleep, or based on a clinical history of dream enactment, are presumed to occur during REM sleep
        Presence of REM sleep without atonia on polysomnography
        Absence of epileptiform activity during REM sleep, unless RBD can be distinguished from any concurrent REM-related seizure disorder
        The sleep disturbance is not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medicine use or substance use disorder

        Information from [1].

        • TABLE 4

          Different features of parasomnias, including DOAs, SHE, idiopathic RBD and nightmares

          DOASHEIdiopathic RBDNightmares
          Age of onset (years)3–8Any ageAfter 50Usually 3–6
          CourseTends to disappearUsually increasesRare spontaneous remissionVariable
          Episodes per nightUsually oneUsually severalOne to severalOne to several
          Occurrence during the nightFirst thirdAny timeLast thirdLast third
          Episode duration1–30 minSeconds–3 min1–2 minSeconds–minutes
          Motor patternVariable: sitting up, pulling at bed clothes, speaking, sleepwalking, screaming, usually with eyes openingHighly stereotyped: complex body movements, kicking or cycling of limbs, rocking body movements, asymmetric tonic/dystonic posturingFinger twitching or flexing to complex dream enactment behaviourMost commonly absent, but rarely can consist of simple movements with preserved REM atonia
          Awareness if awakenedUsually absentVariableUsually presentUsually present
          RecallUsually absentVariableUsually present, sometimes with vivid detailUsually present, sometimes with vivid detail
          PSG featuresCyclic alternating pattern, hypersynchronous delta activity, possible periodic limb movements (confusional arousals/sleepwalking), increased autonomic function (sleep terrors)Epileptiform features on sleep EEGREM sleep without atoniaVariable: may be normal, may display reduced sleep efficiency and increased wakefulness, may identify sleep disrupting pathology

          Reproduced and modified from Loddo et al. [33].

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          What respiratory physicians should know about parasomnias
          Imran Johan Meurling, Guy Leschziner, Panagis Drakatos
          Breathe Sep 2022, 18 (3) 220067; DOI: 10.1183/20734735.0067-2022

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          What respiratory physicians should know about parasomnias
          Imran Johan Meurling, Guy Leschziner, Panagis Drakatos
          Breathe Sep 2022, 18 (3) 220067; DOI: 10.1183/20734735.0067-2022
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