Current Perspectives on Nonrapid Eye Movement Parasomnias

Abstract

Non-REM (NREM) parasomnias comprise abnormal sleep-related behaviors, autonomic nervous system function, and emotional experiences that typically arise out of deep NREM sleep. Categorized broadly as disorders of arousal (DoA), confusional arousals (CoA), sleepwalking (SW), and sleep terrors (ST) share common pathophysiological mechanisms and contributing factors. Sexsomnia is classified as a variant of CoA and SW, while sleep-related eating disorder is classified as a separate NREM parasomnia. These parasomnias emerge due to incomplete dissociation of wakefulness from NREM sleep, resulting in partial arousal characterized by decreased consciousness during motor and emotional manifestations. The behaviors emerge as a result of the interplay of various predisposing and priming factors with the additional layer of precipitating conditions. Cyclic alternating patterns and abnormal slow wave synchronization increase susceptibility to developing these behaviors in the background of genetic predisposition. We will discuss current diagnostic criteria, differential diagnoses, implications, and management of these parasomnias. Recent scientific developments in this area will be discussed, especially in reference to etiopathogenesis and treatment strategies of lesser-studied subtypes such as sexsomnia. The mainstay of treatment comprises alleviating the contributing factors and treating any comorbid sleep disorders that may curtail sleep duration and also increase abnormal arousal. Behavioral interventions can be beneficial, although sometimes less established pharmacotherapy is also utilized.

Keywords

non-REM parasomnias - sleepwalking - sleep terrors - sleep-related eating disorder - confusional arousals - sexsomnia - disorders of arousal - somnambulism

Publikationsverlauf

Accepted Manuscript online:
25. März 2025

Artikel online veröffentlicht:
24. April 2025

• References

• 1 American Academy of Sleep Medicine. International Classification of Sleep Disorders. Text revision. Springer; 2023
• 2 Irfan M, Schenck CH, Howell MJ. Non-REM disorders of arousal and related parasomnias: an updated review. Neurotherapeutics 2021; 18 (01) 124-139
• 3 Avidan AY. The clinical spectrum of the parasomnias. Sleep Med Clin 2024; 19 (01) 1-19
• 4 Siclari F. Consciousness in non-REM-parasomnia episodes. J Sleep Res 2025; 34 (01) e14275
• 5 Mahowald MW, Schenck CH. Status dissociatus–a perspective on states of being. Sleep 1991; 14 (01) 69-79
• 6 Castelnovo A, Lopez R, Proserpio P, Nobili L, Dauvilliers Y. NREM sleep parasomnias as disorders of sleep-state dissociation. Nat Rev Neurol 2018; 14 (08) 470-481
• 7 Pressman MR. Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications. Sleep Med Rev 2007; 11 (01) 5-30 , discussion 31–33
• 8 Terzaghi M, Sartori I, Tassi L. et al. Dissociated local arousal states underlying essential clinical features of non-rapid eye movement arousal parasomnia: an intracerebral stereo-electroencephalographic study. J Sleep Res 2012; 21 (05) 502-506
• 9 Sardar H, Baroni A. Pathogenesis of parasomnias. In: Encyclopedia of Sleep and Circadian Rhythms. Elsevier; 2023: 29-38
• 10 Bassetti C, Vella S, Donati F, Wielepp P, Weder B. SPECT during sleepwalking. Lancet 2000; 356 (9228) 484-485
• 11 Castelnovo A, Amacker J, Maiolo M. et al. High-density EEG power topography and connectivity during confusional arousal. Cortex 2022; 155: 62-74
• 12 Cataldi J, Stephan AM, Marchi NA, Haba-Rubio J, Siclari F. Abnormal timing of slow wave synchronization processes in non-rapid eye movement sleep parasomnias. Sleep 2022; 45 (07) zsac111
• 13 Guilleminault C. Hypersynchronous slow delta, cyclic alternating pattern and sleepwalking. Sleep 2006; 29 (01) 14-15
• 14 Tassinari CA, Cantalupo G, Högl B. et al. Neuroethological approach to frontolimbic epileptic seizures and parasomnias: the same central pattern generators for the same behaviours. Rev Neurol (Paris) 2009; 165 (10) 762-768
• 15 Parrino L, Halasz P, Tassinari CA, Terzano MG. CAP, epilepsy and motor events during sleep: the unifying role of arousal. Sleep Med Rev 2006; 10 (04) 267-285
• 16 Juszczak GR, Swiergiel AH. Serotonergic hypothesis of sleepwalking. Med Hypotheses 2005; 64 (01) 28-32
• 17 Kawashima T, Yamada S. Paroxetine-induced somnambulism. J Clin Psychiatry 2003; 64 (04) 483
• 18 Wilson SJ, Lillywhite AR, Potokar JP, Bell CJ, Nutt DJ. Adult night terrors and paroxetine. Lancet 1997; 350 (9072) 185
• 19 Jacobs BL, Martín-Cora FJ, Fornal CA. Activity of medullary serotonergic neurons in freely moving animals. Brain Res Brain Res Rev 2002; 40 (1–3): 45-52
• 20 Futenma K, Inoue Y, Saso A, Takaesu Y, Yamashiro Y, Matsuura M. Three cases of parasomnias similar to sleep terrors occurring during sleep-wake transitions from REM sleep. J Clin Sleep Med 2022; 18 (02) 669-675
• 21 Mainieri G, Rochat MJ, Cantoni E. et al. Functional connectivity and metabolic brain alterations in sleepwalkers. Eur J Neurol 2025; 32 (02) e70008
• 22 Horváth A, Papp A, Szűcs A. Progress in elucidating the pathophysiological basis of nonrapid eye movement parasomnias: not yet informing therapeutic strategies. Nat Sci Sleep 2016; 8: 73-79
• 23 Irfan M, Schenck CH, Howell MJ. Non-rapid eye movement sleep and overlap parasomnias. Continuum (Minneap Minn) 2017; 23 (4, Sleep Neurology): 1035-1050
• 24 Dolder CR, Nelson MH. Hypnosedative-induced complex behaviours : incidence, mechanisms and management. CNS Drugs 2008; 22 (12) 1021-1036
• 25 Stallman HM, Kohler M, White J. Medication induced sleepwalking: a systematic review. Sleep Med Rev 2018; 37: 105-113
• 26 Irfan M. Sleep terrors. Sleep Med Clin 2024; 19 (01) 63-70
• 27 Liendo A, Irfan M. Sleep terrors. In: Encyclopedia of Sleep and Circadian Rhythms. Elsevier; 2023: 88-94
• 28 Rossi J, Gales A, Attali V. et al. Do the EEG and behavioral criteria of NREM arousal disorders apply to sexsomnia?. Sleep 2023; 46 (07) zsad056
• 29 Idir Y, Oudiette D, Arnulf I. Sleepwalking, sleep terrors, sexsomnia and other disorders of arousal: the old and the new. J Sleep Res 2022; 31 (04) e13596
• 30 Avidan AY, Hasan R, Badami V, Schenck CH. Hand dominance shift during sleep in sexsomnia: a clue to pathophysiology?. J Clin Sleep Med 2025
• 31 Vasiliu O. Current evidence and future perspectives in the exploration of sleep-related eating disorder-a systematic literature review. Front Psychiatry 2024; 15: 1393337
• 32 Kaplan K, Petitto L, Revana A. Parasomnias: Diagnosis and Management. In: Sleep Medicine. Springer International Publishing; 2023: 159-176
• 33 Fulda S, Hornyak M, Müller K, Cerny L, Beitinger PA, Wetter TC. Development and validation of the Munich parasomnia screening (MUPS). Somnologie (Berl) 2008; 12 (01) 56-65
• 34 Arnulf I, Zhang B, Uguccioni G. et al. A scale for assessing the severity of arousal disorders. Sleep 2014; 37 (01) 127-136
• 35 Manni R, Terzaghi M, Repetto A. The FLEP scale in diagnosing nocturnal frontal lobe epilepsy, NREM and REM parasomnias: data from a tertiary sleep and epilepsy unit. Epilepsia 2008; 49 (09) 1581-1585
• 36 Loddo G, La Fauci G, Vignatelli L. et al. The arousal disorders questionnaire: a new and effective screening tool for confusional arousals, sleepwalking and sleep terrors in epilepsy and sleep disorders units. Sleep Med 2021; 80: 279-285
• 37 Mainieri G, Loddo G, Provini F, Nobili L, Manconi M, Castelnovo A. Diagnosis and management of nrem sleep parasomnias in children and adults. Diagnostics (Basel) 2023; 13 (07) 1261
• 38 Blaszczyk B, Wieczorek T, Michalek-Zrabkowska M, Wieckiewicz M, Mazur G, Martynowicz H. Polysomnography findings in sleep-related eating disorder: a systematic review and case report. Front Psychiatry 2023; 14: 1139670
• 39 Drakatos P, Leschziner G. Value of polysomnography and other diagnostic tools to diagnose and treat parasomnias. In: Encyclopedia of Sleep and Circadian Rhythms. Elsevier; 2023: 179-190
• 40 Vetrugno R, Manconi M, Ferini-Strambi L, Provini F, Plazzi G, Montagna P. Nocturnal eating: sleep-related eating disorder or night eating syndrome? A videopolysomnographic study. Sleep 2006; 29 (07) 949-954
• 41 Al-Attas AA, Al-Attas AA, Al-Attas MA, Swailem SK. Epileptic nocturnal wanderings in a young female: a rare case report and review of the literature. Oman Med J 2024; 39 (06) e701
• 42 Augustine A. Nonrapid eye movement parasomnias. J Clin Neurophysiol 2023; 40 (03) 224-229
• 43 Pilon M, Montplaisir J, Zadra A. Precipitating factors of somnambulism: impact of sleep deprivation and forced arousals. Neurology 2008; 70 (24) 2284-2290
• 44 Mundt JM, Schuiling MD, Warlick C. et al. Behavioral and psychological treatments for NREM parasomnias: a systematic review. Sleep Med 2023; 111: 36-53
• 45 Byars KC, Simon SL. American Academy of Pediatrics 2016 Safe Sleep Practices: implications for pediatric behavioral sleep medicine. Behav Sleep Med 2017; 15 (03) 175-179
• 46 Hurwitz TD, Mahowald MW, Schenck CH, Schluter JL, Bundlie SR. A retrospective outcome study and review of hypnosis as treatment of adults with sleepwalking and sleep terror. J Nerv Ment Dis 1991; 179 (04) 228-233
• 47 Hauri PJ, Silber MH, Boeve BF. The treatment of parasomnias with hypnosis: a 5-year follow-up study. J Clin Sleep Med 2007; 3 (04) 369-373
• 48 Drakatos P, Marples L, Muza R. et al. NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients. Sleep Med 2019; 53: 181-188
• 49 Galbiati A, Rinaldi F, Giora E, Ferini-Strambi L, Marelli S. Behavioural and cognitive-behavioural treatments of parasomnias. Behav Neurol 2015; 2015: 786928
• 50 Vincent N, Dirkse D, Giannouli E, McQuarrie A. Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias. J Clin Sleep Med 2023; 19 (03) 499-509
• 51 Schenck CH, Mahowald MW. Long-term, nightly benzodiazepine treatment of injurious parasomnias and other disorders of disrupted nocturnal sleep in 170 adults. Am J Med 1996; 100 (03) 333-337
• 52 Bruni O, Ferri R, Miano S, Verrillo E. L-5-Hydroxytryptophan treatment of sleep terrors in children. Eur J Pediatr 2004; 163 (07) 402-407
• 53 Provini F, Albani F, Vetrugno R. et al. A pilot double-blind placebo-controlled trial of low-dose pramipexole in sleep-related eating disorder. Eur J Neurol 2005; 12 (06) 432-436
• 54 Winkelman JW. Efficacy and tolerability of open-label topiramate in the treatment of sleep-related eating disorder: a retrospective case series. J Clin Psychiatry 2006; 67 (11) 1729-1734
• 55 Winkelman JW, Wipper B, Purks J, Mei L, Schoerning L. Topiramate reduces nocturnal eating in sleep-related eating disorder. Sleep 2020; 43 (09) zsaa060
• 56 Varghese R, Rey de Castro J, Liendo C, Schenck CH. Two cases of sleep-related eating disorder responding promptly to low-dose sertraline therapy. J Clin Sleep Med 2018; 14 (10) 1805-1808
• 57 Lopez R, Dauvilliers Y. Challenges in diagnosing NREM parasomnias: implications for future diagnostic classifications. Sleep Med Rev 2024; 73: 101888
• 58 Wang X, Yuan N, Zhu J, Wang B, Zhang W, Liu Y. Fever-induced acute sleep terrors in children and adolescents following SARS-CoV-2 infection. Sleep Breath 2024; 28 (04) 1767-1770
• 59 Sychev DA, Ostroumova OD, Cherniaeva MS, Ismailova SV, Shakhgildian NV. Medication induced sleepwalking. Med Alph 2022; (21) 11-17
• 60 Wallace DM, Maze T, Shafazand S. Sodium oxybate-induced sleep driving and sleep-related eating disorder. J Clin Sleep Med 2011; 7 (03) 310-311
• 61 Ferrándiz-Santos JA, Mataix-Sanjuan AL. Amitriptyline and somnambulism. Ann Pharmacother 2000; 34 (10) 1208-1208
• 62 Oulis P, Kokras N, Papadimitriou GN, Masdrakis VG. Bupropion-induced sleepwalking. J Clin Psychopharmacol 2010; 30 (01) 83-84
• 63 Yeh Y-W, Chen C-H, Feng H-M, Wang S-C, Kuo S-C, Chen C-K. New onset somnambulism associated with different dosage of mirtazapine: a case report. Clin Neuropharmacol 2009; 32 (04) 232-233
• 64 Landry P, Warnes H, Nielsen T, Montplaisir J. Somnambulistic-like behaviour in patients attending a lithium clinic. Int Clin Psychopharmacol 1999; 14 (03) 173-175
• 65 Paquet V, Strul J, Servais L, Pelc I, Fossion P. Sleep-related eating disorder induced by olanzapine. J Clin Psychiatry 2002; 63 (07) 597
• 66 Chiu Y-H, Chen C-H, Shen WW. Somnambulism secondary to olanzapine treatment in one patient with bipolar disorder. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32 (02) 581-582
• 67 Hensel J, Pillmann F. Late-life somnambulism after therapy with metoprolol. Clin Neuropharmacol 2008; 31 (04) 248-250
• 68 von Vigier RO, Vella S, Bianchetti MG. Agitated sleepwalking with fluoroquinolone therapy. Pediatr Infect Dis J 1999; 18 (05) 484-485
• 69 Varkey BM, Varkey LM. Topiramate induced somnabulism and automatic behaviour. Indian J Med Sci 2003; 57 (11) 508-510
• 70 Casez O, Dananchet Y, Besson G. Migraine and somnambulism. Neurology 2005; 65 (08) 1334-1335
• 71 Kales JD, Kales A, Soldatos CR, Chamberlin K, Martin ED. Sleepwalking and night terrors related to febrile illness. Am J Psychiatry 1979; 136 (09) 1214-1215
• 72 Laroche M, Biabani N, Drakatos P. et al. Group cognitive behavioural therapy for non-rapid eye movement parasomnias: long-term outcomes and impact of COVID-19 lockdown. Brain Sci 2023; 13 (02) 347