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Current Perspectives on Sleep-Related Injury, Its
Updated Differential Diagnosis and Its Treatment
Juan A. Pareja, Ph. D., M.D., Carlos H. Schenck, M.D., Mark W. Mahowald, M.D.
This article provides an update on the differential diagnosis of sleep-related behavior
disorders (viz. parasomnias) that cause nocturnal injury, including life-threatening injury
to self or bedpartner. A catalog of nocturnal injuries is provided. Current treatments are
discussed. Guidelines are given on the assessment of injurious nocturnal behaviors.
Extensive polysomnographic (PSG) monitoring and comprehensive clinical evaluations
are required for the proper diagnosis (and any comorbidity) to be identified and the
appropriate treatment(s) to be initiated. In 1989, a report on a series of 100 adults with
recurrent sleep-related injuries identified five disorders as being responsible for the
nocturnal injuries: disorders of arousal (sleepwalking/sleep terrors [SW/ST]: NREM
parasomnias); rapid-eye-movement (REM) sleep behavior disorder (RBD); nocturnal
dissociative disorders; nocturnal seizures; and obstructive sleep apnea/periodic limb
movements. Other disorders known to cause sleep-related injuries include nocturnal
eating disorders; nocturnal scratching disorders; rhythmic movement disorders; bruxism;
cerebral anoxic attacks; drug intoxication and withdrawal states; and Munchausen
syndrome by proxy. Five types of nocturnal seizures can cause sleep-related injury:
complex partial seizures; frontal lobe seizures; paroxysmal nocturnal dystonia; episodic
nocturnal wandering; and paroxysmal periodic motor attacks. Malingering, which is not
a psychiatric disorder, can also produce the complaint of sleep-related injury. Treatment
of injurious parasomnias is usually effective and safe, even with long-term, nightly
treatment. Benzodiazepines, particularly clonazepam, are the cornerstone of treating
injurious SW/ST and RBD, and are effective adjuncts in the treatment of various other
parasomnias. Parasomnias are rarely a direct manifestation of a psychiatric disorder, and
when co-morbidity is present, treatment of the psychiatric disorder alone does not usually
control the parasomnia. Conversely, pharmacotherapy of psychiatric disorders can
induce or exacerbate parasomnias. Parasomnias represent striking examples of
dissociated states of mind and behavior surrounding sleep, and their scientific
understanding requires a close interlinking of clinical and basic research. Parasomnias
inherently carry forensic implications, which are discussed in this article. (Sleep and
Hypnosis 2000;1:8-21)
Keywords: parasomnias, REM sleep behavior disorder, sleepwalking/sleep
terrors/disorders of arousal, nocturnal seizure disorders, nocturnal eating disorders,
nocturnal scratching disorders, forensic medicine, injury |
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