Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences

STUDY OBJECTIVES: To formulate the first classification of sleep related disorders and abnormal sexual behaviors and experiences. DESIGN: A computerized literature search was conducted, and other sources, such as textbooks, were searched. RESULTS: Many categories of sleep related disorders were represented in the classification: parasomnias (confusional arousals/sleepwalking, with or without obstructive sleep apnea; REM sleep behavior disorder); sleep related seizures; Kleine-Levin syndrome (KLS); severe chronic insomnia; restless legs syndrome; narcolepsy; sleep exacerbation of persistent sexual arousal syndrome; sleep related painful erections; sleep related dissociative disorders; nocturnal psychotic disorders; miscellaneous states. Kleine-Levin syndrome (78 cases) and parasomnias (31 cases) were most frequently reported. Parasomnias and sleep related seizures had overlapping and divergent clinical features. Thirty-one cases of parasomnias (25 males; mean age, 32 years) and 7 cases of sleep related seizures (4 males; mean age, 38 years) were identified. A full range of sleep related sexual behaviors with self and/or bed partners or others were reported, including masturbation, sexual vocalizations, fondling, sexual intercourse with climax, sexual assault/rape, ictal sexual hyperarousal, ictal orgasm, and ictal automatism. Adverse physical and/or psychosocial effects from the sleepsex were present in all parasomnia and sleep related seizure cases, but pleasurable effects were reported by 5 bed partners and by 3 patients with sleep related seizures. Forensic consequences were common, occurring in 35.5% (11/31) of parasomnia cases, with most (9/11) involving minors. All parasomnias cases reported amnesia for the sleep-sex, in contrast to 28.6% (2/7) of sleep related seizure cases. Polysomnography (without penile tumescence monitoring), performed in 26 of 31 parasomnia cases, documented sexual moaning from slow wave sleep in 3 cases and sexual intercourse during stage 1 sleep/wakefulness in one case (with sex provoked by the bed partner). Confusional arousals (CAs) were diagnosed as the cause of "sleepsex" ("sexsomnia") in 26 cases (with obstructive sleep apnea [OSA] comorbidity in 4 cases), and sleepwalking in 2 cases, totaling 90.3% (28/31) of cases being NREM sleep parasomnias. REM behavior disorder was the presumed cause in the other 3 cases. Bedtime clonazepam therapy was effective in 90% (9/10) of treated parasomnia cases; nasal continuous positive airway pressure therapy was effective in controlling comorbid OSA and CAs in both treated cases. All five treated patients with sleep related sexual seizures responded to anticonvulsant therapy. The hypersexuality in KLS, which was twice as common in males compared to females, had no reported effective therapy. CONCLUSIONS: A broad range of sleep related disorders associated with abnormal sexual behaviors and experiences exists, with major clinical and forensic consequences.     

Practice parameters for the indications for polysomnography and related procedures: an update for 2005

These practice parameters are an update of the previously-published recommendations regarding the indications for polysomnography and related procedures in the diagnosis of sleep disorders. Diagnostic categories include the following: sleep related breathing disorders, other respiratory disorders, narcolepsy, parasomnias, sleep related seizure disorders, restless legs syndrome, periodic limb movement sleep disorder, depression with insomnia, and circadian rhythm sleep disorders. Polysomnography is routinely indicated for the diagnosis of sleep related breathing disorders; for continuous positive airway pressure (CPAP) titration in patients with sleep related breathing disorders; for the assessment of treatment results in some cases; with a multiple sleep latency test in the evaluation of suspected narcolepsy; in evaluating sleep related behaviors that are violent or otherwise potentially injurious to the patient or others; and in certain atypical or unusual parasomnias. Polysomnography may be indicated in patients with neuromuscular disorders and sleep related symptoms; to assist in the diagnosis of paroxysmal arousals or other sleep disruptions thought to be seizure related; in a presumed parasomnia or sleep related seizure disorder that does not respond to conventional therapy; or when there is a strong clinical suspicion of periodic limb movement sleep disorder. Polysomnography is not routinely indicated to diagnose chronic lung disease; in cases of typical, uncomplicated, and noninjurious parasomnias when the diagnosis is clearly delineated; for patients with seizures who have no specific complaints consistent with a sleep disorder; to diagnose or treat restless legs syndrome; for the diagnosis of circadian rhythm sleep disorders; or to establish a diagnosis of depression.     

NREM‐related parasomnias in Machado–Joseph disease: clinical and polysomnographic evaluation

Spinocerebellar ataxias (SCA) are autosomal dominant neurodegenerative disorders that affect the cerebellum and its connections, and have a marked clinical and genetic variability. Machado–Joseph disease (MJD) or spinocerebellar ataxia type 3 (SCA3)—MJD/SCA3—is the most common SCA worldwide. MJD/SCA3 is characterized classically by progressive ataxia and variable other motor and non‐motor symptoms. Sleep disorders are common, and include rapid eye movement (REM) sleep behaviour disorder (RBD), restless legs syndrome (RLS), insomnia, excessive daytime sleepiness, excessive fragmentary myoclonus and sleep apnea. This study aims to focus upon determining the presence or not of non‐REM (NREM)‐related parasomnias in MJD/SCA 3, using data from polysomnography (PSG) and clinical evaluation. Forty‐seven patients with clinical and genetic diagnosis of MJD/SCA3 and 47 control subjects were evaluated clinically and by polysomnography. MJD/SCA3 patients had a higher frequency of arousals from slow wave sleep (P < 0.001), parasomnia complaints (confusional arousal/sleep terrors, P = 0.001; RBD, P < 0.001; and nightmares, P < 0.001), REM sleep without atonia (P < 0.001), periodic limb movements of sleep index (PLMSi) (P < 0.001), percentage of N3 sleep (P < 0.001) and percentage of N1 sleep (P < 0.001). These data show that NREM‐related parasomnias must be included in the spectrum of sleep disorders in MJD/SCA3 patients.     

Periodic leg movements during sleep and wakefulness in narcolepsy

The objectives of the study were to measure the prevalence of periodic leg movements during NREM and REM sleep (PLMS) and while awake (PLMW) and to assess the impact of PLMS on nocturnal sleep and daytime functioning in patients with narcolepsy. One hundred and sixty-nine patients with narcolepsy and 116 normal controls matched for age and gender were included. Narcoleptics with high and low PLMS indices were compared to assess the impact of PLMS on sleep and Multiple Sleep Latency Test (MSLT) variables. More narcoleptics than controls had a PLMS index greater than 5 per hour of sleep (67% versus 37%) and an index greater than 10 (53% versus 21%). PLMS indices were higher both in NREM and REM sleep in narcoleptic patients, but the between-group difference was greater for REM sleep. A significant increase of PLMS index was also found with aging in both narcoleptic patients and controls. PLMW indices were also significantly higher in narcoleptic patients. Patients with an elevated index of PLMS had a higher percentage of stage 1 sleep, a lower percentage of REM sleep, a lower REM efficiency and a shorter MSLT latency. The present study demonstrates a high frequency of PLMS and PLMW in narcolepsy, an association between the presence of PLMS and measures of REM sleep and daytime functioning disruption. These results suggest that PLMS represent an intrinsic feature of narcolepsy.     

Violent somnambulism: A parasomnia of young men with stereotyped dream-like experiences

Objective

To characterize a subgroup of arousal parasomnias associated with violent behavior in adults.

Design

A pilot study on clinical and polysomnographic data of 13 adult patients seen in a tertiary sleep center for the suspicion of arousal parasomnia associated with violence.

Results

Nine young patients (8 males 1 female) had a common pattern of abnormalities: similar ‘claustrophobic’ dream-like experiences and complex, vehement dream enactments; no REM sleep without atonia on polysomnography. We call this syndrome ‘violent somnambulism’.The rest of the patients had alcoholic delirium, partial epilepsy, possible REM sleep behavior disorder and a single sleep walking episode provoked by a sleeping pill.

Conclusions and hypothesis

Sleep related violence needs thorough diagnostic evaluation for preventing life-threatening consequences. Violent somnambulism appears to be a distinct NREM sleep-related overlap parasomnia.     

Hypersynchronous delta sleep EEG activity and sudden arousals from slow-wave sleep in adults without a history of parasomnias: clinical and forensic implications

STUDY OBJECTIVES: To determine the frequency of classical markers of non-rapid eye movement (NREM) parasomnias--hypersynchronous delta sleep (HSD) electroencephalogram waves and sudden arousals from slow-wave sleep (SWS)--in patients without histories of somnambulism or other NREM parasomnias. DESIGN: Retrospective review. SETTING: Sleep disorders center laboratory. PATIENTS: 82 consecutive patients without a history of parasomnias who underwent diagnostic polysomnograms; 57 men and 25 women, mean age 48+/-13.3 years, were included without regard to diagnosis or findings. All patients had at least 30 seconds of stage 3 or 4 sleep during the polysomnogram. MEASUREMENTS AND RESULTS: The primary diagnosis of all but 4 patients was obstructive sleep apnea (mean respiratory disturbance index, 30 +/- 23.6 [range, 2.7-117] per hour of sleep). Polysomnograms were then reviewed for the presence of HSD and SWS arousals. A total of 235 arousals (mean, 2.9 +/- 2.7; range, 0-14) from stage 3 or 4 sleep were noted. Eight-five percent of all patients had at least 1 SWS arousal and 45% had 3 or more SWS arousals; 85.1% of all arousals from SWS were secondary to sleep-disordered breathing, and 5.9% were secondary to leg movements. At least 1 episode of HSD (mean, 1.4 +/- 1.6; range, 0-9) was noted in 65.8% of patients. CONCLUSIONS: HSD and SWS arousals were a common finding in patients without clinical histories of sleepwalking or other parasomnias but who were found to have frequent respiratory-related arousals during sleep. HSD and SWS arousals thus have a low specificity for NREM parasomnias and, without further research, are not useful for the objective confirmation of parasomnias in clinical evaluations and in the forensic evaluation of sleepwalking as a legal defense.     

Sleep-related dissociative disorder in a 6-year-old girl

Sleep-related dissociative disorders are parasomnias that can emerge at any point during the sleep period and are associated with traumatic life experiences. No reports to date have described this parasomnia in a school-age child. This case report discusses presentation, diagnosis, and treatment of a 6-year-old girl with this diagnosis. Sleep-related dissociative disorder should be considered in young children who have experienced traumatic life events and who present with abnormal sleep patterns and bizarre behavior. Early identification and intensive psychotherapy can be efficacious for these children.     

Variability of periodic leg movements in various sleep disorders: implications for clinical and pathophysiologic studies

STUDY OBJECTIVES: Periodic leg movements in sleep (PLMS) are a frequent phenomenon in various sleep disorders. The pathophysiology of PLMS is still not understood, but recent studies indicate a hypoactivity of the dopaminergic system in subjects with PLMS. In the present study, we investigated the intrasubject variance of PLMS from one night to the other because a fluctuation in the number of PLMS may influence the outcome of pharmacologic and pathophysiologic studies. DESIGN: Retrospective observational study. SETTING: Data collection occurred in the sleep disorders unit. PATIENTS: Sleep electroencephalogram and PLMS data of 115 patients with PLMS monitoring over 2 consecutive nights were evaluated retrospectively. Patients were grouped into the following diagnostic categories: restless legs syndrome, insomnia secondary to a psychiatric disorder, primary insomnia, sleep apnea syndrome, and narcolepsy or idiopathic hypersomnia. INTERVENTIONS: N/A. RESULTS: In 27% of the entire patient population, we found a considerable variability of the PLMS index (difference between nights > 10/hour) and, in 19% of patients, variability of the PLMS arousal index (difference between nights > 5/hour) across the 2 investigated nights. The intraindividual variance occurred most frequently and to the highest extent in patients with RLS. CONCLUSIONS: The variability of PLMS indexes should considered if the PLMS recording is performed in support of the clinical diagnosis or in the interpretation of studies investigating drug efficacy. Furthermore, the variability of PLMS may be an indicator of an instability of the dopaminergic system that should be taken into account in studies investigating central nervous system dopaminergic activity.     

Short‐interval leg movements during sleep entail greater cardiac activation than periodic leg movements during sleep in restless legs syndrome patients

Periodic leg movements during sleep (PLMS) are sequences of ≥4 motor events with intermovement intervals (IMI) of 10–90 s. PLMS are a supportive diagnostic criterion for restless legs syndrome (RLS) and entail cardiac activation, particularly when associated with arousal. RLS patients also over‐express short‐interval leg movements during sleep (SILMS), which have IMI <10 s and are organized mainly in sequences of two movements (doublets). We tested whether the cardiac activation associated with SILMS doublets differs from that associated with PLMS in a sample of 25 RLS patients. We analysed time–series of R–R intervals synchronized to the onset of SILMS doublets or PLMS that entailed an arousal during non‐rapid eye movement (NREM) sleep. We assessed cardiac activation based on the R–R interval decrease with respect to baseline during NREM sleep without leg movements. We found that the duration of the R–R interval decrease with SILMS doublets was significantly longer than that with PLMS, whereas the maximal decrease in R–R interval was similar. Scoring SILMS in RLS patients may therefore be relevant from a cardiac autonomic perspective.     

Basal sympathetic predominance in periodic limb movements in sleep with obstructive sleep apnea

Because the impact of periodic limb movements in sleep (PLMS) is controversial, no consensus has been reached on the therapeutic strategy for PLMS in obstructive sleep apnea (OSA). To verify the hypothesis that PLMS is related to a negative impact on the cardiovascular system in OSA patients, this study investigated the basal autonomic regulation by heart rate variability (HRV) analysis. Sixty patients with mild‐to‐moderate OSA who underwent polysomnography (PSG) and completed sleep questionnaires were analysed retrospectively and divided into the PLMS group (n = 30) and the non‐PLMS group (n = 30). Epochs without any sleep events or continuous effects were evaluated using HRV analysis. No significant difference was observed in the demographic data, PSG parameters or sleep questionnaires between the PLMS and non‐PLMS groups, except for age. Patients in the PLMS group had significantly lower normalized high frequency (n‐HF), high frequency (HF), square root of the mean of the sum of the squares of difference between adjacent NN intervals (RMSSD) and standard deviation of all normal to normal intervals index (SDNN‐I), but had a higher normalized low frequency (n‐LF) and LF/HF ratio. There was no significant difference in the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, the Short‐Form 36 and the Hospital Anxiety and Depression Scale between the two groups. After adjustment for confounding variables, PLMS remained an independent predictor of n‐LF (β = 0.0901, P = 0.0081), LF/HF ratio (β = 0.5351, P = 0.0361), RMSSD (β = ?20.1620, P = 0.0455) and n‐HF (β = ?0.0886, P = 0.0134). In conclusion, PLMS is related independently to basal sympathetic predominance and has a potentially negative impact on the cardiovascular system of OSA patients.     

The prevalence of restless sleep disorder among a clinical sample of children and adolescents referred to a sleep centre

Restless sleep disorder (RSD) is a newly described sleep disorder in children characterized by large body movements and repositioning that lasts all night with at least five body movements per hour and a significant impact on daytime behaviours. The authors have previously identified and described the syndrome and compared the sleep parameters and sleep‐related movements to those in children with restless legs syndrome, normal controls and snorers. The current study is a retrospective review of the sleep diagnosis in 300 consecutive children seen and evaluated in a single sleep disorders centre; 252 children underwent polysomnography, as clinically indicated, to identify the proper diagnosis. The current research estimates the prevalence of RSD in a sleep clinical setting to be 7.7% and compares it to the prevalence of other common sleep disorders in the same setting. Another important addition to the literature is the fact that RSD can coexist with other sleep disorders, such as habitual snoring and parasomnia, without confounding the diagnosis.     

Effects of a lifestyle intervention on REM sleep‐related OSA severity in obese individuals with type 2 diabetes

The aim of this study was to determine if an intensive lifestyle intervention (ILI) reduces the severity of obstructive sleep apnea (OSA) in rapid‐eye movement (REM) sleep, and to determine if longitudinal changes in glycaemic control are related to changes in OSA severity during REM sleep over a 4‐year follow‐up. This was a randomized controlled trial including 264 overweight/obese adults with type 2 diabetes (T2D) and OSA. Participants were randomized to an ILI targeted to weight loss or a diabetes support and education (DSE) control group. Measures included anthropometry, apnea–hypopnea index (AHI) during REM sleep (REM‐AHI) and non‐REM sleep (NREM‐AHI) and glycated haemoglobin (HbA1c) at baseline and year 1, year 2 and year 4 follow‐ups. Mean baseline values of REM‐AHI were significantly higher than NREM‐AHI in both groups. Both REM‐AHI and NREM‐AHI were reduced significantly more in ILI versus DSE, but these differences were attenuated slightly after adjustment for weight changes. Repeated‐measure mixed‐model analyses including data to year 4 demonstrated that changes in HbA1c were related significantly to changes in weight, but not to changes in REM‐AHI and NREM‐AHI. Compared to control, the ILI reduced REM‐AHI and NREM‐AHI during the 4‐year follow‐up. Weight, as opposed to REM‐AHI and NREM‐AHI, was related to changes in HbA1c. The findings imply that weight loss from a lifestyle intervention is more important than reductions in AHI for improving glycaemic control in T2D patients with OSA.     

Arousal reactions in sleepwalking and night terrors in adults: the role of respiratory events

STUDY OBJECTIVES: The aim of the study was to determine the role of respiratory events, assessed by means of esophageal pressure monitoring, during arousals from slow wave sleep in adult patients with parasomnias. DESIGN: N/A. SETTING: N/A. PATIENTS: Ten patients with parasomnias (sleepwalking, night terrors, or both) and 10 control subjects matched for gender and age underwent 3 consecutive nights of polysomnography. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: By increasing sleep fragmentation, esophageal pressure monitoring has a deleterious effect on sleep architecture in patients with parasomnias and in control subjects. Respiratory events occur more frequently in parasomniacs than in controls. Respiratory effort seems to be responsible for the occurrence of a great number of arousal reactions in parasomniacs and is involved in triggering the parasomnia episodes. CONCLUSION: Sleep-disordered breathing seems to be frequently associated with parasomnias during slow wave sleep, emphasizing the utility of performing esophageal pressure monitoring in cases of sleep walking or night terrors.     

The high prevalence of obstructive sleep apnea among patients with bipolar disorders

Introduction: Sleep plays an important role in maintaining stability in bipolar disorders, and sleep disturbances can trigger mood episodes. Obstructive sleep apnea (OSA) is a common sleep disorder, yet the co-occurrence with bipolar disorder has not been methodically studied. Methods: This is a chart review of 482 consecutively seen patients with a bipolar disorder who underwent routine screening for OSA using a self-report sleep apnea questionnaire. Positive screens were referred for a sleep study. Results: A positive screen was found in 214 (44.4%) patients. Sleep studies were obtained on 114 patients, and 101, were diagnosed with OSA: point prevalence 21%. Discussion: The 21% prevalence fails to consider the false negative rate of the questionnaire, or the exclusion of patients who screened positive but failed to get a sleep study. Taking these into consideration it is estimated that the true prevalence of OSA in this study may be as high as 47.5%. The co-occurrence of OSA and bipolar disorders is markedly higher than previously thought. Of note, OSA may play a role in refractory bipolar, disorders, and carries significant mortality and morbidity that overlap, with the mortality and morbidity found with bipolar disorders. Limitations: This was a retrospective study based on a self-report questionnaire. Polysomnographic confirmation was performed in only a subgroup of subjects. Conclusions: The data suggest that unrecognized OSA may play a major role in the mortality and morbidity of bipolar disorders. All patients diagnosed with a bipolar disorder should be screened with an OSA questionnaire.     

Pediatric parasomnias

Parasomnias in childhood are common, and often more frequent than in adults. The large number of parasomnias underscore that sleep is not simply a quiescent state, but can involve complex episodes of movement, ranging from subtle to dramatic and complex. Clinicians should be aware that many pediatric parasomnias are benign, self-limited, and may not persist into late childhood or adolescence. Importantly, parasomnias in childhood often differ in type from adults. Nevertheless, parasomnias across ages can be classified as: 1) disorders of arousal (from non-rapid eye movement, or NREM, sleep); 2) parasomnias usually associated with REM sleep; and 3) other parasomnias. We detail here issues in the clinical diagosis, evaluation, and management of multiple pediatric parasomnias. The further study of parasomnias in children may help elucidate the multi-factorial etiologies of these fascinating conditions, shedding light on the potential genetic bases as well as environmental contributions.     

Is there a common motor dysregulation in sleepwalking and REM sleep behaviour disorder?

This study sought to determine if there is any overlap between the two major non‐rapid eye movement and rapid eye movement parasomnias, i.e. sleepwalking/sleep terrors and rapid eye movement sleep behaviour disorder. We assessed adult patients with sleepwalking/sleep terrors using rapid eye movement sleep behaviour disorder screening questionnaires and determined if they had enhanced muscle tone during rapid eye movement sleep. Conversely, we assessed rapid eye movement sleep behaviour disorder patients using the Paris Arousal Disorders Severity Scale and determined if they had more N3 awakenings. The 251 participants included 64 patients with rapid eye movement sleep behaviour disorder (29 with idiopathic rapid eye movement sleep behaviour disorder and 35 with rapid eye movement sleep behaviour disorder associated with Parkinson's disease), 62 patients with sleepwalking/sleep terrors, 66 old healthy controls (age‐matched with the rapid eye movement sleep behaviour disorder group) and 59 young healthy controls (age‐matched with the sleepwalking/sleep terrors group). They completed the rapid eye movement sleep behaviour disorder screening questionnaire, rapid eye movement sleep behaviour disorder single question and Paris Arousal Disorders Severity Scale. In addition, all the participants underwent a video‐polysomnography. The sleepwalking/sleep terrors patients scored positive on rapid eye movement sleep behaviour disorder scales and had a higher percentage of ‘any’ phasic rapid eye movement sleep without atonia when compared with controls; however, these patients did not have higher tonic rapid eye movement sleep without atonia or complex behaviours during rapid eye movement sleep. Patients with rapid eye movement sleep behaviour disorder had moderately elevated scores on the Paris Arousal Disorders Severity Scale but did not exhibit more N3 arousals (suggestive of non‐rapid eye movement parasomnia) than the control group. These results indicate that dream‐enacting behaviours (assessed by rapid eye movement sleep behaviour disorder screening questionnaires) are commonly reported by sleepwalking/sleep terrors patients, thus decreasing the questionnaire's specificity. Furthermore, sleepwalking/sleep terrors patients have excessive twitching during rapid eye movement sleep, which may result either from a higher dreaming activity in rapid eye movement sleep or from a more generalised non‐rapid eye movement/rapid eye movement motor dyscontrol during sleep.     

A matched comparison of MMPI responses in patients with primary snoring or obstructive sleep apnea.

STUDY OBJECTIVE: To compare the MMPI responses between nonapneic primary snoring (PS) and obstructive sleep apnea (OSA). DESIGN: Cross sectional with matched samples. SETTING: University sleep disorders center. PATIENTS: All PS patients (n = 49) available in a series of 428 clinical referrals to a sleep disorders center, and age and gender-matched OSA patients (n = 49) selected from the 199 available OSA patients in the series. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment and multiple sleep latency test (MSLT). OSA patients exhibited a mean of 2.3 elevated MMPI scales, which was significantly more than the PS mean of 1.6 elevations, and attributable to higher OSA scores on Depression (D) and Hypochondriasis (Hs). Approximately twice as many OSA patients than PS patients showed disturbed scores on D (49% vs. 25%, p < .05) and Hy (35% vs. 16%, p < .05). On nine of the ten MMPI clinical scales, both patient groups exceeded the elevation rate expected in nondistressed individuals. Among OSA patients, but not PS patients, number of MMPI elevations had a significant negative correlation with sleep efficiency and average blood saturation during NREM, and a significant positive correlation with wake time after sleep onset. CONCLUSIONS: Compared to patients with PS, those with OSA have more intense depressive symptoms (e.g., pessimism, inactivity, guilt) and somatic concerns. General psychopathology is associated with blood oxygen saturation only among OSA patients. Nonetheless, PS patients show psychological maladjustment that is qualitatively similar, but quantitatively less severe, than that characterizing OSA.     

Sleep state distribution of obstructive events in children: is obstructive sleep apnoea really a rapid eye movement sleep‐related condition?

Obstructive sleep apnoea (OSA) in children is commonly considered to occur predominantly in rapid eye movement (REM) sleep, but clinical experience suggests that this is not universally the case. We hypothesized that there would be a subgroup of children with OSA who have non‐REM (NREM) predominance of obstructive events and that these children share certain clinical characteristics. Thus, we aimed to compare the obstructive apnoea–hypopnoea index (OAHI) in REM versus NREM sleep and to assess factors influencing the distribution of events by sleep state. Polysomnography (PSG) recordings of 102 children aged 0–18 years with moderate to severe OSA (OAHI ≥5 h^?1) were reviewed. OAHI was calculated separately for REM and NREM sleep. A REM predominance index (RPI) was determined using log transformation [RPI = log (REM OAHI + 0.5) ? log (NREM OAHI + 0.5)] and compared with possible influencing factors using multiple linear regression. Analysis showed that obstructive events were more common in REM sleep (median REM OAHI 21.4 h^?1, median NREM OAHI 8.3 h^?1, P < 0.001). Mean RPI was significantly greater than zero (P = 0.003). However, a substantial minority of children (30.4%) had a higher NREM than REM OAHI. The factors that were related significantly to NREM predominance were older age (P = 0.02), higher arousal index (P < 0.001) and higher SpO₂ nadir (P < 0.001). Our findings demonstrate that while OSA is a REM sleep‐related problem in the majority of children, there is a significant subset of children with NREM predominance of obstructive events. This finding highlights the importance of considering sleep state distribution of events in studies of the pathophysiology and outcomes of OSA in childhood.     

NREM Arousal Parasomnias and Their Distinction from Nocturnal Frontal Lobe Epilepsy: A Video EEG Analysis

Study Objectives.

To describe the semiological features of NREM arousal parasomnias in detail and identify features that can be used to reliably distinguish parasomnias from nocturnal frontal lobe epilepsy (NFLE).

Design.

Systematic semiologial evaluation of parasomnias and NFLE seizures recorded on video-EEG monitoring.

Patients.

120 events (57 parasomnias, 63 NFLE seizures) from 44 subjects (14 males).

Interventions.

The presence or absence of 68 elemental clinical features was determined in parasomnias and NFLE seizures. Qualitative analysis of behavior patterns and ictal EEG was undertaken. Statistical analysis was undertaken using established techniques.

Results.

Elemental clinical features strongly favoring parasomnias included: interactive behavior, failure to wake after event, and indistinct offset (all P < 0.001). Cluster analysis confirmed differences in both the frequency and combination of elemental features in parasomnias and NFLE. A diagnostic decision tree generated from these data correctly classified 94% of events. While sleep stage at onset was discriminatory (82% of seizures occurred during stage 1 or 2 sleep, with 100% of parasomnias occurring from stage 3 or 4 sleep), ictal EEG features were less useful. Video analysis of parasomnias identified three principal behavioral patterns: arousal behavior (92% of events); non-agitated motor behavior (72%); distressed emotional behavior (51%).

Conclusions

Our results broadly support the concept of confusion arousals, somnambulism and night terrors as prototypical behavior patterns of NREM parasomnias, but as a hierarchical continuum rather than distinct entities. Our observations provide an evidence base to assist in the clinical diagnosis of NREM parasomnias, and their distinction from NFLE seizures, on semiological grounds.

Citation:

Derry CP; Harvey AS; Walker MC; Duncan JS; Berkovic SF. NREM arousal parasomnias and their distinction from nocturnal frontal lobe epilepsy: a video EEG analysis. SLEEP 2009;32(12):1637-1644.     

Relations between sleep stage, posture and effective nasal CPAP levels in OSA.

A retrospective analysis of positional data from 100 male patients with obstructive sleep apnea (OSA) was conducted to determine whether or not 1) the degree of positional dependency was similar in rapid eye movement (REM) compared to non-REM (NREM) sleep, 2) positional dependency correlated with effective levels of nasal continuous positive airway pressure (CPAP) and 3) patients with positional OSA preferentially avoided sleeping in the supine position. The apnea-hypopnea index (AHI) was scored separately for sleep state (NREM and REM) and for posture [off back (AHI-O) and on back (AHI-B)]. The ratio of AHI-O/AHI-B was used to define positional OSA as AHI-O/AHI-B less than or equal to 0.50 (P group) and nonpositional OSA as 0.50 less than AHI-O/AHI-B (NP group). A group of 31 patients who had sufficient sleep time in NREM and REM sleep in both sleep postures was selected. In this group 9 out of 22 subjects who showed positional dependency during NREM sleep became nonpositional during REM sleep (0.05 less than p less than 0.10). The mean effective nasal CPAP level was slightly, but significantly, lower in the P group than in the NP group (8.0 versus 9.1 cm H2O; p less than 0.05). In addition, a correlation between AHI and effective nasal CPAP levels was found (r = 0.491; p = 0.0001). The P group had less supine sleep time (SST) than the NP group (32% versus 45% of total sleep; p less than 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)