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  • Cited by 9
Cambridge University Press
Online publication date:
November 2010
Print publication year:
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Book description

The first authoritative review on the parasomnias - disorders that cause abnormal behavior during sleep - this book contains many topics never before covered in detail. The behaviors associated with parasomnias may lead to injury of the patient or bed-partner, and may have forensic implications. These phenomena are common but often unrecognized, misdiagnosed, or ignored in clinical practice. With increasing awareness of abnormal behaviors in sleep, the book fulfils the need for in-depth descriptions of clinical and research aspects of these disorders, including differential diagnosis, pathophysiology, morbidity, and functional consequences of each condition, where known. Appropriate behavioral and pharmacological treatments are addressed in detail. There are authoritative sections on disorders of arousal, parasomnias usually associated with REM sleep, sleep-related movement disorders and other variants, and therapy of parasomnias. Sleep specialists, neurologists, psychiatrists, psychologists and other healthcare professionals with an interest in sleep disorders will find this book essential reading.


"This is a good reference for practicing sleep clinicians and will likely serve as a helpful reference for sleep researchers."
--Doody's Review Service

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  • Chapter 9 - Sexsomnias
    pp 70-80
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    If the notions of dream and nightmare are centuries old, going back to ancient Egyptian and Jewish civilizations, the distinction between nightmares and parasomnias is recent. As parasomnias became distinguishable from nightmares, a possible link between such episodic nocturnal phenomena and seizure disorders was proposed. In 1999, Ohayon et al. in their epidemiological studies on sleepwalking and sleep terrors found that obstructive sleep apnea syndrome was the most common sleep disorder associated with parasomnias between the ages of 15 and 24 years. Epileptic disorders were shown to be rarely involved in abnormal behavior during non-rapid eye movement (NREM) sleep, but when sleep-related seizure disorders are present, specific seizure entities are implicated. Nocturnal polysomnography has allowed the dissociation of NREM from REM sleep abnormal behavior. The initial description of what is now known as REM sleep behavior disorder (RBD) came from Japanese researchers.
  • Chapter 10 - Medico-legal consequences of parasomnias
    pp 81-96
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    Arousal parasomnias occur mainly during non-rapid eye movement (NREM) sleep. This group consists of confusional arousals, sleepwalking and sleep terrors. Sleepwalking and sleep terrors can be triggered by stress, sleep deprivation, alcohol ingestion, and almost all sedative medications. This group of parasomnias is composed of three disorders occurring essentially during rapid eye movement (REM) sleep. Sleep paralysis is one of the main symptoms associated with narcolepsy, but it can also occur individually. REM sleep behavior disorder is characterized by a loss of generalized skeletal muscle REM-related atonia and the presence of physical dreamenactment. Polysomnographic recordings of individuals with RBD showed a reduction of the tonic phenomena of REM sleep and the activation of the phasic phenomena. Parasomnias are frequent in the general population; more than 30% of individuals experiences at least one type of parasomnia. At the genetic level, there is growing evidence that many parasomnias have a genetic component.
  • Chapter 11 - Confusional arousals
    pp 99-108
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    This chapter briefly reviews the use of structural and functional neuroimaging in the assessment and management of parasomnias. The majority of the work in the area of neuroimaging and parasomnias and sleep-related movement disorders has been in the area of RLS and PLMD. The scope of the work performed to date has been driven by, and constrained by, clinical manifestations of the disorder and by the measurements currently available by using neuroimaging tools. The most extensive work has been performed in the area of central dopaminergic dysfunction in these disorders. Neuroimaging methods allow determination of brain volumetric changes in patient samples to see if structural cerebral abnormalities may play a role in the disorder. Low-dose opioid treatment has been used in the management of some RLS patients, and nuclear medicine study reveals regional brain function associated with sleepwalking.
  • Chapter 12 - Sleepwalking
    pp 109-118
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    Many of the parasomnias are manifestations of central nervous system activation and autonomic nervous system changes with skeletal muscle activity. Parasomnias can contribute to impaired academic or occupational performance, disturbances of mood and social adjustment. Identification of the presence of any psychological trauma or history of such trauma is important when trying to understand the possible sources of parasomnia. There is a predisposition to sleep-related dissociative disorder in victims of physical or sexual abuse or post-traumatic stress disorder (PTSD). Secondary sleep enuresis is also noted in these patients. This chapter begins with a thorough history-taking, keeping in mind the Parasomnia Classification in the International Classification of Sleep Disorders, 2nd edition (ICSD-2) and the differential diagnosis of abnormal behaviors and events during sleep. Seizures should always be considered in the differential of parasomnias, and formal EEG studies should be performed with appropriateness.
  • Chapter 13 - Sleep terrors
    pp 119-128
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    The fundamental elements of video-polysomnography are suggested by its name: video (watching patients and their body movements) polysomnography (recording the state of wakefulness or the different stages of sleep). Nowadays, digital polysomnographic recording systems can allow the video to be modified off-line to enlarge patient's details, select the most important polysomnographic parameters and allow modification of the amplitude with appropriate filter settings and also to modify the EEG derivations. Polysomnographic technician performs several tasks during overnight recording: supervision of the recording to ensure perfect functioning of electrodes and transducers; integration of the recording with additional electrodes if new events occur during night; intervention during an event to prevent injury to the patient; intervention during the recording to verify space and time orientation in the patient; and intervention during recording to question the patient about the event.
  • Chapter 14 - REM sleep behavior disorder
    pp 131-141
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    Sleepwalking is not the only NREM parasomnia that has been observed to be associated with medication or substance. It is, however, the most common group, the one most familiar to psychiatrists, who noted this as a side effect following initiation or escalation of some medications used for treating their patients, particularly those with bipolar depression in manic episodes, schizoaffective patients and anxiety patients with insomnia. This chapter covers the published reports in which sleepwalking event occurred closely following the initiation of medication and its resolution on withdrawal from the drug. The anti-depressant medications and their effects on sleep, few studies give the effects on slow-wave sleep (SWS). The benzodiazepine that has been most clearly associated with sleep-related eating disorder (SRED) is triazolam, although it is associated with initiation of several other NREM parasomnias.
  • Chapter 15 - Recurrent isolated sleep paralysis
    pp 142-152
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    The REM sleep behavior disorder (RBD) is the parasomnia most commonly associated with an underlying neurological condition (the so-called symptomatic RBD). RBD usually occurs in setting of neurodegenerative diseases such as Lewy body dementia (LBD), Parkinson's disease (PD), and multiple system atrophy (MSA), and it may precede the development of Parkinsonism by many years. The disorders of arousal are the most frequent of the NREM sleep parasomnias. They may be triggered by prior sleep deprivation, alcohol, emotional stress and febrile illness. Different medications have been associated with RBD or REM sleep without atonia (RSWA), particularly psychotrophic and antihypertensive drugs. In the last two decades, some studies have demonstrated that arousals secondary to apneas, hypopneas and irregular breathing can be the trigger for sleepwalking and related disorders in children and adults. Hallucinations, both diurnal and nocturnal, have been described in PD associated with cognitive decline and RBD.
  • Chapter 16 - Nightmare disorder
    pp 153-160
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    Sleep disturbances and nightmares are a normal and characteristic response to trauma; however, they tend to be transient features that resolve with time. Nightmares are among the most prominent complaints of patients with post-traumatic stress disorder (PTSD). The prominence of disturbing nightmares that represent traumatic experiences in PTSD and the relationship between REM sleep and dream mentation has focused investigators on the role of this sleep stage in the disorder. Clinicians who evaluate patients with sleep disorders would be well advised to evaluate for histories of trauma and post-traumatic stress symptoms and those treating PTSD to evaluate for sleep problems including insomnia, sleep-disordered breathing, and complex sleep-related behaviors. Due to the hypothesized role for excessive noradrenergic activity in mediating sleep aspects of PTSD, the alpha-1 adrenergic antagonist prazosin was applied to treating nightmares and sleep disruption in the disorder.
  • Chapter 17 - Sleep-related dissociative disorder
    pp 163-174
  • View abstract


    Sexual arousal and sleep have never been at odds. Some of the well-known physiological phenomena associated with sleep were described centuries ago, most notably wet dreams, nocturnal emissions in males, and nocturnal orgasms in females. A significant number of case reports and first epidemiological and Meta studies suggest that sexual behavior in sleep primarily represents a distinctive variation of known types of NREM arousal parasomnias. Sexsomnia treatment has two objectives. First is to educate patients concerning their disorder. The second treatment objective is to provide pharmacological intervention when necessary, most often in the form of clonazepam, a common medication that is easily administered and titrated. Patients who suffer from sexsomnia are at higher risk of being charged for sexual offences. The legislatures across the world differ considerably when dealing with this issue, and those jurisprudent differences are present even at national levels.
  • Chapter 18 - Sleep enuresis
    pp 175-183
  • View abstract


    The parasomnias most frequently associated with forensic consequences are the disorders of arousal (confusional arousals, sleepwalking/sleep terrors) and their variant sexsomnia, parasomnia due to drug or substance and REM sleep behavior disorder (RBD). There are numerous historical cases documenting sleep-related crimes dating back to the seventeenth century. The insanity defense and automatism remain relevant to criminal liability today, but the Model Penal Code (MPC) definitions still rely on ideas that have not kept up to date with developments in neuroscience. It is important that experts providing evidence for apparent sleep-related forensic cases be acutely aware of and follow guidelines laid down by their respective professional and regulatory bodies in their particular jurisdictions. The assessment of a person accused of a violent act that may have arisen from sleep requires a systematic and thorough evaluation of all possible diagnoses.

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