Summary: Arousal disorders, including the mysterious actions of sexsomnia, sleepwalking, and sleep terrors, remain a significant gray area in sleep medicine.
A new study reveals that unlike other sleep disorders, arousal disorders lack consensus treatment guidelines. Most existing publications on NREM parasomnias are either mere case reports or uncontrolled trials.
However, preliminary findings indicate cognitive behavioral therapy, hypnosis, sleep hygiene, and scheduled awakenings might be effective treatments.
Arousal disorders, distinct from other sleep ailments, lack established treatment guidelines.
Jennifer Mundt’s study reveals potential efficacy in treatments like cognitive behavioral therapy, hypnosis, and scheduled awakenings for arousal disorders.
Parasomnias can be dangerous, resulting in injuries, and patients often lack any memory of their actions during such episodes.
Source: Northwestern University
If you have sleep apnea or insomnia, sleep specialists have well-vetted guidelines for the best evidence-based treatments.
Not so if you have arousal disorders, which include sexsomnia (engaging in sexual activity during sleep), sleep “walking” (walking or running around the house or even doing complex behaviors like driving a car), sleep terrors (screaming and intense fear while asleep), or sleep eating.
Unlike nearly every other type of sleep disorder, there are no consensus treatment guidelines for arousal disorders, says Jennifer Mundt, assistant professor of neurology at Northwestern University Feinberg School of Medicine.
In a newly published study in Sleep Medicine, Mundt did the first systematic review on treating NREM (non-rapid eye movement) parasomnias. Many of the 72 publications from 1909 to 2023 were only case reports or uncontrolled trials.
“These disorders can be dangerous and result in injuries to the sleeper or loved ones, so it’s important that symptoms are evaluated and treated,” Mundt said. “And we need to have guidelines, so patients are getting the most effective treatment, which is not necessarily a medication.”
Randomized, controlled trials are needed to determine the efficacy of behavioral treatments for these parasomnias, Mundt said.
In the study, Mundt found the treatments with the most evidence about their effectiveness are cognitive behavioral therapy, hypnosis, sleep hygiene and scheduled awakenings (waking the sleeper shortly before the time they usually have a parasomnias episode).
Mundt specializes in behavioral treatments for sleep disorders including insomnia, nightmares, NREM parasomnias, narcolepsy and idiopathic hypersomnia.
Patients often don’t recall their unusual night behaviors, or they may have only a vague recollection of it.
“Some people don’t know they have it or what’s going on with them at night,” Mundt said. “They may not come into a sleep clinic until they’ve injured themselves. Or, they say, ‘My kitchen had all these wrappers on the counter, so I know I was eating.’
“I’ve had some people video themselves at night, trying to confirm what’s happening. It’s unsettling to not know what you are doing in your sleep. I’ve seen people who have ended up in the emergency room with cuts or lacerations from punching a window or mirror or wall.
“I’ve had people who have taken medication in their sleep or eaten so much they feel sick the next morning. The brain tends to want to eat junk food, like salty, sweet and fatty snacks. Some people eat so much they feel uncomfortable or gain weight. One colleague had a patient who ate a whole block of cheese in their sleep.”
The estimated lifetime prevalence for parasomnias is 6.9% for sleepwalking, 10% for sleep terrors, 18.5% for confusional arousals, 7.1% for sexsomnia, and 4.5% for sleep-related eating. Sleepwalking, sleep terrors and confusional arousals (when someone is in a confused state while remaining in bed) are more common in childhood and often remit by adolescence. Sexsomnia and sleep-related eating typically begin in adulthood.
“Doctors often tell parents their children will grow out of it. But not everyone grows out of it,” Mundt said.
The title of the paper is “Behavioral and psychological treatments for NREM parasomnias: A systematic review.”
Behavioral and psychological treatments for NREM parasomnias: A systematic review
Non-rapid eye movement (NREM) parasomnias are often benign and transient, requiring no formal treatment. However, parasomnias can also be chronic, disrupt sleep quality, and pose a significant risk of harm to the patient or others. Numerous behavioral strategies have been described for the management of NREM parasomnias, but there have been no published comprehensive reviews. This systematic review was conducted to summarize the range of behavioral and psychological interventions and their efficacy.
We conducted a systematic search of the literature to identify all reports of behavioral and psychological treatments for NREM parasomnias (confusional arousals, sexsomnia, sleepwalking, sleep terrors, sleep-related eating disorder, parasomnia overlap disorder). This review was conducted in line with PRISMA guidelines. The protocol was registered with PROSPERO (CRD42021230360). The search was conducted in the following databases (initially on March 10, 2021 and updated February 24, 2023): Ovid (MEDLINE), Cochrane Library databases (Wiley), CINAHL (EBSCO), PsycINFO (EBSCO), and Web of Science (Clarivate). Given a lack of standardized quantitative outcome measures, a narrative synthesis approach was used. Risk of bias assessment used tools from Joanna Briggs Institute.
A total of 72 publications in four languages were included, most of which were case reports (68%) or case series (21%). Children were included in 32 publications and adults in 44. The most common treatment was hypnosis (33 publications) followed by various types of psychotherapy (31), sleep hygiene (19), education/reassurance (15), relaxation (10), scheduled awakenings (9), sleep extension/scheduled naps (9), and mindfulness (5). Study designs and inconsistent outcome measures limited the evidence for specific treatments, but some evidence supports multicomponent CBT, sleep hygiene, scheduled awakenings, and hypnosis.
This review highlights the wide breadth of behavioral and psychological interventions for managing NREM parasomnias. Evidence for the efficacy of these treatments is limited by the retrospective and uncontrolled nature of most research as well as the infrequent use of validated quantitative outcome measures. Behavioral and psychological treatments have been studied alone and in various combinations, and recent publications suggest a trend toward preference for multicomponent cognitive behavioral therapies designed to specifically target priming and precipitating factors of NREM parasomnias.