Exploring the Link Between Parasomnias and Comorbid Sleep Disorders

The Connection Between Parasomnias and Obstructive Sleep Apnea (OSA)

The comorbidity most strongly associated with parasomnias, however, is obstructive sleep apnea (OSA). OSA is a disease that is characterized by the fact that the upper airway structures narrow and/or collapse during sleep, and the individual suffers from partial or complete apnoea and/or hypopnea numerous times during the night. It has been established that OSA is highly prevalent within a parasomnia population, particularly within NREM parasomnias such as sleepwalking and night terrors.

It has been hypothesized that the association between OSA and parasomnias should be attributed to the disruptions of sleep resulting from apnea events. This can be disruptive enough to pull the sleeper from NREM into a lighter stage where they are likely to be experiencing parasomnias. However, these are the following possible reasons: Due to the lack of oxygen in the body and due to the body’s attempt to get the airway open again. It has also been reported that the treatment of the associated OSA may decrease the intensity of the parasomnia episodes.

For example, OSA has been accompanied by parasomnias, and people with both disorders had decreased parasomnia manifestations after starting CPAP for the treatment of OSA. Apnea causes the airway to be blocked from time to time; therefore, with the use of CPAP that delivers a constant flow of air, apnea events occur rarely, thus stabilizing the nights and hence reducing cases of parasomnias.

Periodic Limb Movement Disorder (PLMD) and Parasomnias

Another clinical sleep disorder found in patients with parasomnias is called Periodic Limb Movement Disorder (PLMD). PLMD is defined by the limb movement, most commonly of the legs during sleep. One of these movements can interfere with the sleep pattern and leave the individual constantly waking during the night, and sometimes even without noticing it.

PLMD is associated with parasomnias, but the two components are intertwined. Because PLMD causes awakenings during the night, it may increase the chance of parasomnias occurring in the same fashion that OSA does by disrupting the normal sleep cycle. Furthermore, research work has also pointed out that treating PLMD can result in reduced parasomnia episodes, which gives hints that the two ailments have a lot in common as far as causation is concerned.

A study on NREM parasomnias and sleepwalking conducted in the UK and which involved 6o patients revealed the undesired truth that a significant number of patients diagnosed with sleepwalking/night terrors also had PLMD. Limb movements during sleep, especially in deep NREM sleep, may disrupt the organization of sleep-wake regulation in the brain and thus cause parasomnia. This case shows that PLMD, when present along with parasomnias, requires treatment of all sleep disorders for optimal symptom control.

Restless Leg Syndrome (RLS) and Its Influence on Parasomnias

This is explained by Restless Leg Syndrome (RLS), which is a neurological disorder that causes a disturbing desire to move the legs due to unpleasant feelings. It is most often increased during moments of idleness, which is why it can be especially stifling at night when a person is attempting to sleep.

Similarly to PLMD, RLS is often linked to parasomnias, which are disorders occurring during sleep. The need to move the legs and the interference with the intended sleep increase arousal, and when sleep is further disrupted, parasomnias may develop. RLS with or without parasomnias When there is optimal management of RLS, the patients with parasomnias complain that those are also less pronounced.

For treating RLS, several recommendations are made, for instance, avoiding foods such as caffeine and alcohol and, in other severe cases, medication. In patients with both RLS and parasomnias, treatment of RLS may help to resolve sleep quality as well as decrease the frequency of parasomniac episodes.

Sleep-Related Eating Disorder (SRED) and Medication-Induced Parasomnias

A sleep-related eating disorder is a form of parasomnia in which a person eats during the night and in the morning cannot recall having done so. SRED can be spontaneous but is frequently associated with the use of particular drugs, which are used to treat insomnia, anxiety, and depression.

Drugs such as zolpidem, which is used to treat insomnia, are related to a higher risk of developing SRED. These drugs can distort the regular structure of the sleep cycle and make the subjects wake up more frequently, during which they experience parasomniac events such as SRED. Furthermore, persons with other sleep disorders, including OSA, are more vulnerable to developing SRED when on a few medications.

The management of medication-induced parasomnias simply involves reviewing the patient’s drug treatment plan. Sometimes it is possible to prevent new parasomnia episodes by changing a certain medication and/or dose levels while continuing the therapy of the original disease.

The Role of Sleep Fragmentation in Comorbid Parasomnias

In this paper, sleep fragmentation is proposed as a shared factor among parasomnias and other associated sleep disorders. Moreso, whether due to OSA, PLMD, or RLS, multiple nighttime awakenings are likely to interrupt the orderly progression through the various stages of sleep, thereby raising the risk of parasomnia. Soodoo interrupts the ability of the brain to enter or to remain in NREM stages, during which parasomnias, including sleepwalking or night terrors, are most likely to happen.

OSA and PLMD leading to the disruption of sleep and the lack of coherent periods of sleep further limit the ability of the brain to stably distinguish between stages of sleep. Therefore, the sleeper may witness part wake patterns during the transition from one sleep stage to another, which is when parasomnias may occur. The parasomnias are thus more likely to occur during a disruption of the normal architecture of the sleep cycle.

Comorbid Parasomnias: A Diagnostic Challenge

Since parasomnias often occur with other sleep disorders, diagnosing them can be quite a problem for physicians and other healthcare practitioners. Similar symptoms manifest themselves in patients with various sleep disorders, which often hinders a physician from making the right diagnosis. For instance, both OSA and parasomnias present with EDS, fatigue, and cognitive dysfunction, which can lead to the wrong diagnosis.

Because of the interactions between parasomnias and other sleep disorders, detailed polysomnography studies are frequently required. They may also have shown that these other conditions are different from each other with the help of analysis of EEG activity, limb movements, respiratory cycles, and other measures during sleep. By knowing what disrupts sleep, then better treatment can be planned by the health care provider.

Treatment Strategies for Comorbid Parasomnias and Sleep Disorders

Approaching parasomnias where the patient’s conditions are accompanied by other sleep disorders involves intervention. If the initial pathology, namely OSA or PLMD, is treated, the patient’s symptoms related to parasomnia will improve substantially. For instance, patients who have OSA and parasomnias will be cured of parasomnias when they undergo CPAP treatment for OSA.

Since parasomnia is often associated with stress, relaxation techniques, managing stress, and good sleep hygiene can also be recommended as useful ways of minimizing parasomnia episodes. Medications might be required to control other diseases, such as RLS or PLMD, but should be used sparingly because in some cases they may worsen parasomnias.

Finally, effective management hinges on a detailed analysis of the patient’s sleep data and the relationship between his/her sleep disorders. The management and attempted treatment of parasomnia as well as the comorbid conditions result in an overall improvement of the sleep well-being of the patient.

Conclusion

Parasomnias are highly associated with other sleep disorders, and the connection between parasomnias and comorbid sleep disorders is intricate. We know that sleep disorders such as OSA, PLMD, and RLS make parasomnias worse by interrupting the normal sleep schedule. Nevertheless, parasomnias can themselves be a part of these disorders’ symptoms complex and make diagnosis and treatment of the primary pathology challenging. To properly diagnose and treat parasomnias that are compounded with other sleep disorders, it is crucial to provide a complex, individualized approach. With further research performed that explores the correlation between parasomnias and other disorders, new treatment approaches follow, meaning that there is hope for patients diagnosed with parasomnias and related illnesses.

References

1. Vincent, N., Dirkse, D., Giannouli, E. and McQuarrie, A., 2023. Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias. Journal of Clinical Sleep Medicine, 19(3), pp.499-509.
2. Limbekar, N., Pham, J., Budhiraja, R., Javaheri, S., Epstein, L.J., Batool-Anwar, S. and Pavlova, M., 2022. NREM parasomnias: Retrospective analysis of treatment approaches and comorbidities. Clocks & Sleep, 4(3), pp.374-380.
3. Inoue, Y., 2015. Sleep‐related eating disorder and its associated conditions. Psychiatry and clinical neurosciences, 69(6), pp.309-320.
4. Lopez, R., Barateau, L., Chenini, S., Rassu, A.L. and Dauvilliers, Y., 2023. Home nocturnal infrared video to record non‐rapid eye movement sleep parasomnias. Journal of Sleep Research, 32(2), p.e13732.
5. Gurbani, N., Dye, T.J., Dougherty, K., Jain, S., Horn, P.S. and Simakajornboon, N., 2019. Improvement of parasomnias after treatment of restless leg syndrome/periodic limb movement disorder in children. Journal of Clinical Sleep Medicine, 15(5), pp.743-748.
6. Limbekar, N., Pham, J., Budhiraja, R., Javaheri, S., Epstein, L.J., Batool-Anwar, S. and Pavlova, M., 2022. NREM parasomnias: Retrospective analysis of treatment approaches and comorbidities. Clocks & Sleep, 4(3), pp.374-380.
7. O’Regan, D., Nesbitt, A., Biabani, N., Drakatos, P., Selsick, H., Leschziner, G.D., Steier, J., Birdseye, A., Duncan, I., Higgins, S. and Kumari, V., 2021. A novel group cognitive behavioral therapy approach to adult non-rapid eye movement parasomnias. Frontiers in Psychiatry, 12, p.679272.
8. Camaioni, M., Scarpelli, S., Gorgoni, M., Alfonsi, V. and De Gennaro, L., 2021. EEG patterns prior to motor activations of parasomnias: a systematic review. Nature and Science of Sleep, pp.713-728.