Walking, talking, eating and fighting in sleep
There are 3 states of consciousness: Wakefulness, NREM (nonrapid eye movement) and REM (rapid eye movement) sleep (link to learn about your sleep). Each state has its own features in respect to alertness, breathing, and muscle tone. There are clear boundaries between these states, and a person can never be in more than one state at a time.
What are the states of consciousness?
Table 1. Characteristics of the 3 Brain States
| Wakefulness | NREM Sleep | REM Sleep | |
|---|---|---|---|
Eye Movements | Present | Slow | Rapid |
Alertness | Alert and aware of
environment | Not alert or aware of environment | |
Brain activity | Active | Not active | Active |
Dreams | None | None | Present |
Motor Activity | Able to move | Muscles relaxed,
no movement | Muscles are paralyzed
(twitches can be seen) |
BP, HR,
Respiration,
Body Temperature
Regulation | Changes based
on activity | Body is at rest and
all are reduced. | Variability is present.
Body is poikilothermic* |
Summary | You are awake, able to
move and respond to
environment. “Active
mind in an active body.” | You are asleep; brain
and body are quiet and
resting. “Quiet mind in
a quiet body.” | You are asleep; brain is
active and muscles are
paralyzed. “Active mind
in a paralyzed body.” |
*absence of body temperature regulation
What are Parasomnias?
For more information: http://sleepeducation.org/sleep-disorders-by-category/parasomnias
NREM Parasomnias
Confusional arousals
Sleep walking
Sleep terrors
Sleep-related eating disorder
REM Parasomnias
REM Behavior Disorder
Sleep Hallucinations
Sleep Paralysis
Nightmare Disorder
NREM parasomnias
- These spells are seen mostly in children <5 years old, but 4% may also be seen in the adult population.
- They occur during slow wave sleep in the first third of night.
- They are disorders or arousal: disturbance in sleep (due to pain, noise) will cause a partial arousal resulting in incomplete transition from sleep to wakefulness (child is neither asleep or awake). The child appears awake and confused (eyes open, looking around, moving), but glassy eyed and without alertness or awareness.
- They are disorders or arousal: disturbance in sleep (due to pain, noise) will cause a partial arousal resulting in incomplete transition from sleep to wakefulness (child is neither asleep or awake). The child appears awake and confused (eyes open, looking around, moving), but glassy eyed and without alertness or awareness.
- They are disorders or arousal: disturbance in sleep (due to pain, noise) will cause a partial arousal resulting in incomplete transition from sleep to wakefulness (child is neither asleep or awake). The child appears awake and confused (eyes open, looking around, moving), but glassy eyed and without alertness or awareness.
- The child will fall back to sleep after these spells with only partial or no memory for these events in the morning.
- These events occur more when the child is sleep deprived or ill.
- A family history is positive (62 – 96% of cases).
- Many times more than 1 type of parasomnia may be seen in the same person.
Child will sit up and look around, appearing strange and confused for a few seconds to minutes (as if they don't know where they are) before falling back to sleep. Spells may occasionally last longer, and your child may become agitated or get out of bed to move around during the spells.
Child will get out of bed and walk. Complex behavior like walking out of the room or house, and even driving can be seen. Occasionally, children may urinate in odd places and the sleepwalker may become violent.
Diagnosis/ treatment: see below
A piercing scream or cry is heard as your child sits up in bed, associated with sweating, pounding of the heart and intense fear. These spells last only seconds to a few minutes. Occasionally it may last longer up to 40 minutes. Sometimes scary images can be seen during these spells and the child may get up and walk around.
These spells are seen in up to 40% of children and can be very disturbing for the parents. The children however, usually fall back to sleep and will have partial or no memory of what happened when they wake up in the morning.
Diagnosis/ treatment: see below
Unlike other NREM parasomnias, SRED is more common in adults (average age of onset 22 - 29 years) and is more common in women (65 – 80%). It is an ongoing and long-lasting problem. Spells consist of preparing and eating food during sleep. This includes out of control eating and drinking behavior, involving consumption of high-carbohydrate and high-fat foods. Many people with SRED have episodes of eating almost every night. Rarely, even inedible and toxic items are eaten.
Weight gain, obesity and other health issues may be seen depending on their eating pattern. Sedative medications such as Zolpidem occasionally precipitate these spells. Other underlying sleep conditions such as sleep apnea, restless legs, and irregular sleep wake cycles may be present.
If these spells are frequent, medication treatment will be required.
Evaluation by a Sleep Specialist is required for appropriate diagnosis and treatment. If possible, record events with a camera or cell phone to show your doctor. They will be very helpful in understanding your events. Occasionally, further testing like a sleep study, epilepsy monitoring or an MRI of brain may be required to make a correct diagnosis.
Although these spells can be disturbing, most children will eventually outgrow them.
Strategies to manage NREM parasomnias (confusional arousals, sleepwalking, sleep terrors and SRED)
1. Avoid triggers which precipitate these conditions like:
a. Irregular sleep wake schedule or sleep loss. This can happen during travel, and may also occur
when your child starts school due to change in their sleep-wake pattern and restriction of nap time.
b. Stress
c. Illness like fever, cough, cold, loose stools.
d. Substances like alcohol, cigarettes and certain medications.
2. If children are having an event, don't try to wake them up, or force them to go back to bed, especially if they are agitated. If you do this, they may become violent. Instead, try to lead them back to bed by placing a reassuring hand on their shoulder.
3. Safety issues: if these spells are occurring frequently:
a. keep all sharp or dangerous objects away from their reach.
b. Don't keep their bed next to the window or allow them to sleep at a height (top bunk bed).
c. Keep alarms on the doors so if they try to go out of the room or house, you will know.
4. Most cases will improve with a regular sleep wake schedule and by correcting potential underlying cause of arousals. Sometimes a benzodiazepine medication may be required.
Confusional arousals
Child will sit up and look around, appearing strange and confused for a few seconds to minutes (as if they don’t know where they are) before falling back to sleep. Spells may occasionally last longer, and your child may become agitated or get out of bed to move around during the spells.
Sleep walking (Somnambulism):
Child will get out of bed and walk. Complex behavior like walking out of the room or house, and even driving can be seen. Occasionally, children may urinate in odd places and the sleepwalker may become violent.
Diagnosis/ treatment: see below
Sleep terrors
A piercing scream or cry is heard as your child sits up in bed, associated with sweating, pounding of the heart and intense fear. These spells last only seconds to a few minutes. Occasionally it may last longer up to 40 minutes. Sometimes scary images can be seen during these spells and the child may get up and walk around.
These spells are seen in up to 40% of children and can be very disturbing for the parents. The children however, usually fall back to sleep and will have partial or no memory of what happened when they wake up in the morning.
Diagnosis/ treatment: see below
Sleep-related eating disorder (SRED)
Unlike other NREM parasomnias, SRED is more common in adults (average age of onset 22 – 29 years) and is more common in women (65 – 80%). It is an ongoing and long-lasting problem. Spells consist of preparing and eating food during sleep. This includes out of control eating and drinking behavior, involving consumption of high-carbohydrate and high-fat foods. Many people with SRED have episodes of eating almost every night. Rarely, even inedible and toxic items are eaten.
Weight gain, obesity and other health issues may be seen depending on their eating pattern. Sedative medications such as Zolpidem occasionally precipitate these spells. Other underlying sleep conditions such as sleep apnea, restless legs, and irregular sleep wake cycles may be present.
If these spells are frequent, medication treatment will be required.
REM parasomnias
REM sleep parasomnias occur when the dream content or muscle paralysis of REM sleep intrude into wakefulness, as in hypnagogic hallucinations and sleep paralysis. Conversely, when the muscle paralysis is absent during REM sleep, dream enactment behavior such as kicking, screaming and punching may be seen as in REM behavior disorder.
Dreams are stories created by our mind while we sleep and our body rests. People with RBD act out their dreams by punching, kicking, screaming and even leaping out of bed. These dreams are vivid, filled with action and may even become violent. Dreams of being attacked by animals, chased by an attacker or being mutilated have been reported. Not all episodes are this violent. Initial spells are usually nonviolent and this condition may remain undetected for years till they become violent and result in injury.
RBD is frequently an early manifestation of a neurodegenerative disorder like Parkinson's disease. It is occasionally precipitated by medications (antidepressants, antipsychotics).
Sometimes underlying sleep apnea can induce violent dreams associated with movements similar to RBD, and is known as pseudo-RBD. Evaluation by a sleep specialist is suggested.
If you see, hear, feel, smell or taste something and are not sure if you are awake or dreaming, you may be having SH, which occur while falling asleep or waking up. While SH occur when are awake. You may see people, hear door knobs open and footsteps or feel bugs crawl on your body.
SH may be complex and associated with sleep paralysis and fear. Occasionally, people have jumped out of bed and injured themselves during these spells.
SH is the intrusion of the dream content of REM sleep into wakefulness.
When should you see a doctor? See below
Sleep paralysis (SP)
If you find yourself unable to move or speak for a few seconds to minutes, while falling asleep or waking up, you may be having SP. Seeing, hearing and feeling things that are not there (sleep hallucinations) may also be present. People have reported a pressure sensation on their chest with a sense of being smothered (as if they will die), or may feel a spinning and floating sensation and have difficulty speaking during these spells.
SP is an intrusion of the muscle paralysis of REM sleep into wakefulness, and is likely to be seen for the first time during adolescence and early 20s.
If daytime sleepiness, sleep hallucinations and cataplexy are also present, SP may be a symptom of Narcolepsy. Recurrent isolated SP may also occur without other symptoms.
SH and SP may be triggered by stress, sleep deprivation, jet lag and panic. While these spells are not life-threatening, they may cause fear and anxiety. If these spells occur occasionally and are not troublesome, following good sleep habits (link to how to get a better night of sleep) should be enough to prevent them. Evaluation by a sleep specialist should be considered:
1) if you have significant daytime sleepiness
2) spells are occurring frequently and disturbing you and your family members.
Nearly 80% of people have occasional nightmares (bad dreams), and 8% of people may have frequent nightmares known as nightmare or dream anxiety disorder.
ND is associated with a fear of going to sleep and worry about having nightmares. You may also experience fear, anxiety, embarrassment, anger, rage or disgust when you wake up from a nightmare. If this occurs frequently, your sleep will be disturbed leading to daytime tiredness.
Dreams and nightmares occur during REM sleep (20-25% of sleep period), which occurs mostly in the final third of the night. Several nightmares with the same story may be seen intermittently during the same night. They may appear very real and become more disturbing before you wake up. People clearly remember details of their nightmares. Disturbing dreams that do not wake you up are not nightmares.
Nightmares can be associated with previous traumatic events as in PTSD (post-traumatic stress disorder). These dreams usually occur earlier in the night. Medications (used to treat depression, hypertension and Parkinson's disease) can also cause nightmares.
When should I see a Sleep Specialist?
If you or your child/family member are having frequent nightmares, causing distress or sleep disturbance, you should visit a doctor trained in Sleep Medicine.
REM behavior disorder (RBD)
Dreams are stories created by our mind while we sleep and our body rests. People with RBD act out their dreams by punching, kicking, screaming and even leaping out of bed. These dreams are vivid, filled with action and may even become violent. Dreams of being attacked by animals, chased by an attacker or being mutilated have been reported. Not all episodes are this violent. Initial spells are usually nonviolent and this condition may remain undetected for years till they become violent and result in injury.
RBD is frequently an early manifestation of a neurodegenerative disorder like Parkinson’s disease. It is occasionally precipitated by medications (antidepressants, antipsychotics).
Sometimes underlying sleep apnea can induce violent dreams associated with movements similar to RBD, and is known as pseudo-RBD. Evaluation by a sleep specialist is suggested.
Sleep hallucinations (SH)
If you see, hear, feel, smell or taste something and are not sure if you are awake or dreaming, you may be having SH, which occur while falling asleep or waking up. While SH occur when are awake. You may see people, hear door knobs open and footsteps or feel bugs crawl on your body.
SH may be complex and associated with sleep paralysis and fear. Occasionally, people have jumped out of bed and injured themselves during these spells.
SH is the intrusion of the dream content of REM sleep into wakefulness.
When should you see a doctor? See below
Sleep paralysis (SP)
If you find yourself unable to move or speak for a few seconds to minutes, while falling asleep or waking up, you may be having SP. Seeing, hearing and feeling things that are not there (sleep hallucinations) may also be present. People have reported a pressure sensation on their chest with a sense of being smothered (as if they will die), or may feel a spinning and floating sensation and have difficulty speaking during these spells.
SP is an intrusion of the muscle paralysis of REM sleep into wakefulness, and is likely to be seen for the first time during adolescence and early 20s.
If daytime sleepiness, sleep hallucinations and cataplexy are also present, SP may be a symptom of Narcolepsy. Recurrent isolated SP may also occur without other symptoms.
When should you see a doctor for SH and SP?
SH and SP may be triggered by stress, sleep deprivation, jet lag and panic. While these spells are not life-threatening, they may cause fear and anxiety. If these spells occur occasionally and are not troublesome, following good sleep habits (link to how to get a better night of sleep) should be enough to prevent them. Evaluation by a sleep specialist should be considered:
1) if you have significant daytime sleepiness
2) spells are occurring frequently and disturbing you and your family members.
Nightmare disorder (ND)
Nearly 80% of people have occasional nightmares (bad dreams), and 8% of people may have frequent nightmares known as nightmare or dream anxiety disorder.
ND is associated with a fear of going to sleep and worry about having nightmares. You may also experience fear, anxiety, embarrassment, anger, rage or disgust when you wake up from a nightmare. If this occurs frequently, your sleep will be disturbed leading to daytime tiredness.
Dreams and nightmares occur during REM sleep (20-25% of sleep period), which occurs mostly in the final third of the night. Several nightmares with the same story may be seen intermittently during the same night. They may appear very real and become more disturbing before you wake up. People clearly remember details of their nightmares. Disturbing dreams that do not wake you up are not nightmares.
Nightmares can be associated with previous traumatic events as in PTSD (post-traumatic stress disorder). These dreams usually occur earlier in the night. Medications (used to treat depression, hypertension and Parkinson’s disease) can also cause nightmares.
What is different about the 3 states of consciousness? (link to learn about your sleep)
Sometimes, features of one state will transition into another, resulting in behaviors such as walking, talking, panic and eating during sleep. These conditions are collectively known as Parasomnias.
What are Parasomnias?
Parasomnias are involuntary activities or sensations experienced while one is in the process of falling asleep, sleeping or waking up. This includes abnormal movements, behaviors, emotions, perceptions and dreams. Although the behaviors appear purposeful and real, the person remains asleep during these spells. Depending on the stage of sleep these events arise from, they are classified as NREM or REM Sleep Parasomnias.
For more information: http://sleepeducation.org/sleep-disorders-by-category/parasomnias
NREM parasomnias
These spells are seen mostly in children <5 years old, but 4% may also be seen in the adult population.
They occur during slow wave sleep in the first third of night.
They are disorders or arousal: disturbance in sleep (due to pain, noise) will cause a partial arousal resulting in incomplete transition from sleep to wakefulness (child is neither asleep or awake). The child appears awake and confused (eyes open, looking around, moving), but glassy eyed and without alertness or awareness.
The child will fall back to sleep after these spells with only partial or no memory for these events in the morning.
These events occur more when the child is sleep deprived or ill.
A family history is positive (62 – 96% of cases).
Many times more than 1 type of parasomnia may be seen in the same person.
Confusional arousals
Child will sit up and look around, appearing strange and confused for a few seconds to minutes (as if they don’t know where they are) before falling back to sleep. Spells may occasionally last longer, and your child may become agitated or get out of bed to move around during the spells.
Sleep walking (Somnambulism):
Child will get out of bed and walk. Complex behavior like walking out of the room or house, and even driving can be seen. Occasionally, children may urinate in odd places and the sleepwalker may become violent.
Diagnosis/ treatment: see below
Sleep terrors
A piercing scream or cry is heard as your child sits up in bed, associated with sweating, pounding of the heart and intense fear. These spells last only seconds to a few minutes. Occasionally it may last longer up to 40 minutes. Sometimes scary images can be seen during these spells and the child may get up and walk around.
These spells are seen in up to 40% of children and can be very disturbing for the parents. The children however, usually fall back to sleep and will have partial or no memory of what happened when they wake up in the morning.
Diagnosis/ treatment: see below
Sleep-related eating disorder (SRED)
Unlike other NREM parasomnias, SRED is more common in adults (average age of onset 22 – 29 years) and is more common in women (65 – 80%). It is an ongoing and long-lasting problem. Spells consist of preparing and eating food during sleep. This includes out of control eating and drinking behavior, involving consumption of high-carbohydrate and high-fat foods. Many people with SRED have episodes of eating almost every night. Rarely, even inedible and toxic items are eaten.
Weight gain, obesity and other health issues may be seen depending on their eating pattern. Sedative medications such as Zolpidem occasionally precipitate these spells. Other underlying sleep conditions such as sleep apnea, restless legs, and irregular sleep wake cycles may be present.
If these spells are frequent, medication treatment will be required.
Evaluation and treatment of NREM parasomnias
Evaluation by a Sleep Specialist is required for appropriate diagnosis and treatment.
If possible, record events with a camera or cell phone to show your doctor. They will be very helpful in understanding your events. Occasionally, further testing like a sleep study, epilepsy monitoring or an MRI of brain may be required to make a correct diagnosis.
Although these spells can be disturbing, most children will eventually outgrow them.
Strategies to manage NREM parasomnias (confusional arousals, sleepwalking, sleep terrors and SRED)
REM parasomnias
REM sleep parasomnias occur when the dream content or muscle paralysis of REM sleep intrude into wakefulness, as in hypnagogic hallucinations and sleep paralysis. Conversely, when the muscle paralysis is absent during REM sleep, dream enactment behavior such as kicking, screaming and punching may be seen as in REM behavior disorder.
REM behavior disorder (RBD)
Dreams are stories created by our mind while we sleep and our body rests. People with RBD act out their dreams by punching, kicking, screaming and even leaping out of bed. These dreams are vivid, filled with action and may even become violent. Dreams of being attacked by animals, chased by an attacker or being mutilated have been reported. Not all episodes are this violent. Initial spells are usually nonviolent and this condition may remain undetected for years till they become violent and result in injury.
REM behavior disorder (RBD)
Dreams are stories created by our mind while we sleep and our body rests. People with RBD act out their dreams by punching, kicking, screaming and even leaping out of bed. These dreams are vivid, filled with action and may even become violent. Dreams of being attacked by animals, chased by an attacker or being mutilated have been reported. Not all episodes are this violent. Initial spells are usually nonviolent and this condition may remain undetected for years till they become violent and result in injury.
RBD is frequently an early manifestation of a neurodegenerative disorder like Parkinson’s disease. It is occasionally precipitated by medications (antidepressants, antipsychotics).
Sometimes underlying sleep apnea can induce violent dreams associated with movements similar to RBD, and is known as pseudo-RBD. Evaluation by a sleep specialist is suggested.
Sleep hallucinations (SH)
If you see, hear, feel, smell or taste something and are not sure if you are awake or dreaming, you may be having SH, which occur while falling asleep or waking up. You are awake during SH, while dreams occur when you are asleep. You may see people, hear door knobs open and footsteps or feel bugs crawl on your body.
SH may be complex and associated with sleep paralysis and fear. Occasionally, people have jumped out of bed and injured themselves during these spells.
SH is the intrusion of the dream content of REM sleep into wakefulness.
When should you see a doctor? See below
Sleep paralysis (SP)
If you find yourself unable to move or speak for a few seconds to minutes, while falling asleep or waking up, you may be having SP. Seeing, hearing and feeling things that are not there (sleep hallucinations) may also be present. People have reported a pressure sensation on their chest with a sense of being smothered (as if they will die), or may feel a spinning and floating sensation and have difficulty speaking during these spells.
SP is an intrusion of the muscle paralysis of REM sleep into wakefulness, and is likely to be seen for the first time during adolescence and early 20s.
If daytime sleepiness, sleep hallucinations and cataplexy (link to daytime sleepiness/ narcolepsy/ cataplexy) are also present, SP may be a symptom of Narcolepsy (link to daytime sleepiness/ narcolepsy). Recurrent isolated SP may also occur without other symptoms.
When should you see a doctor for SH and SP?
SH and SP may be triggered by stress, sleep deprivation, jet lag and panic. While these spells are not life-threatening, they may cause fear and anxiety. If these spells occur occasionally and are not troublesome, following good sleep habits (link to how to get a better night of sleep) should be enough to prevent them. Evaluation by a sleep specialist should be considered:
1) if you have significant daytime sleepiness
2) spells are occurring frequently and disturbing you and your family members.
Nightmare disorder (ND)
Nearly 80% of people have occasional nightmares (bad dreams), and 8% of people may have frequent nightmares known as nightmare or dream anxiety disorder.
ND is associated with a fear of going to sleep and worry about having nightmares. You may also experience fear, anxiety, embarrassment, anger, rage or disgust when you wake up from a nightmare. If this occurs frequently, your sleep will be disturbed leading to daytime tiredness.
Dreams and nightmares occur during REM sleep (20-25% of sleep period), which occurs mostly in the final third of the night. Several nightmares with the same story may be seen intermittently during the same night. They may appear very real and become more disturbing before you wake up. People clearly remember details of their nightmares. Disturbing dreams that do not wake you up are not nightmares.
Nightmares can be associated with previous traumatic events as in PTSD (post-traumatic stress disorder). These dreams usually occur earlier in the night. Medications (used to treat depression, hypertension and Parkinson’s disease) can also cause nightmares.
When should I see a Sleep Specialist?
If you or your child/family member are having frequent nightmares, causing distress or sleep disturbance, you should visit a doctor trained in Sleep Medicine.
