Non-Rapid Eye Movement Sleep Arousal Disorders DSM-5 307.46 (F51.3)
DSM- 5 Category: Sleep-Wake Disorders
Introduction
The DSM-5 describes non-rapid eye movement sleep arousal disorders as “recurrent episodes of incomplete awakening from sleep.” (American Psychiatric Association, 2013). During these episodes, patients experience sleepwalking or sleep terrors. Although the majority of sleepwalking episodes involve benign behaviors such as walking and talking, some patients engage in sexual activity or sleep eating. Nearly three quarters of patients who experience non-rapid eye movement sleep arousal disorders have sustained injury during an episode. Although most cases of sleep walking or sleep terrors do not need treatment, simple interventions can help reduce instances and improve sleep.
Symptoms
According to the DSM-5, non-rapid eye movement sleep arousal disorders are characterized but partial arousal during sleep. This can be manifested through sleepwalking or sleep terrors. During sleepwalking, an individual gets out of bed and walks around. During these episodes, the individual will not respond coherently to communication. During sleep terrors, the individual will appear to wake from sleep and scream or cry as if panicked. After both types of episodes, the individual will not remember the incident. After an individual awakens from a sleep terror, no nightmare is recalled. Both types of episodes typically last 1-10 minutes but can last longer (American Psychiatric Association, 2013).
The Distinction Between Nightmares and Sleep Terrors
When a child experiences a sleep terror, parents often assume the child experienced a nightmare. Nightmares are significantly different from sleep terrors. During a nightmare, a child may awaken. After a nightmare, a child can be comforted and recall details. Conversely, a child experiencing a sleep terror remains asleep and is unable to recall the event. Children may talk, sit or even walk during a night terror (Durand, 2008).
Specialized Forms of Sleepwalking
Sleepwalking episodes can include a variety of behaviors. The DSM-5 explains that individuals experiencing a sleepwalking episode may walk out of rooms, buildings or even drive a car. In rare cases, sleep walking individuals may engage in violent behavior. Some patients urinate or sustain injuries during the episode. Specialized forms of sleepwalking include engaging in sexual activity during sleep or eating during sleep (American Psychiatric Association, 2013).
Sexual activity during sleep, also called sexsomnia, is extremely rare. However, because of its intimate nature, it is estimated that sexsomnia is under-reported. Additionally, because the patient is unable to remember any activities that occur during non-rapid eye movement sleep disorders, a bed partner is required for the patient to be aware of the activity (Bejot, et al., 2008). Sleep eating is also very rare, with a prevalence of less than 2%. Among adults who sleep-eat, more than 60% are obese. In some cases, adults who sleep-eat consume non-food items or inappropriate, such as raw meat (Lundgren, Allison & Stunkard, 2012).
Prevalence
Isolated non-rapid eye movement sleep arousal disorders are very common, especially among children. The DSM-5 estimates that as many as 30% of children will experience at least once sleepwalking episode and nearly 40% of children will experience at least once sleep terror episode. Frequency among individuals typically diminishes with age. The prevalence of recurring episodes is much less. Only 2-3% of children and adults sleepwalk often. Only about 2% of adults experience sleep terror (American Psychiatric Association, 2013). Although sleep walking and sleep terrors are distinctly different experiences. They often occur during the same episode. More than half of adults who sleep walk also experience sleep terror and nearly three quarters of adults who experience sleep terrors also sleepwalk (Reite, Weissberg & Ruddy, 2008).
Causes of Non-Rapid Eye Movement Sleep Disorders
Environmental causes account for most instances of sleep walking and night terror episodes. Use of medications or sedatives is a common cause in adults. In children and adults, episodes often occur during a period of stress or sleep deprivation. According to the DSM-5, as many as 80% of individuals who experience a sleep walking or sleep terror episode have a family history of similar occurrences (American Psychiatric Association, 2013).
Social Consequences of Non-Rapid Eye Movement Sleep Arousal Disorders
The most common social problem related to sleep walking and sleep terrors is disruption of other family members. Parents of children who sleepwalk often experience anxiety regarding the safety of the child. Adults who experience sleep disruptions often experience embarrassment after the fact. This can create problems in romantic relationships (American Psychiatric Association, 2013). Adults and children who experience sleepwalking and night terror episodes are at risk for injury. Approximately 75% of adults and children who have experienced such episodes have reported injury (Reite, Weissberg & Ruddy, 2008). Adults who sleep eat are at increased risk of choking or ingesting harmful foods or non-food items (Lundgren, Allison & Stunkard, 2012).
Adults who engage in sexual or violent activity during sleep are at risk for relational and legal consequences (American Psychiatric Association, 2013). Sexsomnia, for example, can cause injury and create fear for the bed partner of a person experiencing the sleep disturbance. The concerns are likely to create stress in the relationship (Bejot, et al., 2010). One study found that adults who experience sexsomnia, as well as their partners, report lower levels of sexual satisfaction and overall relationship satisfaction than adults without such sleep disturbances (Klein & Houlihan, 2010)
Treatment for Non-Rapid Eye Movement Sleep Disorders
In general, children tend to outgrow sleep walking and sleep terrors. In some cases, however, treatment is necessary. Because sleep terrors and sleepwalking often occur as a response to poor sleep, improving sleeping conditions is the first line of defense for adults and children. Methods of improving sleep conditions involve setting a regular bedtime, practicing relaxation, limiting food and drink before sleeping and establishing a bedtime routine (Durand, 2008).
If an adult or child experiences recurrent sleep terrors, scheduled awakening may be helpful. Sleep terrors typically occur within the first few hours after the individual falls asleep. If the timing of the incident can be roughly predicted, the patient can be awakened prior to experiencing the sleep terror. If the patient is able to fall back to sleep without further intervention, the sleep cycle may be improved and sleep terrors will cease (Durand, 2008).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Durand, V.M. (2008). When children don’t sleep well: Interventions for pediatric sleep disorders, therapist guide. USA: Oxford University Press.
Reite, M., Weissberg, M. & Ruddy, J.R. (2008). Clinical Manual for evaluation of treatment of sleep disorders. Washington D.C.: American Psychiatric Publishing.
Klein, L.A. & Houlihan, D. (2010). Relationship satisfaction, sexual satisfaction, and sexual problems in sexsomnia. International Journal of Sexual Health 22(2): 84-90
Bejot, Y., Juenet, N., Garrouty, R., Maltaverne, D., Nicolleau, L., Giroud, M. & Didi-Roy, R. (2010). Sexsomnia: An uncommon variety of parasomnia. Clinical Neurology and Neurosurgery 112(1): 72-75
Lundgren, J.D., Allison, K.C. & Stunkard, A.J. (2012). Night eating syndrome: research, assessment, and treatment. New York, N.Y.: Guilford Press.
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