Dr. James Bavis discusses parasomnias-- a group of sleep disorders that involve unwanted events or experiences that occur while you are falling asleep, sleeping or waking up.
James Bavis, MD
A member of the Summa Health Neuroscience Institute, James R. Bavis, M.D., has special interests in Sleep Medicine, Epilepsy, Parkinson’s Disease and Other Movement Disorders, Headaches (Botox Injections), Multiple Sclerosis and Myasthenia Gravis. He graduated from Case Western Reserve University School of Medicine and pursued an Internal Medicine internship at Wake Forest University Baptist Medical Center in Winston-Salem, NC. Dr. Bavis also completed a residency at Wake Forest University Baptist Medical Center in neurology and a fellowship at the Cleveland Clinic Foundation in Sleep and Neurophysiology. He is board certified by the American Board of Psychiatry and Neurology.
Scott Webb (Host): Parasomnias are a group of sleep disorders that involve unwanted events or experiences that occur while you are falling asleep, sleeping or waking up. Parasomnias may include abnormal movements, behaviors, emotions, perceptions, or dreams. Although the behaviors may be complex and appear purposeful to others, you remain asleep during the event and often have no memory that it occurred. If you have a parasomnia, it may find it difficult to sleep through the night. And joining me today to help us understand parasomnias is Dr. James Bavis. He's a Neurologist and Sleep Medicine Specialist at Summa Health. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Doctor, it's so great to have you on. This is an interesting topic. What are parasomnias?
James Bavis, MD (Guest):Parasomnias involve all sorts of different behaviors that people are doing during their sleep. Of course, when you're sleeping, you should just be lying in bed and breathing and not really moving very much, but when you have jerks or twitches or walking or talking, any of those things, we just lump them all together into the term parasomnia which just means abnormal behaviors during sleep.
Host: Yeah, so abnormal behaviors during sleep. And I know it's a long list, but maybe you can run through this. What are the most common parasomnias?
Dr. Bavis: The most common parasomnias involve jerking of the limbs at night. They're in a family of movements that most people know as restless leg syndrome. Technically, the restless leg syndrome is occurring before you fall asleep, where you have discomfort in the limbs and a need to move them, need to get up and walk around because the limbs are bothering you. And that keeps you from falling asleep. Depending on what study you read, about 40 to 70% of those folks will actually have jerking of the limbs while they are asleep. And then not only can they wake up their bed partner, but they may wake up themselves and have restless sleep because of the limbs jerking while they are asleep.
Now, the limbs jerking while they are asleep goes under the heading of periodic limb movement disorder. And then a lot of those people will also get a related thing called sleep related leg cramps, or most people call them Charlie Horses. So, those are the most common. Obviously, pretty much everybody knows somebody who has a history of sleep walking or sleep talking. Those are very common. And those are the ones that most of the time we're dealing with. There are some other ones that we deal with, where patients will have behaviors during deep dream state sleep, something called REM sleep behavior disorder, where they'll yell, kick, scream, punch, fight, like they're having a fight or an argument with somebody in dream state. And they'll have no recollection of it until the bed partner or somebody else wakes them up out of it. And then they hopefully go right back to sleep. But those are the main ones that we see. There are all sorts of other little more rare things that occur in some that occur at different ages of life as well. Host:And Doctor, assuming that nightmares, sleep terrors, sleep panic attacks kind of fall under this umbrella. I'm sure. There's a bit of a confusion regarding those things and one from the other. So, maybe you can kind of sort that out for us.
Dr. Bavis:Sure. So, nightmares are just bad vivid memories. They can be extreme. They can make somebody very upset, even not want to go to sleep because they're having bad nightmares. But those are not the same thing as sleep terrors. Sleep terrors occur in children, usually children old enough to be sleeping on their own, but in kindergarten, first grade, maybe second grade, but usually by then they grow out of it where they just in the middle of the night suddenly are screaming bloody murder. Sometimes they can even be running around the room and screaming and the parent comes in and hugs them and tries to get them calmed down there. They're not even responding to the parent and either they eventually fall back asleep or they are awakened finally by the parent and they have absolutely no recollection what was going on.
They don't have any recollection of a nightmare. They have no idea why the parent's in the room, they’re surprised to find the lights on in the room. That's a sleep terror so sometimes people will come in and say, they're adults and they'll come in and see me, and they'll say, I'm having sleep terrors. Well, no, you're having really bad nightmares. There's another condition called sleep panic attacks and sleep panic attacks, what happens is they're there more often than not is no dream associated with it. The person just has an arousal out of sleep and they will just suddenly go into a panic attack. They don't necessarily have to have any kind of nightmare or a bad experience right before this happens. They just suddenly go into a panic attack after arousing out of asleep. And we're not totally sure why exactly that happens. We know that in other situations like sleep walking and sleep talking, people will have an increase in their heart rate and other things that are associated with panic attacks, but we don't know exactly why certain people will go into sleep panic attacks. But those are not necessarily tied into anything to do with nightmares. I have to sometimes make sure that when the person says sleep terrors or sleep panic attacks, that they're really not just talking about really bad nightmares and more often than not, they are just talking about really bad nightmares.
Host:Yeah. And you do see how there could be some confusion. Because there's just enough overlap there. And sometimes people wake up and sometimes they don't. Sometimes they're told about it by somebody else the next day, and so confusing and sometimes frightening for them and probably their bed partners and their parents. So, there's a lot to unpack there. And I guess I'm wondering, do parasomnias run in families? Are there environmental factors? Is it a whole host of things?
Dr. Bavis:It is a whole host of things. Now, the exceptions are restless leg syndrome, periodic limb movement disorder. Those conditions, there is a very strong family history associated with that. For the restless legs syndrome in particular, if you have an identical twin, that develops restless legs, you have an 85% chance of getting the restless legs yourself. So, a very strong genetic tendency there, and there actually have been genes, not many, less than a handful that have been found to be associated with it, but we don't have the full mechanism for restless legs and periodically movement disorder worked out. There may be some inherited tendency to get a REM sleep behavior disorder, but that's still not totally proven. And I have personal experience where families will report that grandpa slept walk and father slept walk and now son is sleep walking. So, I think there probably is. But has that been proven? No, that has not been proven?
Host:Yeah. Gotcha. And you know, some of the things you've talked about here, I remember as a kid, I was a sleep walker. I was a sleep talker and my mom would often catch me right before I decided to walk down the stairs and say, Scott, go back to your room. So, I guess natural followup for me anyway, is are some parasomnias more common in children than adults because some of this stuff sounds like my kids and sounds like me when I was a kid. And then other stuff seems really more adult related.
Dr. Bavis:Yeah, absolutely. The sleep terrors for example, are almost exclusively children and then the sleep walking and sleep talking is typically more common in kids and young adults. They are usually are very uncommon in full adults, although it can happen at any age. This condition called REM behavior disorder, most of the time where the person is yelling, kicking, screaming, when they're in deep dream state sleep, most of the time that is an older adult or at least a middle aged person. Although there are exceptions with that. Most of the time that's in older folks. And then sometimes you'll get some crossover things. You'll get a sleepwalker that will eat in the middle of the night. And that's for some reason, a little bit more common in adults than children. But yes, there is some relationship to stage of life and when the sleep disorders occur,
Host:I've heard that old, I don't know if it's a wives tale or how to refer to it, but that we're not supposed to wake people if they're sleepwalking or sleep talking. Is that just a myth or is that a real thing, Doctor?
Dr. Bavis:That is a real thing. We worry about with the little kids and having the sleep terrors that you could potentially see worsening of it when you go in and turn the light on and start interacting with the child. There's been some change in that, we used to tell the parents don't do that. Try not to turn on the light, just try to be near the child so they don't jump out of the bed or something. Now it appears that really doesn't need to be the case that if the parent runs in and hugs the child, it's okay. It's not going to make anything worse. The sleepwalkers you primarily want to make sure they don't fall down the stairs or go out the window. You don't really have to do anything else with them. Have people gotten in the way of a sleep walker and gotten harmed? Yes, they have. So obviously you don't want to particularly if it's a bigger person, you don't want to like, just stand right in front of them and they don't mean to do any harm, but they might bump into you. With the REM behavior disorder, that's a very interesting situation because that's in deep dream state sleep. And actually you can with yelling or calling out to them, get them to snap out of it. The brain during deep dream state sleep, as opposed to other stages of sleep can actually respond to auditory information. Hey, you're dreaming will sometimes actually get it to settle down. So, in that case, an older person, that's yelling, kicking, screaming while they're in deep dream state sleep, you can actually get them to settle down sometimes if you call out to them. Now the problem with the REM sleep behavior disorder patients, is because they're in deep dream state sleep, they can actually do some very complicated things that a regular sleep walker can't do. There have been cases where they have grabbed the gun at the bedside and shot it at the person that they are having the dispute with in their dream and potentially put the bed partner at risk.
I've had patients that pulled TV sets down from cabinets onto their heads and kicked the dog did all sorts of stuff that they have no recollection of later. So, the point in telling you that, and going back to your question is that, if they're not snapping out of it when you're yelling at them, you don't necessarily want to be in their way. Cause often the dreams that are going on are unpleasant fights and you just want to make sure you're not taking a swing or taking a kick.
Scott Webb (Host): Yeah, definitely. And I, I do remember when my mom would yell out to me, I would just immediately and instinctively just turn around and walk right back to my room and climb right back into bed. I never made it all the way down the stairs. I never fell down the stairs. So, knock on wood. Can some parasomnias be triggered by other sleep disorders, like sleep apnea?
James Bavis, MD (Guest): Absolutely. Just to back up and explain sleep apnea. In sleep apnea the airway in the back of the throat which is held open by muscles, in people with sleep apnea when their muscles relax during sleep, the airway closes off on them, and then they're not breathing for a period of time. And the body has to react to that. Eventually there has to be an arousal and the airway is opened by contracting the muscles in the back of the throat. What can happen though is if the person has that very brief arousal, just two or three seconds and then goes immediately right back to sleep while they might go into a sleep arousal as a result of that not breathing. And so then if they're prone to having REM sleep behavior disorder, or if they're prone to having sleepwalking or sleep talking, they'll start having those behaviors, because parts of the brain shifted it back into sleep and other parts are not fully back into that sleep mode and so things can happen in that twilight between wake and asleep were the person starts having the behaviors. So, yes, absolutely. And in fact, when somebody has sleep apnea, they may jerk as a result of not breathing. Their brain is trying to get the body to arouse so that it'll contract those muscles in the back of the throat and they might jerk their legs.
And so the person sometimes will be in the sleep lab and they're having frequent jerking of the limbs at night. And they're also having sleep apnea. I do not treat the jerking of the limbs until I fixed the sleep apnea. And then if the sleep apnea being fixed, stopped the jerking of limbs, then we're done. And every once in a while you get somebody, fix the sleep apnea. Now their brain is getting more oxygen. And actually they're like start jerking more, which in that case, you know, that they actually had periodic limb movement disorder all along and now you need to treat both things. So, sleep apnea will trigger it. If the person has the periodic limb movement, jerking of the limbs at night, sometimes that'll cause an arousal and then they sleep walk or sleep talk, or do these other things because the leg jerking woke them up.
So, absolutely. If you can find the underlying cause and treat that, then often that'll fix the problem. That's why when it comes to these disorders that jerky of the limbs at night, or the REM sleep behavior disorder, we do usually get unless it's a child, we do usually get an overnight sleep study. And check to see if there's something going on, that's causing the arousals in the first place, particularly the REM sleep behavior disorder, because you do get quite a few older adults that have sleep apnea that is bad during deep dream state sleep. And if you fix the obstructive sleep apnea, then they stop having the abnormal behaviors during deep dream state sleep.
Host:Yeah. And you mentioned diagnosis and treatment, and that's where I wanted to go next is, how are these things, how are parasomnias diagnosed? And can you get to the root cause of at least most of them? And then what are the treatment options?
Dr. Bavis:With the pediatric cases, most of the diagnosis for those conditions are based on the history, sometimes and to some extent the physical exam, but most of the time, reassurance and, and just following the patient and making sure it's going away as they get older, is all that is needed. If you have a patient that continues to have sleep walking, sleep talking, and they're going to go to camp or do a sleep over, there might be a situation there where you might want to medicate them. Just so they don't have the embarrassment of doing something funny while they're at the friend's house. But most of the time you don't have to medicate. They grow out of it and then everything's fine. With adults though, it's much more complicated and there's no guarantee of growing out of it. So, you have to get the sleep study and see. Now there are some exceptions. If you have somebody who's got straightforward restless legs, they describe the discomfort when they are sitting or lying down. It's more at night after the sun goes down. And it's a very straightforward history. You don't necessarily need to get a sleep study in that particular case. When you have somebody with the REM sleep behavior disorder, the standard treatment for that is a medicine called Gabapentin. Gabapentin is more famous for being used for nerve pain, especially in diabetics with diabetic neuropathy, where they get burning, tingling, stinging in their feet.
You can actually use the Gabapentin at night only and that will help reduce the discomfort in the limbs. There are some other medicines that we use for that as well. They're called dopamine agonists. But we nowadays use those if the Gabapentin doesn't work. And the reason for that is that there's a small risk with the dopamine agonists of actually about 2% of people will actually get worsening of the limb jerking or the restless legs feeling.
So, that's one out of every 50. So, if you can use the Gabapentin and get the relief, then that works out better for the patient because they don't, you don't take any risk of making it worse. The restless leg syndrome, most of the time, there's nothing wrong that we can find. The patients with restless leg syndrome need their iron level checked because when there is something wrong, often that's a low or borderline level of the iron. And then we also check thyroid because sometimes, thyroid disease will be associated with restless leg syndrome. But as we, touched on a little earlier, the restless leg syndrome has such a strong inherited part to it that a lot of times, there's no iron problem or a thyroid problem. The REM behavior disorder, that does have to have the sleep study to be certain. You can get a pretty good idea based on the history. And that one it's a little more difficult to treat. That one, the patients are tried on many different things. And if we have to treat, we'll try different medications, including the Gabapentin I mentioned earlier. The medicine that is pretty reliable to work is a medicine called clonazepam, which is a sedative medication. It's in the same family with Valium. But it's not one we'd like to use unless we really have to because there's risk of falling and memory loss with chronic use of that medicine. But sometimes you have a situation with the REM behavior disorder where if you don't treat the person, then they could harm themselves, or they could hurt the bed partner. And so you finally have to just do it, if you can't get any other medicine to work.
Host:Doctor, I feel like I could talk to you all afternoon. As we wrap up here today, anything else you want to tell folks about parasomnias, diagnosis, treatment, general outlook for people with parasomnias as they go through life? Anything else?
Dr. Bavis:The most important of the parasomnias turns out to be this REM behavior disorder. Why it's important is that we are discovering that it can be the first signs of an underlying neurological problem. In a study done in Canada, they followed 1200 people who had REM behavior disorder and 75% of them ended up with Parkinson's Disease or a similar brain disease in that family.
So, many people are hoping that the discovery of that connection between those two, can help us to not only figure out how Parkinson's Disease occurs, which is a condition where people have tremors and they get a slow response time of the muscles and eventually end up not being able to walk because they get stooped and they shuffle and they fall. But it may also provide an opportunity to jump in and prevent Parkinson's Disease, if you can figure out how the REM behavior disorder leads to the Parkinson's Disease. The REM behavior disorder tends to occur 25 to 30 years before the onset of Parkinson's Disease. So it, it gives people an opportunity that maybe we could nip the problem in the bud at that point. Not everybody with REM behavior disorder goes on to get Parkinson's Disease. There's that one in four people, and a lot of those people, particularly if they're younger, if they're a young adult, they will actually have something called narcolepsy, which is a whole other sleep disorder that we could have a whole other conversation about.
But, in narcolepsy, the part of the brain that controls the movements that are supposed to shut down movements during deep dream state sleep, doesn't work as well. And so the young adults with REM behavior disorder, have to be checked for narcolepsy, as they may have narcolepsy causing the REM behavior disorder.
Host: Really amazing and so much to take in there. I think one of my takeaways today is just going to be how much we can learn about ourselves and perhaps each other, from what we do while we sleep. Possibly being able to predict and diagnose early onset Parkinson's through a sleep disorder. It's absolutely mind boggling. It's amazing. This has been just so great having you on. I hope we get to get back on and talk. Yeah. Talk about narcolepsy and a whole bunch of other stuff. So, Doctor, thank you so much for your time and you stay well. Dr. Bavis:Thank you.
For more information, visit Summahealth.org/sleep. And if you found this podcast helpful and informative, please share it on your social channels and be sure to check out the entire podcast library for additional topics of interest. Host:This is Healthy Vitals apodcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.