1. Disorders of arousal (from NREM sleep)

2. Parasomnias usually associated with REM sleep

3. Other parasomnias.

1. Sleep-related dissociative disorders

2. Sleep enuresis

3. Sleep-related groaning (catathrenia)

4. Exploding head syndrome

5. Sleep-related hallucinations

6. Sleep-related eating disorder

7. Unspecified parasomnia

8. Parasomnia due to a drug or substance

9. Parasomnia due to a medical condition.

Definition

Sleep-related dissociative disorders are parasomnias that can emerge from any stage of sleep, either at transition from wakefulness or within several minutes after awakening from non-rapid eye movement (NREM) sleep or rapid eye movement (REM) sleep.¹

Sleep-related dissociative disorders are also known as nocturnal (psychogenic) dissociative disorders, hysterical somnambulistic trance, and dissociative pseudoparasomnia. Dissociative identity disorder, dissociative fugue and dissociative disorder NOS (not otherwise specified) have been identified with sleep-related dissociative disorders.1,4,5

Etiology

Dissociation is a defense mechanism when other mature adaptive defenses fail. It is a primitive psychological defense wherein the distressing experience is kept apart from typical consciousness, resisting integration with the individual’s daily activities. These experiences may emerge as activity when environmental conditions are conducive or prompt them.⁶ The pathophysiology of dissociation is not clear. It is proposed that it is a functional disconnection among various brain regions. Sleep periods are vulnerable to a wide range of dissociative phenomena across all sleep stages and after arousals and full awakenings from all sleep stages.

Epidemiology

Women are more often affected than men. Onset ranges from childhood to adulthood. The course often remains chronic and severe. Events can occur several times weekly to multiple times nightly.¹

Signs and Symptoms

Most sleep-related dissociative disorders have corresponding daytime episodes of disturbed behavior, confusion, and associated amnesia. Additionally, patients with sleep-related dissociative disorder have often experienced⁷ combat,⁸ adult interpersonal violence⁹ or natural disasters.¹⁰ Dissociation is often associated with post-traumatic stress and is considered to be mainly a post-traumatic response.^8,10 Complications include injuries to the patient and/or bed partner, including ecchymoses, lacerations, fractures, and burns.¹

Diagnostic Criteria

Differential Diagnosis

PSG Findings

EEG wakefulness before, during and after the episodes. The alpha EEG rhythm with disorders of arousals and sleep-related dissociative disorders can be distinguished by looking at the lag time between EEG arousal and behavioral arousal. There is a lag time of 15 to 60 seconds in sleep-related dissociative disorder. There is no lag time in disorders of arousals.¹¹

Management

Comprehensive approach that includes cognitive-behavioral therapy, supportive psychotherapy, and post-traumatic disorder treatment.⁵

Early identification and intensive therapeutic interventions for dissociative symptoms in children appear to be particularly efficacious. A psychiatric treatment plan is helpful for supporting cognitive/emotional processing of trauma-related material in order to develop greater affect regulation capacities.¹⁰

Prognosis/Clinical Course

The course often remains chronic and severe.

Definition

Sleep enuresis is defined as recurrent involuntary voiding of urine occurring during sleep at least twice a week, for at least 3 consecutive months, in a child who is at least 5 years of age.¹ Sleep enuresis is considered primary in a child who has never been consistently dry for 6 consecutive months. It is considered secondary in a child who had previously been dry for 6 consecutive months and then began wetting at least twice a week for a period of at least 3 months.¹

Etiology

The exact etiology of primary sleep enuresis is unknown. Factors thought to contribute to persistent nocturnal incontinence after 5 years of age include: