eMedicine Specialties > Psychiatry > Adult

Parasomnias: Differential Diagnoses & Workup

Author: Sat Sharma, MD, FRCPC, FACP, FCCP, DABSM, Program Director, Associate Professor, Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Manitoba; Site Director of Respiratory Medicine, St Boniface General Hospital
Contributor Information and Disclosures

Updated: Apr 4, 2007

Differential Diagnoses

Anxiety Disorders
Obstructive Sleep Apnea-Hypopnea Syndrome
Panic Disorder
Posttraumatic Stress Disorder
Sleep Disorder, Geriatric

Other Problems to Be Considered

Dissociative fugue
Epilepsy
Hypnagogic hallucinations
Sundowning

Workup

Laboratory Studies

  • No specific lab studies are necessary for parasomnias. The only studies that could be helpful are those related to the differential diagnosis, such as studies for substance abuse or evidence of medical illnesses that could mimic a parasomnia.
  • For RLS and PLMD, a CBC count should be performed to exclude anemia as an underlying cause. Even in the absence of microcytic anemia, serum ferritin and serum iron levels should be measured to estimate iron stores. These tests should be followed by appropriate investigations to elicit the cause of the iron-deficiency anemia.

Imaging Studies

  • Imaging studies generally are of little utility in diagnosing a parasomnia. Their usefulness is only in determining the presence of a source for the medical illness that may be causing the parasomnia.

Other Tests

  • Polysomnography may be indicated for some of the parasomnias but not all of them. Episodes of sleepwalking and sleep terrors arise abruptly during arousals from stage III and IV of NREM sleep. Postarousal EEG may show the persistence of sleep, the admixture of sleep and wakefulness, or complete wakefulness.
  • Polysomnogram of patients with REM sleep behavior disorder exhibits loss of REM atonia on submental EMG findings. Limb twitching also may be present on EMG findings. One must exclude epileptiform EEG activity during REM sleep.
    • When the differential diagnosis includes sleep-related epilepsy, polysomnography with an extended montage should be performed.
    • Otherwise, the hallmark of the various parasomnias is whether they occur during REM sleep, at the sleep-wake transition, or during slow-wave sleep.
  • Formal sleep studies are not indicated in most cases of RLS. However, PLMD is diagnosed primarily by using a polysomnographic study.
    • PLMDs are recognized by EMG findings, both of the anterior tibialis muscles are recorded.
    • The EMG findings may show a single contraction or a cluster of several contractions. A sequence of at least 4 muscle contractions that last 0.5-5 seconds and occur at 4- to 90-second intervals establishes the diagnosis.
    • The muscle twitches are associated with electroencephalographic signs of arousal, such as K complex followed by alpha activity, which may either precede or follow muscular contractions.
    • A PLMD index (ie, number of periodic limb movements per hour of sleep) of more than 5 per hour is considered abnormal.
    • The PLMD primarily occurs during stages I and II of NREM sleep and generally varies from night to night.
    • The frequency of PLMD is greatly increased in the first half of the night and then wanes.
    • Actigraphy may be useful in quantifying PLMD but lacks reliable validation data for widespread clinical use.
    • A suggested immobilization test (SIT) can be performed in the awake state. The patient lies in bed motionless, and repetitive leg movements are counted to assess severity of RLS. This test needs further validation before it can be considered a reliable diagnostic tool.

Procedures

No procedures are indicated.

    More on Parasomnias

    Overview: Parasomnias
    Differential Diagnoses & Workup: Parasomnias
    Treatment & Medication: Parasomnias
    Follow-up: Parasomnias
    Multimedia: Parasomnias
    References
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    References

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    Further Reading

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    Keywords

    nightmare disorder, sleep terror disorder, sleepwalking disorder, rapid eye movement sleep behavior disorder, REM sleep behavior disorder, non–rapid eye movement, NREM, restless legs syndrome, RLS, periodic limb movement disorder, PLMD, dyssomnias, sleep drunkenness, microsleeps

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    Contributor Information and Disclosures

    Author

    Sat Sharma, MD, FRCPC, FACP, FCCP, DABSM, Program Director, Associate Professor, Department of Internal Medicine, Divisions of Pulmonary and Critical Care Medicine, University of Manitoba; Site Director of Respiratory Medicine, St Boniface General Hospital
    Sat Sharma, MD, FRCPC, FACP, FCCP, DABSM is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
    Disclosure: Nothing to disclose.

    Medical Editor

    Mohammed Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System
    Mohammed Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association
    Disclosure: Nothing to disclose.

    Pharmacy Editor

    Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
    Disclosure: Nothing to disclose.

    Managing Editor

    Iqbal Ahmed, MD, Program Director, General and Geriatric Psychiatry Residency Programs, Department of Psychiatry, Vice Chair for Education, Professor, John A Burns School of Medicine, University of Hawaii
    Iqbal Ahmed, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, American Association for Geriatric Psychiatry, and American Psychiatric Association
    Disclosure: Nothing to disclose.

    CME Editor

    Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry, Assistant Professor, Department of Medicine, Froedtert Hospital, Medical College of Wisconsin
    Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association
    Disclosure: lilly Honoraria Speaking and teaching; BMS Honoraria Speaking and teaching; Forest Labs Honoraria Speaking and teaching; AstraZeneca Honoraria Speaking and teaching; Pfizer Grant/research funds Other; Northstar Grant/research funds Other; Novartis  Other

    Chief Editor

    Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA
    Stephen Soreff, MD is a member of the following medical societies: American College of Mental Health Administration
    Disclosure: Nothing to disclose.

     
     
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