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Arousal disorders can be dangerous, but still no consensus on best treatment

If you have sleep apnea or insomnia, sleep specialists have well-vetted guidelines for the best evidence-based treatments. Not so if you have arousal disorders, which include sexsomnia (engaging in sexual activity during sleep), sleep “walking” (walking or running around the house or even doing complex behaviors like driving a car), sleep terrors (screaming and intense fear while asleep), or sleep eating. 

If you have sleep apnea or insomnia, sleep specialists have well-vetted guidelines for the best evidence-based treatments. Not so if you have arousal disorders, which include sexsomnia (engaging in sexual activity during sleep), sleep “walking” (walking or running around the house or even doing complex behaviors like driving a car), sleep terrors (screaming and intense fear while asleep), or sleep eating. 

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Unlike nearly every other type of sleep disorder, there are no consensus treatment guidelines for arousal disorders, says Jennifer Mundt, assistant professor of neurology at Northwestern University Feinberg School of Medicine. 

In a study in Sleep Medicine (The title of the paper is “Behavioral and psychological treatments for NREM parasomnias: A systematic review.”), Mundt did the first systematic review on treating NREM (non-rapid eye movement) parasomnias. Many of the 72 publications from 1909 to 2023 were only case reports or uncontrolled trials. 

“These disorders can be dangerous and result in injuries to the sleeper or loved ones, so it’s important that symptoms are evaluated and treated,” Mundt said. “And we need to have guidelines, so patients are getting the most effective treatment, which is not necessarily a medication.”

Randomized, controlled trials are needed to determine the efficacy of behavioral treatments for these parasomnias, Mundt said.

In the study, Mundt found the treatments with the most evidence about their effectiveness are cognitive behavioral therapy, hypnosis, sleep hygiene and scheduled awakenings (waking the sleeper shortly before the time they usually have a parasomnias episode). 

Patients often don’t recall their unusual night behaviors, or they may have only a vague recollection of it.

“Some people don’t know they have it or what’s going on with them at night,” Mundt said. “They may not come into a sleep clinic until they’ve injured themselves. Or, they say, ‘My kitchen had all these wrappers on the counter, so I know I was eating.’

“I’ve had some people video themselves at night, trying to confirm what’s happening. It’s unsettling to not know what you are doing in your sleep. I’ve seen people who have ended up in the emergency room with cuts or lacerations from punching a window or mirror or wall.

“I’ve had people who have taken medication in their sleep or eaten so much they feel sick the next morning. The brain tends to want to eat junk food, like salty, sweet and fatty snacks. Some people eat so much they feel uncomfortable or gain weight. One colleague had a patient who ate a whole block of cheese in their sleep.”

The estimated lifetime prevalence for parasomnias is 6.9% for sleepwalking, 10% for sleep terrors, 18.5% for confusional arousals, 7.1% for sexsomnia, and 4.5% for sleep-related eating. Sleepwalking, sleep terrors and confusional arousals (when someone is in a confused state while remaining in bed) are more common in childhood and often remit by adolescence. Sexsomnia and sleep-related eating typically begin in adulthood. 

“Doctors often tell parents their children will grow out of it. But not everyone grows out of it,” Mundt said.

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