Clinical Features and Pathophysiology of Disorders of Arousal in Adults: A Window Into the Sleeping Brain

Abstract

Introduction: Disorders of Arousal (DoA) are NREM parasomnias that have been typically regarded as self-limited childhood manifestations. It is now clear that DoA can persist in adults, often presenting with distinctive characteristics. So far, few studies have described the clinical course and characteristics of DoA in adulthood, therefore a large part of their semiology is ignored. The aim of this study is to describe the clinical manifestations of DoA in an adult population and to provide a pathophysiological interpretation of their features. Methods: We screened our database for all 1,600 adult (≥15 years) patients with sleep-related motor behaviors between 1995 and 2016. We identified 45 patients with typical DoA episodes, of whom a complete history, neurological examination and diagnostic video-polysomnography (VPSG) were available. All patients provided a detailed description of their episodes (with particular regards to semiology, frequency, and association with stressful life events) in different life periods. VPSG recordings were reviewed and DoA episodes were identified and assigned to three different categories according to their complexity. Results: Our population was composed of 45 adult patients ranging between 15 and 76 years. Sleepwalking was reported by 86% of patients, possibly associated with complex interactions with the environment and violent behaviors in 53% of cases; distressing mental contents were reported by 64%. Recall of the episodes was reported in 77% of patients. Non-restorative sleep was reported in 46% of patients. Stress was a potential episode trigger in 80% of patients. VPSG recordings documented 334 DoA episodes. According to our classification of motor patterns, 282 episodes (84%) were Simple Arousal Movements (SAMs), 34 (10%) Rapid Arousal Movements (RAMs) and 18 (5%) Complex Arousal Movements (CAMs). Discussion: Our study confirms that DoA in adulthood present with distinctive characteristics, such as non-restorative sleep, violence and complex, or bizarre behaviors. Alternative classifications of DoA based on motor patterns could be useful to characterize DoA episodes in adults, as different motor patterns often coexist in the same individual and minor episodes are more common but generally underreported by patients. Prospective studies are needed for a definitive characterization of DoA in adulthood throughout the life course.

Parasomnias, sleep-related movement disorders and physiological sleep variants in focal epilepsy: A polysomnographic study

“…In our sample we only found a positive association between DoA and younger age as described in the general population [28]. However, being a retrospective study, we were not able to reconstruct the anamnestic data of DoA in childhood and we could only rely on PSG findings which are rarely able to record the more complex behaviors of DoA, especially in adults [33]. Regarding sleep-related movement disorders, except for PLM which has been extensively studied, the other disorders have been poorly investigated in relation with epilepsy [13].…”

Behavioural and emotional profiles of children and adolescents with disorders of arousal

“…Finally, at a thorough semi‐structured interview, about 60% of patients and/or their parents subjectively connected nocturnal clinical episodes to stressful diurnal situations. Although a longitudinal study capturing the reciprocal fluctuations of perceived stress and DOA episodes’ severity has not been conducted and might pose several methodological issues, a hint in this direction comes also from a recent retrospective analysis, where stress emerged as a potential episode trigger in 80% of adult patients with typical DOA episodes (Baldini et al., 2019). An older observational study found that stress or argument were precipitating factors in 58% of subjects in an adult sample (Oudiette et al., 2009).…”

Differentiating Oneiric Stupor in Agrypnia Excitata From Dreaming Disorders

“…Of them, 29 (64%) reported frightening and distressing contents, variably alternating with neutral contents in four of them. Fearful contents included someone chasing or trying to kill the patient, the ceiling falling on the patient, a truck running over the patient, mice infesting the house, being inside a box from which it was impossible to escape, a fire, walls crashing during an earthquake, thieves entering the house or a fox in the room ( 136 , 137 ).…”