Restless legs syndrome

General characteristics of parasomnias

Parasomnias are a group of motor, autonomic, or behavioral phenomena that are strictly chronologically tied to the sleep period (can occur during sleep onset, during sleep itself, or upon awakening). In neurological practice, it is important to understand that these conditions generally have a benign course. They do not indicate a serious psychiatric or neurological disease. Onset typically occurs in the prepubertal period (starting at 3–4 years of age). A characteristic feature of parasomnias is their capacity for spontaneous regression: symptoms independently subside and completely cease as the individual grows and the nervous system matures. In addition, in clinical practice, a clear family history is often traceable, indicating a possible genetic predisposition to these conditions.

Arousal disorders: confusion and sleepwalking

Common phenomena include confusional arousals (also known in clinical literature as "sleep drunkenness"). This condition can last from several minutes to several tens of minutes. During this period, the patient exhibits marked disorientation in both time and space. A temporary impairment of mnemonic functions, accompanied by a noticeable slowing of speech and thought activity, is typical. Productive contact with people around them is sharply limited at this moment, and the patient's behavior appears completely inadequate to the current situation.

Another classic manifestation is sleepwalking (somnambulism). It is characterized by unconscious motor activity directly during sleep: patients may simply sit up in bed or wander around the room. At the same time, movements appear discoordinated. Sleepwalking is often accompanied by vocalizations (somniloquy). As a rule, an episode of somnambulism ends quite favorably — either spontaneously when the patient returns to bed, or with the gentle assistance of others.

Sleep terrors and nightmares: differential diagnosis

It is extremely important to differentiate between sleep terrors and nightmares, as they have different pathogenesis and clinical presentation.

• Sleep terrors occur as a result of a sharp, unexpected awakening from non-REM sleep (NREM sleep). In children, the attack looks dramatic: the child suddenly wakes up with a loud scream or cry, demonstrating vivid autonomic markers of panic (tachycardia, tachypnea). At this moment, the child is completely unreachable for contact. Attempts to wake them only lead to increased confusion. The attack lasts up to several tens of minutes and invariably ends with a return to sleep. In the morning, there is complete amnesia for the attack. In adult patients, episodes of sleep terrors may be complicated by aggressive behavior. Therapy includes elimination of triggers, psychotherapy, and the prescription of sedatives.
• Nightmares are frightening, extremely vivid dreams that cause the patient to wake up from REM sleep. Unlike sleep terrors, nightmares occur episodically in the vast majority of healthy children aged 3 to 6 years. Treatment comes down to the normalization of the emotional background, psychotherapy, and the exclusion of stressful factors.

REM sleep behavior disorder

The pathogenesis of this syndrome is based on the loss of normal, physiological inhibition of motor system activity during rapid eye movement sleep. Normally, muscle atonia occurs during this phase, but in pathology, patients acquire the ability to literally "act out" and physically embody the plots of their dreams.

Motor activity can vary from simple, stereotyped twitches to complex, coordinated actions that are often aggressive in nature (punching, kicking). This creates a high risk of injury to both the patient and the sleeping partner. Characteristic feature: after waking up, the patient vividly remembers the details and plot of their dream, but at the same time completely amneses their own physical actions. Episodes may repeat many times in one night or occur rarely, at intervals of several months. The drug of choice for pharmacological correction (the most effective agent) is clonazepam. Pramipexole and melatonin preparations are used as alternatives.

Nocturnal enuresis: approaches to diagnosis and therapy

Nocturnal enuresis is defined as involuntary urination during sleep. This diagnosis becomes valid only if the child's age exceeds 4–5 years. Epidemiologically, the problem is quite relevant: up to the age of five, it is recorded in 20% of children. In the vast majority of patients, enuresis resolves spontaneously by age 15, but in 0.5–1% of individuals, it persists into adulthood.

Treatment is structured stepwise:

1. Non-pharmacological methods (first line): strict restriction of fluid intake in the evening, mandatory emptying of the bladder before going to bed. A particularly effective method is the use of an enuresis alarm («bedwetting alarm») — a special sensor device that generates a sharp acoustic signal at the slightest dampening of the bedding. This helps develop a stable reflex control over bladder filling.
2. Pharmacotherapy: prescribed exclusively when behavioral measures are ineffective. Anticholinergic drugs (e.g., Oxybutynin 2.5–5 mg at night) or tricyclic antidepressants (Imipramine 10–75 mg at night) are used.
3. Psychotherapy: high efficacy has been demonstrated with family psychotherapy sessions aimed at reducing anxiety within the family.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Physiology of sleep phase transitions and mechanisms of muscle atonia
• Autonomic manifestations in sleep terrors
• The role of anticholinergic agents in urology
• Cognitive-behavioral techniques for pelvic floor function control

Other topics in "Chapter 32. Sleep-Wake Disorders"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.