Journal of Sleep Disorders & Therapy
Open Access

The Role of Polysomnography in the Diagnosis of Adult Parasomnias

Natasha Greg^{* *}Correspondence: Natasha Greg, Department of Psychology and Behavioral Sleep Medicine, University of Sydney, Sydney, Australia, Email:

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Description

Parasomnias in adults represent a fascinating and often underappreciated category of sleep disorders that disrupt the boundary between sleep and wakefulness. They manifest as abnormal behaviors, emotions, perceptions, or dreams occurring during sleep or sleep-wake transitions. While many people are familiar with parasomnias in children, particularly conditions such as sleepwalking and night terrors that often diminish with age, the presence of parasomnias in adults poses unique diagnostic and therapeutic challenges. These phenomena not only affect the affected individual’s sleep quality but may also carry potential consequences for cohabitants, household members, and, in some cases, public safety.

REM parasomnias are particularly concerning in adults because they can manifest with vivid, often violent dream enactment behaviors. The most well-recognized condition in this category is REM Sleep Behavior Disorder (RBD), in which the normal muscle atonia of REM sleep is lost, allowing individuals to act out their dreams. These behaviors may include talking, shouting, thrashing, punching, or attempting to flee, often resulting in injury to the patient or their bed partner. RBD is especially significant because of its strong association with neurodegenerative diseases, particularly alpha-synucleinopathies such as Parkinson’s disease and dementia with Lewy bodies. In many cases, RBD precedes the onset of overt neurological symptoms by years or even decades, making it an important early biomarker of neurodegenerative risk.

Diagnosing parasomnias in adults requires a multifaceted approach that begins with a thorough clinical history. Patients themselves may provide limited or inaccurate accounts because of amnesia or partial awareness of their nocturnal behaviors, which makes collateral information from bed partners, roommates, or family members invaluable. A detailed sleep history should include the timing, frequency, duration, and nature of the episodes, as well as potential triggers such as sleep deprivation, alcohol use, medications, or stress. Clinicians must also consider comorbid sleep disorders, including obstructive sleep apnea and restless legs syndrome, both of which can exacerbate parasomnias by increasing arousals from sleep. Psychiatric comorbidities, particularly anxiety, depression, and post-traumatic stress disorder, often coexist with parasomnias and complicate both diagnosis and treatment. In some cases, distinguishing parasomnias from nocturnal seizures or other neurological disorders is crucial, requiring careful evaluation.

Polysomnography with extended video monitoring is the gold standard diagnostic tool for many parasomnias, especially when the diagnosis remains uncertain or when potentially injurious behaviors are reported. This modality is particularly essential for confirming REM Sleep Behavior Disorder, where loss of REM atonia can be objectively documented. However, because parasomnias often occur sporadically, capturing events during a single-night study may not always be feasible, highlighting the importance of combining polysomnographic data with detailed clinical reports and sleep diaries.

The management of parasomnias in adults is multifactorial and highly individualized, requiring both non-pharmacological and pharmacological strategies. One of the most important steps in management is the identification and elimination of precipitating factors. Sleep hygiene plays a central role, as sleep deprivation and irregular sleep schedules are among the strongest triggers of parasomnia episodes. Patients are advised to maintain consistent bedtimes and wake times, avoid alcohol and sedative medications, and manage stress effectively. Treating comorbid conditions, particularly sleep-disordered breathing, can also significantly reduce parasomnia frequency. For example, continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea has been shown to alleviate parasomnia symptoms in some cases.