Current perspectives on sleep-related injury, its updated differential diagnosis and its treatment

This article provides an update on the differential diagnosis of sleep-related behavior disorders (viz. parasomnias) that cause nocturnal injury, including life-threatening injury to self or bedpartner. A catalog of nocturnal injuries is provided. Current treatments are discussed. Guidelines are given on the assessment of injurious nocturnal behaviors. Extensive polysomnographic (PSG) monitoring and comprehensive clinical evaluations are required for the proper diagnosis (and any comorbidity) to be identified and the appropriate treatment(s) to be initiated. In 1989, a report on a series of 100 adults with recurrent sleep-related injuries identified five disorders as being responsible for the nocturnal injuries: disorders of arousal (sleepwalking/sleep terrors [SW/ST]: NREM parasomnias); rapid-eye movement (REM) sleep behavior disorder (RBD); nocturnal dissociative disorders; nocturnal seizures; and obstructive sleep apnea/periodic limb movements. Other disorders known to cause sleep-related injuries include nocturnal eating disorders; nocturnal scratching disorders; rhythmic movement disorders; bruxism; cerebral anoxic attacks; drug intoxication and withdrawal states; and Munchausen syndrome by proxy. Five types of nocturnal seizures can cause sleep-related injury: complex partial seizures; frontal lobe seizures; paroxysmal nocturnal dystonia; episodic nocturnal wandering; and paroxysmal periodic motor attacks. Malingering, which is not a psychiatric disorder, can also produce the complaint of sleep-related injury. Treatment of injurious parasomnias is usually effective and safe, even with long-term, nightly treatment. Benzodiazepines, particularly clonazepam, are the cornerstone of treating injurious SW/ST and RBD, and are effective adjuncts in the treatment of various other parasomnias. Parasomnias are rarely a direct manifestation of a psychiatric disorder, and when co-morbidity is present, treatment of the psychiatric disorder alone does not usually control the parasomnia. Conversely, pharmacotherapy of psychiatric disorders can induce or exacerbate parasomnias. Parasomnias represent striking examples of dissociated states of mind and behavior surrounding sleep, and their scientific understanding requires a close interlinking of clinical and basic research. Parasomnias inherently carry forensic implications, which are discussed in this article.