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Official reprint from UpToDate®

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Approach to abnormal movements and behaviors during

sleep
Author: Bradley V Vaughn, MD
Section Editor: Alon Y Avidan, MD, MPH
Deputy Editor: April F Eichler, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: May 2022. | This topic last updated: Mar 10, 2022.

INTRODUCTION

Abnormal movements and behaviors during sleep are part of a larger group of nocturnal
events that may occur during sleep, wake, or the transitions into or out of sleep. These events
are most common early in life, affecting approximately 15 to 20 percent of children and 4
percent of adults [1-4].

Nocturnal events are typically divided into simple behaviors (eg, single movements, repetitive
or periodic movements, rhythmical movements) and complex behaviors (eg, sleep talking,
sleepwalking, sleep terrors, dream enactment) ( table 1).

A detailed history, including a clear description from the patient and ideally a bed partner or
caregiver witness, is the cornerstone of establishing clues about the underlying etiology. The
challenge for the clinician is to recognize when certain nocturnal events signal an underlying,
treatable disorder, an emerging neurological abnormality, or a benign age-appropriate episode.

An approach to the evaluation and diagnosis of abnormal movements and behaviors during
sleep is presented here. Additional topics on the diagnosis and treatment of specific
parasomnias, sleep-related movement disorders, and other paroxysmal neurological events in
both children and adults can be found elsewhere. (See "Parasomnias of childhood, including
sleepwalking" and "Disorders of arousal from non-rapid eye movement sleep in adults" and
"Rapid eye movement sleep behavior disorder" and "Clinical features and diagnosis of restless

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legs syndrome and periodic limb movement disorder in adults" and "Restless legs syndrome
and periodic limb movement disorder in children" and "Sleep-related epilepsy syndromes".)

TYPES OF NOCTURNAL EVENTS

Classification — Although classification and nomenclature of sleep-related movements and

behaviors have varied over time, most schema attempt to classify behaviors according to the
type of movement (ie, simple or complex) and the underlying sleep physiology, ie, whether
movements are associated with transitions of sleep and wake, non-rapid eye movement
(NREM), or rapid eye movement (REM) sleep ( table 1).

Most simple movements occur during the transition from wake to sleep or sleep to wake or
during light, NREM sleep ( figure 1). Complex behaviors can result from disruption of the
control mechanisms of the three normal states of being: wake, NREM sleep, and REM sleep.

Occasionally, simple or complex motor patterns during sleep are a manifestation of seizures,
dissociative psychiatric events, or even physiological states such as hypoglycemia. Therefore,
clinicians should be aware that nocturnal events may be a manifestation of specific neurologic,
medical, psychiatric, or sleep disorders. On the other hand, some of these behaviors,
specifically the disorders of arousal and nightmares, may be normal in childhood.

Simple or single movements — Simple movements during sleep are typically quick, single
movements involving only one body area ( table 2A). They tend to occur in the transition
periods between sleep and wakefulness ( figure 1) and are classified by the International
Classification of Sleep Disorders, Third Edition (ICSD-3), as movement disorders of sleep [1].

● Hypnic jerks – Hypnic jerks are a common example of simple sleep-related movements.
They consist of a sudden, brief jerk of the whole body or one or more segments at sleep
onset, often associated with the sense of falling. Hypnic jerks can occur at any age and are
a benign phenomenon, sometimes related to sleep deprivation or excessive caffeine or
other stimulant intake.

Some hypnic jerks are accompanied by sensory phenomena, most commonly a kinetic
sensation of falling but sometimes a brief visual, auditory, or tactile sensation. These
sensory starts or sleep-related hallucinations can also occur without a motor
accompaniment. Such symptoms can be distressing to patients and may lead to sleep
avoidance or delayed sleep onset.

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● Exploding head syndrome – A more dramatic, multisensory phenomenon that also

occurs at sleep onset is called exploding head syndrome, consisting of a painless
sensation of head explosion [5-9]. The ICSD-3 classifies this event under "other
parasomnias," but due to its clinical features, it is sometimes confused with a headache
syndrome or even subarachnoid hemorrhage. There is typically no actual movement
associated with this phenomenon, but in one case series, two-thirds of individuals noted
muscle jerks or twitches, and over 80 percent noted tachycardia or sense of fear [8].

● Propriospinal myoclonus – Propriospinal myoclonus at sleep onset consists of flexion or

extension jerks in the abdomen, trunk and/or neck during relaxed wakefulness and
drowsiness, as an individual attempts to fall asleep. Propriospinal myoclonus that persists
throughout the day has been linked to spinal cord pathology in a minority of patients;
however, there is no evidence that propriospinal myoclonus that is limited to sleep onset is
associated with structural nervous system damage. Magnetic resonance imaging (MRI) of
the spine is usually normal, but approximately one fifth of patients may show focal lesions
of unclear significance [1]. (See "Symptomatic (secondary) myoclonus", section on
'Propriospinal myoclonus'.)

● Epileptic myoclonus – Sudden jerks of the limbs that occur with waking or soon after
waking in children or adolescents may represent epileptic myoclonic jerks, a type of
seizure that is common in patients with juvenile myoclonic epilepsy (JME). These patients
usually have other types of generalized seizures as well; with careful history taking, nearly
all patients with JME have myoclonic seizures, but almost never in isolation. (See "Juvenile
myoclonic epilepsy", section on 'Clinical features'.)

● Benign sleep myoclonus of infancy – Benign sleep myoclonus of infancy, also called
benign neonatal sleep myoclonus, refers to brief jerks of the limbs during NREM sleep in
young infants. The jerks are usually bilateral and symmetric. They typically occur during
the first few weeks of life and resolve by two to three months of age. The movements are
benign but can be confused with seizures. However, unlike the jerks of myoclonic seizures
or severe myoclonic epilepsy syndromes of infancy, benign myoclonus occurs exclusively
during sleep, does not continue when the infant is awoken, and is associated with normal
neurologic development. (See "Nonepileptic paroxysmal disorders in infancy", section on
'Benign neonatal sleep myoclonus'.)

● Bruxism – Bruxism (teeth grinding) consists of quick jerks or grinding movements

involving the muscles of mastication. Bruxism typically occurs at sleep onset or in
association with arousals from sleep and may recur multiple times per night. Primary
consequences include dental pathology, temporomandibular joint dysfunction, and
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morning headaches. (See "Sleep-related bruxism (tooth grinding)" and "Polysomnography

in the evaluation of abnormal movements during sleep", section on 'Sleep-related
bruxism'.)

● Nocturnal leg cramps – Nocturnal leg cramps are painful, sustained muscle contractions,
most commonly in the calf, foot, or thigh, that may occur at any time during the night.
They typically last from seconds to minutes and are relieved by forceful stretching of the
affected muscles. The main differentiating feature compared with other sleep-related leg
movements is the presence of sustained muscle contraction. (See "Nocturnal leg cramps".)

Periodic or rhythmic movements — Periodic or rhythmic movements that may occur in or

around sleep include body or head rocking or banging, hypnagogic foot tremor, and periodic
limb movements of sleep ( table 2B).

● Sleep-related rhythmic movement disorder – Rhythmic movements involving large

muscle groups at sleep onset (eg, body rocking and rolling, head rocking and rolling) may
occur in early childhood as the child is trying to fall asleep. In most cases, the movements
are not associated with significant clinical consequences and are considered
developmentally normal.

When the movements or behaviors significantly interfere with normal sleep or daytime
function, or result in self-harm or injury, they are classified as a sleep-related rhythmic
movement disorder [1]. Sleep-related rhythmic movement disorder rarely occurs in
adolescents and adults, sometimes in association with other sleep disorders such as
obstructive sleep apnea or restless legs syndrome (RLS), in which case it may improve with
treatment of the sleep disorder, or in association with affective and neurodevelopmental
disorders [10].

● Hypnagogic foot tremor – Hypnagogic foot tremor is a rapid, rhythmic movement of one
foot that occurs at the onset of sleep or during light NREM sleep. It is believed to be a
physiologic phenomenon; in one series of 375 consecutive adults undergoing
polysomnography for other reasons, hypnagogic foot tremor was noted in 8 percent of
patients and was not associated with disrupted sleep [11].

Alternating leg muscle activation (ALMA) is a related phenomenon that consists of brief
activation of the anterior tibialis in one leg in alternation with similar activity in the other
leg during sleep or arousals from sleep [1]. Most individuals are unaware of the
movements. ALMA has been identified primarily in patients with sleep-related breathing
disorders and periodic limb movements. There may be an association with antidepressant
use.
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● Periodic limb movements of sleep – Periodic limb movements of sleep are episodes of
repetitive and highly stereotyped limb movements occurring every 5 to 90 seconds,
primarily during the first half of the night and during NREM sleep. Most people who have
periodic limb movements do not have any symptoms associated with them. They occur
with increased frequency in older adults with and without other sleep or neurologic
disorders. In particular, most patients with RLS have evidence of these movements in
sleep. (See "Clinical features and diagnosis of restless legs syndrome and periodic limb
movement disorder in adults", section on 'Periodic limb movements of sleep' and
"Polysomnography in the evaluation of abnormal movements during sleep", section on
'Periodic limb movements of sleep'.)

Complex movements and behaviors (parasomnias) — Complex movements and behaviors

during sleep, or parasomnias, encompass common or bizarre behaviors as well as seemingly
purposeful movements, perceptions, dreaming, and autonomic output during sleep or sleep
transitions. While the simple movements described above tend to occur during the transition
between sleep and wakefulness, more complex behaviors may occur in a variety of sleep states.

The ICSD-3 categorizes parasomnias into three major groups: events associated with NREM
sleep, events associated with REM sleep, and other parasomnias [1].

During NREM sleep — Events associated with NREM sleep include disorders of arousal (eg,
sleepwalking, sleep terrors, confusional arousals) and sleep-related eating disorder ( table 2C
).

● Disorders of arousal – Sleepwalking, confusional arousals, and sleep terrors are a mixture
of NREM sleep and wake states, such that the features of the two states are combined [1].
These disorders represent a continuum of behaviors evoked from deep NREM sleep,
possibly related to compromised ability to inhibit or fully permit arousal from sleep
[12,13]. All three are characterized by minimal cognitive functioning, amnesia for the
events, and features of appearing awake, such as eyes open. Some patients report a
memory of vague, visual imagery and auditory impressions.

Events are often triggered by stimuli, occur after acute sleep deprivation or psychosocial
stressors, and involve a variety of nonstereotyped behaviors. Sleep-disordered breathing
events such as an apnea or other sleep disorders may also serve as a trigger. Disorders of
arousal occur most commonly in children and adolescents. (See "Parasomnias of
childhood, including sleepwalking", section on 'Clinical features' and "Disorders of arousal
from non-rapid eye movement sleep in adults".)

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● Sleep-related eating disorder (SRED) – SRED is similar to other disorders of arousal and
occurs due to a mixture of wake and NREM sleep. SRED is characterized by episodes of
recurrent involuntary and amnestic eating during the sleep period. Patients often
consume peculiar forms of food (eg, raw hamburger, cake mix) with partial or no memory
of the event. In many cases, SRED may be related to treatment with a hypnotic agent or a
comorbid sleep disorder such as RLS. (See "Disorders of arousal from non-rapid eye
movement sleep in adults", section on 'Sleep-related eating disorder'.)

SRED should be differentiated from night eating syndrome (NES), which is characterized by
recurrent episodes of evening hyperphagia and middle-of-the-night eating, resulting in a
delay in the circadian pattern for eating [14]. (See "Eating disorders: Overview of
epidemiology, clinical features, and diagnosis", section on 'Unspecified feeding or eating
disorder'.)

During REM sleep — REM sleep-related parasomnias include recurrent isolated sleep
paralysis, nightmares, and REM sleep behavior disorder (RBD) ( table 2C).

● Recurrent isolated sleep paralysis – Recurrent isolated sleep paralysis is characterized

by the intrusion and persistence of REM sleep-related atonia into wakefulness [13,15].
Patients with sleep paralysis experience partial or complete inability to move or call out,
and many will have a dramatic sense of impending doom or urgency to flee. Individuals
may remember these events for years. Some events are accompanied by hallucinations,
often visual or a sense of a presence in the room. Although sleep paralysis can occur as
part of the classic narcolepsy tetrad, in most cases, sleep paralysis is an isolated symptom
and is related to sleep deprivation. (See "Clinical features and diagnosis of narcolepsy in
adults", section on 'Clinical features'.)

● Nightmare disorder – Complex visual imagery during REM sleep is the hallmark of
nightmare disorder. Nightmares are distressing dreams that have an emotional carryover
into wakefulness. While nightmares usually do not have a motor component, they may
end abruptly with the patient screaming or, less frequently, experiencing a sudden jerk or
brief movement [16,17]. True, more complex or violent dream enactment is not consistent
with nightmare disorder, but is what defines RBD. RBD is more common in older men and
is strongly prognostic of neurodegeneration. Nightmares should also be distinguished
from sleep terrors ( table 3). (See "Parasomnias of childhood, including sleepwalking",
section on 'Sleep terrors' and "Nightmares and nightmare disorder in adults" and
"Disorders of arousal from non-rapid eye movement sleep in adults", section on 'Sleep
terrors'.)

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● REM sleep behavior disorder (RBD) – RBD is characterized by complex movements or

behaviors during REM sleep ("dream-enactment behavior") that occur due to a pathologic
loss of muscle paralysis (atonia) that normally occurs during REM sleep (associated with
REM sleep without atonia [RSWA] on polysomnography). The movements often
correspond to a dream in which the individual is being attacked or needs to defend
him/herself [18,19]. Movements range from relatively brief limb or chin movements to
more complex, violent movements such as punching, leaping out of bed, or yelling.
Associated vocalization is common, and language may be laden with expletives. (See
"Rapid eye movement sleep behavior disorder", section on 'Clinical features'.)

RBD is most commonly seen in older males in association with Parkinson disease, multiple
system atrophy, and dementia with Lewy bodies [18,19]. The disorder may predate other
symptoms of alpha-synuclein neurodegeneration (ie, alpha-synucleinopathies) by decades
[20]. In younger patients, the distribution across sexes is more equal, and narcolepsy or
medications (particularly the serotonergic antidepressants) are often implicated [21]. (See
"Rapid eye movement sleep behavior disorder", section on 'Etiology'.)

Vocalization — Vocalization during sleep is a common nocturnal event. Vocalization can be

simple or more complex and can be associated with a variety of sleep-related movements and
behaviors, both physiologic and pathologic.

Most vocalizations are utterances or short phrases, such as those seen in the normal variant of
sleep talking. Talking can also be a feature of the disorders of arousals (sleepwalking, sleep
terror, or confusional arousals) or RBD. The key distinction between physiologic sleep talking
and disorders of arousal or REM sleep is the inclusion of other motor behaviors.

Monotonous expiratory groaning during sleep may indicate a sleep-related breathing disorder
called catathrenia. Catathrenia is characterized by prolonged expirations, primarily during REM
sleep, that can be very distressing to the bed partner and caregivers [22]. The disorder can be
treated with continuous positive airway pressure (CPAP).

Nocturnal epilepsy — The differential diagnosis of abnormal movements or behaviors during

sleep includes nocturnal seizures. While a generalized tonic clonic seizure out of sleep is usually
obvious by history and not easy to confuse with a sleep disorder (bilateral tonic clonic
movements, often with tongue biting and/or urinary incontinence, postictal drowsiness and
confusion), some patients have focal seizures involving stereotyped, complex behaviors that
occur predominantly or exclusively at night.

Behaviors associated with epileptic seizures can range across a wide spectrum and they can be
difficult to distinguish from parasomnias. The main clue that events are seizures rather than
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parasomnias is the stereotyped nature of seizures [23,24]. Sleep-related hypermotor epilepsy,

previously called nocturnal frontal lobe epilepsy, is one example of an epilepsy syndrome
involving predominantly nocturnal seizures with complex behaviors [25]. Onset of seizures is
typically in late childhood or adolescence but can occur in adulthood. These events can be very
complex and appear volitional or bizarre, and patients may have more than one type of event,
each with stereotypic behavior. Electroencephalography (EEG) is often normal during
wakefulness. (See "Sleep-related epilepsy syndromes", section on 'Nocturnal (sleep-related)
focal epilepsies'.)

As discussed above, brief myoclonic jerks upon awakening are another type of seizure that
occurs in relation to sleep-wake transitions, usually in association with juvenile myoclonic
epilepsy. (See 'Simple or single movements' above.)

Panic or dissociative events — Some psychiatric symptoms, such as panic or dissociative

events, occur during the night [26-29]. In the majority of patients, however, symptoms are not
limited to the sleep period. Most patients with dissociation or panic have diurnal symptoms, a
history of traumatic events, or other symptoms of major mood disorders [30]. (See "Disorders
of arousal from non-rapid eye movement sleep in adults", section on 'Others'.)

EVALUATION

The goal of the evaluation of a patient with abnormal movements or behaviors during sleep is
threefold:

● Obtain a clear historical description of the events from an observer, including a direct
description from a bed partner when possible

● Assess whether the patient is at risk for harm to self or others as a result of the
movements or behaviors and note their frequency and severity

● Determine possible priming, precipitating, or predisposing factors that may facilitate the
episodes (ie, untreated primary sleep disorder such as obstructive sleep apnea (OSA), or a
new medication that was temporally associated with the events)

History — Clinical features are the cornerstone of differentiating nocturnal events (

table 2A-C). In addition to the event description, the history should also focus on recognition
of any provocative or predisposing factors (eg, family history of parasomnia or epilepsy, sleep
deprivation, medications, certain medical or neurologic disorders) and clues to an underlying
sleep disorder.

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Event description — Eye witness descriptions are of fundamental importance to the

diagnosis. Patients presenting for an evaluation of nocturnal events should be encouraged to
bring an observer of the events with them, or the observer should be available for a conference
call during the visit.

An event description should be obtained from a bed partner when possible, as many nocturnal
events cannot be recalled by the individual. The witness should be asked to describe or even act
out the behaviors that occur during the events to help identify important features such as eyes
being open or closed, posturing of one hand, specific facial posture, or stereotypic behavior.
Patients and witnesses also should be asked if the events have caused injury or near-harm to
self or others.

In addition to the behavioral characteristics of the events, historical features that can help
distinguish the type of event include the following:

● Time of night – The time of night when events occur is a clue to the sleep stage out of
which the event arises ( figure 1). (See "Stages and architecture of normal sleep", section
on 'Sleep staging'.)

• Simple movements, such as hypnic starts, occur during the transition from drowsiness
to sleep, or in the early stages of non-rapid eye movement (NREM) sleep.

• For more complex movements and behaviors, the timing may provide a clue to
whether the event is a disorder of arousal (associated with NREM sleep, which
predominates in the first hour or two of the sleep period) or rapid eye movement (REM)
sleep behavior disorder (RBD, associated with REM sleep, which predominates in the
second half of the sleep period).

• Nocturnal seizures and psychiatric events can occur at any time of night. However,
seizures very rarely occur during REM sleep due to protective effects of muscle atonia
and electroencephalography (EEG) desynchronization.

● Duration of the event – This can help distinguish NREM from REM complex behaviors.

• Most movements associated with RBD are brief, lasting seconds (and rarely beyond a
minute). Disorders of arousal can last seconds to several minutes.

• Frontal lobe seizure duration is more variable: some seizures are brief (eg, posturing
lasting several seconds), whereas others may consist of bizarre behaviors lasting from
30 to 60 seconds.

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• Prolonged events (ie, lasting over thirty minutes to an hour) are more likely psychiatric
in origin.

● Variable versus stereotyped behaviors – Events that have the same behavior each time
(stereotypic and monomorphic), especially at the start of the events, are more likely to be
seizures, with some exceptions (eg, rhythmic movement disorder, periodic limb
movements). Events that vary in behavior (polymorphic) from one event to the next are
less likely to be seizures.

● Eyes open or closed – Most disorders of arousal (eg, sleepwalking, night terrors) are
associated with open eyes, whereas the complex movements and behaviors of RBD are
associated with closed eyes.

● Memory recall – Most patients with RBD have reasonable dream recall that is congruent
with the semiology of the behaviors performed. Patients with disorders of arousal have
either partial recall or no recall of the events. Patients with seizures may have recall if the
events are brief, the patient awakens, and the seizure does not involve both hippocampi;
once both hippocampi are involved, however, the patient may not have complete memory
for the event.

● Age of onset – Most of the NREM-related parasomnias begin during early childhood and
resolve by adolescence. By contrast, RBD primarily affects older adults, usually males,
except when the disorder is related to medications (eg, antidepressants) or another sleep
disorder such as narcolepsy.

● Family history of nocturnal events – Many of the disorders of arousal (eg, sleepwalking,
night terrors) are hereditary, and a family history of similar events in siblings or parents
can provide reassurance of the benign nature of the events. Some forms of sleep-related
epilepsy also have a strong genetic component. (See "Sleep-related epilepsy syndromes".)

There are several partially-validated questionnaires that can help identify patients with specific
parasomnias or distinguish among types of parasomnias.

● The Mayo Sleep Behavior Questionnaire is a 16-item questionnaire designed to predict the
likelihood of RBD as well as other disorders (eg, restless legs syndrome) [31]. It is available
online for clinical use. The single question, "Have you ever seen the patient appear to 'act
out his or her dreams' while sleeping?", has also been validated in a community-based
sample [31].

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● The Frontal Lobe Epilepsy and Parasomnia (FLEP) scale can help to distinguish frontal lobe
seizures from parasomnias and may be helpful in directing which study to order next [32].
Those with scores suggesting frontal lobe epilepsy may benefit from video EEG recording,
while those more likely to have parasomnia should have video polysomnography.
Although somewhat helpful, the scale has a significant gray zone that demonstrates its
limitations for seizures originating from locations other than the frontal lobe and some
parasomnias.

Provocative and predisposing factors — Some nocturnal events can be provoked or

exacerbated by poor sleep quality, medications, or other related factors. The history should
include questions about a broad range of possible provocative factors, such as [1]:

● Poor sleep hygiene

● Sleep deprivation
● Circadian rhythm disturbances (eg, jet lag)
● Fever or other illnesses
● Emotional stress
● Medication use
● Ingestion of alcohol or sedatives before sleep onset

If provocative factors are not immediately obvious, patients with nocturnal events should be
asked to keep an event diary listing events and any associated changes in activity, medications,
herbs, supplements, or other potentially inciting issues.

A variety of nocturnal events can be caused or exacerbated by medications or other neurologic,

psychiatric, or medical disorders [33-38]. Some sedative-hypnotics, especially those with short
half-lives, such as the nonbenzodiazepine benzodiazepine receptor agonists (eg, zolpidem,
zaleplon, eszopiclone), have been implicated in initiating complex sleep-related behaviors such
as sleep-related eating, sleepwalking, and even driving [33]. These medications now carry a US
Food and Drug Administration (FDA) warning about the potential for these events, which have
included rare cases of serious injury including death [39]. (See "Pharmacotherapy for insomnia
in adults", section on 'Nonbenzodiazepine BZRAs' and "Disorders of arousal from non-rapid eye
movement sleep in adults", section on 'Clinical manifestations'.)

Medical problems that provoke arousals, such as chronic obstructive pulmonary disease
(COPD), hypoglycemia, gastroesophageal reflux, congestive heart failure, or renal disease, and
neurologic issues ranging from head trauma, brain tumors, and encephalitis, have been
reported to initiate complex sleep-related movements or behaviors.

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A family history of similar events may be relevant for some nocturnal events. Genetic factors
play a role in disorders of arousal from NREM sleep, particularly sleepwalking, as well as in
some sleep-related epilepsy syndromes. (See "Disorders of arousal from non-rapid eye
movement sleep in adults", section on 'Pathophysiology and genetics'.)

Symptoms of other sleep disorders — Patients with abnormal movements in sleep should
also be questioned regarding symptoms of other sleep disorders, which can exacerbate
nocturnal events. The history should therefore probe for symptoms of specific sleep disorders:

● Obstructive sleep apnea – Does the patient have loud snoring or witnessed pauses in
breathing (apneas)? Are there other symptoms or risk factors suggestive of OSA, such as
obesity? Sleep apnea can aggravate disorders of arousal, bruxism, epilepsy, and rhythmic
movement disorder. (See "Clinical presentation and diagnosis of obstructive sleep apnea
in adults", section on 'Clinical features'.)

● Narcolepsy – Particularly in patients who describe sleep paralysis or dream enactment

behavior, are there additional cardinal features of narcolepsy such as inability to maintain
sleep at night and wakefulness during the day, cataplexy, daytime sleep attacks, and
hypnagogic hallucinations? (See "Clinical features and diagnosis of narcolepsy in adults",
section on 'Clinical features'.)

● Periodic limb movement disorder – Patients are usually unaware of periodic limb
movements of sleep, and therefore bed partners should be queried. Such patients should
also be asked about associated daytime symptoms such as impaired functioning or
excessive daytime sleepiness. (See "Clinical features and diagnosis of restless legs
syndrome and periodic limb movement disorder in adults", section on 'Diagnosis'.)

Physical examination — Most individuals presenting with abnormal movements or behaviors

during sleep will have a normal physical and neurologic examination. The goal of the exam is to
detect any signs of trauma from the events themselves (eg, tooth wear associated with
bruxism, bruises or injuries from complex sleep-related behaviors) and to detect signs of an
underlying medical or neurologic disorder that may be associated with the events.

A history suggestive of a disorder of arousal such as sleepwalking should prompt a search for
signs of a sleep-fragmenting disorder such as OSA (eg, elevated blood pressure, increased body
mass index, crowded airway, enlarged tonsils, large neck circumference).

Individuals with dream enactment behaviors suggestive of RBD or older adults with nighttime
confusion should be screened for depression and have a complete neurologic examination to
look for signs of cognitive impairment, cogwheeling, lack of arm swing, mask-like facies,
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orthostatic hypotension, hypokinesis, or other features of parkinsonism [23,40]. Patients

suspected of having epileptic seizures also should be evaluated for focal neurologic findings,
suggesting a cerebral hemisphere lesion.

Overnight video polysomnography — In-laboratory, overnight polysomnography (PSG) can

provide important information in determining the etiology of the nocturnal events, with the
goal of capturing the physiology of each sleep state and evaluating the possibility of other
contributing sleep disorders [1]. While many patients can be diagnosed and treated based on
the history alone, overnight PSG should be obtained if the history is atypical (eg, unusual age of
onset, high frequency of events, stereotypic behaviors, or a mixture of symptoms), if the patient
reports significant daytime sleepiness, when other sleep disorders are suspected (eg, OSA,
narcolepsy), or the patient is at risk for harming themselves or others ( table 4) [41]. Home
sleep apnea testing (HSAT) is not informative for the evaluation of complex movements during
sleep.

PSG performed to investigate nocturnal events should include all of the following components
(see "Polysomnography in the evaluation of abnormal movements during sleep"):

● Complete respiratory monitoring

● Time-synchronized high definition video monitoring
● Electromyographic recording from all four limbs ("expanded EMG/RBD/parasomnia
montage")
● A complete 10-20 set of cephalic EEG electrodes
● Ability to extensively review the electroencephalogram

Patients with disorders of arousal are relatively unlikely to have events in the laboratory but
may demonstrate suggestive PSG features such as continuation of slowing, or prolonged sleep
inertia (partial and prolonged confusion) when arousing from slow wave sleep [42,43]. Patients
with RBD more commonly have events in the laboratory and demonstrate increased muscle
activity in isolated muscle groups, such as the forearm musculature, during REM sleep, often
exceeding established norms for REM sleep. (See "Rapid eye movement sleep behavior
disorder", section on 'Video polysomnography'.)

The presence of wakefulness on PSG prior to and during the nocturnal events may suggest a
dissociative disorder, although panic events may occur out of light sleep.

Other testing — Neuroimaging is not necessary in the majority of patients presenting with
abnormal movements or behaviors during sleep. One exception may be when the nocturnal
behavior was temporally related to a neurologic event (eg, stroke or multiple sclerosis
exacerbation).
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A magnetic resonance imaging (MRI) study of the brain and referral to neurology is indicated in
patients diagnosed with nocturnal seizures as part of a broader evaluation to determine the
underlying etiology. When the diagnosis of seizure is in doubt, sleep-deprived EEG and
ambulatory or inpatient video EEG monitoring may be useful. (See "Seizures and epilepsy in
children: Clinical and laboratory diagnosis" and "Evaluation and management of the first
seizure in adults" and "Video and ambulatory EEG monitoring in the diagnosis of seizures and
epilepsy".)

Neuroimaging should also be considered when the onset of a parasomnia is associated with
abnormal neurologic signs or symptoms, as rare cases of secondary RBD or narcolepsy related
to pathologic processes in the diencephalon or rostral pons have been described. (See "Rapid
eye movement sleep behavior disorder", section on 'Pontine lesions' and "Clinical features and
diagnosis of narcolepsy in adults", section on 'Secondary narcolepsy'.)

As RBD may be a prodromal symptom of neurodegeneration, patients with events consistent

with the disorder should undergo a careful neurologic examination and may require additional
studies depending upon the clinical context (eg, structural and/or metabolic neuroimaging,
neuropsychological testing, formal neurology consultation). (See "Rapid eye movement sleep
behavior disorder", section on 'Evaluation'.)

In very rare cases, new REM and NREM parasomnias are a presenting sign of an autoimmune
encephalopathy due to antibodies against IgLON5 [44], which can be detected in serum and/or
cerebrospinal fluid. Such patients typically have accompanying symptoms of gait instability,
dysarthria, dysautonomia, and bulbar dysfunction [45]. (See "Paraneoplastic and autoimmune
encephalitis", section on 'Anti-IgLON5 disease'.)

MANAGEMENT

Management strategies vary according to the type of movement or behavior, its frequency and
severity, and whether or not an underlying sleep or other medical or neurologic disorder is
present.

Specific parasomnias — Simple sleep-related movements such as hypnic starts and

infrequently occurring disorders of arousal (eg, sleepwalking, confusional arousals, sleep
terrors) rarely need to be treated. Patients should be educated about triggers for events,
including sleep deprivation, and counseled about ensuring a safe sleep environment.
Medications that may be implicated in the behaviors (eg, serotonergic antidepressants for rapid
eye movement (REM) sleep behavior disorder (RBD), short-acting hypnotics for complex sleep-

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related behaviors) should be discontinued if possible. RBD tends to be very responsive to either
melatonin or clonazepam, and all patients should be educated about maximizing
environmental safety (eg, removing sharps from the bedroom). (See "Parasomnias of childhood,
including sleepwalking", section on 'Management' and "Disorders of arousal from non-rapid eye
movement sleep in adults", section on 'Management' and "Rapid eye movement sleep behavior
disorder".)

Sleep-related movement disorders — Patients with periodic limb movements associated with
arousals and significant daytime sleepiness can respond to pharmacologic therapy with a
gabapentinoid, dopamine agonist, or other medications used to treat restless legs syndrome.
(See "Management of restless legs syndrome and periodic limb movement disorder in adults",
section on 'Periodic limb movement disorder'.)

Ongoing movements or behaviors, unclear diagnosis — For most parasomnias and

abnormal movements, however, patients will continue to have minor occurrences, despite
medication or behavioral modification. The overarching goal of therapy is to keep the patient
and others safe from current and future harm. If there are minor residual movements that do
not impact safety, patients should be reassured and clinicians should resist the urge to over-
treat.

Treatment of patients with ongoing, frequent abnormal nocturnal movements or behaviors can
be challenging. Clinicians may find themselves baffled as to how to proceed or what metric to
use to determine success. One simple tool is the event diary. Patients or caregivers can keep a
log of the events, including the timing of the event during the night, duration, and substances
used. In this way, potential provocative factors can be examined for possible linkage. The
patient or bed partner can be asked to grade the severity of the event, noting if the patient was
at risk for harm, or if the event was disruptive to the bed partner or caregiver. This simple
mechanism connects the patient as an active participant in the process of guiding therapy.

Some patients do not respond to therapy. For these patients, the event calendar may also
provide further clues leading to an alternative diagnosis or underlying treatable sleep disorder.
The history described above should be repeated in order to identify additional clues (see
'History' above):

● Patients with very frequent events may benefit from video electroencephalography (EEG)
monitoring, so that several events can be captured and analyzed in more detail.

● In patients with disorders of arousal, the re-emergence of events may signal new or
worsening sleep apnea or inadequate therapy of a medical disorder that is causing
frequent arousals from sleep.
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● Confusional events at night in older adults may be a sign of medication intolerance or

progression of an underlying neurocognitive disorder.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Parasomnias,
hypersomnias, and circadian rhythm disorders".)

SUMMARY AND RECOMMENDATIONS

● Timing in relation to sleep – Abnormal movements and behaviors during sleep are part
of a larger group of nocturnal events that may occur during wakefulness, the transition
into or out of sleep, or during sleep itself. Most sleep-related movement disorders and
parasomnias have a relationship with a particular sleep stage or transition period in the
sleep-wake cycle ( figure 1). (See 'Introduction' above.)

● Classification of events – Events can be initially characterized into brief or simple events
versus events that contain more complex behaviors such as talking, multipart movements,
and emotional expression ( table 1).

• Simple and/or periodic movements or sensory events ( table 2A and table 2B) are
usually not associated with major pathophysiological consequences, although they
may be distressing to patients. Examples include hypnic jerks, exploding head
syndrome, sleep-related bruxism (teeth grinding), body rocking, and period limb
movements of sleep. (See 'Simple or single movements' above and 'Periodic or
rhythmic movements' above.)

• Complex events typically require further investigation to determine the underlying

etiology and possible link to other sleep, medical, neurologic, or psychiatric disorders (
table 2C). Examples include sleepwalking, confusional arousals, sleep terrors, and
rapid eye movement (REM) sleep behavior disorder. (See 'Complex movements and
behaviors (parasomnias)' above.)

● History – A clear description of the events is key to the evaluation of all abnormal
movements and behaviors during sleep. The history should include a detailed description
of the witnessed movements or behaviors, timing during the night ( figure 1), duration,

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and frequency of the event, the individual's memory for the event, dream recall, whether
eyes are open or closed, and any stereotypic features. (See 'Event description' above.)

Bed partners and patients may also note certain provocative factors such as sleep
deprivation, alcohol, medications, or stimuli associated with the events. Other key
characteristics include age of onset, family history for similar events, and symptoms of
other neurologic, medical, psychiatric, or sleep disorders. (See 'Provocative and
predisposing factors' above and 'Symptoms of other sleep disorders' above.)

● Indications for polysomnography – Video polysomnography with extended

electroencephalography (EEG) is useful when the history is atypical, when there are
symptoms suggestive of an underlying sleep or neurologic disorder, or the patient or bed
partner is at risk for injury ( table 4). (See 'Overnight video polysomnography' above.)

● Management – Management strategies vary according to the type of movement or

behavior, its frequency and severity, and whether or not an underlying sleep or other
medical or neurologic disorder is present. (See 'Management' above.)

• Patients should be educated about common triggers for events, including sleep
deprivation and alcohol, and counseled about ensuring a safe sleep environment.

• Effective pharmacologic therapy is available for certain disorders, such as REM sleep
behavior disorder (RBD). (See 'Specific parasomnias' above.)

• Simple sleep-related movements such as hypnic starts and infrequently occurring

disorders of arousal (eg, sleepwalking) do not need to be treated. Clinicians should
resist the urge to over-treat while monitoring the character and frequency of events
over time. (See 'Ongoing movements or behaviors, unclear diagnosis' above.)

Use of UpToDate is subject to the Terms of Use.

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Topic 97850 Version 16.0

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GRAPHICS

Classification of abnormal sleep-related movements

Simple movements
Involving quick jerks of limbs or body

Hypnic jerks

Propriospinal myoclonus

Benign myoclonus of infancy

Epileptic myoclonus

Isolated or nonperiodic limb movements

Involving muscles of mastication

Bruxism

Facial myoclonus

Palatal myoclonus

Prolonged contractions

Leg cramps

Periodic movements
Of the limbs

Periodic limb movements

Rhythmical movements
Of the limbs

Hypnic foot tremor

Alternating leg muscle activation

Of the body or head

Rhythmical movement disorder of sleep (body rocking, juxta capita)

Vocalizations
Monotonous (groaning)

Catathrenia

Utterances of talking
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Without other movements

Sleeptalking – normal variant

With movements (see "Complex movements and behaviors" below)

Complex movements and behaviors: Nonstereotyped

NREM sleep-related parasomnias

Disorders of arousal (from NREM sleep)

Confusional arousals

Sleepwalking

Sleep terrors

Sleep-related eating disorder

REM-related parasomnias

REM sleep behavior disorder

Recurrent isolated sleep paralysis

Nightmare disorder

Other parasomnias

Exploding head syndrome (sensory)

Sleep-related hallucinations (sensory)

Sleep enuresis

Parasomnia due to a medical disorder

Parasomnia due to a medication or substance

Psychogenic events originating in sleep

Panic attacks

Dissociative events

Complex movements: Stereotyped

Epileptic seizures

Psychogenic events (sometimes)

NREM: non-rapid eye movement; REM: rapid eye movement.

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Timing of sleep-related movements and behaviors throughout the sleep period

REM: rapid eye movement.

* Examples include hypnic jerks, hypnagogic foot tremor, periodic limb movements, and sleep-related rhyth

¶ Disorders of arousal from non-REM sleep include confusional arousals, sleep-related abnormal sexual beh
sleepwalking, and sleep-related eating disorder.

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Simple or single movements during sleep: Distinguishing clinical features

Benign
Propriospinal Explod
Hypnic sleep Nocturnal
Bruxism myoclonus at head
jerk myoclonus leg cramp
sleep onset syndro
of infancy

Behavior Quick single Sudden Brief jerks, Sudden jerk, Sustained Painless
jerk with or closure of usually typically in the muscle sensatio
without jaw or bilateral and trunk, neck, and contraction explosio
tactile, grinding of symmetric limbs the head
kinetic, teeth may be
visual, or associat
auditory with a
sensation startle
moveme

Age of onset Any Any Infancy Childhood or Childhood Adulthoo

adulthood or
adulthood

Family No Variable Variable No Variable No

history

Time of Sleep onset Sleep onset Any time Light NREM Any Usually n
occurrence or upon during sleep sleep sleep on
resumption but can
of sleep variable

Frequency Variable Multiple Multiple per Multiple per Variable Rare

per night night night

Duration Milliseconds Seconds Milliseconds Milliseconds Up to Seconds

several
minutes

Memory of Yes No No Yes Yes Yes

event

Stereotypical Yes No No No No Yes (sim

movements sensatio
each tim

PSG findings Sudden jerk Temporalis Brief Brief myoclonus Prolonged Usually
at sleep and myoclonus in NREM sleep muscle occurs in
onset masseter contraction light slee
activation,
rhythmic
periodic
chin
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muscle
artifact

Associated None Clenching None Can be seen in None None

clinical (benign) sound, (benign) individuals with (benign)
findings tooth wear, spinal cord
scars inside pathology
cheeks and
tongue

PSG: polysomnogram.

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Periodic or rhythmic movements during sleep: Distinguishing clinical

features

Sleep-related
Periodic limb Hypnagogic foot rhythmic
movements tremor and ALMA movement
disorder

Behavior Repetitive movement Rapid rhythmical Rhythmical movement

of limbs, typically legs, movement of one foot (rocking or rolling) of
most commonly with or alternating body or head
triple flexion movement of legs

Age of onset Any Any Early childhood

Family history Variable Unknown Variable

Time of occurrence First half of the night; Near sleep onset Before sleep onset
most commonly during
NREM sleep

Frequency Multiple per night Nightly Nightly

Duration 0.5 to 5 seconds Usually 4 to 15 Seconds to hours

seconds, may recur

Memory of event Variable Variable Yes

Stereotypical Yes Yes Yes

movements

PSG findings Periodic limb Limb movements Rhythmical movement

movements of sleep artifact near sleep
onset

Associated clinical Commonly seen in None (benign) May be seen in normal

findings association with children
restless legs syndrome

ALMA: alternating leg muscle activation; PSG: polysomnogram.

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Complex movements during sleep: Distinguishing clinical features

Sleep- Recurrent
Disorders REM sleep
related REM isolated
of behavior
eating nightmares sleep
arousal disorder
disorder paralysis

Behavior Confused, Eating high Sometimes Vivid, Inability to Varia

semi- caloric or combative, disturbing move with pani
purposeful unusual violent dream dreams, may preservation sym
movement foods with enactment with end with a of eye and
with eyes eyes open eyes closed sudden jolt or diaphragmatic
open jerk movement

Age of onset Childhood Variable Older adults Childhood or Variable Adol

or adulthood adul
adolescence

Family Yes Unknown No No No No

history

Time of First third of First half of During REM Second half of Upon Any
occurrence night night sleep the night awakening
most
common
(during REM
sleep)

Frequency Once per Variable Variable; a few May be Variable, less Varia
night but times per month nightly than weekly
not every to nightly
night

Duration Minutes Minutes Seconds to a Movement Seconds to a Varia

minute lasts seconds minute minu

Memory of Usually Usually Fragmentary to Yes Yes Non

event none none, or full dream recall

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limited

Stereotypical No No No No No No
movements

PSG findings Arousals Arousal Excessive EMG Awakening Arousal from Occu
from slow- from NREM tone during REM out of REM REM sleep state
wave sleep sleep sleep sleep
appearing
distressed

Associated May Morning May be May be None (benign) Othe

clinical indicate anorexia, associated with associated unde
findings another unexplained parkinsonism, with stress, diso
problem weight gain, narcolepsy, or psychological anxi
causing comorbid medications trauma, or
arousals RLS (antidepressants) medication
(eg, sleep effect
apnea)

REM: rapid eye movement; PSG: polysomnogram; NREM: non-REM; EMG: electromyography; RLS:
restless legs syndrome.

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Key clinical features of sleep terrors versus nightmares

Characteristic Sleep terror Nightmare

Timing during the night First third (deep slow wave Last third (REM sleep)
sleep)

Presentation of fear During the event After the event

behaviors

Movements Common Rare

Severity Severe Mild

Vocalizations Common Rare

Autonomic (sympathetic) Severe and intense Mild

output

Amnesia Present Absent

State on waking Confused/disoriented Normal

Injuries or violence Common Rare

Displacement from bed Common Very rare

REM: rapid eye movement.

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Indications for video polysomnography in patients with nocturnal events

Atypical presentation for a parasomnia (time of night, behavioral description)

Events are injurious or have significant potential for injury or significant disturbance to patient's
home life

Unusual age of onset

Unusual frequency of the events

Patient has excessive daytime sleepiness or complaints of insomnia

Complaints suggestive of sleep apnea, periodic limb movements, or other sleep disorders

Events are stereotyped or repetitive

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Contributor Disclosures
Bradley V Vaughn, MD Speaker's Bureau: American Academy of Neurology[Sleep, Epilepsy and General
Neurology];American Academy of Sleep Medicine[Sleep, Epilepsy and General Neurology];Medical
Education Resources[Sleep, Epilepsy and General Neurology]. All of the relevant financial relationships
listed have been mitigated. Alon Y Avidan, MD, MPH Consultant/Advisory Boards: Avadel
Pharmaceuticals [Narcolepsy];Eisai Pharma [Insomnia];Harmony Biosciences [Narcolepsy];Idorsia
Pharmaceuticals [Insomnia];Jazz Pharmaceuticals [Narcolepsy];Merck Pharmaceuticals [Insomnia].
Speaker's Bureau: Eisai Pharma [Insomnia];Harmony Biosciences [Narcolepsy];Merck Pharmaceuticals
[Insomnia]. All of the relevant financial relationships listed have been mitigated. April F Eichler, MD,
MPH No relevant financial relationship(s) with ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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