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The result is a sudden start or bodily jerk of large amplitude, which rouses the incipient sleeper It may involve one or both legs or the trunk (less often, the arms) and may be associated with a frightening dream or sensory experience If the start occurs repeatedly during the process of falling asleep and is a nightly event, it may become a matter of great concern to the patient The starts are more apt to occur in individuals in whom the sleep process develops slowly; they are especially frequent under conditions of tension and anxiety Polygraphic recordings have shown that these bodily jerks occur at the moment of falling asleep or during the early stages of sleep Sometimes they appear as part of an arousal response to a faint external stimulus and are then associated with a frontal K complex in the EEG It is probable that some relationship exists between these brusque nocturnal jerks and the sudden isolated jerk of a leg, or arm and leg, that occurs occasionally in a healthy, fully conscious person These bodily jerks are not variants of epilepsy Nor should these somnolescent starts be referred to as nocturnal myoclonus, a term that has also been used incorrectly to designate the relatively mild, repetitive leg movements that occur during sleep, mainly in stages 3 and 4 (see above, under Insomnia ) A small proportion of otherwise healthy infants exhibit rhythmic jerking of the hands, arms, and legs or abdomen, both at the onset and in the later stages of sleep (benign neonatal myoclonus) The movements begin in the rst days of life and disappear within months There may be a familial tendency toward these movements Coulter and Allen differentiate this state from myoclonic epilepsy and neonatal seizures by the absence of EEG changes and its occurrence only during sleep Sensory Paroxysms Sensory centers may be disturbed in a similar way to the above described sleep starts, either as an isolated phenomenon or in association with motor phenomena The patient, dropping off to sleep, may be roused by a sensation that darts through the body, a sudden ash of light, or a sudden crashing sound or thunderclap sensation the exploding head syndrome (Pearce) Sometimes there is a sensation of being turned or lifted and dashed to the ground; conceivably these are sensory paroxysms involving the labyrinthine-vestibular mechanism A paroxysm of head pain (cephalalgia fugax) is yet another example Though apparent causes for concern by some patients, these sensory paroxysms are benign Nocturnal Paroxysmal Dystonia This is yet another parasomnic disorder, characterized by paroxysmal bursts of generalized choreoathetotic, ballistic, and dystonic movements occurring during NREM sleep (Lugaresi et al) Sometimes the patient appears awake and has a fearful or astonished expression, or there are repetitive utterances and an appearance of distress, similar to what is seen in night terrors, discussed further on The attacks may begin at any age, affect both sexes alike, and are usually nonfamilial Two forms of this disorder have been recognized: in one, the attacks last 60 s or less; they may be diurnal as well as nocturnal; some patients in addition have epileptic seizures of the more usual type; and all respond to treatment with carbamazepine The studies of Tinuper and coworkers, utilizing prolonged video-EEG monitoring, indicate that these brief attacks of nocturnal paroxysmal dystonia may actually be epileptic seizures of frontal lobe origin In a second and much rarer type, the attacks are longer lasting (2 to 40 min) Ictal and interictal EEGs during wakefulness and sleep are normal, and these attacks do not respond to anticonvulsants of any type Except for the lack of familial incidence and occurrence only during sleep,.

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the disorder is very much the same as the familial paroxysmal dystonic choreoathetosis decribed by Lance (see page 68) Sleep Paralysis Curious paralytic phenomena, referred to as preand postdormital paralyses, may occur in the transition from the sleeping to the waking state Sometimes in the morning and less frequently when falling asleep, otherwise healthy persons though awake, conscious, and fully oriented are seemingly unable to activate their muscles Respiratory and diaphragmatic function and eye movements are usually not affected, although a few patients have reported a sensation of being unable to breathe They lie as though still asleep, with eyes closed, and may become quite frightened while engaged in a struggle for movement They have the impression that if they could move one muscle, the paralysis would be dispelled instantly and they would regain full power It has been stated that the slightest stimulus, such as the touch of a hand or calling the patient s name, will abolish the paralysis Such attacks are observed in patients with narcolepsy (discussed later in this chapter) and with the hypersomnia of the pickwickian syndrome and other forms of sleep apnea Some cases are familial The weakness or paralysis is thought to be a dissociated form of the atonia of REM sleep Usually the attacks are brief (minutes) and transient; if they occur in isolation and only on rare occasions, they are of no special signi cance If frequent, as in narcolepsy, they can be prevented by the use of tricyclic antidepressants, particularly clomipramine, which has serotonergic activity Night Terrors and Nightmares The night terror (pavor nocturnus) is mainly a problem of childhood It usually occurs soon after falling asleep, during stage 3 or 4 sleep The child awakens abruptly in a state of intense fright, screaming or moaning, with marked tachycardia (150 to 170 beats per minute) and deep, rapid respirations Children with night terrors are often sleepwalkers as well, and both kinds of attack may occur simultaneously The entire episode lasts only a minute or two, and in the morning the child recalls nothing of it or only a vague unpleasant dream It has been suggested that night terrors and somnambulism represent impaired or partial arousal from deep sleep, since EEGs taken during such episodes show a waking type of mixed frequency and alpha pattern Children with night terrors and somnambulism do not show an increased incidence of psychologic abnormalities and tend to outgrow these disorders The persistence of such problems into adult life, however, is said to be associated with signi cant psychopathology (Kales et al) It has been said that diazepam, which reduces the duration of stages 3 and 4 sleep, will prevent night terrors Selective serotonin reuptake inhibitors have also been used successfully, especially when night terrors are associated with sleepwalking Frequent night terrors have reportedly been eliminated by having parents awaken the child for several successive nights, just prior to the usual time of the attack or at the rst sign of restlessness and autonomic arousal (Lask) Frightening dreams or nightmares are far more frequent than night terrors and affect children and adults alike They occur during periods of normal REM sleep and are particularly prominent during periods of increased REM sleep (REM rebound) following the withdrawal of alcohol or other sedative-hypnotic drugs that had suppressed REM sleep chronically Autonomic changes are slight or absent, and the content of the dreams can usually be recalled in considerable detail Some of these dreams (eg, the ones occurring in the alcohol-withdrawal period) are so vivid that the patient may later have dif culty in separating them from reality; indeed, they.

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The Set Status of Module Command (SET_MODULE_STATE) allows you to activate or deactivate a module from Web item Analysis at runtime in a Web application Depending on the settings in the module, this changes the standard display or the standard behavior of Web item Analysis The parameters to set up this function are listed and described in Table 6-11