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may merge with the hallucinations of delirium tremens Nightmares are of little signi cance as isolated events Fevers dispose to them, as do conditions such as indigestion and the reading of bloodcurdling stories or exposure to terrifying movies or television programs before bedtime Some patients report nightmares when rst taking certain medications such as beta blockers, and particularly in our experience, L-dopa We have also consulted on a few patients who complain of almost nightly nightmares and concurrent severe headaches, but without apparent depression or other psychiatric illness; the nature of their problem is obscure Persistent nightmares may be a pressing medical complaint and are often accompanied by other behavioral disturbances or neuroses Somnambulism and Sleep Automatism This condition occurs far more commonly in children (average age, 4 to 6 years) than in adults and is often associated with nocturnal enuresis and night terrors, as indicated above It is estimated that 15 percent of children have at least one episode of sleepwalking, and that 1 in 5 sleepwalkers has a family history of this disorder Motor performance and responsiveness during the sleepwalking incident vary considerably The most common behavioral abnormality is for a patient to sit up in bed or on the edge of the bed without actually walking When walking about the house, he may turn on a light or perform some other familiar act There may be no outward show of emotion, or the patient may be frightened (night terror), but the frenzied, aggressive behavior of some adult sleepwalkers, described below, is rare in the child Usually the eyes are open, and such sleepwalkers are guided by vision, thus avoiding familiar objects; the sight of an unfamiliar object may awaken them Sometimes they make no attempt to avoid obstacles and may injure themselves If spoken to, they make no response; if told to return to bed, they may do so, but more often they must be led back Sometimes they repeatedly mutter strange phrases or perform certain repetitive acts, such as pushing against a wall or turning a doorknob back and forth The episode lasts for only a few minutes, and the following morning they usually have no memory of it or only a fragmentary recollection A popular belief is that the sleepwalker is acting out a dream The observations of sleep laboratories are at variance with this view, since somnambulism has been found to occur almost exclusively during stage 4 of NREM sleep and during the rst third of the night, when stage 4 sleep is most prominent and dreaming is least likely to occur In fact, the entire nocturnal sleep pattern of such individuals does not differ from normal Also, there is no evidence that somnambulism is a form of epilepsy It is probably allied to talking in one s sleep, although the two conditions seldom occur together Sleepwalking must be distinguished from fugue states and ambulatory automatisms of complex partial seizures (page 277) The major consideration in the treatment of childhood somnambulism is to guard patients against injury by locking doors and windows, removing dangerous objects from the patients usual routes of march, having them sleep on the ground oor, etc Children usually outgrow this disorder; parents should be reassured on this score and disabused of the notion that somnambulism is a sign of psychiatric disease Somnabulism in Adults The onset of sleepwalking or night terrors in adult life is most unusual and suggests the presence of psychiatric disease or drug intoxication Almost always, the adult sleepwalker has a history of sleepwalking as a child, although there.

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may have been a period of freedom between the childhood episodes and their re-emergence in the third and fourth decades Adult somnambulism also occurs during stages 3 and 4 of NREM sleep but, unlike the childhood type, need not be con ned to the earlier part of the night Somnambulism in the adult, as in the child, can be a purely passive event unaccompanied by fear or other signs of emotion More frequently, however, the attack is characterized by frenzied or violent behavior associated with fear and tachycardia, like that of a night terror and sometimes with self-injury Very rarely, crimes have been committed during sleepwalking; there is some anecdotal evidence that large bedtime doses of psychotropic or sedative drugs may have induced this phenomenon (Luchins et al), but the authors are skeptical that organized and planned sequential activity is possible The nding of normal sleep patterns on polysomnography distinguishes these attacks from complex partial seizures They can be eliminated or greatly reduced by the administration of clonazepam (05 to 10 mg) at bedtime Some patients respond better to a combination of clonazepam and phenytoin or to urazepam (Kavey et al) Half-waking somnambulism, or sleep automatism, is a closely related disorder in which an adult, half-roused from sleep, goes through a fairly complex series of purposeful but inappropriate acts, such as going to a window, opening it, and looking out, but afterward recalling the episode only vaguely and partially REM Sleep Behavior Disorder This is a more recently recognized parasomnic disorder, occurring in adult life, most commonly in older men without a history of childhood sleepwalking It is characterized by attacks of vigorous and often dangerous motor activity accompanied by vivid dreams (Mahowald and Schenck) The episodes are of varying frequency, occurring once every week or two or several times nightly The characteristic features are angry speech with shouting, violent activity with injury to self and bedmate, a very high arousal threshold, and the detailed recall of a nightmare of being attacked and ghting back or attempting to ee The violent episodes, which occur exclusively during REM sleep, are out of keeping with the patient s waking personality Polysomnographic recordings during these episodes have disclosed augmented muscle tone (ie, absence of atonia) but no seizure activity The rare appearance of this disorder with pontine infarctions has been mentioned (page 340) In a series of 93 cases of REM sleep behavior disorder reported by Olson et al, more than half were associated with some other neurologic disorder, such as Parkinson disease, multiple system atrophy, and dementia These episodes can be suppressed by the administration of clonazepam in doses of 05 to 10 mg at bedtime Discontinuation of medication, even after years of effective control, has resulted in relapse.

Nocturnal Epilepsy (See also Chap 16)

These commands are also found in the standard Web template 0ANALYSIS_PATTERN I think at this point a list of these commands will be sufficient There is very little difference between these commands and what you read in the preceding Commands for Web Items section Just as the name conveys, these commands are for the actual Web template, whereas the other commands were for specific parts of the Web items The commands for Web templates that you can create with the command wizard are listed and described in Table 6-12, along with their parameters