Sleep Talking: Should you be Concerned?

Symptoms | Epidemiology | Causes | Differential Diagnosis/Comorbid Conditions 

Evaluation/Diagnosis | Management 

Overview

Sleep talking or nocturnal vocalization is quite common, especially in children, and is considered physiologic when experienced in isolation without disrupting sleep. 

These physiologic vocalizations are most commonly short phrases or sounds that occur in both rapid eye movement (REM) and non-rapid eye movement (NREM) sleep.[1]

About two-thirds of adults report having experienced sleep talking at some point in their lives.[2]

However, sleep talking is considered a parasomnia when it is disruptive of sleep or includes motor behaviors, indicating more severe sleep disorders. 

A parasomnia is any sleep disorder that involves altered nocturnal experiences or behaviors that disrupt sleep, with examples that include sleepwalking, night terrors, dream enactment, confusional arousals, and a variety of movements.[3,4]

Parasomnias include NREM arousal disorders like sleepwalking, night terrors, and confusional arousals, as well as REM sleep behavior disorder (RBD).[5]

While normal sleep talking occurs in REM and NREM sleep, sleep talking is more prevalent in patients with parasomnias.

Symptoms

Sleep talking often occurs during sleep transitions: from wakefulness to sleep, sleep to wakefulness, or during sleep stage transitions.[6]

Sleep vocalizations vary widely between individuals, differ by sleep stage, and can be simple or complex, ranging from simple sounds to entire conversations.[7][8]

Most often, vocalizations consist of just a few words, and negative terms (e.g., no, not) are the most common.[9]

Sleep talking is similar in syntax and semantics compared to awake talking and mimics conversational patterns, including turn-taking.[10]

This pattern is true for both healthy individuals experiencing physiologic sleep talking and those for which sleep talking is accompanied by parasomnia, such as RBD or sleepwalking.[11]

Symptoms might also include difficulty staying asleep, daytime fatigue, waking up disoriented, or not remembering vocalizations or accompanying nocturnal behaviors.

Epidemiology

Abnormal sleep behaviors, like sleep talking, are a common behavioral phenomenon in children in both males and females.[12]

Parasomnias are observed in 15-20 percent of children and about 4 percent of adults.[13, 14, 15, 16]

About two-thirds of adults report having experienced sleep talking at some point in their lives.[17] Those who report sleep talking as adults also experienced this behavior during childhood.[18]

In one study, 11.9 percent of children, aged 6-11 years, evaluated as part of the Tucson Children’s Assessment of Sleep Apnea study (TuCASA), experienced sleep talking, resolving in about half of the children five years later.[19]

Another study associated with TuCASA collected several objective measures (e.g., oxygen saturation, heart rate, breathing) using polysomnography. 

They similarly reported that 11.3 percent of children in the study experienced sleep talking at least five times per month. Importantly, data is based on parental recall and thus sleep talking may be underrepresented in the study population.  

Causes

Several factors can contribute to parasomnias, like sleep talking. Some examples of contributing or precipitating factors include poor sleep hygiene, sleep deprivation, disruption of the normal circadian rhythm, emotional stress, medications, and fever or other illness.[20]

A twin study determined that genetic influences accounted for 88-96 percent concerning sleep talking, with a minimal environmental contribution.[21] 

Differential Diagnosis/Comorbid Conditions

Most sleep vocalizations are considered normal variants. However, sleep talking can also accompany other injuries or parasomnias. [22, 23]

Sleep talking is a symptom of several parasomnias, including rhythmic movement disorder (RMD), RBD, confusional arousal, and catathrenia. 

For this reason, it is vital to work with your healthcare provider to determine whether experienced vocalizations are simply physiologic sleep talking or are a symptom of a more severe sleep disorder. 

Monotonous expiratory groaning during sleep may be indicative of the breathing disorder, catathrenia. This disorder is characterized by a distinct breathing pattern of prolonged expirations accompanied by groaning, primarily during REM sleep, which can be startling and distressing for bed partners. [24]

Sleep talking is more prevalent in patients with parasomnias, especially RBD. This sleep disorder is characterized by motor movements that occur during REM sleep due to a lack of atonia (i.e., muscle paralysis) that usually occurs during this sleep stage. [25, 26]

These episodes usually coincide with a dream resulting in dream enactment. Interestingly, the type of language used by sleep talkers differs based on accompanying parasomnias.[27, 28]

For example, patients experiencing RBD are more likely to have aggressive, violent speech with heavy use of expletives than those who experience sleepwalking.[29]

Sleep disruption, as a result of sleep talking, with or without comorbid parasomnias, can result in additional comorbidities. 

Indeed, in children, sleep talking is associated with chronic snoring and occasionally impaired learning and language development when sleep is disrupted.[30]

Sleep talking can also be associated with other cognitive disorders. Patients who have experienced traumatic brain injury commonly experience sleep behavior disorders, including sleep talking.[31]

Approximately one-third of those who experience sleep-related hypermotor epilepsy (SHE) experience, or have a family history of, other parasomnias, including sleepwalking and sleep talking.[32]

In patients with Parkinson’s disease, parasomnias are experienced at a much higher rate. Parkinson’s patients experience sleep talking at seven times the rate of other populations.[33]

Evaluation/Diagnosis

Evaluation involves patient- or bed partner-reported experiences of the nocturnal behaviors to first determine whether the behaviors pose a risk to the patient or others and then identify possible precipitating factors that may lead to episodes. 

Additionally, objective measures used for diagnosis might include overnight or multi-night monitoring or polysomnography (PSG), which involves monitoring respiration and abnormal changes in electroencephalography (EEG) and a review of video recordings. 

Sleep studies are indicated when accompanied by other factors, such as chronic snoring or other obstructive sleep apnea indicators. 

Management

In the absence of motor involvement, these episodes are unlikely to be dangerous; however, some sounds may help identify other potentially concerning conditions. 

For sleep talking behaviors that affect breathing, such as catathrenia, treatment with continuous positive airway pressure (CPAP) can be successful. 

If precipitating or priming events can be identified, patients can work to manage or avoid triggers. Many sleep behavior disorders are responsive to melatonin or clonazepam.[34, 35]

Conclusions

In most instances, sleep talking is a normal variant that poses little risk to patients. However, conditions such as catathrenia may be distressing to patients and sleeping partners and can be treated. If accompanied by chronic snoring or indicators of apnea, it is vital to have the person evaluated. If sleep talking is disrupting sleep or accompanied by nocturnal motor behaviors, seeking the aid of a healthcare provider is strongly advised.  

References:

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2. Bjorvatn, B., Grønli, J., & Pallesen, S. (2010). Prevalence of different parasomnias in the general population. Sleep medicine, 11(10), 1031–1034. https://doi.org/10.1016/j.sleep.2010.07.011
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10. Arkin, A. M., Toth, M. F., Baker, J., & Hastey, J. M. (1970). The frequency of sleep talking in the laboratory among chronic sleep talkers and good dream recallers. The Journal of nervous and mental disease, 151(6), 369–374. https://doi.org/10.1097/00005053-197012000-00002
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