Sleepwalk (Somnambulism)

Sleepwalking may include sitting up, walking around, and doing complex activities while appearing awake.

Sleepwalking is characterized by a complex action behavior (walking) during sleep. Occasionally, the person may talk, but it does not make sense. The person's eyes are commonly open, but have a characteristic glassy "look right through you" character.

Sleepwalking activities may include simply sitting up and appearing awake while remaining asleep, getting up and walking around, or complex activities such as moving furniture, going to the bathroom, dressing, and undressing, and similar activities. Some people even drive a car while asleep. The episode can be very brief (a few seconds or minutes) or can last for 30 minutes or longer. Upon waking, the sleepwalker has no memory of his or her behaviors.

Sleepwalking most commonly occurs during early childhood and less commonly during adolescence.

Sleepwalking has been described in medical literature dating before Hippocrates (460 BC-370 BC). In Shakespeare's tragic play, Macbeth, Lady Macbeth's famous sleepwalking scene ("out, damned spot") is ascribed to her guilt and resulting insanity as a consequence of her involvement in the murder of her father-in-law.

One common misconception is that a person sleepwalking should not be awakened. It is not dangerous to awaken a sleepwalker, although it is common for the person to be confused or disoriented for a short time when awake.

Another misconception is that a person cannot be injured while sleepwalking. Injuries caused by sleepwalking, for example, tripping and loss of balance, are common.

Sleepwalking seems to be associated with inherited (genetic), environmental, physiologic, and medical factors.

Genetic factors

One study documented that sleepwalking is ten times more likely if a first-degree relative has a history of sleepwalking.

Environmental factors

Sleep deprivation, chaotic sleep schedules, fever, stress, magnesium deficiency, and alcohol intoxication can trigger sleepwalking. Drugs, for example, sedatives/hypnotics (drugs that promote sleep), neuroleptics (drugs used to treat psychosis), minor tranquilizers (drugs that produce a calming effect), stimulants (drugs that increase activity), and antihistamines (drugs used to treat symptoms of allergies) associated with an increased likelihood of sleepwalking.

Physiologic factors

Physiologic factors that may contribute to sleepwalking include:

• The length and depth of slow wave sleep (stages III and IV of non-REM sleep). These stages are more commonly seen in younger children and thus may explain the age differences in the frequency of sleepwalking.
• Conditions such as pregnancy and menstruation are known to increase the frequency of sleepwalking.
• Arrhythmias (abnormal heart rhythms)
• Fever
• Gastroesophageal reflux (acid reflux or GERD - food or liquid regurgitating from the stomach into the food pipe)
• Nighttime asthma
• Nighttime seizures (convulsions)
• Obstructive sleep apnea (a condition in which breathing stops temporarily while sleeping)
• Psychiatric disorders, for example, posttraumatic stress disorder (PTSD), panic attacks, or dissociative states (for example, multiple personality disorder)

When is sleepwalking most common?

While most frequent in children (2 to 14 percent), sleepwalking is typically a benign, self-limited maturational occurrence and often decreases with the onset of puberty. However, at least 25 percent of children with recurrent sleepwalking may continue the disorder into adulthood. Chronic sleepwalking in children is often associated with other subtle sleep disorders, behavioral problems, and poor emotional regulation.

The following are examples of symptoms of sleepwalking:

• Episodes range from quiet walking around the room to agitated running or attempts to "escape." The person sleepwalking may appear clumsy and dazed in his or her behavior.
• Typically, the eyes are open with a glassy, staring appearance as the person quietly roams around the house. However, they do not walk with their arms extended in front of them as is inaccurately depicted in movies.
• On questioning the person's sleepwalking, responses are slow with simple thoughts and contain nonsense phraseology or absent responses. If the person is returned to bed without awakening, they usually do not remember the event.
• Older children, who may awaken more easily at the end of an episode, often are embarrassed by the behavior (especially if it is inappropriate). Instead of walking, some children perform repeated behaviors (such as straightening their pajamas). Bedwetting may also occur.
• Sleepwalking is not associated with previous sleep problems, sleeping alone in a room or with others, fear of the dark (achluophobia), or anger outbursts.
• Some studies suggest that children who sleepwalk may have been more restless sleepers between the ages of four and five, and more restless with more frequent awakenings during the first year of life.

Sleepwalking, night terrors and confusional arousals are all related, common non-REM sleep disorders that tend to overlap in some of their symptoms. Approximately 15%-20% of young children through mid-adolescence will experience some or all of these behaviors. Moreover, seizures occurring during sleep (nocturnal seizures) can cause movement disorders during sleeping.

• Night terrors: Like sleepwalking, night terrors tend to occur during the first half of a night's sleep - often within 30 to 90 minutes of falling asleep.
  • Also like sleepwalking, they occur during stage III of non-REM sleep. However, unlike sleepwalking, an individual with night terrors will portray sudden and often agitated arousal that may appear to parents as violent and terrifying behaviors. During such an episode, the child characteristically will not be comforted by an embrace from a parent or caregiver.
  • Night terrors often start during the toddler years with a peak incidence between five and seven years of age. During these times evidence of a surge in autonomic nervous system activity is evident. Accelerated heart and respiratory rates, dilated pupils, and sweating are characteristics.
  • Triggers for night terrors may include sleep deprivation, stress, and medications (stimulants, sedatives, antihistamines, etc.). Unlike sleepwalking, episodes of night terrors may recur for several weeks in a row, abate completely, and later return.
• Confusional arousals: Similar to night terrors, confusional arousals are characterized by a sudden and violent arousal from sleep with behaviors described as agitated and semi-purposeful in the pattern.
  • Speech is generally coherent (unlike sleepwalking).
  • A distinguishing point between night terrors and confusional arousals is the lack of autonomic nervous system (accelerated heart/respiratory rates, dilated pupils, sweating) phenomena in the latter.
  • Confusional arousals tend to occur during the first half of a night's sleep (during stage II non-REM sleep). They are characteristically short-lived, lasting 5 to 15 minutes but can last up to 30 minutes in duration. Amnesia for the event is characteristic.
• Nocturnal seizures: Several important differential points help delineate the above three sleep behaviors from seizure activity. Seizures by their nature are very brief, often lasting only a few minutes.
  • In addition, seizure events are likely to be confused with the above; and are characterized by a series of repeated, stereotypical, and frequent behaviors occurring in clusters.
  • Moreover, seizures more commonly occur in the second half of the night's sleep. Patients often will have postictal (symptoms after the seizure) complications such as headache, extreme grogginess, hard to arouse, as well as incontinence of urine and stool.
  • To assist in establishing a correct diagnosis a neurologist may perform a video-EEG study to help clarify the issue. Home videos taken on a smartphone are often very helpful in establishing the diagnosis.

Sleepwalking usually does not require a visit to your healthcare professional. However, the condition should be discussed with your healthcare professional if sleepwalking:

• Is accompanied by other symptoms
• Is frequent
• Includes potentially dangerous activities (such as driving)

If you have any history of the strange activity or sleepwalking while taking medications for insomnia like zolpidem (Ambien), you should also speak to your physician.

Usually, no exams and tests are necessary. However, a medical evaluation may be completed to rule out medical causes of sleepwalking. Occasionally, a psychological evaluation can determine whether excessive stress or anxiety is the cause of sleepwalking. Sleep study tests may be done in persons in whom the diagnosis is still unclear.

Your healthcare professional will ask about your symptoms and medical history. They may even suggest some tests to find out whether a medical condition is causing sleepwalking, which may include:

• Physical exam
• Polysomnography (sleep study)
• Electroencephalography (EEG)

Sleepwalking characteristically occurs during the first or second sleep cycles, specifically, during stages III and IV, otherwise known as deep sleep. Due to the short time frame involved, sleepwalking tends not to occur during naps.

Parasomnias are a group of sleep behaviors common in children, teens, and occasionally adults. To understand parasomnias, it is helpful to understand the physiology of sleep.

Sleep occurs in two broad categories defined by characteristic changes during an EEG (electroencephalogram, “brain wave test”). The two categories are REM (rapid eye movement) and non-REM (NREM) sleep cycles. Non-REM sleep has four “levels” characterized by unique patterns of the EEG.

• Stage I: introduction to sleep during which there is generalized muscle relaxation and effort is required to keep your eyes open.
• Stage II: beginning to sleep (light sleep)
• Stage III and IV: deep sleep
• REM sleep: associated with dreaming

An entire sleep cycle from Stage I (non-REM) through REM sleep lasts between 90 and 120 minutes and repeats 4 to 5 times during the sleep experience. Each “level” of non-REM and REM sleep lasts between 5 to 15 minutes.

A large Canadian study reviewed sleep patterns of children aged 2.5 to 6 years and discovered approximately 88% of them experienced parasomnias and 15% were sleepwalkers.

Treatment for occasional sleepwalking usually isn't necessary. In children who sleepwalk, it typically goes away by their teen years.

If sleepwalking leads to the potential for injury, is disruptive to family members, or results in embarrassment or sleep disruption, treatment may be needed. Treatment generally focuses on promoting safety and eliminating causes or triggers.

Sleepwalking Home Remedies

A person who has a sleepwalking disorder can take the following measures:

• Get adequate sleep
• Meditate or do relaxation exercises
• Avoid any kind of stimuli (auditory or visual) before bedtime
• Keep a safe sleeping environment, free of harmful or sharp objects
• Sleep in a bedroom on the ground floor if possible to prevent falls and avoid bunk beds
• Lock the doors and windows
• Remove obstacles in the room, tripping over toys or objects is a potential hazard
• Cover glass windows with heavy drapes
• Place an alarm or bell on the bedroom door and if necessary, on any windows

Medical treatments

Sleepwalking may be associated with an underlying medical condition, for example, gastroesophageal reflux disease (GERD), obstructive sleep apnea, periodic leg movements (restless leg syndrome), or seizures. To help prevent sleepwalking, underlying medical conditions should be treated.

Medications for the treatment of sleepwalking disorder may be necessary in the following situations:

• When the possibility of injury is real
• When continued behaviors are causing significant family disruption or excessive daytime sleepiness
• When other measures have proven to be inadequate

Medications

Benzodiazepines, such as estazolam (ProSom), or tricyclic antidepressants, such as trazodone (Desyrel), are useful. Clonazepam (Klonopin) in low doses before bedtime and continued for three to 6 weeks is usually effective.

Medication can often be discontinued after three to five weeks without recurrence of symptoms. Occasionally, the frequency of episodes increases briefly after discontinuing the medication.

Other remedies

Relaxation techniques, mental imagery, and anticipatory awakenings are preferred for long-term treatment of persons with sleepwalking disorder.

• Relaxation and mental imagery should be undertaken only with the help of an experienced behavioral therapist or hypnotist.
• Anticipatory awakenings consist of waking the child or person approximately 15-20 minutes before the usual time of an event and then keeping him or her awake through the time during which the episodes usually occur.

Sleepwalking may or may not reduce with age, as described above. It usually does not indicate a serious disorder, although it can be a symptom of other disorders.

A common complication is an injury sustained during sleepwalking activities.

The following tips could help prevent sleepwalking:

• Avoid the use of alcohol or central nervous system depressants if prone to sleepwalking.
• Avoid fatigue or insomnia, because this can instigate an episode of sleepwalking.
• Avoid or minimize stress, anxiety, and conflict, which can worsen the condition.