Sleepwalking Overview

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.

Sleepwalking is characterized by complex behavior (walking) accomplished while asleep. Occasionally nonsensical talking may occur while sleepwalking. The person's eyes are commonly open but have a characteristic glassy "look right through you" character. This activity most commonly occurs during middle childhood and young adolescence. Approximately 15% of children between 4-12 years of age will experience sleepwalking. Generally sleepwalking behaviors are resolved by late adolescence; however, approximately 10% of all sleepwalkers begin their behavior as teens. A genetic tendency has been noted.

There are five stages of sleep. Stages 1, 2, 3, and 4 are characterized as non-rapid eye movement (NREM) sleep. REM (rapid eye movement) sleep is the sleep cycle associated with dreaming as well as surges of important hormones essential for proper growth and metabolism. Each sleep cycle (stages 1,2,3,4, and REM) lasts about 90-100 minutes and repeats throughout the night. Thus the average person experiences 4-5 complete sleep cycles per night. Sleepwalking characteristically occurs during the first or second sleep cycle during stages 3 and 4. Due to the short time frame involved, sleepwalking tends not to occur during naps. Upon waking, the sleepwalker has no memory of his behaviors.

Sleepwalking Causes

Genetic factors

Sleepwalking occurs more frequently in identical twins, and is 10 times more likely to occur 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, sedative/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 allergy) can cause sleepwalking.

Physiologic factors

* The length and depth of slow wave sleep, which is greater in young children, may be a factor in the increased frequency of sleepwalking in children.

* Conditions, such as pregnancy and menstruation, are known to increase the frequency of sleepwalking.

Associated medical conditions

* Arrhythmias (abnormal heart rhythms)

* Fever

* Gastroesophageal reflux (food or liquid regurgitating from the stomach into the food tube or esophagus)

* Nighttime asthma

* Nighttime seizures (convulsions)

* Obstructive sleep apnea (a condition in which breathing stops temporarily while sleeping)

* Psychiatric disorders, for example, posttraumatic stress disorder, panic attack, or dissociative states (for example, multiple personality disorder)

Sleepwalking Symptoms

* Episodes range from quiet walking about the room to agitated running or attempts to "escape." Patients may appear clumsy and dazed in their behaviors.

* Typically, the eyes are open with a glassy, staring appearance as the person quietly roams the house. They do not, however, walk with their arms extended in front of them as is inaccurately depicted in movies.

* On questioning, responses are slow with simple thoughts, contain non-sense phraseology, or are absent. If the person is returned to bed without awakening, the person usually does 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 was inappropriate). In lieu of walking, some children perform repeated behaviors (for example, straightening their pajamas). Bedwetting may also occur.

* Sleepwalking is not associated with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark), or anger outbursts.

* Some studies suggest that children who sleepwalk may have been more restless sleepers when aged 4-5 years, and more restless with more frequent awakenings during the first year of life.

When to Seek Medical Care for SleepWalking

For children and adults, sleepwalking is usually a sign of lack of sleep, intense emotional problems, stress, or fever. As these conditions resolve, sleepwalking incidences disappear.

In most cases, no treatment is necessary because sleepwalking rarely indicates any serious underlying medical or psychiatric problem.

In most children, sleepwalking disappears at puberty. However, it can occasionally persist into adulthood or may even begin in adulthood.

Consult a sleep specialist if the person is having frequent episodes, injuring himself or herself, or showing violent behavior.

Differential Diagnosis

Sleepwalking, night terrors, and confusional arousals are all 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.

* Night terrors: Like sleepwalking, night terrors tend to occur during the first half of a night's sleep, often within 30-90 minutes from falling asleep. Also, like sleepwalking, night terrors occur during stage 3 and 4 sleep. However, unlike sleepwalking, an individual with night terrors will portray a sudden and often agitated arousal that may appear to parents as violent and terrified behaviors. Night terrors often start during the toddler years with a peak incidence between 5–7 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 characteristic. Triggers for night terrors may include sleep deprivation, stress, or 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 pattern. Speech is generally coherent (unlike in sleepwalking). A distinguishing point between night terrors and confusional arousals is the lack of autonomic nervous system phenomena in the latter. Confusional arousals tend to occur during the first half of a night's sleep (during stages 3 and 4). They are characteristically short-lived, lasting only 5 - 30 minutes in duration. Affected individuals typically have no memory of the event.

* Nocturnal seizures: Several important differential points help delineate the above three sleep behaviors from seizure activity that occurs at night. Seizures by their nature are very brief, lasting often only a few minutes. In addition, seizure events likely to be confused with the above are characterized by a series of repeated, stereotypical, and frequent behaviors occurring in clusters. Importantly, seizures more commonly occur in the second half of the night's sleep. Patients often with have post-ictal (post-seizure) issues including headache, extreme grogginess, being 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.

Sleepwalking Treatment

Self-Care at Home

The following measures can be taken by a person who has a sleepwalking disorder:

* Get adequate sleep.

* Meditate or do relaxation exercises.

* Avoid any kind of stimuli (auditory or visual) prior to bedtime.

* Keep a safe sleeping environment free of harmful or sharp objects.

* Sleep in a bedroom on the ground floor if possible. To prevent a fall, 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 Treatment

If sleepwalking is caused by underlying medical conditions, for example, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements (restless legs syndrome), or seizures, the underlying medical condition should be treated.

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

* The possibility of injury is real.

* Continued behaviors are causing significant family disruption or excessive daytime sleepiness.

* Other measures have proven to be inadequate.

Medications

Benzodiazepines, such as estazolam (ProSom), or tricyclic antidepressants, such as trazodone (Desyrel), have been shown to be useful. Clonazepam (Klonopin) in low doses before bedtime and continued for 3-6 weeks is also usually effective.

Medication can often be discontinued after 3-5 weeks without recurrence of symptoms. Occasionally, the frequency of episodes increases briefly after discontinuing the medication.

Other Therapy

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 awake through the time during which the episodes usually occur.

Prevention

* Limit stress

* Avoid alcohol intake

* Avoid sleep deprivation

Outlook

The outlook for resolution of the disorder is excellent.

* Sleepwalking is not a serious disorder, although children can be injured by objects or falls during sleepwalking.

* Although disruptive and frightening for parents over the short term, sleepwalking is not associated with long-term complications.

* Prolonged disturbed sleep may be associated with school and behavioral issues.

Sleep Walking

Is a Sleep Disorder characterized by walking or other activity while seemingly still asleep. Sleepwalking (Somnambulism) is a series of complex behaviors that are initiated during slow wave sleep and result in walking during sleep. Sleepwalking is a rapid eye movement (REM) behavior disorder occurring in the dream stage of sleep. During this phase, the body releases a chemical that paralyzes the body. However, those who sleepwalk do not have this chemical trigger, hence the behavior.

Symptoms and Features:

Ambulation (walking or moving about) that occurs during sleep. The onset typically occurs in pre-pubertal children.
amnesia following an episode
polysomnographic monitoring demonstrates the onset of an episode during stage 3 or 4 sleep
other medical and psychiatric disorders can be present but do not account for the symptom
the ambulation is not due to other sleep disorders such as REM sleep behavior disorder or sleep terrors.
Fatigue (which is not the same as drowsiness),
stress and
anxiety

The normal sleep cycle involves distinct stages from light drowsiness to deep sleep. Rapid eye movement (REM) sleep is a different type of sleep, in which the eyes move rapidly and vivid dreaming is most common. During a night, there will be several cycles of non-REM and REM sleep. Sleep walking (somnambulism) most often occurs during deep non-REM sleep (stage 3 or stage 4 sleep) early in the night. It can occur during REM sleep near morning.

In children, the cause is usually unknown but may also be related to fatigue, prior sleep loss, or anxiety. In adults, sleep walking is usually associated with a disorder of the mind but may also be seen with reactions to drugs and/or medications and alcohol, and medical conditions such as partial complex seizures. In the elderly, sleep walking may be a symptom of an organic brain syndrome or REM behavior disorders.

The sleep walking activity may include simply sitting up and appearing awake while actually 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 actually asleep. The episode can be very brief (a few seconds or minutes) or can last for 30 minutes or longer.

One common misconception is that a sleep walker should not be awakened. It is not dangerous to awaken a sleep walker, although it is common for the person to be confused or disoriented for a short time on awakening. Another misconception is that a person cannot be injured when sleep walking. Actually, injuries caused by such things as tripping and loss of balance are common for sleep walkers.

Sleep walking occurs at any age, but it occurs most often in children aged 6 to 12 years old. It may occur in younger children, in adults, or in the elderly, and it appears to run in families. Sleepwalking (somnambulism) is fairly common, especially among children. An estimated 15 percent of all children between the ages of 5 and 12 have walked in their sleep at least once, and most outgrow the disorder. Typically, the child (or adult) sleepwalker sits up, gets out of bed, and moves about in an uncoordinated manner. Less frequently, the sleepwalker may dress, open doors, eat, or go to the bathroom without incident and usually will avoid obstacles. But sleepwalkers don't always make their rounds in safety. They sometimes hurt themselves, stumbling against furniture and losing their balance, going through windows, or falling down stairs.

In children, sleepwalking is not believed to be influenced by psychological factors.
In adults, it could indicate a personality disturbance.

Usually, it is enough for parents of sleepwalkers to provide their children with emotional support. They should also lock windows and doors and make sure the child does not sleep near stairways and potentially dangerous objects. For severe cases, a doctor may prescribe drugs.

Medical reports show that about 18% of the population are prone to sleepwalking. It is more common in children than in adolescents and adults. Boys are more likely to sleepwalk than girls. The highest prevalence of sleepwalking was 16.7% at age 11 to 12 years of age. Sleepwalking can have a genetic tendency. If a child begins to sleepwalk at the age of 9, it often lasts into adulthood.

For some, the episodes of sleepwalking occur less than once per month and do not result in harm to the patient or others. Others experience episodes more than once per month, but not nightly, and do not result in harm to the patient or others. In its most severe form, the episodes occur almost nightly or are associated with physical injury. The sleepwalker may feel embarrassment, shame, guilt, anxiety and confusion when they are told about their sleepwalking behavior.

Amnesia is another danger that usually follows a sleepwalking episode. Sleepwalkers usually remember little to nothing. But there are times sleepwalkers have a vague memory of an episode where they think they were being burned, buried alive, caught under a roof or trying to escape a dangerous situation. Sleepwalking primarily occurs in young children and is more prevalent in boys than girls.

Sleepwalking episodes can range from sitting up in bed to walking, and can even lead to frantic attempts to escape as if threatened or fleeing. During an episode, a sleepwalker exhibits behaviors such as sitting up with glassy eyes, picking at the blankets, making body movements and walking around the house. Sleepwalkers may also urinate, defecate or avoid looking at another person who attempts to communicate with them. Exiting through a window is not an uncommon practice, either.

Homicide or suicide during sleepwalking has rarely been reported when a person has tried to awaken a sleepwalker.

Sleepwalking can be treated with drugs, but hypnosis has also proven to be successful on a short-term basis.

An important component in dealing with this disorder is to make the environment as safe as possible, such as having sleepwalker's bedroom on the ground floor, removing hazardous items from the house, locking windows and placing an alarm on the bedroom door.

It is very important that if the sleepwalker exits the house, or is having frequent episodes and injuries are occurring -- DO NOT delay, it is time to seek professional help.

In a few instances, sleepwalking can result in violent behavior. It is very important that a chronic sleepwalker seek professional help.

Treatment:
There are some things a sleepwalker can do:

Make sure you get plenty of rest; being overtired can trigger a sleepwalking episode.
Develop a calming bedtime ritual. Some people meditate or do relaxation exercises; stress can be another trigger for sleepwalking.
Remove anything from the bedroom that could be hazardous or harmful.
The sleepwalker's bedroom should be on the ground floor of the house. The possibility of the patient opening windows or doors should be eliminated.

An assessment of the sleepwalker should include a careful review of the current medication so that modifications can be made if necessary.

Hypnosis has been found to be helpful for both children and adults.

An accurate psychiatric evaluation could help to decide the need for psychiatric intervention.

Benzodiazepines have been proven to be useful in the treatment of this disorder. A small dose of diazepam or lorazepam eliminates the episodes or considerably reduces them.

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Friday, July 24, 2009

Sleep Walking in Detail