Disease: Sleepwalking

    Sleepwalking facts

    • Sleepwalking is not a serious disorder, although children can be injured by objects during sleepwalking.
    • Although disruptive and frightening for parents in the short-term, sleepwalking is not associated with long-term complications.
    • Prolonged disturbed sleep may be associated with school and behavioral issues.
    • The outlook for resolution of the disorder is excellent.

    What is sleepwalking?

    Sleepwalking is a disorder characterized by walking or other activities while seemingly still asleep.

    What are the causes, incidence, and risk factors of sleepwalking?

    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 a complex behavior (walking) occurring while asleep. Occasionally nonsensical talking may occur. 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 wane by late adolescence. However, approximately 10% of all sleepwalkers begin their behavior as teens. It appears that persons with certain inherited genes have an increased tendency toward developing sleepwalking behaviors.

    There are 4 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. Stage 3 sleep is known for surges of important hormones essential for proper growth and metabolism. Each sleep cycle (stages N1, N2, N3, and REM) last about 90-100 minutes and repeats throughout the night. The average person experiences four to five complete sleep cycles per night. Sleepwalking characteristically occurs during the first or second sleep cycles, during stages 3, otherwise known as deep sleep. Due the short time frame involved, sleepwalking tends not to occur during naps. Upon waking, the sleepwalker has no memory of his or her behaviors.

    The sleepwalking activity 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 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 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 on awakening. Another misconception is that a person cannot be injured when sleepwalking; however, injuries caused by such events as tripping and loss of balance are common for sleepwalkers.

    What are associated factors to consider?

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

    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 allergies) can cause sleepwalking.

    Physiologic factors

    Physiologic factors that may contribute to sleepwalking include:

    • 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 (acid reflux - food or liquid regurgitating from the stomach into the food pipe);
    • nighttime asthma;
    • nighttime seizures (convulsions);
    • obstructive sleep apnea (condition in which breathing stops temporarily while sleeping); and
    • psychiatric disorders, for example, posttraumatic stress disorder, panic attacks, or dissociative states (for example, multiple personality disorder)

    What are symptoms of sleepwalking?

    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. They do not, however, walk with their arms extended in front of them as is inaccurately depicted in movies.
    • On questioning the person sleepwalking, responses are slow with simple thoughts, 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 was inappropriate). In lieu 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.

    What are the signs and tests for sleepwalking?

    Usually, no exams and tests are necessary. However, a medical evaluation may be completed to rule out medical causes of sleepwalking.

    Additionally, a psychological evaluation can determine whether excessive stress oranxiety is the cause of sleepwalking.

    Sleep study tests may be done in persons in whom the diagnosis is still unclear.

    What other conditions will my doctor consider before diagnosing sleepwalking?

    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 disorder during sleeping.

    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, they occur during stage 3 of 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 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 characteristic.

    Triggers for night terrors may include sleep deprivation, stress, 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 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 3). 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.

    What is the treatment for sleepwalking?

    Self-Care at Home

    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) 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 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; and
    • place an alarm or bell on the bedroom door and if necessary on any windows.
    Medical treatments

    If sleepwalking is caused by underlying medical conditions, for example, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements (restless leg syndrome), or seizures; the underlying medical condition 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; and
    • when 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 three to six weeks is usually effective.

    Learn more about: ProSom | Desyrel | Klonopin

    Learn more about: ProSom | Desyrel | Klonopin

    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.

    What are associated factors to consider?

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

    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 allergies) can cause sleepwalking.

    Physiologic factors

    Physiologic factors that may contribute to sleepwalking include:

    • 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 (acid reflux - food or liquid regurgitating from the stomach into the food pipe);
    • nighttime asthma;
    • nighttime seizures (convulsions);
    • obstructive sleep apnea (condition in which breathing stops temporarily while sleeping); and
    • psychiatric disorders, for example, posttraumatic stress disorder, panic attacks, or dissociative states (for example, multiple personality disorder)

    What are symptoms of sleepwalking?

    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. They do not, however, walk with their arms extended in front of them as is inaccurately depicted in movies.
    • On questioning the person sleepwalking, responses are slow with simple thoughts, 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 was inappropriate). In lieu 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.

    What are the signs and tests for sleepwalking?

    Usually, no exams and tests are necessary. However, a medical evaluation may be completed to rule out medical causes of sleepwalking.

    Additionally, a psychological evaluation can determine whether excessive stress oranxiety is the cause of sleepwalking.

    Sleep study tests may be done in persons in whom the diagnosis is still unclear.

    What other conditions will my doctor consider before diagnosing sleepwalking?

    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 disorder during sleeping.

    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, they occur during stage 3 of 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 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 characteristic.

    Triggers for night terrors may include sleep deprivation, stress, 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 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 3). 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.

    What is the treatment for sleepwalking?

    Self-Care at Home

    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) 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 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; and
    • place an alarm or bell on the bedroom door and if necessary on any windows.
    Medical treatments

    If sleepwalking is caused by underlying medical conditions, for example, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements (restless leg syndrome), or seizures; the underlying medical condition 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; and
    • when 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 three to six weeks is usually effective.

    Learn more about: ProSom | Desyrel | Klonopin

    Learn more about: ProSom | Desyrel | Klonopin

    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.

    Source: http://www.rxlist.com

    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. They do not, however, walk with their arms extended in front of them as is inaccurately depicted in movies.
    • On questioning the person sleepwalking, responses are slow with simple thoughts, 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 was inappropriate). In lieu 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.

    Source: http://www.rxlist.com

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