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Sleepwalking

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 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.

Symptoms

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.

 

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 excessivestress or anxiety is the cause of sleepwalking.

 

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

Causes

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 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) 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 and 4. 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 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 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.

Treatment

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;
  • 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;
  • 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.

 

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.
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