Sleepwalking is a sleep disorder where the sleeper arises from the slow wave, deep sleep stage and performs tasks that only a conscious person does. A sleepwalker usually performs simple repeated behaviors but sometimes they transgress into complex and often violent actions that they do not remember anything about when awake. Sleepwalkers are difficult to awaken, with a dim and glazed over expression over their faces during the sleepwalk incidents. In the past, sleepwalking was thought of as a dreamer acting out a dream.
Sleepwalking Definition, Classification and Interpretation:
Sleepwalking is formally known as somnambulism or noctambulism. It belongs to the parasomnia family. Parasomnias are sleep disorders that involve abnormal movements, perceptions, behaviors and emotions that occur while falling asleep, sleeping, between sleep stages or while attempting to wake from sleep.
Parasomnias can occur at any sleep stage and during either rapid eye movement (REM) sleep or non-rapid eye movement sleep (NREM). Among NREM parasomnias are sleepwalking, confusional arousals, night terrors (sleep terrors), teeth grinding (bruxism), restless legs syndrome (RLM) and periodic limb movements (PLM), sleep sex and sleep-related eating disorder (SRED). REM parasomnias include REM sleep behavior disorder (commonly known as RBD), recurrent isolated sleep paralysis and catathrenia.
Slow-wave (deep) sleep is the third stage of NREM sleep. It has about 20%-50% of delta activity (an aid in characterizing the depth of sleep). If a person is woken up from this stage of sleep he/she will feel groggy and his/her mental performance will be slightly impaired.
Sleepwalking behaviors might be recognized as automatic behaviors, which are spontaneously produced (often purposeless) verbal or motor behaviors without conscious self-control or self-censorship. Arguing that sleepwalking behaviors are insane automatisms or non-insane automatisms are important in courts where crime is involved.
Nocturnal Sleep-Related Eating Disorder (NSRED) is a state of sleepwalking that includes behaviors connected to a person’s conscious wishes or wants. It is also called somnambulistic eating and it combines the traits of a parasomnia with an eating disorder. NSRED should be completely distinguishable from night eating syndrome (NES) where the person is conscious and aware of what he/she is doing.
In NSRED the patients are unaware and asleep as they consume large amounts of food uncontrollably. They don’t remember any of their actions when they are awake and usually complain of unexplained injuries. Many NSRED patients also create harmful or bizarre food combinations. Some attempt to eat spoiled or rotten food, some eat from the wastepaper basket and other attempt to swallow potentially harmful substances like wood, ashes, glue or soap. Some NSRED patients attempt to blend weird food mixtures or use knives and forks to eat their food, harming themselves in the process. It is especially dangerous when diabetics attempt to consume pint after pint of sugar or hypertensives scourge salt.
This parasomnia is most common in women, especially those who undergo extreme dieting, are alcoholics, drug addicts or have other sleep disorders. Symptoms include significant weight gain over a short period of time, depression, irritability during daytime and sleep disruption with vivid dreaming.
Prevalence of sleepwalking is very high in children ages 3-8. It often occurs in children suffering from sleep apnea or bedwetting (nocturnal enuresis). Sleep apnea is a dyssomnia (abnormal behavior or psychological event that occur during sleep) where the patient pauses in breathing during sleep. These pauses cause the person to wake up to breathe in air and counteract the carbon dioxide built up in the blood stream due to inconsistent breathing. Night terrors are related to sleepwalking and sometimes they run concomitantly in families with hereditary sleep disorders.
Sleepwalking is less common in adults than children. It is not always a sign of psychological disorder.
Psychological disorders like schizophrenia, post-traumatic stress disorder (PTSD), hysteria, depression, obsessive compulsive disorder (OCD) and anxiety neuroses are predisposing factors for sleepwalking. Also patients with migraine headaches or Tourette syndrome (a neurological disorder that causes a person to make repetitive, stereotyped, involuntary movements and vocalizations commonly known as tics) are 4-6 more likely to sleepwalk than people without those diseases. Most antidepressants, antihistamines, anxiolytics, anti-Parkinsonism drugs and mood stabilizers are known to include sleepwalking as a side effect.
Causes and Predisposing Factors to Sleepwalking:
Many people ask “Why do people sleepwalk?” Some even ask “Why do I sleepwalk?” A lot of people who sleepwalk don’t know the cause of their distress. The exact reason behind sleepwalking is unknown, especially since scientists stopped looking into this phenomenon since a very long time, until very recently when nocturnal polysomnograpy came into the picture. There are many contributing factors to sleepwalking, though.
It differs from children to adults. Many sociologists believe that some children suffer sleepwalking due to delay in maturation, especially in the central nervous system. Hereditary sleepwalking is very evident in children who have at least one parent who was affected with sleepwalking (45%) and even greater when both parents were affected (60%).
Identical twins are ten times more likely to sleepwalk than regular siblings. Sleepwalking is not related to sex or race. Apart from the inherited trait, sleepwalking could be attributed to medical conditions such as arrhythmias, head injuries, hyperthyroidism, stroke, fever, gastroesophageal reflux disease (GERD), nighttime asthma, nighttime seizures and various psychotic disorders.
Environmental factors that cause sleepwalking include:
- Sleep deprivation.
- Chaotic sleep schedules/ Interrupted sleep.
- Noisy sleep environment.
- Going to bed with a full bladder.
- Stress: It causes the body to act up to go back to normal, so when the person goes to sleep, the body systems haven’t recovered from their stressed condition and thus cannot function properly during state of sleep.
- Alcohol: Even though it acts as a sedative, sleep resulting from alcohol is usually poor in quality. When the sleeper is intoxicated, the problem of increased clumsiness is present. Sleepwalking will be risky at this point because the sleepwalker may stumble or fall into things and this further complicates the process.
In psychoanalysis, sleepwalking has been interpreted through varying contexts. Sigmund Freud, the founding father of psychoanalysis, believed that sleepwalking was connected to fulfilling repressed sexual wishes. He further studied it in his essay “A Metapsychological Supplement to the Theory of Dreams” stating that sleepwalking results from the clash between preconscious daytime thoughts and repressed unconscious impulses which are expressed as mobility during sleep.
Symptoms of Sleepwalking:
In addition to walking during sleep, other symptoms of sleepwalking include (in a varying degree of complexity):
- Automatic behaviors: Chewing, lip-smacking, rubbing their eyes, pulling at clothing, wandering around looking confused.
- Simple behaviors: Sleep-talking, sitting up in bed, cleaning or standing in the dark staring at nothing.
- Complex, dangerous behaviors: Cooking, driving, screaming, violent gestures, grabbing at hallucinated objects, attacking the person attempting to wake them up.
- Inappropriate behaviors: This occurs in case of children. Behaviors like this include walking into parents’ room while they’re having sex or urinating in closets. When a child awakes and discovers what he/she has done, this might add to their embarrassment or cause significant psychological distress.
Should I Wake a Sleepwalker?
Waking a sleepwalker is one of the most controversial scientific topics. Many scientists suggest that instead of waking them, it is better to gently guide them back to bed. It was commonly believed that if you woke a sleepwalker, you might put that person into shock and he/she would suffer a heart attack or go into a coma. This has been disproved by sleep scientists who warn that waking up sleepwalkers may not put them in the best of shape, but it won’t kill them.
Sleep experts have hinted that waking a sleepwalker would result in them being disoriented, confused and agitated. A sleepwalker once described it on an online blog as something similar to “the distress you feel when woken up by the alarm in the middle of the night”. Feelings of distress, grogginess and confusion as well as the inability of the sleepwalker to remember anything from their nighttime experience are often the results of waking up a sleepwalker. However, there’s a potential for the person doing the waking to get hurt. It is advised to try and avoid approaching the sleepwalker if he/she is in a violent state. The greatest aim at that point would be to put them out of harm’s way.
Sleepwalking Treatment and Prevention:
Treatment for sleepwalking differs from adults to children. In case of children, sleepwalking is usually outgrown over time. In case of underlying parasomnias, it might be best to treat the underlying causes in order to prevent sleepwalking.
In recent studies, scientists discovered that most children who suffer from either restless legs syndrome (RLM) or periodic limb movements (PLM) or sleep-disorder breathing (SDB), regularly sleepwalk. After treatment of RLM or SDB, sleepwalking symptoms usually disappeared thus indicating that the former usually triggers the latter. To overcome sleepwalking as a side effect of sleep apnea, children’s respiration during sleep should be monitored. Methods of treatment include introducing nasal cannula/pressure transducer system and/or esophageal manometry to the child during sleep.
The most important aspect of treating sleepwalking is dealing with it while trying to minimize the damages involved. Creating a safe, contained sleeping environment for your kid is a must. Locking all doors and windows is unavoidable as well as removing all sharp objects from the sleep area.
It is rare that doctors prescribe medications to treat sleepwalking. It is usually the result of an underlying illness and stops when the illness is cured. If it is a side effect of certain drugs, sleepwalking will cease automatically as soon as the drug course is over. Sometimes doctors prescribe low dose benzodiazepines and tricyclic antidepressants to treat severe cases of somnambulism. However in most cases, one of two measures should be followed either separately or simultaneously. These two measures are sleep hygiene and hypnosis.
Sleep hygiene is a series of different practices and regulations to assure a sound and healthy sleep. To achieve the required sleep hygiene measures, several steps should be followed:
- Maintaining a regular wake and sleep pattern.
- Spending an appropriate time in bed.
- Don’t exceed sleeping hours to more than 8 hours/day.
- Avoid napping during the day.
- Avoid stimulants such as nicotine, caffeine too close to bedtime.
- Avoid alcohol (a sedative but it disrupts the quality of sleep) too close to bedtime.
- Exercise regularly.
- Stay away from large meals before bedtime.
- Ensure adequate exposure to sunlight.
- Associate your bed with sleep.
- Maintain a relaxing and pleasant sleeping environment.
Hypnosis is a state of deep physical relaxation but with retention of an active and focused mind. As a preventive measure for sleepwalking, hypnosis has been proved valid by many psychotherapists. In small-scale studies conducted by researchers results have shown that properly screened sleepwalkers experienced significant improvement with clinical hypnosis. Hypnosis has shown positive results for other parasomnias as well, such as night terrors and nightmares. The theory behind this comes from the positive effect that hypnosis has on relaxing the body. When this occurs, the sleeper enjoys less disrupted sleep as well as a decrease in the frequency and severity of the sleepwalking episodes.
Sleepwalking Validity from a Legal Point of View:
While many argue that extreme behaviors rarely occur during a sleepwalking episode, some people go as far as homicide while sleepwalking. In fact homicidal sleepwalking has more than once raised the question whether sleepwalking is real or not. About 68 cases of murder during a sleepwalking act had been reported in literature up to the year 2005.
Most homicidal sleepwalking cases have been highly complicated, especially when the sanity of the accused is questionable. In the 2013 psychological thriller “Side Effects” the heroine is a woman who murders her husband while sleepwalking due to a side effect of the antidepressant she is taking. Many real-life homicides took place during a sleepwalking episode. The defendants were either acquitted on the grounds of temporary insanity or ruled out as not guilty, on the condition that they would be admitted to a mental institution.
There are various articles that give detailed descriptions on how to fake sleepwalking. They describe the sleepwalker’s state as realistically as possible, steering away from the comical way they present it on TV. However, some people have been discussing on forums how it would be really “cool” to sleepwalk for real. Many try to associate it with lucid dreaming, despite dreams and sleepwalking being in completely different sleep stages.
Sleepwalking is no game. It is a tough and dangerous process to the sleeper and those living with him/her. Special treatment should be provided to those suffering from sleepwalking along with methods of coping and prevention. Many sleep research centers provide all the required information and consultation for night wanderers who can’t seem to grasp the cause behind their misery.