Somnambulism (Sleep Walking)

Author: Gregory Ackroyd, MD, Consulting Staff, North Bay Sleep Medicine Institute
Coauthor(s): O'Neill F D'Cruz, MD, Professor, Departments of Neurology and Pediatrics, Director, Pediatric Sleep
Program, University of North Carolina; Stephen J Sharp, MD, Assistant Professor of Neurology and Pediatrics, Uniformed
Services University of the Health Sciences, Bethesda, Maryland
Contributor Information and Disclosures
Updated: Mar 25, 2010

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 Overview
 Differential Diagnoses & Workup
 Treatment & Medication
 Follow-up

 References
 Keywords

Introduction

Background
Somnambulism (ie, sleepwalking) is a disorder of arousal that falls under the parasomnia group. Parasomnias
are undesirable motor, verbal, or experiential events that occur during sleep. These phenomena occur as
primary sleep events or secondary to systemic disease. They are categorized as those occurring in rapid eye
movement (REM) sleep; those occurring during non–rapid eye movement (NREM) sleep; and miscellaneous
types that do not relate to any specific sleep state.

Pathophysiology
The parasomnias have been thought to represent not pathologic cerebral functioning but rather a response to
CNS activation that results in sleep-wake or REM-NREM state confusion, instability, or overlap. Recent studies,
however, demonstrate differences between sleep patterns and neuronal sleep control mechanisms in
individuals with parasomnias compared with those without. Normal sleep involves cyclic hypnic patterns
throughout the night between wakefulness, NREM, and REM states. The CNS remains active during all sleep-
wake states, although rapid changes are required in neural networks, rhythms, and neurotransmitters with state
changes. The length of each cycle averages 50 minutes for a full-term newborn, increasing to approximately 90
minutes by adolescence.

Slow wave sleep (SWS) normally occurs in the first 2 hypnic cycles; younger children have an additional SWS
period toward the end of the sleep period. Children typically enter their deepest sleep within 15 minutes of
sleep onset, and this first SWS period lasts from 45-75 minutes. This explains why it is easy to move children
without rousing them soon after sleep onset. Parasomnias occur as children are caught in a mixed state of
transition from one sleep cycle to the next (eg, NREM-wakefulness). This transition state is characterized by a
high arousal threshold, mental confusion, and unclear perception.

Sleepwalkers appear to have an abnormality in slow wave sleep regulation. The dissociation that occurs
between body and mind sleep appears to arise from activation of thalamocingulate pathways with persisting
deactivation of other thalamocortical arousal systems. The first slow wave sleep period of the night is
considered to be more disturbed in somnambulistic individuals, and the entire NREM-REM sleep cycle is more
fragmented. Because these disorders occur more frequently in children, these differences have been
suggested as signs of CNS immaturity.

Frequency
United States

Disorders of arousal are all more prevalent in children than adults. Confusional arousals are reported in 5-15%
of children. Sleep terrors have an incidence of approximately 1%.

International

In Sweden, the incidence of quiet sleepwalking is reported as 40% with a yearly prevalence of 6-17%. Only 2-
3% report more than 1 episode per month, and 33% report only a single episode.

In a survey of adults in the United Kingdom, 2.2% reported having night terrors, 2.0% reported sleep walking,
and 4.2% reported confusional arousals.

Mortality/Morbidity
The NREM parasomnias are rarely associated with any significant morbidity, although children can strike
objects during sleepwalking and occasionally become injured. Sleep-disordered breathing and, to a lesser
extent, restless legs syndrome have been associated in children, although with less frequency than reported in
adults. The incidence of associated sleep disorders has been reported to be as high as 61%.

Morbidity in adolescents and adults may be more significant. More complex motor behaviors such as driving a
car, cooking, eating, or playing a musical instrument have been reported. Injurious behaviors to the patient
and/or bed partner may be associated with forensic medicine implications. An increased incidence of
psychiatric disorders such as neuroses, panic disorder, phobias, and suicidal ideations has been reported in
both these groups. Sleep-disordered breathing, including a sense of choking or blocked breathing, has also
been reported. The respiratory events may have a deleterious effect on sleep by increasing arousals and sleep
fragmentation.

Race
No racial predilection is known.

Sex
Sleepwalking and confusional arousals have an equal incidence in males and females. Sleep terrors are more
common in boys.

Age
Sleepwalking occurs most commonly in middle childhood and preadolescence, with a peak incidence in
children aged 11-12 years. Confusional arousals are most common in toddlers and preschool-aged children.
Sleep terrors occur most commonly in children aged 4-12 years.

Clinical

History
The most common pediatric parasomnia disorders of arousal include sleepwalking, confusional arousals, and
sleep terrors. Parasomnia events have a predilection for occurring during deep sleep (stages III and IV, or
SWS), are known to occur during all stages of NREM sleep, and are possible at any time during the night. As
most SWS is achieved in the earlier segments of the sleep period, these phenomena usually are seen in the
first one third of the sleep cycle and rarely during naps.

 General and sleep related medical history is usually sufficient to differentiate parasomnias from other
disorders. Pertinent questions include the following:
o Detailed description of the event
o Level of consciousness before, during, and after the event
o Time of night and sleep cycle when the events occur
o Daytime sleepiness
o Associated injury
o Memory of the event
o Family history
o Any precipitating factors
 Nocturnal frontal lobe seizures and some psychiatric conditions present the most difficult diagnostic
dilemmas. A history of stereotypical short attacks that repeat during the night, most frequently during
stage II sleep, suggests seizures rather than a parasomnia. Onset in later childhood or adolescence,
persistence into adulthood, recurring nocturnal agitation, and daytime complaints such as fatigue or
sleepiness are also suggestive of a seizure disorder.
 Sleepwalking
o Episodes range from quiet walking about the room to agitated running or attempts to
"escape." Subjects may later report attempting to escape dangerous situations or terrifying
threats. Typically, the eyes are open with a glassy, staring appearance as the child quietly
roams the house.
o On questioning, responses are slow or absent. If returned to bed without awakening, the child
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).
o Sleepwalking has no association with previous sleep problems, sleeping alone in a room or
with others, achluophobia (fear of the dark), or anger outbursts.
o 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.
 Confusional arousals
o Episodes consist of disorientation, memory impairment, and slow mentation and often are
accompanied by inconsolable crying and thrashing movements in bed. This disorder is
common in younger children but decreases in frequency with age.
o In infants, episodes manifest by crying and moving about in bed.
o The eyes may be closed or opened, as in sleep terrors, but the child does not appear to feel
panic.
o Events typically last from 3-13 minutes and range in frequency from 2 times per night to 2
times per year. Attempting to awaken the child often prolongs the course, and successful
wakening by parents typically brings about an end to the episode.
 Sleep terrors
 o These are the most anxiety provoking for parents. Episodes frequently begin with a "blood-
curdling" scream, which is accompanied by the appearance of panic with wide-open eyes,
tachycardia, tachypnea, dilated pupils, diaphoresis, and flushing.
o This may be followed by panic-driven motor activity, such as hitting the wall or running around
the room.
o While typically not dangerous, the behavior is sometimes violent enough to result in injury to
the patient or others; property damage also may result.
o The inability of the parent to console the child is a hallmark of the episode (which is typically
shorter than confusional arousals), and amnesia for the event is usually complete.
o Sleep terrors usually resolve by adolescence, although the disorder occasionally persists into
adulthood.

Physical
Physical and neurological examinations are typically normal in these children.

Causes

 Genetic
o Sleepwalking occurs more frequently in monozygotic twins and is 10 times more likely if a
first-degree relative has a history of sleepwalking.
o An increased frequency of DQB1*04 and *05 alleles is reported. DQB1 genes have also been
implicated in narcolepsy and other disorders of motor control during sleep such as REM
behavior disorder.
 Environmental: Sleep deprivation, chaotic sleep schedules, fever, stress, magnesium deficiency, and
chemical or drug intoxication (eg, alcohol), sedative/hypnotics (eg, Zolpidem 1 ), combination of valproic
acid and zolpidem2 , antidepressants (eg, bupropion3 , paroxetine, amitriptyline), neuroleptics (eg,
lithium, reboxetine), minor tranquilizers, stimulants, antibiotics (eg, fluoroquinolone), anti-Parkinson
medications (eg, levodopa), anticonvulsants (eg, topiramate), and antihistamines can trigger
parasomnias.
 Physiologic
o The length and depth of SWS, which is greater in young children, may be a factor in the
increased frequency of parasomnias in children.
o Conditions such as pregnancy and menstruation are known to increase frequency in patients
with parasomnias.
 Associated medical conditions
o Arrhythmias
o Chronic paroxysmal hemicrania
o Migraine
o Fever
o Gastroesophageal reflux
o Nocturnal asthma
o Nocturnal seizures
o Obstructive sleep apnea: Children with obstructive sleep apnea or Tourette syndrome are at
greater risk of having parasomnias along with their underlying disorder. 4,5
o Chronic sleepwalking, especially in adults, is frequently associated with sleep-disordered
breathing. Treatment of the sleep-disordered breathing with continuous positive airway
pressure (CPAP) or surgery typically improves or resolves the sleepwalking. Noncompliance
 with CPAP is associated with persistence or recurrence of sleepwalking. Serotonin has been
postulated as the physiologic link between these two disorders.
o Psychiatric disorders
 Posttraumatic stress disorder
 Panic attack
 Dissociative states
o Hyperthyroidism6 : Thyrotoxicosis has been associated with an increased incidence of
sleepwalking, and achievement of euthyroidism is associated with improvement or resolution
of the symptoms. Sleepwalking may occur as an early symptom, and the onset of
sleepwalking in a patient out of the normal expected age range should be evaluated for
hyperthyroidism. The mechanism for the sleepwalking is considered to be increased fatigue in
combination with longer periods of non-REM sleep.

Differential Diagnoses
Benign Childhood Epilepsy Neonatal Seizures
Benign Neonatal Convulsions Periodic Limb Movement Disorder
Benign Positional Vertigo Psychogenic Nonepileptic Seizures
Chronic Paroxysmal Hemicrania REM Sleep Behavior Disorder
Cluster Headache Shuddering Attacks
Complex Partial Seizures Temporal Lobe Epilepsy
Epilepsy in Children with Mental Retardation Tonic-Clonic Seizures
Febrile Seizures Tourette Syndrome and Other Tic Disorders
First Seizure: Pediatric Perspective
Headache: Pediatric Perspective
Other Problems to Be Considered
Arrhythmias
Benign epilepsy syndromes
Dissociative states
Dream anxiety attacks
Epilepsy in children
Gastroesophageal reflux
Nocturnal asthma
Panic attack
Posttraumatic stress disorder
Sleep apnea
Tonic seizures

Miscellaneous sleep disorders: These are not sleep state specific. While the more common disorders
frequently generate questions for the pediatrician, they are generally less anxiety provoking than the NREM
parasomnias.

 Benign neonatal sleep myoclonus

 Bruxism: Nocturnal bruxism occurs in 15-22% of the population, usually in stage II sleep. The bite
force may be considerably stronger than during wakefulness, resulting in tooth or gum injury.
  Congenital hypoventilation syndrome
 Enuresis
 Infant sleep apnea
 Nocturnal paroxysmal dystonia
 Periodic limb movements
 Rhythmic movement disorder
o Behaviors include head banging, body rolling, or body rocking.
o Onset is usually in children younger than 9 months (prevalence is 60% at that age but only
5% in children aged 5 y).
o Episodes rarely last more than 15 minutes. They occur during the drowsy state just prior to
sleep onset, occasionally extending into light sleep.
 Somniloquy (sleep talking)

Normal NREM parasomnias

 Hypnagogic or hypnopompic imagery (a state of feeling awake but having dreams intrude; occurs at
sleep onset or offset)
 Sleep starts or hypnic jerks (typically a myoclonic jerk occurring at sleep onset, but also manifested
rarely as a sudden flashing light, loud cracking, snapping noise, or sudden pain)

REM-related parasomnias: These disorders are caused by disruptions in the REM-wakefulness transition;
except for nightmares, these disorders are much less common in children than in adults.

 REM behavior disorder, cataplexy, and wakeful dreaming are considered abnormal.
 Anxiety dreaming or nightmares are considered normal.

Workup

Laboratory Studies
No specific laboratory studies are indicated in the workup of routine parasomnias.

Other Tests

 Polysomnogram with or without multiple sleep latency testing should be reserved for the few cases in
which the diagnosis is still unclear after a careful history and physical. The abnormal behavior during
SWS is generally diagnostic. Sleep deprivation can be used as a tool to induce somnambulistic
episodes in the sleep laboratory.
 Microarousals and sleep state disorganization are observed frequently and often noted on EEG alone,
if performed during nocturnal sleep.
 Hypersynchronous slow delta-wave activity has been observed in the sleep electroencephalogram of
sleepwalkers; however, controversy remains regarding these findings on polysomnography

Treatment

Medical Care
  General guidelines
o Reassurance is the mainstay of treatment. The benign nature of the events and subsequent
disappearance in most cases should be emphasized.
o If environmental or predisposing factors are discovered, an attempt should be made to
eliminate them. Assure adequate sleep, regulation of sleep cycle, and treatment of underlying
medical conditions (eg, gastroesophageal reflux, obstructive sleep apnea, periodic leg
movements, seizures).
o Avoid auditory, tactile, or visual stimuli early in the sleep cycle. These have been shown to
induce events in some patients with parasomnias.
o Instruct parents to lock windows and doors, remove obstacles and sharp objects from the
room, and add alarms (if necessary) to decrease the likelihood of injury during an episode.
o Depending on the situation, comforting the child and gently redirecting him or her to bed may
be appropriate. Attempts to confront or wake up patients during the events frequently
lengthens the parasomnia episode and may induce resistance or violence from the patient.
 Pharmacological measures may be necessary in the following situations:
o The possibility of injury is real.
o Continued behaviors are causing significant family disruption or excessive daytime
sleepiness.
o Unusual symptoms are present.
o Nonpharmacological interventions have proven to be inadequate.
o Benzodiazepines, tricyclic antidepressants, and serotonin reuptake inhibitors have been
shown to be useful. Clonazepam in low doses before bedtime and continued for 3-6 weeks is
usually effective.
o Medication often can be discontinued after 3-5 weeks without recurrence of symptoms.
Occasionally, frequency of episodes increases briefly after discontinuing the medication
because of rebound sleep.
 Nonpharmacological measures
o Relaxation techniques, mental imagery, and anticipatory awakenings are preferred for long-
term management. The first 2 techniques should be undertaken only with the help of an
experienced behavioral therapist or hypnotist.
o Anticipatory awakenings consist of waking the child 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.

Surgical Care
Sleepwalking associated with sleep-disordered breathing may improve or resolve with surgical treatment of the
respiratory disorder.

Medication

The goal of pharmacotherapy is to reduce morbidity and to prevent complications. In addition to the agents
listed below, up to 6 mg Melatonin may be used at bedtime.

Tricyclic antidepressants
These agents, comprising a complex group of drugs, have central and peripheral anticholinergic effects and
sedative effects. They block the active reuptake of norepinephrine and serotonin.
 Amitriptyline (Elavil)

Increases synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting reuptake at

presynaptic neuronal membrane. Useful as analgesic for certain types of chronic and neuropathic pain.

 Dosing
 Interactions
 Contraindications
 Precautions
Adult

30-100 mg/d PO hs

Pediatric

Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO hs; increase gradually to 100 mg/d in divided doses

 Dosing
 Interactions
 Contraindications
 Precautions
 Dosing
 Interactions
 Contraindications
 Precautions
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Nortriptyline (Aventyl HCl, Pamelor)

Has demonstrated effectiveness in treatment of chronic pain. Increases synaptic concentration of serotonin
and/or norepinephrine in CNS by inhibiting their reuptake by presynaptic neuronal membrane. Additional
pharmacodynamic effects such as desensitization of adenyl cyclase and downregulation of beta-adrenergic
receptors and serotonin receptors appear to play role.

 Dosing
 Interactions
 Contraindications
 Precautions
Adult

25 mg PO tid/qid; not to exceed 150 mg/d

Pediatric

<25 kg: Not recommended

25-35 kg: 10-20 mg/d PO
 35-54 kg: 25-35 mg/d PO
>54 kg: Administer as in adults

 Dosing
 Interactions
 Contraindications
 Precautions
 Dosing
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 Precautions

Benzodiazepines
A large group of compounds with a benzene ring nucleus fused to a 7-sided diazepine ring. Benzodiazepines
bind to specific receptors in association with GABA-binding sites on chloride channels. The frequency of
channel opening is increased, increasing flow of chloride ions into neurons. Their relatively high therapeutic
index and lower abuse potential than many of other sedative-hypnotics have made them sedative-hypnotic
drugs of choice.

Clonazepam (Klonopin)

Believed to enhance activity of inhibitory neurotransmitter GABA in CNS. Antiseizure and antipanic
effectiveness has been demonstrated. Generally considered DOC for disorders of arousal.

 Dosing
 Interactions
 Contraindications
 Precautions
Adult

0.5 mg PO hs initial dose for sleep disorders; may increase rapidly to 1 mg prn

Pediatric

0.25 mg PO 1 h before hs initial dose; increase cautiously prn

Follow-up

Further Outpatient Care

Ongoing reassurance at regular health maintenance visits is usually sufficient.

Prognosis
  The childhood parasomnias are not associated with long-term sequelae. Although disruptive and
frightening for parents in the short term, these disorders rarely cause injury. Furthermore, the
prognosis for resolution with maturation is excellent.
 Prolonged disturbed sleep may be associated with school and behavioral issues. A relationship with
hyperactivity is suggested but not clear.
 Adolescents with sleep terrors or sleepwalking have an increased prevalence of other sleep disorders,
neurotic traits, and other psychiatric disorders.
 Rare reports describe incidences of serious injury, sexual misconduct, or violent behavior occurring
during somnambulism in adults. Most serious injuries have occurred as a result of leaping through
windows. Some apparent "suicides" have likely been the unfortunate result of a sleep behavior. Violent
behavior toward others may also rarely occur and has been used as a legal defense. The violent
behavior aspect appears to occur more frequently in men than in women.

Patient Education
For excellent patient education resources, visit eMedicine's Sleep Disorders Center. Also, see eMedicine's
patient education articles Disorders That Disrupt Sleep (Parasomnias), Sleepwalking, and REM Sleep Behavior
Disorder.

Miscellaneous

Medicolegal Pitfalls
Recognizing the occasional child with seizures as the etiology of nocturnal events is imperative. This
differentiation can be made with an in-depth history of the episodes. A polysomnogram may be needed to
clarify the diagnosis.