John Everett Millais, The Somnambulist, 1871
|Classification and external resources|
|Specialty||Psychiatry, Sleep medicine|
Sleepwalking, also known as somnambulism or noctambulism, is a phenomenon of combined sleep and wakefulness. It is classified as a sleep disorder belonging to the parasomnia family. Sleepwalking occurs during slow wave sleep stage in a state of low consciousness and perform activities that are usually performed during a state of full consciousness. These activities can be as benign as sitting up in bed, walking to a bathroom, and cleaning, or as hazardous as cooking, driving, violent gestures, grabbing at hallucinated objects, or even homicide.
Although sleepwalking cases generally consist of simple, repeated behaviours, there are occasionally reports of people performing complex behaviours while asleep, although their legitimacy is often disputed. Sleepwalkers often have little or no memory of the incident, as their consciousness has altered into a state in which it is harder to recall memories. Although their eyes are open, their expression is dim and glazed over. Sleepwalking may last as little as 30 seconds or as long as 30 minutes.
Sleepwalking occurs during slow-wave sleep (N3) of non-rapid eye movement sleep (NREM sleep) cycles. Sleepwalking typically occurs within the first third of the night when slow wave sleep is most prominent. Usually, if sleepwalking occurs at all, it will only occur once in a night.
Three common diagnostic systems that are generally used for sleepwalking disorders are International Classification of Diagnoses, the International Classification of Sleep Disorders 3, and the Diagnostic and Statistical Manual. Polysomnography is the only accurate measure of sleepwalking. Other measures commonly used include self-report (e.g.), parent (e.g.), partner or house-mate report.
Sleepwalking should not be confused with alcohol- or drug-induced blackouts, which can result in amnesia for events similar to sleepwalking. During an alcohol-induced blackout (drug-related amnesia), a person is able to actively engage and respond to their environment (e.g. having conversations or driving a vehicle), however the brain does not create memories for the events. Alcohol-induced blackouts can occur with blood alcohol levels higher than 0.06g/dl. A systematic review of the literature found that approximately 50% of drinkers have experienced memory loss during a drinking episode and have had associated negative consequences similar to sleepwalkers, including injury and death.
There are two subcategories of sleepwalking—sleepwalking with sleep-related eating and sleepwalking with sleep-related sexual behavior (sexsomnia).
Sleep eating involves consuming food while asleep. These sleep eating disorders are more often than not induced by stress related reasons. Another major cause of this sleep eating subtype of sleepwalking is sleep medication, such as Ambien for example (Mayo Clinic). There are a few others, but Ambien is a more widely used sleep aid. Because many sleep eaters prepare the food they consume, there are risks involving burns and such with ovens and other appliances. As expected, weight gain is also a common outcome of this disorder, because a food that is frequently found contains high carbohydrates. As with sleepwalking, there are ways that sleep eating disorders can be maintained. There are some medications that calm the sleeper so they can get longer and better-quality rest, but more often than not activities such as yoga can be introduced to reduce the stress and anxiety causing the action.
According to the National Sleep Foundation in the U.S., sleepwalking is prevalent in 1–15% of the general populace. Sleepwalking is most prevalent in children, and usually disappears by adolescence. Sleepwalking in adults is less common, but when it does occur, the events occur three times more often per year and last for more years than in children. Sleepwalking in old age is rare and usually indicates another disorder. Old-age disorders may include delirium, drug toxicity or a seizure disorder.
Sleepwalking events are common in childhood and decrease with age. According to Lavie, Malhotra and Pillar, the peak age is 4–8 years, when prevalence is 20% frequency of events. Another report states that the peak age is eleven or twelve, with an estimated 25% of children having experienced at least one episode. It is also known that "between 25–33% of somnambulists have nocturnal enuresis" (bed-wetting). Like sleepwalking, enuresis is more common in children and fades away as the child ages. Some children who sleepwalk are also affected by night terrors. However, night terrors are much more common in adult sleepwalkers, up to 50% more common. Some parents worry about the psychological implications of sleepwalking on their child, but Larissa Hirsch, MD, editor of the website KidsHealth, says, "Sleepwalking is not usually a sign that something is emotionally or psychologically wrong with a child. And it doesn't cause any emotional harm."
The persistence or onset of sleepwalking in adulthood is less common than in children. A 2012 study conducted by the Stanford University School of Medicine showed that the prevalence of sleepwalking adults in the United States was higher than once thought, with 3.7% of participants reporting two or more episodes per month. As mentioned above, drug or alcohol use can cause sleepwalking, and in many cases, adults might sleepwalk only after consuming alcohol or drugs and not otherwise. It is a misconception that adult sleepwalking always indicates a psychological disorder. Sleepwalking can, however, be a symptom of people with psychological disorders. In one study, adult test subjects were given the Minnesota Multiphasic Personality Inventory, a psychiatric test. According to the study, patients showed "outwardly directed behavior patterns ... suggest[ing] that these adults had difficulty handling aggression. They did not support an interpretation of sleepwalking as 'hysterical dissociation'."
The cause of sleepwalking is not known. A number of, as yet unproven, hypotheses are suggested for why it might occur. These include a delay in the maturity of the central nervous system, increased slow wave sleep, sleep deprivation, fever, and excessive tiredness.
There may be a genetic component to sleepwalking. One study found that 45% of children who sleepwalked had one parent who sleepwalked. This rose to 60% of children if both parents sleepwalked. Thus, heritable factors may predispose an individual to sleepwalking, but expression of the behavior may also be influenced by environmental factors.
Sleepwalking may be inherited as an autosomal dominant disorder with reduced penetrance. Genome-wide multipoint parametric linkage analysis for sleepwalking revealed a maximum logarithm of the odds score of 3.44 at chromosome 20q12-q13.12 between 55.6 and 61.4 cM.
A number of medications are thought to trigger sleepwalking. These include: chlorpromazine (Thorazine), perphenazine (Trilafon), lithium, triazolam (Halcion), amitriptyline (Elavil, Endep), zolpidem (Ambien), Quetiapine (Seroquel) and beta blockers.
A number of conditions, such as Parkinson's Disease, are thought to trigger sleepwalking in people without a previous history of sleepwalking.
Comorbid medical and psychological disorders
In the study "sleepwalking and sleep terrors in prepubera children" they found that if a child had another sleep disorder such as restless leg syndrome (RLS) or sleep-disorder breathing (SDB) that they had a greater chance of sleepwalking. The study found children with chronic parasomnias may often also present SDB or, to a lesser extent, RLS. Furthermore, the disappearance of the parasomnias after the treatment of the SDB or RLS periodic limb movement syndrome suggests that the latter may trigger the former. The high frequency of SDB in family members of children with parasomnia provided additional evidence that SDB may manifest as parasomnias in children. Children with parasomnias are not systematically monitored during sleep, although past studies have suggested that patients with sleep terrors or sleepwalking have an elevated level of brief EEG arousals. When children receive polysomnographies, discrete patterns (e.g., nasal flow limitation, abnormal respiratory effort, bursts of high or slow EEG frequencies) should be sought; apneas are rarely found in children. Children's respiration during sleep should be monitored with nasal cannula/pressure transducer system and/or esophageal manometry, which are more sensitive than the thermistors or thermocouples currently used in many laboratories. The clear, prompt improvement of severe parasomnia in children who are treated for SDB, as defined here, provides important evidence that subtle SDB can have substantial health-related significance. Also noteworthy is the report of familial presence of parasomnia. Studies of twin cohorts and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias. RLS and SDB have been shown to have familial recurrence. RLS has been shown to have genetic involvement.
In some cases, sleepwalking in adults may be a symptom of a psychological disorder. One study suggests higher levels of dissociation in adult sleepwalkers, since test subjects scored unusually high on the hysteria portion of the "Crown-Crisp Experiential Index". Another suggested that "A higher incidence [of sleepwalking events] has been reported in patients with schizophrenia, hysteria and anxiety neuroses". Also, patients with migraine headaches or Tourette Syndrome are 4–6 times more likely to sleepwalk.
There have been no clinical trials to show that any psychological or pharmacological intervention is effective in preventing sleepwalking episodes. Despite this, a wide range of treatments have been used with sleepwalkers. Psychological interventions have included psychoanalysis, hypnosis,scheduled or anticipatory waking, assertion training, relaxation training, managing aggressive feelings, sleep hygiene, classical conditioning (including electric shock), and play therapy. Pharmacological treatments have included an anticholinergic (biperiden), antiepileptics (carbamazepine, valproate), an antipsychotic (quetiapine), benzodiazepines (clonazepam, diazepam, flurazepam, imipramine, and triazolam), melatonin, a selective serotonin reuptake inhibitor (paroxetine), a barbiturate (sodium amytal) and herbs.
There is no evidence about whether waking sleepwalkers is harmful or not, though the sleepwalker is likely to be disoriented if awakened because sleepwalking occurs during the deepest stage of sleep. Unlike other sleep disorders, sleepwalking is not associated with daytime behavioral or emotional problems—this may be because the sleepwalker's sleep is not disturbed—unless they are woken, they are still in a sleep state while sleepwalking.
Sleepwalking can sometimes result in injury, assault, or the death of someone else. For this reason, sleepwalking can be used as a legal defence. However, sleepwalking is a difficult case to prove. It is impossible to prove absolutely that a crime occurred in the context of a sleepwalking episode because there is no objective means to assess it retrospectively. It relies on probability and circumstantial evidence of a behaviour that often has no witnesses (including the defendant, because amnesia is a feature of sleepwalking). Even a history of sleepwalking does not support that it was a factor during any given event.
Alternative explanations, such as malingering and alcohol and drug-induced amnesia, need to be excluded. The differential diagnosis may also include other conditions in which violence related to sleep is a risk, such as REM Sleep Behavior Disorder (RSBD), fugue states, and episodic wandering." In the 1963 case Bratty v Attorney-General for Northern Ireland, Lord Morris stated, "Each set of facts must require a careful examination of its own circumstances, but if by way of taking an illustration it were considered possible for a person to walk in his sleep and to commit a violent crime while genuinely unconscious, then such a person would not be criminally liable for that act."
In the case of the law, an individual can be accused of non-insane automatism or insane automatism. The first is used as a defense for temporary insanity or involuntary conduct, resulting in acquittal. The latter results in a "special verdict of not guilty by reason of insanity." This verdict of insanity can result in a court order to attend a mental institution.
Other examples of legal cases involving sleepwalking in the defence include:
- 1846, Albert Tirrell used sleepwalking as a defense against charges of murdering Maria Bickford, a prostitute living in a Boston brothel.
- 1981, Steven Steinberg, of Scottsdale, Arizona was accused of killing his wife and acquitted on the grounds of temporary insanity.
- 1991, R v Burgess: Burgess was accused of hitting his girlfriend on the head with a wine bottle and then a video tape recorder. Found not guilty, at Bristol Crown Court, by reason of insane automatism.
- 1992, R. v. Parks: Parks was accused of killing his mother-in-law and attempting to kill his father-in-law. He was acquitted by the Supreme Court of Canada.
- 1994, Pennsylvania v. Ricksgers: Ricksgers was accused of killing his wife. He was sentenced to life in prison without parole.
- 1999, Arizona v. Falater: Falater, of Phoenix, Arizona, was accused of killing his wife. The court concluded that the murder was too complex to be committed while sleepwalking. Falater was charged with first-degree murder, and given life sentence with no parole.
- 2008, Brian Thomas was accused of killing his wife while he dreamt she was an intruder, whilst on holiday in West Wales. Thomas was found not guilty.
Sleepwalking has attracted a sense of mystery, but it had not been seriously investigated and diagnosed until the last century.[clarification needed] The 19th-century German chemist and parapsychologist Baron Karl Ludwig von Reichenbach made extensive studies of sleepwalkers and used his discoveries to formulate his theory of the Odic force.
Sleepwalking was initially thought to be a dreamer acting out a dream. For example, in one study published by the Society for Science & the Public in 1954, this was the conclusion: "Repression of hostile feelings against the father caused the patients to react by acting out in a dream world with sleepwalking, the distorted fantasies they had about all authoritarian figures, such as fathers, officers and stern superiors." This same group published an article twelve years later with a new conclusion: "Sleepwalking, contrary to most belief, apparently has little to do with dreaming. In fact, it occurs when the sleeper is enjoying his most oblivious, deepest sleep—a stage in which dreams are not usually reported." More recent research has discovered that sleepwalking is actually a disorder of NREM (non-rapid eye movement) arousal. Acting out a dream is the basis for a REM (rapid eye movement) sleep disorder called REM Behavior Disorder (or REM Sleep Behavior Disorder, RSBD). More accurate data about sleep is due to the invention of technologies such as the electroencephalogram (EEG) by Hans Berger in 1924 and BEAM by Frank Duffy in the early 1980s.
In 1907, Sigmund Freud spoke about sleepwalking to the Vienna Psychoanalytic Society (Nunberg and Federn). He believed that sleepwalking was connected to fulfilling sexual wishes and was surprised that a person could move without interrupting their dream. At that time, Freud suggested that the essence of this phenomenon was the desire to go to sleep in the same area as the individual had slept in childhood. Ten years later, he speculated about somnambulism in the article "A Metapsychological Supplement to the Theory of Dreams" (1916–17 ). In this essay, he started to clarify and expand his hypothetical ideas on dreams. The dreams is a fragile equilibrium that is only partially successful because the repressed unconscious impulses of the unconscious system. This does not obey the wishes of the ego and maintain their countercathexis. Another reason why dreams are partially successful is because certain preconscious daytime thoughts can be resistant and these can retain a part of their cathexis as well. It is probable how unconscious impulses and day residues can come together and result in a conflict. Freud then wondered about the outcome of this wishful impulse which represents an unconscious instinctual demand and then it becomes a dream wish in the preconscious. Furthermore, Freud stated that this unconscious impulse could be expressed as mobility during sleep. This would be what is observed in somnambulism, though what actually makes it possible remains unknown.
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