Somnambulism (ie, sleepwalking) is a disorder of arousal that falls under the Parasomnias group of disorders. Parasomnias are undesirable motor, verbal, or experiential events that occur typically during non-Rapid Eye-Movement (NREM) sleep. The disorder is usually benign, self-limited and rarely requires treatment.

Sleepwalking was once thought to be an acting out of dreams, however, sleepwalking actually takes place during deep sleep, not during REM sleep when dreams most typically occur. Because sleepwalking tends to occur in NREM or slow wave sleep, it will tend to occur in the earlier segments of the sleep period, during the first third of the sleep cycle and will rarely occur during naps. A sleepwalker will often perform routine activities such as dressing and cleaning. Sleepwalking is most frequent in children (up to 14%) and tends to decrease with the onset of puberty. However, at least 25% of children with recurrent sleepwalking may continue to sleepwalk in adulthood (approximately 1% of adults). Bouts of sleep walking can be triggered by stress, anxiety and excessive alcohol. Epilepsy is an important differential diagnosis.

In both children and adults, sleepwalking can be precipitated by a range of conditions such as insufficient sleep, irregular sleep schedules, staying up late or waking early in the morning. Other factors include fever, stress, medications (such as phenothiazines, chloral hydrate, and lithium) and other sleep disorders such as obstructive sleep apnea.

Symptoms

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 subject quietly roams the house.

On questioning, responses are slow or absent. If returned to bed without awakening, the subject 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).

Sleepwalking has no association with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark), or anger outbursts.

Assessment

The diagnosis of sleepwalking is generally made by history alone and rarely requires or warrants the expense of an overnight sleep study. An overnight sleep study may be suggested if there are other sleep related concerns. There are no laboratory tests for sleepwalking. Differential Diagnoses include epilepsy, febrile seizures, Narcolepsy, Periodic Limb Movement Disorder and Obstructive Sleep Apnea

Treatment

Non-pharmacological -

Sleepwalking is a highly treatable condition. In general, the best treatment is reassurance. The relatively benign nature of the events and the subsequent disappearance in most cases should be emphasized.

Every effort should be made to eliminate any environmental or predisposing factors that may be playing a role. For example, ensure adequate, age appropriate sleep duration, address any underlying medical conditions that can exacerbate sleepwalking such as GERD, Obstructive Sleep Apnea and Periodic Limb Movement.

Auditory, tactile or visual stimuli (loud TVs, radios etc) early in the sleep cycle have also been shown to induce sleepwalking in some patients.

Safety steps should be encouraged. Patients should lock doors and windows, remove obstacles and sharp objects from the room. In some cases alarms might be helpful to decrease the likelihood of one of the main concerns about sleepwalking, injury.

In some cases a person sleepwalking can be re-directed to bed in a gentle way, especially if it is a child. However, attempting to confront or wake the person can lengthen the episode and may induce resistance or even violence from the sleepwalker.

Some experts recommend anticipatory awakenings which consist of waking the patient 15-20 minutes before the usual episode onset time and keeping them awake through the time during which the episodes typically occur. This is generally more helpful in children than adults.

Pharmacological -

If the sleepwalker is in real danger of injury, if stress and sleep management have not been effective and/or if the disorder is causing excessive daytime sleepiness, pharmacological measures may be necessary.

A range of Benodiazipines (such as Clonazepam or lorazepam), tricyclic antidepressants (such as Amitriptyline), serotonin antagonist and reuptake inhibitors (such as trazadone) and the serotonin reuptake inhibitors have been shown to be useful. Clonazepam and lorazepam in low doses before bedtime and used for 3-6 weeks is usually effective. These medications prevent the partial awakenings that cause sleepwalking episodes.

Medication often can be discontinued with physician supervision after 3-5 weeks without a recurrence of symptoms and this expectation should be shared with the patient as these can be addictive medications. Patients should also be informed that the frequency of episodes may increase briefly after medication is discontinued due to rebound sleep issues.

In the U.S. Military, sleepwalking is considered an “other designated physical or mental condition” that can trigger an involuntary administrative separation due to behavior that is sufficiently severe that the member’s ability to effectively perform military duties is significantly impaired. In most cases both a medical and mental health evaluation is required. Each of the Services have a policy guiding this type of administrative discharge.

In my personal experience I have been involved directly or indirectly in at least dozen admin seps for sleepwalking. Many of the cases that made it to the admin sep process probably could have been prevented by a knowledgeable provider network AND a motivated patient. In some cases the member had already attached him or herself to the admin sep process and was not “ideally motivated” for treatment. I would suggest assessing for malingering if there appears to be sufficient “secondary gain”, good treatment effort has failed and the provider is motivated (and it is in the best interest of the Service) to do so. Members seeking medical or behavioral health care have frequently been successfully treated by the minimal interventions mentioned here.

Dr. Bill Brim is the Deputy Director for the Center for Deployment Psychology and a subject matter expert on insomnia and sleep disturbances related to deployment.