Sleepwalking

Symptoms Of Sleepwalking 

Sleepwalking is a parasomnia, which is an undesired movement during sleep. Despite the name, sleepwalking is not limited to only walking while sleeping. It can involve several other strange and inappropriate activities while sleeping, such as:

• Sitting with open eyes, having a blank look
• Doing routine activities such as brushing teeth and getting dressed
• Having a glazed expression
• Facing difficulty in waking up
• Having a feeling of confusion
• Returning to bed suddenly
• Talking or shouting while walking 
• Having sleep terrors
• Running
• Eating 
• Engaging in sexual behavior (sexsomnia)
• Urinating in inappropriate places
• Trying to escape from a threat that is dreamed or imagined
  
  

It's important to note that these sleepwalking episodes are typically short-lived, lasting from a few seconds to half an hour. One of the most distinctive features of sleepwalking is the inability to recall the incident upon waking up, adding to its mysterious nature. 

In rare cases, a person can do violent behavior that can prove to be risky. Such behavior includes:

• Trying to drive a car
• Leaving the house
• Climbing out of a window
• Attacking the other person involved in waking

Causes Of Sleepwalking 

Human beings have two phases of the sleep cycle. Each phase varies in muscle tone, brain functions, and eye movements.

Non-rapid eye movement (NREM): These stages of deeper sleep progressively shift from N1 to N3. Approximately 75% of sleep is spent in the NREM stages.

• N1 (light sleep)- 5% of sleep

• N2 (deeper sleep)- 25%

• N3 (deepest sleep)- 45%

Note: Sleepwalking, night terrors, and bedwetting occur in the N3 stage.

Rapid eye movement (REM): This stage is not considered the restful stage of sleep. REM is associated with dreaming and usually starts after 90 minutes of sleeping. The main characteristic of REM is irregular muscle movements, including eye movements. About 25% of an individual's sleep duration is REM. 

What causes sleepwalking?

The brain controls all the phases of sleep. There are various theories stating the causes of sleepwalking. These include:

• It is suggested that a lack of brain supply in the brain can disturb the sleep cycle, which may contribute to sleepwalking

• Dysregulation in the sleep/wake cycles in the maturation phase of sleep causes sleepwalking

What happens during the N3 phase that triggers sleepwalking?

The brain activities are the slowest during the N3 phase, also known as slow-wave sleep. It occurs in two cycles. Sleepwalkers have an abnormality in the transition phase from the NREM cycle to wakefulness. In this transition state, it is almost impossible to wake up the individual. This shifting phase also has a high arousal threshold, mental confusion, and unclear perception, which are the signs of sleepwalking. 

Interesting fact!

Men experience more nighttime awakenings than women because they spend more time in the N1 stage of sleep. However, women find it difficult to fall asleep because they maintain slow-wave sleep for longer than men. 

Risk factors For Sleepwalking

Sleepwalking occurs during deep sleep. Any factor that triggers physical activity while mainly remaining asleep is a risk for sleepwalking. These factors include:

1. Age

Children are more prone to develop sleepwalking as soon as they start walking. 

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2. Family history

Persons having a family history of sleepwalking are more prone to develop this condition. As per some studies, individuals with a first-degree relative of sleepwalking are ten times more likely to develop sleepwalking. 

Identical twins also have a higher chance of developing sleepwalking than non-identical twins.

3. Sleep deprivation

Lack of sleep also increases the risk of developing sleepwalking. This is because of the longer duration spent in deep sleep. 

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4. Chaotic sleep schedules

People with chaotic sleep schedules, such as those with changing work shifts, repeated nighttime awakenings, and travelers who have often changed time zones, are more prone to this sleep disorder. 

5. Medications

Some medications may have a sedative effect that can contribute to sleepwalking. Examples of such medications include:

• Antibiotics (such as levofloxacin and ciprofloxacin)
• Anticonvulsants (such as valproic acid and topiramate)
• Antidepressants (such as bupropion, paroxetine, and amitriptyline)
• Sedatives (such as zolpidem)
• Antipsychotics (such as lithium and reboxetine)
• Selective serotonin reuptake inhibitors (SSRIs) (such as fluoxetine)
• Quinine

6. Alcohol

The consumption of alcohol is associated with an increased incidence of sleepwalking.

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7. Medical conditions

The conditions that affect the brain and sleep also increase the risk of sleepwalking. These disorders include: 

• Fever

• Obstructive sleep apnea 

• Restless leg syndrome (powerful urge to move the limbs, especially the legs, when lying down)

• Hyperthyroidism

• Migraine headaches

• Head injury

• Encephalitis (brain inflammation)

• Arrhythmia 

• Chronic paroxysmal hemicrania (recurrent unilateral episodes of headache )

• Stroke

• Bloating

• Gastroesophageal reflux(GERD)

• Nocturnal asthma

• Magnesium deficiency

8. Stress

Stress can also induce sleepwalking by altering sleep patterns. 

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Note: Conditions such as pregnancy and menstruation are known to increase the frequency of episodes of sleepwalking. 

Diagnosis Of Sleepwalking 

There are no specific tests to diagnose sleep talking. However, the following aid in diagnosing the condition:

1. Medical history

A thorough medical history is necessary to assess the condition. The doctor may ask questions regarding the following:

• Another sleep disorder
• Medical condition
• Medication use
• Mental health disorder
• Substance abuse

2. Physical examination

The physician may conduct a physical examination to differentiate sleepwalking from other conditions, such as nocturnal seizures, alternative sleep disorders, or panic episodes that may present similarly and affect the sleep cycle. 

It is also done to look out for any signs of injury. 

3. Maintaining a sleep diary

The doctor generally asks that a sleep diary be maintained for at least two weeks. The diary serves as a tool for monitoring sleep habits and patterns and helps reveal how sleep affects daily activities. 

What information does a sleep diary contain?

A sleep diary contains all the related information and other details that may alter sleep quality, such as medications, alcohol, and food habits. 

• Bedtime 
• Wake-up time
• How long it takes to fall asleep
• The number and duration of sleep interruptions
• The number and duration of daytime naps
• Perceived sleep quality
• Consumption of alcohol, caffeine, and tobacco
• Daily medications
• Daily exercise

4. Electroencephalography (EEG)

Electroencephalography (EEG) measures brain activity using metallic discs attached to the scalp. Since the brain governs sleep, investigating brain alterations can facilitate the identification of sleepwalking causes.

5. Polysomnography

It includes an examination of the quality of sleep using a sleep study. A sleep study records the brain's activities, heart rate, and breathing while sleeping. It also assesses sleeping behavior, such as moving arms and legs or doing any unusual activity.

Polysomnography is not used for routine sleepwalking diagnosis. In most cases, medical history and reports from self or others are sufficient to make a diagnosis. 

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Prevention Of Sleepwalking 

Sleepwalking can be prevented by having an adequate amount of sleep. The following measures help in improving the quality of sleep.

• Maintain a sleep schedule and follow sleep hygiene guidelines. This includes sleeping and waking up at the same time every day.
• Get early morning sunlight. Spending 15-30 minutes in sunlight keeps the body's biological clock in order. 
• Stay active during the day, as a sedentary lifestyle can hamper a good night's sleep.
• Limit daytime naps.
• Mind what you eat by avoiding large meals and beverages before bedtime.
• Switch off the television and computers two hours before sleep time. The light from the screen interferes with the sleep cycle.
• Discourage using tablets and smartphones in bed, as the blue light from these gadgets interferes with the release of melatonin, the sleep hormone.
• Avoid intake of caffeine, nicotine, and alcohol before sleeping.
• Create a relaxing pre-bedtime ritual such as taking a warm bath, reading, or listening to soft music.
• Sleeping in complete darkness can help you eliminate nightlights and any other light coming from outside. This helps secrete melatonin and promote sound sleep.

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Specialist To Visit 

Sleeptalking in children is very common and can be managed without medical treatment. Parents of sleepwalkers should keep a close eye on their kids to prevent any injury. 

An immediate medical attention is required if: 

• Continues for a long period of time
• Frequent 
• Accompanied by other symptoms
• Presents with dangerous activities such as driving 

The specialist doctors that may help include:

• General Physician
• Sleep disorder specialist
• Neurologist
• Psychiatrist
• Paediatrician
• Behavioral therapist

General physician helps diagnose the condition and refers patients to specialists, depending on the symptoms.

Sleep disorder specialist helps manage the condition as they have expertise in sleep medicine. 

Neurologists help to diagnose and manage the neurological causes that may be responsible for sleepwalking.

Psychiatrist- sleepwalking can affect mood, which can lead to anxiety, depression, low sex drive, and more, which a psychiatrist can manage.

A pediatrician helps diagnose and manage the condition in children. 

A behavioral therapist helps manage sleepwalking by changing one's way of thinking. It helps individuals cope better with the factors that trigger episodes of sleepwalking. 

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Treatment Of Sleepwalking

Sleepwalking does not require treatment and resolves on its own as the child grows up. In most cases, sleepwalking episodes are rare and do not pose a significant risk to the individual and the people around him. The severe and more frequent episodes require medical intervention.  

Treatment considerations

• Treatment protocol depends upon the patient's age, frequency of episodes, and severity of the sleepwalking symptoms
• Any predisposing factors, such as lack of sleep, medications, and medical conditions, are identified and eliminated

1. Reassurance

The mainstay of treatment is reassuring the individual that sleepwalking will go away on its own.

2. Medications

Medications are usually prescribed if there is a : 

• High chance of injury due to sleepwalking
• Significant family disruption or excessive daytime sleepiness
• Failure of other methods

There are no approved medications for sleepwalking, but the following medications are proven to be beneficial: 

• Clonazepam
• Gabapentin 
• Estazolam
• Trazodone
• Melatonin (in severe cases)

Typically, medications can be stopped after three to five weeks without the reappearance of symptoms. 

3. Scheduled (anticipatory) waking

Every sleepwalking episode usually occurs at a particular time. Scheduled waking involves waking the individual 15-30 minutes before that time. This helps prevent partial awakening, which serves as a tool to induce sleepwalking. It is a very effective technique in reducing sleepwalking episodes in children. 

Home-care For Sleepwalking 

Several practices can be done at home to reduce the episodes of sleepwalking. 

1. Smell essential oils

Some fragrances make it easy to fall asleep. The scent of essential oils such as lavender, vetiver, frankincense, and clary sage helps to reduce anxiety and makes the sleep journey pleasing. 

These essential oils can be directly smelled by placing a few drops on the tissue and holding it close to the nose. 

2. Enrich your diet with nutrients

The inadequate amount of calcium and magnesium can affect sleep quality. It is advisable to add these nutrient-rich foods to help people sleep soundly, which helps reduce episodes of sleepwalking. These foods include:

• Milk
• Yogurt
• Cheese
• Leafy green
• Nuts
• Seeds
• Beans
• Whole grains

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3. Load up on omega-3 fatty acids.

A sufficient amount of omega-3 fatty acids also makes sleep easier. Eat a few servings of wild salmon or tuna each week, or consider taking a supplement. 

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4. Add tryptophan-rich foods

Tryptophan aids in producing a neurotransmitter called serotonin, which helps induce sleep. Such foods include:

• Quinoa
• Nuts
• Seeds
• Tofu 
• Cheese
• Chicken
• Fish
• Oats
• Beans
• Lentils
• Eggs
  

5. Try sleep-promoting teas

These teas have been used for centuries to make falling asleep easier and staying asleep longer. Here are a few teas for sleep to consider adding to your bedtime routine:

• Chamomile (Babune ka phool): It promotes a feeling of calm. Add a teaspoon of chamomile leaves to boiling water for 10 minutes to make it.
  
  

• Passionflower (Krishna kamal ka phool): It acts as a mild sedative. Add a teaspoon of passionflower to boiling water for 10 minutes.
  
  

• Valerian (Tagar): It’s known for helping people fall asleep faster and wake less often throughout the night. It can be made by boiling valerian root in water. 

Complications Of Sleepwalking

Sleepwalking can have serious health consequences such as:

• Injury by falling or colliding with something while walking or running
• Cut and puncture wounds by mishandling sharp objects
• Embarrassment through violent and unusual actions such as sexually explicit behavior, aggressive outbursts, or urinating in the wrong place
• Daytime sleepiness
• Tiredness
• Insomnia

Some activities while sleepwalking, such as driving a car or falling through a window, can even be life-threatening. 

Moreover, sleepwalking can significantly disrupt the sleep of those sharing a living space with the affected individual, such as a spouse, roommate, or housemate. 

Sleepwalking can also be associated with other conditions, such as:

• Confusional awakenings
• Rhythmic movement problems
• Sleep-disordered breathing
• Night terrors
• Sleep talking
• Bruxism (a condition in which an individual grinds, gnashes, or clenches teeth)

Alternative Therapies For Sleepwalking

The following alternative therapies can aid the conventional treatment options:

1. Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is a talking therapy that helps manage problems by changing one's way of thinking. It helps individuals cope better with the factors that trigger episodes of sleepwalking and improves their sense of control over behavior. 

2. Hypnotherapy

It includes controlling the individual's mind. Sleepwalkers are made to believe they will wake up if they touch the ground, which helps disrupt the sleepwalking process. The recorded hypnosis session also helps the individual. These interventions are done daily for about two to three weeks. 

3. Mental imagery

This is done by establishing a precise and distinct objective for what you wish to visualize and accomplish. It is followed by shutting the eyes and taking deep breaths to relax the mind and body.

This is more effective if done under the guidance of an experienced behavioral therapist.

4. Relaxation techniques

Relaxation techniques such as meditation and deep breathing exercises also help establish a regular and relaxing routine before bedtime. 

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Living With Sleepwalking

Sleepwalking is often seen in children, and episodes gradually decline in adolescents. People living with sleepwalking should watch their sleep patterns. 

Caregivers and spouses of individuals should be educated about the scheduled waking. 

1. Reduce elements that can cause injuries

Persons with sleepwalking are at high risk of injuring themselves. The following measures minimize the chances of injury:

• Keep sharp objects or weapons out of reach of children
• Keep the doors and windows close
• Remove tripping hazards from the floor
• Make sure your child does not sleep in an elevated bed (bunk bed)
• Use door or bed alarm, if possible 

2. Improve sleep hygiene

Poor sleeping habits such as inconsistent sleep schedule and drinking caffeine or alcohol close to bedtime increase the frequency of episodes of sleepwalking. The following measures help in inducing sound sleep, which reduces the risk of sleepwalking:

• Avoid any noise early in the sleep cycle
• Use a comfortable mattress, taking into account your sleeping position and body type
• Avoid caffeine and alcohol at bedtime

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3. Choose your bedroom wisely

Individuals or parents with a child who sleepwalks should always choose their bedrooms on the house's first floor. This helps minimize the injury. 

Managing sleepwalking in children

Parents should take the following steps to avoid unsafe situations:

• Avoid holding the child down or waking them up during sleepwalking
• Avoid slapping and shouting at the child
• Guide the child back to their bed
• Make sure that the child is getting enough sleep
• Maintain a sleep diary for your child