Phoenix Rising Sleep Medicine
A Case of Parasomnia
Published on May 11, 2003
A 28-year-old male with a history of sleepwalking benefitted from taking sertraline and clonazepam as well as avoiding stressful situations and maintaining a regular sleep schedule.
A 28-year-old architect’s assistant/draftsman was referred to the Sleep Medicine Clinics, Buffalo Medical Group PC, Buffalo, NY, on June 26, 2002, for evaluation of sleepwalking. He had a history of sleepwalking beginning at age 8; had no symptoms of depression, panic attacks, or anxiety; did not use street drugs; and occasionally drank alcohol. He was physically active in sports. There was some work-related stress present, such as deadlines to complete projects. He habitually went to bed at 10:30 pm and woke up at 6 am. On weekends, he slept until 7:30 am. He had no symptoms of sleep apnea. He had fuzzy (or no) recollection of his dreams. Once, he woke to find himself stuck in the closet; another time, he found himself playing basketball in his living room. He would also dream of someone breaking into his house, at which time he would shout. He had not injured himself or harmed others. He had a history of stuttering, for which he underwent speech therapy. There was no family history of sleep disorders. He had shown no evidence of violent behavior. He was worried about causing injury to his wife and newborn child. He was also concerned about safety issues, such as the possibility that he might lock himself in the closet, drive the car, or play basketball in the living room again and damage furniture. He had no history of nocturnal enuresis or rapid–eye-movement (REM) behavioral disorder, but he did talk in his sleep. The results of physical examination were normal, except for slight deviation of the nasal septum, a mildly large soft palate and uvula, a large neck size (46 cm), and a weight of 109 kg at a height of 188 cm. His Epworth sleepiness score was 7/24.
The patient was advised to avoid stressful situations, maintain a regular sleep schedule and good sleep hygiene, avoid excessive consumption of coffee and other caffeinated beverages, and avoid alcohol. Safety issues were addressed, including locking the windows and bedroom doors at night, keeping car keys in a secure place, and keeping his hunting guns locked. Clonazepam was instituted at 0.5 mg and gradually increased to 1 mg at bedtime. Over the next several months, the patient’s sleepwalking became worse; he started having two to three episodes per week during which he thought that someone was robbing his house. He woke at these times to find himself at the doorway, shouting. His 2-week sleep diary showed satisfactory sleep hygiene, but frequent nighttime awakenings. Diagnostic nocturnal polysomnography (PSG) showed sleep efficiency of 87%, increased REM sleep, absent d sleep, an arousal index of 20.2, a total of 27 hypopneas with a hypopnea index of 4.6, moderate snoring, and oxygen saturation of 95%. The patient was seen by a neurologist and underwent an MRI scan of the brain. This showed no evidence of multiple sclerosis or other neurodegenerative disorders. Sertraline (50 mg) was added to the patient’s drug regimen of clonazepam (1 mg).
At his follow-up visits for the past several months, the patient reports that his sleepwalking has subsided and that he sleeps well and is well rested.
Sleepwalking (somnambulism) episodes frequently begin with paroxysmal bursts of high-amplitude, slow-wave sleep activity.1,2 Somnambulism is a disorder of arousal characterized by partial recurrent episodes in which the individual awakens from non-REM (NREM) sleep (usually stages 3 and 4), typically during the first third of the night, and displays a series of complex behaviors. These range from simply sitting up in bed to walking; frantic attempts to escape; and automatic behaviors such as dressing, eating, performing bathroom functions, preparing meals, and even driving.3 Eating during sleepwalking may manifest itself as part of a sleep-related eating syndrome. During sleepwalking, coordination is poor, speech is incoherent, clumsiness is common, and the patient finds it hard to communicate. Patients are usually difficult to awaken during these episodes; if awakened, they are confused and may become aggressive or combative.1,2 There is some overlap with night terrors, but the overactivity of the sympathetic nervous system that is present in night terrors is absent in sleepwalking.1,2 Talking during sleep (somniloquy) can occur simultaneously.
In children, sleepwalking usually occurs during the first third of the night, when slow-wave sleep is present1; however, recent studies in adults1 have recorded episodes beginning in stage-2 NREM sleep and frequently taking place during the second half of the night. Episodes in children are rarely violent and movements often are slow, but episodes in adults can be frenzied and violent. Sleepwalking may be terminated spontaneously, by the patient returning to bed, or simply lying down and continuing to sleep outside the bed. Typically, there is total amnesia for such episodes.1,2
Sleepwalking can occur after any age as children learn to walk, but peak incidence is between the ages of 4 and 8, and it usually disappears during adolescence.1-3 The onset of sleepwalking can occur in adulthood; however, most adult sleepwalkers have also had episodes during childhood. A strong family history of parasomnia is usually present.4 Precipitating factors for sleepwalking episodes are conditions that deepen sleep and/or disrupt slow-wave sleep. These include stress, pain, sleep apnea, a distended bladder, fever, sleep deprivation, and the use of alcohol or certain medications (including phenothiazines, tricyclic antidepressants, lithium, and central–nervous-system depressants).1,2 Sleepwalking during slow-wave sleep rebound has been reported in a patient with obstructive sleep apnea. Episodes can be triggered by forced arousal during deep sleep in the early part of the night.5
Until recently, persistence of sleepwalking into adulthood was believed to be a manifestation of underlying psychopathology, but investigators6 have found that at least 50% of adult sleepwalkers have no underlying psychopathology. In PSG, the classic finding is a sudden arousal occurring in slow-wave sleep. During prolonged arousal, there usually is tachycardia with persistence of slow-wave EEG activity, despite the presence of high-frequency EEG activity and an increase in electromyographic amplitude. Video recording during PSG to document body movements may confirm a diagnosis of this parasomnia. On nights without episodes, the PSG shows three or more direct, slow-wave-wakefulness transitions, which are rarely seen in individuals without sleepwalking.7 Sleep monitoring is indicated when sleepwalking has resulted in bodily injury or the patient has failed to respond to simple measures.
Differential diagnosis for sleepwalking includes REM behavioral disorder (which occurs during REM sleep, usually in the later part of the night, does not involve confusional arousals, and permits the individual to recall dreams on waking); seizure disorders, such as temporal-lobe seizures; and dissociative states.1,2
Schenck et al6 reported sleep-related injury in 100 adult patients. Out of these, 54 had night terrors/sleepwalking (33% with onset after age 16 and 70% with episodes arising from sleep stages 1 and 2, as well as slow-wave sleep); 36 had REM behavioral disorder; and two had nocturnal seizures. Psychological evaluation of these individuals identified 50% as having depression, substance abuse, or dysthymia; the other half of the group had no identifiable psychopathology
Sleepwalking can lead to social embarrassment and self-injury, including cuts, burns, and other injuries that may arise from walking into dangerous situations. A sleep terror may precede (and evolve into) a sleepwalking episode. Violent behavior, including homicide, has been reported during episodes of sleepwalking.
Therapy for sleepwalking includes environmental precautions (avoiding sleep deprivation, irregular sleep schedules, and stress; sleeping on the ground floor; keeping doors and windows closed and bolted; and removing sharp and potentially dangerous objects from the bedroom) and reassurance. Hypnosis and psychotherapy have been reported1,2 to be effective. Benzodiazepines (clonazepam 0.5 mg to 2 mg at bedtime) and/or tricyclic antidepressants may be tried.8 Selective serotonin-reuptake inhibitors also have been beneficial. Therapy for young children with sleepwalking is seldom necessary.8 Parents can be reassured that their children will outgrow such episodes. Slow-wave sleep rebound after prior sleep deprivation (as seen after the institution of nasal CPAP for sleep apnea) can precipitate episodes of sleep walking.9
Taj M. Jiva, MD, is clinical assistant professor of medicine and director of Sleep Medicine Clinics, Phoenix Rising Medical, PC, Buffalo, NY; and Naseer Masoodi, MD, is chief medical resident, State University of New York at Buffalo School of Medicine.