AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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:
• • Detailed description of the event
  • Level of consciousness before, during, and after the event
  • Time of night and sleep cycle when the events occur
  • Daytime sleepiness
  • Associated injury
  • Memory of the event
  • Family history
  • 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
• • 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.
  • 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).
  • Sleepwalking has no association with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark), or anger outbursts.
  • 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
• • 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.
  • In infants, episodes manifest by crying and moving about in bed.
  • The eyes may be closed or opened, as in sleep terrors, but the child does not appear to feel panic.
  • 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
• • 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.
  • This may be followed by panic-driven motor activity, such as hitting the wall or running around the room.
  • While typically not dangerous, the behavior is sometimes violent enough to result in injury to the patient or others; property damage also may result.
  • 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.
  • 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
• • Sleepwalking occurs more frequently in monozygotic twins and is 10 times more likely if a first-degree relative has a history of sleepwalking.
  • 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), antidepressants (eg, bupropion, 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
• • The length and depth of SWS, which is greater in young children, may be a factor in the increased frequency of parasomnias in children.
  • Conditions such as pregnancy and menstruation are known to increase frequency in patients with parasomnias.
• Associated medical conditions
• • Arrhythmias
  • Chronic paroxysmal hemicrania
  • Migraine
  • Fever
  • Gastroesophageal reflux
  • Nocturnal asthma
  • Nocturnal seizures
  • Obstructive sleep apnea: Children with obstructive sleep apnea or Tourette syndrome are at greater risk of having parasomnias along with their underlying disorder.
  • 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.
  • Psychiatric disorders
  • • Posttraumatic stress disorder
    • Panic attack
    • Dissociative states
  • Hyperthyroidism: 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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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
• • Behaviors include head banging, body rolling, or body rocking.
  • Onset is usually in children younger than 9 months (prevalence is 60% at that age but only 5% in children aged 5 y).
  • 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)

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

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab 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

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• General guidelines
• • Reassurance is the mainstay of treatment. The benign nature of the events and subsequent disappearance in most cases should be emphasized.
  • 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).
  • Avoid auditory, tactile, or visual stimuli early in the sleep cycle. These have been shown to induce events in some patients with parasomnias.
  • 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.
  • 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:
  • The possibility of injury is real.
  • Continued behaviors are causing significant family disruption or excessive daytime sleepiness.
  • Unusual symptoms are present.
  • Nonpharmacological interventions have proven to be inadequate.
  • 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.
  • 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
  • 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.
  • 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

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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.

Drug Category: 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.

Drug Name	Amitriptyline (Elavil)
Description	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.
Adult Dose	30-100 mg/d PO hs
Pediatric Dose	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
Contraindications	Documented hypersensitivity; patients who have taken MAOIs in past 14 d
Interactions	Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; use caution in elderly persons

Drug Name	Nortriptyline (Aventyl HCl, Pamelor)
Description	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.
Adult Dose	25 mg PO tid/qid; not to exceed 150 mg/d
Pediatric Dose	<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
Contraindications	Documented hypersensitivity; narrow-angle glaucoma; patients who have taken MAOIs in past 14 d
Interactions	Cimetidine may increase levels; may increase PT in patients stabilized on warfarin
Pregnancy	D - Unsafe in pregnancy
Precautions	Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; because of pronounced effects in cardiovascular system, use caution in elderly persons

Drug Category: 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.

Drug Name	Clonazepam (Klonopin)
Description	Believed to enhance activity of inhibitory neurotransmitter GABA in CNS. Antiseizure and antipanic effectiveness has been demonstrated. Generally considered DOC for disorders of arousal.
Adult Dose	0.5 mg PO hs initial dose for sleep disorders; may increase rapidly to 1 mg prn
Pediatric Dose	0.25 mg PO 1 h before hs initial dose; increase cautiously prn
Contraindications	Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma
Interactions	Cimetidine, disulfiram, isoniazid, and estrogens may increase plasma levels of 2-keto benzodiazepines; antacids and food may decrease absorption, and smoking may decrease metabolism; may increase plasma levels of phenytoin and digoxin; additive CNS depressant effects with other benzodiazepines and sedative drugs
Pregnancy	D - Unsafe in pregnancy
Precautions	In patients with multiple seizure types, may worsen generalized tonic-clonic seizures; abrupt withdrawal may cause status epilepticus; caution in renal impairment and those with difficulty handling secretions; tolerance of adverse effects rarely a problem; monitor for daytime sedation when increasing dose

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal 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.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Ajlouni KM, Ahmad AT, El-Zaheri MM, et al. Sleepwalking associated with hyperthyroidism. Endocr Pract. Jan-Feb 2005;11(1):5-10. [Medline].
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• Guilleminault C, Kirisoglu C, da Rosa AC, et al. Sleepwalking, a disorder of NREM sleep instability. Sleep Med. Mar 2006;7(2):163-70. [Medline].
• Guilleminault C, Lee JH, Chan A, et al. Non-REM-sleep instability in recurrent sleepwalking in pre-pubertal children. Sleep Med. Nov 2005;6(6):515-21. [Medline].
• Hublin C, Kaprio J, Partinen M, et al. Prevalence and genetics of sleepwalking: a population-based twin study. Neurology. Jan 1997;48(1):177-81. [Medline].
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• Lu ML, Shen WW. Sleep-related eating disorder induced by risperidone. J Clin Psychiatry. Feb 2004;65(2):273-4. [Medline].
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• Owens J, Opipari L, Nobile C, Spirito A. Sleep and daytime behavior in children with obstructive sleep apnea and behavioral sleep disorders. Pediatrics. Nov 1998;102(5):1178-84. [Medline].
• Plazzi G, Vetrugno R, Provini F, Montaqna P. Sleepwalking and other ambulatory behaviours during sleep. Neurol Sci. Dec 2005;26 Suppl 3:s193-8. [Medline].
• Rosen GM, Mahowald MW, Ferber R. Sleepwalking, confusional arousals, and sleep terrors in the child. In: Principles and Practice of Sleep Medicine in the Child. 1995:99-106.
• Sattar SP, Ramaswamy S, Bhatia SC, Petty F. Somnambulism due to probable interaction of valproic acid and zolpidem. Ann Pharmacother. Oct 2003;37(10):1429-33. [Medline].
• Stores G. Practitioner review: assessment and treatment of sleep disorders in children and adolescents. J Child Psychol Psychiatry. Nov 1996;37(8):907-25. [Medline].
• Wise MS. Parasomnias in children. Pediatr Ann. Jul 1997;26(7):427-33. [Medline].
• Zucconi M, Oldani A, Ferini-Strambi L, et al. Nocturnal paroxysmal arousals with motor behaviors during sleep: frontal lobe epilepsy or parasomnia?. J Clin Neurophysiol. Nov 1997;14(6):513-22. [Medline].

Somnambulism (Sleep Walking) excerpt

Article Last Updated: Mar 8, 2007