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 exhibit 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 another person involved upon waking

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:

• A lack of brain supply can disturb the sleep cycle, contributing to sleepwalking.
• Dysregulation in the sleep/wake cycles during 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.

Sleepwalking occurs during deep sleep. Any factor that triggers physical activity while primarily 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. Here are eight practical ways to improve your child’s sleeping habits.
2. Family history: Individuals with a family history of sleepwalking are more likely to develop this condition. Studies indicate that individuals with a first-degree relative who sleepwalks are ten times more likely to experience sleepwalking. Identical twins also have a higher chance of developing sleepwalking compared to non-identical twins.
3. Sleep deprivation: Lack of sleep increases the risk of developing sleepwalking due to the longer duration spent in deep sleep.
4. Chaotic sleep schedules: People with chaotic sleep schedules, such as those with changing work shifts, repeated nighttime awakenings, and travelers frequently changing time zones, are more prone to this sleep disorder.
5. Medications: Some medications may have a sedative effect that contributes to sleepwalking. Examples 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.
7. Medical conditions: 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.

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 sleepwalking. 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 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
   Polysomnography 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 engaging in unusual activities. 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.

Are you tossing and turning in bed and unable to enjoy a well-rested sleep? Listen to our expert discuss various sleep disorders.

Sleepwalking can be prevented by ensuring an adequate amount of sleep. The following measures can help improve the quality of sleep:

• Maintain a sleep schedule and follow sleep hygiene guidelines, including going to bed and waking up at the same time every day.
• Get early morning sunlight. Spending 15-30 minutes in sunlight helps regulate the body's biological clock.
• Stay active during the day, as a sedentary lifestyle can hinder a good night's sleep.
• Limit daytime naps.
• Be mindful of your diet by avoiding large meals and beverages before bedtime.
• Switch off televisions and computers two hours before sleep, as the light from screens interferes with the sleep cycle.
• Avoid using tablets and smartphones in bed, as the blue light from these devices disrupts the release of melatonin, the sleep hormone.
• Steer clear 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.
• Sleep in complete darkness by eliminating nightlights and any external light, which helps promote the secretion of melatonin and encourages sound sleep.

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Sleepwalking does not require treatment and typically resolves on its own as the child matures. In most cases, sleepwalking episodes are rare and do not pose a significant risk to the individual or those around them. However, severe and more frequent episodes may necessitate medical intervention.

Treatment considerations

Treatment protocol depends on 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, should be identified and addressed.

• Reassurance: The mainstay of treatment is reassuring the individual that sleepwalking will resolve on its own.
• Medications: Medications are usually prescribed if there is a high chance of injury due to sleepwalking, significant family disruption, or excessive daytime sleepiness, or if other methods have failed. Although there are no approved medications specifically for sleepwalking, the following have shown benefits:
  • Clonazepam
  • Gabapentin
  • Estazolam
  • Trazodone
  • Melatonin (in severe cases)
  Typically, medications can be discontinued after three to five weeks without the reappearance of symptoms.
• Scheduled (anticipatory) waking: Every sleepwalking episode usually occurs at a specific time. Scheduled waking involves waking the individual 15-30 minutes before that time, which helps prevent partial awakening, a trigger for sleepwalking. This technique is particularly effective in reducing sleepwalking episodes in children.

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

1. Smell essential oils
   Some fragrances facilitate falling asleep. The scent of essential oils such as lavender, vetiver, frankincense, and clary sage helps to reduce anxiety and makes the sleep journey more pleasant. These essential oils can be directly inhaled by placing a few drops on a tissue and holding it close to the nose.
2. Enrich your diet with nutrients
   An inadequate amount of calcium and magnesium can affect sleep quality. It is advisable to include these nutrient-rich foods to help promote sound sleep, which can reduce episodes of sleepwalking. These foods include:
   • Milk
   • Yogurt
   • Cheese
   • Leafy greens
   • Nuts
   • Seeds
   • Beans
   • Whole grains
   Fulfill the calcium demand by adding supplements to your routine.
3. Load up on omega-3 fatty acids
   A sufficient intake of omega-3 fatty acids also facilitates easier sleep. Consume a few servings of wild salmon or tuna each week, or consider taking a supplement.
4. Add tryptophan-rich foods
   Tryptophan aids in the production of serotonin, a neurotransmitter that helps induce sleep. Foods rich in tryptophan 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 aid in falling asleep and staying asleep longer. Consider adding the following teas to your bedtime routine:
   • Chamomile (Babune ka phool): Promotes a feeling of calm. Add a teaspoon of chamomile leaves to boiling water for 10 minutes to prepare.
   • Passionflower (Krishna kamal ka phool): Acts as a mild sedative. Add a teaspoon of passionflower to boiling water for 10 minutes.
   • Valerian (Tagar): Known for helping people fall asleep faster and wake less often throughout the night. It can be prepared by boiling valerian root in water.

Sleepwalking can have serious health consequences such as:

• Injury from falling or colliding with objects while walking or running
• Cut and puncture wounds from mishandling sharp objects
• Embarrassment from violent and unusual actions, including sexually explicit behavior, aggressive outbursts, or urinating in inappropriate places
• 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)

The following alternative therapies can aid the conventional treatment options:

• Cognitive Behavioral Therapy: Cognitive behavioral therapy (CBT) is a talking therapy that helps manage problems by changing one's way of thinking. It assists individuals in coping better with the factors that trigger episodes of sleepwalking and improves their sense of control over behavior.
• Hypnotherapy: This therapy involves controlling the individual's mind. Sleepwalkers are conditioned to believe they will wake up if they touch the ground, which helps disrupt the sleepwalking process. Recorded hypnosis sessions also aid the individual. These interventions are typically performed daily for about two to three weeks.
• Mental Imagery: This technique involves establishing a precise and distinct objective for what you wish to visualize and accomplish. It is followed by closing the eyes and taking deep breaths to relax the mind and body. This approach is more effective when done under the guidance of an experienced behavioral therapist.
• Relaxation Techniques: Relaxation techniques such as meditation and deep breathing exercises help establish a regular and calming routine before bedtime. Here are five easy relaxation techniques that can be practiced at home.

Sleepwalking is often seen in children, and episodes gradually decline in adolescents. People living with sleepwalking should monitor their sleep patterns. Caregivers and spouses of individuals should be educated about scheduled waking.

1. Reduce Elements That Can Cause Injuries

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

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

2. Improve Sleep Hygiene

Poor sleeping habits such as an inconsistent sleep schedule and consumption of caffeine or alcohol close to bedtime increase the frequency of sleepwalking episodes. The following measures can help induce sound sleep, thereby reducing the risk of sleepwalking:

• Avoid noise early in the sleep cycle.
• Use a comfortable mattress, considering your sleeping position and body type.
• Avoid caffeine and alcohol at bedtime.

3. Choose Your Bedroom Wisely

Individuals or parents with a child who sleepwalks should choose bedrooms on the first floor of the house to minimize the risk of 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 or shouting at the child.
• Guide the child back to their bed.
• Ensure that the child is getting enough sleep.
• Maintain a sleep diary for your child.