Sleepwalking
A sleep disorder involving walking or performing complex behaviors while in a state of partial arousal from deep sleep.
What is Sleepwalking?
Sleepwalking (somnambulism) is a parasomnia involving complex behaviors, most notably walking, that occur during partial arousal from deep non-REM sleep (stages N3). Sleepwalkers appear awake with their eyes open but are actually in a state of incomplete awakening, unresponsive or only partially responsive to their environment, and have no memory of the episode upon full awakening. Episodes typically occur during the first third of the night when deep sleep is most prominent. Behaviors can range from simply sitting up in bed to walking, eating, or even driving, and can occasionally result in injury.
Prevalence
Sleepwalking is common in children, affecting up to 15-30% at some point during childhood, with peak prevalence between ages 8-12. Most children outgrow it by adolescence. In adults, prevalence is approximately 2-4%. There is a strong genetic component: the risk is 10 times higher if a first-degree relative is affected, and identical twins show high concordance.
Causes
Sleepwalking occurs when the brain becomes partially aroused from deep sleep, but fails to fully awaken. Contributing factors include: genetics (most important factor), sleep deprivation, irregular sleep schedules, stress and anxiety, fever (especially in children), certain medications (sedatives, hypnotics, some antidepressants), alcohol, sleeping in unfamiliar environments, sleep disorders that fragment sleep (sleep apnea, restless legs), and conditions causing frequent arousal from deep sleep. The immature brain in children makes incomplete arousals more likely.
Symptoms
Walking during sleep
The hallmark symptom is getting out of bed and walking while remaining in a sleep state. Eyes are typically open but have a glassy, unfocused appearance.
Difficulty awakening during episode
Sleepwalkers are difficult to wake and may become confused or agitated if awakened. It's generally recommended to gently guide them back to bed.
No memory of the event
Upon waking the next morning, the person has no recollection of the sleepwalking episode or any events that occurred.
Complex behaviors
Beyond walking, sleepwalkers may perform complex activities like eating, dressing, opening doors, going outside, or even driving.
Blank expression
During episodes, the face appears blank and unresponsive. The person may not recognize family members or respond to their names.
Episodes during first third of night
Most sleepwalking occurs in the first few hours after falling asleep, when deep (slow-wave) sleep is most abundant.
Potential for injury
Sleepwalkers may trip, fall, walk into objects, or leave the house, potentially resulting in injury.
Diagnosis
Self-Assessment Questions
If you answer yes to any of these questions, consider consulting a sleep specialist:
- 1Has anyone observed you walking around while appearing asleep?
- 2Do you wake up in unexpected places or find evidence of activities you don't remember?
- 3Do family members report that you're difficult to wake during these episodes?
- 4Do you have no memory of these events the next morning?
- 5Do episodes occur in the first few hours after falling asleep?
- 6Do you have family members who sleepwalk?
Diagnosis is typically clinical, based on history from bed partners or family members. Polysomnography is not usually required but may be done to rule out other conditions or when episodes are frequent, violent, or associated with injury.
Clinical History
Detailed description of events from witnesses, including timing, behaviors, responsiveness, and duration, is the primary diagnostic tool.
Sleep Diary
Tracking sleep patterns and episodes can identify triggers and patterns.
Polysomnography
Sleep study may be performed to capture episodes (if frequent), rule out sleep apnea or seizures, or when diagnosis is uncertain. Extended video-EEG may be needed.
Neurological Evaluation
May be indicated if seizures are suspected or if episodes begin in adulthood without apparent cause.
Treatment
For most people, especially children, sleepwalking resolves without specific treatment. Management focuses on safety measures and addressing triggers. Medication is reserved for frequent, dangerous, or disruptive episodes.
Safety Precautions
The first priority is preventing injury: lock windows and doors, install alarms, remove obstacles, sleep on ground floor if possible, and secure dangerous objects.
Address Triggers
Treating sleep deprivation, sleep apnea, and restless legs can reduce episodes. Managing stress and avoiding alcohol helps.
Scheduled Awakenings
For children with predictable timing, briefly waking them 15-30 minutes before usual episode time can disrupt the pattern.
Benzodiazepines
Clonazepam at bedtime can be effective for frequent or dangerous episodes by reducing deep sleep transitions and arousals.
Antidepressants
SSRIs or tricyclic antidepressants may help some patients, possibly by affecting sleep architecture.
Hypnotherapy
Some evidence supports hypnosis as a treatment for parasomnia, particularly in children and adolescents.
Lifestyle Adjustments
- •Maintain a consistent sleep schedule with adequate sleep time
- •Avoid alcohol, especially before bed
- •Reduce stress through relaxation techniques
- •Create a safe sleep environment (clear pathways, lock doors)
- •Install alarms on bedroom doors
- •Sleep on the ground floor if possible
- •Address any underlying sleep disorders
- •Avoid sleep deprivation, which is a common trigger
- •Be cautious with new medications that may affect sleep
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