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Sleepwalking

sleep walking, sleep walking in suburbia
Sleepwalking, also known as somnambulism or noctambulism, is a phenomenon of combined sleep and wakefulness1 It is classified as a sleep disorder belonging to the parasomnia family2 Sleepwalking occurs during slow wave sleep stage in a state of low consciousness and perform activities that are usually performed during a state of full consciousness These activities can be as benign as sitting up in bed, walking to a bathroom, and cleaning, or as hazardous as cooking, driving,3 violent gestures, grabbing at hallucinated objects,4 or even homicide567

Although sleepwalking cases generally consist of simple, repeated behaviours, there are occasionally reports of people performing complex behaviours while asleep, although their legitimacy is often disputed8 Sleepwalkers often have little or no memory of the incident, as their consciousness has altered into a state in which it is harder to recall memories Although their eyes are open, their expression is dim and glazed over9 Sleepwalking may last as little as 30 seconds or as long as 30 minutes4

Sleepwalking occurs during slow-wave sleep N3 of non-rapid eye movement sleep NREM sleep cycles Sleepwalking typically occurs within the first third of the night when slow wave sleep is most prominent9 Usually, if sleepwalking occurs at all, it will only occur once in a night4

Contents

  • 1 Diagnosis
    • 11 Subtypes
  • 2 Epidemiology
  • 3 Causes
  • 4 Comorbid medical and psychological disorders
  • 5 Treatment
  • 6 Crime
  • 7 History
  • 8 In fiction
  • 9 References
  • 10 External links

Diagnosisedit

Three common diagnostic systems that are generally used for sleepwalking disorders are International Classification of Diagnoses,1 the International Classification of Sleep Disorders 3,10 and the Diagnostic and Statistical Manual2 Polysomnography is the only accurate measure of sleepwalking Other measures commonly used include self-report eg11, parent eg12, partner or house-mate reportcitation needed

Sleepwalking should not be confused with alcohol- or drug-induced blackouts, which can result in amnesia for events similar to sleepwalking During an alcohol-induced blackout drug-related amnesia, a person is able to actively engage and respond to their environment eg having conversations or driving a vehicle, however the brain does not create memories for the events13 Alcohol-induced blackouts can occur with blood alcohol levels higher than 006g/dl14 A systematic review of the literature found that approximately 50% of drinkers have experienced memory loss during a drinking episode and have had associated negative consequences similar to sleepwalkers, including injury and death13

Other differential diagnoses include Rapid eye movement sleep behavior disorder, confusional arousals, and night terrors

Subtypesedit

There are two subcategories of sleepwalking—sleepwalking with sleep-related eating and sleepwalking with sleep-related sexual behavior sexsomnia2

Sleep eating involves consuming food while asleep These sleep eating disorders are more often than not induced by stress related reasons Another major cause of this sleep eating subtype of sleepwalking is sleep medication, such as Ambien for example Mayo Clinic There are a few others, but Ambien is a more widely used sleep aid15 Because many sleep eaters prepare the food they consume, there are risks involving burns and such with ovens and other appliances As expected, weight gain is also a common outcome of this disorder, because a food that is frequently found contains high carbohydrates As with sleepwalking, there are ways that sleep eating disorders can be maintained There are some medications that calm the sleeper so they can get longer and better-quality rest, but more often than not activities such as yoga can be introduced to reduce the stress and anxiety causing the action16

Epidemiologyedit

The lifetime prevalence of sleepwalking is estimated to be 46%–103%17 A meta-analysis of 51 studies, that included more the 100,000 children and adults, found that sleepwalking is more common in children with an estimated 5%, compared with 15% of adults, sleepwalking at least once in the previous 12 months17 The rate of sleepwalking does not vary across ages during childhood17

Causesedit

The cause of sleepwalking is not known A number of, as yet unproven, hypotheses are suggested for why it might occur These include a delay in the maturity of the central nervous system,4 increased slow wave sleep,18 sleep deprivation, fever, and excessive tiredness

There may be a genetic component to sleepwalking One study found that 45% of children who sleepwalked had one parent who sleepwalked This rose to 60% of children if both parents sleepwalked9 Thus, heritable factors may predispose an individual to sleepwalking, but expression of the behavior may also be influenced by environmental factors19 Genetic studies using common fruit flies as experimental models reveal a link between night sleep and brain development mediated by evolutionary conserved transcription factors such as AP-2 20

Sleepwalking may be inherited as an autosomal dominant disorder with reduced penetrance Genome-wide multipoint parametric linkage analysis for sleepwalking revealed a maximum logarithm of the odds score of 344 at chromosome 20q12-q1312 between 556 and 614 cM21

Medications, primarily in four classes—benzodiazepine receptor agonists and other GABA modulators, antidepressants and other serotonergic agents, antipsychotics, and β-blockers— have been associated with sleepwalking22 The best evidence of medications causing sleepwalking is for Zolpidem and sodium oxybate—all other reports are based on associations noted in case reports22

A number of conditions, such as Parkinson's Disease, are thought to trigger sleepwalking in people without a previous history of sleepwalking23

Comorbid medical and psychological disordersedit

In the study "sleepwalking and sleep terrors in prepubera children" they found that if a child had another sleep disorder such as restless leg syndrome RLS or sleep-disorder breathing SDB that they had a greater chance of sleepwalking The study found children with chronic parasomnias may often also present SDB or, to a lesser extent, RLS Furthermore, the disappearance of the parasomnias after the treatment of the SDB or RLS periodic limb movement syndrome suggests that the latter may trigger the former The high frequency of SDB in family members of children with parasomnia provided additional evidence that SDB may manifest as parasomnias in children Children with parasomnias are not systematically monitored during sleep, although past studies have suggested that patients with sleep terrors or sleepwalking have an elevated level of brief EEG arousals When children receive polysomnographies, discrete patterns eg, nasal flow limitation, abnormal respiratory effort, bursts of high or slow EEG frequencies should be sought; apneas are rarely found in children Children's respiration during sleep should be monitored with nasal cannula/pressure transducer system and/or esophageal manometry, which are more sensitive than the thermistors or thermocouples currently used in many laboratories The clear, prompt improvement of severe parasomnia in children who are treated for SDB, as defined here, provides important evidence that subtle SDB can have substantial health-related significance Also noteworthy is the report of familial presence of parasomnia Studies of twin cohorts and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias RLS and SDB have been shown to have familial recurrence RLS has been shown to have genetic involvement24

In some cases, sleepwalking in adults may be a symptom of a psychological disorder One study suggests higher levels of dissociation in adult sleepwalkers, since test subjects scored unusually high on the hysteria portion of the "Crown-Crisp Experiential Index"25 Another suggested that "A higher incidence of sleepwalking events has been reported in patients with schizophrenia, hysteria and anxiety neuroses"26 Also, patients with migraine headaches or Tourette Syndrome are 4–6 times more likely to sleepwalk

Treatmentedit

There have been no clinical trials to show that any psychological or pharmacological intervention is effective in preventing sleepwalking episodes27 Despite this, a wide range of treatments have been used with sleepwalkers Psychological interventions have included psychoanalysis, hypnosis,scheduled or anticipatory waking, assertion training, relaxation training, managing aggressive feelings, sleep hygiene, classical conditioning including electric shock, and play therapy Pharmacological treatments have included an anticholinergic biperiden, antiepileptics carbamazepine, valproate, an antipsychotic quetiapine, benzodiazepines clonazepam, diazepam, flurazepam, imipramine, and triazolam, melatonin, a selective serotonin reuptake inhibitor paroxetine, a barbiturate sodium amytal and herbs27

There is no evidence about whether waking sleepwalkers is harmful or not, though the sleepwalker is likely to be disoriented if awakened because sleepwalking occurs during the deepest stage of sleep Unlike other sleep disorders, sleepwalking is not associated with daytime behavioral or emotional problems12—this may be because the sleepwalker's sleep is not disturbed—unless they are woken, they are still in a sleep state while sleepwalking

Crimeedit

See also: Homicidal sleepwalking

Sleepwalking can sometimes result in injury, assault, or the death of someone else For this reason, sleepwalking can be used as a legal defence However, sleepwalking is a difficult case to prove28 It is impossible to prove absolutely that a crime occurred in the context of a sleepwalking episode because there is no objective means to assess it retrospectively It relies on probability and circumstantial evidence of a behaviour that often has no witnesses including the defendant, because amnesia is a feature of sleepwalking Even a history of sleepwalking does not support that it was a factor during any given event

Alternative explanations, such as malingering and alcohol and drug-induced amnesia, need to be excluded The differential diagnosis may also include other conditions in which violence related to sleep is a risk, such as REM Sleep Behavior Disorder RSBD, fugue states, and episodic wandering"29 In the 1963 case Bratty v Attorney-General for Northern Ireland, Lord Morris stated, "Each set of facts must require a careful examination of its own circumstances, but if by way of taking an illustration it were considered possible for a person to walk in his sleep and to commit a violent crime while genuinely unconscious, then such a person would not be criminally liable for that act"30

In the case of the law, an individual can be accused of non-insane automatism or insane automatism The first is used as a defense for temporary insanity or involuntary conduct, resulting in acquittal The latter results in a "special verdict of not guilty by reason of insanity"31 This verdict of insanity can result in a court order to attend a mental institution32

Other examples of legal cases involving sleepwalking in the defence include:

  • 1846, Albert Tirrell used sleepwalking as a defense against charges of murdering Maria Bickford, a prostitute living in a Boston brothel
  • 1981, Steven Steinberg, of Scottsdale, Arizona was accused of killing his wife and acquitted on the grounds of temporary insanity33
  • 1991, R v Burgess: Burgess was accused of hitting his girlfriend on the head with a wine bottle and then a video tape recorder Found not guilty, at Bristol Crown Court, by reason of insane automatism34
  • 1992, R v Parks: Parks was accused of killing his mother-in-law and attempting to kill his father-in-law He was acquitted by the Supreme Court of Canada33
  • 1994, Pennsylvania v Ricksgers: Ricksgers was accused of killing his wife He was sentenced to life in prison without parole35
  • 1999, Arizona v Falater: Falater, of Phoenix, Arizona, was accused of killing his wife The court concluded that the murder was too complex to be committed while sleepwalking Falater was convicted of first-degree murder and sentenced to life with no possibility of parole33
  • 2008, Brian Thomas was accused of killing his wife while he dreamt she was an intruder, whilst on holiday in West Wales36 Thomas was found not guilty37

Historyedit

Sleepwalking has attracted a sense of mystery, but it had not been seriously investigated and diagnosed until the last centuryclarification needed The 19th-century German chemist and parapsychologist Baron Karl Ludwig von Reichenbach made extensive studies of sleepwalkers and used his discoveries to formulate his theory of the Odic force

Sleepwalking was initially thought to be a dreamer acting out a dream4 For example, in one study published by the Society for Science & the Public in 1954, this was the conclusion: "Repression of hostile feelings against the father caused the patients to react by acting out in a dream world with sleepwalking, the distorted fantasies they had about all authoritarian figures, such as fathers, officers and stern superiors"38 This same group published an article twelve years later with a new conclusion: "Sleepwalking, contrary to most belief, apparently has little to do with dreaming In fact, it occurs when the sleeper is enjoying his most oblivious, deepest sleep—a stage in which dreams are not usually reported"39 More recent research has discovered that sleepwalking is actually a disorder of NREM non-rapid eye movement arousal4 Acting out a dream is the basis for a REM rapid eye movement sleep disorder called REM Behavior Disorder or REM Sleep Behavior Disorder, RSBD4 More accurate data about sleep is due to the invention of technologies such as the electroencephalogram EEG by Hans Berger in 1924 and BEAM by Frank Duffy in the early 1980s40

In 1907, Sigmund Freud spoke about sleepwalking to the Vienna Psychoanalytic Society Nunberg and Federn He believed that sleepwalking was connected to fulfilling sexual wishes and was surprised that a person could move without interrupting their dream At that time, Freud suggested that the essence of this phenomenon was the desire to go to sleep in the same area as the individual had slept in childhood Ten years later, he speculated about somnambulism in the article "A Metapsychological Supplement to the Theory of Dreams" 1916–17 1915 In this essay, he started to clarify and expand his hypothetical ideas on dreams The dreams is a fragile equilibrium that is only partially successful because the repressed unconscious impulses of the unconscious system This does not obey the wishes of the ego and maintain their countercathexis Another reason why dreams are partially successful is because certain preconscious daytime thoughts can be resistant and these can retain a part of their cathexis as well It is probable how unconscious impulses and day residues can come together and result in a conflict Freud then wondered about the outcome of this wishful impulse which represents an unconscious instinctual demand and then it becomes a dream wish in the preconscious Furthermore, Freud stated that this unconscious impulse could be expressed as mobility during sleep This would be what is observed in somnambulism, though what actually makes it possible remains unknown41

In fictionedit

The sleepwalking scene from William Shakespeare's tragic play Macbeth 1606 is one of the most famous scenes in all of literature

The Cabinet of Dr Caligari 1920 is a German expressionist film telling the story of an insane hypnotist who uses a somnambulist to commit murders

Referencesedit

  1. ^ a b c World Health Organization 1992 The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines Version 2016 Geneva: World Health Organization
  2. ^ a b c American Psychiatric Association 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Washington, DC: American Psychiatric Publishing
  3. ^ SLEEP: Sex While Sleeping Is Real, and May Be No Joke, Michael Smith, MedPage Today Staff Writer, Published: June 19, 2006, access date 08-11-2011
  4. ^ a b c d e f g Swanson, Jenifer, ed "Sleepwalking" Sleep Disorders Sourcebook MI: Omnigraphics, 1999 249–254, 351–352
  5. ^ "Sleepwalk to Murder" 10 October 2008 
  6. ^ "Sleepwalking, sleep murder, sleep walking, automatism, sleep apnea, insanity defense, obstructive sleep apnea, narcolepsy, insomnia, cataplexy, sleepiness, sleep walking, daytime sleepiness, upper airway, CPAP, hypoxemia, UVVP, uvula, Somnoplasty, obesity, airway obstruction, EEG, electroencephalogram, EMG, Epworth Sleepiness Scale, BiPAP, REM behavior disorder, murder, crime, sleep apnea surgery, morbidity, sleep apnea, Scott Falater, Steven Steinberg, Ken Parks, Burgess, sleepiness, journal Sleep, respiratory failure, breathing disorders, daytime sleepiness, upper airway, CPAP, hypoxemia, palate, throat, obesity, airway obstruction, EEG, electroencephalogram, sleep specialists, night terrors, psychiatrists, bruxism, parasomnias, EMG, Epworth Sleepiness Scale, Lawrence Martin, MD" 
  7. ^ "CNN - 'Sleepwalker' convicted of murder" 25 June 1999 Retrieved 13 January 2015 
  8. ^ Rachel Nowak 2004-10-15 "Sleepwalking woman had sex with strangers" New Scientist Retrieved 2007-04-30 
  9. ^ a b c Lavie, Peretz, Atul Malhotra, and Giora Pillar Sleep disorders : diagnosis, management and treatment : a handbook for clinicians London: Martin Dunitz, 2002 146–147
  10. ^ American Academy of Sleep Medicine 2014 International Classification of Sleep Disorders – Third Edition ICSD-3 Author
  11. ^ Stallman, H M, Kohler, M, Wilson, A, Biggs, S N, Dollman, J, Martin, J, Kennedy, D, and Lushington, K 2016 Self-reported sleepwalking in Australian senior secondary school students Sleep Medicine, 25, 1-3 doi: http://dxdoiorg/ 101016/jsleep201606024
  12. ^ a b Stallman, H M, Kohler, M J, Biggs, S, N, Lushington, K, & Kennedy, J D 2016 Childhood sleepwalking and its relationship to daytime and sleep related behaviors Sleep and Hypnosis doi:http://dxdoiorg/105350/SleepHypn2016180122
  13. ^ a b Wetherill, R R & Fromme, K 2016 Alcohol-induced blackouts: A review of recent clinical research with practical implications and recommendations for future studies Alcoholism: Clinical and Experimental Research, 40 5, 922-935 doi:http://dxdoiorg/101111/acer13051
  14. ^ Hartzler B, Fromme K 2003 Fragmentary and en bloc blackouts: similarity and distinction among episodes of alcohol-induced memory loss Journal of Studies in Alcohol, 64, 547–550 doi:http://dxdoiorg/1015288/jsa200364547
  15. ^ Staff, Mayo Clinic "Sleep-related Eating Disorders" Mayo Clinic Retrieved 5 May 2014 
  16. ^ Clinic, Cleveland "Sleep-Related Eating Disorders" Cleveland Clinic Retrieved 5 May 2014 
  17. ^ a b c Stallman, H M, & Kohler, M 2016 The prevalence of sleepwalking: A systematic review and meta-analysis PlOS ONE, 1111, e0164769 doi:http://dxdoiorg/101371/journalpone0164769
  18. ^ Pressman "Factors that predispose, prime and precipitate NREM parasomnias in adults: clinical and forensic implications" Sleep Med Rev 111 2007:5–30
  19. ^ Kales, A; Soldatos, C R; Bixler, E O; Ladda, R L; Charney, D S; Weber, G; Schweitzer, P K 1 August 1980 "Hereditary factors in sleepwalking and night terrors" 137 2: 111–118 doi:101192/bjp1372111 PMID 7426840 – via bjprcpsychorg 
  20. ^ Kucherenko, Mariya M; Ilangovan, Vinodh; Herzig, Bettina; Shcherbata, Halyna R; Bringmann, Henrik 2016-01-01 "TfAP-2 is required for night sleep in Drosophila" BMC Neuroscience 17: 72 doi:101186/s12868-016-0306-3 ISSN 1471-2202 PMC 5103423 PMID 27829368 
  21. ^ "Neurology" Journal, January 4, 2011 76:12-13 published by the American Academy of Neurology wwwNeurologyorg
  22. ^ a b Stallman, H M, Kohler, M, & White, J 2017 Medication-induced sleepwalking: A systematic review Sleep Medicine Reviewsdoi:http://dxdoiorg/101016/jsmrv201701005
  23. ^ Poryazova, R, Waldvogel, D,, Bassetti, C L2007 Sleepwalking in patients with Parkinson disease Archives of Neurology, 64 10, 1524-1527 doi:http://dxdoiorg/101001/archneur64101524
  24. ^ Guilleminault, Christian; Palombini, Luciana; Pelayo, Rafael; Chervin, Ronald D 1 January 2003 "Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them" 111 1: e17–e25 doi:101542/peds1111e17 PMID 12509590 – via pediatricsaappublicationsorg 
  25. ^ Crisp, AH; Matthews, BM; Oakey, M; Crutchfield, M; et al 1990 "Sleepwalking, night terrors, and consciousness" British Medical Journal 300 6721: 360–362 doi:101136/bmj3006721360 PMC 1662124 PMID 2106985 
  26. ^ Orme, JE 1967, "The Incidence of Sleepwalking in Various Groups", Acta Psychiatrica Scandinavica, Vol 43, Iss 3, pp 279–28
  27. ^ a b Stallman, H M, & Kohler, M 2016 A systematic review of treatments for sleepwalking: 100 years of case studies Sleep and Hypnosis doi:http://dxdoiorg/105350/SleepHypn2016180118
  28. ^ Stallman, H M 2015 Sleepwalking as a Defence for Illegal Behaviour: A Commentary on Popat & Winslade Neuroethics, 83, doi :http://dxdoiorg/101007/s12152-015-9237-4
  29. ^ Culebras, Antonio "Somnambulism" Clinical Handbook of Sleep Disorders, Massachusetts: Butterworth-Heinemann, 1996 317–319
  30. ^ Mackay, Irene 1992 "The Sleepwalker is Not Insane" The Modern Law Review 55: 715–716 
  31. ^ Lederman, Eliezer "Non-Insane and Insane Automatism: Reducing the Significance of a Problematic Distinction" The International and Comparative Law Quarterly 344 1985: 819
  32. ^ a b c Martin, Lawrence "Can sleepwalking be a murder defense", 2009
  33. ^ Heaton-Armstrong A Editor, Shepherd E Editor, Wolchover D Editor 2002 Analysing Witness Testimony: Psychological, Investigative and Evidential Perspectives: A Guide for Legal Practitioners and Other Professionals Blackstone Press ISBN 1-85431-731-8  CS1 maint: Multiple names: authors list link
  34. ^ Lyon, Lindsay "7 Criminal Cases that Involved the 'Sleepwalking Defense'", US News and World Report May 2009
  35. ^ de Bruxelles, Simon 18 November 2009 "Sleepwalker Brian Thomas admits killing wife while fighting intruders in nightmare" The Times London Retrieved 2009-12-26 
  36. ^ "Login" 
  37. ^ Society for Science & the Public "Sleepwalking Cause" The Science News-Letter 27 February 1954: 132
  38. ^ Society for Science & the Public "Sleepwalker Not Dreaming" The Science News-Letter, 25 June 1966: 508
  39. ^ "Electroencephalography", Medical Discoveries, 2009
  40. ^ "Somnambulism" International Dictionary of Psychoanalysis 2005 

External linksedit

Media related to Sleepwalking at Wikimedia Commons

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