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Treatment of somnambulism with anticipatory awakening
Abstract
A 8-year-old boy with a 6-year history of parasomnia (twice-weekly sleepwalking with enuresis) was treated by awakening him for 5 nights before the episodes. The sleepwalking stopped entirely. Anticipatory awakening may be a simple, inexpensive, low-risk therapy for somnambulism.
... Nine publications reported the use of scheduled awakenings for the treatment of sleep terrors or sleepwalking [24,25,29,30,[54][55][56][57][58]. These consisted of case reports [54,55,58], case series [57], quasi-experimental studies [29,30,56], and RCTs [24,25]. ...
... Nine publications reported the use of scheduled awakenings for the treatment of sleep terrors or sleepwalking [24,25,29,30,[54][55][56][57][58]. These consisted of case reports [54,55,58], case series [57], quasi-experimental studies [29,30,56], and RCTs [24,25]. A trial by Vincent and colleagues [25] was a notable exception to overall trends; their study included adult participants, while all other reports were on the treatment of children. ...
... In his and all subsequent studies, the average timing of the parasomnia episodes was identified and parents were asked to intervene by waking their child before such an episode occurred. Parents were instructed to wake their children 10-15 min before the usual time of an episode [57], 15 min before [24,54], 15-30 min before [56], or 30 min before [29,30,58]. Additionally, the amount of time the child was to remain awake varied, with some protocols requiring a brief awakening only long enough to verify the child was awake [24,29,30,56], and others instructing parents to keep the child awake for around 5 min [57,58] or at least 15 min [54]. ...
BACKGROUND:
Non-rapid eye movement (NREM) parasomnias are often benign and transient, requiring no formal treatment. However, parasomnias can also be chronic, disrupt sleep quality, and pose a significant risk of harm to the patient or others. Numerous behavioral strategies have been described for the management of NREM parasomnias, but there have been no published comprehensive reviews. This systematic review was conducted to summarize the range of behavioral and psychological interventions and their efficacy.
METHODS:
We conducted a systematic search of the literature to identify all reports of behavioral and psychological treatments for NREM parasomnias (confusional arousals, sexsomnia, sleepwalking, sleep terrors, sleep-related eating disorder, parasomnia overlap disorder). This review was conducted in line with PRISMA guidelines. The protocol was registered with PROSPERO (CRD42021230360). The search was conducted in the following databases (initially on March 10, 2021 and updated February 24, 2023): Ovid (MEDLINE), Cochrane Library databases (Wiley), CINAHL (EBSCO), PsycINFO (EBSCO), and Web of Science (Clarivate). Given a lack of standardized quantitative outcome measures, a narrative synthesis approach was used. Risk of bias assessment used tools from Joanna Briggs Institute.
RESULTS:
A total of 72 publications in four languages were included, most of which were case reports (68%) or case series (21%). Children were included in 32 publications and adults in 44. The most common treatment was hypnosis (33 publications) followed by various types of psychotherapy (31), sleep hygiene (19), education/reassurance (15), relaxation (10), scheduled awakenings (9), sleep extension/scheduled naps (9), and mindfulness (5). Study designs and inconsistent outcome measures limited the evidence for specific treatments, but some evidence supports multicomponent CBT, sleep hygiene, scheduled awakenings, and hypnosis.
CONCLUSIONS:
This review highlights the wide breadth of behavioral and psychological interventions for managing NREM parasomnias. Evidence for the efficacy of these treatments is limited by the retrospective and uncontrolled nature of most research as well as the infrequent use of validated quantitative outcome measures. Behavioral and psychological treatments have been studied alone and in various combinations, and recent publications suggest a trend toward preference for multicomponent cognitive behavioral therapies designed to specifically target priming and precipitating factors of NREM parasomnias.
... In these cases only, treatments should be proposed [57]. Treatments are mostly the same as in adults [58], except for one method that has been especially developed in children: anticipatory awakenings [59,60]. This treatment is especially appropriate when SW episodes occur at a highly predictable time each night and parents are willing to implement the treatment protocol for at least 1-4 weeks. ...
... The evidence for the efficacy of scheduled awakenings as a treatment for SW in young children is limited. These uncontrolled case reports showed that treated children had no reoccurrence of parasomnia at 6-12 months of follow-up [59,60]. ...
Opinion statement:
Sleepwalking (SW) is a parasomnia, an abnormal behavior occurring during sleep. SW is a non-REM sleep parasomnia, an arousal disorder, like sleep terrors and confusional arousals. SW results from an incomplete arousal from slow-wave sleep, some regions of the cerebral cortex being awake and allowing movement and vision for example and others being asleep, preventing memorization or judgment. Usually, SW is a quiet wandering of a child that occurs rarely (several times a month or a year), requiring no medical advice and treatment. To reassure the family and to secure the environment are the only things to do. However, sometimes, SW can become crippling because of its frequency (several times a week or a night) because of the risks associated with the behavior (going outside, manipulating sharp objects, etc.) or violence (throwing objects, using weapons, etc.) or because of its consequences on everyday quality of life (sleepiness, fatigue, insomnia, anxiety, and depressive symptoms). In these conditions, treatment is required. It first associates sleep hygiene, reduction of alcohol consumption, and interruption of the treatments that could have promoted the episodes and the securing of the environment. The treatment of precipitants inducing sleep fragmentation such as sleep disordered breathing can be beneficial, reducing the number of events. If episodes persist or are too dangerous, medical treatment is needed. No adequate large controlled trial of drugs has yet been conducted in SW so that no medication has been evaluated properly for efficacy or side effects. However, experts in the field use clonazepam. This treatment is in our experience often effective. If inefficacious, antidepressants can also be proposed. Psychotherapy should be associated to improve anxiety and sometimes insomnia. Few published cases have described that deep relaxation, hypnosis, and cognitive behavioral therapy could be effective.
... However, the management of DOA is poorly codified, and no controlled studies have been conducted to evaluate the efficacy of behavioural or pharmacological interventions 133 . Application of scheduled awakenings showed positive results in child sleepwalkers in two case series 135,136 . Scheduled awakening involves quietly waking the child ~0.5 h before they are most likely to experience a parasomnia episode. ...
Non-rapid eye movement (NREM) sleep parasomnias (or NREM parasomnias) are fascinating disorders with mysterious neurobiological substrates. These conditions are common and often severe, with social, personal and forensic implications. The NREM parasomnias include sleepwalking, sleep terrors and confusional arousals - collectively termed disorders of arousal (DOAs) - as well as less well-known entities such as sleep-related sexual behaviours and eating disorders. Affected patients can exhibit waking behaviours arising abruptly out of NREM sleep. Although the individual remains largely unresponsive to the external environment, their EEG shows both typical sleep-like and wake-like features, and they occasionally report dreaming afterwards. Therefore, these disorders offer a unique natural model to explore the abnormal coexistence of local sleep and wake brain activity and the dissociation between behaviour and various aspects of consciousness. In this article, we critically review major findings and updates on DOAs, focusing on neurophysiological studies, and offer an overview of new clinical frontiers and promising future research areas. We advocate a joint effort to inform clinicians and the general public about the management and follow-up of these conditions. We also strongly encourage collaborative multicentre studies to add more objective polysomnographic criteria to the current official diagnostic definitions and to develop clinical practice guidelines, multidisciplinary research approaches and evidence-based medical care.
... Traditionally, hypnotherapy has been used to treat patients with NREM parasomnias, especially with sleep walking [20]. Anticipatory awakening before the time that NREM parasomnia events are expected to occur has also been utilised therapeutically [21]. ...
Background
Non-REM parasomnias are not uncommon conditions in the general population. Current treatment options are based on small case series and reports. In this study, we aimed to present the clinical experience from a large cohort of patients.
Patients
Five hundred and twelve patients with Non-REM parasomnia or parasomnia overlap disorder (POD), who had undergone a video polysomnography and were exposed to treatment, were retrospectively identified. Treatment outcome was assessed based on patients’ reports, and treatment approach on a locally accepted hierarchy of interventions.
Results
Forty percent of patients were diagnosed with sleepwalking, 23.8% with mixed-phenotype and 10% with POD. Ultimately, 97.2% reported adequate control of their symptoms. Moreover, 60.1% were treated with pharmacotherapy and 32.0% without, consistent across all phenotypes (p=0.09). Benzodiazepines were the most common drugs prescribed (47.1%,p<0.05). In the end, 37.7% of our patients were receiving a benzodiazepine as part of their successful treatment, 11.7% an antidepressant, 9.2% a z-drug, and 10.7% melatonin. 13.2%, 12.1% and 5.8% of our patients reported good control of their symptoms with sleep hygiene, management of sleep-disordered breathing, and psychological interventions (cognitive behavioral therapy (CBT) or mindfulness-based stress reduction (MBSR)), as monotherapy, respectively.
Conclusion
The treatment approach to effective treatment of the patients with Non-REM parasomnias or POD offering first sleep hygiene advice, next treatment of concurrent sleep disorders and management of other priming factors like stress and anxiety, and lastly pharmacotherapy for Non-REM parasomnia is supported by our results. Non pharmacological interventions were effective in one third of our patients, and CBT/MBSR and melatonin appeared promising new treatments.
... They then awaken their child about 15- 20 min before the typical time of occurrence of the episode for a period of 1 month. It has been reported that the epi- sodes cease as soon as this intervention is started, and the benefit is maintained on long-term follow-up [84,85]. Hypnosis (including self-hypnosis) has been found to be effective in both children and adults with sleepwalking or sleep terrors [84,[86][87][88][89][90][91]. ...
Parasomnias are defined as “disorders characterized by abnormal behavioral, experiential, or physiological events occurring in association with sleep, specific sleep stages, or sleep–wake transitions” in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The clinical presentation and polysomnographic characteristics, associated factors, pathophysiology, prevalence, and treatment options of the NREM sleep parasomnias (somnambulism and sleep terrors), REM sleep parasomnias (nightmare disorder, recurrent isolated sleep paralysis, and REM sleep behavior disorder), and other parasomnias (sleep enuresis, sleep-related bruxism, sleep-related rhythmic movement disorder, somniloquy, and sleep-related groaning) are reviewed in this chapter. Some of these phenomena remind us that wakefulness and sleep states are not as mutually exclusive as one might believe.
... L'intérêt de la technique des éveils programmés a été rapporté dans plusieurs études de cas chez l'enfant (Frank et al., 1997;Tobin, 1993). Elle consiste dans un premier temps à tenir un agenda des épisodes parasomniaques afin de déterminer l'horaire le plus fréquent de survenue des accès parasomniaques. ...
Parasomnias are sleep disorders characterized by undesirable behavioral or experiential phenomena occurring during sleep. Disorders such as sleepwalking (somnambulism), sleep terrors and confusional arousal are classified under the term “Non Rapid Eye Movement (NREM) Sleep-related parasomnias” as they frequently occur during sudden arousals from slow wave sleep. They often coexist within the same individual and are considered as different phenotypes for a similar underlying pathophysiology.
The widespread belief that NREM parasomnias are benign disorders is actually challenged as they can result in various adverse consequences such as violent and injurious behaviors and daytime functional impairment. Our first three studies investigated the clinical phenotype and the consequences of NREM parasomnias, especially subjective and objective daytime sleepiness and chronic pain. We found that almost an half of sleepwalkers had complaint of sleepiness with an increased objective sleep propensity in the morning. We also reported a high frequency of chronic pain, headaches and migraine in patients and described a frequent analgesia phenomenon during injurious parasomniac episodes.
The diagnosis of NREM parasomnias is usually made from clinical history, without polysomnographic-based diagnostic criteria. If recent works suggested that NREM parasomnia were associated with subtle changes on the NREM microstructure, the diagnostic performances of these parameters have been poorly studied with appropriate design. We developed a new polysomnographic scoring method that offers a good classification rate of NREM parasomnia patients and controls.
Despite almost five decades of clinical and laboratory investigations, the pathophysiology of NREM parasomnias remains poorly understood. One model is currently used to conceptualize the mechanisms of the disease. A predisposed patient is primed by conditions that impair slow wave sleep stability resulting in dissociated arousal precipitated by arousing stimuli. Our further works will investigate the pathophysiology of NREM parasomnia using innovative genetic, electrophysiological and functional imagery approaches.
... The theory of causal mechanisms differs between interventions. Behavioural therapies, such as classical conditioning (Edmonds, 1967; Meyer, 1975), scheduled waking (Frank, Spirito, Stark, & Owens-Stively, 1997; Tobin, 1993) and hypnosis to wake when one's feet touch the floor (Kennedy, 2002), aim to extinguish the behaviour by associating it with wakefulness or an unpleasant stimulus. Sleep hygiene, also a behavioural therapy, aims to prevent hypothesized triggers for sleepwalking, such as sleep deprivation or a full bladder. ...
While generally harmless, sleepwalking can result in injury to the sleepwalker and/or others, prompting help-seeking. This is the frst study to systematically review the scientifc evidence underpinning treatments for sleepwalking. A literature search of CINAHL, EMBASE, PsycINFO, PubMed, and ScienceDirect was conducted with the keywords 'sleepwalking' OR 'somnambulism', current to 29 February 2016. Studies were included if they reported on any intervention for sleepwalking. Of the original 53 sourced papers, 44 met the inclusion criteria and were subsequently included for review. None had a methodology that could demonstrate efcacy or effectiveness. Case and case series reports dominate the literature with patients treated with a range of psychological, pharmacological and other interventions. While the results of this review highlight potential treatments, well-designed randomized control trials of theoretically supported interventions that include assessment of adverse effects are urgently needed. Psychological interventions-scheduled waking and hypnosis-are potential frst line interventions for evaluation, especially with children, as they are theoretically grounded, case studies suggest they may be effective, and they do not have the side-effects of pharmacological interventions.
... However, the limited evidence that is available is compelling and consistent. Three studies examined scheduled awakenings for sleepwalking, including a multiple-baseline controlled study of three participants [20], and case studies of a 7-year-old and 8-year-old boys [21,22]. For sleep terrors, Lask [19] treated 19 children ages 5-13 years with scheduled awakenings and found resolution of episodes within 1 week of treatment for all the patients. ...
Non-rapid eye movement (NREM) parasomnias are common in childhood and include a range of clinical presentations including confusional arousals, sleepwalking, sleep terrors, and sleep-related eating disorder. While parasomnia episodes can be dramatic and elicit concern from parents, parasomnias are predominantly benign and self-limited. A comprehensive clinical evaluation is necessary for appropriate diagnosis and ruling out underlying medical disorders. For youth with parasomnia episodes that are infrequent or limited in severity, standard treatment recommendations, including safety measures and minimizing triggering factors, are highlighted. Scheduled awakening is an evidence-based behavioral treatment that can be effective at decreasing or resolving frequent and severe NREM parasomnias but may be burdensome for parents to implement.
... 100 Psychotherapies-hypnosis, cognitive behavioral therapy, or relaxation or self-hypnosis may occasionally be helpful. 101,102 Anticipatory awakening before the usual onset of sleepwalking events has proven to be effective in children. 103 Pharmacological therapy not yet informing therapeutic strategies There are just a few studies on clinical trials of the pharmacologic treatment of parasomnias, and their results are contradicting. ...
Nonrapid eye movement (NREM) or arousal parasomnias are prevalent conditions in children and young adults, apparently provoked by any medical, physical, mental, or pharmacologic/toxic agent disturbing normal biorhythm and causing sleep fragmentation or abundant amount of slow wave sleep. The nadir and the ascending slope of the first sleep cycle of night sleep are the typical periods when NREM parasomnias, especially sleepwalking may occur on sleep-microstructural level; microarousals are the typical moments allowing NREM parasomnias. While sleep-disturbing factors have a clear precipitating effect, a genetic predisposition appears necessary in most cases. A candidate gene for sleepwalking has been identified on chromosome 20q12-q13.12 in one sleepwalking family. NREM parasomnias have a genetic and clinical link with nocturnal-frontal lobe epilepsies; possibly through an abnormality of the acetylcholine-related sleep-control system. The association of NREM parasomnias with the human leukocyte antigen system might be the sign of an autoimmune background to be further clarified. In the treatment of arousal parasomnias, the main tools are adequate sleep hygiene and the management of underlying conditions. Their pharmacotherapy has remained unresolved; the best options are clonazepam and some of the antidepressants, while a psychotherapy approach is also justified.
... Anticipatory awakenings are used in children with NREM parasomnias [23]. This treatment is most appropriate when SW episodes occur at a highly predictable time each night [10] and parents are willing to implement the treatment protocol for at least 1-4 weeks. ...
Parasomnias are unpleasant or undesirable behaviours or experiences that occur predominantly during or within close proximity to sleep. Pharmacological treatments of parasomnias are available, but their efficacy is established only for few disorders. Furthermore, most of these disorders tend spontaneously to remit with development. Nonpharmacological treatments therefore represent valid therapeutic choices. This paper reviews behavioural and cognitive-behavioural managements employed for parasomnias. Referring to the ICSD-3 nosology we consider, respectively, NREM parasomnias, REM parasomnias, and other parasomnias. Although the efficacy of some of these treatments is proved, in other cases their clinical evidence cannot be provided because of the small size of the samples. Due to the rarity of some parasomnias, further multicentric researches are needed in order to offer a more complete account of behavioural and cognitive-behavioural treatments efficacy.
... U dzieci wykazano skuteczność budzenia antycypacyjnego (ang. anticipatory akwakenings) [120,138,139]. Metoda ta polega na wybudzaniu dziecka około 15-30 minut przed spodziewanym wystąpieniem epizodu i upewnieniu się, czy dziecko nie zasnęło ponownie przez okres 5 minut [136]. ...
STRESZCZENIE Somnambulizm (sennowłóctwo, lunatyzm, ang. sleepwal-king) należy do parasomnii i polega na występowaniu złożo-nych zachowań podczas snu wolnofalowego (SWS), których skutkiem jest chodzenie podczas snu ze zmiennym stanem świadomości i zaburzeniami oceny. Epizody somnambulizmu występują w pierwszej połowie nocy, podczas snu głębokiego (stadia 3 i 4 NREM, czasem w stadium 2). Somnambulizm jest częstszy wśród dzieci i w większości przypadków z wiekiem samoistnie ustępuje. Nie ustalono jednoznacznej przyczyny patofizjologicznego mechanizmu występowania somnambu-lizmu, chociaż najnowsze dane sugerują dziedziczenie auto-somalne dominujące o zmienne penetracji. W rozpoznaniu somnambulizmu spełnione muszę być następujące kryteria: A) chodzenie podczas snu; B) w trakcie trwania snu zmienny stan świadomości lub zaburzenia oceny w trakcie chodu są demon-strowane przez co najmniej jedną z następujących cech: 1) pro-blemy z wybudzaniem pacjenta podczas epizodu; 2) splątanie po wybudzeniu z epizodu; 3) amnezja (całkowita lub częściowa) epizodu; 4) rutynowe zachowania pojawiające się o niewłaści-wym czasie; 5) niewłaściwe lub bezsensowne zachowania; 6) niebezpieczne lub potencjalnie niebezpieczne zachowania; C) zaburzenie nie jest dostatecznie wyjaśnione przez inne zaburzenia snu, choroby, zaburzenia psychiczne, używane leki lub substancje. Istnieje spora grupa czynników nasilających epizody somnambulizmu, spośród których najczęściej wymie-niany jest lek zolpidem. Epizody somnambulizmu powinny być różnicowane z nocnymi napadami padaczkowymi z płata czołowego, z innymi parasomniami oraz z nocnymi napadami panicznego lęku. Dotychczas nie powstały żadne rekomendacje lub algorytmy, które wskazywałby, jak należy leczyć pacjentów z epizodami somnambulizmu, chociaż przy bardziej nasilonych objawach najczęściej zalecanymi lekami są benzodiazepiny. Słowa kluczowe: somnambulizm, nocne napady padaczkowe z płata czołowego, parasomnie u dzieci ABSTRACT Somnambulism (or sleepwalking) is an arousal parasomnia and consists of series of complex behaviors that are initiated during slow-wave sleep and result in walking during sleep. Episodes occur in the first half of the night during NREM sleep (stages 3 and 4, occasionally stage 2). Somnambulism is more common in children than in adults and resolves spontaneously with age. There has not been set a clear pathophysiological mecha-nism for the causes of occurrence of sleepwalking, although recent data suggest autosomal dominant inheritance with variable penetration. Diagnostic criteria of somnambulism are: A) ambulation occurs during sleep; B) sleepwalking is demon-strated by at least one of the following: 1. difficulty in arous-ing the patient during an episode,:2. mental confusion when awakened from an episode, 3. amnesia (complete or partial) for the episode, 4. routine behaviors that occur at inappropri-ate times, 5. inappropriate or nonsensical behaviors, 6. danger-ous or potentially dangerous behaviors; C) the sleepwalking is not better explained by another reason. There is a large group of factors increasing episodes of sleepwalking, among which, the most frequently mentioned drug is zolpidem. Episodes of somnambulism should be differentiated from nocturnal frontal lobe epilepsy, other parasomnias and nocturnal panic attacks. So far there were no recommendations or algorithms indicating to the treatment of patients with episodes of somnambulism, although when the symptoms are more severe the most fre-quently prescribed drugs are benzodiazepines.
... This technique involves purposefully arousing the parasomniac just prior to the onset of a typical episode. Sustained positive results in 4 children have been reported; however, there is negligible data in adults [224,225]. This method appears to be a relatively low-risk therapy. ...
Parasomnias are abnormal behaviors emanating from or associated with sleep. Sleepwalking and related disorders result from an incomplete dissociation of wakefulness from nonrapid eye movement (NREM) sleep. Conditions that provoke repeated cortical arousals, or promote sleep inertia lead to NREM parasomnias by impairing normal arousal mechanisms. Changes in the cyclic alternating pattern, a biomarker of arousal instability in NREM sleep, are noted in sleepwalking disorders. Sleep-related eating disorder (SRED) is characterized by a disruption of the nocturnal fast with episodes of feeding after an arousal from sleep. SRED is often associated with the use of sedative-hypnotic medications; in particular, the widely prescribed benzodiazepine receptor agonists. Recently, compelling evidence suggests that nocturnal eating may in some cases be a nonmotor manifestation of Restless Legs Syndrome (RLS). rapid eye movement (REM) Sleep Behavior Disorder (RBD) is characterized by a loss of REM paralysis leading to potentially injurious dream enactment. The loss of atonia in RBD often predates the development of Parkinson's disease and other disorders of synuclein pathology. Parasomnia behaviors are related to an activation (in NREM parasomnias) or a disinhibition (in RBD) of central pattern generators (CPGs). Initial management should focus on decreasing the potential for sleep-related injury followed by treating comorbid sleep disorders. Clonazepam and melatonin appear to be effective therapies in RBD, whereas paroxetine has been reported effective in some cases of sleep terrors. At this point, pharmacotherapy for other parasomnias is less certain, and further investigations are necessary.
Non-REM parasomnias are often observed during childhood and adolescence, by which time they typically remit. For a small percentage, these nocturnal behaviors can persist into adulthood, or in some cases, present as a new onset in adults. Non-REM parasomnias (also known as disorders of arousal) can offer a diagnostic challenge in patients who have an atypical presentation where REM sleep parasomnias, nocturnal frontal lobe epilepsy, and overlap parasomnia should be considered as part of the differential. The purpose of this review is to discuss the clinical presentation, evaluation, and management of non-REM parasomnias. The neurophysiology behind non-REM parasomnias is considered, and this gives insights into their cause and the potential for treatment.
An 8-year-old boy was brought in by his parents for consultation of his nocturnal behaviours. The parents reported that he had repeated episodes of nocturnal screaming since the age of 3. Initially, he presented with loud screaming that happened after an hour of sleep. He looked confused, frightened and sweated profoundly during the screaming. The episode mostly lasted for a few minutes or less, then he would fall back to sleep. Since the age of 6, parents reported instead of screaming, sometimes he would leave his bed and walk around at home. He might mumble and mostly looked dazed. At most times, he went back to bed and fell asleep. He had no memory recollection about the screaming or walking upon waking up. As the condition happened rarely, a few times per year, they did not seek medical advice till now when these episodes occurred more frequently. Two weeks ago, he attempted to open the window during the nocturnal wandering and was stopped by his parents. They attempted to wake him but ended up with him fiercely screaming and crying. It took an hour to wake him up fully. Parents reported that he may have such episode if he has febrile illness. The boy had no other medical problems, apart from being overweight. He gained a significant amount of weight in past 1–2 years. Father reported he had similar events in his childhood, but just a few occasions and he no longer had such condition since he grew up.
Parasomnias are an exceptionally common occurrence in childhood. In some children, these abnormal sleep behaviors become problematic such as by causing nocturnal disruption to the sleep of themselves and/or their family or interferes with daytime function. This article will cover the various parasomnias presenting in early development, with a unique pediatric lens.
Parasomnias are defined as “undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep.” They occur during the night, without altering the normal structure of sleep, the evolution is usually benign, with spontaneous resolution at puberty. The prevalence is variable depending on the type of parasomnia and the age of occurrence. They are classified as NREM and REM parasomnias and other parasomnias. NREM-related parasomnias are defined as recurrent episodes of incomplete awakening from NREM sleep, characterized by abnormal sleep-related complex movements and behaviors associated with various degrees of autonomic nervous system activation, inappropriate or scarce responsiveness to the external environment that are difficult to differentiate from other episodes occurring during sleep like seizures. REM-related parasomnias are an admixture of the elements of REM sleep together with wakefulness. They comprise REM behavior disorder, nightmare disorders, and sleep paralysis. REM-related parasomnias are more likely to occur later in the night. Other parasomnias include sleep enuresis that is common in childhood and associated with daytime dysfunction and psychological consequences. The management of parasomnias is different for each single disorder, but NREM parasomnias have similar pathophysiology and similar treatment, either pharmacological or non-pharmacological.
Nightmares are reported to occur 2–8% in the general population (American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014). While they may be dismissed as “bad dreams,” nightmares may be indicative of another disorder occurring in sleep. Nightmares are part of a category of sleep disorders referred to as parasomnias—“undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep” (American Academy of Sleep Medicine. International classification of sleep disorders, 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014). Parasomnias are categorized by the stage of sleep in which they occur: NREM sleep—typically observed in the first half of the night, versus REM sleep—associated with the latter half of the sleep period. NREM parasomnias are also referred to as “disorders of arousal” and include sleep terrors, sleepwalking, and confusional arousals. REM sleep parasomnias include REM behavior disorder (RBD) and nightmares (dreams with negative content that may cause awakening). It is important to identify what kind of parasomnia the “nightmare” represents, as there may be serious consequences such as injury to ones’ self or others that can occur. Additionally, as in the case of RBD, it may be a potential sign of another neurodegenerative process, such as parkinsonism. Polysomnogram is often utilized in the evaluation of parasomnias and can also be helpful to exclude other disorders, which may mimic these conditions.
The nonrapid eye movement (NREM) parasomnias range from age-related developmental phenomena in children to aggressive and injurious motor behaviors in all age groups. These parasomnias are commonly referred to as disorders of arousal and are an important cause of sleep-related injury. Genetic predisposition plays a role in the disorders of arousal, most evident in sleepwalking. Important concepts guiding our current understanding of the pathophysiology of the NREM parasomnias include sleep state instability (a propensity for arousal during NREM sleep), sleep inertia (incomplete awakening from NREM sleep), state dissociation (an ability to simultaneously straddle both NREM sleep and wakefulness), and activation of central pattern generators (permitting expression of subcortically determined motor behaviors without conscious higher cortical input). Management is multifaceted with an emphasis on education and nonpharmacologic measures. The purpose of this chapter is to review wake and NREM neurobiology and update our current understanding of NREM parasomnia pathophysiology, epidemiology, genetics, clinical features, precipitating factors, neurophysiologic evaluation, diagnosis, and clinical management.
Background:
Non-rapid-eye-movement (NREM) parasomnias are disorders of sleep ranging from confusional arousals to sleepwalking and sleep-related eating disorders. Historically, antidepressants and benzodiazepines were recommended in treatment of NREM parasomnias. In this case report, we are reporting the use of buspirone in a patient with NREM parasomnias, which produced substantial resolution of symptoms.
Case presentation:
A 38-year-old man presented with confusional arousals and somnambulism. In addition, the patient had significant anxiety with work-related stress. Given the patient's concerns of side effect profile of other medications indicated in NREM parasomnias and the patient's history of anxiety, we started the patient on buspirone. The patient had significant improvement in his symptoms immediately after starting the medication with sustained relief from symptoms.
Conclusion:
Buspirone can be considered an effective alternate treatment option for NREM parasomnias when other medications are not preferred or cannot be prescribed.
The International Classification of Sleep Disorders, third edition (ICSD-3), defines parasomnias as “undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep” (American Academy of Sleep Medicine. International Classification of Sleep Disorders. Darien: American Academy of Sleep Medicine; 2014). Parasomnias include a number of different sleep-related behaviors, cognitions, and emotions, from sleep talking or rhythmic movements during sleep to vivid and disturbing nightmares. Parasomnias commonly occur in typically developing children and adolescents, as well as in those with neurodevelopmental conditions. Although parasomnias tend to diminish with increasing child age, parasomnias that are frequent, dangerous, or prolonged can result in disrupted sleep, injury, or other negative psychosocial consequences, for those experiencing the event and for others in the home. This chapter reviews the diagnostic criteria, prevalence, and behavioral manifestation of both non-REM-related and REM-related parasomnias, with a focus on the office evaluation and management of these disorders among youth with comorbid neurodevelopmental conditions. Additionally, information is provided on classification challenges, differential diagnosis, safety concerns, and the assessment of potential psychosocial impacts of parasomnias for youth with neurodevelopmental conditions. This chapter also presents important directions for future research on the assessment and treatment of parasomnias for youth with neurodevelopmental conditions.
Pediatric sleep disorders are common, have significant effects on daytime functioning of children and families, and most are amenable to some combination of behavioral management strategies and pharmacological treatment. It is particularly important for the primary care physician to screen for sleep problems in children, especially in high-risk populations. A detailed history evaluating circumstances related to the sleep problem should be obtained. Addition of pharmacological therapy to non-pharmacological interventions for pediatric sleep disorders for disorders such as insomnia, parasomnias, narcolepsy, RLS or PLMs should be diagnostically driven, and should consider both the best match between the medication type and individual patient, as well as the dosing regimen with the least side effects. Until these medications are systematically studied or newer specific agents are developed for pediatric sleep problems, it is necessary for practitioners looking after children to optimize quality of life and sequalae related to sleep problems, while minimizing potential side effects.
Human sleep alternates between periods of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. Sleep and wakefulness are modulated by homeostatic and circadian regulatory mechanisms. Like most physiological systems, sleep and wakefulness are also governed by a circadian oscillator located in the suprachiasmatic nucleus (SCN) of the hypothalamus. Patients with sleep disorders often benefit from a general medical evaluation to investigate contributing factors. Fatigue and sleepiness may be associated with endocrine disorders such as hypothyroidism. The major symptom of Insomnia Disorder is dissatisfaction with the quantity or quality of sleep. Insomnia is associated with a wide variety of medical disorders, including pulmonary, cardiovascular, and metabolic disorder. Breathing-Related Sleep Disorders (BRSD) encompasses three entities: Obstructive Sleep Apnea Hypopnea (OSAH), Central Sleep Apnea (CSA), and Sleep-Related Hypoventilation (SRH).
Nocturnal enuresis is characterized by a highly complex interaction of somatic and psychiatric factors. A primary monosymptomatic, a symptomatic (with diurnal micturition problems) and a secondary form (following a dry interval) can be differentiated. Despite deep sleep with difficult arousal, the sleep architecture itself is normal and enuretic episodes occur in every sleep stage without urodynamic changes. Changes in the circadian AVP-rhythm with nocturnal polyuria have been demonstrated repeatedly. Formal genetically, many families are compatible with an autosomal dominant mode of inheritance. Linkage studies have shown a linkage of nocturnal enuresis with regions on chromosomes Nr. 8, 12 and 13. There is a significantly increased rate of psychiatric problems. The associations are complex, with psychiatric factors occurring both reactively following the enuresis, as well as being causally involved in secondary, but not in primary monosymptomatic nocturnal enuresis.
Sleepwalking or somnambulism is a parasomnia characterized by complex, quasi-purposive, motor behavior in N3 sleep. Several factors including drugs, psychosocial stressors, and endocrine factors act on a background of genetic predisposition to generate this disorder. The episodes usually occur during first few cycles of non-rapid eye movement sleep and last up to 30 min. On polysomnography, they are characterized by increased delta power in temporal relation to the event and otherwise abnormally fragmented N3 sleep. Increased rate of cyclic alternating patterns is also seen. The disorder frequently coexists with psychological morbidity including externalized anxiety, aggression, panic, or phobias in adults. Other sleep disorders including night terrors and sleep disordered breathing and neurological disorders including migraine and Tourette syndrome are known to co-occur with sleepwalking. The important differential consideration is to exclude partial-onset seizures, and overnight video-electroencephalogram (EEG) monitoring or combined polysomnography with video-EEG may be very helpful in establishing the diagnosis. Sleepwalking has been cited as a defense against homicide or other crimes with reported success, but from a clinical perspective, it is difficult to establish the exact nature of the episode during which the alleged crime was committed. Management of this enigmatic entity often involves multidisciplinary care and includes drug therapy and adaptive measures to address safety of the patient and others and to improve sleep hygiene. Although there is lack of sufficient controlled evidence, the bulk of anecdotal reports support use of benzodiazepines, especially clonazepam. Also, there is limited information about some nonpharmacologic measures.
Confusional arousals and sleep terrors are common parasomnias and fall on the opposite ends of arousal parasomnia spectrum. Confusional arousals begin with moaning and proceed to movements which may sometimes be complex. Sleep inertia and sexsomnia are considered subtypes of confusional arousal. Sleep terrors are intense and most dramatic of the parasomnias and are associated with loud scream, cry, complex motor movements, and intense autonomic activation. In both the parasomnia, inability to arouse the child, amnesia for the event, and worsening of agitation with attempt to awaken the child are seen. Both the disorders are common in children and resolve by adolescence. There is a strong family history of parasomnia in most cases. Obstructive sleep apnea, restless leg syndrome, and periodic limb movements are precipitating factors. Separation anxiety is associated with sleep terrors, whereas mental disorders are sometimes associated with adolescent and adults with confusional arousal. Dissociation of wakefulness and sleep, and nonrapid eye movement (NREM) instability are suggested as pathophysiological mechanisms. Differentiation from nocturnal seizures is important. Video EEG and polysomnography facilitate differential diagnoses and rule out precipitating factors. Behavioral therapies as well as improving sleep quality are essential in controlling the events. There is limited evidence on pharmacological treatments, but benzodiazepine and tricyclic antidepressants are commonly used. Legal and societal implications are vital to note due to complexity of the motor movements involved with the parasomnia.
The ultimate goal of cognitive and behavioral therapy is to improve mental and physical health by correcting maladaptive patterns of thought and behavior. This chapter describes cognitive and behavioral interventions for parasomnias, along with the evidence for the effectiveness of these therapies. Cognitive and behavioral interventions for parasomnias may be condition-specific, such as use of the urine alarm for sleep enuresis or imagery rehearsal training (IRT) for nightmares. Other interventions are more general, such as providing education about principles of good sleep-hygiene or use of cognitive reframing for sleep disruption associated with anxiety and depressive disorders. The evidence-based literature on cognitive and behavioral treatments included in this chapter is summarized for sleep enuresis, sleepwalking, sleep terrors, nightmares, nocturnal panic, rhythmic movement disorder, isolated sleep paralysis, exploding head syndrome, catathrenia, sleep-related eating disorder, and rapid eye movement (REM) sleep behavior disorder. The majority of cognitive and behavioral therapeutic techniques actively engage the patient in homework assignments and self-administered protocols. These interventions have the potential to improve a patient’s sense of self-efficacy and may generalize to other aspects of mental health and behavior. Case examples and a summary of practical points are also provided to demonstrate how the evidence is applied in clinical practice.
Parasomnias are a group of clinical disorders observed during sleep. They often involve undesirable motor disorders. These fairly heterogeneous physical disorders are not due to alterations in the processes responsible for sleep and awake states, but occur in subjects who are predisposed, at the moment of sleep-wake transition phases or during the different stages of sleep. They have little effect, in general, on the quality of wakefulness.
Conclusions: Pediatric sleep disorders are common, have significant effects on daytime functioning of children and families, and most are amenable to some combination of behavioral management strategies and pharmacological treatment. It is particularly important for the primary care physician to screen for sleep problems in children, especially in high-risk populations. A detailed history evaluating circumstances related to the sleep problem should be obtained. Addition of pharmacological therapy to non-pharmacological interventions for pediatric sleep disorders for disorders such as insomnia, parasomnias, narcolepsy, RLS or PLMs should be diagnostically driven, and should consider both the best match between the medication type and individual patient, as well as the dosing regimen with the least side effects. Until these medications are systematically studied or newer specific agents are developed for pediatric sleep problems, it is necessary for practitioners looking after children to optimize quality of life and sequalae related to sleep problems, while minimizing potential side effects.
Scheduled awakenings (SA) has demonstrated efficacy for treating young children with chronic and severe sleepwalking (SW) and sleep terrors (ST). There are three primary hypotheses regarding the underlying mechanism for scheduled awakenings in reducing or eliminating SW and ST. First, it has been proposed that repeated scheduled awakenings alter the child's sleep cycle in such a way that the altered underlying electrophysiology of partial arousal is either prevented or interrupted, and results in remission of the disturbing behavioral features of these events. However, this proposed mechanism does not explain why partial arousal events do not return once SA is discontinued. An alternative hypothesis suggests that the repetition of scheduled awakenings conditions the patient to spontaneously arouse (i.e., self arousal) just prior to a parasomnia episode and thus avoids the event altogether despite the abnormal physiology. A third possible mechanism has been proposed based on the increased susceptibility for partial arousal parasomnias in sleep-deprived individuals during rebound slow-wave sleep.
The focus of this chapter is sleepwalking, also known as somnambulism. That people sometimes engage in complex ambulatory behaviors during sleep has been known for centuries. Shakespeare, for instance, described in Macbeth a now famous sleepwalking episode during which a guilt-ridden Lady Macbeth tries to wash imaginary blood stains from her hands while speaking of the crimes she and her husband have committed. Until the early to mid 1960s, sleepwalkers were generally thought to be in a dissociative state related to dreaming, possibly enacting repressed traumatic experiences. Following Broughton's landmark contribution and the early work of Kales and his collaborators, sleepwalking was conceptualized as a “disorder of arousal.” Together with confusional arousals and sleep terrors, sleepwalking constitutes one of the key non-rapid-eye-movement (NREM) sleep parasomnias. The clinical presentation, PSG characteristics, prevalence, associated factors, pathophysiology and treatment of this parasomnia will be reviewed. Two variants of somnambulism, namely sleep-related abnormal sexual behaviors (sexsomnia) and sleep-related eating disorder, are not discussed here as they are covered elsewhere in this volume (see Chapters 9 and 21). Clinical findings Clinical presentation The symptoms and manifestations that characterize sleepwalking can show great variations both within and across predisposed patients. The sleepwalker's emotional expression can range from calm to extremely agitated, while the actual behavioral manifestations can range from simple and isolated actions (e.g. sitting up in bed, pointing at a wall, fingering bed sheets) to complex organized behaviors (e.g. rearranging furniture, cooking or eating, getting dressed, driving a vehicle).
Parasomnias are defined as unpleasant or undesirable behavioral or experiential phenomena that occur predominantly or exclusively during the sleep period. These were initially thought to represent a unitary phenomenon, often attributed to psychiatric disease. As more parasomnias are being carefully studied both polygraphically and clinically, it is becoming apparent that parasomnias are not a unitary phenomenon, but rather are due to a large number of completely different conditions, most of which are diagnosable and treatable. Moreover, most, in fact, are not the manifestation of psychiatric disorders and are far more prevalent than previously suspected. The parasomnias may be conveniently categorized as primary parasomnias (disorders of the sleep states per se), and secondary parasomnias (disorders of other organ systems manifest themselves during sleep). The primary sleep parasomnias can be classified according to the sleep state of origin: rapid eye movement (REM) sleep, non-REM (NREM) sleep, or miscellaneous (i.e., those not respecting sleep state).
There appears to be a lot of confusion in the medical community about what constitutes a parasomnia and how prevalent these conditions are. In the past, any sleep disorder that was not breathing related or did not present with prominent insomnia or daytime sleepiness was called a parasomnia. The International Classification of Sleep Disorders second edition (ICSD 2) restructured the different sleep disorders into pathophysiologically based categories. According to the ICSD 2, parasomnias are undesirable physical or experiential events that occur in and around sleep. It lists 16 parasomnias divided into three categories: NREM parasomnias or disorders of arousal, REM parasomnias, and other parasomnias.
This chapter discusses arousal parasomnias. Sleepwalking and sleep terrors have been described as “disorders of arousal.” It is classically associated with a confusional arousal preceded by a burst of delta waves that most commonly occurs out of slow-wave sleep or stage 3–4 NREM sleep. Autonomic nervous system reactions of variable intensity are seen with the confusional arousal. It is likely that many patients with arousal parasomnias never seek medical help. The events may be minor, self-limiting, or might have gone unnoticed. Common reasons for consult are: the individual or others come to harm, other people are inconvenienced or threatened, there are endless sleep interruptions (if they recognize/remember), and secondary complications such as alcoholism occur. Arousal parasomnias in adults are never benign. Aside from morbidity because of other underlying conditions, it can potentially lead to injury to the affected individual and those nearby. Resolution of events dramatically improves safety and quality of life of patients and families. Therefore, all adults with sleep terrors and sleepwalking should be evaluated and treated as necessary.
Parasomnias are classified into nonrapid eye movement and rapid eye movement sleep parasomnias. It is important for the clinician to consider other parasomnia mimics that present to the sleep disorders clinic. These conditions can be differentiated by taking a detailed sleep history and conducting nocturnal polysomnograms to evaluate for potential comorbidities and better characterize the disorder. Mainstays of treatment include treating any underlying primary sleep disorders that induce sleep fragmentation and could trigger the parasomnia, as well as implementing safety precautions to protect patients and their household. Pharmacologic treatment of many parasomnias is also available if needed and clinically indicated.
Opinion statement:
Dyssomnias are sleep disorders associated with complaints of insomnia or hypersomnia. The daytime sleepiness of narcolepsy is treated by a combination of planned daytime naps, regular exercise medications such as modafinil, or salts of methylphenidate, or amphetamine. Cataplexy that accompanies narcolepsy is treated with anticholinergic agents, selective serotonin reuptake inhibitors, or sodium oxybate. Children with neurodevelopmental disabilities such as autism have sleep initiation and maintenance difficulties on a multifactorial basis, with favorable response to melatonin in some patients. Childhood onset restless legs syndrome is often familial, associated with systemic iron deficiency, and responsive to iron supplementation and gabapentin. Parasomnias are episodic phenomena events which occur at the sleep -- wake transition or by intrusion on to sleep. Arousal parasomnias such as confusional arousals and sleep walking can sometimes be confused with seizures. A scheme for differentiating arousal parasomnias from nocturnal seizures is provided. Since arousal parasomnias are often triggered by sleep apnea, restless legs syndrome, or acid reflux, treatment measures directed specifically at these disorders often helps in resolution. Clonazepam provided in a low dose at bedtime can also alleviate sleep walking and confusional arousals. Obstructive sleep apnea affects about 2 percent of children. Adeno-tonsillar hypertrophy, cranio-facial anomalies, and obesity are common predisposing factors. Mild obstructive sleep apnea can be treated using a combination of nasal corticosteroids and a leukotriene antagonist. Moderate to severe obstructive sleep apnea are treated with adeno-tonsillectomy, positive airway pressure breathing devices, or weight reduction as indicated. This paper provides an overview of the topic, with an emphasis on management steps. Where possible, the level of evidence for treatment recommendations is indicated.
This paper describes four children, ages 8 to 12 years, with frequent, prolonged, or dangerous disorders of arousal. None had any significant psychological or behavioral problems. Each had a polysomnogram that showed sudden arousals out of slow-wave sleep associated with complex behavior. All responded to a short course of imipramine, 20 to 60 mg at bedtime, followed by and in conjunction with training in relaxation and mental imagery (self-hypnosis). Once the correct diagnosis was made, the treatment strategy was to (1) demystify the symptom complex through education, (2) establish prompt control of the symptoms with the use of imipramine, (3) train the children in self-regulation with self-hypnosis, and (4) discontinue the medication while maintaining control of the arousals. Over a 2-3 year follow-up all children remain asymptomatic. This is the first report of successful use of self-hypnosis for the treatment of polysomnogram-proven disorders of arousal in the pediatric population. Also reported are seven additional children who were treated equally successfully with hypnosis without the use of medication.
Epidemiological, behavioral and etiological variables related to sleep disturbances were investigated in a survey of 1695 children in Grades 1 to 12 from 11 randomly selected schools. Sleep-walking, nightmares and sleep-talking were strongly associated with each other as well as to a family history of sleep-walking. Enuresis, however, was not related to the other sleep variables. Socioeconomic status of father was weakly related to enuresis and sleep-talking but not to sleep-walking or nightmares. Gender was not related to any of the sleep disturbances. The behavioral variables, physical activity, attention, emotional excitability, and feelings easily hurt showed a small association with the sleep disturbances. Parents most frequently attributed causes of sleep-walking and nightmares to over-tiredness and over-excitement. As well, parents' comments indicated that they tend to associate specific events such as illness or more often, frightening TV content with nightmares, but not sleepwalking.
A great perturbation in nature, to receive at once the benefit of sleep and do the effects of watching. In this slumbery agitation, besides her walking and her other actual performances, what, at any time, have you heard her say? —W. Shakespeare
THE BEHAVIOR of somnambulists has led to a general belief that sleepwalking is the acting out of a dream.1-3 In a previous study 4 we observed the relation of sleepwalking to the sleep-dream cycle directly, by utilizing the rapid eye movement (REM) method of dream detection * and obtaining electroencephalographic (EEG) recordings throughout the night by means of special cables or a biotelemetry unit which allowed for subject mobility. Nine subjects (seven male and two female) ages 9 to 23 years were studied for a total of 47 subject nights in our laboratory. Six of the subjects were children and three adults, age 16 years being
We evaluated with clinical interviews and polysomnographic examinations 10 adults with the complaint of sleepwalking, often accompanied by violent behavior or self-injury. During the polysomnographic studies, 8 patients had 47 distinct somnambulistic episodes. All episodes occurred in non-REM sleep, with 91% occurring in slow-wave sleep. Contrary to previous reports, episodes were not confined to the 1st 3rd of the night. Clinical EEGs were normal in 5 of 6 patients. In the 7 patients tried on 1 or more treatment regimens, clonazepam effectively suppressed the somnambulism in 5 of 6 patients in whom it was tried, carbamazepine in 1 of 3, flurazepam in 2 of 2, and a combination of clonazepam and phenytoin in one.
Few data currently exist concerning the sleep problems of preadolescents. A parent report questionnaire concerning sleep habits and problems was developed. The questionnaires were completed by the parents of 1000 unscreened elementary school children attending the third, fourth, and fifth grades. The schools were randomly selected from an urban area. Of the 1000 questionnaires, 972 were completed and could be used for statistical analysis. Among the parents, 24% reported sleeping poorly and 12% regularly relied on sedatives to induce sleep. Sleep difficulties lasting more than 6 months were present in 43% of the children. In 14% (132 of 972), sleep latency was longer than 30 minutes, and more than one complete arousal occurred during the night at least two nights per week. The following variables were seen among the poor sleepers: lower parental educational and professional status, parents who were more likely to be divorced or separated, and more noise or light in the rooms were they slept. They also presented a higher incidence of somnambulism, somniloquia, and night fears (nightmares and night terrors) than the children who slept well. Boys who slept poorly were significantly more likely to have insomniac fathers (P less than .010). Regular use of sedatives was described in 4% (5 of 132) of the children who slept poorly. Among the "poor sleepers," 21% (33 of 132) had failed 1 or more years at school. School achievement difficulties were encountered significantly more often among the poor sleepers than among the children without sleep problems (P = .001). Of the families with children suffering from sleep problems, 28% expressed a desire for counseling.(ABSTRACT TRUNCATED AT 250 WORDS)
Night-terrors and somnambulism are comparatively rare in adults and are most often associated with stage 4 sleep, especially delta activity. Although the data are limited, reports suggest that imipramine, which may control nocturnal enuresis, a stage 4 sleep disorder, and diazepam, which suppresses stage 4 sleep, may effectively treat the condition. This paper describes two patients with night-terrors and somnambulism who responded to imipramine but not to diazepam. Possible mechanisms of diazepam and imipramine, including effects on stage 4 sleep and pervasive anxiolytic actions, are discussed.
The authors studied seven children with either pavor nocturnus or somnambulism, or both, in an attempt to find a method of treating these sleep disorders. Each child received imipramine orally at bedtime for a minimum of eight weeks. In all seven patients a complete cessation of symptoms resulted. Although the drug seems to be an effective treatment for these disorders, its mechanism of action is not yet known.
Nightly ingestion of diazepam, 10mg, alleviated some or all symptoms of intractable sleepwalking in several otherwise healthy adults. Some other patients did not respond as well. The results of this double-blind, crossover study suggest that diazepam is effective for the treatment of adult sleepwalking in some individuals. Data from this study are consistent with uncontrolled case reports of such treatment. Serious side effects or tolerance to the medication did not develop in any of the subjects studied. Other benzodiazepines, which may be more or less effective, remain unstudied. Psychiatric and social histories of these adult sleepwalkers are consistent with earlier work by the authors, which indicates little evidence for an association between uncomplicated sleepwalking and serious psychopathology.
A single-blind, rater-blind, modified crossover design was used to evaluate a simple, practical method of clinical treatment of sleepwalking. Subjects who had severe somnambulism, but were otherwise free of psychiatric illness, responded well to six brief sessions of specialized hypnotherapy. Follow-up at one year has revealed lasting improvement of both subjective and objective symptoms. A brief review of the subject of sleepwalking, as well as detailed information concerning histories of sleep symptoms and emotional problems in these and other sleepwalkers, is presented.
The occurrence and course of somnambulism and its correlations with behavioral variables have been investigated annually from 6 to 16 years of age in a sample recruited by random means. The prevalence was highest at 11-12 year. No sex difference was found. Apart from sporadic occurrences, the longitudinal data reveal a group of children for whom somnambulism is rather persistent. But even in this group the somnambulism is usually unrelated to other sleep disturbances (apart from "bad" dreams), deviant behavior or known environmental factors. These children have more inhibited aggression and a more developed mental defence against anxiety as determined by Rorschach tests. At school they appear to be more popular than other children.
Disorders of arousal and epilepsy during sleep
- Guilleminault
Guilleminault C, Silvestri R. Disorders of arousal and epilepsy during sleep. In: Sterman MB, Shouse MN, Passouant P, eds. Sleep and epilepsy. New York: Academic Press, 1982:513-31.
Atlas of electroencephalography
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Gibbs FA, Gibbs EL. Atlas of electroencephalography; vol 1. Cambridge: Addison-Wesley Press, ! 950.
Sommambulism in childhood: prevalence, course and behavioral correlations
- Klackenberg
Solve your child's sleep problems
- Ferber