Assessment and treatment of sleepwalking in clinical practice.

BACKGROUND: Sleepwalking is a relatively common and innocuous arousal disorder during non­rapid eye movement sleep. OBJECTIVE: This paper provides a review of the most recent science on sleepwalking to guide clinical decision-making. DISCUSSION: Most patients who sleepwalk do not require treatment, but comorbid sleep disorders that result in daytime tiredness, and behaviour and emotional problems require assessment and interventions. In the absence of clinical trials, tentative, low-risk treatments - scheduled waking and hypnosis - are suggested for sleepwalking that results in distress or violence towards others. People who sleepwalk and are violent may benefit from impulse-control interventions.

Is there a common motor dysregulation in sleepwalking and REM sleep behaviour disorder?

This study sought to determine if there is any overlap between the two major non-rapid eye movement and rapid eye movement parasomnias, i.e. sleepwalking/sleep terrors and rapid eye movement sleep behaviour disorder. We assessed adult patients with sleepwalking/sleep terrors using rapid eye movement sleep behaviour disorder screening questionnaires and determined if they had enhanced muscle tone during rapid eye movement sleep. Conversely, we assessed rapid eye movement sleep behaviour disorder patients using the Paris Arousal Disorders Severity Scale and determined if they had more N3 awakenings. The 251 participants included 64 patients with rapid eye movement sleep behaviour disorder (29 with idiopathic rapid eye movement sleep behaviour disorder and 35 with rapid eye movement sleep behaviour disorder associated with Parkinson's disease), 62 patients with sleepwalking/sleep terrors, 66 old healthy controls (age-matched with the rapid eye movement sleep behaviour disorder group) and 59 young healthy controls (age-matched with the sleepwalking/sleep terrors group). They completed the rapid eye movement sleep behaviour disorder screening questionnaire, rapid eye movement sleep behaviour disorder single question and Paris Arousal Disorders Severity Scale. In addition, all the participants underwent a video-polysomnography. The sleepwalking/sleep terrors patients scored positive on rapid eye movement sleep behaviour disorder scales and had a higher percentage of 'any' phasic rapid eye movement sleep without atonia when compared with controls; however, these patients did not have higher tonic rapid eye movement sleep without atonia or complex behaviours during rapid eye movement sleep. Patients with rapid eye movement sleep behaviour disorder had moderately elevated scores on the Paris Arousal Disorders Severity Scale but did not exhibit more N3 arousals (suggestive of non-rapid eye movement parasomnia) than the control group. These results indicate that dream-enacting behaviours (assessed by rapid eye movement sleep behaviour disorder screening questionnaires) are commonly reported by sleepwalking/sleep terrors patients, thus decreasing the questionnaire's specificity. Furthermore, sleepwalking/sleep terrors patients have excessive twitching during rapid eye movement sleep, which may result either from a higher dreaming activity in rapid eye movement sleep or from a more generalised non-rapid eye movement/rapid eye movement motor dyscontrol during sleep.

[Life-threatening sleepwalking (Elpenor's syndrome) in a 10-year-old child]. / Somnambulisme avec mise en danger vital (syndrome d'Elpénor) chez un enfant.

Though benign in the majority of cases, sleepwalking sometimes causes injuries due, among other causes, to falls. Such accidents can be life-threatening - a situation that has been termed Elpenor syndrome (in reference to an accident experienced by a character in Homer's epic The Odyssey) - in particular when entailing defenestration. This syndrome has been described in adults and adolescents; we report here a case in a child. OBSERVATION: This 10-year-old girl was admitted at night to our hospital after a 3-m fall at home. She was alert (Glasgow score, 15) at admission; a frontal wound and a deformation of the right wrist were noted. Brain CT scans showed a frontal skull fracture and frontal lobe contusion, wrist x-rays showed a displaced right fracture. The patient underwent urgent neurosurgery (wound excision and suture after reduction of skull fracture) and closed reduction and immobilization of the wrist fracture, both under general anesthesia. She underwent a psychiatric assessment in the intensive care unit 3 days after her fall. She was alert, well-oriented in time and space, and spoke fluently. She had no memory of her fall, only remembering going to bed in the evening before the accident and waking up in the ambulance on the way to the hospital. She displayed no sign of a concurrent mental illness and no suicidal ideas. Her parents reported that the evening of the accident she and her two brothers had all fallen asleep about 11:00 pm while watching TV, in the double bed of the guest room, placed just beside its window. At approximately 1:00 am, her father, who was going to bed and had just made noise in the hall, heard a cry from the guest room. He entered the room immediately and saw the opened window and his daughter lying on the outside ground; the brothers only awakened after the fall. The family had returned 2 days before from a 6-month stay in the United States, with jet-lag, sleep deprivation, and a disorganized sleep/wake rhythm in the patient. There was no medication before the accident, no substance use (including caffeine), and no concurrent medical problem. Over the 2 preceding years, the patient had undergone two witnessed episodes of early-nighttime arousal with altered consciousness and calm wandering (including going downstairs on one occasion), both strongly suggesting sleepwalking. There was a history of sleepwalking in her father and her older brother. Life-threatening sleepwalking (Elpenor syndrome) was diagnosed. The child and her parents were educated about sleepwalking; regularization of sleep schedules and sleep extension (avoidance of sleep deprivation, short napping when possible) were prescribed. We also recommended securing the home (bed, windows, and stairways). No pharmacological treatment was instituted. During the following 18 months, the child manifested only one noted sleepwalking episode, without risk-taking. She had no neurological or psychopathological sequela from her accident, of which she never had a memory. CONCLUSION: Elpenor syndrome can occur in a child; consequently, it is important to inform parents of children with sleepwalking about the necessity of always securing the night-time environment.

Parasomnia Overlap Disorder with Sexual Behaviors during Sleep in a Patient with Obstructive Sleep Apnea.

ABSTRACT: Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of NREM sleep parasomnias. Sexsomnia has been reported as part of parasomnia overlap disorder (POD) in two other patients. We present the case of a 42-year-old male patient with video-polysomnography (vPSG) documented POD. The patient had sleepwalking, sleep-related eating, confusional arousals, sexsomnia, sleeptalking, and REM sleep behavior disorder (RBD). Confusional arousals and RBD were documented during the vPSG. This case had the added complexity of obstructive sleep apnea (OSA) playing a role in sleepwalking and sleep related eating, with good response to nasal continuous positive airway pressure (nCPAP). The sexsomnia did not respond to nCPAP but responded substantially to bedtime clonazepam therapy.

Sleep deprivation impairs inhibitory control during wakefulness in adult sleepwalkers.

Sleepwalkers often complain of excessive daytime somnolence. Although excessive daytime somnolence has been associated with cognitive impairment in several sleep disorders, very few data exist concerning sleepwalking. This study aimed to investigate daytime cognitive functioning in adults diagnosed with idiopathic sleepwalking. Fifteen sleepwalkers and 15 matched controls were administered the Continuous Performance Test and Stroop Colour-Word Test in the morning after an overnight polysomnographic assessment. Participants were tested a week later on the same neuropsychological battery, but after 25 h of sleep deprivation, a procedure known to precipitate sleepwalking episodes during subsequent recovery sleep. There were no significant differences between sleepwalkers and controls on any of the cognitive tests administered under normal waking conditions. Testing following sleep deprivation revealed significant impairment in sleepwalkers' executive functions related to inhibitory control, as they made more errors than controls on the Stroop Colour-Word Test and more commission errors on the Continuous Performance Test. Sleepwalkers' scores on measures of executive functions were not associated with self-reported sleepiness or indices of sleep fragmentation from baseline polysomnographic recordings. The results support the idea that sleepwalking involves daytime consequences and suggest that these may also include cognitive impairments in the form of disrupted inhibitory control following sleep deprivation. These disruptions may represent a daytime expression of sleepwalking's pathophysiological mechanisms.

Pain in Sleepwalking: A Clinical Enigma.

STUDY OBJECTIVES: Sleepwalking is a disorder characterized by arousal specifically from slow wave sleep with dissociated brain activity that may be related to lower nociceptive state. Our objectives were to assess the frequency of chronic pain, headache, and migraine in sleepwalkers compared to controls, examine the impact and determinants of pain in sleepwalkers, and report analgesia frequency during injurious parasomnia episodes. DESIGN: Cross-sectional case-control study. SETTING: Data were collected at the Sleep Disorders Center, Montpellier, France. PARTICIPANTS: One hundred patients with sleepwalking were assessed for disease characteristics, sleep (polysomnography, sleepiness, and insomnia), pain (chronic pain, multidimensional pain inventory, headache, and migraine), depressive symptoms, and quality of life compared to 100 adult controls. Pain perception was retrospectively assessed during injurious parasomnia episodes. MEASUREMENTS AND RESULTS: Raw association data showed that lifetime headache, migraine, and chronic pain at time of study were significantly associated with sleepwalking (also called somnambulism). Compared to controls, sleepwalkers reported more frequent daytime sleepiness, and depressive and insomnia symptoms. After adjustments, sleepwalking was associated with increased risk for headache and migraine only. Compared to pain-free sleepwalkers, sleepwalkers with chronic pain were more likely to be older and to have greater daytime sleepiness, insomnia, and depressive symptoms, with no difference in polysomnography assessment. Of the 47 sleepwalkers with at least one previous violent parasomnia episode, 78.7% perceived no pain during episodes, allowing them to remain asleep despite injury. CONCLUSION: Our results highlight the clinical enigma of pain in sleepwalking patients with complaints of frequent chronic pain, migraine, and headache during wakefulness but who report retrospectively experience of analgesia during severe parasomnia episodes, suggesting a relationship between dissociated brain activity and nociceptive dysregulation.

Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors.

STUDY OBJECTIVES: To characterize the clinical, polysomnographic and treatment responses of patients with disruptive nocturnal behaviors (DNB) and nightmares following traumatic experiences. METHODS: A case series of four young male, active duty U.S. Army Soldiers who presented with DNB and trauma related nightmares. Patients underwent a clinical evaluation in a sleep medicine clinic, attended overnight polysomnogram (PSG) and received treatment. We report pertinent clinical and PSG findings from our patients and review prior literature on sleep disturbances in trauma survivors. RESULTS: DNB ranged from vocalizations, somnambulism to combative behaviors that injured bed partners. Nightmares were replays of the patient's traumatic experiences. All patients had REM without atonia during polysomnography; one patient had DNB and a nightmare captured during REM sleep. Prazosin improved DNB and nightmares in all patients. CONCLUSIONS: We propose Trauma associated Sleep Disorder (TSD) as a unique sleep disorder encompassing the clinical features, PSG findings, and treatment responses of patients with DNB, nightmares, and REM without atonia after trauma.

Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports.

OBJECTIVE: To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS). SEARCH METHODS: We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles. SELECTION CRITERIA: Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided. DATA EXTRACTION AND ANALYSIS: Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed. RESULTS: Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case. CONCLUSION: SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.

Automatism and driving offences.

Automatism is a rarely used defence, but it is particularly used for driving offences because many are strict liability offences. Medical evidence is almost always crucial to argue the defence, and it is important to understand the bars that limit the use of automatism so that the important medical issues can be identified. The issue of prior fault is an important public safeguard to ensure that reasonable precautions are taken to prevent accidents. The total loss of control definition is more problematic, especially with disorders of more gradual onset like hypoglycaemic episodes. In these cases the alternative of 'effective loss of control' would be fairer. This article explores several cases, how the criteria were applied to each, and the types of medical assessment required.

Defending sleepwalkers with science and an illustrative case.

OBJECTIVE: To test whether laboratory-based research differentiating sleepwalkers (SW) from controls (C) can be applied in an uncontrolled forensic case as evidence the alleged crime was committed during an arousal from sleep in which the mind is not fully conscious due to a SW disorder. METHODS: A PSG study recorded 8 months after the defendant was charged was analyzed independently by spectral analysis. Slow wave activity (SWA) and cyclic alternating pattern (CAP) rates were computed. Clinical interviews and police records were reviewed for data re: the defendant's sleep prior to the event and use of drugs, alcohol, and stimulants. RESULTS: The SWA distribution was abnormally low and flat, significantly lower than published controls; in the first NREM cycle, CAP rate 55 was above normal. Two weeks of prior sleep deprivation was confirmed from interviews and defendant's observed daytime sleepiness. Caffeine intake the day before the event was calculated at 826 mg over 14 hours. Snoring and a mild breathing disorder were present in the PSG. CONCLUSION: Testimony based on spectral analysis of PSG recorded following an alleged criminal event supported a SW explanation for the non-rational behaviors charged. The defendant was acquitted of all charges and has been successfully treated.

Biperiden for treatment of somnambulism in adolescents and adults with or without epilepsy: clinical observations.

BACKGROUND: Sleepwalking in adolescents and adults may lead to serious injuries and require treatment. Anecdotal treatment recommendations include benzodiazepines (which also work in focal seizures of the frontal lobe that are an important differential diagnosis), imipramine and amitriptyline. METHODS: We assessed in a follow-up study of 4 years (medium, range: 2-7 years) the usefulness of the antiparkinsonian drug biperiden (Akineton©), an acetylcholine antagonist with high affinity for muscarinic M1-type receptors, in four consecutive cases of arousal disorder with sleepwalking and confusional behavior in adolescents and adults with or without epilepsy who did not respond to diazepam, clonazepam or amitriptyline. FINDINGS: The adjunctive use of biperiden was associated with reduction or remission of sleepwalking episodes in four consecutive treatment-refractory cases of arousal disorder with sleepwalking and confusional behavior. In contrast, biperiden showed no effect in a patient with REM behavioral disorder. INTERPRETATION: Although our observations do not and cannot establish the efficacy or safety of biperiden, it may be useful to consider biperiden for treatment of sleepwalking, if needed. A putative cholinergic mechanism of arousal disorders, including sleepwalking, provides a reasonable hypothesis why the anticholinergic agent biperiden might work. Evidence for efficacy and safety from randomized controlled trials is needed to confirm our preliminary observations.

[Complex injuries associated with somnambulism]. / Komplekse skader i forbindelse med søvngaengeri.

Up to 3% of adults walk in their sleep and some perform complex behaviours. Treatment recommendations for sleepwalking are inconsistent. This case report describes a 64-year-old man who climbed out of a 2nd floor toilet window during somnambulism. He fell 6-8 meters and fractured the tibia, fibula, cervical columna, lumbal columna, calcaneus, costae and suffered a pneumothorax. Evidence to support sleepwalking treatment is lacking and besides benzodiazepines, prevention is the preferred treatment choice according to the literature.