Assessment and Treatment of Sleepwalking in Clinical Practice

CLINICAL

Assessment and treatment of sleepwalking in clinical practice

Helen M Stallman

Background Sleepwalking is characterised by: There is some evidence for a genetic • partial arousal during non-rapid eye predisposition for sleepwalking in Sleepwalking is a relatively common movement (NREM) sleep, typically some people, although this is not well and innocuous arousal disorder during during the first third of the night understood. Monozygotic twins have non‑rapid eye movement sleep. • dream content that may or may not be been found to be more concordant for 5,6 Objective recalled sleepwalking than dizygotic twins. • dream-congruent motor behaviour that One study found more Caucasians who This paper provides a review of the most may be simple or complex sleepwalk (35.0%) than non-sleepwalkers recent science on sleepwalking to guide • impaired perception of the environment (13.3%) were DQB1*0501-positive, which clinical decision-making. • impaired judgement, planning and is suggestive of the DQB1 genes being problem-solving. implicated in motor disorders in sleep.7 Discussion Memory of episodes varies between A study of a single family across four episodes and between those who generations suggested that sleepwalking Most patients who sleepwalk do not sleepwalk, ranging from complete may be transmitted as an autosomal require treatment, but comorbid sleep 8 disorders that result in daytime tiredness, amnesia to complete recall of the dominant trait with reduced penetrance. episode.1 Analgesia has been noted and and behaviour and emotional problems Associated problems require assessment and interventions. In those who sleepwalk are often unaware 2,3 the absence of clinical trials, tentative, of being injured until they awaken. Sleepwalking has been associated with low-risk treatments – scheduled waking This paper provides a review of the most other sleep problems such as confusional and hypnosis – are suggested for recent science on sleepwalking, to guide arousals or awakenings, rhythmic sleepwalking that results in distress or clinical decision-making. movement problems, sleep disordered violence towards others. People who A recent meta-analysis showed breathing, night terrors, sleep talking and sleepwalk and are violent may benefit the estimated lifetime prevalence of bruxism.9–11 It has also been associated from impulse-control interventions. sleepwalking is 6.9% (95% confidence with daytime tiredness, and behavioural interval [CI]: 4.6, 10.3).4 There was no and emotional problems in children.12–14 significant difference in lifetime reports However, comorbid sleep disorders, of sleepwalking between children and rather than sleepwalking per se, have adults, suggesting that initial onset been found to account for these daytime of sleepwalking in adults is rare and problems.11 It is essential, therefore, requires further investigation. The current that presentations of sleepwalking with prevalence rate of sleepwalking, within the daytime tiredness and/or behavioural past 12 months, was significantly higher and emotional problems, particularly in in children 5.0% (95% CI: 3.8, 6.5) than in children, include an assessment of other adults 1.5% (95% CI: 1.0, 2.3).4 This may be sleep disorders. the result of less slow wave sleep during adulthood and, hence, fewer opportunities Assessment for sleepwalking, less observed Although our knowledge of sleepwalking sleepwalking or maturational changes. is still in its infancy, Figure 1 provides

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guidelines on the assessment and be useful for forensic cases or when (SSRIs), and tricyclic antidepressants.15 treatment of sleepwalking in clinical there is uncertainty about the differential These have only been described in practice based on what is currently diagnosis. patients without a previous history known and least likely to cause adverse Case studies have identified a of sleepwalking, so their effect effects. Polysomnography is the only number of classes of medications that on sleepwalkers is not known. If infallible measure of sleepwalking, may trigger sleepwalking, including sleepwalking is triggered by a prescribed if it occurs. However, it is costly and antibiotics, anticonvulsants, atypical medication, discontinuation should be inconvenient, and there are difficulties antidepressants, typical and atypical considered. in capturing infrequent and irregular antipsychotics, benzodiazepines, behaviour, such as sleepwalking. It is lithium, non‑benzodiazepine hypnotics, Violence during therefore not recommended for routine noradrenergic and specific serotonergic sleepwalking assessment of sleepwalking. A history antidepressants, noradrenaline Patients who sleepwalk do not seek out using self-report and reports from others re-uptake inhibitors, quinine, selective other people while sleepwalking, but of sleepwalking behaviour are sufficient and non‑selective beta blockers, may inadvertently encounter them.16 They in most cases. Polysomnography may selective serotonin re-uptake inhibitors can be led back to bed and do not need

Sleepwalking

Yes Consider discontinuing Drug-induced triggering drug

Yes Safety planning for family members Violence while sleepwalking

Yes Daytime tiredness, behavioural or Assess and treat comorbid Assess and treat impulsivity emotional problems sleep disorders

Abstain from alcohol and drugs Safe sleep environment

No Distressed Reassurance – no treatment

Yes

Scheduled waking Hypnosis

Figure 1. Flowchart for the assessment and treatment of sleepwalking

to be awakened. As the most common Scheduled waking involves waking the Author emotion experienced during sleepwalking sleepwalker briefly 15–30 minutes before Helen M Stallman PhD, DClinPsych, CertMedEd, is fear, triggering a fight/flight response, they would normally sleepwalk. Hypnosis Senior Lecturer, Psychology, Centre for Sleep Research, School of Psychology, Social Work and a very small proportion of people who that provides the hypnotic suggestion Social Policy, University of South Australia, Adelaide, sleepwalk are sometimes violent towards that sleepwalker will wake if their feet South Australia. [email protected] others. Reports in the literature are touch the ground is based on a similar Competing interests: None. Provenance and peer review: Not commissioned, limited to violence by men, typically premise of disrupting the sleepwalking externally peer reviewed younger men. It is hypothesised that process. A recorded hypnosis session those who sleepwalk and are violent can be implemented independently by References have impulsive tendencies that are the patient. Both interventions should be 1. Zadra A, Pilon M. Parasomnias II: Night terrors and somnambulism. In: Morin CM, Espie CA, exacerbated in sleepwalking because done daily for about two to three weeks. editors. Oxford handbook of sleep and sleep of the emotional arousal and impaired Although sleep hygiene is routinely disorders. Oxford: Oxford University Press, 2012; p. 577–98. frontal cortical function during sleep recommended for treating sleepwalking, 2. Lopez R, Jaussent I, Dauvilliers Y. Pain in that would ordinarily inhibit impulsive there have been no empirical studies sleepwalking: A clinical enigma. Sleep aggression.17 It is imperative that priority evaluating its effectiveness – it is therefore 2015;38(11):1693–98. 3. Edmonds C. Severe somnambulism: A case be given to ensure the safety of other not a recommended intervention for study. J Clin Psychol 1967;23(2):237–39. family members. It is hypothesised that sleepwalking at this stage. 4. Stallman HM, Kohler M. Prevalence of treatments for impulsive aggression sleepwalking: A systematic review and meta- analysis. PLoS One 2016;11(11):e0164769. may reduce the tendency for violence Conclusion 5. Bakwin H. Sleep-walking in twins. Lancet 17 during sleepwalking. However, it is Sleepwalking is a relatively common and 1970;2(7670):466–67. also important that people at risk of innocuous arousal disorder during NREM 6. Hublin C, Kaprio J, Partinen M, Heikkilä K, violence during sleepwalking abstain from sleep. Most people who sleepwalk do not Koskenvuo M. 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Guilleminault C, Lee JH, Chan A, Lopes MC, 19 Huang YS, da Rosa A. Non-REM-sleep instability or windows ) or may simply cause in recurrent sleepwalking in pre-pubertal significant embarrassment, such as Case children. Sleep Med 2005;6(6):515–21. being found naked wandering down the Lily, aged 8 years, presented to her 10. Nevéus T, Cnattingius S, Olsson U, Hetta J. Sleep habits and sleep problems among a community 20 street. Locking windows and external general practitioner following a four-year sample of schoolchildren. Acta Paediatr doors and removing breakable objects is history of sleepwalking, on average, 2001;90(12):1450–55. recommended. It is important not to lock twice a week. She had not sustained 11. Stallman HM, Kohler M, Biggs S, Lushington K, Kennedy D, Martin AJ. 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In early childhood. Pediatrics 2007;119(5):1016–25. If sleepwalking is causing distress to the 14. Steinsbekk S, Wichstrøm L. Stability of addition to psychoeducation about safe sleep disorders from preschool to first grade sleepwalker or their family members, or sleep environments, treatment involved and their bidirectional relationship with the sleepwalker is limiting their activities teaching Lily’s parents to do scheduled psychiatric symptoms. J Dev Behav Pediatr 2015;36(4):243–51. (eg not going on school camps or waking – briefly waking Lily nightly 15. Stallman HM, Kohler M, White J. Medication travelling), psychological interventions – for three weeks, 20 minutes before she induced sleepwalking: A systematic review. scheduled waking or hypnosis – hold the usually sleepwalked. No sleepwalking Sleep Med Rev 2017;[Epub ahead of publication]. 16. Pressman MR. 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17. Stallman HM, Bari A. A biopsychosocial model of violence during sleepwalking: Review and reconceptualization. BJPsych Open 2017;3(2):96–101. 18. The Times. News in brief: £1.3m for window fall sleepwalker. The Times. 14 Nov 2000. 19. New York Times. Badly hurt while sleepwalking. New York Times. 30 January 1895: 9. 20. Xie Q. Naked sleepwalker found in Manchester city centre at 4am by police – who returned him to his hotel after posing for a selfie. Daily Mail Australia. 30 May 2016. 21. Stallman HM, Kohler M. A systematic review of treatments for sleepwalking: 100 years of case studies. Sleep and Hypnosis 2016:[EPub ahead of publication].