Sleep walking and more

Occasionally a patient will be referred to me for problems such as sleepwalking. Sleepwalking, which can be regarded as a 'disorder of arousal' is probably reasonably prevalent. About 2% of the adult population have been estimated to suffer from this disorder, which is much more frequent in kids. Around the same number of adults probably suffer from 'sleep terrors', and around twice as many from 'confusional arousals'.

These disorders usually involve arousal out of NREM sleep. They are particularly phenomena of slow wave sleep - which usually occurs most in the first part of the night. Lots of slow wave sleep is often seen in younger people particularly after sleep deprivation. Although it may seem self-explanatory, these disorders have in common:

• mental confusion and disorientation
• the presence of automatic behaviour
• lack of responsiveness to efforts to wake the person, or in fact to any external stimuli
• amnesia for what happens during the episode
• little recall of dreaming during the episode

Confusional arousals involve disorientation, slowness in speech and response after wakening. They are much more likely to occur in patients with bipolar disorder and in younger patients. They are also more likely to occur when hypnagogic hallucinations are present (which will be the subject of a future post). They are slightly more likely in patients with OSA, insomnia or hypersomnia.

Getting regular, adequate amounts of sleep, which results in less slow wave sleep (the stage of sleep during which the arousal usually happens), may help to combat the problem. The sleep environment should be secured. The apparently distressed or confused person should, if possible, be left alone. If the episode occurs at a predictable time during sleep, then scheduled waking before the episode can be of benefit. Benzodiazepines and tricyclics, which suppress slow wave sleep, may be of benefit and can be tried.

Sleep terrors involve a sudden arousal from slow wave sleep. This arousal is usually with a scream or cry, and accompanied by behavioural manifestations of fear. Sleep terrors and sleep walking each seem to have some genetic component; there is frequently a family history of this sort of behaviour. In adults and adolescents sleep terrors are more frequently accompanied by anxiety and substance abuse disorders. They have, in adult women, been described to be precipitated by menstruation. Treatment is similar to treatment of confusional arousals. Treatment maynot be required once an explanation is given. Psychotherapy, hypnosis or cognitive behavioural therapy may help in adults. Various benzodiazepines, Paroxetine and melatonin have been used with reports of success. Treatment of associated restless legs syndrome or sleep disordered breathing is almost always effective.

Sleepwalking usually occurs inthe first third of the night, and is also a disorder of slow wave sleep (mostly. Sleep walkers generally wake often out of slow wave sleep - which is an interesting fact for me, but perhaps not for you). Sleep deprivation often makes it worse. Benzodiazepines have been used where treatment is required. Hypnosis may be helpful.

Andrew