Somnambulism (Sleep Walking) Clinical Presentation

The most common pediatric parasomnia disorders of arousal include sleepwalking, confusional arousals, and sleep terrors. Parasomnia events have a predilection for occurring during deep sleep (stages III and IV, or SWS), are known to occur during all stages of NREM sleep, and are possible at any time during the night. As most SWS is achieved in the earlier segments of the sleep period, these phenomena usually are seen in the first one third of the sleep cycle and rarely during naps.

• General and sleep related medical history is usually sufficient to differentiate parasomnias from other disorders. Pertinent questions include the following:

  • Detailed description of the event
  • Level of consciousness before, during, and after the event
  • Time of night and sleep cycle when the events occur
  • Daytime sleepiness
  • Associated injury
  • Memory of the event
  • Family history
  • Any precipitating factors
• Nocturnal frontal lobe seizures and some psychiatric conditions present the most difficult diagnostic dilemmas. A history of stereotypical short attacks that repeat during the night, most frequently during stage II sleep, suggests seizures rather than a parasomnia. Onset in later childhood or adolescence, persistence into adulthood, recurring nocturnal agitation, and daytime complaints such as fatigue or sleepiness are also suggestive of a seizure disorder.
• Sleepwalking

  • Episodes range from quiet walking about the room to agitated running or attempts to "escape." Subjects may later report attempting to escape dangerous situations or terrifying threats. Typically, the eyes are open with a glassy, staring appearance as the child quietly roams the house.
  • On questioning, responses are slow or absent. If returned to bed without awakening, the child usually does not remember the event. Older children, who may awaken more easily at the end of an episode, often are embarrassed by the behavior (especially if it was inappropriate).
  • Sleepwalking has no association with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark), or anger outbursts.
  • Some studies suggest that children who sleepwalk may have been more restless sleepers when aged 4-5 years and more restless with more frequent awakenings during the first year of life.
• Confusional arousals

  • Episodes consist of disorientation, memory impairment, and slow mentation and often are accompanied by inconsolable crying and thrashing movements in bed. This disorder is common in younger children but decreases in frequency with age.
  • In infants, episodes manifest by crying and moving about in bed.
  • The eyes may be closed or opened, as in sleep terrors, but the child does not appear to feel panic.
  • Events typically last from 3-13 minutes and range in frequency from 2 times per night to 2 times per year. Attempting to awaken the child often prolongs the course, and successful wakening by parents typically brings about an end to the episode.
• Sleep terrors

  • These are the most anxiety provoking for parents. Episodes frequently begin with a "blood-curdling" scream, which is accompanied by the appearance of panic with wide-open eyes, tachycardia, tachypnea, dilated pupils, diaphoresis, and flushing.
  • This may be followed by panic-driven motor activity, such as hitting the wall or running around the room.
  • While typically not dangerous, the behavior is sometimes violent enough to result in injury to the patient or others; property damage also may result.
  • The inability of the parent to console the child is a hallmark of the episode (which is typically shorter than confusional arousals), and amnesia for the event is usually complete.
  • Sleep terrors usually resolve by adolescence, although the disorder occasionally persists into adulthood.

Physical and neurological examinations are typically normal in these children.

• Genetic

  • Sleepwalking occurs more frequently in monozygotic twins and is 10 times more likely if a first-degree relative has a history of sleepwalking.
  • An increased frequency of DQB1*04 and *05 alleles is reported. DQB1 genes have also been implicated in narcolepsy and other disorders of motor control during sleep such as REM behavior disorder.
• Environmental: Sleep deprivation, chaotic sleep schedules, fever, stress, magnesium deficiency, and chemical or drug intoxication (eg, alcohol), sedative/hypnotics (eg, Zolpidem^[1] ), combination of valproic acid and zolpidem^[2] , antidepressants (eg, bupropion^[3] , paroxetine, amitriptyline), neuroleptics (eg, lithium, reboxetine), minor tranquilizers, stimulants, antibiotics (eg, fluoroquinolone), anti-Parkinson medications (eg, levodopa), anticonvulsants (eg, topiramate), and antihistamines can trigger parasomnias.
• Physiologic

  • The length and depth of SWS, which is greater in young children, may be a factor in the increased frequency of parasomnias in children.
  • Conditions such as pregnancy and menstruation are known to increase frequency in patients with parasomnias.
• Associated medical conditions

  • Arrhythmias
  • Chronic paroxysmal hemicrania
  • Migraine
  • Fever
  • Gastroesophageal reflux
  • Nocturnal asthma
  • Nocturnal seizures
  • Obstructive sleep apnea: Children with obstructive sleep apnea or Tourette syndrome are at greater risk of having parasomnias along with their underlying disorder.^{[4, 5]}
  • Chronic sleepwalking, especially in adults, is frequently associated with sleep-disordered breathing. Treatment of the sleep-disordered breathing with continuous positive airway pressure (CPAP) or surgery typically improves or resolves the sleepwalking. Noncompliance with CPAP is associated with persistence or recurrence of sleepwalking. Serotonin has been postulated as the physiologic link between these two disorders.
  • Psychiatric disorders
    • Posttraumatic stress disorder
    • Panic attack
    • Dissociative states
  • Hyperthyroidism^[6] : Thyrotoxicosis has been associated with an increased incidence of sleepwalking, and achievement of euthyroidism is associated with improvement or resolution of the symptoms. Sleepwalking may occur as an early symptom, and the onset of sleepwalking in a patient out of the normal expected age range should be evaluated for hyperthyroidism. The mechanism for the sleepwalking is considered to be increased fatigue in combination with longer periods of non-REM sleep.