Sleep Walking Disorder - Essay Example

Sleep Walking Disorder Sleep walking disorder is the most common parasomnia occurring more commonly in children. Though it is a disorder with benign symptoms, parents are often worried because of the bizarre nature of motor automatisms in the child. The diagnosis is possible on clinical history, however, detailed history, physical examination and further investigations are necessary to rule out any medical cause related to the disease. Hypothesis This writer believes that sleep walking disorder is a benign condition occurring in children with no pathological cause in brain, and hence the anxious parents must be reassured about spontaneous resolution of symptoms. Introduction Sleep walking disorder or somnambulism or noctambulism falls into the category of parasomnias which are actually categorized under sleep disorders. Sleep disorders are the most common problems encountered in psychiatric practice. According to the American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR), sleep disorders can be classified into 3 types (Bonds & Lucia, 2006): 1. Primary sleep disorders: These occur due to an endogenous disturbance in sleep-wake generating or timing mechanisms. They are often complicated by behavioral conditioning. Primary sleep disorders are further subdivided into parasomnias and dyssomnias. 2. Secondary sleep disorders, related to mental health 3. Others, related to a general medical condition or substance abuse Parasomnias are disruptive sleep-related disorders characterized by undesirable physical or verbal behaviors or experiences during sleep. These phenomena occur as primary sleep events or secondary to systemic disease. The other disorders categorized under parasomnias are sleep terror disorder, REM sleep behavior disorder, restless legs syndrome and periodic limb movement disorder (Ackroyd & Cruz, 2007). Diagnostic criteria According to the American Psychiatric Associations DSM-IV-TR, the diagnostic criteria for sleep walking disorder include (Kaplan et al, 1991): 1. Repeated episodes of rising from bed during sleep and walking about, usually occurring during the first third of the major sleep episode. 2. While sleep walking, the person has a blank, staring face and is relatively unresponsive to the efforts of others to communicate with him or her, and can be awakened only with great difficulty. 3. On awakening (either from sleep walking episode or the next morning), the person has amnesia for the episode. 4. Within several minutes after awakening from the sleep walking episode, there is no impairment of mental activity or behavior (although there may be a short period of confusion or disorientation). 5. The sleepwalking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 6. The disturbance is not due to direct physiological effects of a substance or a general medical condition. Prevalence Sleep walking disorder is more common in children than in adults. The incidence is about 2% world wide (Ackroyd & Cruz, 2007). There is no sex difference noted in the occurrence of symptoms in this disorder. The prevalence is highest at 11-12 years of age (Klackenberg, 1982). The condition is not related to socioeconomic status or race of the individual. Mortality and morbidity Parasomnias are seldom associated with morbidity. Sometimes, children can injure themselves by striking at objects. In adults and adolescents, morbidity may be more severe. Complex behaviors like driving a car, cooking and eating can occur. They can injure others also, especially their partners. Sleep walking disorder can also be comorbid with neuroses, panic disorder, phobias, and suicidal ideations (Ackroyd & Cruz, 2007). Pathophysiology In all parasomnias including sleep walking disorder, there is no pathology in the brain. The symptoms occur as a response to CNS activation that leads to sleep-wake or REM-NREM state confusion. However, studies have demonstrated patterns of sleep electro-encephalogram different from the normal sleep cycle patterns. Normal sleep electro-encephalogram consists of cyclic hypnic patterns throughout the night between wakefulness, NREM, and REM states. During the first 2 hypnic cycles, slow sleep wave sleep (SWS) occurs. Children, especially those who are young, actually have an additional SWS period towards the end of the sleep period, probably due to immaturity of the brain. Also, they enter their deepest sleep within 15 minutes of sleep onset and the first SWS period lasts from 45-75 minutes (Ackroyd & Cruz, 2007). Inability of the brain to fully awaken from slow-wave sleep due to disordered arousal mechanism is thought to lead to these motor automatisms (Pazzi, 2005). Hence sleep walking occurs more frequently in this cycle. Also, during transition from one sleep cycle to the next, the child has high arousal threshold, mental confusion, and unclear perception (Ackroyd & Cruz, 2007). Thus, children can be moved easily during sleep without arousing them. Also, some studies have shown activation of thalamocingulate pathways with persisting deactivation of other thalamocortical arousal systems leading to abnormality in slow wave sleep regulation in sleep walkers and dissociation between body and mind sleep. (Ackroyd & Cruz, 2007). Etiology Multiple factors are considered in the etiology of sleepwalking disorder. Since the length and depth of SWS which is greater in young children is related to increased frequency of parasomnias in children, disrupted arousal mechanism due to physiological immaturity of the brain has been thought of as a cause. The physiological states which precipitate the symptoms are pregnancy and menstruation (Ackroyd & Cruz, 2007). Since sleepwalking is seen more commonly in monozygotic twins, genetic involvement has been hypothesized (Ackroyd & Cruz, 2007). This is further supported by the fact that sleep walking disorder is 10 times more likely in a child whose first-degree relative has a history of sleepwalking. Also, increased frequency of DQB1-04 and -05 alleles is reported in children with sleep walking disorder. Sleep deprivation and chaotic sleep patterns have been linked with sleepwalking disorder. Stress and illness also increase the symptoms. Interactions with certain drugs like sedatives, antidepressants, neuroleptics, antibiotics and antihistaminics can trigger the episodes (Ackroyd & Cruz, 2007). Nocturnal presentation of symptoms in asthma, gastroesophageal reflux and seizures can be associated with sleep walking disorder. Hyperthyroidic states are associated with sleep walking and return to euthyroid states results in resolution of symptoms. Sleepwalking disorder occurs as a comorbid condition with dissociative disorders panic disorder and post-traumatic stress disorder (Ackroyd & Cruz, 2007). Clinical manifestations Sleep walking is the most common parasomnia (Ackroyd & Cruz, 2007). Like other parasomnias, sleep walking occurs during deep sleep and can occur in any stage of NREM sleep. It is unlikely to occur during naps and is usually seen in the first one third of the cycle (Ackroyd & Cruz, 2007). The clinical presentation of sleep walking can vary from person to person. In some, there may be only quiet walking in the room and the individual may simply return to bed. Others may have more severe symptoms like agitated behavior, running and escaping attempts (Ackroyd & Cruz, 2007). During these episodes, the individual appears to be wide awake although he is actually sleeping. The eyes are open with a glassy, staring appearance. When the individual is confronted and questioned, the responses are slow or absent (Ackroyd & Cruz, 2007). It is possible to awake these individuals from sleep and if they are not woken up, most of them go back to bed and do not remember the episode. Older children and adults are often embarrassed by these episodes. As thought by common man, sleep walking is not associated with previous sleep problems, fear of dark, emotional stress or sleeping alone in the room or sleeping with others. Sleep walking needs to be differentiated from other parasomnias like confusion arousals and sleep terrors which mimic sleep walking disorder. In confusional arousals, the person is often disoriented and has memory impairment. Children with confusional arousals cry inconsolably and move thrashingly in bed (Ackroyd & Cruz, 2007). However, the child does not appear to be in a panic state. The eyes may be closed or open. Confusional arousal episodes last from 3 to 13 minutes and the frequency can occur from 2 times per night to 2 times per year (Ackroyd & Cruz, 2007). The episode can be aborted by waking up the child successfully. Sleep terrors usually occur in children and they resolve in adolescence. In sleep terrors, the child often screams loudly as if there is some danger or attack. There is panic typically writ on the face. The eyes are wide open. Sleep terrors in children actually cause anxiety in parents. Clinically, the child will have symptoms of severe panic like tachycardia, tachypnoea, dilated pupils, diaphoresis, and flushing (Ackroyd & Cruz, 2007). Some individuals may even show panic driven activity like running out of the room which can lead to injuries. In sleep terrors, the individuals can not be woken up from sleep, which is the hallmark of sleep terrors. Hence the amnesia for the event is complete (Ackroyd & Cruz, 2007). Physical and neurological examinations are typically normal in all children with parasomnias. Differential diagnosis Sleep walking disorder needs to be differentiated from other miscellaneous sleep disorders like sleep apnea, rhythmic movement disorder, nocturnal bruxism, sleep talking, nocturnal dystonia and enuresis (Ackroyd & Cruz, 2007). Investigations The diagnosis of sleep walking disorder is made based on clinical history. Investigations are necessary only to rule out other associated medical causes as discussed above. If the diagnosis is in doubt, polysomnogram may be done. Abnormal behavior during SWS is diagnostic. Video poly somnography may also be useful if done at home (Plazzi, 2005). However, in all patients, a detailed history and examination must be under taken not to miss any associated medical condition. Prognosis All parasomnias, including sleepwalking disorder resolve in few years without any sequelae (Ackroyd & Cruz, 2007). Most of the patients are free of symptoms in early adolescence. However, the disturbed sleep in older children and adolescents can be associated with sleep- deprivation related behaviors in school affecting their studies. Serious injuries can occur to the individual and to others during agitated behaviors. Some may even exhibit sexual misconduct. Case study 10 year old John was brought by his anxious parents to the child psychiatrist with complaints of not being attentive at school. They reported that the school authorities frequently complained of John sleeping in the school. On further enquiry, the parents revealed that they noticed John getting up in the middle of sleep in the nights and wandering about in the room once in every 4 to 5 days. They also noticed that he fell asleep during the classes on the days following his night walking. They said that John would act as if he was sleeping with eyes wide awake during those episodes and would not remember these incidents in the next morning. He also was difficult to wake up during that time. Each episode would last for about 10 minutes and John would simply walk around the room and then go back to bed. Parents revealed that the maternal uncle also had similar symptoms during childhood. John did not have any health related issues. Epilepsy, asthma, nocturnal enuresis and gastroesophageal reflux were ruled out in clinical history and examination. He was not on any medication. His behavior and conduct was normal and had normal intelligence. The psychiatrist made a diagnosis of sleep walking disorder. He simply reassured the parents that there are good chances that the symptoms resolve spontaneously in early adolescence. He also attributed the inattention in school to sleep walking disorder. He advised the parents not to wake up the child during these episodes and to gently help him to go back to bed. He asked them to come back if the symptoms changed to violent behavior. Treatment The mainstay of treatment is reassurance. Parents and partners should be advised about the benign nature of the symptoms. If other associated medical conditions are discovered, they should be treated appropriately. Parents should be instructed to keep the room safe like remove injuring objects and keep all the doors and windows locked. They should also be advised not to wake the child during the episode but gently redirect him to the room. Medications are indicated only if the behavior during the episodes is agitated and injurious either to the individual or to others and conservative management has failed. The most commonly used medication is a benzodiazepine like clonazepam which is given in low doses before bedtime (Ackroyd & Cruz, 2007). Other drugs which may be used are tricyclic antidepressants, and serotonin reuptake inhibitors. The drugs may be stopped after 3-5 weeks of treatment. Non-pharmacological measures which can be advised of older children, adolescents and adults are relaxation techniques and mental imagery. A behavior therapist may be necessary for these treatments. Anticipatory awakenings may be tried in children which consists of waking the child approximately 15- 20 minutes before the usual time of the episode (Ackroyd & Cruz, 2007). Conclusion Sleep walking disorder is common in children and has a benign course and good prognosis. It can sometimes lead to decreased attention in school due to deprived sleep in the nights. Hence any child with day time sleepiness must be looked into sleep walking disorder. In most cases no active treatment is needed unless there is agitated behavior. References Ackroyd, G. & Cruz, N.F.D. (2007). Somnambulism (Sleep Walking). eMedicine from WebMD. Retrieved on 18th November, 2007 from: http://www.emedicine.com/neuro/topic638.htm Bonds, C.L. & Lucia, M.A. (2006). Sleep Disorders. emedicine from WebMD. Retrieved on 18th November, 2007 from: http://www.emedicine.com/med/topic609.htm Klackenberg, G. (1982). Somnambulism in childhood--prevalence, course and behavioral correlations. A prospective longitudinal study (6-16 years). Acta Paediatr Scand., 71(3):495-9 Kaplan, H. I., Benjamin, J.S., & Grebb, J.A. (1991). Behavioural Sciences Clinical Psychiatry. (7th edi.). Baltimore: Williams and Wilking Plazzi, G.,Vetrugno, R., Provini, F., & Montagna, P. (2005). Sleepwalking and other ambulatory behaviours during sleep. Neurosciences, 26(3), 193-198. Conclusion Read More