RGoodell Somnambulism Final Paper

Rachel Goodell
Mental Health of Children and Adolescents
Final Paper: Somnambulism
May 3, 2013
Introduction
Somnambulism, more commonly known as “sleepwalking,” is a specific
parasomnia that emerges during non-rapid eye movement (NREM) sleep. Patients
afflicted with somnambulism display with partial arousal during slow-wave sleep
(typically in stages 3 or 4, and occasionally stage 2). Episodes usually occur during
the first few hours of sleep when deeper sleep stages are more prevalent and persist
anywhere from 30 seconds to 30 minutes; they can occur as little as 3-4 times per
year or as often as 3-4 times per week or more (Ghalebandi et al., 2011; Hoban,
2010; Hughes, 2007; Kotagal, 2008; Lam et al., 2009; Wills & Garcia, 2002; Zadra,
Desautels, & Montplaisir, 2013; Zadra, Pilon, & Montplaisir, 2008).
Episodes may present with varying degrees of complexity. Some episodes
may include quiet and aimless wandering while others may include agitated or
complex behaviors, such as getting dressed or driving. Patients typically
misperceive or are unresponsive to external stimuli, and are difficult to awake. They
may also display poor judgment or perform senseless or irrational behaviors. Upon
full arousal immediately following an episode, patients may display confusion and
partial or complete amnesia of the event (Hoban, 2010; Kotagal, 2008; Lam et al.,
2009; Petit et al., 2007; Pilon, Montplaisir, & Zadra, 2008; Wills & Garcia, 2002;
Zadra, Desautels, & Montplaisir, 2013; Zadra, PIlon, & Montplaisir, 2008).
Diagnosis

Rachel Goodell
May 3, 2013
Diagnosis of somnambulism is often difficult and can include inconsistent
criteria. The American Academy of Sleep Medicine uses the following criteria to
diagnose somnambulism (Figure 1):
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR),
however, includes additional criteria, such as (American Psychiatric Association,
2000):
• Behavior must happen repeatedly;
• Patient “has a blank, staring face” and is unresponsive during episodes;
• Lack of mental impairment upon arousal; and
• Behavior significantly affects quality of life or general functioning.
Panel: Somnambulism diagnostic criteria of the American Academy of Sleep Medicine—second
International Classification of Sleep Disorders (Zadra, Desautels, & Montplaisir, 2013)
A) Ambulation occurs during sleep
B) Persistence of sleep, a changed state of consciousness, or impaired judgment
during ambulation shown by at least one of the following:
• Difficulty in arousal of the person
• Mental confusion when awakened from an episode
• Amnesia (complete or partial) for the episode
• Routine behaviors that occur at inappropriate times
• Inappropriate or nonsensical behaviors
• Dangerous or potentially dangerous behaviors
C) The disturbance is not better explained by another sleep, medical, neurological,
or mental disorder; drug use; or substance use disorder

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May 3, 2013
Additionally, there is no official diagnostic protocol for determining
somnambulism, and most diagnosticians rely on patient or family accounts of events
because episodes are difficult to reproduce in laboratory settings (Kotagal, 2008;
Pilon, Montplaisir, & Zadra, 2008; Zadra, Pilon, & Montplaisir, 2008). Kotagal
recommends recording events when possible to provide a better understanding of
the nature of the disorder.
Epidemiology
Lifetime prevalence rates vary from approximately 4.3 percent of the
population to 15 percent (Hedger Archbold et al., 2002; Hoban, 2010; Laberge et al.,
2000; Lam et al., 2009; Oluwole, 2010; Petit et al., 2007; Shang, Shur-Fen Gau, &
Soong, 2006). Olewole (2010) found that 4.3 percent of Nigerian adults recalled ever
having a somnambulistic episode, while Shang, Shur-Fen Gau, and Soong (2006)
found a lifetime prevalence of 8.6 percent in Taiwanese preschool to third grade
students. It should be noted that peak prevalence occurs between 10-12 years of
age, so many children may not have yet experienced their first episode (Hoban,
2010; Laberge et al., 2000; Petit et al., 2007; Zadra, Desautels, & Montplaisir, 2013).
Petit et al. (2007), however, saw a 14.5 percent lifetime prevalence of at least
occasional episodes for 6-year-old children in Quebec. Hedger Archbold et al. (2002)
also found a lifetime prevalence of 15 percent in American children ages 2 to 13
years, and Laberge et al. (2000) saw a lifetime prevalence of 13.8 percent for 13-
year-old children in Quebec. In adolescents, Ipsiroglu et al. (2002) found a lifetime
prevalence of 15.1 percent in children 11 to 15 years old.

Rachel Goodell
May 3, 2013
Current prevalence estimates varied just as widely—ranging from 0.1
percent to 13.5 percent, particularly because of inconsistent criteria and change
over age groups (Bharti, Malhi, & Kashyap, 2006; Ghalebandi et al., 2011; Hughes,
2007; Khan et al., 1989; Lehmkhul et al., 2008; Liu et al., 2005; Nevéus et al., 2001;
Zadra, Desautels, & Montplaisir, 2013). Nevéus et al. (2001) reported a total 7
percent prevalence for Swedish children ages 6 to 10 years. Of those children, 4.3
percent experienced daily/nightly episodes, 10 percent experienced at least weekly
episodes, and 90 percent experienced at least monthly episodes. Shang, Shur-Fen
Gau, and Soong (2006) found a 1 percent prevalence in Taiwanese children ages 4 to
9 years. Ghalebandi et al. (2011) also saw a 1.4 percent prevalence of at least 3
episodes each week in Iranian elementary school children, and Bharti, Malhi, and
Kashyap (2006) saw a 1.9 percent prevalence in children 3 to 10 years old.
Several studies further stratified their results by age. Lemkuhl et al. (2008)
reported 0.1 percent prevalence for German kindergarteners who experienced
episodes at least weekly, and 3.2 percent prevalence for those experience episodes
less frequently. Kahn et al. (1989) found a 5 percent prevalence of at least one
episode every month for the previous six months in 8- to 10-year-old Belgian
children. Liu et al (2005) saw a prevalence of 0.6 percent in Chinese children ages 2
to 12 years, with 1.1 percent prevalence at 2 years, 0.2 percent for ages 3 to 5 years,
0.6 percent ages 6 to 10 years, and 0.9 percent ages 11 to 12 years. In Quebec, Zadra,
Desautels, and Montplaisir (2013) saw a 3 percent prevalence in children ages 2.5 to
4 years, 11 percent in ages 7 to 8 years, and 13.5 percent at 12 years. In adults,

Rachel Goodell
May 3, 2013
prevalence estimates vary from 0.53 percent to 4 percent (Hughes, 2007; Lam et al.,
2009; Oluwole, 2010; Zadra, Desautels, & Montplaisir, 2013).
Findings regarding gender differences have also been mixed. Hedger
Archbold et al. (2002) saw a significant difference in lifetime prevalence between
boys (17 percent) and girls (13 percent) ages 2 to 13 years, as well as Petit et al.
(2007) between boys and girls ages 2.6 to 6 years, with 61.7 percent of sleepwalkers
being male and 38.3 being female. Olewole (2010) also saw a higher prevalence in
adult males than adult females. However, Laberge et al. (2000) and Zadra, Pilon, and
Montplaisir (2008) saw no gender differences.
Etiology and Risk Factors
Approximately 80 percent of sleepwalkers have one or more family members
that also sleepwalk, suggesting that there is a significant genetic component (Hoban,
2010; Hughes, 2007; Kotagal, 2008; Zadra, Desautels, & Montplaisir, 2013). This
component appears to make it difficult for patients to sustain slow-wave sleep
stages and dissociate between wakefulness, rapid eye movement (REM) sleep, and
NREM sleep, particularly while their central nervous system is still maturing
(Hughes, 2007; Kotagal, 2008; Lam et al., 2009; Pilon, Montplaisir, & Zadra, 2008).
As such, most children who experience somnambulism tend to outgrow the disorder
in adolescence (Hughes, 2007; Kotagal, 2008; Lam et al., 2009; Shang, Shur-Fen Gau,
& Soong, 2006; Wilson, 2008; Zadra, Desautels, & Montplaisir, 2013); however,
approximately 25 percent of childhood sleepwalkers continue into adulthood and

Rachel Goodell
May 3, 2013
approximately 20 percent of adult sleepwalkers developed the disorder in
adulthood (Lam et al., 2009; Zadra, Desautels, & Montplaisir et al., 2013).
Several studies have identified a number of “triggers” that tend to increase
the likelihood of a somnambulistic episode in genetically predisposed individuals,
particularly triggers that disrupt, fragment, or manipulate slow-wave sleep. Most
notably, sleep deprivation has been shown to both increase the frequency and
intensity of somnambulism (Hoban, 2010; Hughes, 2007; Pilon, Montplaisir, &
Zadra, 2008; Zadra, Desautels, & Montplaisir, 2013; Zadra, Pilon, & Montplaisir,
2008). Sleep-related breathing problems, such as sleep apnea, as well as periodic
limb movement have also been shown to affect slow-wave sleep and increase
somnambulism (Hoban, 2010; Hughes, 2007; Ipsiroglu et al., 2002; Kotagal, 2008;
Nevéus et al., 2001; Zadra, Desautels, & Montplaisir, 2013).
Other triggers include use of central nervous system stimulants or
depressants, excessive alcohol and/or caffeine consumption, stress, and intense
exercise before bedtime (Hughes, 2007; Lehmkhul et al., 2008; Oluwole, 2010; Pilon,
Montplaisir, & Zadra, 2008; Wilson, 2008; Zadra, Desautels, & Montplaisir, 2013).
Additionally, it is possible to induce sleepwalking episodes in most young children.
This is accomplished by standing a child upright or calling their name during slow-
wave sleep (Pilon, Montplaisir, & Zadra, 2008).
Comorbidities
Several disorders have been found to be associated with somnambulism,
particularly other parasomnias. Laberge et al. (2000) found that 81 percent of 11-

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May 3, 2013
year-old sleepwalkers also talked in their sleep (somniloquy), 17 percent had night
terrors, and 1 percent had all three. Furthermore, Petit et al. (2007) found that 98.5
percent of 2.5- to 6-year-old sleepwalkers also had somniloquy, and 41.1 percent
had night terrors. Several other studies have also found significant comorbidities
with night terrors, somniloquy, spontaneous confused arousals, and nightmares
(Hughes, 2007; Kotagal, 2008; Laberge et al., 2000; Nevéus et al., 2001; Petit et al.,
2007; Shang, Shur-Fen Gau, & Soong, 2006; Wilson, 2008; Zadra, Pilon, &
Montplaisir, 2008).
Somnambulism has also been shown to be associated with anxiety disorders,
particularly separation anxiety (Hughes, 2007; Kotagal, 2008; Petit et al., 2007;
Zadra, Desautels, & Montplaisir, 2013). This comorbidity has been shown to
continue into adulthood, with 25 percent of adult sleepwalkers also suffering from
anxiety or mood disorders (Zadra, Desautels, & Montplaisir, 2013). Hughes (2007)
also found associations with aggression and hostility; hysteria; panic disorder; and
simple phobias, while Shang, Shur-Fen Gau, and Soong (2006) found associations
with aggression and attention deficit. Petit et al. (2007) also saw comorbidities with
hyperactivity-inattention disorders. Hedger Archbold et al. (2002) and Shang, Shur-
Fen Gau, and Soong (2006) reported comorbidities with neurological problems, and
behavioral and emotional disorders, respectively; however, Nevéus et al. (2001)
found little to know psychological implications associated with somnambulism.
Several other studies have also shown comorbidities with involuntary or
sleep-related movements, particularly restless leg syndrome and periodic limb

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May 3, 2013
movement (Hoban, 2010; Kotagal, 2008; Zadra, Desautels, & Montplaisir, 2013).
Hughes (2007) also reported a relationship with Tourette’s syndrome, and Shang,
Shur-Fen Gau, and Soong saw an association with teeth grinding (bruxism).
Quality of Life
Somnambulistic episodes, particularly in childhood, are generally benign and
do little to disrupt daily functioning or quality of life (Petit et al., 2007). Petit et al.
(2007) also found that there is little effect on the quantity or quality of sleep as a
result of a sleepwalking event. Despite this, excessive or extreme events can cause
emotional, psychological, and physical harm.
Pilon, Montplaisir, and Zadra (2008) reported that somnambulism is the
primary cause of violence and self-inflicted injury during sleep. Several studies have
described potential dangerous activities that could lead to injury or death during a
sleepwalking episode, such as jumping out of windows, walking outside during
inclement weather, cooking, or driving (Hoban, 2010; Hughes, 2007; Kotagal, 2008;
Wilson, 2008; Zadra, Desautels, & Montplaisir, 2013). Hoban (2010) found the risk
of injury to be relatively low in familiar settings; however, the risk increases
significantly in new environments.
In addition to self-injury, sleepwalking can also cause harm and even death
to others. Several studies discussed instances of violent outbursts and murder while
sleepwalking (Hughes, 2007; Zadra, Desautels, & Montplaisir, 2013; Zadra, Pilon, &
Montplaisir, 2008). Furthermore, sleepwalkers may also engage in property
destruction or sexual activity (Hughes, 2007; Zadra, Desautels, & Montplaisir, 2013),

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May 3, 2013
and their nighttime movements may affect the sleep patterns and mood of other
household members (Petit et al., 2007; Shang, Shur-Fen Gau, & Soong, 2006).
Lehmkhul et al. (2008) and Shang, Shur-Fen Gau, and Soong (2006) found
lowered school performance in sleepwalkers. Additionally, Zadra, Desautels, and
Montplaisir (2013) saw an increase in daytime drowsiness associated with
sleepwalking episodes.
Treatment
Most cases of somnambulism go untreated as they are generally not
problematic and are resolved on their own as a child gets older (Kotagal, 2008; Wills
& Garcia, 2002). As such, Zadra, Desautels, and Montplaisir (2013) reported that no
controlled clinical trials with reasonable power have been performed to test various
treatment efficacies.
Several studies recommended installing safety devices in the environment.
These could include higher door locks, baby gates on stairs, and safeguarding
dangerous items such as guns, other weapons, and car keys (Hoban, 2010; Wills &
Garcia, 2002). Additionally, family members are encouraged to not disturb or
attempt to wake a sleepwalker if they are not in danger, as this may aggravate the
episode. If necessary, a family member can attempt to lead the sleepwalker back to
their bed (Kotagal, 2008; Wills & Garcia, 2002).
Another popular treatment method is to remove potential triggers for
somnambulistic episodes. This could include treating sleep-related breathing
problems or periodic limb movement—which has been shown to completely

Rachel Goodell
May 3, 2013
eliminate episodes in some patients, reducing stress, and maintaining a consistent
sleep schedule (Hoban, 2010; Kotatal, 2008; Wills & Garcia, 2002; Zadra, Desautels,
& Montplaisir, 2013).
Scheduled awakenings have also been used to prevent sleepwalking
episodes, especially in children. This entails fully waking the child approximately 15
to 20 minutes prior to the typical sleepwalking episode onset in an effort to “reset”
the sleep cycle. However, this method also has the potential to induce an episode, so
caution is recommended. Other treatments that are used less frequently but have
been shown to be effective are hypnosis and drug treatment with benzodiazepines
(Hoban, 2010; Hughes, 2007; Kotagal, 2008; Wills & Garcia, 2002; Zadra, Desautels,
& Montplaisir, 2013).
Case Study
Stein and Ferber (2001) presented a case study of a 13-year-old male who
had experienced two sleepwalking episodes in the previous three months. In the
first incident, the young man suffered minor injuries after he fell down a flight of
stairs at camp, whereas in the second, he exited a friend’s home and was unable to
re-enter. The patient presented with no family history of somnambulism or personal
history of parasomnia.
The researchers found his anecdotal episodes to be consistent with a
sleepwalking diagnosis (e.g., timing of events, description of events, and
environment conditions), and as such, did not recommend additional testing to rule
out other options. They suggested that the events were likely triggered by factors

Rachel Goodell
May 3, 2013
such as a shift in sleep schedule, change in sleep environment, or stress (Stein &
Ferber, 2001).
No specific treatment was recommended for the patient, as the disorder was
so far limited to only two episodes. The researchers did suggest altering
environmental factors, such as sleeping away from the door in unfamiliar
environments and installing a high lock. Additionally, they recommended
maintaining a consistent sleep schedule and ensuring the patient got adequate sleep
every night. If the episodes persisted or worsened, Stein and Ferber (2001)
suggested scheduled awakenings or low-dose benzodiazepines.
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