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The Question: I am a sleepwalker and I’m afraid I might hurt myself some night because I live alone. My husband died three years ago and my children have left for university. Sleepwalking is common in my family – my father, sister and some of my children and nephews also do it. We are also troubled by insomnia. There’s a shortage of physicians where I live in rural Ontario and I haven’t had a regular family doctor for years. Lately, when my sleepwalking started to get a lot more frequent, I went to the emergency room of the local hospital. I was told my recent sleepwalking is likely related to my depression due to the death of my husband. I was prescribed an antidepressant, but it seems to make my problems with insomnia and sleepwalking worse. What am I to do?
The Answer: You have good reason to be concerned. And I can imagine you must feel frustrated by the lack of doctors in your area. Going to the local emergency department is not an ideal way to treat a complex and persistent medical condition.
You need a family physician and to see a doctor with certification in sleep medicine, says Dr. Brian Murray, a sleep specialist at Sunnybrook Health Sciences Centre.
Of course, it could take a while to find a primary-care doctor. But that doesn’t mean treatment for your sleep problem has to be put on hold in the meantime. Any doctor can refer you to a specialist. So you could go to a local walk-in medical clinic and make the request of the physician on duty.
To see a sleep specialist, you will likely need to travel to a larger city and may be asked to stay overnight in sleep lab. The effort could be well worth it. Dr. Murray says most cases of sleepwalking can be successfully treated. An assessment by a qualified sleep specialist should provide a proper diagnosis – and that’s the first step to understanding and managing your problem.
In fact, there are two major types of sleepwalking. One occurs during slow-wave sleep, and is known as slow-wave sleep arousal. The other happens during REM sleep and, not surprisingly, is called REM-sleep behaviour disorder.
In both cases, the sleepwalker isn’t quite awake and isn’t fully asleep. “It is in these overlap areas, between two states, where bizarre things can happen,” says Dr. Murray, who is also an associate professor at the University of Toronto.
Slow-wave sleep arousal is the most common form of sleepwalking and it tends to run in families, suggesting a genetic component to the disorder.
“It usually starts in childhood and then goes away as the person grows older. But in some ‘champion’ sleepwalkers, it persists for a long time,” say Dr. Murray.
“If you try to wake sleepwalkers they will be confused and it takes a long time to come around. They might not recall the event the next day,” he adds.
Slow-wave sleep, also referred to as deep sleep, allows the brain to recover from its daily activities. It’s also a time that is necessary for proper brain function.
Research shows that “slow-wave” sleepwalking episodes are triggered by a combination of two factors – the person is in a very deep, intense sleep and is then suddenly aroused.
Dr. Murray says very deep sleep can follow a period of sleep deprivation.
“The deep sleep is the brain compensating for sleep deprivation,” he explains. “When you are sleep deprived, your brain craves slow-wave sleep. So it’s payback time when you finally do fall asleep.”
These individuals can be jarred from their deep slumber by a loud noise or another medical condition such as sleep apnea. And once aroused, the deep sleeper may be launched on another episode of nocturnal wandering.
“The behaviours can be quite complex. I have had patients opening doors, walking down the street, driving or even swimming. Really surprising things have occurred in these states.”
Even so, this type of sleepwalking can be prevented by relatively simple lifestyle changes. For instance, taking a nap in the afternoon may reduce the brain’s craving for very deep sleep at night, says Dr. Murray. And the use of a white-noise machine can help muffle disturbing sounds like the neighbour’s barking dog or a door slamming shut.
Furthermore, getting proper treatment for co-existing medical conditions, such as sleep apnea, can reduce the chance of being stirred from a deep sleep.
The other major type of sleepwalking – REM-sleep behaviour disorder – can also be triggered by sleep apnea. Once the apnea is successfully treated, the sleepwalking usually stops.
It’s also worth noting that some cases are linked to the use of certain antidepressant medications that disrupt the sleep cycle.
REM sleep – or Rapid Eye Movement sleep – is the time when most people experience vivid dreams.
During REM sleep, most muscles of the body will normally become temporarily paralyzed.
But some people don’t experience this protective paralysis. If they become slightly aroused during REM sleep, they can move around and act out their dreams – sometimes in a violent fashion.
(If no other cause is identified, the REM sleep behaviour disorder can also be an early warning of Parkinson’s disease.)
Dr. Murray says most of these cases – up to 90 per cent – can be successfully treated with a small dose of clonazepam. “It prevents the arousal from REM,” he explains.
Clonazepam is one of a class of drugs called benzodiazepines, which are commonly known as tranquillizers and sleeping pills.
“In general, we don’t recommend benzodiazepine medications because they don’t actually give you normal sleep,” he said. But, for people with REM-related sleepwalking, it has a desirable effect and can prevent serious injury.
So with this background in mind, let’s return to your question. Unusual sleep behaviours in adults are always concerning. You need to be assessed by a sleep specialist who can rule out other conditions that could be contributing to your problem. In relatively rare cases, the sleepwalking stems from an underlying medical disorder such as epilepsy. A careful sleep assessment can sort out the diagnosis.
The good news is that most cases are manageable – and a sleep specialist can provide you with a treatment plan.
Paul Taylor is Sunnybrook’s Patient Navigation Advisor. His column Personal Health Navigator provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog is reprinted on healthydebate.ca with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca