Current Biology
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Quick guide
Sleepwalking
Isabelle Arnulf
What is sleepwalking? Sleepwalking
(or somnambulism) corresponds
to undesirable behaviors, including
ambulation, that are initiated during
sudden but partial arousals from
deep slow wave sleep. During sleep,
the cortex activity, as measured by
electroencephalography (EEG), is
progressively slowed from fast to deep
slow wave sleep, a prolonged and
restorative stage during which we are
quiet, deeply asleep and difficult to
wake. After 90 minutes of slow wave
sleep on average, a clear increase of
EEG frequency characterizes REM
sleep. This pattern (fast, slow, then rapid
EEG activity) repeats three to five times
per night.
What kinds of behavior are observed?
During an episode, the sleeper suddenly
raises the head, opens the eyes and
looks around in a confused manner.
She may then sit up in bed, scream,
speak, swear or mumble, stand up,
walk, run, text, search in drawers or
handle objects as if she was awake (see
Video S1 in Supplemental Information,
published with this article online).
However, the lack of full awareness and
responsiveness (with mental confusion
when questioned), inappropriate or
potentially dangerous behaviors,
inappropriate emotion, dreamlike
mentation, and poor recollection of
the event suggest that she is partly
asleep. Quiet, routine behaviors, such
as children preparing to go to school or
taking their breakfast at 2 am, are also
possible. Symptoms of intense fear
(with prolonged, inconsolable sobbing
in children) characterize a variant named
sleep terror (Video S2). Sleepwalking
and sleep terrors, however, both arise
during slow wave sleep, frequently
co-occur in the same patient or family,
and have a strong genetic background.
They mostly occur during the first third
of the night. The episodes are generally
brief (a few minutes), although rare and
severe cases of sleepwalking lasting
several hours have been reported. As
many as 17% of children sleepwalk, and
2 to 4% of adults (mostly young adults,
R1288 Current Biology 28, R1283–R1295, November 19, 2018 © 2018 Elsevier Ltd.
who often sleepwalked as children) still
regularly ambulate or scream at night.
Is it dream walking? Amnesia of
the episode is frequent, especially
in children, but adults sometimes
remember that they ‘have done
something’. Plus, most adults
occasionally recall some short dreamlike
mentation: mostly an unpleasant visual
scene (e.g., ceiling collapse, tsunami,
insects or snakes in the bed, or being
cooped up or buried alive) associated
with apprehension and displayed in the
bedroom. Their behavior is congruent
with the dream scene (e.g., a man
pulled his wife out of the bed to save
her from being run over by a train),
justifying the old term ‘dream walking’.
However, recall of detailed and long,
frightening dreams characterizes REM
sleep nightmares rather than sleep
terrors.
What if I eat when asleep?
Several new, specialized variants of
sleepwalking have been described.
Some patients (mostly women) go to
the kitchen and eat every night. This
sleep-related eating disorder is distinct
from nocturnal bulimia (although
eating is compulsive in both disorders)
because subjects have already slept
before the eating episode and are
confused, as indicated by the ingestion
of inedible food (e.g., eating food for
animals or a sandwich with tobacco
inside, or drinking detergent) and by
some aggressive resistance when
prevented from eating. Sexsomnia
corresponds to any sexual behavior
(masturbation, fondling, sexual assault)
performed asleep, as indicated for
example by concomitant snoring and
amnesia of the behavior. Here, men are
more often affected than women. In the
parasomniac swallowing and choking
syndrome, sleepers are suddenly
awaken from slow wave sleep by the
horrible feeling that a stone or a coin
(or electric cables, lizard tail, even a
computer…) is stuck in their throat to
the point of choking them, despite the
airways being totally open.
Is sleepwalking a disease? The main
consequences of sleepwalking and
its variants are injuries to oneself or to
somebody else in the vicinity. This is
the case in more than half of patients
in clinical series. Patients who dart
out of bed may break things, open a
window, fall and even die (sometimes
confounded with a suicide). They
can also injure their bed partner, who
sometimes describe a super-human
force in such cases. Often, the sleeper
discovers her bruises and even fractures
the next morning, as anesthesia is
frequent during sleepwalking. Medico-
legal cases of nocturnal violence
(including assault and homicide)
caused by sleepwalkers are fortunately
exceptional, except in sexsomnia.
Patients are often ashamed or guilty of
these uncontrolled behaviors; they may
fear hurting loved ones, to the point
of hesitating to go to bed. Eventually,
almost half of adults with sleepwalking
or sleep terrors feel tired or abnormally
sleepy during daytime.
If I sleep talk or gesture when asleep,
am I a sleepwalker? Dream-enacting
or confusional behaviors during sleep
are prevalent in non-pathological
populations. They are not considered a
disorder if they are infrequent, harmless
and do not disturb sleep. Many young
mothers dream of their baby in danger,
and will sit up while in bed, anxiously
checking that the baby is safe.
Occasional sleep talking is common, as
is occasional laughing, crying, anger,
fear, and motor activity occurring when
awakening from a corresponding dream.
However, subjects with frequent sleep
talking are often sleepwalkers too.
Are there disorders that mimic
sleepwalking? Under the action of
some psychotropic drugs, mostly
benzodiazepines, hypnotics or gamma-
hydroxy-butyrate (the “rape” drug),
some people display prolonged,
amnestic automatic behaviors, including
rare cases of ‘sleep driving’, with
clumsiness and prolonged retrograde
amnesia. Indeed, the lifetime prevalence
of nocturnal wandering is 29% in adults,
with the use of hypnotics and serotonin
reuptake inhibitors as a major risk factor.
In partial nocturnal seizures, patients
have stereotypic behaviors and may
stand up and walk with confusion. After
a traumatic event, some patients have
nightmarish flash backs of the event
during sleep, and concomitant dream
enacted behaviors (such as shouting,
fighting) in the bed, which arise, in
contrast to classical sleepwalking,
during all sleep stages. During REM
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sleep behavior disorder, middle-age
patients shout, gesticulate, box and
kick while they have their eyes closed
lying in bed, and this occurs as a result
of loss of the atonia system during
this sleep stage (a loss predictive of
neurodegenerative disorder). Psychiatric
dissociative behaviors at sleep onset are
also observed in conversion neurosis
or after sexual abuse, but patients are
totally awake (although they deny it).
What happens in the brain during
sleepwalking? In concordance
with the behavioral observation of
partial arousal, there is an unusual
coexistence of wake- and sleep-like
activity within cortical and sub-cortical
areas of the brain. In surface EEG and,
more rarely, deep brain stereo-EEG or
functional brain imaging, some cortical
(mostly dorsolateral frontal and parietal
associative cortex) areas are ‘asleep’
when some subcortical (thalamus,
cingulum, amygdala, cerebellum)
and cortical (motor cortex, insula,
temporopolar and occipital cortices)
areas are ‘awake’. The persistence of
sleep markers in the hippocampus (the
site of immediate memory) during the
episode may explain the difficulty of
sleepwalkers to recall the event. The
deactivation of associative cortex may
explain altered consciousness, loss of
insight and disinhibited behaviors.
What causes sleepwalking? The
fundamental cause is unknown.
Although stress and stressful events
often trigger more frequent or severe
episodes, data suggest the lack of
a definitive association between
a history of major psychological
trauma, severe psychopathology
and sleepwalking or night terrors.
Rather, genetic and maturational
factors are likely to play a major role.
Many sleepwalking and sleep-terror
cases run in families. Compared
to the general population, first-
degree relatives of sleepwalkers
have a 10 times higher frequency
of sleepwalking. In a twin study, the
concordance rate of sleepwalking
was 5.3 times greater in monozygotic
versus dizygotic twins for adult
sleepwalking. Yet, DNA studies are
lacking. Sleepwalking is more frequent
in children than in adults, and abates
during the teenage years in 80% of
the cases, suggesting that changes in
the arousal pattern (which is naturally
associated with slow rather than rapid
EEG waves in children, unlike adults)
or in the sleep depth reduce this
phenomenon. One may also imagine
that these behaviors are adaptive
remnants, having increased the
probability of survival across evolution,
by facilitating rapid motor behaviors
in case of sudden awakenings. In this
vein, the coexistence of wake-like and
sleep-like EEG patterns allows birds
and aquatic mammals to continue
swimming, flying or monitoring the
environment.
How is sleepwalking diagnosed?
Many sleepwalkers do not seek medical
help until they hurt themselves or their
loved ones, or feel exhausted in the
morning. Physicians make a diagnosis
and rule out alternative conditions
by interviewing the patients and the
parents or partners. The severity of
sleepwalking can be measured via
the Paris Arousal Disorders Severity
scale. In addition, adults, especially
doubtful cases, may benefit from one
to two nights of video-sleep monitoring
in a sleep disorder unit. Prolonged
episodes are infrequent in the clinic,
but multiple arousals from slow wave
sleep (some of them with persistent
localized slow waves during behaviors)
and confusional arousals are frequent.
Sleep deprivation and sudden noises
potentiate the events during the test.
Plus, it helps identifying potential
triggers (e.g., noises and respiratory
events) and recognizing alternative
conditions.
How can sleepwalking be treated? It
depends on the severity and frequency
of the behaviors. One cannot change
a genetic vulnerability, but you can
reduce precipitating and triggering
factors. As sleep deprivation (which
increases slow wave sleep) and
situational stresses (which increases
emotions and arousals during
sleep) often precipitate episodes,
sleepwalkers may benefit from regular
sleep routines and sufficient sleep
amounts (going to bed earlier, or
napping in the afternoon), as well as
from relaxation. Fever or exercise-
induced high temperature (which
increases slow wave sleep) should
be reduced before sleep using a cold
shower or paracetamol intake. Anything
Current Biology 28, R1283–R1295, November 19, 2018 R1289
that triggers arousals during slow wave
sleep should be avoided, including
sudden noises, physical contact with
the bed partner, snoring, alcohol intake,
gastro-esophageal reflux, and periodic
leg movements during sleep. Safety
measures include closing doors and
windows, closing shutters, sleeping
with pajamas on (never naked) and
not in the upper bunk bed, switching
a nightlight on, but never strapping
the children to the bed as they may be
strangled. Parents or partners should
avoid restraining the sleepwalker
(except if she is about to defenestrate),
speak quietly, reassure, and suggest
that they go back to bed. In children,
forced awakenings scheduled about
15 min before the usual time of the
episode, and repeated for one month
are often efficacious to reduce the
episodes. Patients with sexsomnia
should never sleep with a minor.
Hypnosis (the suggestion of returning
to bed and resuming sleep) has been
beneficial in small series. No drug
has been specifically developed as a
treatment for sleepwalking (illustrating
the neglect of this disorder), but clinical
experience indicates some benefit of
drugs stimulating the GABA system
(e.g., clonazepam or gabapentine)
taken one hour before sleep.
SUPPLEMENTAL INFORMATION
Supplemental Information contains two
videos, and can be found with this
article online at https://doi.org/10.1016/
j.cub.2018.09.062.
Where can I find out more?
Oudiette, D., Leu, S., Pottier, M., Buzare, M.A.,
Brion, A., and Arnulf, I. (2009). Dreamlike
mentations during sleepwalking and sleep terrors
in adults. Sleep 32, 1621–1627.
Pressman, M.R. (2007). Factors that predispose,
prime and precipitate NREM parasomnias in
adults: Clinical and forensic implications. Sleep
Med. Rev. 11, 5–30.
Terzaghi, M., Sartori, I., Tassi L., Rustoni V.,
Proserpio P., Lorusso G., Manni R., and
Nobili., L. (2012). Dissociated local arousal
states underlying essential clinical features of
non-rapid eye movement arousal parasomnia:
An intracerebral stereo-electroencephalographic
study. J. Sleep Res. 21, 502–506.
Zadra, A., Desautels, A., Petit, D., and Montplaisir, J.
(2013). Somnambulism: clinical aspects and
pathophysiological hypotheses. Lancet Neurol.
12, 285–294.
Institut du Cerveau et de la Moelle, Sorbonne
University, Pitié Salpêtrière Hospital, Paris,
France.
E-mail: isabelle.arnulf@aphp.fr