with Mark Eric Dyken, MD
Department of Neurology
University of Iowa Hospitals and Clinics

First Published: November 2000
Last Revised: December 2000
Peer Review Status: Internally Peer Reviewed

Regarding my son, I need help on this subject. It is getting to the point where he is rolling his eyes. His doctor doesn't know why he is doing this.

If he does this when he sleeps, there are a variety of movements associate with sleep called parasomnias. That is the general topic we are discussing today (sleepwalking or somnambulism). The twitching is hard to envision, as it is not actually something I am seeing and this is one of the difficulties with sleep medicineÉ in that the history given to the physician is often relatively vague. But as they say, seeing is believing or in Missouri, the show me state, one picture is worth a thousand words. If on occasion a physician performs a full examination and listens to the history and a diagnosis is not clear, then I would recommend and overnight sleep study to analyze the episode as it occurs. If in the laboratory setting, you can actually see the spell and look at all the physiologic associates we monitor in the laboratory, we can rule out a sleep related parasomnia and other disorders such as seizures in sleep which you allude to when you describe your son's eyes rolling back. It appears that there is enough concern should this be an otherwise normal parasomnia to rule out a seizure and to give comfort to the family; a sleep study could be justified.

What causes sleepwalking? Is it a "learned" behavior and/or something that's in response to a person's waking environment, or is it biological in origin?

It is possibly a combination of things. Anna Freud, SigmundÕs daughter did a lot of investigative work on this subject and sleepwalking is a relatively "normal" finding in the pediatric population. There appears to be a genetic or inherited factor as it often runs in families, but as we age, the phenomena of sleep walking generally resolves. Psychologists and other investigators have shown that children who sleep walk are usually normal in every respect but a few studies have suggested that in some of the parasomnias some children may have inner conflicts that they are not able to verbalize. And in a few cases, family counseling and reassurance have been all the therapy necessary in patients with frequent parasomnias. So there appears to be a tendency for children to have this, a tendency for an inherited component, and especially as the patient becomes older, a possible psychological element. And as such all the factors you mentioned may come into play to some degree.

Can sleepwalking be caused by a person going through emotional trauma?

Normal children can sleep walk and they generally outgrow the problem by age 15. The old literature suggested that when the few children who persisted in having sleep walking episodes as adults, that there may be strong psychological problems that may make the problem worse. My anecdote, my impression is that this is often overstated. Nevertheless, in an adult with sleepwalking, I routinely have my group of neuropsychologists who specialize in insomnia (sleep disorders) perform a Minnesota Multiphasic Personality Inventory (MMPI) to look for underlying psychological personality and social factors which might be contributing to the disorder. My anecdote is that I have had a world-class athlete who had significant sleep walking to the point of jumping out a window and separating his shoulder during the height of the basketball season. When the stress associated with the season was reduced during the summer months improved but did not completely resolve.

When should sleep walking been seen as a problem? If my son sleepwalks once/year, should I be worried?

We generally, according to standards set in the International Classification of Sleep Disorders, consider severe sleep walking as occurring greater than or equal to 1 time per week. As such one even per year seems relatively minimal. Nevertheless, my anecdote comes back to haunt us, and I personally have had only two sleep walking events as a child, one of which led to my tripping over a glass table, which subsequently left a permanent scar on my shoulder. Rarely, as our good friend Dr. Gerald Rosen, the pediatric sleep expert from Minneapolis, Minnesota, reports that there are rare but probable yearly events reported during the winter where children have sleep walking events which led them outside and they subsequently could not find their way back inside and freeze to death. The point I want to make is that although this is a relatively benign problem in most instances, the children have a potential for harming themselves. As such preventative medicine is recommended and that involves protecting their sleeping environment.

Is there any connection with sleep apnea and sleepwalking?

Sleep apnea can on occasion be misdiagnosed as sleepwalking. A person with severe sleep apnea, that is where an individual stops breathing for prolonged periods as night while sleeping, may drop their oxygen levels so low that it affects their thinking and behavior, essentially a "sleep drunk" like state which might be misinterpreted as sleepwalking. Otherwise the two have no real connection at all.

Are sleep terrors and sleepwalking similar?

Yes. These are parasomnias of similar origin in that they both generally come out of a specific sleep stage that many refer to as deep delta sleep. This stage of sleep generally occurs in the first one third of the patient's nighttime sleeping period. In some cases there appears to be a spectrum of activity which ranges from confusional arousals to night terrors to actual sleep walking all or few of which behaviors we might capture during a sleep study. If there is a clinical report of sleep walking, and we perform a sleep study and capture only a confusional arousal, it suggests to us that there somnambulism is the major problem and not a seizure or sleep apnea with a relative sleep drunk state that we talked about earlier and which represent part of the differential diagnosis. Rarely do we actually capture a sleepwalking event in the lab, but it is not unusual for us to capture confusional arousal from deep delta sleep in patients with suspected sleep walking in the lab.

Do children grow out of sleepwalking?

Anna Freud reported that according to Piaget there are major developmental stages throughout all age groups. In these terms she implied that sleepwalking in children in most part represented one of these normal developmental stages, which would eventually be outgrown in most stages.

How common is sleepwalking in adults? Is there anything a person can do to prevent it?

Some statistics suggest that 1 percent or less of the adult population may sleep walk. As indicated before, many experts believe that adults who sleep walk often have strong underlying psychological difficulties that may be responsible in some way for the nighttime behavior. In some reports, fever with illness, sleep deprivation, the excessive use of certain drugs may also make sleep walking worse. In these cases, as stated before, in an attempts to prevent further sleep walking episodes, the neuropsychologists in our insomnia clinic will thoroughly evaluate for these possibilities and then institute appropriate behavioral, cognitive or recommend medications that might be deemed appropriate for what would otherwise the primary problems. When we have an otherwise normal individual, child or adult, who for example would like to go on a mountain-side campout, where sleep walking could be life threatening, we often recommend a single night 's use of a medicine in the group of drugs called benzodiazepines. These medications, simplistically put, insert a fast brain wave activity that in some regards parallels a disruption of the normal deep delta brain wave pattern from where sleep walking generally arises. As such, a marked reduction in the capacity to sleep walk is generally appreciated. Nevertheless, there are many hazards that are possible with the chronic use of these medications, although there use can be considered in severe cases.

Should I be concerned if my child sleepwalks?

If there are no other problems with the child's quality of life during the day, such as inappropriate sleepiness or behavioral problems such as hyperactivity, I wouldn't be overly concerned. Nevertheless, as we suggested earlier, I would protect the child's bedroom environment. I would avoid having their bed at the top of the stairs. I would avoid having sharp or potentially dangerous objects in the child's room. And I personally, because we have the resources for this available locally, have a small alarm mechanism that would awaken me should my child open the door late at night, so I could gently direct them back to their bed and avoid the potential dangers we discussed earlier.

My son sleepwalks, he is almost 12 years old. Will this affect his future when filling out applications for hire?

No. Normal kids sleep walk. Almost 20 - 40 percent in some people's studies, of all normal kids have parasomnia at least once in their lifetimes, I have had it twice, it did not affect my getting a job, but it is really not anyone's damn business. Philosophically be very careful what you offer as part of your personal information on any job application, as I do not mean to seem sarcastic, but this is a normal phenomena, but if you mention it, the boss may have no idea what it is and may conveniently find another reason not to hire you as you have essentially become a labeled person.

What causes sleepwalking and at what age does this usually stop?

It is not unusual to see it very early, it often follows a period where the child has confusional arousals and possibly night terrors and it may persist up to age of 15 years in otherwise normal children. As stated previously, there is a small percentage of adults who will continue to have sleepwalking.

My son is considered a genius but is very uptight. Could this cause the sleepwalking?

My first thought is that anything is possible, but since this is a normal phenomena, my answer would be no. As I stated before I would be hesitant to label any child abnormal because of sleepwalking, as it is a normal phenomena.

Is sleep walking a problem suffered mostly in children or can it happen in adults as well?

Rarely, although it may be under reported as anecdotally many of my adult patients are embarrassed of their sleep walking and do not report it. We do evaluate the problem differently than we do for children as was described earlier.

Are there violent tendencies when sleepwalking or when trying to wake someone up?

That has been reported. But these patients generally do not have directed violence. It is important to realize that sleepwalkers are actually sleeping. If you try to wake them up, it is potentially very threatening to this confused/sleeping individual. The attempt to awake a sleepwalker has been the general period of time where there have been reports of relative violence as the confused patient may in some respects try to defend themselves or fend off the individual who may appear in some regard to be attacking them. Usually it is best to gently lead the patient back to their room without any active attempts to awaken them. This is routine associated with no major problems.