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Walking in Your Sleep and Other Unusual Sleep Behaviors: A Review of Parasomnias

Few medical disorders arouse as much interest as parasomnias. Parasomnias are sleep disorders in which we see a variety of behaviors that we do not think of as occurring in sleep. Walking, talking, shouting, screaming, eating, flailing about are behaviors we associate with wakefulness. When we see them occurring in someone who is asleep, we are witnessing a parasomnia.

Somnambulism (Sleepwalking) Somnambulism is the Latin term for sleepwalking. A wide variety of behaviors have been described. Sometimes the behavior can be vigorous and complex, such as moving quickly down the stairs and opening the front door. Other times it is less dramatic and may not even include actually getting out of the bed (lifting up the covers and calmly checking what is underneath or checking out the contents of the night table drawer). Contrary to the popular image, the sleepwalker does not have his/her eyes closed with arms out-lifted. Their eyes are open and they do not necessarily move around like a zombi. They can move quite smoothly as they negotiate stairs and open windows. On the other hand, their level of coordination is unpredictable so that while they could easily walk down the stairs one night, they could fall down the stairs and injure themselves the next.

Their degree of awareness of the environment is also variable. A sleepwalker might move about seemingly with no recognition of the environment or anyone in it. Alternatively, he/she might recognize a partner in the bedroom or see strange people and creatures as well. A patient might awaken in another room with different clothes on and have no sense of how he got there. One of my patients awoke her husband and asked for help as she tried to pick up the fish from the aquarium off the curtains and put them back into the water.

Night Terrors

Night terrors (or sleep terrors) is a first cousin of sleepwalking and it, too, is considered a disorder of arousal. The major difference is that sleep terrors has the added feature of intense emotion: terror. The subject might just sit up in bed screaming loudly in obvious terror, or he/she might scream and get up and run to escape imminent danger. It is very common in young children. It is very upsetting to parents to see their child in such terror and yet find themselves unable to console, as the child is unresponsive to the reassuring environment. As with sleepwalking, the subjects are caught between sleep and wakefulness. Everything said above about sleepwalking applies to sleep terror, including the importance of protecting the subject from the danger of their moving about in a confused state. This disorder too, especially in adults, merits proper evaluation and can be treated, when necessary, with very low doses of medications. An important part of treatment is reassuring the parents (as well as the subject) that the subject is not crazy or tormented and that there are no monsters inside them pushing to come out. Most often children are treated without medication, but there are times when the behavior is so vigorous and dangerous, or presents such a major social/family problem that medications might be used for a short period. The disorder runs in families and is genetically based.

Confusional Arousals Still another cousin of sleepwalking, and another disorder of arousal, is confusional arousal. It is seen most often in very young children but it can occur in adolescents and adults. In this disorder, the subject appears mostly awake as he/she cries and shouts and moves about in an agitated and confused manner, unresponsive to attempts to console. Attempts to console can even increase the agitation. As mentioned above in the sleep terror discussion, subjects and parents must understand that the behavior does not suggest the individual is tormented. It does suggest that they come from a family with a genetic predisposition for parasomnias.

Somniloquy (Sleep talking)

Sleep talking is such a common phenomenon that it would not even be classified as a disorder. It can occur in any stage of sleep and can be either intelligible or mumbling and gibberish.

Sleep Eating Disorder

This disorder is a specific type of sleepwalking. In the sleep eating disorder, subjects move in a sleepwalking state to the kitchen to eat a variety of foods from the refrigerator and/ cabinets. The entire episode can occur in a sleepwalking state or subjects might arouse to wakefulness halfway to the kitchen. Yet even if they fully awaken before reaching the kitchen, they are driven to continue their trip to the kitchen to eat. They are not eating because they are hungry. Often the sleep eater has a history of past problems with food or weight. This disorder requires considerable experience to treat and usually requires a combination of behavioral approaches and medications. Sleep eating is distinct from the disorder in which subjects have an uncontrollable habit of awakening in the night and purposefully getting up and getting something to eat.

Hypnagogic Hallucinations

Hypnagogic hallucinations are episodes of seeing and hearing things as one is falling asleep. As the subject drifts off to sleep, he/she moves into a state that combines the environment, of which the subject is still partially aware, with a dream-like state of sleep, in which he might see people and hear them talking. The experiences are often frightening. Sleep deprivation, irregular sleep schedules, and medications all can predispose to occurrences of this phenomenon.

Sleep paralysis

Sleep paralysis is a state is which one is totally paralyzed for a few seconds as one awakens from sleep. The state of very low muscle tone, which characterizes dream sleep, persists into wakefulness and is often very frightening to the subject, at least the first few times it happens. What is happening is that the brain is awakening from the dream sleep state before the body, again leaving the subject in a partially awake, partially asleep state. As with hypnagogic hallucinations, sleep deprivation predisposes to this phenomenon. Sleep paralysis and hypnagogic hallucinations can occur at the same time, creating a particularly frightening experience for the subject.

REM Sleep Behavior Disorder

Built into our biologic system is a wonderful mechanism for protecting us when we go into rapid eye-movement sleep (REM sleep), the state of sleep in which we dream. To keep us from running around in our dreams, our muscles go into a state of paralysis. In that safe state, we can think of kicking and hitting and running, yet lie perfectly still. As we age, the mechanism responsible for that paralysis can periodically fail. In those times of failure, one can act out a dream. Older people who yell, shout and kick vigorously, and even get out of bed and move around the room, are likely experiencing this disorder. The behavior is often quite vigorous and the subject and his/her partner can be hurt with a hard punch or kick and vigorous movements that cause them to fall out of bed. In contrast to the absence of any recall in sleepwalking or sleep terrors, recall of the dream that is being acted out in this disorder is usually quite good. Contrary to what is commonly thought when one witnesses such behavior, psychological issues are of no significance and it does not portend Alzheimer’s disease. Because of the high incidence of injury in this disorder proper evaluation and treatment is essential.

Bruxism (Teeth grinding)

Teeth grinding can occur in adults and children. While it is commonly thought to be a symptom of stress, there is little scientific evidence supporting its association with any significant psychological problems. If the grinding is severe, it is advisable for the subject to wear a tooth guard to protect his/her teeth from injury.

Body Rocking and Head Banging

These disorders are most commonly seen in children and are usually outgrown by adolescence. They can continue into adulthood. The young child might bang or roll his/her head against the pillow or rock his/her body with such vigor that the crib can actually move across the floor. The banging and rocking usually begins before the subject falls asleep and then occurs periodically throughout sleep independent of sleep stage, starting and stopping abruptly. While commonly seen in children with organic brain syndromes, it in no way implies a brain syndrome. It can be seen in perfectly normal children and adults. Treatments include behavioral therapy and medications, but success is usually limited.

The mysterious behaviors of the parasomnias fascinate both the medical community and the general public. The increasing research into their causes promises to be an exciting venture for many years to come.