Sleepwalking, sleeptalking and other parasomnias are common and can be a real problem

sleepwalkingAlthough sleepwalking or other behaviours during sleep such as sleeptalking can be seen as being as being something funny, they can cause real problems for people. Walking out of the bedroom or even out of the house can cause safety concerns. I’ve seen many people who have injured themselves sleepwalking, and are seeking help. Sleepwalking can also disturb a partner, so it’s not uncommon for me to see people who have always had sleepwalking or sleeptalking that becomes a problem once they move in with a partner. In addition to sleepwalking or sleeptalking there are other behaviours that can happen during sleep, such as sleep-eating, sleep-sex (sexsomnia), night terrors, yelling and many others. All these behaviours are called parasomnias.

How do parasomnias occur?

Whilst parasomnias can take a number of forms with different behaviours, the underlying mechanism is similar. The brain doesn’t sleep as a single unit, and different parts of the brain can behave as if they are partially awake at times through the night. This is what happens with parasomnias. For a parasomnia to occur, there needs to be activation of the more primitive parts of the brain, such as the brain stem and parts that control automatic responses and behaviours, whilst other parts of the brain, such as the cerebral cortex remain deactivated. This results in someone having active muscles and being able to respond to simple inputs or questions, so they can carry out simple, basic or automatic behaviours, but not being conscious or having any recollection of what has happened.

Parasomnias can occur very commonly during pre-school and primary school aged years, when the cerebral cortex sleeps very deeply and is hard to wake up. Although parasomnias usually settle once children start high school, for around 2 in 100 people, parasomnias persist in to adult life. In adults, parasomnias usually begin to resolve by themselves by the mid 30s. If someone develops parasomnias out of the blue in their 40s or older, I look hard for underlying neurological causes or medications that may be causing parasomnias.

What are the typical features of parasomnias?

Parasomnias are characterized by abnormal or unusual behaviour during sleep. Behaviours typically occur in the first few hours of the night, and people usually have no, or little recollection of events occurring, apart from sometimes feeling more tired the next day. Behaviours are also often characterized as having an unfiltered or high-adrenaline response, with yelling, screaming and swearing.

  • Sleepwalking – can be simple such as just sitting up or wandering around the bedroom. It can be more complex though and involve opening doors, climbing out windows and even leaving the house. More complex behaviours such as driving a car are much less likely to be parasomnias.
  • Sleeptalking – can be mumbling, talking or even yelling. Very often the content of sleep talking is less ‘filtered’ and more aggressive and violent than how someone would talk when they are awake.
  • Sleep-eating – whilst it’s very common for people with insomnia or disturbed sleep to feel hungry at night (night-eating syndrome), there is another form that can occur as a parasomnia where people have no recollection of eating. Often people have a preference for carbohydrates and I’ve seen people whole tubs of ice-cream, and uncooked pasta or rice during their sleep.
  • Sleep-sex (sexsomnia) – sexualised behaviour such as masturbation or intercourse can occur as a form of parasomnia. I see it in men and women, and it commonly causes problems with relationships. It can end up in court, particularly if sexsomnia occurs with someone that is not a regular partner.

What makes parasomnias worse?

Parasomnias are usually made worse by 3 factors, 2 that increase sedation of the cortex (sleep deprivation and alcohol), and 1 that increases activation of the brain stem / arousal system (stress):

  • sleepwalking, sleepwalking and other parasomniasSleep deprivation – the more tired people are, the more likely parasomnias are to occur. I see some people who very predictably develop parasomnias during busy work periods or coming up to exams
  • Alcohol – alcohol and other sedatives including some prescription medications increase the risk of parasomnias. Alcohol has the effect of sedating the cerebral cortex and also activating the brain stem, which is the mechanism via which parasomnias occur.
  • Stress – stress can increase the risk of parasomnias occurring. Often stress and sleep deprivation occur together, with work or study deadlines, and this combination can bring out parasomnias.

Once parasomnias start to cause problems such as safety problems or disturbing a partner, people can be anxious or fearful of parasomnias continuing to occur. This increases the likelihood of getting more parasomnias, so people can get in to a vicious cycle of escalating trouble with parasomnias, which often is the trigger for them to get help and see a sleep specialist.

How are parasomnias treated?

The general principles of managing parasomnias are:

  • Avoiding trigger factors – avoiding things that make parasomnias worse like sleep deprivation, alcohol or other sedatives is an important first step
  • Managing stress – if stress is a trigger for parasomnias, learning stress management techniques can help people better manage parasomnias
  • Psychology-based strategies – in addition to stress management, there is a role for psychology-based strategies such as cognitive behavioural therapy, mindfulness and hypnosis. People with parasomnias can get anxious about parasomnias occurring, which can make things worse. Psychology-based strategies can be used to reduce this. There is also some research showing that hypnosis can reduce the frequency of episodes of parasomnias.
  • Use of medication – benzodiazepines, such as clonazepam, can be very effective in reducing parasomnias. If the above measures don’t work, or if people are having unsafe or disturbing parasomnias, I’ll use a benzodiazepine such as clonazepam in addition, in doses between 0.25-1.0mg. Some of my US-based colleagues prefer to use other benzodiazepines such as temazepam.

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