Sleepwalking, Screaming, Arousals With Panic & Frantic, Behaviors

Idiopathic Somnambulism

(sleepwalking, typically in a calm, non-agitated fashion):

  • Often occurs in children–particularly boys. It usually but not always resolves before adulthood.
  • Can represent an arousal disorder, occurring during arousals from very deep, stage 4 non-REM sleep. In fact, standing a child up in that stage of sleep can induce sleepwalking!
  • Can also result from certain medications–such as certain sleeping pills (example: Ambien), sleep apnea and other conditions.

Sleepwalking is not necessarily harmless! It can result in serious injury, particularly if the individual walks outside.

Night Terrors (sleep terrors, pavor nocturnus)

  • Commonest in children, especially boys. Usually outgrown but can persist into adulthood.
  • Can “run in families”.
  • Also occurs from slow wave sleep and thus, most frequent during first few hours of sleep.
  • Typical description: a child who sits up in bed and screams out frantically, confused and unable to recognize parents or family–even to the point of combativeness that can last 20 minutes or so.
  • Usually no (or at most, hazy) dream recall. Patient usually doesn’t remember having had these on the next morning.

Nightmares (Dream anxiety attacks)

  • Occur at any age.
  • Occur in REM sleep–so more likely to occur later during sleep.
  • Patient usually can be awakened quickly and if awakened, typically can recall the dream in vivid detail.

Other causes of sleepwalking and frantic behaviors in sleep:

  • Non-agitated sleepwalking in adults — can result from sleep apnea, high fevers, and various medications (particularly “tranquilizers” and other “nerve pills”).
  • Agitated, frantic walking–or even running–in sleep, with high risk of self injury (broken bones, running out of second story windows and the like) — can be due to:

Panic attacks

  • Occur in non-REM sleep, usually stage 2: so any time of night, and no vivid dream recall.
  • Look for: aggravation by stress, caffeine and certain medications (stimulants, decongestants, diet pills, some asthma medications and adrenaline-like drugs (which may be given with local anesthetics for dental procedures as well as for allergic reactions.
  • Often seem associated with: a tense personality style, a tendency to flush when anxious, and–in some but not all patients)–a history of anxiety attacks in wakefulness.

Night terrors

  • See above. If a patient having a night terror leaves the bed, frantic sleepwalking can result.
  • Common in children, during first few hours of sleep. Little or no dream recall.
  • REM behavior disorder.
  • Common and potentially dangerous syndrome. Serious injuries and even some deaths have resulted.
  • Patient fails to develop the protective paralysis during REM sleep that normally prevents us from acting out our dreams. Thus, more likely to occur later in sleep.
  • It is usually obvious to observers that the patient is acting out a dream–frequently, a violent one. Typical example: patient, while dreaming of fighting off an assailant, attacks bedpartner instead.
  • Occurs most frequently in men over age 60, sometimes in conjunction with other neurological disorders, but often without any other concurrent illnesses– and occasionally in younger individuals, particularly if they have narcolepsy.
  • Can be markedly aggravated or precipitated by: certain medications (for example, antidepressants), sleep apnea, and withdrawal from alcohol and certain drugs. RBD is a neurological rather than a psychological disorder, but it seems to worsen in some people during times that they’re under more stress.
  • Often responds to a particular drug (clonazepam, Klonopin®), which, however, can make sleep apnea and daytime sleepiness worse–so sleep recordings are usually important before starting treatment.

Sleep-related seizures

  • Can cause complex, agitated behaviors which in some cases look much the same each time they occur.
  • Some types (especially originating from the frontal lobes of the brain) cause very bizarre, violent attacks with screaming out that may occur many times each night, and with EEGs (brain wave tests) that turn out normal.

Sleep apnea

  • Status dissociatus
  • A confused, agitated state with prominent body movements and vocalizations, during which it is impossible to score a particular sleep stage.

Implications of the above abnormal behaviors:

  • While placid sleepwalking and typical night terrors in children will usually be “outgrown” without any need for specific treatment, serious injuries still are possible–and some patients have even walked outside in freezing weather. Thus, any possibility of self-injury obviously should be eliminated (for example, by blocking access to windows, doors and open stairwells, and by installing alarm systems). Treatment may be warranted in severe or persistent cases.
  • A formal sleep evaluation is warranted in all the other problems listed–particularly whenever a serious underlying cause or serious consequences appear possible.
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