Sleeping on Their Feet Those Who Suffer from Nighttime Parasomnias Just Can’t Stay Still

For most people, hardly a day goes by without some kind of miscommunication or misunderstanding, leading to confusion or distress.

For those who sleepwalk, nighttime is no different. Only, in this case, it’s different parts of the brain that aren’t communicating correctly.

The broad category of nighttime activities known as ‘parasomnias’ typically occur when someone is transitioning out of deep, ‘slow-wave’ sleep, and include sleepwalking, night terrors, and more exotic behaviors such as sleep eating and even sleep sex, often with no memory of the behavior come morning.

In these cases, “typically, parts of the brain are in different sleep stages,” said Dr. Michael Coppola, medical director of Total Sleep at Mercy Medical Center. “The brain may be asleep, but part of it may be awake, which is why you’re walking. These are instances when parts of the brain are not all at the same sleep phase at the same time, and the coordination between sleep stages is off.”

Dr. Karin Johnson, attending neurologist in Sleep Medicine at Baystate Medical Center, said that most sleepwalkers will just get up, wander about, and return to their room. “You shouldn’t try to force someone to wake up, but make sure they’re safe and lead them back toward bed. You don’t necessarily want to wake them up because they’ll be more confused in that state.”

But not all instances of acting out during sleep are parasomnias, doctors say, and some are more serious than others. As part of this month’s focus on sleep medicine, The Healthcare News examines sleepwalking, night terrors, and other phenomena that keep people from resting soundly.

Early to Rise

Coppola explained that abnormal behaviors of sleep fall into three main groups. The first is confusional arousals, which occur when people wake prematurely from light sleep, often confused or yelling, and sometimes with difficulty breathing. Sleep apnea, a blockage of the airway that keeps people from reaching deep, restorative sleep, is a common culprit (see related story, page 9). “These are probably more common than true parasomnias,” he said.

Parasomnias, on the other hand, arise from deeper sleep. The activity known as sleepwalking can actually encompass virtually any activity; people have been reported to houseclean, cook, bathe, text or e-mail, walk a dog, attempt to have sex with their partner, even commit violence while in the throes of a parasomnic experience. Sleepwalking has even been used as a defense, both successfully and not, in murder cases.

Most sleepwalking is harmless in itself — as long as the sleeper doesn’t wander outside or into a dangerous situation, that is — and rather benign. However, one type of parasomnia, night terrors, which occur mainly in children, can be terrifying.

Parents who have experienced these events with their kids know that it’s nearly impossible to ‘wake up’ the part of the brain that’s experiencing the terror, even though the child may be physically up and walking or flailing about. The sleeper will wake with a start, typically crying, screaming, and displaying a look of intense fear, and will be completely unresponsive to any efforts to comfort him or her. Many sufferers see spiders, snakes, or people in the room, while some simply experience a general dread. Typically, the episode lasts five to 15 minutes, sometimes longer. The effect, to an observer, isn’t unlike watching someone hallucinating.

“These children are transitioning out of a very deep sleep,” Coppola said. “They basically have an inconsolable fear, and while it can be a disturbing thing for a child, there’s no long-term psychological damage from it” — again, as long as the child is kept physically safe as he thrashes and fights.

“People always confuse night terrors with nightmares,” Johnson said, “but if a kid is remembering what happened in the morning, it’s probably more a nightmare, whereas if he’s waking up screaming and then going back to sleep with no memory in the morning, that’s usually a night terror. In that case, the primary goal is to make sure they don’t hurt themselves. The child may scream and flail, and it can be very frightening for people watching it, but the child will usually calm back down and have no memory of it in the morning.”

Because night terrors tend to happen around the same time every night — typically, from 60 to 90 minutes after shuteye — one trick some parents have tried successfully is to gently wake the child shortly before they expect the event to begin, then let him or her drift back to sleep.

According to the American Academy of Sleep Medicine, up to 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of adults report having at least an occasional nightmare, and about 75{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children can remember having at least one nightmare during childhood. Confusional arousals occur in about 17{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children and fewer than 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of adults. On the other hand, between 2{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} and 5{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of adults suffer from night terrors, and up to 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children. These phenomena often run in families.

“Most sleepwalking and night terrors happen much more as kids,” Johnson said. “Most people outgrow them by the time they’re adults, and most people don’t need any particular treatment. Almost every parasomnia is worsened by sleep deprivation, and some people going to an unfamiliar place sleepwalk; going to a hotel or on vacation may bring it out.” Safeguards to protect chronic sleepwalkers might include door alarms, not leaving dangerous items sitting out, and making sure windows and sliding doors are locked, she suggested.

A More Serious Matter

The third category of sleep disturbance, Coppola explained, is REM sleep behavior disorders, which arise, usually later in the evening, from a completely different sleep phase than parasomnias — specifically, the rapid-eye-movement cycle in which people dream — but also result in physical movement, which can occasionally be violent.

“It occurs when people start acting out their dreams during REM sleep,” he said. “Normally, during REM sleep, the muscles are paralyzed, and for good reason. When people lose their ability to suppress muscle activity, they will act out their dreams.

“It’s different from sleepwalking,” he continued, “because someone who’s sleepwalking can’t describe their behavior to you if you wake them up. But a person with REM sleep behavior disorder is quite aware of the dream after waking up.”

This condition — which occurs mainly in men over age 60 — is especially worrisome, Johnson said, because it is often associated with future Parkinson’s disease, dementia, and other neurodegenerative disorders — sometimes up to 10 years before the onset of the disease. Unlike common parasomnias, doctors will often treat these sleep disorders with antidepressant medications.

“It can be a harbinger of further degenerative brain conditions, commonly Parkinson’s,” Coppola agreed. “It’s important to be seen by a neurologist to sort them out and make sure they’re not seizures.”

Of course, even absent this possibility, REM sleep behavior disorders can be disturbing and sometimes painful for both the dreamer and their sleeping partner.

“I’ve had patients dreaming they were doing something who actually wound up doing that action,” he added — in one case, sustaining a head injury requiring 10 stitches when a dreamer fell while moving between the bed and the dresser. “Or, they may dream someone is attacking them, and punch back, only to wake up their wife.”

That’s a recipe for separate bedrooms — yet another result of a brain that can’t quite agree with itself.