What is somnambulism? The manifestation of sleepwalking in adults - causes and specific methods of treatment of the disease Possible symptoms of sleepwalking

Many have come across such a term as “sleepwalking” and know that a sleepwalker is a person who walks in a dream with outstretched arms forward.

But this knowledge is not entirely correct.

In reality, sleepwalking looks quite intimidating, because from an ordinary person a somnambulist is distinguished only by a glassy look and ignoring the voice of relatives who call him and try to understand what is happening.

Is sleepwalking a mental disorder in adults and children?

Somnambulism is a form of disruption of natural nocturnal sleep, which is accompanied by unconscious talking and walking.

This is a very indeterminate phenomenon, occurring in 2.5% of the population.

Such episodic sleepwalking is considered the norm if repeated 1-2 times a month. A person can sleepwalk due to emotional trauma, the use of drugs, alcohol: the reasons can be very different.

And it mostly affects the males. Signs of such a problem most often appear in children aged 4 to 16 years, adults are much less susceptible to this disease.

F51.3 - under this number, this disorder fell into the ICD-10, although in most cases it is not a problem that requires treatment.

Features of patients suffering from the disease

Somnambulism is a sleep disorder, but not a mental disorder! This is subject to very impressionable, emotional people who have certain structural features of the brain.

Outwardly, such people look quite calm and restrained. This disorder can also occur in people who experience some kind of failure for a long time.

Causes

In most cases, episodic sleepwalking no longer bothers after 17 years.

But adults are exposed to this in different ways:

• acute stress;
• chronic lack of sleep;
• taking drugs and alcohol in large quantities;
• eating junk food, the habit of having a tight dinner;
• recent traumatic brain injury;
• panic attacks;
• heredity.

There are also quite serious causes of somnambulism: various heart problems (tachycardia or heart failure), formations in the brain, aneurysms, Parkinson's disease.

Hormonal surges also affect the brain, so pregnant women can also suffer from this ailment.

Diabetics also experience bouts of sleepwalking as their blood sugar drops at night.

Symptoms and signs in adults

Absolutely the same in both children and adults.

During nighttime adventures, human behavior changes dramatically. He begins to move smoothly, often various body movements occur "on the machine."

The look of the lunatic is frozen, the pupils are constricted. Not in all cases, the somnambulist actively moves in his sleep, he can perform any actions while lying in bed: straighten his pajamas, rub his eyes, and so on.

Sometimes a sleepwalker just gets out of bed, sits and talks.

A lunatic may come, for example, to a table and simply stand still. Such attacks can last from 5 minutes to 1.5 hours.

Although there are cases when somnambulists actively walk around the house: turn on appliances, open doors and windows, take knives.

In such cases, you need to take care of the complete safety of the person.

Very rarely, but there are sleepwalkers who leave the house: they can go to the store, swim in the river and even drive (but they won’t go far: an accident will happen immediately)!

In such cases, of course, accidents often happen to a person.

Types and forms of the syndrome

There are several types of somnambulism: from the most harmless to aggressive and even dangerous.

Alcoholic

This form of somnambulism occurs with excessive alcohol consumption. A person, having drunk a fairly large amount of alcohol, goes to bed, but begins to walk in his sleep.

Most often, this phenomenon occurs once and no longer bothers the person. If such episodes are repeated repeatedly, then you should reconsider your lifestyle and consult a specialist.

Sexual

A sleepwalker in a dream can show unconscious sexual activity.

This phenomenon is called sexsomnia.

This form affects people who are promiscuous, while excessively using alcohol and (or) drugs.

The manifestation of this form is sexual intercourse in a dream, or other sexual activity.. Usually, after that, a person does not remember what happened, and if he does, then as an ordinary erotic dream.

Sexsomnia is caused by the same reasons as with sleepwalking, but the determining factor is physical contact with a partner. This form of sleepwalking affects both men and women equally.

Sleep conversations

It is rather "mini sleepwalking", expressed in speaking during sleep. Can occur in any phase of sleep, unlike true sleepwalking. And depending on the phase, conversations can be both slurred and quite clear.

Talking in a dream can occur in absolutely any person. Most often, this type occurs and passes in the future.

But there are also cases when adults talk in their sleep. This may be due to a genetic predisposition. In any case, this phenomenon is harmless.

Attacks of night eating and drinking

Night eating and drinking syndrome is a dangerous phenomenon, although it seems that there is nothing to worry about.

But in addition to the consumption of ordinary food, a person can also eat inedible items: washing powder, paints, various creams ...

And if a person wants to cook something in a dream using a gas stove, then this will be dangerous not only for the somnambulist himself, but also for the people around him.

Rapid eye movement behavior disorder

This disorder occurs during REM sleep. The average person has a defensive reaction to movements from dreams.

That is, when a person sees a dream in which he makes any movements, in reality he does not move. But if the protection fails, then this syndrome occurs.

With this form, actions from a dream are embodied in reality. This is already more serious than simple sleepwalking with primitive movements.

In this state, a person can perform complex movements, such as pinching, kicking, jumping, and many others. And it is very difficult to wake a person at such moments.

Condition Diagnostics

If the episode of sleepwalking happened for the first time, and the day before there was some kind of stressful situation, then going to the doctor is not necessary.

But if this happens systematically, then you need to contact a neurologist, psychoneurologist or psychiatrist.

A specialist can help with the diagnosis, that is:

It is best that the somnambulist is accompanied by a witness to all nightly activities at the reception of a specialist.

The doctor will ask questions, talk with the patient and prescribe additional methods that will help to refute or confirm the diagnosis.

It could be:

• electroencephalography(research method that allows to establish epileptic foci);
• ultrasound examination of cerebral vessels(allows you to determine the nature of blood flow in the vessels);
• computed or magnetic resonance imaging(detect any changes, including neoplasms);
• polysomnography(a method that is carried out in a special sleep laboratory, where sensors will be connected to the patient, and they will monitor the patient's condition during sleep).

The doctor may also prescribe consultations of other specialists: a cardiologist, a pulmonologist, an endocrinologist. This will help diagnose diseases that could cause somnambulism.

Treatment of somnambulism

Medical

Medicines are necessary when a person during bouts of sleepwalking poses any danger to himself or his loved ones.

The doctor may prescribe antidepressants or sedatives and sedatives, or tranquilizers.

There are quite a few such as Trazodone (Desyrel), ProSom or Klonopin.

This method of treatment is used only by prescription! It also happens when sleepwalking attacks become more frequent after a course of medication, but this is not for long.

The method of warning awakenings

With this method, it is important to know at what time the attacks occur and how long they last.

It consists in the fact that a person is awakened 15-20 minutes before the start of the episode and is not allowed to sleep all the time, how long it should last.

This is used for a long course of treatment.

Relaxation

This method is more related to traditional medicine. It involves taking a bath (sitz bath or foot bath) before bed with various oils such as:

• St. John's wort;
• sage;
• mint;
• Melissa;
• sweet clover

The water should be warm, the duration of the procedure is about 10 minutes.

Yoga classes can also be attributed to relaxation.

They can help you deal with stress, a possible cause of sleepwalking.

Sometimes the method of mental images is used in the treatment. This method will be effective if done under the supervision of an experienced behavioral therapist (which may include a hypnotist).

Man's lifestyle

Daily regime

The daily routine of a person suffering from somnambulism should include a balanced diet (eating 5-6 times a day in small portions, observing the proportions of BJU), good rest (sleeping at least 8 hours a day).

Also, do not worry about trifles, minimize stress.

Do they take to the army

They take it if somnambulism is caused by a disease such as, for example. But there is no mere sleepwalking in the Schedule of Diseases.

If the symptoms of sleepwalking arose during the service, then the person is hospitalized and a thorough examination is done. Upon detection of mental abnormalities that are the cause of sleepwalking, the young man is commissioned.

How to avoid injury

To prevent various dangers, you need to follow the rules:

• do not leave the somnambulist alone at night;
• remove all light sources;
• block doors and windows (or put bars on windows);
• take care that the sleepwalker does not trip over anything and does not stumble on sharp corners;
• do not leave wires under your feet;
• do not leave the keys (of the house, car) in prominent places.

Consequences and complications

Somnambulist during his adventures can get various kinds of injuries. It is also possible to reduce efficiency and drowsiness during the day. In addition, sleepwalkers often interfere with the sleep of others.

Prevention measures

Sleepwalking is not such a serious disease, in most cases it goes away on its own. And when the cause is eliminated, this problem will disappear.

For prevention, you should ventilate the bedroom, do exercises to relax before going to bed. Do not go to bed in a “broken state”. A leisurely walk or a cool shower will help relieve fatigue.

Thus, somnambulism is not a sentence. It is successfully treated and is not considered a serious problem.

But at the same time, it can appear as a result of any diseases, so if an attack of sleepwalking has not occurred for the first time, then there is no need to drag out time, it is better to contact a specialist.

Video

Interesting facts about sleepwalking in this video:

Somnambulism (sleepwalking) is a pathological condition in which a person in a state of sleep can perform actions unusual for a sleeping person. If you do not delve into and do not pay close attention to it, then by the nature of the movements, its activity may seem adequate and purposeful. However, such an impression is deceptive, since the consciousness of a person at this moment is clouded, since he is in a state of half sleep and does not give an account of his own actions.

The danger of somnambulism lies in the fact that a half-asleep patient can perform actions that the dream prompts him to do and this cannot be controlled. A person can harm himself, which often manifests itself in falls and physical injuries. In an extremely rare form of the disease, the patient may show aggression towards other people. Most often this happens with those who are trying to help, stop, return a person to bed, or just get in the way.

In its usual non-critical form, somnambulism manifests itself in the fact that a person can walk in a dream or just sit on a bed. The half-sleep-half-wake period continues in most cases no more than one hour, after which the patient falls asleep normally, returning to his bed. Waking up in the morning, people do not remember their nightly adventures at all.

Sleepwalking is most common in children of preschool and primary school age. In adolescence, manifestations of somnambulism are associated with hormonal changes in the body. In most cases, sleepwalking passes without any pathological consequences in the process of growing up a child.

In adults, somnambulism indicates mental, psychological, neurological and physiological disorders. If the manifestations of sleepwalking in children are easy enough to observe and timely correct if necessary, then the causes of this condition in an adult must be carefully clarified. If timely diagnosis and treatment are not carried out, then the patient's condition may worsen, attacks become more frequent and eventually result in serious deviations.

In the past, this pathology was called "sleepwalking", but in modern medicine it is considered incorrect. It arose from a combination of the Latin words "moon" and "madness". However, in fact, somnambulism is not associated with the cycles of the moon, as it was believed in antiquity, the term lunatic is sometimes used out of habit.

Causes of somnambulism

Sleep is divided into two phases: slow fast. The slow phase is the longest, it accounts for 80% of the total night's rest. It is divided into several states - drowsiness, medium and deep sleep. The REM sleep phase takes a significantly shorter time, on average about 20%.

A full night's sleep includes 3 to 5 cycles, each of which lasts from one and a half to two hours. First, the person falls into a short nap, then falls into a deep sleep. Slow-wave sleep is the first 2-3 cycles, REM sleep is short-term and is typical for pre-morning and morning hours.

Slow-wave deep sleep is the main part of our rest. Fast bears such a name not only because of its brevity, but also because at this time a person’s eyes move quickly in a dream. This happens before awakening, when a person sees dreams.

Somnambulism manifests itself in the phase of deep sleep, when a person's consciousness is most detached. The cause of this condition is believed to be sudden bursts of electrical nerve activity in some neurons of the brain. In this state, part of the brain is asleep, while the other part continues to be active. To put it simply, we can say that the part of the brain responsible for conscious meaningful activity is in a state of sleep, and the centers that control motor coordination are active.

In children, sleepwalking in most cases is associated with immaturity and insufficient development of the central nervous system. Children, due to their emotionality and impressionability, perceive the information received during the day very sensitively. Due to the functional immaturity of the nervous system and excessive loads, they develop a state of partial sleep. Active games, strong emotional experiences, overexcitation due to computer games, cartoons, video programs in the evening or an excess of information can contribute to its manifestation. In fact, the child's brain simply does not have time to calm down and this is manifested by night walks.

Other causes of somnambulism in children include:

• heredity - manifestations of somnambulism occur in almost half of the children, one of whose parents suffered from sleepwalking at some point in their lives;
• fever disease;
• stress that the child's psyche could not cope with;
• epilepsy - sleepwalking can be one of the signs, and can also be one of the early manifestations of the disease.

In adults, sleepwalking is a rather rare phenomenon; diseases can provoke it:

• neurosis of various etiologies, most often hysterical and obsessive-compulsive disorder;
• vegetative-vascular dystonia with panic attacks;
• diabetes mellitus with nocturnal hypoglycemia;
• migraine;
• intoxication with brain damage;
• a state of chronic stress;
• obstructive sleep disorders;
• chronic fatigue syndrome;
• magnesium deficiency in the body (with malnutrition or illness);
• consequences of traumatic brain injury;
• vascular diseases of the brain;
• epilepsy;
• neoplasms of the brain;
• senile dementia;
• drug addiction, alcoholism;
• cardiac arrhythmia;
• taking certain medications.

A sharp loud sound or a sudden flash of light can cause sleepwalking, disturbing the peace of a sleeping person. It is this factor that led to the fact that sleepwalking in the past was directly associated with the influence of the full moon. In fact, there is nothing mystical about somnambulism, it is caused by disorders of the brain.

Symptoms of somnambulism

Not all people who are prone to somnambulism walk in their sleep. Signs of the disease may be other manifestations of partial sleep. The passive symptoms of somnambulism include a condition in which the patient in a dream sits up on a bed with open eyes and a fixed gaze. As a rule, after sitting like this for a short time, he goes to bed and continues to sleep peacefully until morning.

In difficult cases, the patient can move around the house and even go outside. At the same time, all movements from the outside look calm and purposeful. The eyes are open, but the eyeballs do not move, the gaze is absent and unconscious. Some patients perform a whole range of actions - take certain things, change clothes, leave the house, walk on the roof, balance at dangerous heights and unstable surfaces.

For all manifestations of somnambulism, a number of generalizing factors have been identified:

1. Lack of awareness. Performing any actions, a person does not react in any way to the speech addressed to him, does not perceive dangerous conditions in his movements. This, as mentioned above, is a sign that part of the brain is in a state of sleep.
2. An absent look. The eyes of the somnambulist are always open, the gaze is focused on something far away. Even if someone comes close to the patient and tries to draw attention to himself, he looks through him. Consciousness is sleeping.
3. Detachment. A person in a state of drowsiness cannot show any emotions, his face does not express them at all, facial expressions in most cases are completely absent, as is the case during deep sleep.
4. Lack of memories. Sleeping consciousness is not able to fix in memory the nightly adventures of a person. In the morning, he remembers absolutely nothing about what happened to him during the night attack.
5. Same ending. For all somnambulists, the end of the attack is the same - he falls asleep in a normal sleep. If he managed to return to his own bed, then he spends the night there until waking up. But the end of a REM sleep can catch him far from his bed, then he goes to bed where he has to. In the morning, such people experience a real shock, because after falling asleep in their bed, it is not clear how they ended up in another place.

Diagnosis of somnambulism

To prescribe the correct effective treatment for sleepwalking, you must first find out the cause that provoked it. To do this, you need to contact a specialist - a neurologist or psychiatrist.

The first stage of diagnosis is a patient interview with a thorough identification of details. You can help the doctor if someone close will mark the time of going to bed, the beginning and end of an attack of somnambulism, the time of morning awakening. Also important factors for the specialist will be the list of medications taken and the main foods from the daily diet.

Depending on the results of the examination and questioning of the patient, the doctor may prescribe instrumental, laboratory tests and consultations of narrow specialists - an endocrinologist, a pulmonologist, a cardiologist. Instrumental studies used in such cases include:

• electroencephalography;
• polysomnography;
• Ultrasound of the vessels of the brain;
• fundus examination;
• MRI of the brain.

Laboratory studies are carried out according to indications. You may need to test for hormones, infection, and blood levels of vitamins and minerals. According to the data collected, the cause of sleepwalking is revealed, on the basis of which therapy is prescribed.

Treatment of somnambulism

In children, the disease goes away on its own in the process of growing up and developing the brain. Treatment of a child suffering from somnambulism most often comes down to correcting the daily regimen, nutrition and psychological stress.

In the case of an adult disease, the treatment process is not so simple and unambiguous, since the causes of its origin are much deeper and more serious. Sleepwalking therapy is carried out with the help of psychotherapy and medications. If attacks of nocturnal movements appear after stress, emotional or mental stress, then first of all, the help of a psychologist or psychotherapist is needed.

Medical treatment

According to individual indications, the patient may be prescribed sedatives or hypnotics, in some cases tranquilizers are used. The choice of drug therapy is a very crucial moment, the specialist takes into account many factors before prescribing a particular drug.

If the patient has vascular, neurological, endocrine or cardiac diseases, the therapy focuses on the treatment of the underlying disease. For example, if the cause of sleepwalking is severe arrhythmia attacks, then it is the heart disease that should be treated. In the case where the problem is caused by neoplasms of the brain, surgery is likely to be required.

Mainly during treatment it is important to create conditions under which a person will feel calm and confident. You can relieve the state of fatigue and anxiety with the help of physiotherapy methods and relaxation practices.

Forecast and prevention of somnambulism

In general, experts give a favorable prognosis for getting rid of sleepwalking. With the help of drugs, physiotherapy, psychotherapy and preventive measures, the manifestations of somnambulism in adults can be eliminated. Problems can arise only in the case of paroxysmal (epileptic) sleepwalking. In such situations, treatment can be lengthy and give only a temporary result. However, with the help of complex methods, in this case, it is possible to achieve stable and long-term remission.

Prevention of somnambulism is primarily based on the elimination of psychologically traumatic factors from the patient's life, the correction of sleep and wakefulness, and the selection of a diet. Experts say that most often the cause of somnambulism is psychological factors, mental and physical overstrain. Relapse prevention concerns simple rules - a person must have a good rest, sleep at least 8 hours a day, eat a balanced diet, minimize stress and eliminate chronic fatigue syndrome.

Speaking about preventive measures, one cannot fail to mention the creation of safe conditions for the somnambulist before, during and after treatment. It is necessary to ensure that windows and doors are always closed in the patient's bedroom, there are no sharp objects and corners. This is necessary to reduce the risk of injury during night attacks.

The scientific name of sleepwalking is somnambulism (from Latin Somnus - sleep and Ambulare - to walk, walk), and the second "folk" synonym for this condition is "sleepwalking". In fact, this pathology has nothing to do with the moon, but is named so, probably due to the fact that it is often detected on bright moonlit nights. This is one of the forms of sleep disorders, the manifestation of which is unconscious walking in a dream.

Somnambulism is a very common phenomenon, according to statistics, every fiftieth inhabitant of our planet suffers from it. The vast majority of people suffering from sleepwalking are children aged 4 to 10-16 years. About why it occurs, how sleepwalking manifests itself, how to deal with this condition and will be discussed in our article.

Causes of sleepwalking

As mentioned above, children are more likely to suffer from sleepwalking, especially boys. This is probably due to the functional immaturity of the central nervous system. Children are naturally emotional, impressionable, and the stress on the nervous system today is so great that, absorbing new information during the day, the brain continues to work actively at night, during the child's sleep. The child’s evening quarrels with family members, worries about parents’ quarrels, active games, computer games, watching cartoons or TV shows before bedtime contribute to the emergence of sleepwalking: under the influence of these factors, the nervous system, which is tired in the evening, is excited and does not have time to calm down for sleep. In such situations, sleepwalking may be accompanied by other disorders of the nervous system - involuntary urination (enuresis), obsessive-compulsive disorder, neurosis-like tics,.

Other risk factors for sleepwalking in children are:

• genetic predisposition (it is known that if one of the parents of a child suffers or suffered from sleepwalking, the probability of developing symptoms of this disorder in a child is approximately 40%, and if both, it increases to 65%);
• high temperature during the illness;
• epilepsy (somnambulism can either accompany epilepsy, being one of its symptoms, or be a predictor of this disease, developing even several years before its onset).

In adults, somnambulism develops much less frequently and, as a rule, is secondary. The main causes of sleepwalking in adults are:

• chronic lack of sleep;
• acute and chronic stress;
• migraine;
• neuroses;
• senile dementia;
• epilepsy;
• aneurysms of cerebral vessels;
• cardiac disorders (severe arrhythmias);
• obstructive sleep apnea syndrome;
• pregnancy and menstruation in women;
• night attacks of bronchial asthma;
• diabetes mellitus (due to nocturnal hypoglycemia, or a decrease in sugar levels below normal at night);
• a hearty dinner before bed;
• irrational nutrition, containing in its composition a large number of unrefined products, leading to a deficiency of the microelement magnesium in the body;
• taking alcohol and drugs;
• taking certain medications (in particular, antipsychotics, sedatives and hypnotics).

When sleepwalking occurs

As you know, sleep includes 2 phases: slow and fast. The non-REM sleep phase consists of 4 stages - from falling asleep to deep sleep. The phase of REM sleep is accompanied by active movements of the eyeballs, it is in this phase that a person sees dreams. The sleep cycle, which includes 2 large phases, lasts an average of 90-100 minutes and is repeated during the night up to 10 times. Sleepwalking occurs, as a rule, during the deep sleep phase (that is, at the end of the 1st phase) of the first or second cycles. During the day, somnambulism occurs extremely rarely, since the duration of daytime sleep is insufficient.

In younger children, non-REM sleep is longer and deeper than in adults: these features also increase the likelihood of them developing sleepwalking.

With regard to physiology, sleepwalking occurs when, during sleep, the inhibition of the functions of the central nervous system does not extend to the areas of the brain responsible for motor functions. That is, the vast majority of body functions are inhibited, but the function of movement is not.

Symptoms of sleepwalking

The main and main symptom of somnambulism is sleepwalking. A person seems to have fallen asleep, but suddenly he suddenly gets up and goes somewhere or performs certain actions. The duration of an attack of sleepwalking can range from a few seconds to half an hour, in rare cases - up to 50 minutes.

Some patients do not walk, but simply sit up in bed, sit for a few seconds or minutes, and go back to bed.

Most people who suffer from sleepwalking get out of bed, then they can turn on the light, or they can walk around the room in the dark, doing some kind of action, and even go outside the home - into the entrance, into the yard, they can get into the car and even start it .

Some sources contain information that, while in a dream, some "lunatics" can drive a car, but this is a myth: reflexes become dull during sleep and a person cannot adequately respond to the events taking place around him, which means that even if he manages to start the car , then he will not go far: an accident will immediately occur.

In some cases, a person, even without getting out of bed, performs certain stereotypical movements (straightens his pajamas, rubs his eyes, and so on): this can also be a manifestation of sleepwalking.

During sleepwalking, a person’s eyes are wide open, but they are like glass - the gaze is directed into the void, it is “absent”, the face does not express any emotions at all, the movements are slow, smooth. If at this moment you turn to the sleepwalker, he will not hear and will not answer questions, but he can pronounce words and incoherent sentences on his own, or simply mumble something under his breath.

The episode of sleepwalking ends spontaneously: the patient returns to his bed or falls asleep in another place. In the morning, he remembers absolutely nothing about his nightly adventures and, waking up not in his bed, can be very surprised. If the phase of active sleepwalking was long, during the day a person feels weakness, drowsiness, weakness, and decreased ability to work.

Episodes of sleepwalking are rarely daily: as a rule, they occur with a frequency of several times a week to 1-2 times a month or less.

During an episode of somnambulism, all kinds of senses are dulled, so the patient does not realize the danger: he can calmly walk on the roof, use a knife, or jump out of the window. A person can harm himself (a quarter of somnambulists get injured during sleepwalking), and the people around him, without suspecting it, therefore, living under the same roof with a lunatic, a number of measures must be taken to avoid this. We will talk about what these events are below.

Diagnosis of sleepwalking

If the episode of sleepwalking happened for the first time, and you can associate it with a stressful situation experienced the day before or overwork, then you can postpone seeking medical help. In the case when such episodes are repeated repeatedly, you should still seek help from a neurologist, neuropsychiatrist or psychiatrist to establish the cause of these phenomena.

To help a specialist make a diagnosis, you or your family should:

• mark on paper the time of falling asleep, after what time the episode of sleepwalking begins, how long it lasts, the patient's behavior during this period, morning awakening;
• think over and note the reasons that could provoke somnambulism (listed at the beginning of the article);
• make a list of the most commonly eaten foods and regularly taken medicines.

Going to the reception, it is highly advisable to take with you a witness of your nightly “journeys”.

The doctor will talk with the patient, ask him a number of necessary questions, conduct an objective examination and prescribe additional research methods that confirm or refute the diagnosis. As a rule, such studies are:

• electroencephalography (determination of the electrical activity of the brain; it is this method that makes it possible to diagnose the presence of epileptic foci in the brain);
• polysomnography (the patient spends the night in a special sleep laboratory, where, before falling asleep, sensors will be connected to him and trace the changes that occur in the nervous system during sleep);
• ultrasound examination of the vessels of the brain (determine the nature of the blood flow in them);
• computed or magnetic resonance imaging (will detect neoplasms, if any, or changes of any other nature);
• consultations of related specialists (endocrinologist, cardiologist, pulmonologist) for the diagnosis of somatic diseases that could provoke the development of sleepwalking.

Principles of treatment of somnambulism

Full sleep and the exclusion of active games before falling asleep will help in the treatment of sleepwalking.

In most children, this disorder resolves on its own as the child grows older.

If sleepwalking occurs infrequently and no pathological changes in the body have been identified, the treatment consists in modifying the lifestyle, namely minimizing the impact of risk factors:

• regular, long (7-8 hours) night sleep;
• before going to bed - a relaxing ritual (for example, you can take a warm bath with relaxing oils, listen to calm music, have a soothing massage session, drink mint tea, etc.);
• exclude watching TV and working at a computer at least 2 hours before bedtime;
• to exclude the use of alcohol;
• avoid stress at work and at home, and if they happen, then try not to carry them into the house, but, so to speak, leave them outside the door;
• if a child suffers from sleepwalking, then the daily regimen should be ensured; make sure he gets enough sleep to get enough sleep; limit watching TV and playing at the computer, do not play active games before going to bed, but play quiet ones (for example, table games), draw, read a book or listen to pleasant music.

In the case when the cause of sleepwalking is any medications taken by the patient, they should be canceled or at least the dosage should be reduced.

If sleepwalking arose against the background of epilepsy, the patient will be prescribed antiepileptic drugs, and when neurosis becomes the cause, tranquilizers and.

With a non-neurological nature of the disease, the disease that caused it is treated (antiarrhythmic drugs are prescribed for arrhythmias, adequate hypoglycemic therapy for diabetes mellitus, and so on).

Even if the episodes of sleepwalking do not stop during the treatment of underlying diseases, disrupting the patient's daily activities, and there is a risk of injury at this time, the patient may be prescribed drugs that affect sleep phases. They are prescribed in low doses, the duration of treatment is from 3 to 6 weeks.

You should not wake up a somnambulist during sleepwalking - this can frighten him, provoking the development of other mental disorders. You should calmly take him by the hand or by the shoulders and, speaking in a low voice, lead him into the room and put him to bed.

Sometimes psychiatrists and psychotherapists use hypnosis as a treatment for sleepwalking.

How to avoid injury

Above, we already wrote that sleepwalkers during sleepwalking can harm their health and the health of others. To prevent this from happening, the following measures should be observed:

• do not leave the patient alone in the room for the night (if you are nearby, you will notice the beginning of the episode in time and put the patient to bed);
• remove bunk beds, arranging a sleeping place for the patient on the first floor;
• during sleep, remove all light sources (floor lamps, nightlights, draw curtains so that moonlight does not pass through the window);
• block the doors and windows of the bedroom before going to bed, and if this is not possible, install bars on the windows (patients may confuse a window with a door and try to "exit" through it);
• if possible, “smooth out” sharp corners on furniture;
• before going to bed, remove objects from under the feet that the patient can stumble on, sharp and fragile objects that can injure him;
• turn off electrical appliances before going to bed, do not leave electrical wires under your feet;
• hide the keys to the front door and the car;
• in severe cases, you can even tie the patient to the bed, but sometimes sleepwalkers somehow untie themselves in a dream;
• you can also put a bowl of cold water in front of the bed of the patient or lay a rag soaked in cold water - when getting up, the person will dip his feet in the water and wake up from this.

In conclusion, I would like to repeat that in the vast majority of cases, sleepwalking is not dangerous and ends with recovery even without treatment, but sometimes it accompanies the course of quite serious diseases. Therefore, in order not to miss these most serious diseases and prevent injury to a person during sleepwalking, you should not “wait for the weather by the sea” or treat a sleepwalker on your own: the right decision would be to seek help from a doctor.

Channel One, the program “Live Healthy” with Elena Malysheva on the topic “Sleepwalking: Symptoms and Treatment”:

Transfer "Doctor on duty" about sleepwalking:

National Geographic TV channel, documentary film Sleepwalking. Myths and Reality":

Somnambulism- a special abnormal state of the central nervous system, in which the individual performs any actions, while being in one of the stages of sleep - the phase of deep slow sleep. This disorder is commonly referred to as "sleepwalking" or "sleepwalking".

According to official data, somnambulism is recorded in more than 2% of the inhabitants of the planet. In most cases, sleepwalking is determined in persons with mental disorders or diseases of the neurotic level, however, this phenomenon can occasionally occur in objectively healthy people. Most often, somnambulism is determined in the age category from 17 to 23 years, regardless of gender.

Somnambulism is manifested in the fact that a sleeping person, being in a special state: half asleep-half awake, gets out of bed and performs familiar actions for him. Somnambulist is able to walk around the apartment, turn on electrical appliances, open water taps, dress, put his appearance in order. In some cases, a sleepwalker performs extremely dangerous actions, for example: driving a car, making suicidal attempts.

An attack of sleepwalking lasts an average of 10 to 30 minutes, but cases of somnambulism lasting about three hours have been recorded. At the end of his nightly "walks", the somnambulist returns to bed, and in the morning does not remember his "adventures" at all.

Causes of somnambulism

Sleepwalking is most often recorded when there is an incorrect transition from the phase of deep slow sleep to the second stage. In some cases, somnambulism is a kind of continuation of nightmares that occur when the brain works in a delta rhythm.

The phenomenon of sleepwalking in most cases is determined in persons who suffer from depressive conditions, in particular, have a history of bipolar disorder. Often, sleepwalking is a companion of the initial stages of schizophrenia. Sleepwalking is also recorded in patients with a neurological profile under the following conditions:

• with neurasthenia;
• with hysterical neurosis;
• with obsessive-compulsive disorder;
• with chronic fatigue syndrome;
• in Parkinson's disease.

One of the most common causes of sleepwalking is epilepsy. Also, somnambulism can develop after a strong emotional shock, being in a chronic stressful state. Often episodes of sleepwalking are determined in people with chronic sleep deprivation due to persistent insomnia.

External factors can also trigger somnambulism:

• loud conversation or harsh sounds in the sleeping person's room;
• sudden flash of bright light;
• excessive lighting in the room, which can also be the result of saturated moonlight during a full moon.

A hereditary predisposition to sleepwalking has been established: at risk are 45% of people in whom one parent suffered from somnambulism and 60% of those in whom both ancestors had this condition.

The mechanism of development of somnambulism

In healthy people, the sleep process starts with the first phase of orthodox (slow) sleep, the scientific name of which is Non-REM sleep. The duration of this stage varies from 5 to 10 minutes. Brain activity operates in the theta wave mode in the range from 4 to 8 Hz. Typical phenomena for this state are drowsiness, fantasies and dreams, illogical thoughts, hallucinogenic visions, visual illusions.

This is followed by the second phase - the stage of light sleep, the duration of which is approximately 20 minutes. The appearance of a sigma rhythm is fixed - accelerated alpha waves in the range from 12 to 20 Hz. In this segment, consciousness is turned off, the threshold of perception rises significantly.

The next stage of sleep, lasting from 30 to 45 minutes, is the phase of slow and deep slow delta sleep, corresponding to the third and fourth stages of sleep. The rhythm of the brain consists of high-frequency delta waves at a frequency of 2 Hz. It is at this stage that a person has nightmares and bouts of sleepwalking.

At the end of the fourth phase, the sleeping person again returns to the second stage, after which the first segment of paradoxical (rapid) sleep, called REM sleep, begins, the duration of which does not exceed 15 minutes. The range of brain activity is beta waves with a frequency of 14 to 30 Hz. It is assumed that fast-wave sleep provides a kind of protection for the human psyche, carries out the processing of incoming information, and establishes links between consciousness and the subconscious sphere.

The above sequence is called sleep cycles, the number of which during a night's rest is five episodes. Failure during stage four sleep is a trigger for somnambulism.

Characteristic features of somnambulism

Somnambulism is characterized by a combination of two conditions: the sleepwalker has signs of drowsiness and wakefulness signals, so the status of the brain can be conditionally called half-awake-half-awake. The somnambulist's brain responds to tactile stimuli and sound signals, but it is unable to connect the received signs into a single chain due to the fact that the vigilance function is "off".

The eyes of a person during sleepwalking in most cases are open, the pupils are significantly dilated. Acceleration of the heart rate and more frequent intermittent breathing are determined. The sleepwalker is able to maintain the balance of the body and deftly carry out a variety of movements, for example: skillfully bypass existing obstacles. The person retains the ability to perform complex actions that require coordinated movements, such as driving a car.

The main danger of somnambulism: the disappearance of feelings and emotions, the inability to logically control their actions. With this abnormal state, the clarity of consciousness disappears: the sleepwalker has no sense of fear, a sense of threat and danger. That is why he can perform such deeds that he would never have dared to do in the waking state. Due to the lack of mind control, a somnambulist can harm himself or cause significant harm to others.

The absence of any sensations in the emotional aspect is evidenced by the “detached” and impartial face of a person. Even in the event of a real threat to life, no changes will occur in the appearance of a sleepwalker. A person's gaze during sleepwalking is focused, but it is not fixed on some object, but is directed into the distance.

After getting up in the morning, the somnambulist has no memory of how he spent the night in an unusual way. An individual often learns about his nightly adventures from relatives, while he perceives information about himself as an absurd evil joke.

All episodes of somnambulism end according to the same scenario: the person returns to bed or goes to bed in some other place and continues to sleep. In the same way, the somnambulist will continue his sleep if he is put to bed by close people.

What to do with a sleepwalker: an algorithm of actions

Doctors do not recommend trying to wake up a sleepwalker: this can be dangerous for a person’s mental health and cause him psychological discomfort. You should not try to stir up the somnambulist by applying physical violence to him. In the case of a violent awakening, a strong attack of fear is likely to develop, in which a person can commit acts that are dangerous for himself and those around him.

It is advisable to carefully take the person by the hand and take her back to bed. Almost all lunatics react to appeals to him and gestures of loved ones, so it would be appropriate to address him with “setting” words, for example: “You are sleeping and will continue to sleep.”

Somnambulism Treatment Methods

In the case of single manifestations of somnambulism, there is no need for therapeutic measures. However, with chronic sleepwalking, medical attention should be sought, as there is a high risk of a person committing life-threatening acts. Treatment is focused on eliminating the underlying disease, in the therapy of which pharmacological agents of various classes are used. The choice of a particular medication is based on the clinical picture of the underlying ailment and the general health of the patient.

Hypnosis is a safe and harmless alternative to medical treatment for somnambulism. During hypnotic sessions, a person is immersed in a state of somnambulism - the deepest stage of hypnosis. At the same time, it is possible to achieve the functioning of the brain in such a mode when it is possible to subordinate all the properties and characteristics of the psyche to the required idea, the necessary feeling, the necessary experience. The criteria for assessing this state during hypnosis can be considered amnesia - memory loss and the appearance of hallucinations with the client's eyes closed. With deep slow delta sleep, it is possible to act directly on the cause of the painful condition: neurotic, anxiety, post-stress or depressive disorders, thereby saving a person from sleepwalking once and for all.

“Tell me, please, where should I go from here?
- Where do you want to go? - answered the Cat.
- I don't care ... - said Alice.
“Then it doesn’t matter where you go,” said the Cat.
- ... just to get somewhere, - Alice explained.
“You’re bound to get somewhere,” said the Cat. “You just have to walk long enough.”

Somnambulism (deep stage of hypnosis) is such a mode of operation of the brain, in which all mental forces are subordinated to one idea or feeling. Amnesia (loss of memory) and hallucinations (with closed eyes) can be considered as the criterion for achieving this state.

• Audio recordings to reach the ultra-deep stages of hypnosis.

For therapeutic purposes, "light somnambulism" is usually used - the middle stage of hypnosis (two points according to Katkov, the level of eyelid catalepsy in Elman's induction), but even this level of immersion will require courage on your part. It will be necessary to get rid of everyday fears about hypnosis (“they will turn into zombies, break the psyche”) and think about why the two-century practice of using hypnosis in medicine has not led to the licensing of hypnotherapy? Having answered this question in yourself, think about the purpose of immersing yourself in somnambulism. Do you want to get rid of a psychosomatic illness or just experience the feeling of hypnotic nirvana? Both are good, but in the first case, one must be prepared for the fact that familiar symptoms will appear at some stage. Do you want to get rid of them? Then, while listening to the recording, you will not only have to put up with them, but also hold on to and even savor them. This is necessary so that the process of therapy begins in the free layers of the psyche that you have opened.

Feel free to handle audio recordings. You can turn on any of them from the place where you can surrender to the surging experiences: and sob excitedly, and laugh convulsively, and fight in tantrums, and express thoughts aloud. You can use both tracks in turn, switching from the first to the second or vice versa as soon as there is any obstacle. The main thing is not to forget that this is not a treatment, but a "probe" - a game of hypnotherapy. The hypnosimulator is designed to create a publicity stunt to get you more serious about the possibilities of hypnotherapy. Therefore, the smoothing or even complete disappearance of painful symptoms should not mislead you - you just got the opportunity to make sure that hypnotherapy is indicated for you. Now you know for sure that you should make an appointment with a live specialist in order to undergo a full course of treatment.

Somnambulism, or sleepwalking, can lead to a wide range of negative effects and is one of the main causes of sleep damage. Accurate diagnosis is critical for proper management and is imperative given the ever-increasing number of forensic cases involving sleep-related violence. Unfortunately, the key points of several widely held opinions about sleepwalking are misguided, and some accepted diagnostic criteria are not consistent with research findings. The traditional view of somnambulism as an arousal disorder may be too limited, a full view must include the idea of ​​a synchronous interaction between the states of sleep and wakefulness. Sleep physiology disturbance, dissociation state, as well as genetic factors may explain the pathophysiology of this disorder.

Despite nearly 50 years of clinical and laboratory research, the pathophysiology of somnambulism (or sleepwalking) remains poorly understood. In addition, unlike most other sleep disorders, somnambulism is still diagnosed primarily or solely on the basis of a patient's medical history. The widely held belief that sleepwalking is a benign disorder is erroneous because somnambulism can lead to various adverse effects. Although somnambulism in childhood is often transient and harmless in nature, sleepwalking in adults has a significant harmful potential, which consists in getting a person into dangerous situations (for example, a person runs into walls or furniture, tries to escape from imaginary threats, leaves his home) , destruction of property, as well as causing serious damage to the sleeper himself, the person sleeping with him in the same bed, (his partner) or other people. Somnambulism has been reported to be a leading cause of damage or aggressive behavior upon awakening from sleep. Episodes resulting in injury to the patient or injury to others are more common than is commonly believed. Most sleepwalking adults seek medical advice precisely because of episodes of aggressive or harmful sleep behavior. The number of judicial precedents regarding violent acts committed in a state of sleep is increasing. While in a state of somnambulism, a person can drive, commit suicide, and even kill or attempt murder, which raises fundamental questions about the forensic consequences of these actions, as well as the neurophysiological and cognitive states that are characteristic of patients during such episodes.

The role of somnambulism during sleep

Based on a number of physiological assessments, including electroencephalogram (EEG) activity, eye movement activity, and muscle tone levels, the sleep period is divided into two very distinct states—rapid eye movement (REM) and non-REM sleep. rapid-eye-movement - nREM). nREM sleep can in turn be divided into three stages, which, according to the revised nomenclature of the American Academy of Sleep Medicine, are called N1 (falling asleep), N2 (light sleep) and N3 (deep or slow-wave sleep). In table. 1 lists the main characteristics of REM sleep and the stages of nREM sleep, and fig. 1 shows the corresponding EEG signs. These stages of sleep are organized into sleep cycles, which are characterized by a certain distribution during a typical night (Fig. 2). Structures of the nervous system involved in sleep stages (eg, brainstem, anterior and posterior hypothalamus, basal forebrain, ventral tegmental region, thalamus, and cerebral cortex), their pathways and relationships, and the neurotransmitters that generate and regulate these various states are numerous and their interaction is complex.

Table 1. Main characteristics of sleep stages. EEG - electroencephalogram

Index	Specific EEG sign	Other characteristics	Sleep disturbance specific to this stage
Awake (eyes closed)	Alpha waves (8-12 Hz)	Alpha rhythm is most pronounced in the occipital region of the cortex
nREM sleep
N1 (start sleep)	Theta waves (4-8 Hz)	Slow rolling eye movements	Hypnagogic twitches, hypnagogic hallucinations
N2 (light sleep)	Sleep spindles (11-16 Hz)	The main background is represented by the theta rhythm with the inclusion of sleep spindles and K-complexes from time to time.	Bruxism, nocturnal lobe epilepsy
N3 (slow wave or deep sleep)	Delta waves (0.5-2 Hz; amplitude >75 μV), slow oscillations (<1 Гц)	Delta waves occupy more than 20% of the sleep period	Somnambulism, night terrors, awakenings with confusion
REM sleep
REM sleep (paradoxical sleep)	Low-amplitude, mixed-frequency sawtooth theta waves	Rapid eye movements, muscle atony, desynchronized EEG	REM sleep behavior disorder, nightmares
nREM (non-rapid eye movement)-dream - slow sleep. REM (rapid eye movement) stage of rapid eye movements.

Figure 1. Electroencephalographic curves depicting relaxed wakefulness and different stages of sleep in healthy individuals

Figure 2. Distribution of different sleep stages during a typical night in healthy individuals
REM (rapid eye movement) - the stage of rapid eye movements

nREM sleep and REM coh alternate during the night in a cycle that averages about 90 minutes. However, deep sleep is predominantly observed in the first third of the night, while periods of REM sleep are the longest during the last third of the night. Somnambulism usually occurs during the deepest stage of sleep (i.e. N3 or slow-wave sleep). Thus, its episodes usually occur in the first third of the night, when slow-wave sleep predominates, although they can also occur during N2 sleep. With this in mind, somnambulism is classified as nREM parasomnia, and confusional awakenings and nightmares are also included in this category. These three parasomnias that can co-exist are defined as awakening disorders and can have different phenotypes for the same underlying cause.

Clinical features and epidemiology

Somnambulism is defined as "a series of complex activities that usually occur during the period of awakening from slow-wave sleep and lead to wandering, while consciousness is impaired and the ability to assess the real situation is altered." Some somnambulistic activities may be mundane and stereotypical, such as gesturing, pointing at a wall, or wandering around a room, but others (especially in adults) are surprisingly complex and may require a high level of planning and motor control—for example, dressing, cooking, playing musical instruments, driving a car. Episodes can last from a few seconds to 30 minutes or more. Most episodes of action are characterized by impaired perception and lack of response to external stimuli, confusion, a sense of threat, and variable retrograde amnesia. The American Academy of Sleep Medicine has defined diagnostic criteria for somnambulism, presented in the second International Classification of Sleep Disorders (box). Pathological sleep-related sexual activities (so-called sexsomnia) and sleep eating, which are separate and specialized variants of nREM sleep parasomnias, are not discussed in this article because they are not directly classified as somnambulism.

Frame. American Academy of Sleep Medicine Criteria for the Diagnosis of Somnambulism (Second International Classification of Sleep Disorders)

BUT. Movement occurs during sleep AT. Persistence of sleep, altered state of consciousness, or impaired ability to make decisions while on the move, as indicated by at least one of the following: It is difficult to wake a person; - confusion of thoughts/consciousness upon awakening during the episode; - episode amnesia (full or partial); - ordinary actions that a person performs at an inappropriate time for this; - inappropriate or ridiculous actions; - dangerous or potentially dangerous activities FROM. This disorder cannot be more accurately explained by the presence of other sleep disorders, physical, neurological or psychiatric diseases.

Adapted from the 2nd International Classification of Sleep Disorders

Somnambulism is more common in children than in adults; most children have, at least temporarily, one or more parasomnias during nREM sleep. However, somnambulism in childhood is usually benign, non-violent, and generally does not require intervention. The prevalence of somnambulism is about 3% in young children (2.5-4 years) and increases to 11% at 7 and 8 years of age and 13.5% at 10 years of age, then decreases to 12.7% by 12 years of age (data unpublished for ages 10 and 12; Fig. 3). The prevalence of somnambulism among adolescents is rapidly declining and reaches 2-4% in adulthood. Thus, most children outgrow the disorder during adolescence, but somnambulism may persist into adulthood—its incidence may be as high as 25%. It is not known why some people retain somnambulism into adulthood and others do not. Somnambulism can also appear de novo in adults.

Figure 3. Prevalence of somnambulism among children aged 2.5-12 years from a prospective cohort study of 1400 children.
Adapted from data from the Quebec Longitudinal Study of Child Development, Quebec Institute of Statistics. Published data only for children aged 2.5-8 years.

There is no evidence to indicate that chronic somnambulism in adulthood is associated with the subsequent development of diseases of the nervous system (no longitudinal studies have been conducted). These data differ from the data obtained in the study of REM sleep behavior disorder - parasomnia, which is characterized by the loss of muscle atony and pronounced motor activity during REM sleep, usually occurring in patients over 50 years of age and associated with the development of neurodegenerative processes, in including Parkinson's disease and dementia with Lewy bodies.

According to epidemiological studies, approximately 25% of adults with sleepwalking self-report the presence of comorbid anxiety and mood disorders. In early childhood, the onset of somnambulism may be associated with separation anxiety, and anxiety or stress may exacerbate these episodes in both children and adults. However, the majority of adults with sleepwalking do not have a mental or personality disorder, and successful treatment of disorders consistent with the first axis according to the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) ), usually does not affect the frequency of sleepwalking.

Approximately 80% of sleepwalkers have at least one other family member with the same condition, and the prevalence of somnambulism is higher in children whose parents have had somnambulism compared to those whose parents did not have the disorder. Compared to the general population, first-degree relatives of a person with somnambulism are 10 times more likely to develop the disorder. According to the results of a population cohort study conducted in Finland among twins, the concordance rate for somnambulism in childhood was 1.5 times higher in monozygotic pairs of twins compared with dizygotic twins, and in somnambulism in adults it was 5 times higher in monozygotes compared to dizygotes. These results indicate that a significant proportion of reported familial cases can be attributed to genetic factors.

Common Misconceptions

Several widely held opinions about somnambulism in the medical and neuroscientific environment, including diagnostic aspects, contradict findings in this area. We will give three main examples: that sleepwalking has no consequences during the daytime, that it is characterized by episode amnesia, and that these are automatic actions that occur in the absence of dream-like representations.

Somnambulism has no effect during the daytime

Daytime sleepiness or impaired daytime functioning has never been part of the clinical presentation of somnambulism. Despite many reports of increased fragmentation of slow-wave sleep, little information is available on subjective or objective levels of attentional activity. A study in 10 adults with somnambulism found that they experienced daytime sleepiness even after nights without sleepwalking episodes. Despite the same proportion of slow-wave sleep, sleepwalkers had a statistically significant reduction in the average latency period of sleep onset (i.e., the time required to transition from a state of wakefulness to sleep) according to the results of its repeated determination (the "gold standard" in conducting an objective assessment excessive daytime sleepiness) compared with the corresponding control group. Seven sleepwalkers (and none of the controls) had a median latency of less than 8 minutes, which is the generally accepted threshold for detecting clinical sleepiness. In a retrospective study by Oudiette et al. used the Epworth sleepiness scale and found that 47% of 43 patients with nREM sleep parasomnia had scores greater than 10 (the cut-off point for diagnosing pathological sleepiness). These results were further supported by our study of 71 adults with sleepwalking, in which 32 (45%) of them were found to score over 10 on the Epworth Sleepiness Rating Scale compared to 8 (11%) in 71 healthy patient of the control group (data not published). In this cohort, sleepiness did not appear to be correlated with the number of nocturnal awakenings, periodic leg movements during sleep, or elevated apnea-hypopnea indices.

Summarizing these results, it can be concluded that excessive daytime sleepiness is an important characteristic of somnambulism. Transcranial magnetic stimulation and neuroimaging were performed to detect daytime functioning impairment in sleepwalkers, the results of which confirmed the view that clinical analysis should not be limited to studying the patient's sleep.

Somnambulism is characterized by episodic amnesia

Because somnambulism is usually diagnosed solely on the basis of clinical history, the validity and validity of the diagnostic criteria are of paramount importance. According to the results of a study examining the reliability of the diagnosis of various parasomnias, based on the criteria presented in the second International Classification of Sleep Disorders, it was concluded that different researchers rated the reliability of the diagnosis of sleepwalking as "satisfactory" due to disagreements regarding episode amnesia criterion, which was also included in the DSM-IV. However, the results of a survey of 94 patients who presented to our sleep clinic for chronic sleeplessness (unpublished data presented at the fourth meeting of the World Association of Sleep Medicine) indicate that a significant proportion of adults with sleepwalking recall certain elements of such episodes. (at least sometimes). Upon awakening, 80% of patients remembered thought processes in their sleep during somnambulistic episodes. In addition, 61% of patients reported that they remember certain actions performed during such episodes, 75% recalled elements upon awakening that they perceived from their environment during somnambulistic episodes, 75% of sleepwalkers reported that during of such episodes, they often or always had emotional experiences: fear, anger, frustration and a sense of helplessness. These data, together with descriptive reports, indicate that most patients can, and do, recall at least a portion of the episodes prior to awakening, suggesting that complete amnesia of the event is not common in adults with somnambulism. In children, somnambulism may be more likely to manifest as automatic actions, and complete amnesia may be more common, probably due to a higher awakening threshold.

Somnambulism is an automatic behavior that occurs in the absence of sleep-like brain activity.

It is now reliably established that dream-like representations are not limited to REM sleep, but also develop during nREM sleep (including slow-wave sleep). It was previously believed that there were no complex dream-like representations during somnambulistic episodes, but a growing body of evidence suggests otherwise. In addition to well-documented cases, empirical evidence confirms that dreams in many cases are not only among the main manifestations of somnambulism, but can also influence the motor aspects of behavior throughout the episode. Oudiette et al. found that 27 (71%) of 38 patients recalled brief, unpleasant dream-like representations associated with sleepwalking episodes. In addition, the content of these dream-like representations, as described by the patients themselves, corresponded to objectively recorded nocturnal behavior, indicating that sleepwalking may be due to dream-like representations. The results of examinations of adults with sleepwalking conducted in sleep laboratories indicate that the phenomenological experiences of patients (if any) are definitely consistent with the actions recorded during the episodes. However, although sleepwalkers are aware of their immediate physical surroundings during an episode and can interact with other people in the vicinity, this is not seen in normal dreams or in REM sleep behavior disordered patients during episodes. In addition, during the episodes, the somnambulist's eyes are usually open, allowing him to navigate, but the dream content during REM and nREM sleep takes place in an autonomous virtual space with very limited awareness of the real physical environment.

Many patients explain somnambulistic actions as being motivated by an internal drive or underlying logic (although decision making is often impaired) that is responsible for performing actions during such episodes. These findings raise important questions about the involvement of sleep-related representations in the onset and development of somnambulistic episodes.

Diagnostics and management tactics

Both nocturnal frontal lobe epilepsy and REM sleep behavior disorder can cause complex, sometimes violent sleep behaviors that can be confused with somnambulism (Table 2). To facilitate differential diagnosis, recommendations and a rating scale for frontal epilepsy and parasomnias are proposed. Difficult cases may warrant a full polysomnography study with extended EEG electrode mounting and continued audio and video recording. Disorders known to increase the lack of deep sleep or the number of awakenings during sleep, or cause confusion, should be considered in the clinical management of patients with somnambulism. Factors that increase the lack of deep sleep include intense exercise in the evening, fever, lack of sleep; disorders that cause repeated awakenings during sleep include sleep apnea and periodic leg movements during sleep (Fig. 4).

Table 2. The main clinical manifestations of somnambulism, nocturnal frontal epilepsy and behavioral disorders during the period REM-sleep

Index	Somnambulism	Nocturnal lobe epilepsy	Behavior Disorders in PhaseREM-sleep
Age at start of development	Usually childhood	Variable
Family history	69-90% of patients	Less than 40% of patients
part of the night	First third of the night	Anytime	Second half of the night
sleep stage	slow wave sleep
Event duration*		From a few seconds to 3 minutes
Number of events per week*
Behavioral manifestations	From simple to complex movements (movement), can be purposeful, eyes open	Extremely stereotyped (eg, pathological set) and aimless, eyes may be open or closed	Typical sweeping movements (for example, the patient "thrashes" the limbs) associated with the content of sleep, eyes closed
May leave the bed		No (patient remains prone or supine)
Can leave the bedroom
Interaction with immediate environment	Can respond to external stimuli or verbal questions, and manage themselves in a family setting		Low level of interaction or its random nature
Full spontaneous awakening after an event
Memories of the event	Variable		Vivid memories of a dream
The state of the mental sphere when awakening after an event	Confusion and disorientation	Usually full awakening	Full awakening and functioning
Awakening threshold		Not applicable
triggers	Sleep deprivation, noise, stress, obstructive sleep apnea, periodic leg movement during sleep	Often missing	Alcohol withdrawal, selective serotonin reuptake inhibitors, tricyclic antidepressants
Activation of the autonomic nervous system	Low to Medium		Missing
Polysomnography results	Frequent awakenings and micro-awakenings during slow-wave sleep, hypersynchronous dalta waves	Often within normal limits, epileptiform changes in about 10% of patients	Absence of muscle atony or excessive phasic activity on electromyogram during REM sleep
Possibility of injury or violence
REM (rapid eye movement) rapid eye movement stage * - estimates of these values ​​are based on averages reported in published studies and should be interpreted with caution because the frequency and duration of episodes vary widely between and within the same patient.

Figure 4. Somnambulism as a disorder of awakening or disturbance of slow-wave sleep

Situations that exacerbate the lack of slow-wave sleep (eg, sleep deprivation) can trigger the development of arousal disorders in individuals with a predisposition to it. Therefore, adequate sleep and a regular sleep schedule are very important for patients with somnambulism. Most of the reasons for the increased frequency of awakening (for example, the influence of adverse exogenous factors, stress) and the presence of concomitant sleep disorders that cause repeated micro-awakenings are also predisposing factors. Thus, clinicians should ensure that breathing problems and movement disorders during sleep are treated to facilitate and control parasomnia.

Disorders that facilitate the onset of dissociation or induce the development of states of confusion may serve as triggers for somnambulism. Sleepwalking has been reported in patients with psychiatric disorders and in individuals taking various psychotropic drugs, including sedatives, hypnotics, antidepressants, neuroleptics, lithium preparations, stimulants, and antihistamines. It is possible that these disorders and drugs facilitate regional dissociation and lead to the development of somnambulism through the management of sleep and alert states.

Regardless of the underlying impairment, precautions should be taken to ensure a safe sleeping environment. In cases where parasomnia continues to cause physical damage or pose a threat, three main treatments are available: hypnosis, scheduled awakenings, and drug therapy. However, as highlighted in a review published in 2009, there have not been adequately powered controlled clinical trials in the treatment of somnambulism. Hypnosis (including self-hypnosis) is effective in both children and adults with chronic somnambulism. In children, the preferred treatment is preemptive or scheduled awakening, a behavioral method in which parents wake their child every night for 1 month, approximately 15 minutes before the time a sleepwalking episode would normally occur.

Medications should only be given when the activity is potentially dangerous or has a severe negative effect on persons sleeping in the same bed as the somnambulist or on other members of the household. Benzodiazepines, especially clonazepam and diazepam, are effective. These drugs reduce the number of awakenings and anxiety and depress slow-wave sleep, but do not always allow adequate control of sleepwalking. Even if pharmacotherapy is preferred, treatment should always include instruction in the need for daily regular sleep and its proper organization, as well as the prevention of sleep deprivation and stress management.

Theoretical foundations for understanding somnambulism

Somnambulism is usually classified as an arousal disorder, but some clinical and experimental studies suggest that somnambulism may develop in association with dysfunction at the level of regulation of slow-wave sleep (see Fig. 4). We explored additional theories and findings from neurophysiological research that support each of the conceptual frameworks.

Somnambulism as a disorder of slow-wave sleep

Two lines of evidence, namely the presence of significant disturbances in slow-wave sleep and the atypical response in sleepwalkers to sleep deprivation, support the view that dysfunction at the level of slow-wave sleep processes is the main cause of the development of somnambulism.

A characteristic feature of the sleep architecture in patients with sleepwalking compared to healthy controls is the lack of continuity of nREM sleep, as evidenced by an increased number of spontaneous awakenings and awakenings recorded on the EEG outside periods of slow-wave sleep, even on nights when episodes are absent. The results obtained are noteworthy, since the number of awakenings during other stages of sleep does not increase.

Sleepwalkers also have disturbances in the depth of sleep, which was quantified in the study of slow-wave activity (the value of the spectral power in the delta frequency range). In particular, their sleep was characterized by a general decrease in slow-wave activity in the first sleep cycles and the extinction of slow-wave activity throughout the night with different dynamics. These results indicate that frequent awakenings from deep sleep in sleepwalkers interfere with the normal increase in slow-wave activity, especially in the first two sleep cycles when they have the most awakenings from deep sleep. Consistent with findings suggesting impaired consolidation of slow-wave sleep, sleepwalkers experience periodic electrocortical events during nREM sleep, defined as sudden changes in EEG frequency or amplitude. These periodic sequences of transient activity on the EEG were studied in accordance with accepted rules and regulations as part of an indicator of a cyclically intermittent pattern - endogenous rhythm, which is considered a physiological marker of nREM sleep instability. An increased rate of the cyclically intermittent pattern has been reported in both adults and children with sleepwalking, even on nights when such episodes were absent. It has been suggested that this abnormal transient EEG activity may lead to repetitive fragmentation of slow-wave sleep and contribute to the development of nREM sleep parasomnias.

Hypersynchronous delta waves, which are commonly defined as multiple continuous high-voltage (>150 µV) delta waves during deep sleep, were probably the first EEG marker described for somnambulism. Regardless of behavioral episodes, patients with sleepwalking had a statistically significant higher rate of hypersynchronous delta waves during nREM sleep compared to controls. However, the beginning of the episode, apparently, is not preceded by a gradual accumulation of hypersynchronous delta waves, but rather a sharp change in high-amplitude slow oscillations is observed (<1 Гц) в течение 20 с непосредственно перед развитием эпизода. Эти процессы могут отражать реакцию коры на активацию головного мозга.

In healthy sleepers, sleep deprivation causes the “rebound phenomenon” of slow-wave sleep and the development of consolidated (i.e., with fewer awakenings) nREM sleep as a result of increased sleep homeostasis pressure (i.e., the physiological need for sleep in order for the body to restore balance between sleep and wakefulness). This physiological response is not observed in sleepwalkers, and sleep deprivation, surprisingly, leads to an increase in the number of awakenings in the slow-wave period during restorative sleep (that is, sleep immediately after sleep deprivation) compared to those recorded during sleep, assessed at baseline (i.e., during a normal nocturnal sleep without deprivation). This atypical response to sleep deprivation appears to be limited to slow-wave sleep; the number of awakenings during N2 and REM sleep decreases.

More important is the fact that sleep deprivation for 25-38 hours increases the number of somnambulistic events recorded in the laboratory by 2.5-5 times compared with the initial estimate. In sleepwalkers, the responses to sleep deprivation are so different from those in healthy sleepers that they are highly sensitive and specific in diagnosing somnambulism in adults. The fact that these studies did not show nocturnal behavioral disturbances in healthy controls indicates that sleep deprivation does not lead to sleepwalking, but rather increases the likelihood of somnambulistic episodes in predisposed individuals.

Sleep deprivation also significantly increases the complexity of somnambulistic events, which has been documented during restorative sleep. Somnambulistic episodes are not only more complex, but more often accompanied by arousal, with forced awakenings from restorative slow-wave sleep. A possible explanation for these results is that other subcortical areas may be involved after sleep deprivation. Two functional MRI studies found that sleep deprivation increased amygdala activation, resulting in negative visual stimuli and significantly enhanced its association with autonomic activation centers in the brainstem. This activation was accompanied by a weakening of the relationship with the prefrontal cortex, the top-down cognitive regulator of emotions.

Somnambulism as an awakening disorder

Somnambulism was originally described as an arousal disorder based on the presence of autonomic and motor activations during sleep, which are the cause of incomplete wakefulness. Three post-awake EEG patterns have been described that are characteristic of most slow-wave sleep awakenings and somnambulistic events in adults with somnambulism or night terrors. The same EEG patterns are detected during a somnambulistic event during the N2 stage of sleep. Delta activity (indicating processes associated with sleep) is recorded in almost half of all episodes during slow-wave sleep and in about 20% of cases during N2 sleep. These results indicate that individuals with somnambulism appear to be stuck between nREM sleep and full wakefulness as measured by the EEG, and therefore during the episodes they are not fully awake (which clinically looks like a lack of conscious awareness or adequate self-esteem) and not fully asleep (on that indicates behavior - are able to interact with other persons and navigate in the immediate environment).

There is other evidence that somnambulism is an arousal disorder.

Awakenings during slow-wave sleep, spontaneous or due to exposure to external stimuli, or due to other sleep disorders, can cause episodes of sleepwalking in individuals with a predisposition to it. Several studies, including a population-based cohort study in preteens, have found an association between somnambulism and obstructive sleep apnea and upper airway resistance syndrome. Treatment of sleep breathing disorders may contribute to the disappearance of somnambulism by restoring or enhancing sleep consolidation.

Experimentally initiated awakenings by auditory stimuli during slow-wave sleep induce episodes in sleepwalkers during normal sleep and (even more often) during restorative sleep. In a study by Pilon et al., the combined effects of sleep deprivation and auditory stimulation induced somnambulistic episodes in all 10 sleepwalkers, but none in the control group. In addition, the average intensity of stimuli that caused somnambulistic episodes during slow-wave sleep (about 50 dB) was similar to that that caused full awakening in sleepwalkers and controls. In another, more comprehensive study, the auditory awakening threshold in sleepwalkers was not statistically significantly different from that in controls for both slow-wave and N2 sleep. However, the average proportion of auditory stimulations that caused awakening during slow-wave sleep was statistically significantly higher in the sleepwalker group than in the control group.

The results indicate that the sleepwalker is neither easier nor more difficult to awaken from deep sleep than the control group, but it is more likely that sleepwalkers have impaired awakening responses. One study confirmed that 50% of post-awakening EEG recordings of sleepwalkers contained significant evidence of delta activity, which could explain post-waking confusion from slow-wave sleep and suggest changes in cortical reactivity.

Somnambulism as a phenotypic manifestation of the simultaneous state of sleep and wakefulness

Regardless of the two theoretical frameworks discussed above, somnambulism should be considered from the standpoint of new models and findings indicating an interaction between wakefulness, REM sleep, and nREM sleep. Although human sleep has traditionally been considered a global process occurring simultaneously throughout the brain, a large body of evidence suggests that sleep—or the functional correlates of sleep—can be controlled by local events. Surface EEG studies have shown that the depth of sleep is not achieved simultaneously in the entire brain and that the topographic difference of certain frequencies is distributed along the anteroposterior axis. Data obtained using intracerebral electrodes showed that EEG patterns of sleep and wakefulness can coexist simultaneously in different areas of the brain. During an episode of sleepwalking in a patient with epilepsy, Terzaghi et al. recorded an EEG pattern of wakefulness in the motor cortex and central cingulate cortex, as well as a concomitant increase in delta wave bursts (indicative of sleep) in the frontal cortex and parietal dorsolateral association cortex, indicating an apparent conflict between wakefulness in the motor and cingulate cortex cortex and at the same time a persistent state of sleep in the associative cortex. The cingulate and motor cortex can cause complex motor actions, and the degree of activation of the fronto-parietal association cortex can explain the different levels of awareness of the environment and the thought processes that accompany wakefulness.

Nobili et al. used a similar strategy and, using deep EEG electrodes, recorded frequent but brief episodes of local activation of the motor cortex, which were characterized by a sudden interruption of the slow-wave pattern and the appearance of a high-frequency EEG pattern, indicating the coexistence of sleep and wakefulness. These episodes of motor cortex activation were observed in parallel with a concomitant increase in slow-wave activity in the dorsolateral prefrontal cortex. When using such a method of neuroimaging as single-photon emission computed tomography (SPECT), during the episode of sleepwalking, on the one hand, deactivation of the fronto-parietal associative cortex (typical for sleep) was revealed, and on the other hand, activation of the posterior cingulate and anterior cerebellar networks without deactivation of the thalamus, which is characteristic of emotionally controlled behavior during wakefulness.

During episodes of somnambulism, there is an inconsistency in the activity of two large brain structures, each of which consists of several areas. Group one: motor plus cingulate cortex and medial prefrontal plus lateral parietal cortex; these areas are associated with the so-called active mode networks of the brain (structures that are activated when performing tasks that require the participation of cognitive functions). The second group: networks of the passive mode of the brain (areas of the cortex that are active during the rest of the brain), respectively.

Disruption of the interaction between these two types of networks is also observed in other pathological conditions, including schizophrenia, Alzheimer's disease and depression.

Taken together, these results confirm that sleep and wakefulness are not mutually exclusive—the notion of local sleep is becoming more and more ingrained. They also indicate that somnambulism and other parasomnias may be the result of an imbalance between two behavioral states. Thus, the concept of "arousal disorder" may be too abstractly limited to fully explain the pathophysiology of somnambulism. A broad and unified view may be that there is a simultaneous activation of localized cortical and subcortical networks that are involved in the physiology of sleep and wakefulness.

Directions for future research

Three promising lines of research may help shed light on the pathophysiological basis of somnambulism. First, using a neuroimaging technique such as positron emission tomography, it is possible to detect subtle changes in cerebral blood flow and metabolism during the sleep-wake cycle in humans and make certain measurements - for example, to study the neural correlates of delta activity during the nREM- sleep. However, there are only a few neuroimaging studies in patients with sleep disorders and only one neuroimaging study in somnambulism, a single case report by Bassetti et al. further facilitate understanding of the nature of parasomnias during nREM sleep.

Second, the overall daytime functioning of sleepwalkers should be investigated to record the nature and extent of impairment. In addition to findings suggesting excessive daytime sleepiness in some patients, data from two studies support the notion that adults with somnambulism have impairments in waking functioning. A study using transcranial magnetic stimulation in sleepwalkers revealed a decrease in excitability in some cortical GABAergic inhibitory networks during wakefulness, and a study using high-resolution SPECT performed during wakefulness in sleepwalkers revealed a decrease in perfusion during frontopolar cortex, superior and middle frontal gyri, superior and inferior temporal gyrus, geniculate gyrus, as well as an additional decrease in perfusion in the limbic structures (hippocampus). Changes in limbic structures may be associated with impaired emotional regulation in patients with sleepwalking during sleep deprivation.

Third, despite several familial case reports, very few molecular studies have been performed to identify genes predisposing to somnambulism. Licis et al. conducted a genome-wide study involving 22 members of the same family. They suggested an autosomal dominant inheritance pattern with reduced penetrance and found a statistically significant association with chromosome 20q12-q13.12. The interval of interest included the adenosine deaminase gene, changes in which are believed to affect the duration and depth of slow-wave sleep. Unfortunately, sequencing did not reveal any coding mutations in this gene. Lecendreux et al. described an association between familial somnambulism and the presence of the HLA DQB1*05 and DQB61*04 alleles. However, the functional significance of these results is unclear as they have not yet been replicated.

An alternative approach to identifying genes that influence complex traits is the associative analysis of candidate genes. Genes that influence sleep homeostasis, sleep depth, or slow wave generation may be interesting candidates. In this regard, in a study involving twins, the significant genetic overlap between parasomnias and dyssomnias confirms that somnambulism is a disorder of regulation of slow-wave sleep, and that there is an association between sleepwalking and excessive sleepiness.

Although a comprehensive understanding of the clinical, neurobiological, and genetic factors associated with chronic somnambulism remains elusive, significant progress has been made towards identifying key links in this disorder between arousal and sleep-related processes. However, some misconceptions about somnambulism have made it difficult to improve clinical judgment and formulate a definition. Validation and application of a polysomnography-based method for diagnosing somnambulism, such as a sleep deprivation protocol, will be beneficial in an unclear diagnosis. But in the context of forensic cases of sleep-related violence, it is not possible to establish whether a sleepwalker had a somnambulistic episode on polymosomnography at the time of past wrongdoing. Since neurophysiological markers of sleepwalking can also be identified in the control group, they cannot be used to provide direct evidence in court. In fact, there are no well-designed clinical trials for the treatment of patients with chronic somnambulism. More efforts are needed to determine the effectiveness of treatment for somnambulism, which should be considered a disorder with a high potential for serious injury, as well as daytime and nighttime effects.