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Sleepwalking, screaming, arousals with panic
and frantic, agitated behaviors
.

THE SLEEP SITE

BRINGING SECRETS OF THE NIGHT TO THE LIGHT OF DAY...

Understanding the symptoms of sleep disorders.

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ABNORMAL BEHAVIORS IN SLEEP.
Click on the topic of interest:
Introduction.
Analyzing the problem.
-Sleepwalking, screaming, arousals with panic & frantic, agitated behaviors.
-Abnormal body movements during sleep.
-Eating during sleep.
-Inappropriate sexual activity during sleep ("sleep sex") .
-Biting of the tongue or inside of the cheek during sleep.
-Bruxism (toothgrinding; toothclenching).
-Night sweats (sleep-related hyperhidrosis).
-Headaches related to sleep.
-Enuresis (bed wetting) and frequent urination at night (nocturia).
-Abnormal heart rhythms during sleep.
-Choking, shortness of breath and chest pains occurring during sleep.
-Sleep paralysis.

ABNORMAL BEHAVIORS IN SLEEP.


Some of these conditions have been termed arousal disorders because they involve arousals from deep, non-REM sleep.

What do they include?  Such problems as screaming out, sleepwalking, abnormal body movements, tongue biting, night sweats, headaches, choking, shortness of breath, chest pains, abnormal heart rhythms, bedwetting, and sleep paralysis.  Descriptions of these problems begin on page 3 of this self-care guide.

What causes them?  Both sleep disorders and a variety of other factors, including medical and neurological conditions and medications that affect sleep.

IMPORTANT:  ALL THESE ARE SYMPTOMS -- NOT DIAGNOSES!   EACH ONE CAN RESULT FROM A NUMBER OF DISTINCT UNDERLYING CAUSES THAT REQUIRE ENTIRELY DIFFERENT TREATMENTS.   So, it is important to clarify their specific cause in each person’s case, if they are to be brought under good control.


How can you help ensure their accurate diagnosis and effective treatment?
Tips for analyzing the problem.

--By simple detective work--and, whenever possible, by asking others to observe carefully what happens to you while you sleep: particularly just before and during any abnormal events that you experience.  ANALYZE YOUR PROBLEM IN EACH OF THE FOLLOWING ASPECTS:

-1. During what stage of sleep do your problems seem to occur? 

Certain disorders occur specifically in rapid eye movement (REM) sleep, while others are particularly likely to  happen in non-REM sleep.  How might you be able to tell the difference?

•     Normal people spend the first 11/2 hours of sleep in progressively deeper stages of non-REM sleep (stage 1 or drowsiness, then stage 2, and then the deepest, soundest stages 3 and 4 which are called ‘slow wave sleep’).  Most of our slow wave sleep occurs during the first few hours of sleep.

•     Next, after about 90 minutes of sleep, the first (and usually briefest) episode of REM sleep occurs, followed by more non-REM sleep, and then, another and longer period of REM sleep, and so on.  Since REM episodes tend to lengthen as we continue to sleep, most of our REM sleep occurs during the last few hours of sleep.

•     In REM sleep, breathing patterns become irregular, rapid eye movements make eyelids flicker, and we experience our most vivid dreaming.  Although we probably have dreams in other stages of sleep, they usually are hazier and more difficult to recall.  Whether we recall dreaming depends on how quickly we awaken after REM sleep has occurred.  Also, some people just don’t remember dreams well.  Also, people will normally develop a limp paralysis during REM sleep to prevent them from being able to act out their dreams--but little body twitches and ‘shudders’ still occur.  If you’ve watched a dog dreaming, it is easy to relate to these.

Ask yourself (and those who’ve observed your sleep) the following questions:

*          When do the problems tend to occur?

 _____  First few hours of sleep (favors slow wave sleep)            

_____  Last few hours of sleep  (favors REM sleep)  

_____  Any time throughout my sleep (favors non-REM stage 2 sleep)

*          Are the following noted at the times the problems occur?  (all of these favor REM sleep)

            _____ Irregular shallow breathing         ______ Recall vivid dreaming

            _____ Eyelids flickering                        ______ Observers feel certain that I was dreaming

            _____ Wake up unable to move (sleep paralysis) 

-2. Exactly what do your abnormal sleep behaviors or events involve? 

Precise observations are a tremendous help in arriving at a correct diagnosis.  Ask yourself and any observers the following questions.  Then, write down anything that might help clarify your problem, if its cause is still unknown:

  • Can I often tell before going to bed that I’ll have a bad night with these problems?  (If so, how?)
  • Can others often tell when I’m on the brink of having them?  (If so, what is it that “tips them off”?)
  • Are the abnormal events or behaviors basically the same each time that they occur?
  • Are any of the following usually true at the times that they happen?

             ___ I’m lying on my back.  ___ I’m snoring.   ___ I’m having trouble breathing.                   

      (All these suggest that sleep apnea or other breathing problems could be causing the abnormal events.)

Exactly what happens? 

(Write down a detailed description of everything that either you or others have noticed about your abnormal events: from the very first indication that an episode is about to begin, and including everything that happens up through the time that it ends.)

Do I ever wake up during or at the end of the episodes?  If so:

Am I confused?          
Do I recall dreaming or any other symptoms?
Am I difficult to wake up at these times?     
 

-3. What might have caused the onset of your problems? 

Try to recall any changes in your life and health that occurred around the time that your problems first occurred.

Ask yourself and others whether any of the following occurred just prior to the time that you first experienced your problems:

Change in medications, whether prescribed or over the counter (began or stopped taking, or changed dosage).
Change in my health status (illness, injury, hospitalization).
Change in my job (different shift, hours/ overtime, new stresses).
Changes in home and family life (stresses, change in residence, illness of family members).
Changes in diet, alcohol consumption/ other recreational drugs, or in my weight.

-4. What might be aggravating your problem or making it happen more frequently?                 

Ask both yourself and others this simple question: “If I wanted to increase my odds of having a really bad night with more frequent or severe problems of this sort, what could I do?”  The answer may help diagnose your difficulty -and simultaneously help identify aggravating factors that you could avoid in order to make your problem much easier to treat.

Do any of the following seem to correlate with your having more frequent or severe problems?

 Stress or worry. Alcohol.
 Sleep deprivation or being overtired. Nasal congestion.
Sleeping elsewhere than in my own bed. Less or more physically active. 
Going to bed earlier or later than usual. Season of the year; room temperature.
Getting up earlier or later than usual. Eating late, or eating certain foods

Now, apply these questions as they relate to any of the following problems
that you have been experiencing.
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SUMMARY OF ABNORMAL BEHAVIORS AND EVENTS:  
GROUPED BY THE SYMPTOMS THAT THEY CAUSE.


I.  SLEEPWALKING, SCREAMING OUT, AROUSALS WITH  PANIC AND FRANTIC, AGITATED SLEEP BEHAVIORS.

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

-Often occurs in children--particularly boys. It usually but not always resolves before adulthood.

-Can represent an arousal disorder, occurring during arousals from very deep, stage 4 non-REM sleep. In fact, standing a child up in that stage of sleep can induce sleepwalking!

-Can also result from certain medications--such as certain sleeping pills (example: Ambien), sleep apnea and other conditions.

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

NIGHT TERRORS  (sleep terrors, pavor nocturnus):

-Commonest in children, especially boys.  Usually outgrown but can persist into adulthood.

- Can “run in families”.

-Also occurs from slow wave sleep and thus, most frequent during first few hours of sleep.

-Typical description: a child who sits up in bed and screams out frantically, confused and unable to recognize parents or family--even to the point of combativeness that can last 20 minutes or so.

-Usually no (or at most, hazy) dream recall.  Patient usually doesn’t remember having had these on the next morning.

NIGHTMARES  (Dream anxiety attacks)

-Occur at any age.

-Occur in REM sleep--so more likely to occur later during sleep.

-Patient usually can be awakened quickly and if awakened, typically can recall the dream in vivid detail.


OTHER CAUSES OF SLEEPWALKING AND FRANTIC BEHAVIORS IN SLEEP:

-Non-agitated sleepwalking in adults -- can result from sleep apnea, high fevers, and various medications  (particularly “tranquilizers” and other “nerve pills”).

-Agitated, frantic walking--or even running--in sleep, with high risk of self injury (broken bones, running out of second story windows and the like) -- can be due to:

-Panic attacks. 

Occur in non-REM sleep, usually stage 2: so any time of night, and no vivid dream recall. 

Look for:  aggravation by stress, caffeine and certain medications (stimulants, decongestants, diet pills, some asthma medications and adrenaline-like drugs (which may be given with local anesthetics for dental procedures as well as for allergic reactions.

Often seem associated with:  a tense personality style, a tendency to flush when anxious, and--in some but not all patients)--a history of anxiety attacks in wakefulness.

-Night terrors.

See above.  If a patient having a night terror leaves the bed, frantic sleepwalking can result.

Commonest in children, during first few hours of sleep.  Little or no dream recall.

-REM behavior disorder.

Common and potentially dangerous syndrome.  Serious injuries and even some deaths have resulted.         

Patient fails to develop the protective paralysis during REM sleep that normally prevents us from acting out our dreams.  Thus, more likely to occur later in sleep. 

It is usually obvious to observers that the patient is acting out a dream--frequently, a violent one. Typical example: patient, while dreaming of fighting off an assailant, attacks bedpartner instead.                                                                                                       
Occurs most frequently in men over age 60, sometimes in conjunction with other neurological disorders, but often without any other concurrent illnesses-- and occasionally in younger individuals, particularly if they have narcolepsy.
                         
Can be markedly aggravated or precipitated by: certain medications (for example, antidepressants), sleep apnea, and withdrawal from alcohol and certain drugs.  RBD is a neurological rather than a psychological disorder, but it seems to worsen in some people during times that they’re under more stress.                                   

Often responds to a particular drug (clonazepam, Klonopin®), which, however, can make sleep apnea and daytime sleepiness worse--so sleep recordings are usually important before starting treatment.           

-Sleep-related seizures. 

Can cause complex, agitated behaviors which in some cases look much the same each time they occur.

Some types (especially originating from the frontal lobes of the brain) cause very bizarre, violent attacks with screaming out that may occur many times each night, and with EEGs (brain wave tests) that turn out normal. 

-Sleep apnea. 

-Status dissociatus.

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

          

IMPLICATIONS OF THE ABOVE ABNORMAL BEHAVIORS:

• While infrequent, placid sleepwalking and typical night terrors in children will usually be “outgrown” without any need for specific treatment, serious injuries still are possible--and some patients have even walked outside in freezing weather.  Thus, any possibility of self-injury obviously should be eliminated (for example, by blocking access to windows, doors and open stairwells, and by installing alarm systems).  Treatment may be warranted in severe or persistent cases.

• A formal sleep evaluation is warranted in all the other problems listed--particularly whenever a serious underlying cause or serious consequences appear possible.        

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Columbus, Ohio, Central Ohio, hospitalssleep, wake, insomnia, sleepiness 

COLUMBUS COMMUNITY HEALTH
REGIONAL SLEEP DISORDERS CENTER
Accredited by the American Academy of Sleep Medicine.

Robert W. Clark, M.D., Medical Director
1430 South High Street, Columbus OH 43207

Tel: [614] 443-7800
Fax: [614] 443-6960

e-mail: flamenco@netexp.net 

 © Copyright 2006 Robert W. Clark M.D. Inc.