Epilepsy
Fugue state
Schizophrenia
Concussion
Dissociative disorder
REM behavior disorder
Nightmare
Table 44.2
List of terms used to describe sleepwalking prior to 1950
Oneirology |
Somnolencia |
Somnomania |
Somnambulism |
Somnolentia |
Sleep drunkenness |
Schlaftrunkenheit |
l’ivresse du sommeil |
Syndrome d’Elpenor |
Oneirodynia |
Noctambulism |
Coma vigil |
Somno-vigilia |
Somnambulismus |
Ecstatis or cataleptic somnambulism |
Somnambulator |
The availability of advanced diagnostic techniques and the start of the modern field of sleep medicine have resulted in ever-expanding and more specific differential diagnoses. Historical descriptions and interpretations of nocturnal wandering generally reflected the state of science, medicine, religious beliefs, and superstitions of that time. However, when the religious and superstitious aspects are removed, the “clinical” description of signs and symptoms in early reports of sleepwalkers is often quite close to current diagnostic descriptions.
There is a large number of case reports or stories of sleepwalkers going back centuries. They typically include elements consistent with current sleepwalking science and theory as well as other elements that are clearly not consistent with modern views. The following case of Negretti, aged 20 years, appears in several nineteenth-century books on sleep and sleepwalking . The common signs and symptoms of sleepwalking and related disorders in modern sleep medicine can be found in Table 44.3 for purposes of comparison and analysis.
Table 44.3
Common signs and symptoms of sleepwalking in modern sleep medicine
1. | Sleep stage and timing: Sleepwalking occurs out of deep sleep (also known as slow-wave sleep or stage 3 or 4 sleep)—usually 40–90 min after sleep onset. Sleepwalking does not occur spontaneously from wakefulness |
2. | Arousal from deep sleep: Not only must the sleepwalker be in deep sleep when the event is triggered but also a sudden arousal must occur while in deep sleep |
3. | Types of triggers: Arousal can be caused by sound, touch, or some internal change or other things going bump in the night |
4. | Duration: Typically last for short period of time—seconds or minutes although longer episodes have been reported |
5. | Deep sleep not dreaming sleep: Sleepwalking is not associated with REM sleep dreaming |
6. | Proximity and provocation: Violent sleepwalking behavior is defensive when another individual is in close proximity or is provocative |
7. | Violence: Sleepwalkers do not seek out victims. Sleepwalking violence is defensive. Typically, victims seek out or encounter sleepwalkers |
8. | Higher level cognitive function: Absence of planning, intent, and memory |
9. | Continuity: Sleepwalking episodes are continuous. They do not usually wax and wane |
10. | Memory: Sleepwalkers generally have complete amnesia for their episodes. The sleepwalker does not forget, but never stores the memory |
11. | Memory from before incident: Sleepwalkers are unable to access memories formed to the immediate past |
12. | Memories formed during the incident: Sleepwalkers are unable to form new memories during the sleepwalking episode itself |
13. | Ease of awakening: Sleepwalkers are extremely hard to awaken |
14. | Situational stress: Reports of stressful situation before episodes of sleepwalking are common—death in family, loss of job, etc. |
15. | Sleep deprivation: Sleep deprivation for 1 or more days prior to sleepwalking episodes is often reported |
16. | Out-of-character behavior: Violent sleepwalkers are almost always found to be nonviolent while awake |
17. | Social interaction: Social interaction requires higher-level cognitive functioning not available to the sleepwalker |
18. | Personal history of NREM arousal parasomnias |
19. | Family history of NREM arousal parasomnias—familial pattern |
On the evening of the 16th of March, 1740, after going to sleep on a bench in the kitchen, he began first to talk, then walked about, went to the dining-room and spread a table for dinner, placed himself behind a chair with a plate in his hand, as if waiting on his master. After waiting until he thought his master had dined, he uncovered the table, put away all of the materials in a basket, which he locked in a cupboard. He afterwards warmed a bed, locked up the house, and prepared for his nightly rest. Being then awakened and asked if he remembered what he had been doing, he answered no. [4]
This case describes behaviors that may be too complex to meet current standards. However, if this was his usual routine, these activities might be considered “automatic behaviors” during an amnestic confusional arousal. His going to the dining room, setting the table, and so forth bears a passing resemblance to behaviors noted in sleep-related eating disorder, which is a variant of sleepwalking . The lack of recall of events would certainly be consistent.
A second case described in several nineteenth-century books is:
A young ecclesiastic was in the habit of getting up during the night, in a state of somnambulism, of going to his room, taking pen, ink, and paper, and composing and writing sermons. When he had finished one page of the paper on which he was writing, he would read over what he had written and correct it…. In order to ascertain whether the somnambulist made any use of his eyes, the Archbishop held a piece of pasteboard under his chin, to prevent him from seeing the paper upon which he was writing; but he continued to write on, without appearing to be incommoded in the slightest degree…. He wrote pieces of music while in this state, and in the same manner, with his eyes closed. [5]
In current sleepwalking theories, sleepwalkers have impaired higher cognitive functions and should not be able to read, write, compose, or correct writings. Sleepwalkers are currently reported to perform their behaviors with eyes open. The report that this young cleric continued to write even when his line of sight was blocked is consistent with early theories attributing special visual abilities or supernatural powers such as clairvoyance to sleepwalkers who were thought to move about and perform various behaviors with eyes closed. Additional information that does not appear in this version of the case history is that his sleepwalking episodes only occurred during the month of March, and that he walked with his eyes closed and often bumped into walls and doors.
The following story appears in several nineteenth-century books [6], often with some details added or eliminated. It concerns complex apparently sleep-related behaviors described by an eyewitness, the prior of the convent where it occurred:
Very late one evening the monk entered the chamber of the Prior, his eyes were open but fixed, the light of two lamps made no impression upon him, his features were contracted, and he carried in his hand a large knife. Going straight to the bed, he appeared to examine if the Prior was there. He then struck 3 blows, which pierced the coverings and even a mat which served as the purpose of a mattress. In returning, his countenance was unbent and was marked by an air of satisfaction. The next day the Prior asked the monk what he had dreamed of the preceding night, and the latter answered that he had dreamed that his mother had been killed by the Prior, and that her ghost had appeared demanding vengeance, that at this sight he was so transported by rage that he had immediately run to stab the assassin of his mother; that a little while after, he awakened bathed in perspiration and very content to find he had only dreamed.
According to another account, thereafter, the monk slept in a locked room. It is quite curious that none of the accounts state whether the prior was actually in bed when the monk attacked with a knife. This story contains a number of elements that would not be considered consistent with sleepwalking in modern times. Sleepwalking with eyes open is consistent with current knowledge. Carrying a knife is also for unknown reasons fairly common in modern cases of sleepwalking violence [7]. However, violent sleepwalkers do not seek out their victims [8]. Sleepwalking violence is thought to be defensive in nature. The victim almost always seeks out or encounters the sleepwalker. The very detailed description of the dream is inconsistent with an NREM arousal parasomnia such as sleepwalking. Sleep terrors are often associated with a frightening image, but these images tend to be static, without a story line. Dreaming, on the other hand, is typically associated with electromyographic (EMG) atonia so that the dreamer lacks the muscle tone to get up and act out his dream. In RBD, first described in 1986 [9], dreams may be enacted; this is due to the effects of neurodegenerative disease on areas of the brain that control EMG atonia during REM sleep. However, RBD patients rarely leave their own beds. Dreamers exist in their own dream world and have little or no knowledge of their location or the location of others. Based on current sleep science, an RBD patient should not be able to navigate from one room to another.
Thus, it can be seen that many early descriptions of “sleepwalking” may not be consistent at all with current definitions or theories. Nevertheless, an historical analysis shows the development or evolution of beliefs and knowledge of sleepwalking that still reflects on our modern views.
Early Greek Contributions
Some of the earliest descriptions of sleepwalking were by early Greek writers. As translated by Weinholt from Greek into German in his Seven Lectures on Somnambulism and to English by Colquhoun [5], a third-century BC Greek, Iamblichus wrote in his treatise De Mysteriis Egyptiorum,
On the approach of such a spirit of prophecy during sleep,” says he, “the head begins to sink, and the eyes involuntarily close: It is, as it were, a middle state between sleeping and waking. In ordinary dreaming, we are fast and perfectly asleep; we cannot precisely distinguish our perceptions. But when our dreams are from God, we are not asleep—we exactly recognise all objects, and sometimes even more distinctly than when awake. And in this species of dreams prophecy has its foundation.
Both Hippocrates and Aristotle are reported to have commented on sleepwalking . As cited and translated from the Greek by Tuke [6], Hippocrates wrote, “I have known many persons during sleep moaning and calling out…and others rising up, fleeing out of doors, and deprived of their reason until awake, and afterwards becoming well and rational as before, although they may be pale and weak.” Aristotle noted “some are moved while they sleep, and perform many things which pertain to wakefulness, though not without a certain phantasm and a certain sense, for a dream is after a certain manner a sensible perception” (p. 5).
Diogenes Laertius, a biographer of Greek philosophers, is reported to have noted two cases of sleepwalking and he himself was reported to read, write, and make corrections to his books while asleep [4]. Many insights into the historical evolution of our understanding of sleepwalking come from court cases and are consistent with current legal concepts of automatism. The 1313 Council of Vienne [10] stated:
If a child, madman or sleeper killed someone he was not culpable.
Fifteenth to Sixteenth Century
Levinus Lemnious (1505–1568) was concerned about the safety of sleepwalkers when he advised “not to call night-walkers by their proper name…whereas you must let them go as they will and retire again at pleasures.”
Diego de Covarrubias (1512–1577) discussed when, and if, the violent actions of a sleeping individual would be considered a sin. Generally, the act of the sleeper would not be a sin, unless the sleeper somehow made prior arrangements to commit the violent act in his sleep. As translated from the Latin by Walker [11]:
It follows of course…that a person who was asleep at the time of the homicide is not at fault, for the obvious reason that he was asleep when he killed his victim; such one lacks understanding and reason, and is like a madman…. For this reason the misdeed of a sleeper is not punished, unless it happens that in his waking state he knew very well that in his sleep he would seize weapons and attack people. For then if he did not take care to prevent himself from doing harm in his sleep to someone, certainly he should be punished, although not in the usual way.
King James I (1566–1625) is reported to have had a keen interest in sleepwalking [10]. He and his mother are said to have had paroxysms associated with loss of consciousness, large mood swings, and insomnia. The lay public during this period attributed nightmares and sleepwalking to the devil. Nightmares and sleepwalking were attributed to a “grave perturbation of spirit” and “ill-directed imagination outside of the control of reason.”
Mathaeuss (1664) noted that a sleepwalker who committed a violent act should be punished if during wakefulness he had a grudge or complaint against the person [11]. McKenzie (1678), a Scottish jurist, noted in an early volume on criminal law [12] that “such as commit any crime whilst the sleep, are compared to infants.”
A famous legal case of the time was that of Colonel Cheyney Culpeper in 1686 [11]. His brother Lord Culpeper was an important member of the court of King James II. Colonel Culpeper was reported to be a “famous dreamer” and apparently was well known to perform complex behaviors in his sleep. During a purported episode of dreaming, he shot a guardsman as well as the guardsman’s horse. Put on trial for manslaughter, his defense was that he had been asleep when he shot the guardsman. He is reported to have produced 50 witnesses who testified to his complex behaviors during sleep. The jury initially returned a guilty verdict of manslaughter, but this verdict was apparently not accepted and the jury was sent out again. They returned with a special verdict of manslaughter while insane. In a few days, the instructions from the court of King James II delayed sentencing and within weeks he had been pardoned most likely resulting from the influence of his brother. This story was reprinted in altered form in at least two nineteenth-century books on sleep.
Seventeenth to Eighteenth Century
The description of sleepwalking as a state between sleep and waking was first put forth during this time period and would be understood and accepted by modern sleep medicine. However, it is confounded with religious beliefs, as well as the assumption that sleepwalkers are acting out dreaming . Starting in the eighteenth century, more physiological concepts of sleepwalking started to appear, whereas the more religious and supernatural views started to decline.
Nineteenth Century
1815: Polidori
The early nineteenth-century and late eighteenth-century views of sleepwalking—typically called oneirodynia—are summed up in a recently translated medical dissertation by John Williams Polidori published in Italian in 1815 [12]. Polidori was the personal physician to Lord Byron and an early writer of horror stories of some note. He shows a remarkable prescience for modern knowledge of sleepwalking. The term oneirodynia as translated from the Greek is literally “walking while in a dream.” It is of interest that Polidori attributes the first use of the term “somnambulism” to Sauvages de la Croix in a medical nosology book, Nosologia Methodica, Amsterdam, Sumptibus Fratrum de Tournes, 1763. This term also appears in several nineteenth-century medical nosologies.
Polidori’s definition of sleepwalking was “a hallucination in which dreamers rise from their bed and expose themselves to various dangers.” Undoubtedly, just as injuries or near misses related to sleepwalking are a fairly common reason for referral to a modern sleep disorders center, at the time only the more dangerous and bizarre episodes of sleepwalking were likely to come to public knowledge or be repeated in books or medical journals. Polidori’s general description of sleepwalking is consistent with several currently accepted aspects of sleepwalking: the sudden arousal from sleep, performance of complex behaviors as if awake, and, most interesting, performance of behaviors that are often typical of wakefulness. This anticipates the concept of so-called automatic behaviors—behaviors that are performed repeatedly so that higher cognitive function becomes unnecessary:
When we discuss [oneirodynia] in a medical context, however, it should be understood to refer not only to someone who walks while in a dream, but also to someone who appears to wake up while still asleep, and who performs actions or speaks as if he were awake. If I might offer a definition of this disease, it is the habit of doing something in sleep that is usually done by those who are awake…. There are as many types as there are distinctions observed in the disease. (p. 76)
…though all passageways to the various senses are open in sufferers from oneirodynia, it appears nonetheless that they experience no sensations beyond those that pertain to the specific action they are performing.
Polidori also anticipates modern concepts of sleepwalking by suggesting it may require several factors to occur. Modern sleepwalking theory supposes that sleepwalking must have a predisposing factor (genetic), a priming factor (usually sleep deprivation and/or situational stress), and a provoking factor or trigger (often a sound, touch, or other form of stimulation) [13, 14]:
We may say that there are three causes of diseases, namely the proximate [proxima], the remote [remota], and the predisposing [praedisponens]. The proximate is that cause from which the disease itself immediately arises; the remote is the cause that precedes the proximate; and the predisposing is the cause that makes men susceptible to a certain disease. But since we know nothing for sure regarding the proximate causes and can do nothing but relay hypotheses, I propose to pass over conjectures and subtle argumentation. And in the case of the other types of causes too we do not know much, whether because of a lack of clinical accounts, or because of the superficial scrutiny applied to old cases and more recent ones, or because of nature’s own delay. The remote causes are varied, but they all seem to affect the brain in some fashion. Thus a wound to the head has at times induced oneirodynia, as may be seen in volume VIII no. xix of the notes of Lenadus. Moreover oneirodynia sometimes presents along with hysteria, epilepsy, and other diseases that arise from an affliction of the brain. This demonstrates plainly that oneirodynia is produced from an internal brain lesion. Yet it is much more typical for no clear cause to appear. The predisposing or determining [determinantes] causes are: intoxication, overeating, food that produces gas, use of too much bedding, placing the head lower than the body, lying on one’s back, study, use of opium, and everything that moves blood to the brain. (p. 777)
Although Polidori lacked knowledge of modern sleep medicine, his model is very close to what is generally accepted today. Polidori is also one of the only writers prior to modern sleep medicine to offer suggestions for treatment. He anticipates current pharmacological and nonpharmacological treatments.
The Curing of the Disease
The health of those suffering from oneirodynia is usually sound, and the disease would pose no danger if it did not draw sufferers into dangerous places. Some authors say that this disease sometimes induces catalepsy [catalepsis] and madness [mania]. Thus we must do everything we can, but—as is generally the case—we do not know of anything to expel the disease.
The indications to be followed are two.
(1) To interrupt the progress of episodes that are underway.
(2) To keep the episodes away once they have withdrawn.
To follow the first indication, we can only remove the predisposing causes. In the case of a sleepwalker, drunkenness, study, and other things that stimulate the mind and afterwards weaken it must be avoided. Tonics may perhaps be given, such as Peruvian Bark, iron and similar things, yet how much and when may be known only through experience. But we must distract the sufferer’s mind from serious matters as much as we are able. During the course of an episode, first of all doors and windows should be closed and every exit blocked. For a certain sleepwalker, believing that he saw Aristotle and other philosophers going out through a window, would have followed them if his friends had not held him back. Second, methods should be applied that may rouse the sufferer from sleep by terrifying him. Beatings, electricity, frigid baths—if they are placed in such a way that the sufferer may fall into them when he strays from his bed in the course of sleepwalking—will perhaps hinder the return of his episodes.
His first suggested treatment involves attempts to remove predisposing causes. In modern sleep medicine, sleepwalkers are often told to avoid sleep deprivation, increase their total sleep time, learn to reduce stress, and eliminate possible triggers with treatment of snoring or sleep apnea. Secondly, there is a suggestion that administration of apparently medicinal substances may reduce or eliminate sleepwalking, although the author admits a lack of knowledge as to dosage and timing of treatment. Finally, Polidori deals with the sleepwalker’s safety. All doors and windows must be closed and exits blocked. The final suggestion of trying to awaken the sleepwalker during an episode would not be accepted currently. And the suggestion that “beatings, electricity or frigid baths” may be used to arouse the sleepwalker is quite inconsistent with current belief that family members speak simply and directly to the sleepwalker in an effort to return him or her to the bedroom. However, the drastic measures suggested by Polidori do suggest that the sleepwalker may be very hard to arouse, which is consistent with modern sleep science.
1835 :C. Prichard
C Prichard writing in the 1835 Cyclopedia of Practical Medicine strongly supported the relationship between dreaming and sleepwalking [4]:
A somnomblulator is a dreamer who is able to act out is dreams. (p. 21)
1838 :Isaac Ray
Isaac Ray, generally thought to be the first American forensic psychiatrist, was the author of Treatise of Mental Jurisprudence of Insanity. Remarkably, this volume contains three chapters on somnambulism [15]. For the most part, Ray’s intention, as with Wharton, is to describe the legal evaluation of sleepwalking as a criminal defense. Anticipating many modern cases in which sleepwalking is presented as a defense for a criminal act, it includes a chapter on how to detect simulated somnambulism . Although he does not discuss etiology in any detail, it is clear he believes sleepwalking is related to dream enactment. However, he also appears to suggest that there is a physiological reason for its occurrence:
§ 508. As the somnambulist does not enjoy the free and rational exercise of his understanding, and is more or less unconscious of his outward relations, none of his acts, during the paroxysms, can rightfully be imputed to him as crimes. (p. 509)
Ray notes that there is no real physiological evidence that the sleepwalker’s body is acting out thoughts occurring in the mind during sleep. He appears to reject more fanciful descriptions of sleepwalkers as possessing supernatural visual abilities:
§ 494. Whether this condition is really anything more than a cooperation of the voluntary muscles with the thoughts which occupy the mind during sleep, is a point very far from being settled among physiologists. While, to some, the exercise of the natural faculties alone seems to be sufficient to explain its phenomena, others have deemed it necessary to suppose that some new and extraordinary powers of sensation are concerned in its production, though unable to convey a very clear idea of their nature or mode of operation.
Ray further suggests that somnambulism is the result of some problem of the brain and that this is linked likely to general conditions that result in health problems:
§ 503. It now scarcely admits of a doubt, that somnambulism results from some morbid condition in the system, involving, primarily or secondarily, the cerebral organism…. The more active forms of sleep-walking seldom, if ever, exist, except in connection with those habits or conditions that deteriorate the general health.
1845 :Colquhoun and Weinholt
The attribution of sleepwalking or other complex behaviors in sleep to God, supernatural forces, or the devil continued well into the nineteenth century. J.C. Colquhoun in his introduction to the English translation of Arnold Weinholt’s Seven Lectures on Somnambulism (1845) lamented the difficulty in shedding religious views of sleepwalking and demanding more scientific ones [5]:
The manifestations of this peculiar affection, however, seem to have always appeared so anomalous and incomprehensible, as to have excited religious veneration and awe, rather than to have been considered as a proper subject for philosophical contemplation. These manifestations, therefore, came to be generally regarded as the immediate consequence of Divine appointment, or as the effects of diabolical agency, according to the peculiar character which the affection might happen to assume, or the particular views entertained by the different observers. Similar notions, upon this subject, appear to have been almost universally entertained during the dark ages of Europe; and even long after science had begun to subject the actual phenomena of nature to the scrutiny of a more strict and searching analysis, somnambulism still continued to constitute a perplexing puzzle for the philosopher and the physician. A variety of instances of the affection, indeed, had been occasionally observed; but the explanation of the phenomena was long held to be a subject far too sacred for profane philosophical speculation; and it was, accordingly, consigned almost entirely to the province of the theologian. Ignorant and crafty men availed themselves of these facts and dispositions for the purpose of extending their influence by enlarging the boundaries of superstition and delusion. And so deeply rooted were these erroneous impressions in the minds of mankind, that even the attempts which have been made, in recent and more enlightened times, to extirpate these unphilosophical and pernicious notions, by explaining the natural causes of the phenomena in question, have been viewed by many as an impertinent and unhallowed inroad upon the sacred territory of the Divine, or as an iniquitous design to extend and perpetuate the empire of Satan. (p. 2)Related posts:
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