Definition :

• Sombanambulism is also called sleep walking. It refers to a state of getting up and walking around while in a state of sleep.
• This occurs predominantly in males.
• There is usually a familial history with association of Eneuresis.

Population susceptible :

• The great majority of the cases takes place in children.
• There also remains a rare cases reporting and those are usually servicemen or men under indictment for an alleged sleep walking spell.
• Moreover about 15 % of the children are alleged to have atleast one sleep – walking episode compared with 2-5% of the adult population.

Characteristic features :

• The behavioural pattern of people suffering from somnambulism vary greatly.
• This may be just about sitting up in the bed and also making repeated banal movements for a minute or two.
• More prolonged examples consists of walking aimlessly about or more rarely may be running, jumping or searching for something.
• In main the behaviour is simple and stereotyped.
• The patient or the subject usually have a blank or purposeless movements.
• But the investigatory eye movements reamins normal and hence the patient escapes from the dangerous obstacles and the injuries are usually avoided.
• Self injury as a result of somanambulism is really rare but if reported they remain as a serious example.
• Though the subject remains indifferent to the environment, the patient remains less reactive and less aware.
• However if any questions raised to the patient, he/she may answer monosylabically.
• And also some of the subject remains suggestible and may carry out simple commands.

After effects :

• There reamins disagreement about the motor performances and dexterity that can be observed.
• For example, Fenwick states that the acts appear to be purposeful, directed and coordinated.
• The patient may dress or partially undress, open and shut doors and put himself seriously at risk.
• Some of the cases have also been described in which the patient walks onto fire and then escapes or allegedly driven cars in a somnambulistic state.

Duration :

• Most of the attacks last for less than 10 minutes.
• But some of the attacks last for more than an hour or more.
• Spontaneous awakening sometimes occurs, but usually the subject returns to bed and continues normal sleep.
• When attempts are made to arouse, result in gradual return to full awareness, often with marked disorientation and sleep drunkenness.
• Dream recall is not reported, and there is usually complete amnesia for what has trasnpired.

Age factor :

• In children, sombanambulism is usually a benign condition, which usually becomes outgrown in later childhood.
• This delayed presentation is due to delayed cerebral maturation.
• In a retrospective study, Kales et al. showed that when the onset was before the age of 10 years it was usually outgrown by 15.
• However, the cases which come to attention in adult life appear frequently to be associated with severe psychopathology.
• Sours studied 14 patients aged between 17 and 27 referred from US Air force bases.
• In most of the cases the problem started at the time of puberty.
• And the course remain persisting at a recurrence rate of attacks occuring every 1-4 months.
• And moreover the Traumatic psychological evenst had seemed to precipitate the condition in many cases – parental death or divorce, a change of school or the birth of a sibling.
• But in some patients, each episode was precipitated by interpersonal tensions or other emotional problems.
• There was a strong evidence of past history of acting out behaviour, delinquency and thefts, and many showed evidence of anxiety, depression and depersonalisation.
• And also hysterial conversion symptoms were common.
• Of the 14 patients, five were diagnosed as schizophrenic and four others were markedly schizoid in personality.
• The remainder were regarded as having character disorders.

Studies and Associated findings :

• Kales et al. similarly found that 29 adults with a present history of sleep – walking showed high levels of psychopathology on the Minnesota Multiphasic Personality Inventory (MMPI).
• But he also found 21 similar cases who have outgrown the condition showed essentially normal patterns.
• In the former, the sleep walking patterns had appeared later and showed intense manifestations.
• However, it is difficult to know how typical these results may be of adult sleep-walkers generally.

Sombanambulism – Etiology:

• The etiology behind somanambulism is still unclear.
• An explanation in psychodynamic terms was previously favoured, especially where episodes had an apparent purpose and also the terms were explicable in terms of current conflicts.
• The sleep-walking was then viewed as a dissociative state, similar to historical fugue.
• But it is now apparent, however, that sleep-walking rests on abnormality of sleep mechanisms of the brain and represents partial arousal out of deep NREM stages of sleep.
• This occures mostly in the first third of the night when stages 3 and 4 predominate, stages during which the dreaming is least likely to occur.
• Kales and Kales review laboratory studies confirms that this condition in children and running counter to popular notion that sleep – walking represents the acting out of a dream.
• Episodes ould sometimes be induced by lifting sombanambulists to their feet during NREM sleep, whereas this did not provoke attacks in children and does not subject to the disorder.

Genetic predisposition :

• An organic basis for the sleep – walking has been established by the demonstration of a genetic association.
• The demonstartion of the genetic association of the condition with the HLA – DQB1 genes was done.
• And therefore from that a significant excess in transmission was observed in familial cases of sombanambulism for the DBQ1*05 and DBQ1*04 haplophytes.
• This suggests that a DBQ1 polymorphic amino acid might be more tightly associated than any single allele.
• This recent finding may implicate the HLA – DBQ1 genes in disordres of motor control during sleep generally since specific DQB1 genes are also associated with narcolepsy and REM behaviour disorder.

Other predisposing factor :

• Conditions that predispose to higher levels of slow – wave sleep, such as sleep depriviation, shiftwork or alcohol consumption.
• All the above things can be expected to increase the frequency of somanambulism.
• This may be commoner during periods of stress and also anxiety.
• Attention has also been drawn to the liability of certain drugs, taken at bedtime, to induce sombanambulism in susceptible individuals.
• Hypnotics, neuroleptics, antidepressants, tranquillisers, stimulants and antihistamines have been incriminated, often in combination and also with alcohol.
• Luchins et al. reported an example, apparently induced by thioridazine and also a derivative of chloral hydrate, during which a 44-year old psychotic women stabbed her daughter to death.
• Sleep laboratory studies have confirmed that the liability of thioridazine to lead to sleep – walking in this patient, which occured repeatedly out of stage NREM sleep.

Violence and Sombanambulism :

• The question of violence towards others during sleep – walking can raise important medicolegal issues.
• And such a defence not uncommonly comes before the courts.
• Simple aggression usually results from the terror and disorientation of partial arousal from the deep slow – wave sleep.
• More difficulty is encountered when weapons have been employed or purposeful coordinated behaviour has been implicit in the act.
• Oswald and Evans described a 14- year old boy who stabbed and severely injured his 5 year old cousin with a knife.
• And also Fenwick reviews other examples from the literature where violence has occured.
• Sleep – walking may also be put forward as a defence against sexual assault.

Sombanambulism – Histories related :

• In appraising such cases, Fenwick points out that a family history and childhood history of sleep – walking greatly increase the chance that the episode in question is genuine.
• A first episode occuring in the adulthood should be viewed with the suspicion.
• Consequently, it is vital to establish the authenticity of an apparent history of childhoodd sleep – walking.
• Genuine sleep – walking is most likely to occur within 2 hours of sleep onset; any witnessses are likely report inappropriate automatic behaviour, usually with an element of confusion.
• And also there will be substantial amnesia for what transpired.
• Triggering factors such as drugs, alcohol, excessive fatigue and stress will often feature in the episode.
• Attempts to conceal the crime will be unusual, the natural response on walking being to summon help immediately.
• This can be helpful if the offence can be shown to be motiveless and also out of character for the individual.

Sombanambulism – Treatment :

• With regard to treatment, the most important factor is protection from injury.
• Doors and Windows should be locked and also dangerous objects must be removed.
• Patients should be advised to avoid situatuions like sleep depreviation and also to avoid taking alcohol before going to bed.
• In children, the psychiatric treatment is hardly required and in adults it is most needed.
• In persistent cases, drugs like Diazepam and Flurazepam are required.