SILVER SPRING, Md., July 11-Harry F. Rosenthal is a classical music buff who has been known to step in as conductor of a symphony orchestra, but he is fast asleep in his bed here when he takes over the baton.
Rosenthal, 78, is a somnambulist, and he says he has been sleepwalking since he was about three years old. Over his professional career as an Associated Press reporter, Rosenthal spent a lot of time in Cape Canaveral during the heyday of the Apollo moon missions, and he became a sleepwalking legend among fellow journalists.
Action Points
- Advise patients concerned about sleepwalking about the need to alarm doors with buzzers to alert others to nighttime activity.
- Tell patients not to lock bedroom doors or otherwise confine sleepwalkers to bed or bedroom.
- Ask patients who are sleepwalkers or parents of sleepwalkers about the presence of guns in their houses. Advise them to remove the guns to a secure place where the sleepwalker cannot access them.
- Consider drug therapy for patients who are violent during sleepwalking.
His sleepwalking was also at times a source of amusement for his wife, Naidene. For example, one night she heard strange noises coming from the bedroom where he was sleeping. "There was Harry sitting up in bed conducting an orchestra -- and he was also vocalizing all the instruments. I brought our kids in to see, too and I even made a tape recording of it."
Rosenthal says he has no memory of his stint as a conductor "or playing all the parts in the orchestra," and he says that is usually the case with his nocturnal adventures. He knows they happen because he wakes up in strange places or he is told about his antics by witnesses. "It's usually just embarrassing," he says.
Rosenthal's story is fairly typical, says Rafael Pelayo M.D., a pediatric neurologist and sleep specialist at the Stanford Sleep Disorders Clinic, but he points out that sleepwalking, which is categorized as a parasomnia along with night terrors, bedwetting, and narcolepsy, is a misnomer.
The sleepwalker is not truly asleep, but is in a dissociated arousal state that occurs during the period of slow wave sleep, Dr. Pelayo says. While it is difficult to come up with hard numbers, experts generally agree that about 10% of the population has experience with sleepwalking, and the peak occurs about the time of puberty.
Mark Mahawald M.D., director of the Minnesota Regional Sleep Disorder Center at Hennepin County Medical Center, a professor of neurology at the University of Minnesota School of Medicine in Minneapolis, says that while there is a childhood peak in the prevalence of sleepwalking, sleepwalking often continues into adulthood, as it did in the case of Rosenthal.
"Sleepwalking is just part of the human condition," Dr. Mahawald says. "I think most people have awakened on a couch or on the floor with no memory of how they got there, but it is not something that people are going to talk about at a cocktail party."
Sleepwalking, says Dr. Mahawald, is often believed to be associated with an underlying psychological disorder, but "there is no evidence of any underlying psychological problems in sleep walkers. The most important determinant is actually a family history."
He adds that sleep deprivation and alcohol use are the two most common triggers for sleepwalking.
"We tend to think that wakefulness and sleep are mutually exclusive, but this is not true, and sleep walking is a good example of this since people in this half-awake state are able to perform complex functions," Dr. Mahawald says.
That ability to perform complex functions can lead to sleepwalkers driving cars, turning on televisions, radios, power tools and even firing guns, says Dr. Pelayo. "Anything that is 'automatic' you can do in your sleep, which is why it is important to find out if there are any weapons in the home of sleepwalkers," he says.
From a treatment standpoint, "safety is the most important factor for sleep walkers," Dr. Pelayo says. "All weapons should be secured."
Thus, doors -- especially bedroom and outer doors -- should be equipped with alarm buzzers that will sound when the door is opened. "Buzzers help alert others so that the sleepwalker can be directed back to bed," Dr. Pelayo says.
An incident in London last week illustrated the need for door alarms. There, a 15-year-old girl was discovered fast asleep atop a construction crane, a sleep site she apparently chose during a nighttime stroll. The girl, who was as surprised as her rescuers, was safely removed from the crane and suffered no apparent injuries.
Similarly, it is not uncommon for a sleep walker to walk out an open window or off a balcony, says Dr. Mahawald, who noted that a sleepwalking college student in his area walked off a third floor roof recently. "He suffered massive injuries, but he did survive," Dr. Mahawald says. "If he hadn't survived it would have been considered a suicide, so I often wonder about the possibility of 'pseudo suicide' among sleep walkers -- life threatening accidents that occur while they are sleepwalking."
Keeping that in mind, Dr. Pelayo said that sleepwalking children should not be allowed to sleep on upper bunks and when a sleepwalker goes to college, he or she should "make sure the door room is on the bottom floor." Dr. Pelayo also recommends covering windows with heavy draperies to prevent injury if sleepwalkers punch the window or attempt to walk through it.
But while safety is a key concern, both Drs. Pelayo and Mahawald say that sleepwalkers should never be locked in rooms or tied to beds, practices that some parents and partners of sleepwalkers have tried over the years.
Both Drs. Mahawald and Pelayo say that sleepwalkers are capable of violence and noted that there have been criminal cases in which persons committed murder while they claimed to be sleeping. Dr. Mahawald said it is "possible for a sleepwalker to commit murder, but it is very difficult to prove that a murderer was sleep walking."
Dr. Mahawald says there is some evidence that suggests sleepwalkers have a heightened pain threshold, which may increase the likelihood of violence. For instance, he says, sleepwalkers may be cut or bruised, yet not awake and not react to the pain.
Last spring a man in Britain was charged with murder for the beating death of his father. The man claimed he was sleepwalking during the murder and a jury acquitted him.
When sleepwalkers exhibit violent behaviors drug therapy is indicated, with benzodiazepines such as Klonopin (clonazepam) or tricyclic antidepressants such as Elavil (amitriptyline) being the drugs of choice.
Dr. Mahawald said that once the sleepwalking is stopped, the patient can be weaned off the drug "and taught self-hypnosis techniques to use before sleep. We've found this approach to be effective at stopping violent behavior during sleepwalking."
Since sleepwalking occurs during slow wave sleep, which usually occurs early in the sleep cycle, Dr. Pelayo said some people have had success with a strategy called anticipatory wakening that requires "the patient to be awakened about 15 minutes after he or she falls asleep. This interrupts the slow wave cycle, the patient is then allowed to go back to sleep and this appears to work in some patients, but the reports are all anecdotal and there are no data to support this approach."
Dr. Mahawald says that while he, too, has heard anecdotal reports about he success of this approach, "I personally don't believe it works. It doesn't make a whole lot of sense. If you interrupt the slow wave cycle, the patient will just go back to sleep and start another slow wave cycle."
Finally, while it may be difficult to wake sleepwalkers, it is not dangerous to do so, says Dr. Pelayo.
Full disclosure: The author of this article has a personal history of somnambulism.