Sleepwalking and depression

Sleep disorders such as sleepwalking, insomnia and many others are very common and sometimes can be triggered by various causes such as stress, physical illnesses that cause pain or frequent urination, working in shifts and many others. Depression is also considered an important factor for developing these disorders. Disturbed sleep can cause a great deal of distress for people, whether it is caused by depression or not. Sleepwalking is a serious disorder for some and a mild annoyance for others.

Depression and sleep disorders

People with depression often suffer from sleeping disorders. Generally, these involve getting less sleep than usual and include:

• Difficulty getting off to sleep - often because of lying in bed with thoughts going round in your head.
• Frequently waking up during the night.
• Waking up early in the morning and not being able to get back to sleep.
• Somnambulism (in rare cases)

If the sleeping disorder is associated with depression, the problems won’t go away simply by getting enough sleep. Even when they get enough hours of sleep, the people suffering from depression often wake up in the morning feeling tired and do not feel refreshed.

Symptoms of sleepwalking

There are several symptoms which are related to somnambulism and some of the most common are:

• ambulation (walking or moving about) that occurs during sleep. The onset typically occurs in pre-pubertal children.
• difficulty waking up during an episode of sleepwalking
• sleeping with eyes open
• blank facial expression
• sitting up and appearing awake during sleep
• amnesia following an episode of sleepwalking
• confusion, disorientation on awakening
• episodes typically occur in the first third of the sleeping process
• fatigue
• stress
• anxiety

Statistic data

It is proven that somewhere between 1% and 17% of U.S. children sleepwalk. Some 18% of Americans are prone to the act. Research has shown that the highest prevalence of sleepwalking was 16.7% in children of 11 to 12 years of age. Boys are more likely to sleepwalk than girls.

Cause of sleepwalking - stress

Sleep problems are frequently asociated with periods of the intense stress. This is why many sleep problems resolve once the stress is gone or the other medical condition behind it subsides. However, some sleep disorders can begin as an acute problem and develop into a chronic sleep problem.

Normal sleep patterns

Sleep can be assessed by measuring the electrical activity that occurs in the brain. We normally undergo several cycles during the night moving through the various stages of sleep. Sleep can be divided into a number of different stages. People tend to go through stages 1 to 4 when they are falling asleep and the reverse when they are waking up. Stages 1 and 2 are regarded as light sleep. Stages 3 and 4 are deep sleep. There is also a fifth stage and it is called the rapid eye movement sleep (REM) because although our eyes remain shut, they move around a lot during this stage. REM sleep is the time during which we have dreams.

REM (Rapid Eye Movement) Sleep

1. REM begins typically after about 90 minutes into sleep.
2. It occurs throughout the night on a 90-100 minute cycle
3. Polygraph measurements during REM sleep appear very similar to those taken of the person in the waking state
4. Vital signs such as pulse rate, ventilation rate and blood pressure are all comparatively high during REM sleep
5. Brain oxygen demand increases above that of supply
6. Body temperature regulation is altered
7. Depressed people demonstrate changes in REM sleep. REM occurs earlier and mostly occurs to the latter half of the period of sleep.
8. Someone waking from REM sleep will usually do so rapidly and report that they were experiencing dreaming.
9. As a person gets older the percentage of time spent in REM sleep decreases.

Non-REM Sleep

1. The pulse rate typically slows by 5-10 beats per minute; ventilation and blood pressure also drop and unlike in REM sleep is stable and regular.
2. Episodic, involuntary movements occur - similar to the jumping/falling movements some people will be familiar with.
3. Someone waking rapidly from deep non-REM half to one hour into sleep will be disorientated and possess disorganized thinking and will be slow in returning to baseline consciousness/cognition.
4. Thus it is suggested (Kaplan) that awaking from deep non-REM sleep will result in specific disorders resulting from the disorientation experienced, such as bedwetting, somnambulism and nightmares.
5. Cerebral blood flow in non-REM sleep is reduced, as it is too almost all body tissues.
6. In the healthy adult, non-REM sleep accounts for 75 percent  of sleep time.

Sleep patterns in depression

The sleep patterns in a person with depression are very different from the normal sleep patterns:

• It takes much longer to get off to sleep.
• The total sleep time is reduced.
• There is little or no deep sleep.
• REM sleep occurs earlier in the night.
• There are more frequent wakenings during the night
• The person wakes up earlier in the morning.

Pathophysiology of somnambulism

Experts are saying that sleepwalking occurs most often at a certain point in the sleep architecture. Various research has proven that this happens at the point where the sleeper's brain waves become larger during the passing into deeper sleep. The patient can also have other REM disorders or psychiatric and medical disorders which do not account for the sleepwalking.

While sleepwalking, the patients' brainwaves show a mixture of types of brainwave patterns, including ones similar to those observed in waking patients, as well as those found in deep sleep.

The exact pathophysiological mechanism is not fully understood, but it involves a partial arousal in the brain where the frontal lobes, responsible for executive functions and decision-making, remain asleep, while the motor cortex, brain stem, and central pattern generators, which coordinate movement, are active. This disconnection results in the performance of movements that are typically automatic or semi-purposeful without conscious awareness or full alertness.

Genetic predispositions can play a role, as sleepwalking is more common in individuals with a family history of the condition. Other contributing factors may include sleep deprivation, febrile illnesses, stress, alcohol, and certain medications that affect the central nervous system. Neuroimaging and electrophysiological studies show abnormal activation in areas controlling locomotion and consciousness during somnambulistic episodes, indicating a complex interplay between neurochemical, genetic, and environmental factors in the manifestation of somnambulism.

How serious is sleep walking?

For some, the episodes of sleepwalking occur less than once per month and do not cause any harm to either the patient or the others. The problem is that some experience sleepwalking more than once per month, in some cases almost nightly, and sometimes it is even associated with physical injuries. In some cases the sleepwalkers can exit the house, walk the streets and even drive a car. It is proven that sleepwalking that starts at an early age, generally disappears as the child gets older. If the child begins to sleepwalk at the age of 9 or older, it often lasts into adulthood.

Differential Diagnosis of sleepwalking

Some disorders have similar or even the same symptoms. The doctor should first rule out the following disorders to establish a precise diagnosis.

• Partial Complex Seizures Occurring during sleep
• REM Behavior Disorder
• Night Terrors
• Malingering
• Dissociative Phenomena
• Medication Effects

Signs and tests for the proper diagnosis

Usually, no examination and testing is necessary for the diagnosis of sleep walking.
If sleep walking is frequent or persistent, an examination which would rule out other disorders (such as partial complex seizures) may be appropriate. Some experts believe that it may be appropriate to undergo a psychological evaluation to look for the underlying causes such as excessive anxiety or stress, or medical evaluation to rule out other causes.

Treatment

Medications

Benzodiazepines are the medicines that help sleeping. They are effective and they have few side effects. However, your body becomes used to them very quickly, so their effect starts to vanish. This means that they are addicctive and that you’ll probably need to take higher doses to achieve the same results. This is particularly the case in depression, since it may take several weeks for the illness itself to respond to treatment.

Antidepressants

Some of the older antidepressants like Amitriptyline and Dothiepin are sedative. As a result, they were used a great deal to help depressed patients who had marked sleep problems.

Other medications

Occasionally other sedative medicines are used along with an antidepressant such as sedative antipsychotics. These medications can help anxiety, agitation, and sleep and, under certain situations, may help somebody respond to an antidepressant if they did not previously.

Some tips for better sleep

• Get into a routine with your sleep times.
• Take some physical exercise during the day.
• Avoid exercise two hours before bedtime.
• Avoid watching disturbing or violent films prior to bedtime.
• Avoid drinking caffeine in the evening after 6pm.
• Drink herbal teas or milky drinks such as Horlicks in the evening.
• Avoid heavy meals two hours before bedtime.
• Avoid alcohol in the evening. While alcohol is sedative, it is not a good idea to try to use it to sort out a sleep problem. This is because alcohol does not lead to normal restful sleep.
• Your bedroom should be warm and familiar with a comfortable bed and quilt, etc.