Walk around or sleepwalking? Unconsciousness or crime?

There is a general assumption that walking during sleep means having somnambulism. It is an erroneous assumption that often leads to diagnostic errors and huge delays towards consulting a physician.

Why? Because walking during sleep may have several causes, and henceforth several possible treatments.

It can be due to somnambulism. Somnambulism is a well-defined illness: it is the most frequent in boys, it is familiar; it begins around 5 – 6 years of age and tends to disappear during adolescence. The occurrences usually appear during the Delta stage of sleep, known as Slow Wave Sleep, about one hour after falling asleep and won’t happen again in the same night. The sleepwalker scarcely remembers – if at all – what happened, walks around the house in an orderly but unconscious manner, which can amount to accidents, like falling through stairs, or through a window, breaking objects, etc. Usually he isn’t aggressive, but can become aggressive if forced or vexed.

Somnambulism can be provoked by certain psychoactive pills, and become worsened by alcohol, drugs, excessive exercise, fever or sleep deprivation.

Knowledge concerning this is very ancient. In Homer’s Odyssey happens to appear the first described case, and alcohol worsened, wherein Elpenor, Trojan war-hero, drunk some wine after a battle and climbed to a roof, where he slept. In the following morning, when he was called for boarding, he woke up, walked around the roof, and fell to his death. The Elpenor Syndrome is based on these events, and on the risks of roaming episodes when you are asleep or when you suddenly wake up in a confusional arousal.

Recently the movie “Side Effects” dealt about this matter, describing a crime perpetrated in a pseudo sleep walking episode, provoked by an antidepressant, and which would have been “perfect” if a psychiatrist had not been investigated through the policeman’s reasoning.

The psychiatrist could have used a more clinical approach, which means that whenever facing a case of nocturnal violence, one must investigate thoroughly and with exemption, performing tests, polysomnography and whatever is required to reproduce the violent episode, in order to achieve clear conclusions: is it a crime, does it result from illness or foul-play.

Violence during Sleep?

Yes, of course. Violence can exist during sleep and is, in that case, particularly dangerous. Why? Because who performs it is unconscious and the intensity of the acts can be enormous.

What are the causes?

Somnambulism, night terrors and the confusional arousals can be the cause of sleep related violence or accidents.

Another case is nocturnal epilepsy. Some epilepsies appear only or mostly during sleep, and manifest themselves through episodes with simple behaviours (limb movement, screams, etc.) or complex behaviours (walking, sitting on the bed, falling from the bed, aggression, striking, etc.). Mistaken for somnambulism, they are not treated. What are the differences? The epilepsies may appear at different hours of the night, or while falling asleep, they may occur repeatedly during the same night, the behavior is stereotyped and there is no recollection on the following day or when waking up. Waking up tends to be arduous, with pain through the body, headaches or confusion. Epilepsies can appear in children, adults, in the elderly, and some of them can even be familiar.

Other cases, while classically appearing mostly in elderly men, are the REM behavior disorder. What is this? It includes episodes that occur in a dream context, during which someone is attacking either the patient or a relative. The patient defends himself and, in that dreamy defense, violently assaults who’s closest, jumps from the bed as if he were flying, etc. When he wakes, with some difficulty, often because someone is screaming or because he injures himself, he stumbles upon what he has caused and shivers: blackened eyes, strangled necks, blood and gore, broken arms, etc. Those who suffer from this usually are peaceful and sane, and isn’t expressing violence in any way, on the contrary: was rather defending himself from it.

What happened? Dreams where he is the victim of violence, and during which he did not have the classical, normal and protective REM atonia, that transiently paralyses us, and he executed exactly what he was dreaming about.

Both epilepsies and REM behavior disorder require an efficient and urgent treatment, by Sleep Medicine specialists or Neurologists. Somnambulism, in most cases, requires protective and prophylactic measures.

Therefore, never mistake one for the others, because most of the times walking around while asleep is not sleepwalking. 

Professor Teresa Paiva,

Lisbon April 26^th 2013

The New Bats

Bats are the only mammals capable of flight.

According to the Wikipedia, there are over 11.116 different species representing one quarter of all mammal species in the world. Besides that, they come in various shapes and sizes, they have a fantastic capacity for environmental adaptation, they have one of the most varied diets amongst mammals and have a sophisticated system of echolocation.

I don’t know which of these characteristics is more enviable. Is it their flight? Is it their sonar? Or perhaps their sleep duration of twenty hours per day? In fact despite their prolonged sleeping hours, they have been tranquilly surviving for millions of years.

Is it envy? Yes, I would say so because nowadays I give consultations to patients of all ages with their sleeping habits upside-down. They go to bed after 6am, and get up in the middle of the afternoon!

They sleep by day, to be awake by night, the night long working, playing, chatting, and surfing on the web, producing or creating something, or simply watching television with more or less zapping.

They are young, teenager or young adults, they are middle aged persons, in creative professions – or not, they are retired elderly who let themselves lull by the night.

Social life - It’s not easy. Health - It’s certainly hard, since, and I will say this often, sleeping by day entails to special and serious health concerns.

Why? We are not bats, or mice, or owls. We are human beings and we were made, genetically and physiologically, to live by day, and the presence of electrical light will not convince our body otherwise.

The day-night regulation, called circadian regulation, was precociously acquired during the evolution of life on Earth by blue bacteria, called cyanobacteria, who wanted to avoid the sun induced mutations in their reproduction cycles. This circadian organisation capacity exists throughout all living beings, in both animals and plants.

It is so old, so intrinsic, and so essential, that electric light will not thwart it.

Back to the bats - these fantastic flying animals had a huge impact on many cultures: if they are a symbol of happiness and longevity in Chinese tradition, and in Cinema, Batman is a saviour, in most cultures these extraordinary animals are associated to something grim, to sadness, to vampires and to death; and in Western Africa, some consider them to be the representation of a “torn soul”.

I have an enormous admiration for bats, but I must say that most bat men and women I have encountered had some sort of angst and sadness, as if something in them was actually “torn”. 

Professor Teresa Paiva

Lisbon April 19th 2013

NEXT WEEK: WALK AROUND OR SLEEPWALKING? UNCONSCIOUSNESS OR CRIME?

Article by Doctor Luís Portela, President of Bial Foundation

The blog "In Search of Lost Sleep"

Why do we need to sleep? What happens inside the human body while we sleep? How important is Sleep in our daily activities? Why do we dream and what is the meaning of dreams? These questions often leave us wanting to learn more about. These questions become of paramount importance when in today’s society, we can see the quality and quantity of Sleep worsen. 

However, while there is much uncertainty surrounding this particular topic, there is also much certainty. Nowadays, it is believed that reducing the number of sleep hours has consequences over the physical and mental health. Sleeping badly can be associated to an increased risk of hypertension, cardiovascular diseases, diabetes, depression and other pathologies. On the other hand, lack of sleep is also responsible for work and traffic related accidents. 

It is unquestionable that sleep plays an important role in balancing our physical, emotional and social development. So, the creation of this space for awareness, education and sharing of doubts regarding this subject is to be commended. I am sure that the blog “In Search of Lost Sleep” will help us to sleep more, to sleep better and to have sweet dreams. 

My blessings to Professor Teresa Paiva,

Doctor Luís Portela, President of Bial Foundation

Lisbon, April 12th 2013

Link to Bial Foundation Website

The Director of Lloyd’s Bank and the President of North Korea

The Director of Lloyd’s bank admitted to having a health problem due sleep deprivation and overwork.

Kim Jong-un, President and Military commander of North Korea, sleeps three hours a day and fasts often.

Horta Osório recognized his situation as a serious one, while Jong-un is believed to be a genius.

In London, it was said that sleep deprivation would reach over 50% of the population. What about in Portugal? There are alarming indicators: 50% of the young adults and teenagers have excessive somnolence. I daily attend patients with sleep deprivation and/or overwork.

They are from all ages, both sexes and all social classes. They are those that rule and those that are ruled. They are executives, officials, salaried and independent workers, merchants and sellers.

They are those that wish to rise in life, and those that are already there. They are rich, poor and remedied. They are those that work in shifts, and those that do not have office hours. They are mothers and fathers, single mothers with dependent children, fathers with two jobs in order to provide for their family. They are those that make it happen in order to pay their debts and those that demand payments. They are those that exercise in powerful positions and those that have little or no power at all. They are many…

At first you work because you have to. You work all night long, going to bed late and getting up early. You hear praises “Well done!” or “What energy!” The good results are obvious: on time replies, the e-mail does not wait, the cellphones always on. Money comes in, or will come in. Success knocks at the door, or will knock at the door.

But… mistakes first start to emerge, fleeting lapses, that word which you cannot remember, that meeting which you forget, the professional error…

Then comes the irritability, then you are on the edge. Then it’s the untimely yawning and the neglect. Memory fades away.

At first, as soon as you get to bed you sleep right away. But latter, you want to sleep and you cannot. Neither by day nor by night. Gaping eyes, head spinning. Sleepless nights, even while on vacations.

Broken sleep, the lost blessing!

Despair, depression, broken memory, sluggish reasoning, bad humor, and “burned out”.

It happens to the best, to those who are best prepared, to the smartest. Genius don’t get little sleep. Some, like Einstein, were considered to be good sleepers. Sleep has guaranteed survival for millions of years. The foremost beneficiary is the brain. Sleep consolidates memory, learning and abstract knowledge, it helps in problem resolution, stimulates creativity and stabilizes emotions.

In order to think and be well, one must sleep!

The body is the other beneficiary. To sleep too much or too little increases the risk of diabetes, obesity, cardiovascular diseases, hypertension, cancer, accidents and reduces life expectancy.

In order to be healthy, one must sleep!

Rules and regularity is required in sleeping, in eating, in resting and in exercising. Beware! Illness results from mistakes in the natural, common sense, rules!

Limits are needed in work, in credit, in expenses, in pleasure, in pain, in everything.

We are not slaves. We need breaks along the day.

We are not as gladiators; instruments to be thrown away when are met with incapacity.

Where did we achieve with so much work, so much unrest, and so much credit, so much everything?

To a country in crisis, a sick society, with sad people and with no future in sight.

Where will Kim Jung-un go, without any control in his warfare strategies, daring and impulsive? What untold suffering will he bring to his people? How much pain, sadness, devastation will spread throughout that region?

Is this the work of a genius brain or rather the end result of a brain suffering from serious decision making issues and impulsive-aggressive tendencies, aggravated by sleep deprivation?

God rested on the seventh day, and we are certainly no gods. 

Professor Teresa Paiva

Lisbon, April 5th 2013

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