Sleepwalking Differential Diagnoses

Updated: Mar 11, 2019
  • Author: Syed M S Ahmed, MD; Chief Editor: Selim R Benbadis, MD  more...
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Diagnostic Considerations

Recognizing the occasional case where seizures are the cause of nocturnal events is imperative. This differentiation can be made on the basis an in-depth history of the episodes. Polysomnography (PSG) may be necessary to clarify the diagnosis.

Conditions that should be kept in mind fall into 3 main categories, as follows:

  • Miscellaneous sleep disorders

  • Normal non−rapid eye movement (NREM) parasomnias

  • Rapid eye movement (REM)-related parasomnias

The relevant miscellaneous sleep disorders are not sleep state−specific. The more common ones frequently generate questions for the pediatrician, but they are generally less anxiety-provoking than the NREM parasomnias are. These disorders include the following:

  • Benign neonatal sleep myoclonus

  • Bruxism – Nocturnal bruxism occurs in 15-22% of the population, usually in stage II sleep; the bite force may be considerably stronger than during wakefulness, resulting in tooth or gum injury

  • Congenital hypoventilation syndrome

  • Enuresis

  • Infant sleep apnea

  • Nocturnal paroxysmal dystonia

  • Periodic limb movements

  • Rhythmic movement disorder - Behaviors include head banging, body rolling, or body rocking; onset is usually before the age of 9 months (prevalence is 60% at that age but only 5% at 5 years); episodes rarely last more than 15 minutes, occurring during the drowsy state just before sleep onset and occasionally extending into light sleep)

  • Somniloquy (sleep talking)

Normal NREM parasomnias are characterized by the following:

  • Hypnagogic or hypnopompic imagery (a state of feeling awake but having dreams intrude; occurs at sleep onset or offset)

  • Sleep starts or hypnic jerks (typically a myoclonic jerk at sleep onset but also, rarely, manifested as a sudden flashing light, loud cracking, snapping noise, or sudden pain)

REM-related parasomnias are caused by disruptions in the REM-to-wakefulness transition; except for nightmares, these disorders are much less common in children than in adults. REM behavior disorder, cataplexy, and wakeful dreaming are considered abnormal. Anxiety dreaming or nightmares are considered normal.

In addition to these and the conditions listed in the differential diagnosis, other problems to be considered include the following:

  • Arrhythmias

  • Dissociative states

  • Dream anxiety attacks

  • Epilepsy in children

  • Gastroesophageal reflux

  • Nocturnal asthma

  • Tonic seizures

Differential Diagnoses