Insomnia and Sleepwalking: When Medication Isn't Enough

Insomnia. Sleepwalking?

Hello, Doctor: My boyfriend has been suffering from severe insomnia for a long time.
He feels particularly alert at night, and even when he is very tired, he still finds it difficult to fall asleep.
He often doesn't fall asleep until morning, and sometimes he stays awake until the afternoon, only to sleep for two or three hours before waking up, and then he can't sleep again that night! This cycle has been ongoing until last month when he visited a psychiatrist.
The doctor diagnosed him with mild anxiety and prescribed him sleeping pills, but we're not sure if the dosage is too low or what, because even after taking the medication, he still can't sleep.
He often ends up taking a second or third pill to finally fall asleep! However, he doesn't want to increase the dosage on his own, so sometimes he just tries to tough it out—but still can't sleep! During his second follow-up appointment, he mentioned this situation to the doctor, who prescribed an additional sleeping pill.
After taking this new medication, he found it somewhat easier to sleep, but he started experiencing sleepwalking! He often gets up multiple times during the night, sitting up, drinking water, urinating, showering, etc., but when I ask him what he was doing the next day, he has no recollection! He explained this issue to the doctor, but the doctor said it was fine as long as he wasn't doing anything dangerous.
He continues to take the medication...
Based on this description, I would like to ask the doctor: is it really okay to experience sleepwalking while taking sleeping pills? Should we consider changing doctors? This sleepwalking at night also affects his sleep quality, right?! Moreover, for me, whenever he gets up at night, I also have to wake up and worry about what he might be doing...
Please help me with this, thank you!!

Lin, 20~29 year old female. Ask Date: 2011/07/11

Dr. Zhong Mingxun reply Psychiatry

Dear Miss Lin,
Regarding the first part about your boyfriend's long-term severe insomnia, there may be underlying issues that could be physiological, psychological, or psychiatric in nature.
Additionally, irregular sleep patterns can exacerbate the problem.
It is essential to identify the relevant causes and address them specifically for effective treatment.
During the treatment process, the combination of sleep medications and maintaining a regular sleep schedule can be very helpful.
In the second part, some sleep medications may trigger sleepwalking or cause him to frequently get up during the night, sitting up, drinking water, urinating, or taking a shower, etc.
However, when asked the next day about what he was doing, he has no recollection.
This suggests a high likelihood of medication side effects, as there are unpredictable risks involved.
Furthermore, this phenomenon indicates poor sleep quality.
It may be worth considering an adjustment of the medication.
If necessary, seeking a second opinion from another psychiatrist could be beneficial.
Sincerely,
Chung Ming-Hsun

Reply Date: 2011/07/11

More Info

Insomnia is a complex condition that can significantly impact an individual's quality of life, and it often requires a multifaceted approach to treatment. Your boyfriend's situation, characterized by severe insomnia and episodes of sleepwalking, raises several important considerations regarding the use of medication and the management of sleep disorders.

Understanding Insomnia and Its Treatment
Insomnia can manifest in various forms, including difficulty falling asleep, staying asleep, or waking too early. In your boyfriend's case, it seems he struggles primarily with the ability to fall asleep and maintain a consistent sleep schedule. The fact that he experiences heightened alertness at night, despite feeling tired, suggests a possible disruption in his circadian rhythm or an underlying anxiety disorder, as indicated by his diagnosis of mild anxiety.

The medications prescribed by his psychiatrist, which likely include sedative-hypnotics, are intended to help him achieve better sleep. However, the need for increasing dosages to achieve the desired effect raises concerns about tolerance, dependence, and the potential for adverse side effects, such as sleepwalking.

The Issue of Sleepwalking
Sleepwalking, or somnambulism, is a parasomnia that occurs during non-REM sleep. It can be triggered by various factors, including sleep deprivation, stress, and certain medications, particularly benzodiazepines and other sedatives. While your boyfriend's doctor may have reassured you that sleepwalking is not inherently dangerous if he is not engaging in risky behaviors, it is still a significant concern for both of you. Sleepwalking can lead to accidents or injuries, and the fact that he is unaware of his actions during these episodes can be distressing.

Medication Management
1. Dosage and Efficacy: It's crucial to communicate openly with the prescribing physician about the effectiveness of the current medication regimen. If your boyfriend feels that the dosage is insufficient, he should not increase it without consulting his doctor. Instead, he should discuss his experiences during follow-up appointments. The doctor may need to adjust the medication or consider alternative treatments.

2. Alternative Treatments: In addition to medication, cognitive-behavioral therapy for insomnia (CBT-I) is a highly effective non-pharmacological treatment. CBT-I focuses on changing sleep habits and misconceptions about sleep, which can help improve sleep quality without the side effects associated with medications.

3. Lifestyle Modifications: Encouraging good sleep hygiene practices can also be beneficial. This includes maintaining a consistent sleep schedule, creating a relaxing bedtime routine, and ensuring a comfortable sleep environment. Reducing caffeine and alcohol intake, especially in the hours leading up to bedtime, can also help.

When to Seek Further Help
If your boyfriend's sleepwalking episodes continue or worsen, or if he experiences other concerning symptoms, it may be time to seek a second opinion or consult a sleep specialist. A sleep study (polysomnography) could provide valuable insights into his sleep patterns and help identify any underlying sleep disorders that may be contributing to his insomnia and sleepwalking.

Conclusion
In summary, while medication can be an effective tool for managing insomnia, it is essential to monitor its effects closely and consider alternative treatments. Sleepwalking is a serious concern that warrants attention, and open communication with healthcare providers is crucial. Encourage your boyfriend to discuss his experiences candidly with his doctor, and explore additional therapeutic options that may improve his sleep quality and overall well-being. Remember, a holistic approach that includes lifestyle changes, therapy, and careful medication management can often yield the best results in overcoming insomnia.

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