Somnambulism down the ages.

ROYAL OPERA HOUSE PROGRAMME NOTE:

LA SONNAMBULA. FINAL DRAFT 10/2/02

Re-published here on the occasion of the first professional season of the opera in Australia since 1965 (and with the same conductor, Richard Bonynge).

Written by Dr Colin Brewer. Medical Director, The Stapleford Centre.

SLEEPWALKING: NATURE OR NURTURE?

Amina was lucky. The Swiss are presumably no more prone to sleep-walking than any other nation but in late 20th Century Basel, an episode chillingly similar to the one in the last act of La Sonnambula ended not in joyous reconciliation but in serious injury and would have been fatal in Amina's time. A seventeen year old boy somnambulated straight out of his bedroom window onto the grass six floors below. He suffered several fractures and his spleen, stomach, colon and other useful abdominal organs burst through his diaphragm into his chest cavity but after some clever anaesthesia and stitch-work, he recovered completely. In a case reported from America, the somnambulist got as far as the window ledge of his 35th floor apartment before waking.

In one respect this young Swiss was more typical than his operatic counterpart. Most sleepwalkers are boys but most of them are not yet teenagers. In children between the ages of 4 and 6, sleepwalking is so common (up to a third have at least one episode) as to constitute a normal variant. Like bedwetting (from which, significantly, the Swiss boy also suffered) it is usually due to a slight delay in the growth, maturity and coordination of the brain and like bedwetting, most people grow out of it without treatment.

Sleep, for the technically minded, has several stages which are clearly demarcated by changes in the pattern of waves seen on the electroencephalogram (EEG) - a recording of the brain's electrical activity similar in principle to the more familiar electrocardiogram but more difficult to interpret because the brain is a much more complex organ than the heart. Normally, we pass through sleep stages 1 to 4, characterised by progressively slower waves on the EEG. This progression is followed by periods of Rapid Eye Movement (REM) sleep - the stage most closely associated with dreaming, during which the brain is relatively active and, as the name indicates, the eyes move rapidly from side to side behind closed eyelids. Anyone who has watched a sleeping dog apparently chasing an imaginary cat may have seen something like this phenomenon. A few further cycles of stages 1-4 sleep followed by REM sleep occur before waking. Perhaps surprisingly, sleepwalking (which sometimes runs in families) does not usually occur during REM sleep but in the deeper stages - 3 to 4 - of non-REM sleep. Stage 3-4 sleep is most frequent in children and usually disappears (as, therefore, does sleep-walking) after the age of 40.

Somnambulists usually have blank expressions and seem to be indifferent to their surroundings. Their behaviour during the episodes, which typically last only a few minutes, often seems clumsy, purposeless or trivial but sometimes involves complex actions. If they wake up before returning to their own bed, they are often confused for a few moments and the usual advice is not to wake them unless they are in imminent danger. Sadly, they don't usually speak, let alone sing, but in many important respects,
Sonnambula presents a clinically accurate picture, including the fact that somnambulism is commonest during the early part of the night. (And just as well: it might be difficult to devise a convincing plot that required the entire population of the village to be out and about and in chorus mode at 4 am)

Like most disturbances of human behaviour, sleepwalking can easily lead to arguments between those in the neuropsychiatric camp who think that the main problem is an abnormality in brain function (for which medication might, in principle, be helpful) and those of the psychodynamic persuasion who favour largely or exclusively psychological explanations and remedies. These two explanations are not mutually exclusive, of course. A physical abnormality affecting the brain or any other organ may be made worse by strong emotions. However, if the underlying physical abnormality or vulnerability isn't there in the first place, the condition associated with it will not occur however much stress and emotion are flying around. The trouble is that while most neuro-psychiatrists readily accept that manifestations of brain dysfunction can be modified by personality, stress, emotion and so forth, the psychodynamic inheritors of the Freudian mantle sometimes behave as if the brain, despite its marvellous complexity, is the only organ of the body that never goes on the blink. Under the microscope, one bit of liver, heart muscle or lung, looks very like any other bit. The brain is much more specialised and the various parts have some splendid Graeco-Roman names (hippocampus, mammillary bodies, locus coeruleus) which are almost a match for Freudian buzzwords like Oedipus and the vagina dentata.

Despite the conclusion of most studies that sleepwalking has 'no demonstrated associations with...psychopathology', and that it chiefly reflects cerebral rather than psychological abnormalities, sleepwalking, like dreaming, provides a fair amount of obvious grist for the Freudian mill. Dreams, for Freud, were famously "the royal road to the unconscious" but as we have seen, somnambulism and dreaming are typically separate and even incompatible activities, characterised by different and fairly specific neurophysiological processes. Although he started his professional life as a neurologist, Freud did not know this, which explains and perhaps excuses his use of 'somnambulism' to include the perambulations of a patient in a hypnotic trance - a horse of a very different colour.

To paraphrase Samuel Butler, 'God cannot rewrite history but psychoanalysts can. Perhaps that is why He tolerates their existence'. Despite Freud's well known caveat that there are times when 'a cigar is only a cigar', Freudians remain enthusiastically wedded to the idea that the complex is preferable to the simple, that sex is a universal rather than a common factor in human behaviour and relationships and to imaginative speculation rather than prosaic evidence - in short, to a baroque as opposed to a Spartan view of mental processes. Baroque is more fun, of course, with lots of interesting decorative details to divert attention from more important considerations, such as whether the foundations are sound but in the past quarter century, a seismic change has affected the status of these foundations. The change is that most people in psychiatry - who are at least as concerned as physicians or surgeons to concentrate on evidence-based treatments - do not now regard psychoanalytic theories as having much explanatory or therapeutic application.

Forty years ago, the psychiatric journals - particularly American ones - were full of learned papers incorporating psychoanalytic concepts and taking them for granted. Around the mid-1970s, these papers gradually disappeared off the face of the academic planet, surviving only in a few specialist psychoanalytical journals. The historian Edward Short has documented the way that the psychiatric establishment in America was very strongly influenced by psychoanalysis and its practitioners before, during and after WW2 and to a much greater extent than any other country. Indeed, it could be argued that as with some of the nastier Latin-American regimes, psychoanalysis could not have survived without US support. Now that that support has largely vanished, psychoanalysis has retreated to the more academically and heuristically undemanding habitats provided by journalism, the counselling industry and the arts - a Pollyanna archipelago where no beautiful hypothesis is ever slain by an ugly and inconvenient fact.

Can psychoanalysis help in cases like Amina's? It's true that she's an orphan and adopted, and both Freudians and neuropsychiatrists might reasonably make something of that. (Perhaps she was dropped on her head as a baby.) On the other hand, she is not obviously unhappy except on account of Elvino's jealousy and she seems popular with her peers for all the right reasons. Losing two parents might have seemed like carelessness to Lady Bracknell but wouldn't have been so unusual in a pre-Bazalgette age when lethal epidemics were still common (and when successful adoptions could occur without the involvement of platoons of social workers). Whatever the underlying causes, the Aminas of this world clearly need help if they're not going to end their days expiring dramatically (perhaps Traviata-style in some rustic Swiss 1830s version of a hospital soap-opera). So what can we actually do to help persistent sleep-walkers who repeatedly somnambulate into dangerous situations? (Amina's compatriot apparently somnambulated again in the orthopaedic ward just as soon as he was unencumbered by weights and pulleys.) Do we go for talking-and-listening or do we reach for the Prozac aerosol?

In many psychotherapy programmes, people are talked through their problems, with or without interpretations, until at some stage they say something like: 'Well, I guess I never really saw it that way before'. The cognitive behaviour therapist treating a patient with spider-phobia will only be successful when the patient comes in practice to see spiders as less frightening and not worth responding to as if they represented a mortal threat. For the patient of a cognitive therapist, progressively exposed to pictures of spiders, then to small dead spiders and finally a real live frisky one, this is likely to be seen on both sides as a matter of familiarity breeding contempt. The patient in psychoanalysis may be more likely to say: 'I have stopped being frightened of spiders because I have come to agree with your view that I am frightened of them because their long legs activate the repressed memory of a time when I saw my parents having sex'. (Which was more or less how Freud interpreted a child's fear of horses in the famous case of 'Little Hans'.) So long as both patients can cope with spiders, does it matter which therapy is used or whether the 'explanation' underpinning the treatment is correct? Isn't relief without explanation better than explanation without relief? (And let's not forget that many conditions improve, sometimes dramatically, once people recognise that they have a problem and go and see someone about it.)

If somnambulism, in a particular case, seems related to stress or distress, a bit of listening, probing, speculating and advising would seem a sensible beginning, especially if their bedroom isn't on the sixth floor. But what do you do if there is no obvious precipitant, or if there is an obvious source of tension or unhappiness but it cannot easily be resolved or come to terms with and they keep on walking despite understanding perfectly why it's happening? The first choice wouldn't actually be Prozac, which can sometimes make sleep problems worse, but that classic mother's little comforter of the 1960s. The texts say that sleeping-tablets of the benzodiazepine group, of which Valium (diazepam) is the best-known member, reliably suppress stage 3-4 sleep, thus removing the particular pattern of brain activity that is necessary for sleep-walking. Like drugs for bedwetting, it shouldn't usually have to be taken forever because somnambulism rarely outlasts adolescence. How fortunate for opera-lovers that Valium, though originally synthesised by a Swiss firm, wasn't around in the 1830s to complicate a touching little story of love and jealousy.


Written by my friend and colleague, London psychiatrist Colin Brewer. Posted with his permission.