What Substances Can Cause Sleep Behaviors?

Is it possible for a medication or a substance like alcohol or other drugs to cause sleep behaviors (parasomnias)?

You may have heard of people doing funny things under the influence of Ambien (zolpidem), a medication prescribed to treat insomnia, but are there other potential causes of sleep behaviors? Learn about the relationship between substances and sleepwalking, sleep eating, sleep-driving, and even REM behavior disorder.

What Medications Cause Sleep Behaviors?

There are a variety of medications, ranging from antidepressants to Alzheimer’s treatments, that can cause sleep behaviors due to their potential effects on muscle control during rapid eye movement (REM) sleep. Rather than normal sleep paralysis occurring, muscle tone is increased and it becomes possible to act dreams out. This can lead to movements and sleep behaviors like hitting, kicking, punching, jumping out of bed, talking, and other activities.

The most commonly used medications that incite muscle tone in REM and REM behavior disorder are selective serotonin reuptake inhibitors (SSRIs), which include:

• Celexa (citalopram)
• Lexapro (escitalopram)
• Prozac (fluoxetine)
• Luvox (fluvoxamine)
• Paxil (paroxetine)
• Zoloft (sertraline)

In addition, tricyclic antidepressants (TCAs) can also cause increased muscle tone in REM and dream-enactment behaviors. TCA medications include:

• Elavil (amitriptyline)
• Pamelor (nortriptyline)
• Norpramin (desipramine)
• Silenor (doxepin)
• Tofranil (imipramine)

Other psychiatric prescription medications that can potentially trigger REM behavior disorder include Effexor (venlafaxine) and Remeron (mirtazapine). Though used less frequently due to other side effects, monoamine oxidase inhibitors like Eldepryl (selegiline) may also contribute.

Finally, anticholinesterase inhibitor medications that reduce the breakdown of acetylcholine and are used to treat Alzheimer’s disease can also cause sleep behaviors. These medications include:

• Aricept (donepezil)
• Exelon (rivastigmine)
• Razadyne (galantamine)
• Namenda (memantine)

There is also evidence that medications called beta-blockers, often used to treat high blood pressure or a fast heart rate (tachycardia), can cause sleep-related hallucinations. These prescription medications may include:

• Coreg (carvedilol)
• Inderal (propranolol)
• Lopressor or Toprol XL (metoprolol)
• Sorine (sotalol)
• Tenormin (atenolol)
• Timolol
• Trandate (labetalol)
• Zebeta (bisoprolol)

Finally, prescription medications that are used to treat insomnia may trigger non-REM parasomnias. These behaviors include sleepwalking, sleep-related eating disorder, and sleep driving. It is possible for sleep sex and even violent acts to occur. It is believed that these medications depress the ability to awaken (by raising the arousal threshold) and that this may impair memory and consciousness. Though part of the brain is turned off, the part that allows movement and activities can be active. These medications are called sedatives or hypnotics and include:

• Ambien (zolpidem)
• Lunesta (eszopiclone)

Though prescription medications may frequently cause parasomnias as a side effect, they are not the only substances that can provoke these sleep behaviors.

Can Alcohol or Drugs Cause Sleep Behaviors?

There is no evidence that alcohol can cause sleepwalking directly. The behavior of someone who is intoxicated differs from someone who is simply sleepwalking. Alcohol modestly affects thinking: though impaired, it is not absent. In contrast, someone who is sleepwalking has no recollection of his or her actions after the fact. Movements, even shockingly complex actions, are preserved in sleepwalking. There is no stumbling or falls despite seeming to be “absent” mentally. In contrast, someone intoxicated by alcohol will have significantly impaired balance and inability to walk normally.

It is believed that alcohol may provoke fragmented sleep, especially due to untreated sleep apnea. Alcohol relaxes the muscles of the upper airway and this may lead to a collapse of the airway in susceptible individuals, resulting in an arousal from sleep. This may provoke mixed states of consciousness and lead to an increased risk of sleepwalking. Though logical, this has not been validated by testing.

Alcohol intoxication may have little role in inciting sleep behaviors, but alcohol withdrawal may provoke these episodes. In addition, there is evidence that withdrawal from illicit substances, including cocaine and amphetamine, may also provoke sleep behaviors. In addition, withdrawal from prescription drugs like barbiturates and meprobamate may also do the same.

Finally, there is evidence that excessive use of caffeine and even chocolate may cause REM behavior disorder.

How to Determine If Behaviors Are Due to a Substance

How do you figure out if a medication or substance that you are using is contributing to sleep-related behaviors? The most important consideration is to examine the timing. Did you start using the substance prior to the onset of the symptoms? Were the behaviors worsened while using it? If the medication or substance is discontinued, do the symptoms or behaviors go away?

In general, it may be necessary to consult with your prescribing physician. If possible, it may be necessary to discontinue the medication to see if the parasomnias resolve.

In many cases, abnormal sleep behaviors observed with hypnotic medications like Ambien occur when the amount taken exceeds the recommended dose or when it is taken improperly. Blood levels may exceed what is deemed to be safe. Women are advised by the Food and Drug Administration (FDA) to take lower doses due to these potential risks. When combined with other medications that act on the brain, or with alcohol, the risks are worsened. In addition, the medication may be taken at the wrong time or there may be inadequate time in bed prior to waking.

The misuse of these medications may cause serious accidents or other harm. The same is true for other drugs that may be abused. It is unclear if the same underlying triggers, including genetics, are important for non-REM parasomnias that are related to drug use.

How to Lower Your Risks and When to Get Help

No matter whether the trigger is a prescribed medication, alcohol, or illicit substance, you should seek help if you experience a sleep-related behavior that is potentially harmful to yourself or others. Start by speaking with your prescribing doctor and, if necessary, see a sleep specialist to identify other potential contributors to these behaviors.

With a thoughtful review of your risk factors, and the discontinuation of potentially contributing medications or substances, you will be able to sleep safely without fear of acting your dreams out in the night.