Breaking the Cycle: Effective Behavioral Strategies for Managing Recurrent Sleepwalking Before Episodes Even Start

Story-at-a-Glance

• Prevention trumps intervention: The most effective behavioral strategies for managing recurrent sleepwalking focus on identifying and eliminating triggers before episodes occur, rather than just responding when they happen
• Sleep apnea is a hidden epidemic among sleepwalkers: Research shows 88% of adult sleepwalkers in one study had undiagnosed obstructive sleep apnea, and treating it resolved sleepwalking in all adequately treated cases
• Scheduled awakening works: Waking patients 15-20 minutes before their typical sleepwalking time and keeping them awake through the vulnerable period can break the cycle
• Psychological factors matter more than previously recognized: Addressing stress, emotional conflicts, and inadequate coping mechanisms can reduce episode frequency by up to 80% in some patients
• Sleep deprivation is both trigger and diagnostic tool: While 25+ hours of sleep deprivation doubles sleepwalking episodes, strategic sleep extension for two weeks can dramatically reduce episode frequency
• The “3 P” framework guides treatment: Understanding predisposing factors (genetics), priming factors (sleep debt, medications), and precipitating factors (stress, sleep fragmentation) allows for targeted behavioral intervention

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When a 33-year-old woman arrived at a sleep clinic in Brazil, her sleepwalking had become so severe that she was wandering her home multiple times each week. She’d started medication, but the side effects were intolerable. What happened next challenges everything most people assume about treating recurrent sleepwalking. Rather than focusing on what to do during episodes or adding more medications, her psychotherapy took a different approach. It focused on helping her develop better coping strategies for daytime conflicts and assert her needs more effectively. Within months, her sleepwalking decreased from several times weekly to once per week, and the episodes that remained were simple and harmless.

This case illustrates what Dr. Antonio Zadra, one of the world’s leading sleepwalking researchers at the University of Montreal, has been demonstrating through decades of research: effective behavioral strategies for managing recurrent sleepwalking aren’t about managing the episodes themselves—they’re about preventing them from happening in the first place.

The Hidden Architecture of Adult Sleepwalking

Before we dive into behavioral strategies, we need to understand what we’re actually dealing with. Adult sleepwalking isn’t the benign childhood phenomenon many assume it to be. Research from Dr. Yves Dauvilliers at Gui-de-Chauliac Hospital in Montpellier, France found striking patterns among 100 adult sleepwalkers. The study showed that 22.8% had nightly episodes and 43.5% had weekly episodes. Perhaps more concerning, 58% reported a history of violent sleep-related behaviors, with 17% experiencing injuries requiring medical care.

The stakes are real. Dauvilliers’s research documented patients with bruises, nosebleeds, fractures, and in one devastating case, a patient who sustained multiple fractures and serious head trauma after jumping from a third-floor window during an episode.

But here’s what most people miss: these aren’t random events. Adult sleepwalking follows a predictable pattern governed by what sleep researchers call the “3 P” framework: predisposing, priming, and precipitating factors.

Predisposing factors include genetic vulnerability (56.6% of adult sleepwalkers have a positive family history). Priming factors are conditions that increase slow-wave sleep or make arousal more difficult—sleep deprivation, certain medications, alcohol, fever. Precipitating factors are the immediate triggers: sleep fragmentation from apnea or restless legs, bedroom noise, stress, or even a bed partner’s movements.

This framework reveals something crucial: remove enough of these factors, and you can prevent sleepwalking without ever addressing the behavior itself.

The Sleep Apnea Revelation: Why Your First Step Might Not Involve Sleep at All

Here’s a finding that should fundamentally change how we approach adult sleepwalking. In a remarkable study, researchers found that 53 out of 60 adult sleepwalkers (88%) had obstructive sleep apnea, and when the sleep apnea was adequately treated, sleepwalking resolved in 100% of those cases.

Let that sink in. The majority of adults seeking help for sleepwalking may actually have an underlying breathing disorder creating micro-arousals from deep sleep dozens or hundreds of times per night. Each arousal is an opportunity for a sleepwalking episode to begin.

Consider the case of a 42-year-old man who presented with recurrent sleepwalking and sleep paralysis. His first incident involved falling from bed and sustaining a forehead injury. Polysomnography revealed moderate obstructive sleep apnea. Although he couldn’t tolerate CPAP therapy initially, treatment with clonazepam resolved his symptoms. The key insight? His adult-onset sleepwalking wasn’t a standalone sleep disorder—it was a symptom of disrupted sleep architecture.

The behavioral strategy here is straightforward but often overlooked: Before implementing complex interventions for effective behavioral strategies for managing recurrent sleepwalking, start with the basics. Get evaluated for sleep-disordered breathing, periodic limb movements, and other conditions that fragment sleep. A two-week trial of sleep extension, going to bed earlier and sleeping as long as possible, can reveal whether sleep debt is a major factor. If you notice fewer episodes during this period, you’ve identified a modifiable trigger.

Scheduled Awakening: The Counterintuitive Approach That Works

One of the most well-established behavioral interventions sounds almost too simple: wake up 15-20 minutes before your typical sleepwalking time and stay awake for a few minutes.

Here’s how it works. Many sleepwalkers have episodes that cluster within predictable windows—often 1-3 hours after sleep onset, during the first cycle of deep slow-wave sleep. By tracking episode timing over several nights (a bed partner can help, or you can review signs like moved objects or unlocked doors), you can identify this window.

Then, you set an alarm for 15-20 minutes before the typical episode time. When it goes off, you wake fully. Perhaps go to the bathroom, get a drink of water, or check your phone for a minute. This brief, full awakening disrupts the brain state that leads to partial arousal and sleepwalking.

The evidence for this technique comes from multiple sources. A systematic review of behavioral treatments for NREM parasomnias found scheduled awakening particularly effective for children, and similar success has been documented in adults. The mechanism appears to be “resetting” the sleep cycle, preventing the incomplete arousal that characterizes sleepwalking.

One caveat: this approach works best when episodes are frequent and predictable. For those with sporadic episodes occurring at random times, other strategies may be more appropriate.

The Psychological Dimension: When Your Mind’s Daytime Defenses Are Breaking Down at Night

Remember the woman whose sleepwalking improved through psychotherapy? Her case isn’t isolated. Research increasingly suggests that for many adults, recurrent sleepwalking reflects inadequate psychological coping mechanisms being overwhelmed by stress.

Studies have shown that sleepwalkers often exhibit unstable behavioral patterns for managing aggression and stress, suggesting a failure of mature defensive mechanisms when faced with overwhelming pressure. The Brazilian study documented two patients whose sleepwalking was closely tied to psychological conflicts—one struggling with suppressed aggression, another with difficulty asserting boundaries in relationships.

Both patients underwent psychotherapy focused not on the sleepwalking itself but on developing better emotional regulation strategies: recognizing and confronting conflicts rather than suppressing them, learning to assert needs, managing aggressive impulses more effectively. As their daytime coping improved, their nighttime sleepwalking decreased.

What does this mean practically? If your sleepwalking worsens during periods of high stress or following emotionally difficult events, addressing the psychological dimension may be as important as managing sleep hygiene. This doesn’t necessarily mean years of psychoanalysis. Cognitive-behavioral approaches, including CBT for insomnia (CBT-I) and Mindfulness-Based Stress Reduction, have shown promise. One study reported improvements in 30 of 40 patients without sleep apnea or periodic limb movements using these approaches.

Sleep Hygiene Isn’t Optional: The Foundation That Everything Else Builds On

I know “sleep hygiene” sounds boring—almost like a cop-out answer. But here’s why it matters specifically for effective behavioral strategies for managing recurrent sleepwalking: every violation of good sleep practices is potentially a priming or precipitating factor.

The research is clear on this. Zadra’s work has shown that sleep deprivation dramatically increases both the frequency and complexity of sleepwalking episodes. In laboratory studies, 25 hours of sleep deprivation followed by recovery sleep induced sleepwalking in 100% of predisposed adults, compared to just 30% during normal sleep conditions.

But it’s not just total sleep deprivation. Anything that fragments or destabilizes slow-wave sleep can trigger episodes. This includes alcohol (which initially deepens sleep but causes fragmentation later), certain medications (particularly benzodiazepine receptor agonists like zolpidem), evening caffeine, irregular sleep schedules, sleeping in unfamiliar environments, and even bedroom noise.

The behavioral intervention here is methodical: For two weeks, maintain strict sleep hygiene. Same bedtime and wake time every day (yes, weekends too). Avoid alcohol and caffeine after noon. Create a dark, quiet, cool bedroom environment. If you sleep with a partner who moves frequently, consider temporary sleeping arrangements to test whether their movements are triggering your arousals.

Dr. Zadra’s research team at the Center for Advanced Research in Sleep Medicine has found that sleepwalkers show altered autonomic nervous system function during deep sleep, with lower “fight or flight” response and higher “rest and digest” activity. This may make them more vulnerable to incomplete arousals when sleep is disrupted. Protecting sleep quality isn’t just good advice—it’s targeting a specific vulnerability.

Medication Audit: The Hidden Trigger in Your Medicine Cabinet

This is one aspect that gets far too little attention. Numerous medications can trigger or worsen sleepwalking in predisposed individuals. The list includes SSRIs, tricyclic antidepressants, beta-blockers, some antibiotics, lithium, antipsychotics, anticonvulsants, and particularly sedative-hypnotics like zolpidem.

The mechanism varies. Some medications increase slow-wave sleep (making episodes more likely). Others impair arousal mechanisms (making partial arousals more probable). Some do both. A systematic review found that zolpidem has been strongly associated with sleepwalking even in people with no prior history.

If you started or changed medications around the time your sleepwalking began or worsened, this may not be coincidental. The behavioral strategy is to work with your prescriber to review your medications. Can any be discontinued safely? Are there alternatives less likely to affect sleep architecture? Sometimes switching from one SSRI to another, or adjusting timing of doses, can make a significant difference.

Environmental Modifications: Making Peace with the Fact That Episodes May Still Occur

Even with perfect implementation of prevention strategies, some episodes may still occur. This doesn’t mean the approach has failed—remember, the goal is reducing frequency and severity, not necessarily achieving complete elimination.

Safety modifications are still behavioral strategies, just secondary ones. The basics include securing windows and doors (especially for upper-floor bedrooms), removing sharp objects and tripping hazards, and placing alarms on bedroom doors. Sleeping on the ground floor is also advisable if possible.

But here’s a nuance worth noting: creating a completely “sleepwalker-proof” environment can paradoxically increase anxiety about episodes, which itself can worsen sleep quality and episode frequency. The goal is reasonable precautions, not a fortress. One patient I’ve read about found that installing a simple bell on the bedroom door gave their partner peace of mind without creating anxiety for the sleepwalker.

The Chronic Sleep Debt Solution: Two Weeks Can Change Everything

Research on sleep deprivation and sleepwalking reveals something interesting: many adult sleepwalkers are chronically sleep-deprived without realizing it. They may think they “function fine” on 6-7 hours, but their bodies are accumulating sleep debt that primes them for episodes.

One of the most powerful behavioral interventions is deceptively simple: sleep extension for two weeks. Go to bed earlier. Sleep as long as your body wants. Don’t set an alarm on weekends. Track your sleepwalking frequency during this period.

The rationale comes from understanding “homeostatic sleep drive”—the pressure to sleep that builds with each hour awake. When this drive is chronically elevated, it makes slow-wave sleep more intense and potentially more unstable, increasing the likelihood of incomplete arousals. A two-week period of sleep extension helps “unload” this accumulated drive.

Many patients are shocked to discover they need 9-10 hours of sleep to feel truly rested. Once they start getting this amount regularly, sleepwalking episodes often decrease markedly or disappear entirely. The challenge, of course, is maintaining this in the context of work, family, and social obligations—but that’s where priorities must be examined honestly.

Stress Management: The Daily Practice That Pays Nighttime Dividends

Here’s an uncomfortable truth: if your stress management strategy is “push through it” or “I’ll relax when things calm down,” you’re likely priming yourself for ongoing sleepwalking. Research from Dauvilliers’s group found that 59% of sleepwalkers identified stress and strong emotions as episode triggers.

The question isn’t whether to manage stress—it’s how. Effective behavioral strategies for managing recurrent sleepwalking must include a daytime component. This might be formal meditation or mindfulness practice, regular exercise (though not within 3 hours of bedtime), or therapy to address ongoing conflicts. Even just protected “decompression time” before bed can make a difference.

The mechanism appears to be bidirectional: poor stress management disrupts sleep quality and increases arousal frequency, while poor sleep reduces stress resilience and impairs emotional regulation. Breaking this cycle requires addressing both ends.

Additionally, learning to identify and address emotional triggers before they build to overwhelming levels can prevent the kind of psychological pressure that may manifest as nighttime episodes. This is especially relevant given research suggesting that sleepwalking may represent a failure of mature defensive mechanisms under stress.

When to Consider More Intensive Interventions

Behavioral strategies aren’t always sufficient. If you’ve implemented these approaches for 6-8 weeks without significant improvement, or if episodes are frequent, dangerous, or severely impacting quality of life, it may be time to consider:

• Polysomnography (sleep study): This can definitively diagnose sleep apnea, periodic limb movements, and other sleep disorders. It can also confirm whether episodes are truly sleepwalking versus another condition like REM sleep behavior disorder or nocturnal seizures.
• Hypnosis: Some research suggests efficacy approaching that of clonazepam (64% improvement in disorders of arousal). This requires working with an experienced sleep specialist or behavioral therapist trained in hypnotherapy for parasomnias.
• Medication: While this article focuses on behavioral approaches, clonazepam has shown 73% efficacy in a retrospective study of 103 adults. However, many clinicians are reluctant to prescribe daily benzodiazepines long-term, and some patients don’t respond or experience side effects.

The Long View: Why Behavioral Strategies Require Patience and Persistence

One of the challenges with behavioral approaches is they rarely work overnight (pun somewhat intended). Unlike taking a medication that might show effects within days, implementing effective behavioral strategies for managing recurrent sleepwalking requires weeks to months of consistent effort.

This can be frustrating, especially when episodes are frequent or frightening. But consider what you’re actually doing: you’re not just suppressing a symptom—you’re addressing the underlying conditions that allow episodes to occur. You’re changing sleep architecture, reducing physiological and psychological priming factors, and eliminating precipitating triggers.

Research from Zadra’s 2024 study on sleep deprivation effects found that younger age and higher home episode frequency both predicted better response to interventions. This suggests that aggressive early implementation of behavioral strategies may be particularly worthwhile.

The Personalized Approach: Why What Works for Others Might Not Work for You

Here’s something that often gets lost in treatment recommendations: sleepwalking in adults is heterogeneous. The person whose episodes are triggered by undiagnosed sleep apnea needs different interventions than the person whose episodes cluster around periods of psychological stress, which differs from the person taking a medication that disrupts sleep architecture.

This is why effective behavioral strategies for managing recurrent sleepwalking must be individualized. Start with the framework:

1. Identify and treat sleep disorders: Get evaluated for sleep apnea, restless legs, periodic limb movements
2. Address sleep debt: Try two weeks of sleep extension
3. Audit medications: Review anything that might affect sleep architecture
4. Implement scheduled awakening: If episodes are frequent and predictable
5. Address psychological factors: If stress or emotional triggers are prominent
6. Optimize sleep hygiene: Universal but often undervalued

Track your results methodically. Keep a log of episode frequency, severity, and any noticed triggers. This data allows you to identify which interventions are helping and which aren’t moving the needle for you specifically.

A Final Reflection: Beyond Just “Stopping the Walking”

Perhaps the most important insight from recent sleepwalking research is this: the goal isn’t just to stop the episodes—it’s to address the underlying sleep and psychological health issues that allow them to occur.

When Dauvilliers’s research found that adult sleepwalkers had significantly higher rates of daytime sleepiness, fatigue, insomnia, depression, and anxiety compared to controls, it revealed that sleepwalking is often a marker of broader problems with sleep quality and mental health.

By implementing effective behavioral strategies for managing recurrent sleepwalking, you’re not just reducing nighttime wandering—you’re improving sleep quality, reducing stress, addressing mood issues, and potentially treating undiagnosed sleep disorders. You’re building better psychological coping mechanisms and eliminating sources of sleep fragmentation.

In other words, the same interventions that reduce sleepwalking often make you healthier and more resilient across multiple domains. That’s the real victory.

What’s your experience with sleepwalking management? Have you discovered triggers or interventions that made a difference? Share your insights in the comments—your experience might be exactly what someone else needs to hear.

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FAQ

Q: What does “effective behavioral strategies for managing recurrent sleepwalking” actually mean?

A: Behavioral strategies are non-medication interventions that address the conditions and triggers that allow sleepwalking episodes to occur. Unlike pharmacological treatments, they focus on modifying sleep patterns, environmental factors, stress levels, and underlying sleep disorders. “Effective” strategies are those supported by clinical research and proven to reduce episode frequency and severity in adult populations. “Recurrent” means the sleepwalking happens repeatedly—multiple episodes per month over extended periods—rather than isolated, occasional events.

Q: What is polysomnography and why does it matter for sleepwalking?

A: Polysomnography (PSG) is an overnight sleep study that records brain waves, blood oxygen levels, heart rate, breathing, eye movements, and leg movements. For sleepwalkers, PSG serves two critical purposes: First, it can diagnose underlying sleep disorders like sleep apnea or periodic limb movements that trigger episodes. Second, if episodes occur during the study, it can confirm the diagnosis and rule out conditions that mimic sleepwalking, such as REM sleep behavior disorder or nocturnal seizures. The catch is that PSG is expensive and episodes don’t always occur during a single night of monitoring.

Q: What are “predisposing, priming, and precipitating factors” in the 3 P framework?

A: This framework, developed by sleep researcher Dr. Mark Pressman and widely used in parasomnia research, explains how sleepwalking episodes occur through three types of factors working together. Predisposing factors are genetic vulnerabilities you’re born with—if your parents had sleepwalking, you’re more likely to experience it. Priming factors are conditions that make episodes more likely by increasing slow-wave sleep or reducing arousal threshold: sleep deprivation, alcohol, certain medications, fever, or stress. Precipitating factors are immediate triggers that actually provoke an episode: a bed partner’s movement, bedroom noise, sleep apnea causing an arousal, or a full bladder. You need elements from all three categories for an episode to occur.

Q: What is slow-wave sleep (SWS) and why is it important for sleepwalking?

A: Slow-wave sleep is the deepest stage of non-REM sleep, characterized by slow brain waves (delta waves) on EEG. It typically occurs in the first third of the night and is when the body does most of its physical restoration. Sleepwalking almost always occurs during arousals from slow-wave sleep—the brain partially wakes while motor systems activate, but consciousness remains offline. Anything that increases slow-wave sleep (like sleep deprivation or alcohol) or makes arousal from it more likely (like sleep apnea or periodic limb movements) increases sleepwalking risk. This is why understanding and protecting slow-wave sleep quality is central to behavioral management strategies.

Q: What is obstructive sleep apnea (OSA) and why is it so common in sleepwalkers?

A: Obstructive sleep apnea is a condition where the airway repeatedly collapses during sleep, causing breathing pauses (apneas) that last 10 seconds or longer. Each apnea ends with an arousal—a brief lightening of sleep to restore breathing. These repeated arousals fragment sleep and can trigger sleepwalking episodes, especially if they occur during slow-wave sleep. Research shows that up to 88% of adult sleepwalkers in some studies have OSA, often undiagnosed. The remarkable finding is that treating OSA with CPAP (continuous positive airway pressure) resolved sleepwalking in 100% of adequately treated cases in one study, suggesting OSA is not just associated with sleepwalking but may be directly causing it through sleep fragmentation.

Q: What is scheduled awakening and how does it work?

A: Scheduled awakening involves waking the sleepwalker 15-20 minutes before their typical episode time and keeping them fully awake for several minutes. The technique requires first identifying when episodes typically occur (often 1-3 hours after sleep onset). Then, you set an alarm or have a partner wake you at the designated time. You must achieve full wakefulness—get up, go to the bathroom, drink water, check your phone—not just briefly open your eyes. This appears to “reset” the sleep cycle and prevent the incomplete arousal that leads to sleepwalking. The evidence for this approach is strong in children and increasingly documented in adults, though it works best when episodes are frequent and predictable rather than sporadic.

Q: What is the autonomic nervous system and how does it relate to sleepwalking?

A: The autonomic nervous system regulates involuntary body functions like heart rate, blood pressure, and digestion. It has two main branches: the sympathetic system (responsible for “fight or flight” responses) and the parasympathetic system (responsible for “rest and digest” functions). Recent research from Dr. Antonio Zadra’s team found that during slow-wave sleep, sleepwalkers show an atypical pattern—elevated parasympathetic (“rest and digest”) activity and reduced sympathetic (“fight or flight”) activity. This altered autonomic function may make them more vulnerable to incomplete arousals and sleepwalking episodes, though exactly how this mechanism works remains under investigation.

Q: What medications are known to trigger or worsen sleepwalking?

A: Multiple medication classes can increase sleepwalking risk: Sedative-hypnotics (especially zolpidem/Ambien), antidepressants (SSRIs, tricyclics), antipsychotics (lithium, various atypicals), beta-blockers, some antibiotics, anticonvulsants, and benzodiazepines. The mechanisms vary—some increase slow-wave sleep duration, others impair normal arousal mechanisms, and some do both. Zolpidem is particularly notorious, with documented cases of complex behaviors including sleep-driving. If you started or changed any medication around the time sleepwalking began or worsened, discuss this with your prescriber—switching to an alternative or adjusting dosing timing may eliminate the problem.

Q: What is sleep architecture and how does it affect sleepwalking?

A: Sleep architecture refers to the pattern and structure of sleep stages throughout the night. Normal sleep cycles between non-REM stages (N1, N2, N3/slow-wave sleep) and REM sleep approximately every 90 minutes. Slow-wave sleep predominates in early cycles, REM in later ones. In sleepwalkers, this architecture may be unstable, with excessive slow-wave sleep, abnormal arousals, or disrupted cycling. Things that alter architecture—sleep deprivation, alcohol, sleep apnea, certain medications—can trigger episodes. This is why behavioral strategies focus on normalizing sleep architecture through consistent schedules, adequate sleep duration, and treating conditions that fragment sleep.

Q: What is cognitive-behavioral therapy for insomnia (CBT-I) and how can it help sleepwalking?

A: CBT-I is a structured program that addresses the thoughts and behaviors that prevent good sleep. It includes sleep restriction (limiting time in bed to match actual sleep time, then gradually increasing), stimulus control (associating bed with sleep only), sleep hygiene education, cognitive therapy (addressing anxiety about sleep), and relaxation training. While developed for insomnia, CBT-I has shown promise for sleepwalking when combined with mindfulness-based stress reduction. One study found improvement in 30 of 40 sleepwalking patients using these approaches. The mechanisms likely involve reducing arousal frequency, improving sleep quality and architecture, and addressing stress that may prime for episodes.

Q: What are the risks of untreated adult sleepwalking?

A: The risks extend beyond the obvious injury hazards. Research shows adult sleepwalkers have significantly higher rates of daytime sleepiness (42% of patients), chronic fatigue, depression, anxiety, and reduced quality of life compared to non-sleepwalkers. Injuries occur in up to 58% of adult sleepwalkers at some point, with 17% experiencing injuries severe enough to require medical care—fractures, lacerations, head trauma. There’s also risk to bed partners who may be injured during episodes. Recent research suggests untreated sleepwalking in older adults may be associated with increased mortality risk related to dementia and Parkinson’s disease, though more research is needed. Additionally, the chronic sleep disruption that underlies sleepwalking affects cognitive function, mood, and overall health.

Q: What is REM sleep behavior disorder and how is it different from sleepwalking?

A: REM sleep behavior disorder (RBD) occurs during REM sleep rather than slow-wave sleep. In RBD, the normal paralysis that accompanies REM sleep doesn’t occur, allowing people to physically “act out” their dreams. This typically involves violent or aggressive behaviors—punching, kicking, yelling—matching dream content. RBD occurs later in the night (when REM predominates) while sleepwalking occurs in early sleep (when slow-wave sleep predominates). RBD is often associated with neurodegenerative diseases like Parkinson’s and requires different treatment. It’s critical to distinguish between them because some sleepwalkers may also have RBD (“parasomnia overlap disorder”), and the treatment approaches differ significantly.

Q: Can psychotherapy really help with sleepwalking?

A: Yes, particularly when psychological factors contribute to episodes. Research documenting two adult cases found that psychotherapy focused on developing better coping strategies—managing aggression, asserting boundaries, confronting rather than suppressing conflicts—reduced episode frequency by up to 80%. The mechanisms appear to involve reducing psychological stress that primes for episodes and improving emotional regulation that may be failing during sleep. This doesn’t mean sleepwalking is “all in your head”—the neurophysiology is real—but for many adults, psychological stressors are significant priming factors. Approaches that have shown benefit include psychodynamic therapy focused on specific conflicts, cognitive-behavioral approaches, and mindfulness-based interventions.