Sleep Violence and Polysomnography

First created | 10/02/2000

Last edited |

Summary by Maurice M. Ohayon, MD, DSc, PhD
Reference to cite:

  1. Ohayon MM. Violence and Sleep. Sleep and Hypnosis, 2000; 2: 1-6.

In the last decade, 16 polysomnographic (PSG) studies involving at least five cases with violent or injurious behaviors during sleep can be found in the MEDLINE.

  • Nine of them included exclusively (or almost) REM behavioral disorder (RBD) (7-15).
  • Two studies were devoted to sleepwalking and/or sleep terrors patients (16,17).
  • Only one compared different parasomnias involving violent or injurious behaviors during sleep (see Table 1) (18).

Kavey et al. (16) studied 10 sleepwalkers with episodes of violent behavior or self-injury. Recorded sleepwalking episodes occurred all in the NREM sleep but were not limited to the first third of the night as suggested by the classifications; near half of recorded episodes occurred in the latter 2/3 of the night.

Moldofsky et al. (17) studied 64 consecutive patients with sleepwalking or sleep terrors. They further divided the patients within three groups: those who committed serious violence during sleep to other individuals, property or self; those with harmful but not destructive behavior and nonviolent behavior during sleep. The serious violent group was composed mainly of men (22/26). Both violent and harmful behaviors were more likely to occur with drug abuse (caffeine, alcohol, drugs). The best predictors of violent group membership were being a man and having <2% stage 4 sleep.

Schenck et al. (18) studied 100 consecutive adults patients with a main complaint of nocturnal injury to themselves and/or their bedpartners. About half of them were with night terrors-sleepwalking, 36 had RBD, seven a dissociative disorder, two nocturnal seizures and one sleep apnea and periodic limb movements disorder. In the night terrors-sleepwalking group, some results were different of the current opinion about this disorder:

  • First, in about one third of cases, the disorder begun in late adolescence or adulthood;
  • Second, all NREM sleep stages are commonly involved;
  • Third, elaborate dreamlike mentation can be present with substantial recall of nocturnal behaviors;
  • Forth, a current mental disorder was present in only one third of this group.


In the RBD group, prodromal symptoms appeared 10 to 40 years before the full manifestation of the disorder in 25% of the studied cases. This prodrome is characterized by sleep talking, yelling, or limbjerking during sleep.
The initial sample of Schenck et al. (7) to describe RBD included four men and one woman, all aged 60 years or over. Four of them had neurological disorders.
In all studies, RBD is observed almost exclusively in men and is frequently associated with a neurological disorder. The polysomnographic results showed a higher REM density than normal in all studies on RBD. Some studies reported excessive slow-wave sleep for the age of patients (7,8,11,13,14) but this was not found in other studies (19). This could be due to the heterogeneity of neurological diseases observed in RBD patients. A study investigated 12 non-epileptic young patients with episodic nocturnal wanderings (20), a disorder that shares many similarities with sleepwalking/night terrors but thought to have an epileptiform etiology because it is responding to anticonvulsants. Nocturnal seizures are difficult to capture on EEG and may have uncertain significance since they can be also observed in many other neurological conditions and also in normal subjects. In this study, the epileptiform etiology have been confirmed only in four of the twelve patients.

Table 1. Summary of the samples including subjects with violent or injurious behaviors during sleep RBD*: REM Behavior Disorder
Authors N of cases M/F Age range Sleep diagnosis
Schenck et al (1986)(7) 5 4/1 60-72 RBD*
Schenck et al (1987)(8) 5 5/0 57-75 RBD
Maselli et al (1988)(20) 12 7/5 19-29 Episodic nocturnal wandering
Shimizu et al (1990)(9) 14 10/4 48-73 RBD
Sforza et al.(1988)(10) 6 5/1 42-69 RBD
Culebras &Moore (1989)(11) 6 4/2 64-74 RBD
Schenck et al (1989)(18) 100 71/29 18-79 Sleepwalking/Night terrors (n=54)
 
RBD (n=36)Others (n=10)
Kavey et al (1990)(16) 10 6/4 18-40 Sleepwalking
Schenck et al.(1990)(12) 70 63/7 10-77 RBD
Schenck &Mahowald (1991)(13) 20 17/3/td> 20-81 17 RBD,3 Sleep walking/Night
terrors
Tachibana et al (1991)(19) 7 3/4 61-81 RBD
Schenck et al.(1992)(43) 17 12/5 8-74 Narcolepsy +RBD
Lapierre &Montplaisir (1992)(14) 5 3/2 44-65 RBD
Moldofsky et al (1995)(17) 64 39/25 18-71 Sleepwalking or Night terrors
Comella et al (1998)(15) 9/61 7/2 9 RBD,52 Parkinson disease

REFERENCES

  1. Fraser JG. The Golden Bough. London: MacMillan, 1960.
  2. Walker N. Crime and insanity in England. University of Edinburgh Press, 1968.
  3. Bonkalo A. Impulsive acts and confusional states during incomplete arousal from sleep: criminological and forensic implications. Psychiatr Q 1974;48:400-409.
  4. Gudden D. Die physiologische und pathologische schlorftrunkenheit. Arch Psychiat 1905;40:989-1015.
  5. Schmidt G. Die Verbrechen in der schlaftrunkenheit. Journal of Neurology and Psychiatry 1943;176:208-253.
  6. Ohayon MM, Caulet M, Priest RG. Violent Behaviour During Sleep. J Clin Psychiatry 1997; 58:369-378.
  7. Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: A new category of parasomnia. Sleep 1986;9:293-308.
  8. Schenck CH, Bundlie SR, Patterson AL, Mahowald MW. Rapid eye movement sleep behavior disorder. A treatable parasomnia affecting older adults. JAMA 1987;257:1786-1789.
  9. Shimizu T, Jnami Y, Sugita Y, et al. REM Sleep without muscle atonia (Stage 1-REM) and its relation to delirious behavior during sleep in patients with degenerative diseases involving the brain stem. Jpn J Psychiatr Neurol 1990;44:681-692.
  10. Sforza E, Zucconi M, Petronelli R, Lugaresi E, Cirignotta F. REM Sleep Behavioral Disorders. Eur Neurol 1988;28:295-300.
  11. Culebras A, Moore JT. Magnetic resonance findings in REM sleep behavior disorder. Neurology 1989;39:1519-1523.
  12. Schenck CH, Mahowald MW. Polysomnographic, neurologic, psychiatric, and clinical outcome report on 70 consecutive cases with REM sleep behavior disorder (RBD): sustained clonazepam efficacy in 89.5% of 57 treated patients. Clev Clin J Med 1990;57(suppl):9-23.
  13. Schenck CH, Mahowald MW. Injurious sleep behavior disorders (parasomnias) affecting patients on intensive care units. Intensive Care Med 1991;17:219-224.
  14. Lapierre O, Montplaisir J. Polysomnographic features of REM sleep behavior disorder: development of a scoring method. Neurology 1992;42:1371-1374.
  15. Comella CL, Nardine TM, Diederich NJ, Stebbins GT. Sleep-related violence, injury, and REM sleep behavior disorder in Parkinson's disease. Neurology 1998;51:526-529.
  16. Kavey NB, Whyte J, Resor SR Jr, Gidro Frank S. Somnambulism in adults. Neurology 1990;40:749-752.
  17. Moldofsky H, Gilbert R, Lue FA, Maclean AW. Sleep-related violence. Sleep 1995;18:731-739.
  18. Schenck CH, Milner DM, Hurwitz TD, Bundlie SR, Mahowald MW. A polysomnographic and clinical report on sleep-related injury in 100 adult patients. Am J Psychiatry 1989;146:1166-1173.
  19. Tachibana N, Sugita Y, Terashima K, Teshima Y, Shimizu T, Hishikawa Y. Polysomnographic characteristics of healthy elderly subjects with somnambulism-like behaviors. Biol Psychiatry 1991;30:4-14.
  20. Maselli RA, Rosenberg RS, Spire JP. Episodic nocturnal wanderings in non-epileptic young patients. Sleep 1988;11:156-161.
  21. Kales JD, Kales A, Soldatos CR, Caldwell AB, Charney DS, Martin ED. Night terrors. Clinical characteristics and personality patterns. Arch Gen Psychiatry 1980;37:1413-1417
  22. Ohayon MM, Guilleminault C, Priest RG. Night terrors, sleepwalking, and confusional arousals in the general population: their frequency and relationship to other sleep and mental disorders. J Clin Psychiatry 1999;60:268-276.
  23. Ohayon MM, Zulley J, Guilleminault C, Smirne S. Prevalence and pathological associations of sleep paralysis in the general population. Neurology 1999;52:1194-200.
  24. Kavey NB, Whyte J. Somnambulism associated with hallucinations Psychosomatics 1993;34:86-90.
  25. Hurwitz TD, Schenck CH, Mahowald MW. Sleepwalking-sleep terrors-REM sleep behavior disorder: overlapping parasomnias. Sleep Research 1991;20:260 (abstract.)
  26. Langel deke A. Delikte in schlafzut nde. Der Nervenarzt 1955;26:28-30.
  27. Raschka LB. Sleep and violence. Can J Psychiatry 1984;29:132-134.
  28. Nofzinger EA, Wettstein. Homicidal behavior and sleep apnea: a case report and medicolegal discussion. Sleep 1995;18:776-782.
  29. Hopwood J, Snell HK. Amnesia in relation to crime. Journal of Mental Science 1933;79:27-41.
  30. Podolsky E. Somnambulistic homicide. Med Sci Law 1961;1:260-265.
  31. Brookes AD. Law, psychiatry and the mental health system. Boston, Little Brown & Co, 1974.
  32. Watkins L. The sleepwalk killers. London, Everest Books, 1976.
  33. Luchins DJ, Sherwood PM, Gillin JC, Mendelson WB, Wyatt RJ. Filicide during psychotropic-induced somnambulism: a case report. Am J Psychiatry 1978;135:1404-1405.
  34. Hartmann E. Two case reports: night terrors with sleepwalking-a potential lethal disorder. J Nerv Ment Dis 1983;171:503-505.
  35. Oswald I, Evans J. On serious violence during sleep-walking. Br J Psychiatry 1985;147:688-691.
  36. Tarsh MJ. On serious violence during sleepwalking. Br J Psychiatry 1986;148:476.
  37. Howard C, D'Orban PT. Violence in sleep: Medico-legal issues and two case reports. Psychol Med London 1987;17:915-925.
  38. Brahams D. Sleepwalking, "disease of the mind"? Lancet 1991;338:375-376.
  39. Ovuga EB. Murder during sleep-walking. East Afr Med J 1992;69:533-534.
  40. Broughton R, Billings R, Cartwright R, et al. Homicidal somnambulism: A case report. Sleep 1994;17: 253-264.
  41. Lemoine P, Lamothe P, Ohayon M. Violence, sleep and benzodiazepines. Am J Foren Psychiatry 1997;18(4):17-26.
  42. Schenck CH, Mahowald MW. An analysis of a recent criminal trial involving sexual misconduct with a child, alcohol abuse and a successful sleepwalking defense: arguments supporting two proposed new forensic categories. Med Sci Law 1998;38:147-152.
  43. Schenck CH, Mahowald MW. Motor dyscontrol in narcolepsy: Rapid-eye-movement (REM) sleep without atonia and REM sleep behavior disorder. Ann Neurol 1992;32:3-10.
Content of this page is extracted from:
Ohayon MM. Violence and Sleep. Sleep and Hypnosis, 2000; 2: 1-6.