Sleep and its disorders

Sleep disorders are very prevalent in the general population and are associated with significant medical, psychological, and social disturbances. Insomnia is the most common. When chronic, it usually reflects psychological/behavioral disturbances. Most insomniacs can be evaluated in an office setting, and a multidimensional approach is recommended, including sleep hygiene measures, psychotherapy, and medication. The parasomnias, including sleepwalking, night terrors, and nightmares, have benign implications in childhood but often reflect psychopathology or significant stress in adolescents and adults and organicity in the elderly. Excessive daytime sleepiness is typically the most frequent complaint and often reflects organic dysfunction. Narcolepsy and idiopathic hypersomnia are chronic brain disorders with an onset at a young age, whereas sleep apnea is more common in middle age and is associated with obesity and cardiovascular problems. Therapeutic naps, medications, and supportive therapy are recommended for narcolepsy and hypersomnia; continuous positive airway pressure, weight loss, surgery, and oral devices are the common treatments for sleep apnea.

An analysis of a recent criminal trial involving sexual misconduct with a child, alcohol abuse and a successful sleepwalking defence: arguments supporting two proposed new forensic categories

The final judgment from a recent criminal trial in the British Columbia (Canada) Supreme Court is summarized and discussed. The trial involved sexual misconduct with a child, excessive alcohol use, and a successful 'sleepwalking (SW) defence' (non-insane automatism). Our comments on this trial provide an opportunity to present our arguments buttressing two newly proposed forensic categories: (i) parasomnia with continuing danger as a non-insane automatism, which originally was proposed for cases involving recurrent, sleep-related violence, but which can also be applied to SW cases involving sleep-related sexual misconduct and alcohol abuse (and other high-risk self-abusive behaviours); (ii) (intermittent) state-dependent continuing danger, an intermediate category within the 'continuing danger' concept, with the core feature being that a person acquitted of a criminal charge on the basis of the 'SW defence' (or some other parasomnia defence), in which the SW episode was provoked by a high-risk behaviour (e.g. alcohol intoxication) should bear full legal culpability for any future episode that was provoked by a recurrence of the high-risk behaviour--provided that the individual had wilfully engaged in that behaviour.

Psychogenic events presenting as parasomnia

A 10-year-old child suddenly developed nocturnal enuresis and nocturnal behaviors similar to parasomnia that were occasionally violent. The child had no recollection of the events. Continuous video/electroencephalograph monitoring revealed the episodic nocturnal events with bizarre behaviors during what was perceived to be sleep, but in fact, the child was fully awake with his eyes closed, prior to and during the events. The attacks ceased with individual psychotherapy and family counseling.

Sleepwalking disorder and mens rea: a review and case report. Maricopa County Superior Court

This paper examines complications of sleepwalking disorder (DSM-IV 307.46), an arousal disorder or parasomnia, in relationship to mens rea, or culpable mental state necessary to a finding of criminal responsibility. The legal history of criminal intent and insanity is reviewed. A case of indecent exposure is discussed in a man with a history of closed head injuries and sleepwalking disorder who was found standing naked in the middle of a busy urban thoroughfare in the wee hours of the morning and arrested. On psychiatric evaluation, the defendant was found to have a long-standing sleepwalking disorder. At trial, scientific literature and psychiatric expert testimony concerning sleepwalking disorder was presented. The psychiatrist opined that the defendant was probably sleepwalking at the time of the alleged offense. No rebuttal testimony was offered by the prosecution. The jury found the man not guilty. The author surveys the legal history of sleepwalking disorder and compares this example with others in which uncontrolled behavior during sleep has resulted in harm to the patient or to others. Clinical and forensic implications of the disorder are reviewed. The parasomnias' impact on forensic practice should be systematically studied. Intervention strategies should be refined and implemented.

The sleepwalking/night terrors syndrome in adults

A third of a million adults in the UK sleepwalk while a million suffer from night terrors. In both conditions the individual is unaware of the fullness of their surroundings and is totally focussed in their concern or activity. Doctors are only likely to become involved if the individual comes to harm or seeks help or if other people are inconvenienced or threatened. The constitutional basis of the disorder is beyond doubt, although the actual expression may be related to stressful life-events resulting from an individual's personality, relationships and circumstances. Treatment may include the provision of a secure environment, counselling, and the use of benzodiazepines and serotonin re-uptake inhibitors.

Epilepsy, aggression, and criminal responsibility

Although epilepsy-related violence can occur, accounts of criminal behavior caused by epilepsy remain rare and unconvincing. The authors describe a case of apparent postictal aggression, resulting in felony assault charges, by a patient who had nocturnal complex partial seizures, followed by what appeared to be sleepwalking and periods of postictal wandering and confusion.

Fear of suicide during sleepwalking

It is generally accepted that sleepwalking (SW) is a state of automatism in which an individual is unaware of, and has no control of, his or her behavior. Recently, Broughton et al. (1994) reported a case of a homicide and an attempted homicide during SW in which somnambulism was a legal defense and led to an acquittal. The wide variety in the clinical manifestations of SW and sleep terrors (ST) may sometimes lead to difficulties in diagnosing these treatable entities. The present case illustrates a diagnostic and clinical problem, deciding between histrionic behavior, suicidal acting out, REM-sleep behavioral disorder, and SW; and assessing the risk of suicide during SW.

Two cases of premenstrual sleep terrors and injurious sleep-walking

There are currently three recognized menstrual-related sleep disorders: premenstrual insomnia, menopausal insomnia and premenstrual hypersomnia. Another category, premenstrual parasomnia (sleep behavior disorder), is now suggested. Case 1, a 17-year-old female, presented with a 6-year history of exclusively premenstrual sleep terrors and injurious sleep-walking that began 1 year after menarche. During the four nights preceding each menses, she would scream and run from her bed. There was no history of premenstrual syndrome. Neurological evaluations had been unrevealing, apart from mild mental retardation and attention deficit disorder; there was no psychiatric history. Polysomnography 3 days before the onset of menses confirmed the diagnosis of sleep-walking. Pharmacotherapies were not satisfactory, but self-hypnosis at bedtime was rapidly effective with benefit sustained at 2.5-year follow-up. Case 2, a 46-year-old woman without psychiatric disorder, presented with a 5-year history of sleep terrors and injurious sleep-walking that initially was not menstrually related, but beginning 8 months prior to referral, she developed an exclusively premenstrual parasomnia that, after polysomnography, was partially controlled with bedtime self-hypnosis and clonazepam, 0.25 mg.

Successful treatment of night terrors and somnambulism with paroxetine

A patient with a 30-year history of somnambulism and night terrors is described. The use of a home ambulatory sleep electroencephalogram (EEG) recording in clarifying the diagnosis and in monitoring the results of treatment is illustrated and successful treatment using a selective serotonin re-uptake inhibitor is reported.

Additional categories of sleep-related eating disorders and the current status of treatment

Sleep-related eating disorders distinct from daytime eating disorders have recently been shown to be associated with sleepwalking (SW), periodic limb movement (PLM) disorder and triazolam abuse in a series of 19 adults. We now report eight other primary or combined etiologies identified by clinical evaluations and polysomnographic monitoring of 19 additional adults (mean age 40 years; 58% female): i) obstructive sleep apnea (OSA), with eating during apnea-induced confusional arousals (n = 3); ii) OSA-PLM disorder (n = 1); iii) familial SW and sleep-related eating (n = 2); iv) SW-PLM disorder (n = 1); v) SW-irregular sleep/wake pattern disorder (n = 1); vi) familial restless legs syndrome and sleep-related eating (n = 2); vii) anorexia nervosa with nocturnal bulimia (n = 2) and viii) amitriptyline treatment of migraines (n = 1). In our cumulative series of 38 patients (excluding six with simple obesity from daytime overeating), 44% were overweight (i.e. > 20% excess weight) from sleep-related eating. Nightly sleep-related binge eating (without hunger or purging) had occurred in 84% of patients. Onset of sleep-related eating was also closely linked with i) acute stress involving reality-based concerns about the safety of family members or about relationship problems (n = 6), ii) abstinence from alcohol and opiate/cocaine abuse (n = 2) and iii) cessation of cigarette smoking (n = 2). Current treatment data indicate a primary role of dopaminergic agents (carbidopa/L-dopa; bromocriptine), often combined with codeine and clonazepam, in controlling most cases involving SW and/or PLM disorder. Fluoxetine was effective in two of three patients. Nasal continuous positive airway pressure therapy controlled sleep-related eating in two OSA patients.

[Somnambulism and pavor nocturnus--review and case report]

A case of night terror with sleepwalking in an adult patient is described. Sleep polygraphic data are presented. The literature related to sleepwalking, night terror and its treatment is reviewed. The psychopathologic patterns of sleepwalking and night terror are illustrated and the differentiations of parasomnias and epileptic seizures discussed. The clinical applications of these findings are described and practical recommendations made for the management of NON-REM parasomnia.

[Non-epileptic sleep disorders (somnambulism) in epilepsy. Diagnostic and therapeutic possibilities]

The case history of a 15 1/2-year-old boy is presented who suffers from screaming fits during the night and epilepsia. The problem has existed since he was eight. He lives alone with his mother in a "partner-like" relationship. The previous diagnosis, namely epilepsy, has masked any possible psychodynamic element. Our diagnostic instruments were: 1. Standardized diagnostics with DSM III-R; 2. psychoanalytically oriented psychodiagnostics; 3. long term EEG-video-monitoring, which eventually succeeded in differentiating his multiple symptoms. Using these methods we were able to differentiate a sleep disorder (somnambulism) from his grandmal epilepsy. We changed his anticonvulsive pharmacological therapy and introduced an individual psychotherapy ("Katathymes Bilderleben"). This kind of psychotherapy is applied for the first time as a therapy for somnambulism. By using this therapeutic concept we cured our patient from his symptoms.

Sleep-related eating disorders: polysomnographic correlates of a heterogeneous syndrome distinct from daytime eating disorders

Over a 5-yr period, 19 adults presented to our sleep disorders center with histories of involuntary, nocturnal, sleep-related eating that usually occurred with other problematic nocturnal behaviors. Mean age (+/- SD) at presentation was 37.4 (+/- 9.1) yr (range 18-54); 73.7% of the patients (n = 14) were female. Mean age of sleep-related eating onset was 24.7 (+/- 12.9) yr (range 5-44). Eating occurred from sleep nightly in 57.9% (n = 11) of patients. Chief complaints included excessive weight gain, concerns about choking while eating or about starting fires from cooking and sleep disruption. Extensive polysomnographic studies, clinical evaluations and treatment outcome data identified three etiologic categories for the sleep-related eating: (a) sleepwalking (SW), 84.2% (n = 16); (b) periodic movements of sleep (PMS), 10.5% (n = 2) and (c) triazolam abuse (0.75 mg hs), 5.3% (n = 1). DSM-III Axis 1 psychiatric disorders (affective, anxiety) were present in 47.4% (n = 9) of the patients, and only two patients had a daytime eating disorder (anorexia nervosa), each in remission for 3-7 yr. Nearly half of all patients fulfilled established criteria for being overweight, based on the body mass index. Onset of sleep-related eating was linked directly to the onset of SW, PMS, triazolam abuse, nicotine abstinence, chronic autoimmune hepatitis, narcolepsy, encephalitis or acute stress. In the SW group, 72.7% (8/11) of patients had nocturnal eating and other SW behavior suppressed by clonazepam (n = 7) and/or bromocriptine (n = 2) treatment. Both patients with PMS likewise responded to treatment with combinations of carbidopa/L-dopa, codeine and clonazepam. Thus, sleep-related eating disorders can generally be controlled with treatment of the underlying sleep disorder.

Simultaneous prepubertal onset of panic disorder, night terrors, and somnambulism

Concurrent acute onset of night terrors, somnambulism, and spontaneous daytime panic attacks meeting the criteria for panic disorder is reported in a 10-year-old boy with a family history of panic disorder. Both the parasomnias and the panic disorder were fully responsive to therapeutic doses of imipramine. A second case of night terrors and infrequent full symptom panic attacks is noted in another 10-year-old boy whose mother has panic disorder with agoraphobia. The clinical resemblance and reported differences between night terrors and panic attacks are described. The absence of previous reports of this comorbidity is notable. It is hypothesized that night terror disorder and panic disorder involve a similar constitutional vulnerability to dysregulation of brainstem altering systems.

A retrospective outcome study and review of hypnosis as treatment of adults with sleepwalking and sleep terror

Hypnosis has been described anecdotally to be effective in the treatment of sleepwalking and sleep terror, potentially dangerous parasomnias. The authors report the use of hypnosis in the treatment of 27 adult patients with these disorders. A total of 74% of these individuals reported much or very much improvement when followed over substantial periods after instruction in self-hypnotic exercises that were practiced in the home. Hypnosis, often preferred over pharmacotherapy by patients, required one to six office visits (mean = 1.6). This represents a very cost-effective and noninvasive means of treatment, especially when constrasted with lengthy psychotherapy and pharmacotherapy.

[The dynamics of the evoked bioelectrical activity of the brain in unconscious states]

In 93 patients with mental disorders evoked bioelectrical activity of brain was studied in states of changed consciousness. Methods of evoked potentials and conditioned negative wave were applied. The obtained data allow to consider that in parameters and dynamics of bioelectrical activity changes of consciousness sphere are reflected.

Sleepwalking, night terrors, and consciousness

OBJECTIVE

To determine some personality and psychoneurotic characteristics of adults who have the sleepwalking-night terrors syndrome.

DESIGN

Prospective assessment of two groups of consecutive patients with a firm diagnosis of either of two specific sleep disorders as established clinically and by polysomnography.

SETTING

Outpatient sleep disorders clinic and sleep laboratory in a tertiary referral centre.

PATIENTS

12 Patients referred consecutively to the clinic in whom a diagnosis of sleepwalking (six) or night terrors (six) was confirmed.

MAIN OUTCOME MEASURES

Psychological characteristics as measured at the time of clinical assessment by means of the Eysenck personality questionnaire, the hostility and direction of hostility questionnaire, and the Crown-Crisp experiential index.

RESULTS

Both groups scored exceptionally highly on the hysteria scale of the Crown-Crisp experiential index and the night terrors group also scored highly on the anxiety scale. The patients with sleepwalking also scored highly on a measure of externally directed hostility.

CONCLUSIONS

The physiological and psychological features identified in these patients, possibly reflecting different expressions of a constitutional cerebral characteristic, may be explored in terms of hysterical dissociation. The findings contribute to the debate concerning the nature of sleepwalking, in particular with and without the forensic aspects.

Sleepwalking disorder during pregnancy: a case report

This report describes a case of sleepwalking during pregnancy. The author reviews the literature on sleepwalking during pregnancy and suggests that sleep during pregnancy merits renewed attention.

Episodic sleep disorders (parasomnias)

In the vast majority of patients with parasomnias, the evaluation can be accomplished in the office setting, based on information from the patients themselves and family members or other observers of the nocturnal events. Parasomnias are episodic sleep disorders that include sleepwalking, night terrors, and nightmares. All three conditions are more prevalent in childhood, when developmental factors appear to be responsible for their occurrence; in the much less frequent cases of a delayed onset or persistence in adulthood, psychopathologic states are often primary in their cause. Based on a number of clinical, physiologic, and etiopathogenetic similarities between sleepwalking and night terrors, these two conditions appear to fall along the same pathophysiologic and therefore nosologic continuum. They are both disorders of impaired arousal, characterized by various degrees of confusion, and they occur early in the night when slow-wave sleep predominates, whereas nightmares may occur at any time of the night, because they are closely associated with REM sleep. Another important issue relating to the assessment of parasomnias is to differentiate between nightmares and night terrors: in addition to the different time of night for their occurrence, nightmares are accompanied by much less anxiety, vocalization, motility, and autonomic discharge. Also, nightmare patients usually have vivid and elaborate recall for the event, whereas patients with night terrors are typically amnesic for their episodes, as are patients who sleepwalk. A mainstay in the management of sleepwalking and night terrors is instructing the patients and their family members to provide for adequate safety measures to prevent accidents that may occur during these events.(ABSTRACT TRUNCATED AT 250 WORDS)

Selected sleep disturbances in school children reported by parents: prevalence, interrelationships, behavioral correlates and parental attributions

Epidemiological, behavioral and etiological variables related to sleep disturbances were investigated in a survey of 1695 children in Grades 1 to 12 from 11 randomly selected schools. Sleep-walking, nightmares and sleep-talking were strongly associated with each other as well as to a family history of sleep-walking. Enuresis, however, was not related to the other sleep variables. Socioeconomic status of father was weakly related to enuresis and sleep-talking but not to sleep-walking or nightmares. Gender was not related to any of the sleep disturbances. The behavioral variables, physical activity, attention, emotional excitability, and feelings easily hurt showed a small association with the sleep disturbances. Parents most frequently attributed causes of sleep-walking and nightmares to over-tiredness and over-excitement. As well, parents' comments indicated that they tend to associate specific events such as illness or more often, frightening TV content with nightmares, but not sleep-walking.

On serious violence during sleep-walking

It is not sufficiently realised that sleep-walking is not an hysterical condition, nor in any way related to epilepsy, nor that it can be accompanied by violent injury to the self or others. Three case reports here include that of a 14-year-old boy who rose from his bed at 2 a.m. and severely stabbed his five-year-old girl cousin. The sleeping mind is not in touch with reality and amnesia for events during sleep is usual.