Medical-legal aspects of sleep medicine

Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports

OBJECTIVE

To review systematically medical-legal cases of sleep-related violence (SRV) and sexual behavior in sleep (SBS).

SEARCH METHODS

We searched Pubmed and PsychINFO (from 1980 to 2012) with pre-specified terms. We also searched reference lists of relevant articles.

SELECTION CRITERIA

Case reports in which a sleep disorder was purported as the defense during a criminal trial and in which information about the forensic evaluation of the defendant was provided.

DATA EXTRACTION AND ANALYSIS

Information about legal issues, defendant and victim characteristics, circumstantial factors, and forensic evaluation was extracted from each case. A qualitative-comparative assessment of cases was performed.

RESULTS

Eighteen cases (9 SRV and 9 SBS) were included. The charge was murder or attempted murder in all SRV cases, while in SBS cases the charge ranged from sexual touching to rape. The defense was based on sleepwalking in 11 of 18 cases. The trial outcome was in favor of the defendant in 14 of 18 cases. Defendants were relatively young males in all cases. Victims were usually adult relatives of the defendants in SRV cases and unrelated young girls or adolescents in SBS cases. In most cases the criminal events occurred 1-2 hours after the defendant's sleep onset, and both proximity and other potential triggering factors were reported. The forensic evaluations widely differed from case to case.

CONCLUSION

SRV and SBS medical-legal cases did not show apparent differences, except for the severity of the charges and the victim characteristics. An international multidisciplinary consensus for the forensic evaluation of SRV and SBS should be developed as an urgent priority.

Diagnosis and treatment of sleep disorders: a brief review for clinicians

Sleep disorders encompass a wide spectrum of diseases with significant individual health consequences and high economic costs to society. To facilitate the diagnosis and treatment of sleep disorders, this review provides a framework using the International Classification of Sleep Disorders, Primary and secondary insomnia are differentiated, and pharmacological and nonpharmacological treatments are discussed. Common circadian rhythm disorders are described in conjunction with interventions, including chronotherapy and light therapy. The diagnosis and treatment of restless legs syndrome/periodic limb movement disorder is addressed. Attention is focused on obstructive sleep apnea and upper airway resistance syndrome, and their treatment. The constellation of symptoms and findings in narcolepsy are reviewed together with diagnostic testing and therapy, Parasomnias, including sleep terrors, somnambulism, and rapid eye movement (REM) behavior sleep disorders are described, together with associated laboratory testing results and treatment.

Legal issues encountered when treating the patient with a sleep disorder

As our understanding of sleep medicine grows, so does our obligation to protect patients and society from the potential harms of sleep disorders. Harm to self and others can take the form of violent behaviors during sleep or from sleep arousals, or from errors in judgment and motor skills due to excessive daytime sleepiness. Motor vehicle accidents and industrial accidents represent the majority of deaths and injuries due to sleep disorders. Errors in judgment and mental capacity can also lead to significant problems in terms of financial costs to businesses, inefficiencies in the workplace, and harm to others (as in the case of medical errors). Sleepiness can be so debilitating to an individual that he or she may qualify for disability compensation. The sleep specialist plays three basic roles in the interaction between the medical and legal fields: the educator, the medical examiner, and the expert witness. The education of the public, court officials, and patients is necessary to increase awareness of sleep disorders and their risks. The medical examination of the patient and subsequent treatment of the sleep disorder can help to minimize the risks of sleep disorders. Finally, if necessary, the sleep specialist may be called upon to provide expert testimony about the medical evidence provided and the likelihood that a sleep disorder contributed to an alleged criminal act.

Predictors of pain and function in persons with spinal stenosis, low back pain, and no back pain

STUDY DESIGN

Longitudinal masked, double-controlled cohort study.

OBJECTIVES

To determine prognosis and predictors of function and pain in persons with spinal stenosis.

SUMMARY OF BACKGROUND DATA

The clinical syndrome of spinal stenosis is common and disabling, but not clearly related to anatomic measures. Prognosis not well studied.

METHODS

Persons 55 to 80 years of age with and without stenosis on preliminary review of magnetic resonance imaging (MRI), and asymptomatic volunteers underwent screening, questionnaires, physical examination, ambulation testing, masked electromyogram (EMG), and masked MRI scans; these were repeated at >18 months.

RESULTS

Twenty-three asymptomatic, 28 back pain, and 32 clinically diagnosed stenosis subjects underwent follow-up. Although initial and follow-up diagnosis tended to agree (kappa = 0.394, P < 001), there were substantial shifts between the three groups. Among persons with clinically diagnosed stenosis, every measure trended for improvement, including significant changes in pain, ambulation, and EMG. Ambulation velocity and Pain Disability Index at follow-up were predicted by initial disability measures. Pain was predicted by initial sleep difficulty but not initial pain. EMG and MRI did not predict function or pain.

CONCLUSION

Clinically recognized spinal stenosis is fluctuating and largely improving, and in continuum with back pain and no symptoms. Since anatomic and neurologic deficits do not predict future function, they should not be weighed heavily in surgical risk-benefit discussions.

Clinical effects of sleep fragmentation versus sleep deprivation

Common symptoms associated with sleep fragmentation and sleep deprivation include increased objective sleepiness (as measured by the Multiple Sleep Latency Test); decreased psychomotor performance on a number of tasks including tasks involving short term memory, reaction time, or vigilance; and degraded mood. Differences in degree of sleepiness are more related to the degree of sleep loss or fragmentation rather than to the type of sleep disturbance. Both sleep fragmentation and sleep deprivation can exacerbate sleep pathology by increasing the length and pathophysiology of sleep apnea. The incidence of both fragmenting sleep disorders and chronic partial sleep deprivation is very high in our society, and clinicians must be able to recognize and treat Insufficient Sleep Syndrome even when present with other sleep disorders.

Parasomnias: epidemiology and management

The category of common sleep disorders known as parasomnias includes disorders of arousal, rapid eye movement (REM) sleep behaviour disorder (RBD), nocturnal seizures, rhythmic movement disorder, and tooth grinding or 'bruxism'. Parasomnias are all characterised as undesirable physical or behavioural phenomena occurring during the sleep period. Although these conditions can be distressing and, in some cases, hazardous to the sleeper and his or her bed partner, it is important to recognise that parasomnias are diagnosable and treatable in the vast majority of patients. Evaluation begins with a careful clinical interview with the sleeper and a family member to elucidate the frequency, duration, description and timing after sleep onset of these behavioural events. Disorders of arousal are the most common type of parasomnia and cover a spectrum from calm sleepwalking to emotionally agitated or complex behaviours, such as dressing or driving, for which the patient usually has no memory upon awaking. 'Sleep terrors' are quite common in young children and are often outgrown. Disorders of arousal represent a partial, as opposed to a full, awakening from deep non-REM sleep, typically occurring within the first 60 to 90 minutes after sleep onset. RBD is characterised clinically by a history of dream-enacting behaviour, and the patient may recall dream content. REM sleep periods typically occur in the latter half of the night. Physiologically, RBD results from a lack of the normal muscle atonia that is associated with REM sleep. RBD has been linked to a number of other neurological conditions; thus, a careful review of systems and a physical examination are crucial. A formal laboratory sleep study or polysomnogram with an expanded electroencephalographic montage can help distinguish among non-REM and REM parasomnias and nocturnal seizures. The latter may manifest clinically as arousals from sleep associated with vocalisation and/or complex behaviours. Rhythmic movement disorder can include head banging or body rocking at sleep onset or during the night. Tooth grinding is a common sleep-related behaviour that, when severe, can result in dental injury. Hypnagogic hallucinations (experience of dream imagery at sleep onset) and sleep-onset paralysis (experience of muscle/body paralysis as one is falling asleep) are symptoms rather than diagnostic categories. These phenomena classically occur in many individuals with narcolepsy, but also may occur in healthy sleep-deprived individuals. Safety precautions and good general sleep hygiene measures are recommended for individuals with a parasomnia, as the disorder can be exacerbated by sleep deprivation and various other factors. When the events are frequent or particularly dramatic, medication with a long- or medium-acting benzodiazepine, such as clonazepam, at bedtime is effective therapy in most cases of non-REM disorders of arousal and RBD. A dental guard may be helpful in tooth grinders. Relaxation training and guided imagery may be helpful strategies for some patients, especially those with disorders of arousal or rhythm movement disorders. There is no evidence of any association between parasomnias and psychiatric illness. Demystification of these conditions and reassurance, particularly for parents of paediatric patients, is an important aspect of clinical intervention.

The hazards and prevention of driving while sleepy

In the present paper the literature bearing on the association between sleepiness and driving is reviewed and the current state of prevention is discussed. Sleepiness may be a factor in about 20% of motor vehicle accidents and studies carried out in controlled environments suggest that the most common changes in driving performance attributable to sleepiness include increased variability of speed and lateral lane position. Higher-order functions including judgement and risk taking may also deteriorate. Moreover, prolonging wakefulness even by a few hours may produce deterioration in driving performance comparable to that seen in drivers with blood alcohol concentrations at levels deemed dangerous by legislation. The majority of prevention efforts to date have focussed on short-term solutions that only mask underlying sleepiness and it is suggested that more emphasis be directed toward primary prevention efforts such as educating drivers about the importance of getting sufficient sleep and avoiding circadian performance troughs. Finally, the important role that health professionals can play in the identification, treatment, and education of sleepy drivers is highlighted.

Diagnosis and management of parasomnias

Parasomnias are unpleasant or undesirable behavioral or experiential phenomena that occur predominately or exclusively during sleep. These phenomena were initially thought to represent a unitary event, often attributed to psychiatric disease. Recent clinical and polygraphic analysis has revealed that they are, in fact, the result of a large number of very different conditions, most of which are diagnosable and treatable. In fact, most are not the manifestation of psychiatric disorders, and they are far more prevalent than previously suspected. Although there are many parasomnias (1,2), from a practical standpoint only the few that comprise the overwhelming majority will be discussed in this review. These include disorders of arousal, rapid-eye-movement sleep behavior disorder, nocturnal seizures, and restless legs syndrome. Most parasomnias are readily diagnosable and, more importantly, are treatable.

Parasomnias: sleepwalking and the law

A recent, well-publicized case in which murder during sleepwalking was offered as a defense, underscores the fact that sleep medicine specialists are asked to render opinions or judgements regarding culpability in legal cases regarding violence claimed to have arisen from sleepwalking episodes. This review addresses this difficult issue from scientific, clinical and legal aspects, with emphasis upon the need for further research, calling for close collaboration between the legal and medical (both clinical and basic science) professions.