Parasomnias manifest different phenotypes of sleep-related behaviors in age and sex groups. A YouTube-based video research highlighting the age slope of sleepwalking

STUDY OBJECTIVE

Finding typical patterns - phenotypes - of sleep behaviors characterizing parasomnias in different age and sex groups.

METHODS

We analyzed YouTube videos on sleep-related behaviors likely representing parasomnias. We applied the search terms "sleepwalking", "somnambulism", "sleep eating", "sleep sex", "sleep talking", and "aggression in sleep" in six languages. We classified those persons shown on the videos into estimated biological sex and age (child, adult, elderly) groups. We scored the activity types by a self-made scale and applied binary logistic regression to analyze the association between sleep behaviors versus sex and age groups by the STATA package, providing a 95% confidence interval and the probability of statistical significance.

RESULTS

224 videos (102 women, 68 children, 16 adults, and 40 elderly people) were scored. Elderly people had significantly (P < 0.012) lower odds of sleepwalking compared to adults and children. Adult females performed complex manual activities during sleepwalking more often than males (P < 0.012). Elderly males had 40-fold odds compared to adults and children, to perform aggressive movements and 70-fold odds of complex movements in bed, compared to adults. Elderly people presented emotional behaviors less frequently than adults (P < 0.004), and females showed them twice as often as males. Adults sleep-talked full sentences more often than children and elderly people (P < 0.001).

CONCLUSION

Our results support the existence of age- and sex-specific parasomnia phenotypes, denoting possible safety measures. The remarkably low odds of sleepwalking in the elderly highlight the possibility of different pathomechanisms in higher age groups compared to children.

BRIEF SUMMARY AND STUDY IMPACT

Parasomnias present highly variable clinical forms and often cause injuries. Identifying typical phenotypes may help risk management and imply theoretical conclusions. Our study supports the existence of age-specific parasomnia phenotypes. We found that adult women have a high risk of performing dangerous activities during sleep, and elderly males often move violently in bed, likely representing dream enactment behaviors. Elderly people of both sexes have low odds of sleep ambulation- likely representing somnambulism; compared to adults and children, constituting a descending "age slope" of somnambulism that might reflect different underlying pathomechanisms in children versus adults and the elderly.

[Strangulation as scenic behavior. A case report of a pseudosuicide in the course of a NREM-parasomnia]

It is generally accepted, that sleepwalkers show complex behaviors leading to non-intended consequences. It is not unusual that these persons are thereby injured. However, sporadically a bizarre endangering of themselves or others is reported also, which ranges from homicide of the life partner to accidental (pseudo-)suicide.In this article, we report on a 28year-old man who unexpectedly attempted to hang himself by a whip at night. We discuss the reasons, why this bizarre act should actually be taken as a scenic behavior in the course of a NREM-parasomnia, and the difficulty to proof this claim.

Sleep in children with Angelman syndrome: Parental concerns and priorities

Angelman syndrome is a rare genetic syndrome, in which sleep disturbances are reported for 20-80% of individuals (Williams et al., 2006). This interview study delineated parental perceptions of sleep problems experienced by children with Angelman syndrome and the impact on parental sleep quality, health and wellbeing. The nature of desired interventions was also explored. Semi-structured interviews were completed with parents of 50 children, aged 16 months-15 years with Angelman syndrome who experienced current or historic sleep problems; predominantly night waking and settling problems. Parents were concerned by the impact of their child's sleep quality upon their own ability to function during the day. The importance of considering parental experiences was evidenced by variability in coping e.g. despite the persistence of sleep problems 20% of parents did not feel the need for any additional support. Amongst a range of types of further support desired, 27% cited further support with a behavioural intervention, and information about the trajectory of sleep problems in Angelman syndrome (18%). The results suggest that behavioural interventions supporting both children and parents in improving their sleep quality and well-being, and longitudinal research into sleep problems should be prioritised.

Stick or Switch: A Selection Heuristic Predicts when People Take the Perspective of Others or Communicate Egocentrically

This paper examines a cognitive mechanism that drives perspective-taking and egocentrism in interpersonal communication. Using a conceptual referential communication task, in which participants describe a range of abstract geometric shapes, Experiment 1 shows that perspective-taking and egocentric communication are frequent communication strategies. Experiment 2 tests a selection heuristic account of perspective-taking and egocentric communication. It uses participants’ shape description ratings to predict their communication strategy. Participants’ communication strategy was predicted by how informative they perceived the different shape descriptions to be. When participants’ personal shape description was perceived to be more informative than their addressee’s shape description, there was a strong bias to communicate egocentrically. By contrast, when their addressee’s shape description was perceived to be more informative, there was a strong bias to take their addressee’s perspective. When the shape descriptions were perceived to be equally informative, there was a moderate bias to communicate egocentrically. This simple, but powerful, selection heuristic may be critical to the cumulative cultural evolution of human communication systems, and cumulative cultural evolution more generally.

Sleep of M&#257;ori and non-M&#257;ori of Advanced Age

AIM

To estimate prevalence and identify predictors and outcomes of reporting sleep problems in M&#257;ori and non-M&#257;ori of advanced age.

METHOD

Participants were 251 M&#257;ori, and 398 non-M&#257;ori adults (79-90 years) from Te Pu&#257;waitanga o Ng&#257; Tapuwae Kia Ora Tonu. Life and Living in Advanced Age: A Cohort Study in New Zealand. Multiple logistic regression identified predictors of reporting a current sleep problem and investigated relationships between current sleep problems and physical and mental health.

RESULTS

26.3% of M&#257;ori and 31.7% of non-M&#257;ori reported a current sleep problem. Reporting a current sleep problem was associated with ethnicity (non-M&#257;ori, adjusted OR=0.52, 95% CI=0.30-0.90), and reporting a past sleep problem (adjusted OR=2.67, 95% CI=1.25-5.72). Sleep problems were related to poorer physical and mental health, and falling.

CONCLUSION

Sleep problems are commonly reported and associated with poorer health. Early recognition and management of sleep problems could improve physical and mental health.

Increased Reward-Related Behaviors during Sleep and Wakefulness in Sleepwalking and Idiopathic Nightmares

BACKGROUND

We previously suggested that abnormal sleep behaviors, i.e., as found in parasomnias, may often be the expression of increased activity of the reward system during sleep. Because nightmares and sleepwalking predominate during REM and NREM sleep respectively, we tested here whether exploratory excitability, a waking personality trait reflecting high activity within the mesolimbic dopaminergic (ML-DA) system, may be associated with specific changes in REM and NREM sleep patterns in these two sleep disorders.

METHODS

Twenty-four unmedicated patients with parasomnia (12 with chronic sleepwalking and 12 with idiopathic nightmares) and no psychiatric comorbidities were studied. Each patient spent one night of sleep monitored by polysomnography. The Temperament and Character Inventory (TCI) was administered to all patients and healthy controls from the Geneva population (n = 293).

RESULTS

Sleepwalkers were more anxious than patients with idiopathic nightmares (Spielberger Trait anxiety/STAI-T), but the patient groups did not differ on any personality dimension as estimated by the TCI. Compared to controls, parasomnia patients (sleepwalkers together with patients with idiopathic nightmares) scored higher on the Novelty Seeking (NS) TCI scale and in particular on the exploratory excitability/curiosity (NS1) subscale, and lower on the Self-directedness (SD) TCI scale, suggesting a general increase in reward sensitivity and impulsivity. Furthermore, parasomnia patients tended to worry about social separation persistently, as indicated by greater anticipatory worry (HA1) and dependence on social attachment (RD3). Moreover, exploratory excitability (NS1) correlated positively with the severity of parasomnia (i.e., the frequency of self-reported occurrences of nightmares and sleepwalking), and with time spent in REM sleep in patients with nightmares.

CONCLUSIONS

These results suggest that patients with parasomnia might share common waking personality traits associated to reward-related brain functions. They also provide further support to the notion that reward-seeking networks are active during human sleep.

Sleep-related automatism and the law

Crimes carried out during or arising from sleep highlight many difficulties with our current law and forensic sleep medicine clinical practice. There is a need for clarity in the law and agreement between experts on a standardised form of assessment and diagnosis in these challenging cases. We suggest that the time has come for a standardised, internationally recognised diagnostic protocol to be set as a minimum standard in all cases of suspected sleep-related forensic cases. The protocol of a full medical history, sleep history, psychiatric history, neuropsychiatric and psychometric examination and electroencephalography (EEG), should be routine. It should now be mandatory to carry out routine polysomnography (PSG) to establish the presence of precipitating and modulating factors. Sleepwalking is classified as insane automatism in England and Wales and sudden arousal from sleep in a non-sleepwalker as sane automatism. The recent case in England of R v. Lowe (2005) highlights these anomalies. Moreover, the word insanity stigmatises sleepwalkers and should be dropped. The simplest solution to these problems would be for the law to be changed so that there is only one category of defence for all sleep-related offences--not guilty by reason of sleep disorder. This was rejected by the House of Lords for cases of automatism due to epilepsy, and is likely to be rejected for sleepwalkers. Removing the categories of automatism (sane or insane) would be the best solution. Risk assessment is already standard practice in the UK and follow up, subsequent to disposal, by approved specialists should become part of the sentencing process. This will provide support for the defendant and protection of the public.

Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity

STUDY OBJECTIVES

To review medical and legal case reports to determine how many appear to support the belief that violence against other individuals that occurs during Disorders of Arousal - sleepwalking, confusional arousal, and sleep terrors - is triggered by direct physical contact or close proximity to that individual and does not occur randomly or spontaneously.

DESIGN

Historical review of case reports in the medical and legal literature.

MEASUREMENTS AND RESULTS

A total of 32 cases drawn from medical and legal literature were reviewed. Each case contained a record of violence associated with Disorders of Arousal; in each, details of the violent behavior were available. Violent behaviors associated with provocations and/or close proximity were found to be present in 100% of confusional arousal patients and 81% of sleep terror patients. Violent behaviors were associated with provocation or close proximity in 40%-90% of sleepwalking cases, depending on whether the legal verdict and other factors were taken into account. Often the provocation was quite minor and the response greatly exaggerated. The specific manner in which the violence was triggered differed among sleepwalking, confusional arousals, and sleep terrors.

CONCLUSIONS

In the cases reviewed, violent behavior directed against other individuals associated with Disorders of Arousal most frequently appeared to follow direct provocation by, or close proximity to, another individual. Sleepwalkers most often did not seek out victims, but rather the victims sought out or encountered the sleepwalker. These conclusions are tempered by several limitations: the selection of cases was not random and may not represent an accurate sample of violent behaviors associated with Disorders of Arousal. Also, final verdicts by juries in reported legal cases should not be confused with scientific proof of the presence or absence of sleepwalking. The pathophysiology of Disorders of Arousal with and without violent behavior could be associated with normally occurring deactivation of the frontal lobes during slow wave sleep (SWS) connected via atypically active thalamocortical pathways to the limbic areas. It is not known if the violent sleepwalker, confusional arousal patient, or sleep terror patient differs from other patients with these disorders. The conclusions of this case series await confirmation by the results of future sleep laboratory based studies.

Increased nocturnal activity associated with adverse childhood experiences in patients with primary insomnia

The present study examined to what extent adverse childhood experiences (ACE), in addition to demographic characteristics, current level of stress, depression, and arousability predisposition, are associated with sleep measures in adult insomnia. Thirty-nine adults suffering from primary insomnia completed self-report questionnaires assessing ACE, current level of stress, predisposition towards increased arousability, and depression. They were monitored for 7 consecutive nights at home with wrist actigraphs to evaluate objective sleep-related activity. Blockwise multiple regression analyses were performed to determine which variables were the most important predictors of sleep measures. ACE proved to be important predictors of actigraphically assessed sleep onset latency, sleep efficiency, number of body movements, and moving time, whereas the set of the remaining variables had no significant impact on these sleep measures. These findings suggest that there is an association between childhood maltreatment history and sleep in patients with primary insomnia. We presume that sleep-related nightly activity can be regarded as an aftereffect of long-lasting stressful experiences in childhood.

Increased sensitivity of the neuronal nicotinic receptor alpha 2 subunit causes familial epilepsy with nocturnal wandering and ictal fear

Sleep has traditionally been recognized as a precipitating factor for some forms of epilepsy, although differential diagnosis between some seizure types and parasomnias may be difficult. Autosomal dominant frontal lobe epilepsy is characterized by nocturnal seizures with hyperkinetic automatisms and poorly organized stereotyped movements and has been associated with mutations of the alpha 4 and beta 2 subunits of the neuronal nicotinic acetylcholine receptor. We performed a clinical and molecular genetic study of a large pedigree segregating sleep-related epilepsy in which seizures are associated with fear sensation, tongue movements, and nocturnal wandering, closely resembling nightmares and sleep walking. We identified a new genetic locus for familial sleep-related focal epilepsy on chromosome 8p12.3-8q12.3. By sequencing the positional candidate neuronal cholinergic receptor alpha 2 subunit gene (CHRNA2), we detected a heterozygous missense mutation, I279N, in the first transmembrane domain that is crucial for receptor function. Whole-cell recordings of transiently transfected HEK293 cells expressing either the mutant or the wild-type receptor showed that the new CHRNA2 mutation markedly increases the receptor sensitivity to acetylcholine, therefore indicating that the nicotinic alpha 2 subunit alteration is the underlying cause. CHRNA2 is the third neuronal cholinergic receptor gene to be associated with familial sleep-related epilepsies. Compared with the CHRNA4 and CHRNB2 mutations reported elsewhere, CHRNA2 mutations cause a more complex and finalized ictal behavior.

Sleepwalking and night terrors: psychopathological and psychophysiological correlates

Sleepwalking and night terrors are considered to be manifestations of the same nosologic continuum. It has been proposed that a sudden arousal from non-rapid eye movement (NREM) sleep is the cause of these disorders. Benign forms of NREM arousal parasomnias occur frequently in childhood and attenuate in teen years; however, they can persist into or begin in adulthood. The available literature documents high levels of psychopathology in adult patients. Sleepwalking and night terrors are most likely to manifest during the first episode of slow wave sleep, but may also appear any time during NREM sleep. The hypersynchronous delta activity, previously considered to be a hallmark of somnambulism, has proven to be unspecific. Post-arousal EEG activity reveals altered consciousness during sleepwalking and sleep terror episodes. Pathophysiology of NREM arousal parasomnias consists of predisposing factors, which may be a genetically determined tendency for deep sleep, facilitating factors which deepen sleep and increase slow wave sleep, and triggering factors which increase sleep fragmentation, such as stress, environmental or endogenous stimuli, and stimulants. Recently published data on low delta power in the first sleep cycle and slow decline of delta power in successive sleep cycles suggest a chronic inability to sustain slow wave sleep.

Adult chronic sleepwalking and its treatment based on polysomnography

Adult sleepwalking affects 2.5% of the general population and may lead to serious injuries. Fifty young adults with chronic sleepwalking were studied prospectively. Clinical evaluation, questionnaires from patients and bed partners, and polysomnography were obtained on all subjects in comparison with 50 age-matched controls. Subjects were examined for the presence of psychiatric anxiety, depression and any other associated sleep disorder. Isolated sleepwalking or sleepwalking with psychiatric disorders was treated with medication. All other patients with other sleep disorders were treated only for their associated problem. Prospective follow-up lasted 12 months after establishment of the most appropriate treatment. Patients with only sleepwalking, treated with benzodiazepines, dropped out of follow-up testing and reported persistence of sleepwalking, as did patients with psychiatric-related treatment. Chronic sleepwalkers frequently presented with sleep-disordered breathing (SDB). All these patients were treated only for their SDB, using nasal continuous positive airway pressure (CPAP). All nasal CPAP-compliant patients had control of sleepwalking at all stages of follow-up. Non-compliant nasal CPAP patients had persistence of sleepwalking. They were offered surgical treatment for SDB. Those successfully treated with surgery also had complete resolution of sleepwalking. Successful treatment of SDB, which is frequently associated with chronic sleepwalking, controlled the syndrome in young adults.

Sleepwalking violence: a sleep disorder, a legal dilemma, and a psychological challenge

OBJECTIVE

The purpose of this article is to further an understanding of the psychological state when aggression follows an episode of partial arousal from early non-REM sleep during which some areas of the brain appear to be functioning as in waking while others appear to remain in a state of sleep. To illustrate this, the author examines a case of homicide for which the defense argued lack of responsibility due to sleepwalking.

METHOD

A review of the forensic literature on sleepwalking aggression and sleep studies suggests that these fall into one or both of two DSM-IV-TR diagnoses: sleepwalking disorder and sleep terror disorder. The new case, which would meet criteria for an overlap disorder in which sleepwalking is followed by sleep terror, is compared to one previously published.

RESULTS

These findings support sleepwalking violence as a distinct overlap disorder with common disturbed psychological functioning during and for a period up to 1 hour following an aggressive episode.

CONCLUSIONS

Research clarifies the pathology of this disorder and highlights the need to both refine the differential diagnosis and test the efficacy of treatment protocols.

Risperidone is effective for wandering and disturbed sleep/wake patterns in Alzheimer's disease

Behavioral and psychological symptoms of dementia (BPSD), especially aggressiveness, wandering, and sleep disturbance, are a major burden for caregivers. Daily sleep/wake patterns and wandering of institutionalized patients with Alzheimer's disease (AD) were visually monitored, and 34 patients who manifested wandering were selected and randomly classified into 2 groups: the risperidone group and the nonrisperidone group. After an administration of low-dose risperidone for the risperidone group, the BPSD were reassessed. The binding potentials of dopamine D2 receptor for preadministration and postadministration of risperidone were assessed using positron emission tomography (PET) for 1 case. After the use of risperidone, aggressiveness and wandering were reduced and the nighttime sleeping hours were increased. The PET revealed that the binding potential of dopamine receptor was increased after administration of the drug, associated with improved sleep/wake patterns and behavioral abnormality. Possible serotonergic modulation of dopaminergic function might explain the neurobiological basis of the effect of risperidone.

A mind to blame: new views on involuntary acts

This article examines the legal implications linked to recent scientific research on human consciousness. The article contends that groundbreaking revelations about consciousness expose the frailties of the criminal law's traditional dual dichotomies of conscious versus unconscious thought processes and voluntary versus involuntary acts. These binary doctrines have no valid scientific foundation and clash with other key criminal law defenses, primarily insanity. As a result, courts may adjudicate like individuals very differently based upon their (often unclear) understanding of these doctrines and the science that underlies them. This article proposes a compromise approach by recommending that the criminal law's concept of voluntariness consist of three parts: (i) voluntary acts, (ii) involuntary acts, and (iii) semi-voluntary acts. The semi-voluntary acts category, which is new, incorporates modern ideas of consciousness and also advances the law. Using some actual criminal cases, this article applies this new three-part grouping and demonstrates how it enhances a more just outcome for defendants, victims, and society.

[Fratricide occurring during a nocturnal episode of somnambulism: a case report]

Occasionally, some people developed violent acts during their sleeping. Fortunately, these acts remain virtual and do not have serious life consequences. However, the execution of the dramatical act may happen in setting automatic activities. The manifestations of these acts are exceptional but very often misappreciated. Among them, we have been confronted to a case of "fratricide expertise" in the north of France. The person concerned is a teenager of 17, accused of the murder of his young brother, by several stabs, in the night. This homicide could be the consequence of multitude of factors. Though he hasn't shown clinical somnambulism, the results of electroencephalogram tracing were symptoms of predisposing factors. We can also imagine the facilitating effect of other factors, ephedrine, more particularly. The rapport with the relevant documents follows an expert's report and can be added to the cases published in the literature in which it was shown that the automatic activity may be at the origin of the medico-legal act of somnambulistic patients. Finally, we have been able to deduce two classes of factors, which may be responsible for violent act execution.

Diagnostic values of polysomnography in forensic medicine

A man accused of a first-degree murder of a two-year-old girl claimed that he had not been conscious during the time of the alleged murder. The possibility that he may have committed the crime while "sleepwalking" was raised. The forensic psychiatrist looked to the sleep disorders facility to conduct polysomnographic investigation of the accused in order to investigate the possibility that he had a parasomnia. Overnight sleep recordings with video surveillance carried out for two consecutive nights showed no evidence of parasomnia. On the basis of the full assessment, the final report of the forensic psychiatrist did not support a legal defense of non-insane automatism and "sleepwalking" was withdrawn as a possible defense by the lawyer of the accused.

Somnambulistic-like behaviour in patients attending a lithium clinic

The prevalence of somnambulistic-like behaviour related to treatment with lithium alone or in combination with other psychotropic medications was evaluated in patients attending a lithium clinic. A written questionnaire on somnambulistic-like behaviour was completed by 389 patients. Information was provided on the time of occurrence, frequency and severity of the episodes, the presence of childhood somnambulism, and the temporal relationship between psychiatric treatment and somnambulistic-like behaviour. Twenty-seven (27) patients (6.9%) presented sleepwalking behaviour related to the onset of treatment with lithium alone or in combination with other psychotropic drugs. Forty-five patients (11.6%) reported childhood somnambulism and 12 of them (27%) had their childhood somnambulism reactivated by the medication. Most patients had a diagnosis of bipolar affective disorder but somnambulistic-like behaviour also occurred in patients with other axis 1 diagnosis. Sleep-related violence was seldomly reported. Therefore, lithium alone or in combination with other psychotropic drugs may induce somnambulistic-like behaviour. A history of childhood somnambulism may increase the risk of developing sleepwalking behaviour while under psychotropic drugs treatment.

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.