244 Postgrad Med J 2001;77:244–249

Is there a dissociative process in sleepwalking and Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from night terrors?

D Hartman, A H Crisp, P Sedgwick, S Borrow

Abstract sociation during wakefulness. The propo- The enduring and contentious hypothesis sition that, within the character structure that sleepwalking and night terrors are of this group, the mechanism still operates symptomatic of a protective dissociative but exclusively within sleep remains a mechanism is examined. This is mobi- possibility. lised when intolerable impulses, feelings (Postgrad Med J 2001;77:244–249) and memories escape, within sleep, the diminished control of mental defence Keywords: sleepwalking; night terrors; dissociation; post-traumatic stress disorder mechanisms. They then erupt but in a limited motoric or aVective form with restricted awareness and subsequent am- Sleepwalking and night terrors are related nesia for the event. It has also been parasomnias, both characterised by sudden suggested that such processes are more arousals from deep (polysomnographic stage likely when the patient has a history of 4) sleep during which the individual may major psychological trauma. In a group present with a constricted awareness of his/her of 22 adult patients, referred to a tertiary surroundings. In the case of sleepwalking, this sleep disorders service with possible arousal is associated with motor activity which sleepwalking/night terrors, diagnosis was may be elaborate and purposive. On the other confirmed both clinically and polysomno- hand the arousal of night terrors manifests as a graphically, and only six patients had a terrified scream accompanied by intense auto- history of such trauma. More commonly nomic discharge, and often motor activity these described sleepwalking/night ter- which is typically stereotyped, perseverative, rors are associated with vivid dream-like and less purposive than that of sleepwalking.12 experiences or behaviour related to flight In practice, these conditions are not distinct, from attack. Two such cases, suggestive of but exist on a continuum as many individuals a dissociative process, are described in will have features of both.3 Night terrors are more detail. distinct from nightmares (which occur in rapid The results of this study are presented eye movement (REM) sleep when muscle tone

largely on account of the negative find- is greatly reduced), but they bear some resem- http://pmj.bmj.com/ ings. Scores on the dissociation question- blance to other, more recently recognised, naire (DIS-Q) were normal, although parasomnias. Thus, REM sleep behaviour disor- generally higher in the small “trauma” der is characterised by complex motor activity subgroup. These were similar to scores similar to that of sleepwalking, but occurs in characterising individuals with post- the context of REM rather than deep sleep.4 traumatic stress disorder. This “trauma” This condition is often precipitated by psycho- group also scored particularly highly on logical trauma, and may be a variant of the

the anxiety, phobic, and depression scales post-traumatic nightmares described by Van on September 27, 2021 by guest. Protected copyright. of the Crown-Crisp experiential index. In der Kolk, et al5 and Hefez et al.6 REM sleep contrast the “no trauma” group scored behaviour disorder is characterised by un- Department of more specifically highly on the anxiety Psychiatry, St George’s pleasant dreams occurring in both REM and Hospital Medical scale, along with major trends to high non-REM sleep and often associated with School, London, and depression and hysteria scale scores. Two motor activity. Van der Kolk and his colleagues South West London cases are presented which illustrate ex- speculated that the nightmares of post- and St George’s ceptional occurrence of later onset of traumatic stress disorder (PTSD) are interme- Mental Health NHS sleepwalking/night terrors with accompa- diate between night terrors and classical Trust, Sleep Laboratory, Atkinson nying post-traumatic symptoms during nightmares, sharing features of both condi- Morley’s Hospital, wakefulness. It is concluded that a history tions. London, UK of major psychological trauma exists in Dissociation is regarded as a crude and D Hartman only a minority of adult patients present- primitive psychological defence which is AHCrisp ing with sleepwalking/night terror syn- utilised because of the inadequacy or failure of P Sedgwick drome. In this subgroup trauma appears S Borrow more mature and adaptive defences in the face to dictate the subsequent content of the of overwhelming stress. Dissociation may be Correspondence to: attacks. However, the symptoms express regarded as maladaptive in that the distressing Professor A H Crisp, themselves within the form of the experience is encapsulated, separated from Psychiatric Research Unit, Atkinson Morley’s Hospital, sleepwalking/night terror syndrome everyday consciousness, and resists integra- Wimbledon, London rather than as rapid eye movement sleep tion with the individual’s day-to-day SW20 0NE, UK related nightmares. The main group of experience. Van der Kolk and Van der Hart’s [email protected] subjects with the syndrome and with no useful account suggests that intense or Submitted 10 April 2000 history of major psychological trauma prolonged trauma, particularly when associ- Accepted 15 August 2000 show no clinical or DIS-Q evidence of dis- ated with extreme physiological arousal and

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developmental immaturity, may resist psychic clinical similarities between patients with Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from integration at a narrative or linguistic level.7 sleepwalking/night terrors and individuals suf- Such experiences are encoded in an enactive, fering from the dissociative disorders that can that is, sensorimotor form, and persist largely arise within PTSD? out of conscious awareness as dissociative (or “somnambulistic”) states. These may emerge Method as activity rather than narrative memory when The study was carried out at a sleep disorders prompted by internal or environmental cues. clinic within an NHS psychiatric service. The This process has been used as an explanatory clinic was a national referral centre for model for the re-enactment of trauma which is sleepwalking and night terrors, and attracted seen in PTSD and multiple personality disor- adult patients who generally had a long history der. of severe sleepwalking or night terrors, often PTSD is characterised by the following complicated by injury to themselves or their features: exposure to a traumatic event accom- panied by intense fear or helplessness; persist- bed partners. The inclusion criteria were poly- ent re-experiencing of the traumatic event somnographic evidence (sudden awakenings (recurrent intrusive memories, recurrent dis- from slow wave sleep) of sleepwalking or night tressing dreams, and distress and physiological terrors during at least one of two consecutive arousal on exposure to cues that resemble nights of polysomnography with infrared video aspects of the event); avoidance of stimuli monitoring, and compliance with Diagnostic associated with the trauma; constriction of and Statistical Manual of Mental Disorders, general responsiveness with emotional numb- fourth revision (DSM-IV)2 criteria for night ing and detachment; and symptoms of in- terrors (“sleep terror disorder”) or sleepwalk- creased arousal such as irritability, hypervigi- ing. Twenty two consecutive referrals meeting lance, or outbursts of anger.2 these criteria were subjected to a detailed psy- While there is a clear constitutional compo- chiatric assessment and where possible a bed nent to the aetiology of sleepwalking and night partner or other informant was also inter- terrors,8 there is also a long tradition of viewed. Particular attention was paid to the psychological theories about the causation of phenomenology of the parasomnia, and to any 1 9 these conditions. Broughton and Fisher et al history of a traumatic experience, using the recognised that mentation does occur in stage DSM-IV standard of severe trauma outside the 4 sleep, although these thoughts are soon for- range of normal human experience. Patients gotten, and the parasomnia may be the conse- were also asked to complete two psychometric quence of a particularly aversive thought questionnaires, the dissociation questionnaire occurring in this stage of sleep. It has been (DIS-Q), and the Crown-Crisp experiential suggested that, in some cases, sleepwalking may be understood as a motoric re-enactment index (CCEI). The DIS-Q was originally of a repressed traumatic experience.10 If sleep- developed to measure the characteristic symp- toms of proposed dissociative disorders such as walking and night terrors do arise as a http://pmj.bmj.com/ response to arousal producing thoughts in multiple personality disorder, depersonalisa- stage 4 sleep, perhaps related to traumatic tion disorder and psychogenic amnesia, but memories, then it would be plausible that also obtains high scores from individuals with these parasomnias reflect one variant of a dis- PTSD and eating disorders. The instrument’s sociative process, in which intolerable experi- validity and reliability are well established.14 In ences are still defended against by being this paper we did not report the scores on the isolated in a dissociated sphere of conscious- subscales of identity confusion, loss of control, ness11 12 within the acutely aroused state that amnesia, and absorption but we used the total on September 27, 2021 by guest. Protected copyright. has interrupted sleep. Crisp has recently DIS-Q score as an index of the severity of dis- suggested that the eruption of sleepwalking sociative experiences during wakefulness. The and night terrors from deep sleep may be a results obtained from the DIS-Q were com- function of the profound resting state of the pared with reference values for “normals” and forebrain and the associated resting of the PTSD patients derived from Vanderlinden.14 usual waking mental defence mechanisms, for The CCEI is a self report questionnaire meas- example selective denial and repression, which uring the constructs of anxiety, phobic anxiety, protect the individual from such experience obsessionality, somatisation, depression and hyste- during normal wakefulness.13 ria, the score range is 0–16 on each scale, which In this study we examine the hypothesis that has been extensively validated in various clini- sleepwalking and night terrors take place by 15 means of a dissociative mechanism. It sup- cal and community samples. This was used as poses that, if this mechanism is operating as a a broad measure of psychopathology and feature of the attack, it may also be present as defensive style, and the CCEI results were a mental characteristic of normal wakefulness. compared with data matched for age and sex This question is elaborated into three more from the earlier population studies and similar 11 specific questions. Firstly, can one find quali- comparative studies of parasomniacs using tative evidence of a dissociative process within this instrument. The above comparisons were normal wakefulness in individuals suVering carried out by means of two sample t tests. Sat- from sleepwalking and night terrors? Sec- terthwaite’s approximation to the degrees of ondly, how frequent is a history of psychic freedom was used when the variances in the trauma in patients presenting with two groups were unequal. Tests were deemed sleepwalking/night terrors? Finally, are there significant at the 5% level.

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Results Table 2 CCEI scale scores (range 0–16); results are mean Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from Of the 22 subjects, 10 were ascribed a diagno- (SD) sis of sleepwalking and 12 one of night terrors. Parasomnias The two groups are combined and examined together in this study; 10 subjects were male “No trauma” “Trauma” Normals* and 12 were female. The median age of onset (n=16) (n=6) (n=352) of the disorder was 8 years (semi-interquartile Anxiety 8.0 (3.7) 12.0 (2.6) 4.6 (3.8) range 12.5 years). The median age at referral to Phobia 3.3 (2.7) 6.5 (3.5) 4.0 (2.9) Obsessionality 7.1 (3.3) 7.7 (3.4) 6.3 (3.1) our adult sleep disorders secondary/tertiary Somatisation 4.1 (3.0) 8.8 (5.5) 3.5 (2.9) referral service, was 35.5 years (semi- Depression 4.0 (2.3) 9.3 (3.3) 2.8 (2.6) interquartile range 9 years). Six (27%) of the Hysteria 5.3 (3.7) 4.0 (2.5) 3.9 (3.1) 22 subjects gave an account, within a lengthy *Crisp et al, 1990 (352 subjects randomly selected from the systematic history taking session, of significant general population, male and female, aged 17–44 years (mean earlier psychologically traumatic experiences: (SD) age 30.8 (8) years).12 in most cases this took the form of severe abuse 1.76; df = 365; p = 0.08) and hysteria (t = 1.76; or neglect during childhood. Examples are df = 365; p = 0.084). The “trauma” group given in the case reports below. scored significantly higher than the control When patients with a history of trauma were group of normals on the anxiety (t = 4.75; df = compared to those without, they were very 356; p = 0.000), phobia (t = 2.09; df = 356; p = similar with regard to age of onset, age of refer- 0.038), and depression (t = 6.07; df = 356; p = ral, sex, and diagnosis (that is sleepwalking or 0.000) subscales and with a trend towards a night terrors). The “trauma” group diVered higher score on somatisation (t = 2.39; df = 5; from the “no trauma” group with regard to the p = 0.063) with Satterthwaite’s approximation phenomenology of the parasomnia. Of those being used for this last analysis. who had a history of trauma, five out of six Two case examples are described in more (83%) reported vivid, dream-like mental con- detail, with information derived from the tent accompanying the event, as compared psychiatric assessments and psychometric with four out of 16 (25%) of those without a questionnaires. These cases are not representa- history of trauma (p=0.049 using Fisher’s tive of the 22 subjects of the study, but were exact test). All the former reported attempting selected because they were typical of the to flee from an attacker, compared with just “trauma” subgroup and demonstrated a plau- 25% of the latter (p=0.003, Fisher’s exact test). sible process linking life experiences and Other themes reported by the “no trauma” subsequent symptoms. Some biographical de- group included searching for a lost object, tails have been changed to ensure anonymity. searching for or consuming food, protecting a bed partner, or behaviour or vocalisation with CASE REPORTS no clear meaning. Two of the six who had Case 1 experienced a traumatic event described men- Case 1 was a 31 year old unmarried women

tal content during the sleepwalking/night who lived with her elderly parents. She http://pmj.bmj.com/ terrors which was an exact re-experiencing of presented with a complaint of “nightmares” of the original event as now reported. five years’ duration, and described them as fol- lows: she would get up and walk in her sleep, 14 DIS-Q RESULTS (TABLE 1) generally after 60–90 minutes of sleep, and The “trauma” and “no trauma” groups were would often leave the house in her nightclothes. not significantly diVerent from the normal ref- On a number of occasions she had driven her erence data with regard to the DIS-Q total car several miles in this condition, and had score. The “no trauma” group very closely come to full awareness in an isolated place, to on September 27, 2021 by guest. Protected copyright. resembled the normal group and scored highly the sound of her car alarm some distance away. significantly lower (p = 0.000, t = −9.27; These events were accompanied by vivid, terri- df=32) than the PTSD group. The “trauma” fying, and stereotyped mental content in which group scored substantially higher than normals she was attempting to fight oV a male attacker. (but not significantly diVerent; Satterthwaite’s This “nightmare” was a re-enactment of an correction used), and closer to the scores of the incident which occurred when she was 10 years PTSD comparison group (again not signifi- old. While out walking, she had been abducted, cantly diVerent). taken to a shed, and raped in a sadistic manner by a man not known to her. He threatened to 12 CCEI RESULTS (TABLE 2) maim her if she spoke of it, and when she The “no trauma” group scored significantly returned home she concealed her internal inju- higher than the control group of matched nor- ries, and “put it to the back of my mind”. She mals on anxiety (t = 3.40; df = 365; p = 0.001), completed school and went on to train as a with trends for higher scores for depression (t = nurse. She remained heterosexually inactive, and was stable and successful in other respects. Table 1 DIS-Q; results are mean (SD) total score She had no psychiatric problems until the onset of her presenting symptom, five years Parasomnias Comparisons* earlier. This was precipitated abruptly by the “No trauma” “Trauma” Normals PTSD experience of nursing a young girl who had also (n=16) (n=6) (n=378) (n=73) been raped and beaten. On psychiatric assessment, she fulfilled the 1.6 (0.4) 2.3 (1.2) 1.5 (0.4) 2.9 (0.7) DSM-IV criteria2 for a major depressive *Vanderlinden 1993.14 episode of moderate severity and also for

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delayed onset PTSD. On the CCEI she had a sleepwalking/night terrors is generally the Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from moderately raised depression score. She scored result of a dissociative response to trauma. within the normal range on all subscales of the However, when the group of patients with DIS-Q. sleepwalking/night terrors with a history of psychological trauma was examined separately, Case 2 subjects appeared to show distinctive charac- Case 2 was a 40 year old married man with two teristics. Sleepwalking and night terrors are children, referred with a complaint of “night- generally described as being associated with mares” since childhood, which had become limited or no mental content during the much worse over the previous two years. In events,2 and this feature is commonly used to these events he would see snakes in his distinguish them clinically from true night- bedroom, or feel that he was being pursued by mares. However, in this study a majority of an evil presence; he would then awaken in a patients with a history of trauma described state of extreme terror and confusion. Over the vivid, nightmare-like experiences in association previous 18 months he had started to demon- with some of their sleepwalking or night terror strate dangerous behaviour during these epi- events. Our patients in the “trauma” group sodes, for example wandering considerable were also more likely to experience sleepwalk- distances outside the house in his pyjamas or ing or night terror events in which the naked, or hitting his wife in bed. These events subjective experience and overt behaviour was were said to take place within an hour or two of one of being attacked and attempting to escape him going to sleep, at between 2 and 3 am. He or fight back, which invites a search for mean- also described bizarre experiences during his ingful links between symptoms and past waking hours: auditory, visual, and olfactory experience. This was graphically suggested by hallucinations which resembled his “night- the two individuals who re-experienced the mares”, a sense that he was in telepathic com- trauma during the sleepwalking and night munication with his mother, and a sense that terror episodes (cases 1 and 2). Van der Kolk et he had more than one person inside him. He al describe similar events among some PTSD had periods of amnesia and subsequently suVerers,5 but it is not clear whether these discovered that he had carried out some bizarre should be regarded as atypical nightmares, activity. As a child he was severely beaten by his atypical sleepwalking/night terror events, or as father and mother who also sexually abused distinct parasomnias, as suggested by Ross and him. He married at the age of 20 and had two Morrison.17 To exclude PTSD suVerers from a children. He had no contact with psychiatric study of sleepwalking and night terrors because services until three months before presentation of their anomalous clinical qualities, as was to the sleep service, when he had a brief admis- done by Hartmann et al without the benefit of sion for depressive symptoms. This was polysomnographic evaluation,18 seems undesir- precipitated by disclosures that one of his chil- able to us. It ignores the possibility that PTSD dren had been sexually abused. suVerers with sleepwalking/night terrors are

On assessment this patient fulfilled DSM-IV merely at one end of the symptomatic spec- http://pmj.bmj.com/ criteria2 for major depressive episode of moder- trum of night terrors. Such outliers may well ate severity, and had symptoms suggestive of have explanatory value for the broad spectrum multiple personality disorder. On the CCEI he of the disorders in question. had markedly raised scores on the anxiety, It is possible that some individuals in the depression, somatisation, and obsessionality sub- non-trauma group had had dramatic experi- scales, and on the DIS-Q he had markedly ences, no longer in the forefront of their minds, raised scores on all subscales, compatible with but which were meaningfully related to their a diagnosis of multiple personality disorder. sleepwalking/night terrors, and that aspects of on September 27, 2021 by guest. Protected copyright. these were being expressed in their sleeping Discussion behaviours; such cases are described, for Our clinic attracts nationwide referrals of example, by Sours.11 In an earlier paper we have patients with sleepwalking and night terrors, described how frantic searching behaviour and the patients studied were therefore prob- within a childhood onset of sleepwalking ably unrepresentative of sleepwalking and night appeared to relate to death of a father shortly terrors in the general population. They were beforehand.13 probably more representative of adult sleep- The results of the psychometric investiga- walking or night terror suVerers who had tions are suggestive rather than conclusive, recently required attention from primary care especially in view of the multiple testing. With services and sometimes from other psychiatric regard to the CCEI, the patients with a history or neurological services because of the severity of a traumatic experience have generally higher or hazardous nature of their symptoms. All 22 scores, suggesting overall higher levels of subjects we report on here yielded polysomno- psychopathology and distress. The high de- graphic confirmation of the diagnosis. Six of pression score is notable but the mean levels of them gave a history of previous severe psycho- anxiety and phobia scores are especially high logical trauma, and this generally occurred in and probably consistent with the very high lev- childhood. While this was a clinically substan- els of arousal said to be a feature of PTSD.2 In tial proportion, it was distinctly less than in the contrast, the “no trauma” group scored highly reported prevalence of childhood trauma only on the anxiety scale of the CCEI and, to a among patients with dissociative disorders or lesser extent, on the depression and hysteria among psychiatric patients in general.16 This scales. The DIS-Q characteristically obtains does not support the hypothesis that high scores in conditions such as multiple

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personality disorder, borderline personality as advocated by Schenck et al20 are, in our Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from disorder and PTSD.14 The results in this study experience, not very eVective except for benzo- were inconclusive with regard to dissociation diazepines but these bring their own addictive during waking hours as measured by the problems in such chronic conditions. DIS-Q. Although diVerences did not reach sta- Thus, just over a quarter of sleepwalking/ tistical significance, there was a pattern in night terror suVerers who have filtered which the “trauma” group resembled PTSD through to a tertiary referral sleep disorders subjects more than normals, while the “no service report the experience of some degree trauma” group closely resembled the normal of dissociative phenomena, as measured by the reference values. DIS-Q, during their waking lives, and also The cases described illustrate the relation- have a history of significant childhood psycho- ship between sleepwalking/night terror phe- logical trauma. This group is also character- nomenology and symptoms reported in the ised by higher levels of psychological distress CCEI and DIS-Q. In cases 1 and 2 there were in general. However, these cases are the histories of childhood physical and sexual exceptions when we consider the patient group trauma. The motoric re-enactment of the as a whole. The majority of our patients circumstances of the trauma is suggestive of the reported normal levels of dissociative process encapsulated repetition described in PTSD2 within normal wakefulness as measured by and also seems to be a classical example of the DIS-Q, and did not report a history of dissociative process as originally described by psychological trauma. One could speculate Pierre Janet.7 Case 1 suVers from moderate that if sleepwalking/night terrors is indeed a depressive symptoms but scores within the successful form of defensive dissociation, then normal range on all subscales of the DIS-Q. the low prevalence of trauma in our study Case 2 suVers from significant psychiatric group might reflect “false negatives” in our morbidity including possible multiple person- history taking, as the subjects were success- ality disorder in his waking hours and has fully excluding painful memories from aware- markedly raised scores on all subscales of the ness. One possible limitation of this study is DIS-Q. the assumption that dissociative experiences In both cases the development of overt psy- during wakefulness are a reliable index of the chiatric symptoms, accompanied by dramatic postulated dissociative process during sleep. It sleepwalking, resulted from a secondary remains possible that a dissociative mech- experience in adulthood which served to draw anism, precipitated by the sudden intense the individual’s attention back to the original arousals that escape into the undefended brain injury. In case 1 (who experienced acute in this syndrome within sleep, may still operate trauma in childhood rather than the chronic at that time. This could then explain both the trauma of case 2) these dissociative events were sensorial deficit that characterises the syn- confined to her sleeping hours and she could drome and also the histrionic sense of tolerate her waking distress and depression. On themselves that these subjects often report (on the other hand, case 2 experienced sleepwalk- the hysteria scale of the CCEI both in our ear- http://pmj.bmj.com/ ing as only one of a wide range of dissociative lier study and again, though to a lesser extent, phenomena throughout the day and night, in this one) but do not display within normal which may reflect the severity of his own wakefulness. psychic injury. Despite our reservations we report this study We would suggest that in certain traumatised because we can find no other accounts of simi- patients dissociative mechanisms may come lar psychometric investigations of this disorder into play within the attack as part of their

in adults in the literature. Adult patients with on September 27, 2021 by guest. Protected copyright. response to the intense arousal from slow wave this syndrome do not readily present them- sleep associated with distress and/or behav- selves, having ceased to complain or seek help iours normally kept in check. Eruptions at this after a succession of failed treatments earlier in time may be facilitated by the state of the brain life. Future studies are needed, combining within deep sleep wherein blood supply to the polysomnography with functional brain imag- cortex is minimal and related cerebral activity, ing techniques and standardised diagnostic including their usual mental defensive questionnaires for post-traumatic and dissocia- strategies, is in abeyance.13 Primitive sensorial tive disorders. restriction, involving the dissociative mech- anism, may then come into play as a measure necessary to protect the individual’s wakeful 1 Broughton R. Sleep disorders: disorders of arousal? Science awareness under these circumstances and until 1968;159:1070–8. 2 American Psychiatric Association. Diagnostic and statistical such times as mental “order” can be restored. manual of mental disorders. 4th Ed. Washington, DC: APA, During such episodes the individual may be 1994. 3 Vela-Bueno A, Soldatos CR. Parasomnias: sleepwalking, considered to be awake rather than asleep, but night terrors, and nightmares. Psychiatry Annals 1987;17: no more fully conscious of themselves than the 465–9. 4 Schenck C, Hurwitz T, Mahowald M. REM sleep behaviour daytime wakeful individual with an alleged dis- disorder. Am J Psychiatry 1988;145:65. sociative mechanism operating to produce an 5 Van der Kolk B, Blitz R, Burr W, et al. Nightmares and trauma: a comparison of nightmares after combat with life- amnesia, or the various expressions of multiple long nightmares in veterans. Am J Psychiatry 1984;141:187– personality disorder. 90. 6 Hefez A, Metz L, Lavie P. Long-term eVects of extreme Such a notion suggests a role for psychody- situational stress on sleep and dreaming. Am J Psychiatry namic psychotherapy as proposed, practised, 1987;144:344–7. 19 10 7 Van der Kolk B, Van der Hart O. Pierre Janet and the break- and reported by Kales et al, Calogeras, down of adaptation in psychological trauma. 11 3 Am J Psychia- Sours, and Vela-Beuno and Soldatos. Drugs try 1989;146:1530–40.

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8 Kales A, Soldatos C, Bixler E, et al. Hereditary factors in 15 Crown S, Crisp AH. Manual of the Crown-Crisp experiential Postgrad Med J: first published as 10.1136/pmj.77.906.244 on 1 April 2001. Downloaded from sleepwalking and night terrors. Br J Psychiatry 1980;137: index. London: Hodder & Stoughton, 1979. 111–18. 16 Chu JA, Dill DL. Dissociative symptoms in relation to 9 Fisher C, Kahn E, Edwards A, et al. A psychophysiological childhood physical and sexual abuse. Am J Psychiatry 1990; study of nightmares and night terrors. III. Mental content 147:887–92. and recall of stage 4 night terrors. J Nerv Ment Dis 17 Ross RJ, Morrison AR. Revising the diVerential diagnosis of 1974;158:174–88. the parasomnias in DSM-IIIR. Sleep 1989;12:287–9. 10 Calogeras RC. Sleepwalking and the traumatic experience. 18 Hartmann E, Greenwald D, Brune P. Night terrors— Int J Psychoanal 1982;63:483–9. 11 Sours JA. Somnambulism. Its clinical significance and sleepwalking: personality characteristics. Sleep Research dynamic meaning in late adolescence and adulthood. Arch 1982;11:121. Gen Psychiatry 1963;9:112–25. 19 Kales JD, Cadieux RJ, Soldatos CR, et al. Psychotherapy 12 Crisp AH, Matthews BM, Oakey M, et al. Sleepwalking, with night terror patients. Am J Psychother 1982;36:399– night terrors, and consciousness. BMJ 1990;300:360–2. 407. 13 Crisp AH. The sleepwalking/night terror syndrome in 20 Schenck CH, Milner DM, Hurwitz TD, et al. Dissociative adults. Postgrad Med J 1996;72:599–604. disorders presenting as somnambulism. Polysomnographic, 14 Vanderlinden J. Dissociative experiences, trauma and hypnosis. video and clinical documentation (8 cases). Dissociation Delft: Eburon, 1993. 1989;2:194–204.

Medical Anniversary

Ernest Besnier, 21 April 1831 Ernest Besnier (1831–1909) was born in Honfleur, France and became an internist. In 1873 he succeeded Bazin as dermatolo- gist at St Louis Hospital, Paris, where his statue may be found. He first presented “lupus pernio de la face—synovites fongueuses (scrofulo-tuberculeuses) sym- metriques des extremities superieures” at a weekly conference at that hospital. He referred to Hutchinson’s patient, John W,

but the distribution of the lesions was suY- http://pmj.bmj.com/ ciently dissimilar to justify his opinion that the two conditions were not identical. Besnier was elected to the Academy of Medicine in 1881 as hygienist because of his contributions to epidemiology. In 1887 he published various articles on leprosy. He built histopathology and parasitology labo- ratories at St Louis Hospital, and we owe to on September 27, 2021 by guest. Protected copyright. him the term and technique of skin biopsy. He translated Kaposi’s textbook Pathology and Treatment of Skin Diseases into French and wrote widely on a variety of skin disor- ders. He died in Paris on 15 May 1909, aged 78 years. Soon afterwards Tenneson provided histological confirmation of sar- coid tissue in lupus perio.—D G James

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