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Sleep-Related Violence, Dissociative Experiences, and Childhood Traumatic Events

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Sleep-Related Violence, Dissociative Experiences, and Childhood Traumatic Events ORIGINAL ARTICLES Sleep-related Violence, Dissociative Experiences, and Childhood Traumatic Events Mehmet Yucel Agargun, M.D., Hayrettin Kara, M.D., Ömer Akil Özer, M.D., Ümit Kıran, M.D., Yavuz Selvi, M.D., Songül Kıran, Ph.D. The aim of the present study was to test whether a relationship between dissociative experiences and violent behavior during sleep (VBS). The group was composed of 253 male and 129 female undergraduate students. The subjects were interviewed for parasomnias and sleep-related violence by using International Classification of Sleep Disorders (ICSD)-revised criteria. Dissociative Experiences Scale (DES) was also administered to the subjects. The subjects with sleep-related violence had higher mean DES score than those never reported VBS. The subjects with sleep-related violence had higher rates of history of physical abuse than the others. Suicidal attempts and self-mutilating behaviors were also more common among these subjects than the others. There is an association between sleep-related violence, childhood abuse, and dissociative experiences. Dissociative experiences may relate not only to daytime symptoms but also symptoms during sleep. (Sleep and Hypnosis 2002;4(2):52-57) Key words: sleep-related violence, dissociative experiences, parasomnias, childhood traumatic events INTRODUCTION the population. They found that night terrors, daytime sleepiness, sleep talking, bruxism, and violent behavior during sleep includes a hypnic jerks were more frequent in subjects Abroad range of behaviors: self-mutilation, with violent or harmful behavior during sleep sexual assault, murder attempt, murder and than the nonviolent subjects, as were suicide. The violent behavior during sleep hypnagogic hallucinations, the incidence of (VBS) can be directed to other subjects, to smoking, caffeine and bedtime alcohol intake. objects, or to self (1). Recently, Ohayon et al (2) In 1989, Schenck et al (3) published a clinical reported violent behavior during sleep as 2 % of and polysomnographic study on 100 From Yuzuncu Yil University School of Medicine Department of consecutive adult patients complaining of sleep- Psychiatry, Van TURKEY related injury. They identified several disorders Address reprint requests to: Dr. Mehmed Yucel Agargun, Yuzuncu Yil as being responsible for causing nocturnal University School of Medicine Department of Psychiatry, Van 65200 violence: sleepwalking, sleep terrors, REM sleep TURKEY Fax: +90 432 216 75 19 E-mail: [email protected] behavior disorder, nocturnal psychogenic dissociative disorders, nocturnal seizures, Accepted March 12, 2002 obstructive sleep apnea, and periodic limb 52 Sleep and Hypnosis, 4:2, 2002 M.Y. Agargun et al. movement disorder. There are many neurologic subjects consisting of undergraduate students in and psychogenic causes of sleep-related violence the Yüzüncü Yil University at Van City were in the literature (see 1 and 4 for a review). included in the study. All students were Parasomnias are a group of undesirable volunteers and recruited through local physiological and behavioral phenomena that announcement for the study. The subjects gave involve skeletal muscle activity and/or written informed consent prior to their autonomic changes. In persons with participation in the study. Subjects with organic parasomnias, sleep and wakefulness are not mental disorders, mental retardation, alcohol mutually exclusive, because dissociated elements and substance abuse, current and past history of of REM sleep, NREM sleep, and wakefulness can psychotic and mood disorders were excluded. become admixed or rapidly oscillate to produce The group was composed of 253 males and 129 abnormal nocturnal twilight states with females. The mean age was 20.9±1.8 years for behavioral dyscontrol. These disorders can cause males and 20.6±1.8 for females. sleep-related injuries and promote psychological All subjects were interviewed for sleep-wake distress from repeated loss of self-control during schedule, the history of suicidal attempts, sleep (5). They usually represent bizarre and aggressive acts to the others, self-mutilating dangerous manifestations and are often behaviors, and alcohol and substance abuse. misdiagnosed and inappropriately treated. The subjects were also questioned about Recently, nocturnal dissociative disorders childhood traumatic events. The history of had been suggested as a type of parasomnia in childhood physical or sexual abuse, paternal the literature. Nocturnal dissociative episodes loss, and paternal separation were obtained. involve elaborate behaviors that appear to The subjects were interviewed for parasomnias represent attempted reenactments of previous and sleep-related violence by using abuse situations (e.g., being choked or punched International Classification of Sleep Disorders by a sibling being beaten or sexually abused by (ICSD)-revised criteria (7). We focused on a parent) (5). These episodes may involve sleepwalking (SW), sleep terror (ST), sleep- violent behavior during sleep. They also may be related eating (SRE), and sleep-related associated with other parasomnias such as dissociative hallucinations (SRDH) involved sleepwalking and sleep terrors. The patients sexual traumas or rape. On the other hand, also had self-mutilating behaviors, such as nocturnal dissociative episodes were suggested genital cutting, self-inflicted burning, and as a diagnostic category and considered in punching through windows (6). In the present differential diagnosis of sleep-related injury (see study, first, we examined the association 4 for a review). Owing to examining the between sleep-related violence, parasomnias, relationship with nightmare disorders in a and dissociative experiences. We also examined previous study (8), we did not consider this the role of dissociative mechanisms in the disorder in the present study. Because the association between sleep-related violence and minimum diagnostic criteria for REM sleep suicidal or self-mutilating behaviors. Since behavior disorder is based on certain parasomnias and dissociative disorders are polysomnographic abnormality and videotaped relatively common in adolescents and young behavioral abnormality (9), we did not evaluate adults, we selected a sample from the this diagnosis. Thus, we focused on only NREM undergraduate students. sleep parasomnias in the study. All interviews were conducted by two of us (MYA and HK). To METHODS provide interrater reliability between two clinicians, we used the kappa statistic. Kappa Individuals from a representative sample of values higher than 0.75 may be regarded as Sleep and Hypnosis, 4:2, 2002 53 Sleep-related Violence, Dissociative Experiences, and Childhood Traumatic Events Table 1. Sleep-related Violence, Dissociative Experiences, and Childhood Traumatic Events Subjects with VBS Subjects without VBS (No=94) (No=288) Mean SD Mean SD t p Age 21.1 1.6 20.7 1.9 1.31 ns1 DES score 35.6 14.9 21.4 13.8 8.60 <0.001 No % No % p2 Male/Female 72/22 28.5/17 181/107 72.5/83 0.017 SW 12 12.7 13 4.5 0.08 ST 33 35.1 41 14 <0.001 SRDH 52 55.3 79 27.4 <0.001 SRE 27 28.7 25 8.6 <0.001 Sexual abuse 10 10.6 16 5.5 ns Physical abuse 25 26.5 35 12.1 0.02 Paternal loss 6 6.4 27 9.3 ns Paternal separation 11 11.7 23 7.9 ns Self-mutilating behavior 38 40.4 35 12.1 <0.001 Suicide attempt 34 36.1 35 12.1 <0.001 1nonsignificant 2Fisher exact test excellent interrater agreement, those from 0.40 themselves or their bed partners. As seen Table 1, to 0.75 as fair to good agreement, those below there was no age difference between the subjects 0.40 as poor agreement (10). In the present with and without VBS. Of subjects with VBS, 72 study, when the interrater reliability was (28.5%) were males and 22 (17%) were females. examined, there was an excellent agreement The rate of males was higher in subjects with VBS (kappa=0.77). than those others (Fisher exact test; p=0.017). Of The Dissociative Experiences Scale (DES) the 94 subjects with VBS, 12 had also SW, 33 had (11) is a 28-item self-report scale assessing the ST, 52 had SRDH, and 27 had SRE and all of frequency of dissociative experiences. Scores parasomnias were more common than those range from 0 to 100, and an average score is without VBS (Fisher exact test; p=0.008; p<0.001; usually reported. The scale contains a variety of p<0.001; p<0.001, respectively). The rates of dissociative experiences, many of which are physical and sexual abuses were higher in subjects normal experiences. The DES has very good with VBS than those others but only rate of validity and reliability, and good overall physical abuse was significantly differ (Fisher psychometric properties. The Turkish version exact test; p<0.001). These subjects also had of the scale has reliability and validity (12) as higher rates of self-mutilating behavior and high as those of its original form. suicide attempt (Fisher exact test; p<0.001). The The statistical Package for the Social Sciences mean DES score of subjects with VBS was higher (SPSS), release 10 was used for statistical analysis. than the others (35.6±14.9 vs 21.4±13.8; Data analyses were performed by using Student’s Student’s t test; t=8.60, p=0.001). t test, chi-square test, and Fisher exact test, when appropriate. The tests were two-tailed. DISCUSSION RESULTS The present study is the first, to our knowledge, that examines the association Ninety-four subjects reported VBS at least once between sleep-related violent behavior and in past year. All of subjects with VBS described dissociative experiences. We found a significant their violent behaviors as potentially harmful for relationship between these two phenomena. 54 Sleep and Hypnosis, 4:2, 2002 M.Y. Agargun et al. The subjects with VBS also reported more combine" (14). During SW episode, complex frequently childhood traumatic events, behaviors such as eating, talking, and violent particularly physical and sexual abuse than the acts may be performed.
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