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 (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 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, , 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 , 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 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- , Van TURKEY related . 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: , 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 , and periodic limb

52 Sleep and Hypnosis, 4:2, 2002 M.Y. Agargun et al. . 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 , 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 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 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 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. The dissociation of other subjects. VBS is usually caused by conscious awareness of behavior seems to reflect neurological conditions in adult or elderly a relative suspension of higher cortical activity population whereas psychogenic causes are with release of lower subcortical functions (15). more prominent in young population (2,4,6). In the present study, we suggest that there is a Our sample represents a young population and strong association between VBS, NREM the present findings suggest that sleep-related parasomnias, and childhood traumatic events. violence may be related to dissociative In our opinion, nocturnal dissociative mechanisms, particularly in this population. disorders are one of cornerstones in The findings related to SW and ST relatively understanding relationship between sleep well-documented in previous studies. SRE is disorders and dissociative phenomena. relatively a new category. SRE can arise from Nocturnal dissociative episodes usually involve any sleep stage with variable dissociation of elaborate behaviors that appear to represent consciousness from the eating behavior, and is attempted reenactments of previous abuse most frequently associated to SW (4). One third situations (eg, being choked or punched by a of the patients suffer injuries from their sibling, being beaten or sexually abused by a confused and impulsive cooking, food parent). Sexualized behavior (eg, pelvic preparation, and eating behavior (13). SRE is a thrusting, rocking) is not uncommon and is heterogenous syndrome and clearly different often paired with defensive behavior (eg, trying from daytime eating disorders. In the present to push or ward someone off, with congruent study, we also described SRDH involved sexual verbalization, such as "Don’t do that, you are traumas or rape. In our opinion, these hurting me, get away"). Onset of nocturnal hallucinations, tactile type, represent a dissociative disorders may be sudden or pathological dissociation in the perceptual gradual, and the course is chronic. Affected domain. They are also considered as subjects usually have a history of repeated or hypnogogic hallucinations. physical or sexual abuse in childhood that may Although hypnotic capacity has not been extend into adolescence and adulthood (5). assessed in our subjects, these hallucinations Sleep may play a key role in daytime may also be considered as a hypnotic dissociative disorders. Sleep may facilitate the phenomena. They may be a pathological analog transition from one personality to the other to hypnotically induced hallucinations such as one, and two or more personalities may flashbacks in post traumatic disorder. In interact in the oneiric state. Transitions from addition, the subjects with SRDH had reported one personality to another during sleep and the physical and sexual abuse in their childhood. sudden shifts of states that induce the Thus, we suggest SRDH is a dissociative dissociative behavior, suggest a parasomnias condition and may result from subjects’ phenomenon (4). In our study, both SRDH and spontaneous and unrecognized abuse of self- VBS were strongly associated with higher DES hypnosis as a dissociative defense mechanism. scores. On the other hand, the findings suggest There is evidence strongly suggesting a that some dissociative conditions may simply relationship between NREM parasomnias, intrude upon sleep states as they do waking particularly SW and dissociation-related ones. Recently, Schenck and Mahowald (5) disorders. Sleep researchers have described SW suggested that, in persons with parasomnias, as "a state of dissociated consciousness in which sleep and wakefulness were not mutually phenomena of sleeping and waking states exclusive, because dissociated elements of

Sleep and Hypnosis, 4:2, 2002 55 Sleep-related Violence, Dissociative Experiences, and Childhood Traumatic Events

REM sleep, NREM sleep, and wakefulness polysomnographic was not performed. could become admixed or rapidly oscillate to Nocturnal dissociative episodes and violent produce abnormal nocturnal twilight states behaviors during sleep were not monitored with behavioral dyscontrol. visually. Second, we used only DES for detect In the present study, we also demonstrated a dissociative experiences but a clinical interview close relationship between VBS and self- was not based for dissociative disorders such as mutilating and suicidal behaviors during day. dissociative identity disorder, dissociative fug, Although an association between violence during and dissociative . Third, we did not sleep and during day have been systematically assess hypnotizability in subjects. It was studied previously, we suggest dissociative expected that more hypnotizable subjects had mechanisms play an important role in this higher DES scores and more experienced SW association. Indeed we also found that persons episodes than those low hypnotizable ones. with self-mutilating behaviors had higher DES Fourth, we did not use a personality inventory or scores than those without. Self-mutilation structured interview schedule for assessing reflects a pathological dissociation. A high personality, particularly borderline personality incidence of a variety of self-injuries behaviors, disorder. In addition, the subjects were including cutting, hitting, burning, stabbing, administered a or an anxiety hair pulling, and neurotic excoriations among instrument. It may be better to understand persons with dissociative disorders (16). In relationship between dissociative experiences addition to daytime, self-mutilation behaviors; and sleep-related violence. Finally, the subjects such as genital cutting, self-burning, and in the present study, were not questioned about punching through windows were documented aggressive acts towards others during the day. An in patients with nocturnal dissociative disorders investigation of the relationship between violent during sleep (6). Our findings confirmed the fact behaviors during the day and during sleep may that dissociation was a hallmark of self- be interesting. mutilation during day and sleep. Suicidal In summary, early traumatic experiences tendency in persons with VBS or parasomnias is such as childhood physical or sexual abuse may relatively newer finding. An association between result in development of dissociative suicidal behavior and sleep disorders have been symptomatology. Dissociative experiences may demonstrated previously by us (17,18), it is related not only to daytime symptoms but also reasonable to suggest that dissociation may be to symptoms during sleep. Sleep-related violent important in suicidal tendency in our subjects. behaviors and sleep-related dissociative Dysphoria is a hallmark of borderline personality hallucinations may combine as sexualized disorder, and this often associated with the behavior and are often paired with defensive initiation of self-mutilating and suicidal behavior. SW, ST, and SRE are related to behaviors. Comorbidity with borderline features suicidal and self-mutilating behaviors. There is is high in patients with dissociative disorders, a close association between sleep-related particularly dissociative identity disorder, violence, childhood abuse, and dissociative although personality characteristics were not experiences. As stated by Schenck and documented by using structured interviews for Mahowald (5) parasomnias cause sleep-related personality disorders. Moreover, both borderline injuries and promote psychological distress patients and dissociative disorders report history from repeated loss of self-control during sleep. of sexual or physical abuse. Dissociation play an important role in sleep- There are some limitations in this study. First, related behavior as well as perception, behavior, diagnoses were made only on the basis of memory and identity. Future research will focus findings from the clinical interview and on dissociated states of wakefulness and sleep.

56 Sleep and Hypnosis, 4:2, 2002 M.Y. Agargun et al.

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