Handbook of Clinical Neurology, Vol. 99 (3rd series) Disorders, Part 2 P. Montagna and S. Chokroverty, Editors # 2011 Elsevier B.V. All rights reserved

Chapter 67 Violent : forensic implications

MARK W. MAHOWALD 1, 3 *, CARLOS H. SCHENK 1, 2, AND MICHEL A. CRAMER BORNEMANN 1, 3 1Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, Minneapolis, MN, USA 2Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN, USA 3Department of Neurology, University of Minnesota Medical School, Minneapolis, MN, USA

In all of us, even in good men, A 33-year-old man met a woman at a party. Both there is a lawless, wild-beast nature had been drinking and fell asleep on a couch. She which peers out in sleep. awakened to find that he was having sex with her. (Plato, The Republic) She pushed him off. He claimed no awareness until he woke up as he fell to the floor. He told police that Acts done by a person asleep cannot be criminal, he only suspected that he had had sex when he went there being no consciousness. to the bathroom to discover that he was still wearing (Fitzgerald, 1961) a condom. Subsequently she filed a criminal complaint resulting in his arrest and charge of sexual assault. INTRODUCTION At trial, sleep experts testified that this behavior was due to a condition termed “sexsomnia”, which is Increasingly, practitioners are asked to similar to , and therefore without con- render opinions regarding legal issues pertaining to vio- scious awareness or culpability, and the man was exon- lent or injurious behaviors purported to have arisen from erated. This judgment has enraged women’s groups. the sleep period. Such acts, if having arisen from sleep without conscious awareness, would constitute an VIOLENCE ARISING FROM THE “”. Automatic behaviors (automatisms) SLEEP PERIOD resulting in acts that may result in illegal behaviors have been described in many different medical, neurological, Violence may be state dependent and psychiatric conditions. Those medical and psychiatric Sleep is not simply the passive absence of wakefulness. automatisms arising from wakefulness are reasonably Not only is sleep is an active, rather than passive, process, well understood. Recent advances in sleep medicine have it is now clear that sleep is comprised of two completely made it apparent that some complex behaviors, occasion- different states: nonrapid eye movement (NREM) sleep ally violent or injurious with forensic science implications, and rapid eye movement (REM) sleep. Recent studies are exquisitely state dependent, meaning that they arise have indicated that bizarre behavioral syndromes can, exclusively, or predominately, from the sleep period. Vio- and do, occur as a result of the incomplete declaration lent behaviors arising from the sleep period are more or rapid oscillation of these states (Mahowald et al., common than previously thought, being reported by 2% 1990; Mahowald and Schenck, 1992). may of the adult population (Ohayon et al., 1997). also play a role in state admixture-related complex beha- CASE EXAMPLE viors (Mahowald and Schenck, 2000; Wertz et al., 2006). Although the automatic behaviors of some “mixed A recent, highly publicized, case in Canada under- states” are relatively benign (e.g., shoplifting in narco- scores interesting and difficult forensic issues raised lepsy) (Zorick et al., 1979), others may be associated with by violent behavior arising from the sleep period. very violent or injurious behaviors.

*Correspondence to: Mark W. Mahowald, M.D., Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, USA. Tel: 612-872-6201, Fax: 612-904-4207, E-mail: [email protected] 1150 M.W. MAHOWALD ET AL. There are a number of factors that permit the conveniently fall into two major categories: neurological appearance of violent or injurious behaviors in the and psychiatric. absence of conscious wakefulness and without con- scious awareness. Animal experimental studies provide preliminary answers. The widely held concept that the NEUROLOGICAL CONDITIONS brainstem and other more “primitive” neural structures ASSOCIATED WITH SLEEP-RELATED participate primarily in elemental/vegetative rather VIOLENT BEHAVIORS than behavioral activities is inaccurate. There are over- Disorders of arousal (confusional arousals, whelming data documenting that highly complex emo- sleepwalking/sleep terrors) tional and motor behaviors can originate from these more primitive structures – without involvement of The disorders of arousal comprise a spectrum ranging higher neural structures such as the cortex (Berntson from confusional arousals (sleep drunkenness) to and Micco, 1976; LeDoux, 1987; Bandler, 1988; Cohen, sleepwalking to sleep terrors (Mahowald and Cramer- 1988; Grillner and Dubic, 1988; Siegel and Pott, 1988; Bornemann, 2005). Although there is usually amnesia Corner, 1990). for the event, vivid -like mentation may occa- sionally be experienced and reported (Schenck et al., Sleep-related disorders associated 1989). Contrary to popular opinion, these disorders with violence may persist into or actually begin in adulthood, and are most often not associated with significant psycho- Violent sleep-related behaviors have been reviewed pathology (Mahowald and Cramer-Bornemann, 2005). recently in the context of automatic behavior in gen- Recent population surveys indicate that disorders of eral (Mahowald et al., 1990; Mahowald and Schenck, arousal in adults are much more prevalent than previ- 2000). There are well documented cases of: somnam- ously appreciated, being reported by 3–4% of all bulistic homicide, filicide, attempted homicide, and adults, occurring weekly in 0.4% (Hublin et al., 1997). suicide; murders and other crimes with sleep drunkenness Febrile illness, prior , and emotional (confusional arousals); and sleep terrors/sleepwalking stress may serve to trigger disorders of arousal in suscep- with potential violence/injury. A wide variety of disorders tible individuals (Bonkalo, 1974; Vela Bueno et al., 1980; may result in sleep-related violence (Mahowald et al., Raschka, 1984). Sleep deprivation is well known to result 1990, 2003). Conditions associated with sleep period- in confusion, disorientation, and hallucinatory phenom- related violence are listed in Table 67.1.These ena (Brauchi and West, 1959; Shurley, 1962; Williams et al., 1962; Belenky, 1979; Babkoff et al., 1989; Nielsen Table 67.1 et al., 1995). Medications such as sedative/hypnotics, neu- roleptics, minor tranquilizers, stimulants, and antihista- Conditions associated with automatic behavior arising mines, often in combination with each other or with from the sleep period alcohol, may also play a role (Luchins et al., 1978; Char- Sleep disorders ney et al., 1979; Huapaya, 1979). It has recently been Disorders of arousal (confusional arousals, sleepwalking, shown that alcohol does not serve as a trigger for disor- sleep terrors) ders of arousal (Pressman et al., 2007). REM sleep behavior disorder Confusional arousals, a milder form of sleepwalking Nocturnal seizures or sleep terrors (also termed “sleep drunkenness”), Automatic behavior: occur during the transition between sleep and wakeful- and idiopathic CNS ness, and represent a disturbance of cognition and atten- tion despite the motor behavior of wakefulness, Sleep deprivation (including jetlag) resulting in complex behavior without conscious aware- Hypnagogic hallucinations ness (Guilleminault et al., 1975a; Roth et al., 1981; Psychogenic disorders Lipowski, 1987). As in other disorders of arousal, these Dissociative states (may arise exclusively from sleep): Fugues may be potentiated by prior sleep deprivation or by the Multiple personality disorder ingestion of sedative/hypnotics before (Roth Psychogenic amnesia et al., 1972). These episodes of “automatic behavior” Posttraumatic stress disorder occur in the setting of chronic sleep deprivation or other Malingering conditions associated with state admixture (shoplifting Munchausen by proxy has been reported during a period of automatic be- havior in a narcoleptic) (Zorick et al., 1979; Parkes, CNS, central nervous system; REM, rapid eye movement. 1985; Mahowald and Schenck, 1994). VIOLENT PARASOMNIAS: FORENSIC IMPLICATIONS 1151 PATHOPHYSIOLOGY OF DISORDERS OF AROUSAL resulting in injury to self or others has been termed “Elpenor’s syndrome”, after an incident in Homer’s The behavioral similarities between documented sleep- Odyssey. A youth named Elpenor became intoxicated walking or sleep terror-related violence in humans and fell asleep on the roof of a house. He was sud- and “sham rage”, as seen in the “hypothalamic savage” denly awakened by noise of others preparing to leave syndrome, are striking (Glusman, 1974). Although it the island of Aeaee (A´ iaiZ), and ran off the rooftop has been assumed that the “sham rage” animal rather than taking the staircase, sustaining a fatal preparations are “awake”, there is some suggestion cervical fracture (Homer, 800 BC). that similar preparations are behaviorally awake and Keeping in mind that not only is sleep a very active yet (partially) physiologically asleep, with apparent process, that the generators or effectors of many com- “hallucinatory” behavior possibly representing REM ponents of both REM and NREM sleep reside in the sleep dreaming occurring during wakefulness, dis- brainstem and other “lower” centers, and that there sociated from other REM-state markers (Kitsikis and are multiple state transitions occurring every night, it Steriade, 1981). is actually surprising that such behaviors do not occur Animal studies indicate a clear anatomical basis for more often than they do. some forms of violent behavior (Siegel and Shaikh, Specific incidents include (Mahowald and Schenck, 1997). The prosencephalic system may serve to control 2005b): and elaborate, rather than initiate, behaviors originat- ing from deeper structures (Berntson and Micco, ● Somnambulistic homicide, attempted homicide, 1976). In humans, confusional arousals that can filicide result in confusion or aggression may be associated ● Murders and other crimes with sleep drunkenness, with electroencephalographic (EEG) evidence of including sleep apnea and narcolepsy rapid oscillations between wakefulness and sleep ● Suicide, or fear of committing suicide (Guilleminaultetal.,1975b;Rothetal.,1981). Such ● Sleep terrors/sleepwalking with potential violence/ behaviors occurring in states other than wakefulness injury (these episodes may be drug induced) may be the expression of motor/affective activity gen- ● Inappropriate sexual behaviors during the sleep erated by lower structures – unmonitored and unmod- state, presumably the result of an admixture of ified by the cortex. Clearly, psychobiological and wakefulness and sleep. sociocultural factors also play a role in both wakeful Violent sleep-related behaviors can also result in and sleep-related violence (Golden et al., 1996; posttraumatic stress in a spouse (Baran et al., 2003). Greene et al., 1997). Very dramatic cases have been tried in the court Treatment of the disorders of arousal include both system using confusional arousal as defense. In one, pharmacological (benzodiazepines and tricyclic anti- the “Parks” case in Canada, the defendant drove depressants) and behavioral () approaches 23 kilometers, killed his mother-in-law, and attempted (Mahowald and Schenck, 2005a). to kill his father-in-law. Somnambulism was the legal Importantly, there are various associations between defense, and he was acquitted (Broughton et al., and confusional arousals. 1994). In another, the “Butler, PA” case, a confu- Patients suffering from obstructive sleep apnea may sional arousal attributed to underlying obstructive experience frequent arousals which may serve to sleep apnea was offered as a criminal defense for trigger arousal-induced precipitous motor activity a man who fatally shot his wife during his usual (Guilleminault and Silvestri, 1982). Disorders of sleeping hours. He was found guilty (Nofzinger and arousal may also be precipitated by adequate or incom- Wettstein, 1995). plete treatment of sleep apnea with nasal continuous Accidental death resulting from self-injury incurred positive airway pressure (Millman et al., 1991; Pressman during sleepwalking may be erroneously attributed to et al., 1995). suicide (“ pseudo-suicide”) (Shatkin et al., 2002; Mahowald et al., 2003). DISORDERS OF AROUSAL AND HUMAN VIOLENCE

The commonly held belief that disorders of arousal are REM sleep behavior disorder (RBD) always benign is erroneous: the accompanying beha- viors may be violent, resulting in considerable injury RBD represents an experiment of nature, predicted in to the individual, others, or damage to the environment 1965 by animal experiments (Jouvet and Delorme, (Schenck et al., 1989; Mahowald et al., 1990). Such 1965) and recently identified in humans (Schenck behaviors have been described in the medical literature et al., 1986). Normally, during REM sleep, there is for over a century (Hammond, 1869). Sleepwalking active paralysis of all somatic muscles (sparing the 1152 M.W. MAHOWALD ET AL. diaphragm and extraocular muscles). In RBD, there is sleep disorders such as obstructive sleep apnea or the absence of REM sleep atonia, which permits the RBD may masquerade as nocturnal seizures (Houdart “acting out” of , often with dramatic and violent et al., 1960; Kryger et al., 1974; Guilleminault, 1983; or injurious behaviors. These oneiric behaviors dis- D’Cruz and Vaughn, 1997). played by patients with RBD are often misdiagnosed as manifestations of a seizure or psychiatric disorders. Compelling hypnagogic hallucinations RBD is often associated with underlying neurological Conversely, recurrent sexually oriented hypnagogic disorders, most notably the synucleinopathies and nar- hallucinations experienced by patients with narco- colepsy (Schenck and Mahowald, 2002; Boeve et al., lepsy may be so vivid and convincing to the victim 2003, 2004; Nightingale et al., 2005). The overwhelming that they may serve as false accusations (Hays, 1992). male predominance (90%) of RBD (Schenck et al., It has been suggested that some cases of “repressed 1993) raises interesting questions relating sexual memories” of childhood abuse may actually be due to hormones to aggression and violence (Moyer, 1968; compelling hypnagogic hallucinations (McNally and Goldstein, 1974). The violent and injurious nature of Clancy, 2005a, b). RBD behaviors has been reviewed extensively elsewhere (Schenck and Mahowald, 1991; Gross, 1992; Schenck Sleeptalking et al., 1993; Dyken et al., 1995; Morfis et al., 1997). Inter- estingly, there is no evidence of aggression during Sleeptalking has also been addressed by the legal sys- wakefulness in patients with RBD (Fantini et al., tem; it is interesting to speculate whether utterances 2005). Treatment with clonazepam is highly effective made during sleep are admissible in court (Regina v. (Schenck and Mahowald, 2002). Warner, 1995). Other sleep disorders, such as the parasomnia overlap syndrome, disorders of arousal, underlying PSYCHIATRIC CONDITIONS sleep apnea, and nocturnal seizures, may perfectly ASSOCIATED WITH SLEEP-RELATED simulate RBD, again underscoring the necessity for VIOLENT BEHAVIORS thorough formal polysomnographic (PSG) evaluation Psychogenic dissociative states of these cases (Nalamalapu et al., 1996; D’Cruz and Vaughn, 1997; Schenck et al., 1997; Iranzo and Waking dissociative states may result in violence Santamaria, 2005). (McCaldon, 1964). It is now apparent that dissociative disorders may arise exclusively or predominately from the sleep period (Fleming, 1987; Schenck et al., 1989). Nocturnal seizures Virtually all patients with nocturnal dissociative dis- The association between seizures and violence has long orders evaluated at our center were victims of repeated been debated. Rarely, nocturnal seizures may result physical and/or sexual abuse beginning in childhood in violent, murderous, or injurious behaviors (Hindler, (Schenck et al., 1989). 1989; Mahowald et al., 1990). Of particular note is the frantic, elaborate, and complex nocturnal motor Posttraumatic stress disorder (PTSD) activity that may result from seizures originating in Dissociative states and injury related to “nightmare” the orbital, mesial, or prefrontal region (Tharp, 1972; behaviors have been reported in association with PTSD Quesney et al., 1984; Williamson and Spencer, 1986; (Bisson, 1993; Coy, 1996). The “limbic psychotic trigger Ludwig et al., 1987; Waterman et al., 1987; Collins reaction” in which motiveless unplanned homicidal acts et al., 1988). “Episodic nocturnal wanderings”, a condi- occur is speculated to represent partial limbic seizures tion clinically indistinguishable from other forms of that are “kindled” by highly individualized and specific sleep-related motor activity such as complex sleepwalk- trigger stimuli, reviving past repetitive stress (Pontius, ing, but which is responsive to antiepileptic therapy, 1997). If so, this would be an example of environmen- has also been described (Pedley and Guilleminault, tally induced changes in brain function. 1977; Maselli et al., 1988; Plazzi et al., 1995). Aggres- sion and violence may be seen preictally, ictally, or Malingering postictally. Postictal wanderings may result in con- fused or violent behaviors (Mayeux et al., 1979; Borum Although uncommon, malingering must also be con- and Appelbaum, 1996). Some postictal violence is sidered in cases of apparent sleep-related violence. often induced or perpetuated by the good intentions Our center has seen a young adult male who developed of bystanders trying to “calm” the patient following a progressively violent behaviors apparently arising from seizure (Fenwick, 1989). As mentioned above, other sleep directed exclusively at his wife. This behavior VIOLENT PARASOMNIAS: FORENSIC IMPLICATIONS 1153 included beating her and chasing her with a hammer. Although the medical concept of automatism is Following exhaustive neurological, psychiatric, and relatively straightforward (complex behavior in the PSG evaluation, it was determined that this behavior absence of conscious awareness or volitional intent), represented malingering. It was suspected that he was the judicial concept is quite different. Legally, there attempting to have the sleep center “legitimize” his are two forms of automatism: “sane” and “insane”. behaviors, should his wife be murdered during one of The “sane” automatism results from an external or these episodes. extrinsic factor, the “insane” from an internal or endogenous cause. This choice results in two very dif- Munchausen syndrome by proxy ferent consequences for the accused: commitment to a mental hospital for an indefinite period of time if In this recently described syndrome, a child is reported “insane”, or acquittal without any mandated medical to have apparently medically serious symptoms that, in consultation or follow-up if “sane”. For example, a fact, are induced by an adult, usually a caregiver, often criminal act resulting from altered behavior due to a parent. The use of surreptitious video-monitoring hypoglycemia induced by injection of too much insu- in centers during sleep (with the par- lin would be a “sane” automatism, whereas the ent present) has documented the true etiology for same act, if due to hypoglycemia caused by an insuli- reported sleep apnea and other unusual nocturnal noma, would be an “insane” automatism. By this spells (Rosenberg, 1987; Griffith and Slovik, 1989; unscientific paradigm, criminal behavior associated Light and Sheridan, 1990; Samuels et al., 1992; Byard with is, by definition, an “insane” automatism and Beal, 1993; Skau and Mouridsen, 1995; Bryk and (Fenwick, 1990b, 1997). In the USA, the approach to Siegel, 1997; Mydlo et al., 1997). automatism varies from state to state (McCall Smith and Shapiro, 1997). MEDICOLEGAL EVALUATION The current legal system, unfortunately, must con- sider a sleep-related violence case strictly in terms of Automatisms and the law choosing between “insane” and “non-insane” auto- Actus non facit reum nisi mens sit rea – the deed matism, without any stipulated deterrent concerning a does not make a man guilty unless his mind is recurrence of sleepwalking with criminal charges that guilty was induced by a recurrence of the high-risk behavior. (Fenwick, 1996) If sleepwalking is deemed an “insane” automatism, then a significant percentage of the population at large In the USA and the UK, a criminal act (actus reus), is “legally insane.” Clearly, dialogue between the med- in order to be criminal, must be paired with a culpable ical and legal professions regarding this important area mental state (mens rea), meaning knowing intent to would be helpful both to the professions and to those commit a crime. The legal definition of automatism arrested during automatisms (Thomas, 1997). is based upon this doctrine. A book has been published One reasonable approach in dealing with the above- that is devoted to the various forensic aspects of sleep mentioned automatisms from a legal standpoint would medicine (Shapiro and McCall Smith, 1997). be to add a category of acquittal that allowed for Most of the above-mentioned conditions resulting innocence based on lack of guilt consequent to set in violent or injurious behaviors are termed “auto- diagnoses – specific illnesses that could be categorized matisms.” Automatism is difficult to define (Fenwick, by a group of subspecialty clinicians in consultation 1990a, b; Jang and Coles, 1995). Fenwick (1996) has with the legal profession (Beran, 1992). proposed the following definition: Another suggestion has been a two-stage trial, An automatism is an involuntary piece of behav- which would first establish who committed the act, ior over which an individual has no control. and then deal separately with the issue of culpability. The behavior is usually inappropriate to the The first part would be held before a jury, the second circumstances, and may be out of character for in front of a judge with medical advisors present the individual. It can be complex, coordinated, (Fenwick, 1990a, b). and apparently purposeful and directed, though One fortunate, and unexplained, fact is that noc- lacking in judgment. Afterwards the individual turnal sleep-related violence is seldom recurrent may have no recollection or only partial and (Guilleminault et al., 1995). Rarely, recurrence is confused memory for his actions. In organic reported, and possibly should be termed a “non-insane automatisms there must be some disturbance of automatism.” Thorough evaluation and effective treat- brain function sufficient to give rise to the above ment are mandatory before the patient can be regarded features. as no longer a menace to society (Schenck and 1154 M.W. MAHOWALD ET AL. Mahowald, 1995). In some cases, clear precipitating consensus (Weintraub, 1995). Interestingly, in Europe, events can be identified, and must be avoided to be expert witnesses are court-appointed – often from lists exonerated from legal culpability. These concepts have of faculties of universities, compensated from a stan- led to the proposal of two new forensic categories: dard scale – and remain independent of both parties (1) “parasomnia with continuing danger as a non-insane (Deftos, 1999). automatism” and (2) “(intermittent) state-dependent To address the problem of junk science in the court- continuing danger” (Schenck and Mahowald, 1992, room, many professional societies are calling for, and 1995, 1998). some have developed, guidelines for expert witness qualifications and testimony (Committee on Medical The role of the sleep medicine specialist Liability, 1989; American College of Physicians, 1990; Bone and Rosenow, 1990). Similarly, the American With the identification of ever increasing causes, man- Sleep Disorders Association and the American ifestations, and consequences of sleep-related violence Academy of Neurology have adopted their own guide- comes an opportunity for sleep medicine specialists to lines detailing: elements of medical expert testimony, educate the general public and practicing clinicians as qualifications of a medical expert, and guidelines for to the occurrence and nature of such behaviors, and the conduct of the medical expert (American Sleep their successful treatment. More importantly, the onus Disorders Association, 1993; Beresford et al., 2006; is on the sleep medicine professional to educate and Williams et al., 2006). Familiarizing oneself with these assist the legal profession in cases of sleep-related vio- guidelines may be helpful in a given case, as the expert lence that result in forensic medicine issues. This often witness from each side should be held to the same presents difficult ethical problems, as most “expert standards (Mahowald and Schenck, 1995). witnesses” are retained by either the defense or the prosecution, leading to the tendency for expert wit- nesses to become an advocate or partisan for either Clinical and laboratory evaluation one side or the other. Historically, this has been fertile of waking, sleep/violence ground for the appearance of “junk science” in the The history of complex, violent, or potentially injurious courtroom (Huber, 1991) – from Bendectin to triazo- motor behavior arising from the sleep period should lam to breast implants. Junk science leads to junk suggest the possibility of one of the above-mentioned justice, and altered standards of care (Weintraub, sleep disorders or psychiatric conditions. It is likely 1995). Recently, much attention has been paid to the that violence arising from the sleep period is more existence and prevalence of junk science in the court- frequent than previously assumed (Broughton and room, with recommendations to minimize its occur- Shimizu, 1995). Our experience with a large number rence. There is some hope that the judicial system is of adult cases of sleep-related injury/violence has paying more attention to the process of authentic repeatedly indicated that clinical differentiation, with- science and may move to accept only valid scientific out formal PSG study, among RBD, disorders of evidence (Foster et al., 1993; Loevinger, 1995). arousal, sleep apnea, and sleep-related psychogenic dissociative states and other psychiatric conditions is Forensic sleep medicine experts as impartial often impossible (Mahowald et al., 1992; Mahowald friends of the court (amicus curiae) and Schenck, 2005a, b). One infrequently employed tactic to improve scientific As mentioned above, the legal implications of auto- testimony is to use a court-appointed “impartial matic behavior have been discussed and debated in expert” (Huber, 1991). When approached to testify, both the medical and legal literature (Prevezer, 1958; volunteering to serve as a court-appointed expert, Fitzgerald, 1961; Williams, 1961; Whitlock, 1963; Shroder rather than one appointed by either the prosecution or and Mather, 1976). As with nonsleep-related automa- the defense, may encourage this practice. Other pro- tisms, the identification of a specific underlying organic posed measures include the development of a specific or psychiatric sleep/violence condition does not estab- section in scientific journals dedicated to expert wit- lish causality for any given deed. Two questions accom- ness testimony extracted from public documents with pany each case of purported sleep-related violence: request for opinions and consensus statements from (1) Is it possible for behavior this complex to have arisen appropriate specialists, or the development of a library in a mixed state of wakefulness and sleep without of circulating expert testimony that could be used to conscious awareness or responsibility for the act? and discredit irresponsible, professional, witnesses (Huber, (2) Is that what happened at the time of the incident? 1991). Good science is not determined by the creden- The answer to the first is usually “yes.” The second tials of the expert witness, but, rather, by scientific can never be determined with surety after the fact. VIOLENT PARASOMNIAS: FORENSIC IMPLICATIONS 1155 To assist in the determination of the putative role of PSG studies may be of value in establishing a diagnosis an underlying sleep disorder in a specific violent act, of RBD or nocturnal seizures. There are absolutely we have proposed guidelines, modified from Bonkalo no PSG findings that serve as reliable markers of disor- (1974) (sleepwalking), Walker (1961) (epilepsy), and ders of arousal (Schenck et al., 1998; Pressman, 2000, Glasgow (1965) (automatism in general), and formu- 2004; Pilon et al., 2006). Even if a sleepwalking epi- lated from our clinical experience (Mahowald et al., sode were captured during a PSG study of an individ- 1990): ual claiming sleepwalking as a defense, the high prevalence of sleepwalking in normal adults would 1. There should be reason (by history or formal sleep render that finding worthless in attributing a remote laboratory evaluation) to suspect a bona fide sleep episode of sleep-related violence to sleepwalking. disorder. Similar episodes, with benign or morbid The proposition that sleep disorders may be a legi- outcome, should have occurred previously. (It timate defense in cases of violence arising from the must be remembered that disorders of arousal sleep period has understandably been met with may begin in adulthood.) immense skepticism (Guilleminault et al., 1995). For 2. The duration of the action is usually brief credibility, evaluations of such complex cases are best (minutes). performed in experienced sleep disorders centers with 3. The behavior is usually abrupt, immediate, impul- interpretation by a veteran clinical polysomnographer. sive, and senseless – without apparent motivation. Due to the complex nature of many of these disorders, Although ostensibly purposeful, it is completely a multidisciplinary approach is highly recommended inappropriate to the total situation, out of (Mahowald et al., 2005). (waking) character for the individual, and without evidence of premeditation. 4. The victim is someone who merely happened to be SUMMARYAND FUTURE DIRECTIONS present, and who may have been the stimulus for It is abundantly clear that violence may occur during the arousal. any of the three states of being. That which occurs dur- 5. Immediately following return of consciousness, ing REM or NREM sleep may have occurred without there is perplexity or horror, without attempt to conscious awareness and may be due to one of a num- escape, conceal or cover up the action. There is ber of completely different disorders. Violent behavior evidence of lack of awareness on the part of the during sleep may result in events that have forensic individual during the event. science implications. The apparent suicide (e.g., leap to 6. There is usually some degree of amnesia for the death from a second-story window), assault, or murder event; however, this amnesia need not be complete. (e.g., molestation, strangulation, stabbing, shooting) 7. In the case of sleep terrors/sleepwalking or sleep may be the unintentional, nonculpable but catastrophic drunkenness, the act may: result of disorders of arousal, sleep-related seizures, a. occur upon awakening (rarely immediately RBD, or psychogenic dissociative states. The majority upon falling asleep) – usually at least 1 hour of these conditions are diagnosable and, more impor- after sleep onset. tantly, are treatable. The social and legal implications b. occur upon attempts to awaken the subject. are obvious. c. have been potentiated by sedative/hypnotic More research, both basic science and clinical, is administration or prior sleep deprivation. urgently needed to identify and elaborate further upon 8. Intoxication with alcohol or other substances the components of both waking and sleep-related precludes the use of the sleepwalking defense violence, with particular emphasis upon neurobiological, (Pressman et al., 2007). neuroplastic, genetic, and socioenvironmental factors Most conditions associated with sleep-related vio- (Elliott, 1992; Blake et al., 1995; Greene et al., 1997). lence are diagnosable and treatable. Clinical evaluation The study of violence and aggression will be greatly should include a complete review of sleep/wake com- enhanced by close cooperation among clinicians, basic plaints from both the victim and the bed partner (if science researchers, and social scientists. available). This should be followed by a thorough general physical, neurological, and psychiatric exami- REFERENCES nation. The diagnosis may be suspected only clinically. American College of Physicians (1990). Guidelines for the Extensive polygraphic study employing an extensive physician expert witness. Ann Intern Med 113: 789. scalp EEG, electromyographic monitoring of all four American Sleep Disorders Association (1993). ASDA guide- extremities, and continuous audiovisual recording are lines for expert witness qualifications and testimony. mandatory for correct diagnosis in atypical cases. APSS Newsletter 8: 23. 1156 M.W. MAHOWALD ET AL. Babkoff H, Sing HC, Thorne DR et al. (1989). 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