Violence in Sleep

Francesca Siclari; Ramin Khatami; Frank Urbaniok; Lino Nobili; Mark W. Mahowald; Carlos H. Schenck; Michel A. Cramer Bornemann; Claudio L. Bassetti

Disclosures

Brain. 2010;133(12):3494-3509. 

In This Article

Abstract and Introduction

Abstract

Although generally considered as mutually exclusive, violence and sleep can coexist. Violence related to the sleep period is probably more frequent than generally assumed and can be observed in various conditions including parasomnias (such as arousal disorders and rapid eye movement sleep behaviour disorder), epilepsy (in particular nocturnal frontal lobe epilepsy) and psychiatric diseases (including delirium and dissociative states). Important advances in the fields of genetics, neuroimaging and behavioural neurology have expanded the understanding of the mechanisms underlying violence and its particular relation to sleep. The present review outlines the different sleep disorders associated with violence and aims at providing information on diagnosis, therapy and forensic issues. It also discusses current pathophysiological models, establishing a link between sleep-related violence and violence observed in other settings.

Introduction

Although generally considered as mutually exclusive, sleep and violence can coexist. One of the first reports dates back to medieval times and relates to a Silesian woodcutter, who after a few hours of sleep woke up abruptly, aimed his axe at an imaginary intruder and killed his wife instead (Gastaut and Broughton, 1965). Another early case was reported by Yellowless in 1878 and describes a young man with a history of sleep terrors who killed his 18-month-old son by smashing him against the wall during the night, taking him for a wild beast that was about to attack his family. In 1893, Charcot was asked to pronounce himself on a case of attempted murder that occurred during an apparent episode of somnambulism, in which a servant, shortly after falling asleep, injured his landlady and another employee with a gun (Brouardel et al., 1893). Nowadays, dramatic reports of somnambulistic homicide still gain considerable attention in the media (Broughton et al., 1994; Cartwright, 2004).

The most widely known condition in this respect is probably sleepwalking, but numerous other disorders with a potential for sleep-related violence exist, including other parasomnias, epilepsy and psychiatric diseases. Important advances in the fields of genetics, neuroimaging and behavioural neurology have expanded the understanding of the mechanisms underlying violence and its particular relation to sleep. Along with this increasing knowledge, neurologists, psychiatrists and sleep specialists assume an increasing role in legal issues related to violent acts committed during sleep. They should be familiar with these conditions as most sleep disorders associated with violence are treatable, thus making the correct diagnosis constitutes the critical first step in the prevention of further violence and ensuring personal and public safety.

The present review will focus on violent behaviour emerging with different sleep disorders, and aims at providing information on diagnosis, therapy and forensic issues. It also discusses current pathophysiological models, establishing a link between sleep-related violence and violence observed in other settings.

Definitions

For the purpose of this review, 'violence' is defined as an aggressive act that inflicts unwarranted physical harm on others (Filley et al., 2001). It is a subset of 'aggression', a broader term encompassing both mental and physical damage. 'Premeditated aggression' (also referred to as instrumental, predatory or proactive aggression) is purposeful and goal-directed. 'Impulsive aggression' (also termed affective, reactive or hostile aggression) constitutes a response to a frustrating or threatening event that induces anger and occurs without regard for any potential goal. It has a particular relevance with regard to sleep-related violence (Volavka, 1999; Blair, 2004; Siever, 2008).

Epidemiology

A study evaluating the frequency of sleep-related violence in the general population by means of telephone interviews reported a prevalence of 2% (Ohayon et al., 1997). However, this percentage might be overestimated, as the study was based on a standardized questionnaire and did not involve assessment by a sleep specialist. Harmful behaviour has been reported in 59% of patients with sleep terrors and sleepwalking that were consecutively recruited at a sleep clinic (Moldofsky et al., 1995) and in 70% of patients with nocturnal wanderings of different aetiologies (Guilleminault et al., 1995), but again these proportions may be overestimated, as patients with sleep-related violent behaviour are more likely to consult sleep clinics.

Epidemiologic studies indicate that gender is the most consistent risk factor for violence in general (Stanton et al., 1997) and this holds true for sleep-related violence. Violent behaviour and injury in arousal disorders is 1.6–2.8 times more common in males (Schenck et al., 1989a; Moldofsky et al., 1995; Guilleminault et al., 1998). About 97% of injuries and 80% of potentially lethal behaviours in rapid eye movement sleep behaviour disorder (RBD) occur in males (Schenck et al., 1989a, 2009). Ictal and peri-ictal aggression is also over-represented in males (Rodin, 1973; Delgado-Escueta et al., 1981; Marsh and Krauss, 2000; Tassinari et al., 2005a).

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