Violence in sleep.

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.

Insights from studying human sleep disorders.

Problems with sleep are one of the commonest reasons for seeking medical attention. Knowledge gained from basic research into sleep in animals has led to marked advances in the understanding of human sleep, with important diagnostic and therapeutic implications. At the same time, research guided by human sleep disorders is leading to important basic sleep concepts. For example, sleep may not be a global, but rather a local, brain phenomenon. Furthermore, contrary to common assumptions, wakefulness, rapid eye movement (REM) and non-REM sleep are not mutually exclusive states. This striking realization explains a fascinating range of clinical phenomena.

Proposed diagnostic criteria for night eating syndrome.

OBJECTIVE: To propose criteria for diagnosis of the night eating syndrome (NES). METHOD: An international research meeting was held in April 2008, and consensus criteria for NES diagnosis were determined. RESULTS: The core criterion is an abnormally increased food intake in the evening and nighttime, manifested by (1) consumption of at least 25% of intake after the evening meal, and/or (2) nocturnal awakenings with ingestions at least twice per week. Awareness of the eating episodes is required, as is distress or impairment in functioning. Three of five modifiers must also be endorsed. These criteria must be met for a minimum duration of 3 months. DISCUSSION: These criteria help standardize the definition of NES. Additional aspects of the nosology of NES yet to be fully elaborated include its relationship to other eating and sleep disorders. Assessment and analytic tools are needed to assess these new criteria more accurately.

A Review of Sleep-Related Violence: The Demographics of Sleep Forensics Referrals to a Single Center.

This review of sleep-related violence reports the nature of the underlying sleep-suspected conditions enountered and helps establish the spectrum of sleep-related behaviors resulting in forensic consequences. This information may begin to bridge the gap between the differing medical and legal concepts of automatisms (complex motor behaviors occurring in the absence of conscious awareness and therefore without culpability). Sleep medicine professionals are increasingly asked by legal professionals whether a sleep-related condition could have played a role in a forensic-related event. Inasmuch as sleep medicine is a relatively young field, there is scant information to address these questions. The three most prevalent criminal allegations of the 351 consecutive possible sleep forensic-related referrals to a single sleep medicine center over the past 11 years were sexual assault, homicide/manslaughter or attempted murder, and driving under the influence. The overwhelming possible sleep disorder implicated was sexsomnia, accounting for 41%, or 145 out of 351 cases. Of the 351 referrals, 111 were accepted following thorough case review. In general, cases not accepted were declined on the basis of little or no merit or contamination by alcohol intoxication. Of those cases accepted, the proposed initial claim that a sleep phenomenon was operant was supported in approximately 50%, which were mostly non-rapid eye movement disorders of arousal. No cases were felt to be due to rapid eye movement sleep behavior disorder.

Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences.

STUDY OBJECTIVES: To formulate the first classification of sleep related disorders and abnormal sexual behaviors and experiences. DESIGN: A computerized literature search was conducted, and other sources, such as textbooks, were searched. RESULTS: Many categories of sleep related disorders were represented in the classification: parasomnias (confusional arousals/sleepwalking, with or without obstructive sleep apnea; REM sleep behavior disorder); sleep related seizures; Kleine-Levin syndrome (KLS); severe chronic insomnia; restless legs syndrome; narcolepsy; sleep exacerbation of persistent sexual arousal syndrome; sleep related painful erections; sleep related dissociative disorders; nocturnal psychotic disorders; miscellaneous states. Kleine-Levin syndrome (78 cases) and parasomnias (31 cases) were most frequently reported. Parasomnias and sleep related seizures had overlapping and divergent clinical features. Thirty-one cases of parasomnias (25 males; mean age, 32 years) and 7 cases of sleep related seizures (4 males; mean age, 38 years) were identified. A full range of sleep related sexual behaviors with self and/or bed partners or others were reported, including masturbation, sexual vocalizations, fondling, sexual intercourse with climax, sexual assault/rape, ictal sexual hyperarousal, ictal orgasm, and ictal automatism. Adverse physical and/or psychosocial effects from the sleepsex were present in all parasomnia and sleep related seizure cases, but pleasurable effects were reported by 5 bed partners and by 3 patients with sleep related seizures. Forensic consequences were common, occurring in 35.5% (11/31) of parasomnia cases, with most (9/11) involving minors. All parasomnias cases reported amnesia for the sleep-sex, in contrast to 28.6% (2/7) of sleep related seizure cases. Polysomnography (without penile tumescence monitoring), performed in 26 of 31 parasomnia cases, documented sexual moaning from slow wave sleep in 3 cases and sexual intercourse during stage 1 sleep/wakefulness in one case (with sex provoked by the bed partner). Confusional arousals (CAs) were diagnosed as the cause of "sleepsex" ("sexsomnia") in 26 cases (with obstructive sleep apnea [OSA] comorbidity in 4 cases), and sleepwalking in 2 cases, totaling 90.3% (28/31) of cases being NREM sleep parasomnias. REM behavior disorder was the presumed cause in the other 3 cases. Bedtime clonazepam therapy was effective in 90% (9/10) of treated parasomnia cases; nasal continuous positive airway pressure therapy was effective in controlling comorbid OSA and CAs in both treated cases. All five treated patients with sleep related sexual seizures responded to anticonvulsant therapy. The hypersexuality in KLS, which was twice as common in males compared to females, had no reported effective therapy. CONCLUSIONS: A broad range of sleep related disorders associated with abnormal sexual behaviors and experiences exists, with major clinical and forensic consequences.

Sleep complaints in the geriatric patient.

Difficulty sleeping is a frequent complaint of elderly patients. But poor sleep is not a normal part of aging. This article discusses the most common sleep problem among older adults-insomnia, its causes, and potential treatments including over-the-counter and prescription medications and behavioral treatments such as relaxation therapy, sleep hygiene, stimulus control, sleep restriction, and cognitive and behavioral therapies.

Test-Retest Reliability of Two Consecutive Mean Sleep Latency Tests in Patients with Hypersomnia.

Reliability of mean sleep latency testing (MSLT) over consecutive days in patients with hypersomnia is unknown. We reviewed MSLTs of patients with hypersomnia without cataplexy who underwent our two consecutive MSLT protocol (N=29). Average MSLs were 10.9 and 10.9 minutes for days 1 and 2, respectively. Agreement for pathological hypersomnia (defined as MSL≤8 minutes) between MSLT days showed k=0.85 for all (N=29) and k=0.76 for those without sleep apnea (N=20). In patients with subjective complaints of hypersomnia, a single MSLT is sufficient (vs. addition of 2nd day MSLT) in the setting of carefully implemented protocol controlling for potential confounding variables.

Prevalence of restless legs syndrome among native South Americans residing in coastal and mountainous areas.

OBJECTIVE: To determine the prevalence of restless legs syndrome (RLS) in native South Americans and identify the impact of geographic location. PARTICIPANTS AND METHODS: An epidemiological telephone survey of RLS symptoms involving natives from coastal and mountainous areas was performed during July 2, 2004, through September 28, 2004. The process consisted of 2 phases: the creation of the epidemiological instrument and the telephone survey. RESULTS: Five hundred adults, 250 from the mountainous regions and 250 from the coastal region (190 men and 310 women; age range, 25-85 years) were interviewed and subsequently divided on the basis of International Restless Legs Syndrome Study Group criteria into those who had RLS (RLS+ group) and those who did not (RLS- group). Ten (2.0%) had RLS. The overall rate of RLS in adults living in the mountainous region at 2816 m above sea level (3.2% [8/250]) was significantly higher than that for adults living in the coastal region at 4 m above sea level (0.80% [2/250]; P = .002). The mean age of the RLS+ group was 49.5 years (SD, 15.20 years; range, 25-85 years). CONCLUSION: Native South American adults have a prevalence of RLS well below that reported in populations with European ancestry but similar to that in Asian and Turkish populations. Furthermore, in Ecuador, geographic differences were identified in areas of similar population density.

Parasomnias: clinical features and forensic implications.

Parasomnias are undesirable behavioral or experiential phenomena arising from the sleep period. Once felt to be a unitary phenomenon, it is now clear that a wide variety of sleep disorders are capable of resulting in complex behaviors arising during sleep. The most common are disorders of arousal and rapid eye movement sleep disorder. Less common conditions include nocturnal seizures and psychogenic dissociative states. Malingering and Munchausen syndrome by proxy, while they are not actually parasomnias, may masquerade as parasomnias. Careful clinical and sleep laboratory evaluation can usually provide an accurate diagnosis with effective therapeutic implications. Due to the potential forensic implications, sleep medicine specialists may be asked to participate in legal proceedings resulting from sleep-related violence. An awareness of the spectrum of such behaviors, and their clinical and legal evaluation, is becoming more important in the practice of sleep medicine.

Sleep disorders: case studies.

This article reviews nine case studies of patients presenting with sleep complaints.

Non-rapid eye movement sleep parasomnias.

Parasomnias are unpleasant or undesirable behavioral or experiential phenomena that occur during sleep. Once believed unitary phenomena related to psychiatric disorders, it is now clear that parasomnias result from several different phenomena and usually are not related to psychiatric conditions. Parasomnias are categorized as primary (disorders of the sleep states) and secondary (disorders of other organ systems that manifest themselves during sleep). Primary sleep parasomnias can be classified according to the sleep state of origin: rapid eye movement sleep, non-rapid eye movement sleep, and miscellaneous (those not respecting sleep state). Secondary sleep parasomnias are classified by the organ system involved.

Rapid eye movement sleep parasomnias.

The recognition of RBD has shed additional scientific light on the "bumps in the night"; expanded knowledge of states of being and state dissociation; opened up new areas of research on brain and mind dysfunction during sleep; expanded knowledge of various neurologic disorders, particularly narcolepsy and parkinsonism; and reaffirmed the vital link between basic research and clinical medicine. Moreover, the safe and effective treatment of RBD with clonazepam is especially gratifying.

Did this father's sleep apnea contribute to the inadvertent death of his infant son?

Sleepiness impairs memory and concentration. We report a case of a patient who inadvertently left his infant son in a car, having forgotten to drop him off at day care. The infant died of heat exposure. There is credible evidence that sleepiness from a combination of sleep deprivation and previously undiagnosed severe obstructive sleep apnea contributed to this tragedy.