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.

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.

Definition and diagnostic criteria of sleep-related hypermotor epilepsy.

The syndrome known as nocturnal frontal lobe epilepsy is recognized worldwide and has been studied in a wide range of clinical and scientific settings (epilepsy, sleep medicine, neurosurgery, pediatric neurology, epidemiology, genetics). Though uncommon, it is of considerable interest to practicing neurologists because of complexity in differential diagnosis from more common, benign sleep disorders such as parasomnias, or other disorders like psychogenic nonepileptic seizures. Moreover, misdiagnosis can have substantial adverse consequences on patients' lives. At present, there is no consensus definition of this disorder and disagreement persists about its core electroclinical features and the spectrum of etiologies involved. To improve the definition of the disorder and establish diagnostic criteria with levels of certainty, a consensus conference using formal recommended methodology was held in Bologna in September 2014. It was recommended that the name be changed to sleep-related hypermotor epilepsy (SHE), reflecting evidence that the attacks are associated with sleep rather than time of day, the seizures may arise from extrafrontal sites, and the motor aspects of the seizures are characteristic. The etiology may be genetic or due to structural pathology, but in most cases remains unknown. Diagnostic criteria were developed with 3 levels of certainty: witnessed (possible) SHE, video-documented (clinical) SHE, and video-EEG-documented (confirmed) SHE. The main research gaps involve epidemiology, pathophysiology, treatment, and prognosis.

Are confusional arousals pathological?

OBJECTIVE: The objective of this study was to determine the extent that confusional arousals (CAs) are associated with mental disorders and psychotropic medications. METHODS: Cross-sectional study conducted with a representative sample of 19,136 noninstitutionalized individuals of the US general population aged 18 years or older. The study was performed using the Sleep-EVAL expert system and investigated sleeping habits; health; and sleep, mental, and medical conditions (DSM-IV-TR, ICSD-II, ICD-10). RESULTS: A total of 15.2% (95% confidence interval 14.6%-15.8%) (n=2,421) of the sample reported episodes of CAs in the previous year; 8.6% had complete or partial amnesia of the episodes and 14.8% had CAs and nocturnal wandering episodes. Eighty-four percent of CAs were associated with sleep/mental disorders or psychotropic drugs. Sleep disorders were present for 70.8% of CAs. Individuals with a circadian rhythm sleep disorder or a long sleep duration (≥9 hours) were at higher risk of CAs. Mental disorders were observed in 37.4% of CAs. The highest odds were observed in individuals with bipolar disorders or panic disorder. Use of psychotropic medication was reported by 31.3% of CAs: mainly antidepressant medications. After eliminating possible causes and associated conditions, only 0.9% of the sample had CA disorder. CONCLUSIONS: CAs are highly prevalent in the general population. They are often reported allegedly as a consequence of the treatment of sleep disorders. For the majority of subjects experiencing CAs, no medications were used, but among those who were using medications, antidepressants were most common. Sleep and/or mental disorders were important factors for CAs independent of the use of any medication.

Delayed emergence of a parkinsonian disorder or dementia in 81% of older men initially diagnosed with idiopathic rapid eye movement sleep behavior disorder: a 16-year update on a previously reported series.

OBJECTIVE: To provide a 16-year update from the authors' 1996 report documenting a 38% conversion from idiopathic rapid eye movement sleep behavior disorder (iRBD) to a parkinsonian disorder at a mean interval of nearly 13 years after the onset of iRBD in a series of 29 males > or =50 years old. METHODS: The methods of evaluation, diagnosis and follow-up were previously described in the 1996 report. All patients had video-polysomnography (vPSG) confirmed RBD. RESULTS: 80.8% (21/26) of patients who were initially diagnosed with iRBD eventually developed parkinsonism/dementia (three of the original 29 patients were lost to follow-up). The distribution of diagnoses was as follows: n=13, Parkinson's disease (PD); n=3, dementia with Lewy bodies (DLB); n=1, dementia (unspecified; profound); n=2, multiple system atrophy (MSA); n=2, clinically diagnosed Alzheimer's Disease (AD) with autopsy-confirmed combined AD plus Lewy body disease pathology. Among the 21 iRBD "converters," the mean age (±SD) of iRBD onset was 57.7±7.7 years; mean age (±SD) of parkinsonism/dementia onset was 71.9±6.6 years; and mean interval (±SD) from iRBD onset to parkinsonism/dementia onset was 14.2±6.2 years (range: 5-29 years). CONCLUSION: The vast majority of men > or =50 years old initially diagnosed with iRBD in this study eventually developed a parkinsonian disorder/dementia, often after a prolonged interval from onset of iRBD, with the mean interval being 14 years while the range extended to 29 years. Also, the specificity of iRBD converting to parkinsonism/dementia is striking. These findings carry important clinical and research implications in the convergent fields of sleep medicine, neurology, and neuroscience, and identify an optimal clinical group for conducting prospective research studies utilizing putative neuroprotective agents to delay the emergence of, or halt the progression to, parkinsonism and/or cognitive impairment as manifestations of either PD, DLB or MSA.

State dissociation, human behavior, and consciousness.

Sleep is clearly not only a whole-brain or global phenomenon, but can also be a local phenomenon. This accounts for the fact that the primary states of being (wakefulness, NREM sleep, and REM sleep) are not necessarily mutually exclusive, and components of these states may appear in various combinations, with fascinating clinical consequences. Examples include: sleep inertia, narcolepsy, sleep paralysis, lucid dreaming, REM sleep behavior disorder, sleepwalking, sleep terrors, out-of-body experiences, and reports of alien abduction. The incomplete declaration of state likewise has implications for consciousness - which also has fluid boundaries. Fluctuations in the degree of consciousness are likely explained by abnormalities of a "spatial and temporal binding rhythm" which normally results in a unified conscious experience. Dysfunctional binding may play a role in anesthetic states, autism, schizophrenia, and neurodegenerative disorders. Further study of the broad spectrum of dissociated states of sleep and wakefulness that are closely linked with states of consciousness and unconsciousness by basic neuroscientists, clinicians, and members of the legal profession will provide scientific, clinical and therapeutic insights, with forensic implications.

Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized controlled clinical trial.

OBJECTIVE: The aim of this study was to investigate the potential of mindfulness-based stress reduction (MBSR) as a treatment for chronic primary insomnia. DESIGN: A randomized controlled trial was conducted. SETTING: The study was conducted at a university health center. PATIENTS: Thirty adults with primary chronic insomnia based on criteria of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th Edition were randomized 2:1 to MBSR or pharmacotherapy (PCT). INTERVENTIONS: Mindfulness-based stress reduction, a program of mindfulness meditation training consisting of eight weekly 2.5 hour classes and a daylong retreat, was provided, with ongoing home meditation practice expectations during three-month follow-up; PCT, consisting of three milligrams of eszopiclone (LUNESTA) nightly for eight weeks, followed by three months of use as needed. A 10-minute sleep hygiene presentation was included in both interventions. MAIN OUTCOMES: The Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), sleep diaries, and wrist actigraphy were collected pretreatment, posttreatment (eight weeks), and at five months (self-reports only). RESULTS: Between baseline and eight weeks, sleep onset latency (SOL) measured by actigraphy decreased 8.9 minutes in the MBSR arm (P < .05). Large, significant improvements were found on the ISI, PSQI, and diary-measured total sleep time, SOL, and sleep efficiency (P < .01, all) from baseline to five-month follow-up in the MBSR arm. Changes of comparable magnitude were found in the PCT arm. Twenty-seven of 30 patients completed their assigned treatment. This study provides initial evidence for the efficacy of MBSR as a viable treatment for chronic insomnia as measured by sleep diary, actigraphy, well-validated sleep scales, and measures of remission and clinical recovery.