Trip Answers

• "Sleep consists of two complex states--NREM and REM sleep--and disturbances of the boundaries between the states of sleep and wakefulness may result in violence. We investigated our population for reports of violence associated with sleep. REM behaviour disorder is rarely associated with injury to the sufferer or others. NREM sleep related nocturnal wandering associated with self-inflicted injuries has variable etiologies. In the elderly, it is associated with dementia. In young individuals, it may be associated with mesio-temporal or mesio-frontal foci and an indication of a complex partial seizure. It also may be related to abnormal alertness and is associated with excessive daytime sleepiness, micro-sleeps, and hypnagogic hallucinations in sleep disorders such as narcolepsy or sleep disordered breathing." (1)

• "Sixty-four consecutive adult patients (mean age 30 years) who were investigated for sleepwalking or sleep terrors were categorised according to clinical history into three groups: serious violence during sleep to other people or to property or self (n = 26); harmful, but not destructive behaviour (n = 12); and nonviolent behaviour (n = 26). Log linear analysis showed that a diathesis (childhood parasomnia and/or family history of parasomnia) and a stressor (psychologic distress, substance abuse and sleep schedule disorder) predicted the presence of sleepwalking or night terror. Serious violent acts were more likely to occur with males (p < 0.004) who showed sleep schedule disorder (p < 0.03).

• "Forty-one subjects between 12 and 63 years of age with a complaint of nocturnal wandering were reviewed retrospectively, and a prospective investigation of their compliance to treatment was performed. Twenty-nine of 41 subjects committed violence against themselves or others ("violent group"). Clinical investigation of their problem involved polysomnography, wake and sleep EEGs and ambulatory EEG recording in the home environment. The nocturnal wandering may have started from NREM sleep or REM sleep, and violence was observed in both of these sleep states.

"If parasomnia (unusual behaviour during sleep; e.g. sleepwalking, sleep talking, automatism) is the sleep complaint:

1. Ensure that the sleep and bed partner are safe.
2. If mild (talking/shouting only or physical activity limited to occasional restlessness less than three nights per week):

• Ensure practice of good sleep hygiene
• Prevent sleep deprivation
• Use general stress reduction strategies (time management, exercise, counselling, etc.)
  Avoid excessive alcohol intake and recreational drug use

If moderate to severe (activity places patient and/or partner at risk more than three times per week and/or causes daytime impairment):

• Commence trial of benzodiazepine; clonazepam (0.5-1.5 mg hs) is commonly used but all are likely effective (no studies demonstrate superiority of a single agent)
• Effective trials should be continued for a year and slowly tapered using the same safety precautions as for mild parasomnia
• Avoid excessive alcohol intake and recreational drug use

C. If problem persists refer patient to an appropriate specialist with an interest in sleep disorders."
 

1. Guilleminault C. et al. Nocturnal wandering and violence: review of a sleep clinic population. J Forensic Sci 1998 Jan;43(1):158-63
2. Moldofsky H. et al. Sleep-related violence. Sleep. 1995; 18(9): 731-9.
3. Guilleminault C. Forensic sleep medicine: nocturnal wandering and violence. Sleep. 1995; 18(9): 740-8.
4. Guidelines and Protocols Advisory Committee. Protocol for Primary Care Management of Sleep Complaints in Adults. Canada, 1999.