In Abnormal Sleep Behavior and the Legal Profession, forensic sleep medicine expert witness John Penek, MD, FCCP, FAASM, writes on Forensic Sleep Medicine – REM Sleep Behavior Disorder.
Things that go bump in the night……and the parasomnias.
Background The American Sleep Disorder Association has now identified more than 80 distinct sleep disorders occurring in children and adults in all age groups. These are a diverse group of disorders that may cause excessive daytime sleepiness, difficulty with sleep maintenance such as insomnias and abnormal sleep behavior, termed parasomnias. The parasomnias are a group of sleep disorders that result in abnormal and often socially unacceptable behavior during sleep or associated with partial or incomplete arousals from sleep. These include nightmares and night terrors, somnambulism (sleep walking), confusion arousals, sleep paralysis, REM sleep behavior disorder and the now well-documented incidence of sexsomnia (abnormal sexual behavior during sleep) that has resulted in charges of rape and child molestation. Other disorders such as narcolepsy and idiopathic hypersomnia may result in sleep at inappropriate times, which may cause accidents and even death.
Forensic Sleep Medicine The development of knowledge in the area of parasomnias has increased rapidly in the last decade. Knowledge of the legal implications of these disorders has now emerged into the field of Forensic Sleep Medicine. Many of these disorders are associated with injury of bed partners or others and are perceived as potentially criminal behavior, it is not uncommon for patients suffering with these disorders to result in being charged with civil and criminal charges. Resulting from the frequent striking nature of these behaviors, the sleep specialist physician is frequently needed to provide testimony for both plaintiff and defense attorneys in these cases. Because these disorders are diverse, I have decided to prepare a series of articles focusing in on specific parasomnias to elucidate the special of these disorders.
Normal Sleep Sleep is part of our lives and, indeed, we sleep between 20-30 years of our life. Sleep disorders are classified in disorders of excessive daytime sleepiness, disorders of sleep maintenance such as insomnia, and a distinct group of disorders known as the parasomnias. Normal sleep is characterized by an individual falling asleep within five to ten minutes peacefully and waking seven to eight hours later feeling refreshed and renewed. An occasional awakening during the night to pass urine or for other bodily functions is not unusual. There are a total of five stages of sleep. Stage I is extremely shallow, and the individual may actually perceive the surroundings somewhat. Stage II is deeper sleep but still not restful sleep. What was previously called Stage III and Stage IV has now been lumped into “Slow Wave Sleep or Delta Sleep” and occurs primarily in the early sleep period and is of restorative value. The fifth stage of sleep is called Rapid Eye Movement Sleep (REM sleep). During this stage the metabolism of the brain increases and the individual is paralyzed, with the exception of his eyes (therefore rapid eye movement) and diaphragm, which keeps air moving in and out of his or her lungs. REM sleep is also the period when we do most of our dreaming and, perhaps as a protective evolutionary development, we are paralyzed and unable to act out our dreams.
REM Sleep Behavior Disorder In this first article in this series, I will concentrate on this disorder, which was initially described in the medical literature in the early 1980’s. REM Sleep Behavior Disorder (RBD) is a condition more commonly occurring in older men but also occurring in both sexes of all age groups. The sufferer loses the paralysis associated with REM sleep and the individual acts out their dreams and, unfortunately, many of these dreams tend to be violent. There have been many recorded cases of minor and even severe trauma to bed partners, as well as several fatalities. During these episodes, the sufferer literally “acts out their dreams” and that unfortunate individual plays no volitional role in his or her actions. Videotapes of this disorder frequently demonstrate bizarre and extremely aggressive dream enacting behavior.
Like all sleep disorders, RBD has occurred in humans for many thousands of years and was often dismissed as oddities or psychiatric illnesses. Before it was documented as a true disease, families often applied “home remedies” In one case, a patient tied a sheet around his waist and tied another to the bed post to stop his nightly wanderings. Before coming to medical attention and treatment, most spouses/ bed partners left for another bedroom to avoid being struck, or worse, during sleep. Because of the bizarre nature of this disorder, it was often an embarrassment to the sufferer and their family and only emerged as a true disease when an astute researcher put together a series of patients with similar abnormal sleep behavior and sleep test results. Then it was a matter of trial and error to determine the best medication for this disorder.
The disorder is diagnosed with an overnight Polysomnogram (Sleep Study) and treatment with several agents is most gratifying and effective. Almost all cases occur in individuals with pleasant and normal demeanors and their abnormal sleep behavior resolves with treatment. Before the diagnosis can be confirmed, other conditions need to be excluded.
Sleep seizure disorders can result in similar abnormal sleep behavior and somnambulism (sleep walking) can look similar to RBD. It has now been determined that a relatively high percentage of patients diagnosed with RBD will go on to develop Parkinson’s disease. The exact nature of this association is subject to ongoing investigation. It is now well recognized that RBD and other parasomnias are the medical explanation for injuries and even fatalities resulting in civil and criminal charges that was previously thought to result from purposeful and criminal behavior.
Summary The parasomnias cause abnormal sleep-related behavior and are commonly associated with traumatic and unfortunate events. Within the last decade, the impact of parasomnias and other sleep disorders on individual behavior has become well documented. Indeed, a new field in Sleep Medicine has emerged and has been termed Forensic Sleep Medicine. This label refers to a variety of sleep disorders that result in a high risk for development of civil and criminal charges, and it is valuable for the legal profession to be aware that these disorders may play a role in diverse civil and criminal charges and, once identified, constitute significant mitigation for these unfortunate individuals.
Conclusion Parasomnias are a group of disorders that result in abnormal sleep behavior resulting in self-injury, injury of bed partners, and, unfortunately, far more dangerous consequences. In this brief article, I have reviewed the background of sleep physiology, as well as REM Sleep Behavior Disorder and its impact on the unfortunate individual who suffers from this. In future articles, I will review other parasomnias that have potential litigious implications.
Dr. John Penek has 30 years experience in the practice of pulmonary diseases, sleep disorders and critical care medicine.