The spectrum of disorders causing violence during sleep

Abstract

Violent behavior during sleep is a common problem, affecting > 2% of the population > 15 years old as found in two large epidemiologic studies. The differential diagnosis of sleep related injury and violence includes: REM sleep behavior disorder (RBD); NREM sleep parasomnias (sleepwalking, sleep terrors); parasomnia overlap disorder (RBD + NREM sleep parasomnias); obstructive sleep apnea; sexsomnia (sleep related abnormal sexual behaviors); sleep related dissociative disorder; trauma-associated sleep disorder/post-traumatic stress disorder; periodic limb movement disorder; rhythmic movement disorder; nocturnal scratching disorder; nocturnal seizures; and miscellaneous/mixed conditions. Careful clinical interviews, preferably with bed partners participating, and extensive, hospital-based, technologist-attended, overnight video-polysomnography (for one or more nights), is crucial for determining the accurate diagnosis that will guide proper therapy. Most of the disorders mentioned above are classified as parasomnias in the International Classification of Sleep Disorders, 3rd Edition, with parasomnias defined as abnormal behavioral, experiential and/or autonomic nervous system activity during entry into sleep, during any stage of sleep, and during emergence from any stage of sleep. Parasomnias are often manifestations of “state dissociation” in which components of one state of being (wake, REM sleep, NREM sleep) intrude into, and become admixed, with other states of being, with clinical consequences. There are forensic implications related to the parasomnias, with inadvertent and unintentional assaults, murder, and “pseudo-suicide” resulting from aggressive and violent behaviors arising from sleep with suspended awareness and judgement.