M. Zaubi

SLEEP RELATED VIOLENCE: A CASE REPORT
Mohammad Zaubi MD*
ABSTRACT
Sleepwalking has been commonly associated with disturbed behaviour and violence. Violence may be
towards other people or rarely towards themselves. A case of sleepwalking is reported with emphasis on the
medico-legal implication involved in such cases.
Key words: DSMIV-Diagnostic, Night terrors, Sleep walking, Statistical manual fourth edition
JRMS December 2009; 16(3): 75-77
Introduction
Sleep-related violence is defined as “aggressive
behaviour arising out of disturbances or dysfunction
during the sleep state that results in the physical
harm of people or destruction of objects in the
physical environment”. (1) It accounts for 2% of the
general population, predominantly males, presenting
with violent behaviour while asleep. (2) Mahowald
classified night terrors and sleep walking among the
main causes of violent behaviour during sleep. (1)
Sleep-walking disorder is not rare in adulthood
accounting for 5%. (3) It occurs characteristically
during the early hours of sleep usually between half
an hour and three hours after onset of sleep during
deep sleep (Non Rapid Eye Movement sleep stage
III and IV). Although it is considered one of the
benign disorders of sleep in childhood, it may be
associated with aggression and violent behaviour in
adulthood.
This case report points at not only the serious
medico-legal complexity of violence during sleep
walking but the perplexity which may take place if
not sufficient consideration is given to sleep
walking disorder which may lead to violence.
Case Report
Mr T, a 36 years old male sergeant in the civil
defence was referred from police court for
*From the Department of Psychiatry, King Hussein Medical Centre, (KHMC), Amman-Jordan
Correspondence should be addressed to Dr. M. Zaubi. P.O. Box 851595 Amman 11185 Jordan
Manuscript received August 13, 2006. Accepted January 11, 2007
evaluation regarding sleep related violence.
On 30/07/97 the patient was asleep in his bed. At
12 midnight he got out of bed, apparently confused,
left home and walked out in the street dressed in
pyjamas crossing the countryside from “Sehab” to
“Jawa”. Then he was naked, wondering around and
at around three am he entered an unfamiliar house
through the main gate, which was open. He went
upstairs and entered a room where three sisters were
sleeping. The father noting the man, tried to restrain
him. He became very violent, hit him on the face
and broke the furniture. The family managed to
overpower him. The police was called and arrest
was soon made. He has no recollection of these
events. The day before this incident, the patient was
extremely anxious following a row with his wife for
irrelevant familial issues.
There were many episodes of sleepwalking and
night terrors during his late childhood. In one
occasion he woke up at midnight, left the house,
went to the garden and poured “kerosene” thinking
it was water to irrigate the plants in the garden. On a
second occasion, he woke up left the house and
entered the neighbour’s garden climbing to the
windows. He was also found at midnight sleeping
under the stairs in the closet. On all occasions, he
had no recollection of these actions indicating that
those happened during sleep. The family realized his
abnormal sleep pattern, sought religious and native
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healers’ help. They believed that he was possessed
by devils.
Family history revealed that his grandfather
suffered from sleep arousal dysfunction including
sleep-related eating disorder associated with
depression. He was treated at “Bethlehem hospital”
long ago.
His childhood was uneventful. His school
performance was average and completed first
preparatory class. His first marriage failed after one
year following marital disharmony. Then he
remarried and is now living with his second wife,
two sons and one daughter. He always maintained
good relationships with his relatives and neighbours.
He is a sergeant in the civil defence with 14 years
service. His work record did not show any serious
disturbance or significant court marshals. He is not a
smoker and no history of drug or alcohol abuse.
The psychiatric evaluation indicated the presence
of reactive anxiety symptoms including despair,
reduced awareness of the surrounding, restlessness
and poor concentration. He had unremarkable
physical examination. EEG and Computed
Tomography of the brain were within normal limits.
His IQ testing was within normal limits (IQ 97).
The characteristics of this case are consistent with
the DSMIV diagnosis of sleep walking disorder. (4)
The patient was reassured and advised to avoid a
stressful situation, alcohol, excessive consumption
of coffee and maintain a regular sleep schedule.
Safety issues were addressed including locking the
windows and bedroom doors at night, sleeping on
the ground floor and removing sharp and potentially
dangerous object from the bedroom. Clonazepam
was instituted at 0.5 mg and gradually increased to
1mg at bedtime.
At follow-up visits for several months, the patient
reported that his sleepwalking has subsided and that
his sleep pattern had improved.
Discussion
Somnambulism is a benign condition, which takes
place during the deep sleep (NREM sleep of stages
III and IV) which are characterized by large
amplitude very slow delta wave. If awakened from
such an episode they remain confused, disoriented
and distressed for short periods. Patients cannot
recall the details of the event. (4)
Sleep-walkers are generally more deep sleepers
and it is more difficult to awake them during sleepwalking.
They appear detached and are often noncommunicative,
although they can become vocal, or
even violent when confronted. (3) They may run, beat
the walls and windows, or even leave the house.
Response is reduced, although the patient may speak
or scream. Behaviours which are more elaborate
such as driving rarely occur. Reactions such as
fleeing or defence against a threat may occur. Any
attempt at restraint generally leads the patient to
react violently and to attack using the hands or any
object available. This patient became very violent at
attempted restraint. They might attack and make
chaos. Under such a condition, it is quite difficult to
expect sleepwalkers passing their ways safe. On the
contrary, self-injury (5) or injuries to others might be
serious. (6)
Variants of sleep-walking characterised by sexual
activity or eating have been described. (7-8)
Aggressive sexual behaviour includes disrobing,
fondling, molesting the partner, or forced
intercourse. This patient may have enacted serious
sexual assault against the girls if was not confronted
by their father.
There is a strong genetic component in all
parasomnia disorders demonstrated by both twin
studies and in families, although the mode of
transmission is not clear. (6) As mentioned earlier the
patient’s grandfather was treated for sleep–related
difficulties including nocturnal eating syndrome
associated with depressive disorder. Furthermore,
Restless Leg Syndrome (RLS) or Periodic Limb
movement Syndrome (PLMS) or Sleep Disordered
Breathing (SDB) in prepubertal children (9) can
trigger it. Recurrence of sleepwalking in adulthood
may be due to prior sleep deprivation, alcohol and
recreational drugs (6) or excessive daytime anxiety
and tension or regular intake of antiepileptic or
psychotropic drugs. (5) It is clear in our case that
anxiety and marital disharmony is significant factor
in provoking this parasomnia disorder.
This event appeared to both parties inexplicable
and intensive police investigation and interrogations
revealed nothing of significance and left no place to
any doubt that a criminal motivation might have
been involved. The court accepted the event as a
sleep walking disorder and the charges were
dropped on the ground of “non insane
automatism” (6) or what suggested by Horn as an
affirmative sleepwalking defence. (10)
Conclusion
This case illustrates the difficulty, which may be
faced when assessing such a patient.
The psychiatrists should give serious consideration
to sleepwalking disorder (somnambulism) when
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they are dealing with violence toward others during
sleep.
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