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Postgraduate Education Corner: CONTEMPORARY REVIEWS IN SLEEP MEDICINE |

Parasomnias*: Clinical Features and Forensic Implications FREE TO VIEW

Michel A. Cramer Bornemann, MD; Mark W. Mahowald, MD; Carlos H. Schenck, MD
Author and Funding Information

*From the Departments of Neurology (Drs. Cramer Bornemann and Mahowald) and Psychiatry (Dr. Schenck), Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, Minneapolis, MN.

Correspondence to: Michel A. Cramer Bornemann, MD, Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415; e-mail: michel9626@yahoo.com



Chest. 2006;130(2):605-610. doi:10.1378/chest.130.2.605
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Published online

Parasomnias are undesirable behavioral or experiential phenomena arising from the sleep period. Once felt to be a unitary phenomenon, it is now clear that a wide variety of sleep disorders are capable of resulting in complex behaviors arising during sleep. The most common are disorders of arousal and rapid eye movement sleep disorder. Less common conditions include nocturnal seizures and psychogenic dissociative states. Malingering and Munchausen syndrome by proxy, while they are not actually parasomnias, may masquerade as parasomnias. Careful clinical and sleep laboratory evaluation can usually provide an accurate diagnosis with effective therapeutic implications. Due to the potential forensic implications, sleep medicine specialists may be asked to participate in legal proceedings resulting from sleep-related violence. An awareness of the spectrum of such behaviors, and their clinical and legal evaluation, is becoming more important in the practice of sleep medicine.

The study of sleep and sleep disorders is still considered by many to be in its infancy. This may in part be attributed to the industrious puritanical influences of Western civilization that continue to place a high premium on ever-increasing productivity, unbridled growth, and a strong carpe diem work ethic in which members of society still take tremendous pride. It is without wonder that Benjamin Franklin contributed to the arduous nature of building a prosperous new nation by suggesting that able-bodied individuals should “plow deep… while sluggards sleep,” and that individuals should be held accountable for their behaviors, even those arising from sleep. However, such an admonishment of sleep can have far-reaching deleterious consequences to both the individual and society, especially in today’s technologically advanced, 24-h, caffeinated workplace. The derision related to the need for sleep or unusual behaviors arising from sleep as being indicative of a constitutional character flaw is slowly being eroded with newfound knowledge and respect.

Aside from the personal and public cost of sleep deprivation and sleep disorders, increasing media attention is being given to parasomnias, or unusual complex behaviors arising from the sleep period, and their potential role in resolving criminal court cases. The status of somnambulism, which is a common expression of parasomnias, and its availability as a sane automatism defense in violent nocturnal dream-enactment behaviors resulting in tragic outcomes have been well-documented in the Canadian Supreme Court case, R. v. Kenneth Parks, and in the State Supreme Court case, State of Arizona v. Scott Falater. Within the last 2 years, there have been internationally publicized cases invoking the “sleepwalking” defense in Bridgeton, NJ; Amherst, MA; Toronto, ON, Canada; York, UK; and even as far away as Inderoy, in western Norway. Despite their broad geographic locations and differing judicial systems, many similarities exist among these cases. In each of these cases, male individuals (all of whom were < 35 years of age) were accused in a criminal court of sexual assault and rape. All of the defendants purported to have absolutely no recall of the alleged attack, and each had cited a history of prolonged complex somnambulism. Many were aware of conditions that may propagate such nocturnal behaviors, including acute alcohol ingestion and sleep deprivation. The Toronto case was particularly notable as the defendant’s ex-girlfriend noted that he had initiated sex with her on several occasions while he was still asleep. It is surprising to note that, despite the complexity and duration of prior somnambulistic episodes, each defendant had never previously reported these abnormal behaviors to a health-care professional. Last, each trial employed the use of a sleep expert. The Bridgeton, NJ, case involved multiple counts of sexual assault involving the prepubescent daughter of the defendant’s girlfriend and employed two sleep experts on opposite sides of the case. To overwhelming widespread public chagrin, each of these defendants was acquitted of criminal charges successfully using the sane automatism defense of sexsomnia, which is a subtype of parasomnia in which an individual engages in sexual activity despite being asleep. Violent behaviors arising from the sleep period are more common than previously thought, being reported by 2% of the adult population.1

The factors that permit the appearance of violent or injurious behaviors in the absence of conscious wakefulness and without conscious awareness have been reviewed elsewhere2 and include sleep/wake state dissociation, the activation of central pattern generators, and sleep inertia. Relatively few parasomnias are known to result in potentially violent or injurious behaviors arising from the sleep period. These parasomnias include the following: (1) disorders of arousal; (2) rapid eye movement (REM) sleep behavior disorder; (3) nocturnal seizures; (4) psychogenic dissociative disorders; (5) malingering; and (6) Munchausen syndrome by proxy.

Disorders of Arousal (Confusional Arousals and Sleepwalking/Sleep Terrors)

The disorders of arousal comprise a spectrum of behaviors ranging from confusional arousals (ie, sleep drunkenness), to sleepwalking, to sleep terrors. Contrary to popular opinion, these disorders may persist into or actually begin in adulthood and are most often not associated with significant psychopathology.3Some population surveys4have indicated that disorders of arousal in adults are far more prevalent than were previously appreciated, being reported by 3 to 4% of all adults and occurring weekly in 0.4% of all adults. Sleep-related sexual activity (ie, sleepsex or sexsomnia) is receiving increasing attention.7

Specific incidents include the following2:

  1. Somnambulistic homicide, attempted homicide, and filicide;

  2. Murders and other crimes with sleep drunkenness, including sleep apnea and narcolepsy;

  3. Suicide or the fear of committing suicide;

  4. Sleep terrors/sleepwalking with potential violence/injury (these episodes may be drug-induced); and

  5. Inappropriate sexual behaviors during the sleep state, which presumably are the results of an admixture of wakefulness and sleep.

Treatments for the disorders of arousal include both pharmacologic approaches (eg, benzodiazepines and tricyclic antidepressants) and behavioral approaches (hypnosis).8

Importantly, other sleep disorders such as obstructive sleep apnea (OSA) may result in behaviors that are indistinguishable from disorders of arousal.9Sleep deprivation and recurrent arousals induced by untreated OSA may predispose the patient to disorders of arousal. Effective treatment of an OSA-induced violent non-REM parasomnia has been reported.10

REM Sleep Behavior Disorder

REM sleep behavior disorder (RBD) represents an experiment of nature, which was predicted in 1965 by animal experiments11and has been identified in humans.12A defining feature of normal REM sleep is active paralysis of all somatic musculature except the diaphragm and extraocular muscles. In an RBD, there is the absence of the expected REM sleep atonia, which permits the “acting out” of dreams, often with dramatic and violent or injurious consequences. Polysomnographic monitoring in patients with RBD reveals increased tonic and/or phasic electromyographic activity, often accompanied by muscle twitching, extremity flailing, or vocalization during REM sleep. RBD is often associated with a growing number of underlying neurologic disorders, most notably the synucleinopathies and narcolepsy, and may be induced by numerous medications, particularly selective serotonin reuptake inhibitors.1315 RBD is often a harbinger of one of the synucleinopathies (eg, Parkinson disease, multiple system atrophy, or dementia with Lewy body disease), often after an extended period of time (> 10 years). For this reason, patients with RBD should be closely followed by a neurologist. The overwhelming male predominance (approximately 90%) in cases of RBD16 raises interesting questions relating sexual hormones to aggression and violence.1718 The violent and injurious nature of RBD behaviors has been extensively reviewed elsewhere.19Interestingly, there is no evidence of aggression during wakefulness in patients with RBD.20 Treatment with clonazepam at bedtime is highly effective.13 Treatment with melatonin may also be effective.19 Because other sleep disorders such as parasomnia overlap syndrome, disorders of arousal, underlying sleep apnea, and nocturnal seizures may perfectly simulate RBD, a thorough formal polysomnographic evaluation of these cases is mandated.2124

Nocturnal Seizures

The association between seizures and violence has long been debated. Rarely, nocturnal seizures may result in violent, murderous, or injurious behaviors.2526 Of particular note is the frantic, elaborate, and complex nocturnal motor activity that may result from seizures originating in the frontal region of the brain. Aggression and violence may be seen preictally, ictally, or postictally. Nocturnal seizures are notoriously difficult to diagnose, as they may perfectly mimic other parasomnias, and the often-expected accompaniments of seizures (ie, EEG abnormalities, postictal confusion, loss of consciousness, bladder incontinence, or tongue biting) may be absent. Other sleep disorders such as OSA or RBD may masquerade as nocturnal seizures. Due to the difficulty in making the diagnosis of nocturnal seizures, a full EEG montage, continuous video monitoring, and interpretation by an experienced electroencephalographer are mandatory.

Psychogenic Dissociative States

Waking dissociative states may result in violence.27It is now apparent that dissociative disorders may arise exclusively or predominately from the sleep period.28 Virtually all patients with nocturnal dissociative disorders who were evaluated at our center were victims of repeated physical and/or sexual abuse beginning in childhood. Psychogenic dissociative states occur without conscious awareness on the part of the individual.

Malingering

Malingering must also be considered in cases of apparent sleep-related violence. Our center has seen a young adult man in whom progressively violent behaviors developed, apparently arising from sleep, that were directed exclusively at his wife. This behavior included beating her and chasing her with a hammer. Following exhaustive neurologic, psychiatric, and polysomnographic evaluation, it was determined that this behavior represented malingering. It was suspected that he was attempting to have the sleep center “legitimize” his behaviors, should his wife be murdered during one of these episodes. While patients with psychogenic dissociative disorders have no conscious awareness of their behaviors, malingerers act with both awareness and intention.

Munchausen Syndrome by Proxy

In this fascinating syndrome, a child or adolescent is reported to have apparently medically serious symptoms, which, in fact, are induced by an adult, who is usually a caregiver and is often a parent. The adult is actually creating the symptom. For instance, a child’s “apnea” may be induced by smothering with a pillow. The use of surreptitious video monitoring in sleep disorders centers during sleep (with the parent present) has documented the true etiology for the reported sleep apnea and other unusual nocturnal spells.29

Treatment will depend on the etiology. In all cases, the sleeping environment should be made safe as follows: sleeping on the first floor or in the basement; placing alarms on windows and doors; and removing sharp or dangerous objects from the bedroom (including guns and knives). Violent disorders of arousal may respond to treatment with medications such as benzodiazepines or imipramine or to behavioral treatments such as hypnosis. An RBD usually responds to treatment with clonazepam at bedtime. Nocturnal seizures may be managed by conventional antiepileptic medications.8,19

The history of complex, violent, or potentially injurious motor behavior arising from the sleep period should suggest the possibility of one of the above-mentioned conditions. Our experience with a large number of adult cases of sleep-related injury/violence has repeatedly indicated that clinical differentiation, without a formal polysomnography study, among RBD, disorders of arousal, sleep apnea, and sleep-related psychogenic dissociative states and other psychiatric conditions may be impossible.

The legal implications of automatic behavior have been discussed and debated in both the medical and legal literature. As with non-sleep-related automatisms, the identification of a specific underlying organic or psychiatric sleep/violence condition does not establish causality for any given deed. The following two questions accompany each case of purported sleep-related violence: (1) is it possible for behavior this complex to have arisen in a mixed state of wakefulness and sleep without conscious awareness or responsibility for the act?; and (2) is that what happened at the time of the incident? The answer to the first is usually “yes.” The answer to the second question can never be determined with surety after the fact.

Among the guidelines to assist in the determination of the putative role of an underlying sleep disorder in a specific violent act, we have proposed the following25:

  1. There should be reason (by history or formal sleep laboratory evaluation) to suspect a bona fide sleep disorder. Similar episodes, with benign or morbid outcome, should have occurred previously.

  2. The duration of the action is usually brief (ie, minutes).

  3. The behavior is usually abrupt, immediate, impulsive, and senseless; without apparent motivation.

  4. The victim is someone who merely happened to be present, and who may have been the stimulus for the arousal.

  5. Immediately following the return of consciousness, there is perplexity or horror, without attempt to escape, conceal, or cover-up the action. There is evidence of lack of awareness on the part of the individual during the event.

  6. There is usually some degree of amnesia for the event; however, this amnesia need not be complete.

  7. In the case of sleep terrors/sleepwalking or sleep drunkenness, the act may occur on awakening (rarely immediately on falling asleep), usually at least 1 h after sleep onset; may occur on attempts to awaken the subject; and may have been potentiated by alcohol ingestion, sedative/hypnotic administration, or prior sleep deprivation.

Most conditions associated with sleep-related violence are diagnosable and treatable. Clinical evaluation should include a complete review of sleep/wake complaints from both the victim and bed partner (if available). This should be followed by a thorough general physical, neurologic, and psychiatric examination. The diagnosis may only be suspected clinically. An extensive polygraphic study employing an extensive scalp EEG, electromyographic monitoring of all four extremities, and continuous audiovisual recording are mandatory for correct diagnosis. Polysomnography studies may be of value in establishing a diagnosis of RBD or nocturnal seizures. Unfortunately, there are absolutely no polysomnography findings that have been objectively verified or for which a scientific consensus has been developed (including the “hypersynchronous delta” pattern) that serve as reliable markers of disorders of arousal.3032 Even if a sleepwalking episode were captured during a polysomnography study of an individual claiming sleepwalking as a defense against a violent act, the high prevalence of sleepwalking in healthy adults would render that finding worthless in attributing a remote episode of sleep-related violence to sleepwalking.

The proposition that sleep disorders may be a legitimate defense in cases of violence arising from the sleep period has understandably been met with immense skepticism.33For credibility, evaluations of such complex cases are best performed in experienced sleep disorders centers with interpretation by a veteran sleep medicine specialist. Due to the complex nature of many of these disorders, a multidisciplinary approach is highly recommended.34 As the degree of consciousness in a sleepwalking case is often pivotal in determining the outcome in criminal court proceedings, it would also appear prudent to involve a neurologist, or at least an individual with an appreciation for the spectrum of the expression of human consciousness.

An ever-broadening fascination with sleep and sleep disorders continues to develop in the general public. This awareness goes far beyond matters that are associated only with OSA and has become ubiquitous, leaving no aspect of our lives unscathed. For example, a patient who has already undergone formal polysomnography monitoring that has ruled out OSA but nonetheless has unremitting poor-quality sleep and consequent daytime hypersomnolence still requires a dedicated sleep physician who is devoted to providing optimal comprehensive care. The same holds for the OSA patient who supposedly has been compliant with treatment but nonetheless continues to experience infrequent episodes of violent nocturnal behaviors. Once the sleep physician has assumed care of the patient, it is the obligation of the physician to maintain an awareness of the wide variety of sleep-related complications, for failure to do so may have profound harmful consequences not for only the patient but for the general public as well. In these situations, the physician must be able to manage sleep disorders that transcend the usual pulmonary pathophysiology or at the very least have the resources to refer an individual to an appropriate sleep disorders center, preferably one that maintains a multidisciplinary approach. Last, a lack of awareness of potential sleep-related consequences or the failure to address these concerns may result in unnecessary legal repercussions in an already litigious society.

It is abundantly clear that violent behavior may arise from the sleep period. That which occurs during REM or non-REM sleep may have occurred without conscious awareness and may be due to one of a number of completely different disorders. Violent behavior during sleep may result in events that have forensic science implications. The apparent suicide (eg, leap to death from a second-story window), and assault or murder (eg, molestation, strangulation, stabbing, or shooting) may be the unintentional, nonculpable but catastrophic result of disorders of arousal, sleep-related seizures, RBD, or psychogenic dissociative states.

Much like the more pervasive sleep deprivation and its multitude of contributing influences, it would be virtually impossible to completely eradicate potentially harmful parasomnias, and the risks it places on the individual and society. Much remains to be understood about parasomnias, including the duration and the extent of complex behaviors along with assessing the degree of their personal accountability. Research into parasomnias to develop objective evidence-based practices has not been performed and would appear to be logistically challenging. However, this does not suggest that as physicians and as a society we should remain complacent and not attempt to minimize the risks as much as possible. Accordingly, we must remain observant and continue to improve our understanding parasomnias. Armed with this knowledge, we cannot only better educate and treat affected patients, but also begin to generate a greater public awareness. As citing ignorance to the risks inherent in the “sleepwalker” will be used less often in episodes of purported violence, the individual will then be accountable for his actions, or lack thereof, and will be left to determine morally appropriate behavior. Only then would the criminal courts be better able to determine guilt or innocence and to ensure the safety and confidence of the public with an unhindered judicial due process. The ongoing development and evolution of evidence-based sleep medicine will continue to be best served with a truly multidisciplinary approach encompassing many basic science and clinical faculties within medicine and the behavioral sciences.

Abbreviations: OSA = obstructive sleep apnea; RBD = rapid eye movement sleep behavior disorder; REM = rapid eye movement

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Ohayon, MM, Caulet, M, Priest, RG (1997) Violent behavior during sleep.J Clin Psychiatry58,369-376. [PubMed]
 
Mahowald, MW, Schenck, CH Violent parasomnias: forensic medicine issues. Kryger, MH Roth, T Dement, WC eds.Principles and practice of sleep medicine2005,960-968 Elsevier/Saunders. Philadelphia, PA:
 
Mahowald, MW, Cramer-Bornemann, MA NREM sleep parasomnias. Kryger, MH Roth, T Dement, WC eds.Principles and practice of sleep medicine2005,889-896 Elsevier/Saunders. Philadelphia, PA:
 
Hublin, C, Kaprio, J, Partinen, M, et al Prevalence and genetics of sleepwalking: a population-based twin study.Neurology1997;48,177-181. [CrossRef] [PubMed]
 
Mangan, MA A phenomenology of problematic sexual behavior occurring during sleep.Arch Sex Behav2004;33,287-293. [CrossRef] [PubMed]
 
Shapiro, CM, Trajanovic, NN, Fedoroff, JP Sexsomnia: a new parasomnia?Can J Psychiatry2003;48,311-317. [PubMed]
 
Guilleminault, C, Moscovitch, A, Yuen, K, et al Atypical sexual behavior during sleep.Psychosom Med2002;64,328-336. [PubMed]
 
Mahowald, MW, Schenck, CH NREM sleep parasomnias.Neurol Clin2005;23,1077-1106. [CrossRef] [PubMed]
 
Guilleminault, C, Silvestri, R Disorders of arousal and epilepsy during sleep. Sterman, MB Shouse, MN Passouant, PP eds.Sleep and epilepsy1982,513-531 Academic Press. New York, NY:
 
Lateef, O, Wyatt, J, Cartwright, R A case of violent non-REM parasomnias that resolved with treatment of obstructive sleep apnea [abstract]. Chest. 2005;;128 ,.:461S
 
Jouvet, M, Delorme, F Locus coeruleus et sommeil paradoxal.CR Soc Biol1965;159,895-899
 
Schenck, CH, Bundlie, SR, Ettinger, MG, et al Chronic behavioral disorders of human REM sleep: a new category of parasomnia.Sleep1986;9,293-308. [PubMed]
 
Schenck, CH, Mahowald, MW REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in sleep.Sleep2002;25,120-130. [PubMed]
 
Boeve, BF, Silber, MH, Ferman, TJ REM sleep behavior disorder in Parkinson’s disease and dementia with Lewy body disease.J Geriatr Psychiatry Neurol2004;17,146-157. [CrossRef] [PubMed]
 
Nightingale, S, Orgill, JC, Ebrahim, IO, et al The association between narcolepsy and REM behavior disorder (RBD).Sleep Med2005;6,253-258. [CrossRef] [PubMed]
 
Schenck, CH, Hurwitz, TD, Mahowald, MW REM sleep behavior disorder: a report on a series of 96 consecutive cases and a review of the literature.J Sleep Res1993;2,224-231. [CrossRef] [PubMed]
 
Goldstein, M Brain research and violent behavior.Arch Neurol1974;30,1-34. [CrossRef]
 
Moyer, KE Kinds of aggression and their physiological basis.Comm Behav Biol1968;2,65-87
 
Schenck, CH, Mahowald, MW REM sleep parasomnias.Neurol Clin2005;23,1107-1126. [CrossRef] [PubMed]
 
Fantini, ML, Corona, A, Clerici, S, et al Increased aggressive dream content without increased daytime aggressiveness in REM sleep behavior disorder.Neurology2005;65,1010-1015. [CrossRef] [PubMed]
 
Schenck, CH, Boyd, JL, Mahowald, MW A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases.Sleep1997;20,972-981. [PubMed]
 
Nalamalapu, U, Goldberg, R, DePhillipo, M, et al Behaviors simulating REM behavior disorder in patients with severe obstructive sleep apnea [abstract]. Sleep Res. 1996;;25 ,.:311
 
D’ Cruz, OF, Vaughn, BV Nocturnal seizures mimic REM behavior disorder.Am J End Technol1997;37,258-264
 
Iranzo, A, Santamaria, J Severe obstructive sleep apnea/hypopnea mimicking REM sleep behavior disorder.Sleep2005;28,203-206. [PubMed]
 
Mahowald, MW, Bundlie, SR, Hurwitz, TD, et al Sleep violence-forensic science implications: polygraphic and video documentation.J Forensic Sci1990;35,413-432. [PubMed]
 
Hindler, CG Epilepsy and violence.Br J Psychiatry1989;155,246-249. [CrossRef] [PubMed]
 
McCaldon, RJ Automatism.Can Med Assoc J1964;91,914-920. [PubMed]
 
Schenck, CS, Milner, DM, Hurwitz, TD, et al Dissociative disorders presenting as somnambulism: polysomnographic, video, and clinical documentation (8 cases).Dissociation1989;4,194-204
 
Mydlo, JH, Maccia, RJ, Kanter, JL Munchausen’s syndrome: a medico-legal dilemma.Med Sci Law1997;37,198-201. [PubMed]
 
Schenck, CH, Pareja, JA, Patterson, AL, et al An analysis of polysomnographic events surrounding 252 slow-wave sleep arousals in 38 adults with injurious sleepwalking and sleep terrors.J Clin Neurophysiol1998;15,159-166. [CrossRef] [PubMed]
 
Pressman, MR Hypersynchronous delta sleep EEG activity and sudden arousals from slow-wave sleep in adults without a history of parasomnias: clinical and forensic implications.Sleep2004;27,706-710. [PubMed]
 
Pilon, M, Zadra, A, Joncas, S, et al Hypersynchronous delta waves and somnambulism: brain topography and effect of sleep deprivation.Sleep2006;29,77-84. [PubMed]
 
Guilleminault, C, Moscovitch, A, Leger, D Forensic sleep medicine: nocturnal wandering and violence.Sleep1995;18,740-748. [PubMed]
 
Mahowald, MW, Schenck, CH, Cramer Bornemann, M Sleep-related violence.Curr Neurol Neurosci Rep2005;5,153-158. [CrossRef] [PubMed]
 

Figures

Tables

References

Ohayon, MM, Caulet, M, Priest, RG (1997) Violent behavior during sleep.J Clin Psychiatry58,369-376. [PubMed]
 
Mahowald, MW, Schenck, CH Violent parasomnias: forensic medicine issues. Kryger, MH Roth, T Dement, WC eds.Principles and practice of sleep medicine2005,960-968 Elsevier/Saunders. Philadelphia, PA:
 
Mahowald, MW, Cramer-Bornemann, MA NREM sleep parasomnias. Kryger, MH Roth, T Dement, WC eds.Principles and practice of sleep medicine2005,889-896 Elsevier/Saunders. Philadelphia, PA:
 
Hublin, C, Kaprio, J, Partinen, M, et al Prevalence and genetics of sleepwalking: a population-based twin study.Neurology1997;48,177-181. [CrossRef] [PubMed]
 
Mangan, MA A phenomenology of problematic sexual behavior occurring during sleep.Arch Sex Behav2004;33,287-293. [CrossRef] [PubMed]
 
Shapiro, CM, Trajanovic, NN, Fedoroff, JP Sexsomnia: a new parasomnia?Can J Psychiatry2003;48,311-317. [PubMed]
 
Guilleminault, C, Moscovitch, A, Yuen, K, et al Atypical sexual behavior during sleep.Psychosom Med2002;64,328-336. [PubMed]
 
Mahowald, MW, Schenck, CH NREM sleep parasomnias.Neurol Clin2005;23,1077-1106. [CrossRef] [PubMed]
 
Guilleminault, C, Silvestri, R Disorders of arousal and epilepsy during sleep. Sterman, MB Shouse, MN Passouant, PP eds.Sleep and epilepsy1982,513-531 Academic Press. New York, NY:
 
Lateef, O, Wyatt, J, Cartwright, R A case of violent non-REM parasomnias that resolved with treatment of obstructive sleep apnea [abstract]. Chest. 2005;;128 ,.:461S
 
Jouvet, M, Delorme, F Locus coeruleus et sommeil paradoxal.CR Soc Biol1965;159,895-899
 
Schenck, CH, Bundlie, SR, Ettinger, MG, et al Chronic behavioral disorders of human REM sleep: a new category of parasomnia.Sleep1986;9,293-308. [PubMed]
 
Schenck, CH, Mahowald, MW REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in sleep.Sleep2002;25,120-130. [PubMed]
 
Boeve, BF, Silber, MH, Ferman, TJ REM sleep behavior disorder in Parkinson’s disease and dementia with Lewy body disease.J Geriatr Psychiatry Neurol2004;17,146-157. [CrossRef] [PubMed]
 
Nightingale, S, Orgill, JC, Ebrahim, IO, et al The association between narcolepsy and REM behavior disorder (RBD).Sleep Med2005;6,253-258. [CrossRef] [PubMed]
 
Schenck, CH, Hurwitz, TD, Mahowald, MW REM sleep behavior disorder: a report on a series of 96 consecutive cases and a review of the literature.J Sleep Res1993;2,224-231. [CrossRef] [PubMed]
 
Goldstein, M Brain research and violent behavior.Arch Neurol1974;30,1-34. [CrossRef]
 
Moyer, KE Kinds of aggression and their physiological basis.Comm Behav Biol1968;2,65-87
 
Schenck, CH, Mahowald, MW REM sleep parasomnias.Neurol Clin2005;23,1107-1126. [CrossRef] [PubMed]
 
Fantini, ML, Corona, A, Clerici, S, et al Increased aggressive dream content without increased daytime aggressiveness in REM sleep behavior disorder.Neurology2005;65,1010-1015. [CrossRef] [PubMed]
 
Schenck, CH, Boyd, JL, Mahowald, MW A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases.Sleep1997;20,972-981. [PubMed]
 
Nalamalapu, U, Goldberg, R, DePhillipo, M, et al Behaviors simulating REM behavior disorder in patients with severe obstructive sleep apnea [abstract]. Sleep Res. 1996;;25 ,.:311
 
D’ Cruz, OF, Vaughn, BV Nocturnal seizures mimic REM behavior disorder.Am J End Technol1997;37,258-264
 
Iranzo, A, Santamaria, J Severe obstructive sleep apnea/hypopnea mimicking REM sleep behavior disorder.Sleep2005;28,203-206. [PubMed]
 
Mahowald, MW, Bundlie, SR, Hurwitz, TD, et al Sleep violence-forensic science implications: polygraphic and video documentation.J Forensic Sci1990;35,413-432. [PubMed]
 
Hindler, CG Epilepsy and violence.Br J Psychiatry1989;155,246-249. [CrossRef] [PubMed]
 
McCaldon, RJ Automatism.Can Med Assoc J1964;91,914-920. [PubMed]
 
Schenck, CS, Milner, DM, Hurwitz, TD, et al Dissociative disorders presenting as somnambulism: polysomnographic, video, and clinical documentation (8 cases).Dissociation1989;4,194-204
 
Mydlo, JH, Maccia, RJ, Kanter, JL Munchausen’s syndrome: a medico-legal dilemma.Med Sci Law1997;37,198-201. [PubMed]
 
Schenck, CH, Pareja, JA, Patterson, AL, et al An analysis of polysomnographic events surrounding 252 slow-wave sleep arousals in 38 adults with injurious sleepwalking and sleep terrors.J Clin Neurophysiol1998;15,159-166. [CrossRef] [PubMed]
 
Pressman, MR Hypersynchronous delta sleep EEG activity and sudden arousals from slow-wave sleep in adults without a history of parasomnias: clinical and forensic implications.Sleep2004;27,706-710. [PubMed]
 
Pilon, M, Zadra, A, Joncas, S, et al Hypersynchronous delta waves and somnambulism: brain topography and effect of sleep deprivation.Sleep2006;29,77-84. [PubMed]
 
Guilleminault, C, Moscovitch, A, Leger, D Forensic sleep medicine: nocturnal wandering and violence.Sleep1995;18,740-748. [PubMed]
 
Mahowald, MW, Schenck, CH, Cramer Bornemann, M Sleep-related violence.Curr Neurol Neurosci Rep2005;5,153-158. [CrossRef] [PubMed]
 
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