A polysomnographically documented case of adult somnambulism with long-distance automobile driving and frequent nocturnal violence: parasomnia with continuing danger as a noninsane automatism?
A case of childhood-onset somnambulism is reported in which a 43-year-old man presented with repeated sleep-related injuries incurred during violent nocturnal activity, which included frenzied running, throwing punches and wielding knives. He had also driven an automobile a long distance during a presumed somnambulistic state. His wife had been repeatedly injured, and she felt that her life was threatened by his nocturnal violence 2-3 times yearly. Polysomnography (PSG) documented multiple episodes of complex and violent behaviors arising exclusively from stage 3/4 sleep, thus confirming the diagnosis of somnambulism. Other causes of sleep-related violence were excluded. The patient responded promptly to treatment with bedtime clonazepam, and benefit was maintained at 5-year follow-up. Although this strictly clinical case did not have any legal repercussions, it does carry forensic implications, particularly when placed in the context of the published medical literature on PSG-documented parasomnias (somnambulism, rapid eye movement sleep behavior disorder) containing explicit examples of recurrent violence, at times life-threatening, directed toward the bed partner and others. Thus, a new medical-legal concept is proposed, consisting of "parasomnia with continuing danger" as a noninsane automatism. Treatment guidelines, within the context of forensic medicine, are presented.
Schenck
C H
CH
Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center (Psychiatry 844), Minneapolis 55415, USA.
Mahowald
M W
MW
D000328:Adult; D017668:Age of Onset; D000927:Anticonvulsants / Q000008:administration & dosage / Q000627:therapeutic use; D001334:Automobile Driving; D002998:Clonazepam / Q000008:administration & dosage / Q000627:therapeutic use; D005554:Forensic Medicine / Q000331:legislation & jurisprudence; D006801:Humans; D008297:Male; D017286:Polysomnography; D012894:Sleep Stages; D012893:Sleep Wake Disorders / Q000150:complications / Q000175:diagnosis; D012895:Sleep, REM; D013009:Somnambulism / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy; D013179:Spouse Abuse; D014754:Violence
D000927:Anticonvulsants; D002998:Clonazepam