title: Disorders of arousal from sleep and violent behavior: the role of physical contact and proximity.
abstract: OBJECTIVE
  To review medical and legal case reports to determine how many appear to support the belief that violence against other individuals that occurs during Disorders of Arousal - sleepwalking, confusional arousal, and sleep terrors - is triggered by direct physical contact or close proximity to that individual and does not occur randomly or spontaneously.
  
  
  METHODS
  Historical review of case reports in the medical and legal literature.
  
  
  RESULTS
  A total of 32 cases drawn from medical and legal literature were reviewed. Each case contained a record of violence associated with Disorders of Arousal; in each, details of the violent behavior were available. Violent behaviors associated with provocations and/or close proximity were found to be present in 100% of confusional arousal patients and 81% of sleep terror patients. Violent behaviors were associated with provocation or close proximity in 40%-90% of sleepwalking cases, depending on whether the legal verdict and other factors were taken into account. Often the provocation was quite minor and the response greatly exaggerated. The specific manner in which the violence was triggered differed among sleepwalking, confusional arousals, and sleep terrors.
  
  
  CONCLUSIONS
  In the cases reviewed, violent behavior directed against other individuals associated with Disorders of Arousal most frequently appeared to follow direct provocation by, or close proximity to, another individual. Sleepwalkers most often did not seek out victims, but rather the victims sought out or encountered the sleepwalker. These conclusions are tempered by several limitations: the selection of cases was not random and may not represent an accurate sample of violent behaviors associated with Disorders of Arousal. Also, final verdicts by juries in reported legal cases should not be confused with scientific proof of the presence or absence of sleepwalking. The pathophysiology of Disorders of Arousal with and without violent behavior could be associated with normally occurring deactivation of the frontal lobes during slow wave sleep (SWS) connected via atypically active thalamocortical pathways to the limbic areas. It is not known if the violent sleepwalker, confusional arousal patient, or sleep terror patient differs from other patients with these disorders. The conclusions of this case series await confirmation by the results of future sleep laboratory based studies.
authors: Sleep Medicine Services, The Lankenau Hospital, Wynnewood, PA 19096, USA. pressmanm@mlhs.org
authors: Mark R
authors: MR
authors: Pressman
mesh_terms: D005104:Expert Testimony / Q000331:legislation & jurisprudence; D006708:Homicide / Q000331:legislation & jurisprudence / Q000523:psychology; D020184:Night Terrors / Q000175:diagnosis / Q000523:psychology; D010550:Personal Space; D020187:REM Sleep Behavior Disorder / Q000175:diagnosis* / Q000523:psychology; D020921:Sleep Arousal Disorders / Q000175:diagnosis* / Q000523:psychology; D012931:Social Environment; D013009:Somnambulism / Q000175:diagnosis* / Q000523:psychology; D014481:United States; D014754:Violence / Q000331:legislation & jurisprudence / Q000523:psychology*
references: Neuroimage. 2005 Oct 15;28(1):14-21
references: 15979343
references: Sleep. 1995 Nov;18(9):740-8
references: 8638066
references: Neuropsychiatry Neuropsychol Behav Neurol. 2001 Jan;14(1):1-14
references: 11234904
references: Neurosci Biobehav Rev. 1982 Summer;6(2):125-43
references: 7048154
references: J Psychiatr Res. 1971 Aug;8(3):167-87
references: 5000109
references: Brain. 2006 Mar;129(Pt 3):655-67
references: 16339798
references: Psychiatr Q. 1974;48(3):400-9
references: 4463401
references: Schizophr Res. 2006 May;84(1):144-64
references: 16616832
references: Sleep. 1994 Apr;17(3):253-64
references: 7939126
references: J Neurosci. 1997 Jun 15;17(12):4800-8
references: 9169538
references: Br J Psychiatry. 1985 Dec;147:688-91
references: 3830330
references: Dis Nerv Syst. 1959 Nov;20:534-6
references: 14433596
references: J Psychiatr Res. 2003 Jul-Aug;37(4):313-24
references: 12765854
references: Psychol Med. 1987 Nov;17(4):915-25
references: 3324143
references: J Neurol Neurosurg Psychiatry. 2001 Dec;71(6):720-6
references: 11723190
references: Science. 1968 Mar 8;159(3819):1070-8
references: 4865791
references: Psychosomatics. 2004 Sep-Oct;45(5):448-9
references: 15345792
references: Am J Psychiatry. 2004 Jul;161(7):1149-58
references: 15229043
references: Sleep Med Rev. 2007 Feb;11(1):5-30; discussion 31-3
references: 17208473
references: Sleep. 1995 Nov;18(9):776-82
references: 8638071
references: Sleep. 1995 Nov;18(9):765-72
references: 8638069
references: Neurology. 1996 May;46(5):1231-8
references: 8628458
references: Neuropsychobiology. 2003;47(4):198-205
references: 12824743
references: J Clin Psychol. 1990 Nov;46(6):696-706
references: 2286660
references: Can J Psychiatry. 1984 Mar;29(2):132-4
references: 6722704
references: Intensive Care Med. 1991;17(4):219-24
references: 1744307
references: Am J Psychiatry. 1989 Sep;146(9):1166-73
references: 2764174
references: Brain. 1997 Jul;120 ( Pt 7):1173-97
references: 9236630
references: J Am Acad Child Psychiatry. 1984 Jul;23(4):438-47
references: 6747150
references: Neuropsychopharmacology. 2006 Dec;31(12):2783-92
references: 16880772
references: Science. 1965 May 14;148(3672):975-7
references: 14277842
references: Child Psychiatry Hum Dev. 2001 Winter;32(2):93-106
references: 11758881
references: J Forensic Sci. 2003 Sep;48(5):1158-62
references: 14535686
references: Neurosci Biobehav Rev. 1993 Winter;17(4):405-25
references: 8309650
references: Lancet. 2000 Aug 5;356(9228):484-5
references: 10981896
references: Clin Electroencephalogr. 1980 Jul;11(3):136-9
references: 7449156
references: Sleep. 1995 Nov;18(9):773-5
references: 8638070