Forensic considerations on violent parasomnias during lifespan

Nocturnal parasomnias are a group of sleep complex manifestation that don't alter the sleep macrostructure, but when persistent during adulthood may be assume violent aspects with relevant forensic implications about the guiltiness

Parasomnias and Antidepressant Therapy: A Review of the Literature

There exists a varying level of evidence linking the use of antidepressant medication to the parasomnias, ranging from larger, more comprehensive studies in the area of RBD to primarily case reports in the NREM parasomnias. As such, practice guidelines are lacking regarding specific direction to the clinician who may be faced with a patient who has developed a parasomnia that appears to be temporally related to use of an antidepressant. In general, knowledge of the mechanisms of action of the medications, particularly with regard to the impact on sleep architecture, can provide some guidance. There is a potential for SSRIs, TCAs, and SNRIs to suppress REM, as well as the anticholinergic properties of the individual drugs to further disturb normal sleep architecture

Management of rapid eye movement sleep behavior disorder in patients with Parkinson's disease

Among all of the devastating effects that Parkinson’s disease (PD) has on an individual, sleep dysfunction is one that can have a profound effect on the entire family of the patient. The most potentially destructive of these sleep syndromes being that of Rapid Eye Movement Sleep Behavior Disorder (RBD). This disorder not only causes sleep impairment to the patient, but can occasionally result in life-threatening injury to the individual or their bed partner. While this condition is manageable with medication, the current treatment of choice is a long-acting benzodiazepine, clonazepam. This drug, while effective in treating RBD, comes with a significant burden of side effects. Patients with neurodegenerative disorders, like PD, are at even higher risk of suffering the negative impacts of this treatment. One potential alternative treatment that has been considered is a supplement of exogenous melatonin, a hormone that plays a role in maintaining one’s circadian rhythm. Several small case studies have shown potential efficacy of this treatment, and with very few side effects. However, this efficacy has not yet been proven by randomized clinical trial. This proposed study will perform a double-blind randomized clinical trial of melatonin vs. placebo in a population of PD patients with RBD. Subjects will be analyzed via polysomnographic sleep study, where symptoms will be scored on the RBD Severity Scale (RBDSS) at baseline and after a treatment intervention. Statistical analysis will then ascertain whether or not a significant symptom reduction is seen following melatonin treatment, compared to a group receiving placebo. If melatonin proves to be efficacious in this patient population, this would give clinicians a new treatment option to consider to effectively manage symptoms of RBD with a much lower risk of potentially harmful side effects. Finding an effective method of managing this condition, the prevalence of which continues to rise worldwide, will have a great impact on improving the safety and quality of life of these patients

Sleepwalking in Parkinson's disease: a questionnaire-based survey

Sleepwalking (SW) corresponds to a complex sleep-associated behavior that includes locomotion, mental confusion, and amnesia. SW is present in about 10% of children and 2-3% of adults. In a retrospective series of 165 patients with Parkinson's disease (PD), we found adult-onset ("de novo”) SW "de novo” in six (4%) of them. The aim of this study was to assess prospectively and systematically the frequency and characteristics of SW in PD patients. A questionnaire including items on sleep quality, sleep disorders, and specifically also SW and REM sleep behavior disorder (RBD), PD characteristics and severity, was sent to the members of the national PD patients organization in Switzerland. In the study, 36/417 patients (9%) reported SW, of which 22 (5%) had adult-onset SW. Patients with SW had significantly longer disease duration (p=0.035), they reported more often hallucinations (p=0.004) and nightmares (p=0.003), and they had higher scores, suggestive for RBD in a validated questionnaire (p=0.001). Patients with SW were also sleepier (trend to a higher Epworth Sleepiness Scale score, p=0.055). Our data suggest that SW in PD patients is (1) more common than in the general population, and (2) is associated with RBD, nightmares, and hallucinations. Further studies including polysomnographic recordings are needed to confirm the results of this questionnaire-based analysis, to understand the relationship between SW and other nighttime wandering behaviors in PD, and to clarify the underlying mechanism

Differential diagnoses of nocturnal fear and movement paroxysm: a case report

Recurrent nocturnal behavioural and movement paroxysms are a diagnostic challenge for the clinical pediatrician. We report on an adolescent girl who presents recurrent stereotypical nightmare-like episodes occurring during non-REM sleep stages 1-2 (N1 and N2). We discuss the differential diagnoses between epileptic and nonepileptic events and between nocturnal frontal and temporal seizures. The pathophysiological and unusual electroencephalographical features are discussed with respect to clinical features and results of interictal FDG-PET. Conclusion In case of stereotypical nightmare-like episodes in children or adolescents, an epileptic origin has to be ruled out before a parasomnia is diagnosed. In addition, a normal awake EEG or interictal sleep EEG in the diagnostic workup may not exclude an epileptic disorder. In case of nightly stereotypic motor or affective events, an epileptic disorder should be discusse

Repercussions of a sleep medicine outreach program

Despite the high prevalence of sleep disorders, many healthcare professionals and lay people have little knowledge of Sleep Medicine. Mindful of such a reality, in 2001 the Sleep Institute of the Associação Fundo de Incentivo à Psicofarmacologia launched a campaign to increase Sleep Medicine awareness. Media features, exhibitions, inserts, and classes were used to reach 2,000,000 people and 55,000 healthcare professionals during the period from 2001 to 2004. To evaluate this program, we compared data for polysomnography referrals to the Institute in 2000 and in 2004. A total of 8805 referrals were evaluated (2000: 2164; 2004: 6641). Over the 4 years of the program, the number of beds increased by 43%; more women were referred (31 vs 37%; P < 0.001), mainly with a diagnostic hypothesis of sleep-disorder breathing (SDB). SDB was the most frequent diagnostic hypothesis in 2000 and 2004. In 2004 there were fewer referrals without a diagnostic hypothesis (27 vs 21%; P < 0.001) and for controlling surgically treated SDB (2.3 vs 1.6%; P < 0.05), and an increase in the following diagnostic hypotheses: non-invasive treatment of SDB (8.3 vs 12.3%; P < 0.001) and insomnia (3.5 vs 6.5%; P < 0.001). Insomnia diagnostic hypothesis was better correlated with SDB on referral documents in 2004 and less with a diagnostic hypothesis of limb movement disturbance. The program helped increase polysomnography referrals, particularly among women. Healthcare professionals appear to have a more developed understanding of sleep disorders.Universidade Federal de São Paulo (UNIFESP) Departamento de PsicobiologiaUniversidade Federal de São Paulo (UNIFESP) Departamento de FarmacologiaUNIFESP, Depto. de PsicobiologiaUNIFESP, Depto. de FarmacologiaSciEL

Treatments for somnambulism in adults: assessing the evidence

Somnambulism, or sleepwalking, is a parasomnia of non-rapid eye movement (NREM) sleep where movement behaviours usually confined to wakefulness are displayed during sleep. Generally, if sleepwalking is causing distress or danger in spite of safety measures, medical or psychological treatment is indicated. Clinicians will need to assess the evidence for treatment options. MEDLINE, EMBASE, PsycINFO and the Ovid Evidence–Based Medicine Reviews (EBM) multifile databases were searched. No properly powered rigorous controlled trials were found for treatment of sleepwalking in adults. Seven reports described small trials with some kind of control arm, or retrospective case series which included 30 or more patients. With no high quality evidence to underpin recommendations for treatments of somnambulism, full discussion with patients is advised. Adequately powered, well-designed clinical trials are now needed, and multi-centre collaborations may be required to obtain the sample sizes required

Violence in sleep

Although generally considered as mutually exclusive, violence and sleep can coexist. Violence related to the sleep period is probably more frequent than generally assumed and can be observed in various conditions including parasomnias (such as arousal disorders and rapid eye movement sleep behaviour disorder), epilepsy (in particular nocturnal frontal lobe epilepsy) and psychiatric diseases (including delirium and dissociative states). Important advances in the fields of genetics, neuroimaging and behavioural neurology have expanded the understanding of the mechanisms underlying violence and its particular relation to sleep. The present review outlines the different sleep disorders associated with violence and aims at providing information on diagnosis, therapy and forensic issues. It also discusses current pathophysiological models, establishing a link between sleep-related violence and violence observed in other setting