Defending sleepwalkers with science and an illustrative case.

OBJECTIVE: To test whether laboratory-based research differentiating sleepwalkers (SW) from controls (C) can be applied in an uncontrolled forensic case as evidence the alleged crime was committed during an arousal from sleep in which the mind is not fully conscious due to a SW disorder. METHODS: A PSG study recorded 8 months after the defendant was charged was analyzed independently by spectral analysis. Slow wave activity (SWA) and cyclic alternating pattern (CAP) rates were computed. Clinical interviews and police records were reviewed for data re: the defendant's sleep prior to the event and use of drugs, alcohol, and stimulants. RESULTS: The SWA distribution was abnormally low and flat, significantly lower than published controls; in the first NREM cycle, CAP rate 55 was above normal. Two weeks of prior sleep deprivation was confirmed from interviews and defendant's observed daytime sleepiness. Caffeine intake the day before the event was calculated at 826 mg over 14 hours. Snoring and a mild breathing disorder were present in the PSG. CONCLUSION: Testimony based on spectral analysis of PSG recorded following an alleged criminal event supported a SW explanation for the non-rational behaviors charged. The defendant was acquitted of all charges and has been successfully treated.

Sleeping together: a pilot study of the effects of shared sleeping on adherence to CPAP treatment in obstructive sleep apnea.

OBJECTIVES: To examine the sleep of married couples, recorded together in the laboratory before and after the husband is treated with continuous positive airway pressure (CPAP) to control his obstructive sleep apnea (OSA). The purpose was to investigate how these data relate to shared sleeping when he is on CPAP and his adherence to this treatment. METHODS: Following a split-night diagnosis of OSA with CPAP titration, 10 married men slept for 2 additional nights with their non-apneic wife while both were recorded. The first night included a standard baseline 12-channel clinical polysomnogram without treatment. Following 2 weeks of home CPAP, the couple returned for a second polysomnography night with the husband on CPAP. Both partners completed Epworth Sleepiness Scales and Sleep Apnea Quality of Life Interviews each lab night. During the intervening 2 weeks, sleep logs were completed daily noting if CPAP was used, the presence of snoring, and where and how well they slept. Adherence data from machine downloads were obtained after an average of 4.6 months. RESULTS: The husbands' baseline sleep differed significantly from their wives on 6 of 7 sleep variables related to OSA and on Epworth Sleepiness Scale scores. Their sleep did not differ the second night, except for his lower percentage of slow wave sleep. Adherence to CPAP was unrelated to OSA severity but positively related to the number of nights the couple slept together during the 2 weeks of home CPAP. The frequency of sleeping together was negatively related to the wives' arousal frequency on laboratory nights. CONCLUSION: Although CPAP controls a husband's sleep-related OSA symptoms, his treatment adherence is strongly related to his wife sharing the bed. Addressing the wife's sensitivity to arousals when bed sharing may improve the husband's treatment adherence.

Relation of dreams to waking concerns.

To test that dreams are influenced by the pre-sleep waking emotional concerns of the sleeper and have an effect on waking adaptation, 20 depressed and 10 control subjects, who were all going through a divorce, were enrolled in a repeated measures study lasting 5 months. A Current Concerns test was administered on three occasions before nights when every REM period was interrupted to record recalled mental content. The degree of waking concern about the ex-spouse correlated significantly with the number of dreams in which the former partner appeared as a dream character. Those who were in remission at the follow-up evaluation had a higher percentage of well-developed dreams than those who remained depressed. Dreams of the former spouse reported by those in remission differed from those who remained depressed in the expression of dream affect and in the within-dream linkage among units of associated memory material. Dreams of the former spouse that are reported by those who are not in remission lack affect and connection to other memories.

Oral appliances for snoring and obstructive sleep apnea: a review.

We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.

The role of sleep in changing our minds: a psychologist's discussion of papers on memory reactivation and consolidation in sleep.

The group of papers on memory reactivation and consolidation during sleep included in this volume represents cutting edge work in both animals and humans. They support that the two types of sleep serve different necessary functions. The role of slow wave sleep (SWS) is reactivation of the hippocampal-neocortical circuits activated during a waking learning period, while REM sleep is responsible for the consolidation of this new learning into long-term memory. These studies provide further insights into mechanisms involved in brain plasticity. Robeiro has demonstrated the upregulation of an immediate-early gene (IEG zif 268) to waking levels, which occurs only in REM and only in connection with new learning. McNaughton and his group have identified electrical indicators that the hippocampus and neocortex are talking to each other by testing the coactivation of hippocampal sharp wave bursts in SWS and shifts from down to up states of activation in the neocortex. In human studies Smith's group reports work on individual differences such as intelligence and presleep alcohol that affect postsleep performance, and Stickgold and collaborators report that a short nap will improve performance if it contains REM sleep. Payne and Nadel suggest that the recall benefit associated with REM sleep may be due to its association with increased cortisol levels. These papers are important not only in their individual contributions but also in revitalizing the work coordinating waking and sleep. This promises to further the understanding of how our unique capacity to learn from experience and modify our behavior takes place.

Sleepwalking violence: a sleep disorder, a legal dilemma, and a psychological challenge.

OBJECTIVE: The purpose of this article is to further an understanding of the psychological state when aggression follows an episode of partial arousal from early non-REM sleep during which some areas of the brain appear to be functioning as in waking while others appear to remain in a state of sleep. To illustrate this, the author examines a case of homicide for which the defense argued lack of responsibility due to sleepwalking. METHOD: A review of the forensic literature on sleepwalking aggression and sleep studies suggests that these fall into one or both of two DSM-IV-TR diagnoses: sleepwalking disorder and sleep terror disorder. The new case, which would meet criteria for an overlap disorder in which sleepwalking is followed by sleep terror, is compared to one previously published. RESULTS: These findings support sleepwalking violence as a distinct overlap disorder with common disturbed psychological functioning during and for a period up to 1 hour following an aggressive episode. CONCLUSIONS: Research clarifies the pathology of this disorder and highlights the need to both refine the differential diagnosis and test the efficacy of treatment protocols.

REM sleep reduction, mood regulation and remission in untreated depression.

The contribution of increased rapid eye movement (REM) pressure through repeated, mild, reduction of (REM) sleep to remission from untreated depression was studied over a 5-month period in 20 depressed and 10 control volunteers. Sixty percent of the depressed subjects were in remission at the end of the study. Sixty-four percent of the variance in remission could be accounted for by four variables: the initial level of self-reported symptoms, the reported diurnal variability in mood, the degree of overnight reduction in depressed mood following interruptions of REM sleep and the quality of dream reports from these awakenings. Increased REM pressure is beneficial for those who are able to construct well-organized dreams.

REM sleep, dream variables and suicidality in depressed patients.

To examine the relationship between the emotional quality of dreams, REM sleep variables and suicidal tendency in depressed individuals, 26 depressed volunteers (10 males and 16 females) were assessed with the Beck Depression Inventory (BDI) and the Hamilton Depression Rating Scale (HDRS), and underwent 3 nights of polysomnography. There was a significant negative correlation between suicidality scores and REM latency and a positive correlation between suicidality and REM percent. Suicidal subjects had a significantly shorter mean REM latency and a higher mean REM percentage than the non-suicidal subjects. As expected in normal subjects, 20 subjects had an increase in dream-like quality (DLQ) of REM reports between the first and second halves of the night. The six subjects with a negative DLQ difference also scored as suicidal. A reduction in dream-like quality of the REM content reports between the first and second halves of the night was found to be associated with suicidal tendency. The findings may indicate that these subjects fail to self-regulate mood and integrate affect into long-term memory networks during sleep. Theoretical and clinical implications of these findings in depression are discussed.

What's new in oral appliances for snoring and sleep apnea: an update.

The number and kind of oral appliances have proliferated in recent years as dentists have responded to the challenge to develop more sophisticated devices for the control of socially disruptive snoring and obstructive sleep apnea. Sleep-disordered breathing is now recognised as being a highly prevalent problem which carries increased social, economic, cognition and health risks. The popular mandibular-advancement devices have a greater level of acceptance by patients than the standard nasal continuous positive airway pressure (CPAP) treatment in recent head-to-head studies. It is important that these patients be followed by sleep clinicians as these appliances are less successful in controlling sleep apnea when the level of severity is high. Research is needed to determine the patients most appropriate for an oromandibular treatment and when CPAP is the treatment of choice. Potential sequences of treatments are suggested.