A Review of Sleep-Related Violence: The Demographics of Sleep Forensics Referrals to a Single Center.

This review of sleep-related violence reports the nature of the underlying sleep-suspected conditions enountered and helps establish the spectrum of sleep-related behaviors resulting in forensic consequences. This information may begin to bridge the gap between the differing medical and legal concepts of automatisms (complex motor behaviors occurring in the absence of conscious awareness and therefore without culpability). Sleep medicine professionals are increasingly asked by legal professionals whether a sleep-related condition could have played a role in a forensic-related event. Inasmuch as sleep medicine is a relatively young field, there is scant information to address these questions. The three most prevalent criminal allegations of the 351 consecutive possible sleep forensic-related referrals to a single sleep medicine center over the past 11 years were sexual assault, homicide/manslaughter or attempted murder, and driving under the influence. The overwhelming possible sleep disorder implicated was sexsomnia, accounting for 41%, or 145 out of 351 cases. Of the 351 referrals, 111 were accepted following thorough case review. In general, cases not accepted were declined on the basis of little or no merit or contamination by alcohol intoxication. Of those cases accepted, the proposed initial claim that a sleep phenomenon was operant was supported in approximately 50%, which were mostly non-rapid eye movement disorders of arousal. No cases were felt to be due to rapid eye movement sleep behavior disorder.

Valid measures of periodic leg movements (PLMs) during a suggested immobilization test using the PAM-RL leg activity monitors require adjusting detection parameters for noise and signal in each recording.

OBJECTIVE AND BACKGROUND: Individuals with restless legs syndrome (RLS) (Willis-Ekbom disease [WED]) usually have periodic leg movements (PLMs). The suggested immobilization test (SIT) measures sensory and motor features of WED during wakefulness. Surface electromyogram (EMG) recordings of the anterior tibialis (AT) are used as the standard for counting PLMs. However, due to several limitations, leg activity meters such as the PAM-RL were advanced as a potential substitute. In our study, we assessed the validity of the measurements of PLM during wakefulness (PLMW) in the SIT for PAM-RL using both default and custom detection threshold parameters compared to AT EMG. METHODS: Data were obtained from 39 participants who were diagnosed with primary WED and who were on stable medication as part of another study using the SIT to repeatedly evaluate WED symptoms over 6-12 months. EMG recordings and PAM-RL, when available, were used to detect PLMW for each SIT. Complete PAM-RL and polysomnography (PSG) EMG data were available for 253 SITs from that study. The default PAM-RL (dPAM-RL) detected leg movements based on manufacturer's noise (resting) and signal (movement) amplitude criteria developed to accurately detect PLM during sleep (PLMS). The custom PAM-RL (cPAM-RL) similarly detected leg movements except the noise and movement detection parameters were adjusted to match the PAM-RL data for each SIT. RESULTS: The distributions of the differences between either dPAM-RL or cPAM-RL and EMG PLMW were strongly leptokurtic (Kurtosis >2) with many small differences and a few unusually large differences. These distributions are better described by median and quartile ranges than mean and standard deviation. Despite an adequate correlation (r=0.66) between the dPAM-RL and EMG recordings, the dPAM-RL on average significantly underscored the number of PLMW (median: quartiles=-13: -51.2, 0.0) and on Bland-Altman plots had a significant magnitude bias with greater underscoring for larger average PLMW/h. There also was an adequate correlation (r=0.70) between cPAM-RL and EMG but with minimal underscoring of PLMW (median quartiles=0.0; -20, 10) and no significant magnitude bias. Two scorers independently scoring 13% of the SITs showed an adequate interscorer reliability of 0.96-0.98. CONCLUSIONS: Our study confirms our expectation that measuring PLMW in a SIT using dPAM-RL is not valid and that adjustments to the detection threshold criteria are required. The PAM-RL, using parameters customized for each SIT provided a valid and reliable measure of PLMW with minimal magnitude bias compared to the AT EMG recordings.

Implanted upper airway stimulation device for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success. STUDY DESIGN: Two consecutive open prospective studies. METHODS: UAS systems were implanted in patients with moderate to severe OSA who failed or were intolerant of continuous positive airway pressure (CPAP). The study was conducted in 2 parts. In part 1, patients were enrolled with broad selection criteria. Apnea hypopnea index (AHI) was collected using laboratory-based polysomnography at preimplant and postimplant visits. Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ) were also collected. In part 2, patients were enrolled using selection criteria derived from the experience in part 1. RESULTS: In part 1, 20 of 22 enrolled patients (two exited the study) were examined for factors predictive of therapy response. Responders had both a body mass index ≤32 and AHI ≤50 (P < .05) and did not have complete concentric palatal collapse. Part 2 patients (n = 8) were selected using responder criteria and showed an improvement on AHI from baseline, from 38.9 ± 9.8 to 10.0 ± 11.0 (P < .01) at 6 months postimplant. Both ESS and FOSQ improved significantly in part 1 and 2 subjects. CONCLUSIONS: The current study has demonstrated that therapy with upper airway stimulation is safe and efficacious in a select group of patients with moderate to severe OSA who cannot or will not use CPAP as primary treatment.

State dissociation, human behavior, and consciousness.

Sleep is clearly not only a whole-brain or global phenomenon, but can also be a local phenomenon. This accounts for the fact that the primary states of being (wakefulness, NREM sleep, and REM sleep) are not necessarily mutually exclusive, and components of these states may appear in various combinations, with fascinating clinical consequences. Examples include: sleep inertia, narcolepsy, sleep paralysis, lucid dreaming, REM sleep behavior disorder, sleepwalking, sleep terrors, out-of-body experiences, and reports of alien abduction. The incomplete declaration of state likewise has implications for consciousness - which also has fluid boundaries. Fluctuations in the degree of consciousness are likely explained by abnormalities of a "spatial and temporal binding rhythm" which normally results in a unified conscious experience. Dysfunctional binding may play a role in anesthetic states, autism, schizophrenia, and neurodegenerative disorders. Further study of the broad spectrum of dissociated states of sleep and wakefulness that are closely linked with states of consciousness and unconsciousness by basic neuroscientists, clinicians, and members of the legal profession will provide scientific, clinical and therapeutic insights, with forensic implications.

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 settings.

A case of reversible restless legs syndrome (RLS) and sleep-related eating disorder relapse triggered by acute right leg herpes zoster infection: literature review of spinal cord and peripheral nervous system contributions to RLS.

Restless legs syndrome (RLS) is thought to be due to abnormalities of iron metabolism in the central nervous system; however, occasional cases are associated with lesions of the spinal cord, spinal rootlets, and peripheral nervous system. This is a case report of RLS exacerbated by shingles with a review of the literature of extra-cerebral lesions or disorders causing or contributing to RLS.

Sleep disorders: case studies.

This article reviews nine case studies of patients presenting with sleep complaints.

Sleep-related violence.

Most violent behaviors arise from wakefulness. It is important to realize that violent behaviors that may have forensic science implications can arise from the sleep period. By virtue of the fact that these behaviors arise from sleep, they are executed without conscious awareness, and, therefore, without culpability. The most common underlying conditions arising from sleep are disorders of arousal (sleepwalking and sleep terrors), the rapid eye movement sleep behavior disorder, and nocturnal seizures. In addition, there are a number of psychiatric conditions (dissociative disorders, malingering, and Munchausen syndrome by proxy) that actually arise from periods of wakefulness occurring during the sleep period. The clinical and medico-legal evaluation of such cases is outlined, and should be performed by a multidisciplinary team of experienced sleep medicine practitioners.