Be careful with Sleep-Disrupting Sleeping Pills

When Can Killers Claim Sleepwalking As a Legal Defense?


Published: January 16, 1996, New York Times

IT is the stuff of television movies and pulp fiction:

A 16-year-old Kentucky girl, dreaming that burglars were breaking into her home and murdering her family, got up in her sleep, picked up two revolvers and fired into the dark house, killing her father and 6-year-old brother and injuring her horrified and bewildered mother.

A vacationing detective, recovering from a nervous breakdown, called upon to help solve a seemingly motiveless murder of a bather on a beach in France, realized after finding prints in the sand made by a stockinged foot that was missing a toe that he himself was the perpetrator, having shot the man with his pistol while walking in his sleep.

A 23-year-old Toronto man with a wife and infant daughter, suffering from severe insomnia caused by joblessness and gambling debts, arose in the night and, still asleep, got in his car and drove 14 miles to his in-law’s home. He stabbed to death his mother-in-law, whom he loved and who called him “a gentle giant,” and tried to kill his father-in-law. He then drove to the police and said “I think I have killed some people . . . my hands,” only then realizing he had severely cut his own hands.

Were they legally culpable for their actions? Is someone who kills in his sleep guilty of murder? Perhaps not. The 16-year-old girl and the 23-year-old man were acquitted. The fate of the French detective is not known. And in the current issue of the journal Sleep, which is devoted to the subject of sleep-related violence, Dr. Meir Kryger, director of the Sleep Disorders Center at the St. Boniface Hospital-Research Center in Winnipeg, Canada, wrote, “The potential for sleep disorders to become the ‘Twinkie’ defense of the 21st century is frightening.”

Dr. Kryger said in an interview that in an increasing number of violent crimes, defendants are contending that they were asleep at the time and therefore not accountable for their actions.

But if a sleep problem is established, said Dr. Clete A. Kushida of the Stanford University Sleep Disorders Clinic, “the courts and the public have to accept that it’s a disease like any other disease.”

Dr. Kryger added, “In my opinion, a person who commits a violent crime while asleep should not be held responsible for the act, but that person cannot be returned to society without treatment.”

These three cases are among the more dramatic examples of a phenomenon known as sleep-related violence, in which part of the brain wakes up enough to allow the person to perform complex acts while the rest of the brain remains unconscious with sleep. To sleep specialists and increasingly to the law, it is called “noninsane automatism” — an act done by a sane person but without intent, awareness or malice. The person who commits the act is typically horrified by what has happened and has no memory of having done it.

Some sleepers have strangled wives they seem to have loved, some have thrown their children out of windows, and some — with eyes open but conscious minds asleep — have driven cars and killed pedestrians or people in other vehicles. Still others have seriously injured themselves by walking through upper-story windows or plate-glass doors.

Despite a few dramatic cases of sleep-related violence that have come to trial, doctors in this country remain largely unaware of the potential dangers of sleep disorders. Millions of Americans have these sleep disorders, though only a small percentage become violent. When such sleep disorders are finally brought to medical attention, patients are often told that they have an emotional problem and are referred for psychotherapy to unearth some unconscious reason for their bizarre behavior.

But psychiatrists and neurologists who specialize in sleep problems insist that most of the disorders that lead to sleep-related aggressive acts are not a result of underlying mental illness. Although severe stress, like having survived a traumatic event, can sometimes trigger the expression of underlying sleep problems, their fundamental cause is a physiological or neurological aberration that disrupts the normal behavior of the brain during sleep and results in partial and often confused arousals.

Researchers have found that the disorders that lead to sleep-related violence can usually be treated effectively with one or more medications, including antiseizure drugs and tranquilizers, that “quiet” the overly active parts of the brain and help to prevent partial arousals during sleep. Patients may also receive counseling to relieve stresses that contribute to their sleep disturbance.

One type of problem, REM sleep behavior disorder, which most often affects men over 60, is especially hazardous because it allows people to act out their dreams while still asleep and thus removed from conscious controls and inhibitions, said Dr. Mark W. Mahowald, who first described this phenomenon in 1986. Normally, during REM, or dream sleep, motor functions are paralyzed, said Dr. Mahowald, a neurologist with the Minnesota Sleep Disorders Center at Hennepin County Medical Center in Minneapolis. The eye muscles, diaphragm and heart continue to function, but people cannot walk, talk or thrash about, he said.

But when a person with the REM disorder is dreaming, all the muscles can continue to work, which would allow a man dreaming about an intruder to bludgeon his sleeping spouse, or a woman dreaming her house is on fire to toss her children from the window.

Somewhat better known are disorders like sleepwalking and night terrors that occur during non-REM sleep — typically the deeper stages of sleep known as slow-wave sleep, stages 3 and 4. Children and adults who sleepwalk or who emit blood-curdling screams, sweat profusely and appear terrified in the course of a night terror are not dreaming.

In the journal, Dr. Carlos H. Schenck, a psychiatrist at the Minnesota center, tells of a 43-year-old man with a non-REM disorder, sleepwalking. The man, he said, “had injured his wife on many occasions by punching her and had once attempted to strangle her.” He had also broken his fingers punching hard objects, injured his knees and ankles when he collided with doorways and furniture or fell down the stairs while walking in his sleep. When the problem was finally brought to medical attention, it was found to be longstanding. The man had begun sleepwalking at the age of 5, often jumping from his bed and running around the house. At 25, while in pajamas and believing that someone was in the house and about to attack him, he got in his car and, still asleep, drove five miles to his parents’ home. During his 15-year marriage, near-nightly sleep episodes included once flinging his wife into the air, then dropping her onto a hardwood floor.

Yet various tests revealed no psychiatric disorder or history of alcohol or substance abuse. During the day, the man had a stable and enjoyable marriage and family life with four children. But when the Minnesota Sleep Center hooked him up for polysomnography, which includes recording of brain waves and muscle action, all sorts of violent incidents would occur. He would sit up rapidly, look about in confusion, talk, throw punches and try to leave the bed, all while his brain recording showed he was still asleep. At last report he had been effectively treated for more than five years with bedtime doses of a Valium-like drug, clonazepam.

Most people who sleepwalk or suffer night terrors, which afflict about 1 percent of the adult population, do not become violent. In trying to determine who might strike out dangerously during sleep, Dr. Harvey Moldofsky and colleagues at the University of Toronto Center for Sleep and Chronobiology examined 64 consecutive patients who visited their clinic. The 26 who had committed serious violent acts, harming property, themselves or other people, were more likely to be men — only three were women — with disordered sleep schedules, like those who do shift work. They were also more likely than the nonviolent group to have experienced recent distressing events and to consume a lot of caffeine and to use other drugs that could further disrupt their sleep. Finally, they demonstrated a reduced ability to wake up because of disturbances in their deep sleep stages.

Two well-recognized physical ailments, sleep apnea and epilepsy, can sometimes result in sleep-related violence and have been used by defendants who said they had no recollection of committing their sleep-related crimes. Sleep apnea, in which patients stop breathing during sleep and then suddenly resume breathing with a raucous snort-like snore, can result in hundreds of confused, partial arousals during the night. Occasionally, sleepwalking may accompany these partial arousals, according to Dr. Christian Guilleminault, who established the Stanford sleep center and edits the Sleep journal.

But Dr. Eric A. Nofzinger, a psychiatrist at the Sleep and Chronobiology Center at the University of Pittsburgh, said that great care must be taken to prevent sleep apnea or epilepsy — or any sleep disorder, for that matter — from becoming a “Twinkie defense.”

He cited a case that occurred two years ago in Butler, Pa. A 37-year-old man fatally shot his wife and contended that he remembered nothing about the incident, which he said must have occurred during a confused arousal precipitated by his severe sleep apnea. The jury rejected this defense and found him guilty of first-degree murder, partly because the man had a history of violence toward his wife during waking hours and partly because he showed no remorse over her death when the police arrived.

In a contrasting case, a man with severe sleep apnea and night terrors who murdered his wife was ultimately acquitted. As recalled by Dr. Moldofsky, one night the man, who had an apparently tranquil marriage, chased his wife into the street, stabbed her repeatedly and finally smashed her head on the pavement, all the while easily brushing off neighbors who tried to stop him. The man then fell asleep in his car and when he awakened seemed very confused and said he could not recall the incident. Although twice convicted by juries, the man successfully appealed both convictions.

Dr. Nofzinger said that for noninsane automatism to be used as a legal defense, the defendant should have a history of a sleep disorder, particularly one that has previously involved aggressive or dangerous acts that are inconsistent with the person’s daytime behavior.

In the best of cases, instances of aggressive or violent acts during sleep can be documented during nights spent in a sleep laboratory, although the disorders may not occur frequently enough to make this practical. It also helps, Dr. Moldofsky said, if the defendant had no motive for committing the crime.

“Although it is quite accepted by society when someone harms himself during sleep,” he said, “when it comes to harming others, people very often cannot believe the act could take place without the person being aware of what was happening. They have difficulty believing a person could remain asleep through such violent acts.”

Yet Dr. Moldofsky described three nonpsychotic men who were charged by the police with assaultive behavior that occurred during sleep this way: “They appeared as automatons, unaware of what they were doing and unresponsive to stimuli from their environment. Their strength was extraordinary, and their violence was involuntary and inconsistent with the reality of the situation. After returning to sleep and then awakening on the following day, they were amnesic for the event. They subsequently harbored intense guilt, remorse and fear of recurrences of such dangerous behavior.”

Dr. Weeks’ Comment:

Be careful with sleeping pills – Ambien, the benzodiazepines (diazepam, clonazepam, temazepam etc) as these agents actually disrupt stage 3.4 deep or restorative sleep.

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