Mark W. Mahowald’s research while affiliated with University of Minnesota Medical Center, Fairview and other places

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.

N A RECENT publication, Ebrahim and colleagues state in their abstract that they have provided an assessment of “all known scientific studies of the effects of alcohol on the nocturnal sleep of healthy volunteers” (Ebrahim et al., 2013, p. 539). Our review of this article found it to be seriously flawed by research design and statistical problems. Ebrahim and colleagues (2013) selected 20 published articles concerned with the effects of alcohol on sleep in humans. Numerous articles were excluded from consideration. Within these articles are 38 groups of subjects based on other criteria such as sex or dose of alcohol administered. Although all sleep stages were addressed, Ebrahim and colleagues (2013) focus on the effects of alcohol on slow-wave sleep (SWS); variously known as or abbreviated as SWS, deep sleep, Stages 3 + 4. Current nomenclature combines stages 3 and 4 sleep and renames them “N3”(Iber et al., 2007). As noted in their conclusion, One area of debate and sometimes controversy has been the issue of the impact of alcohol on SWS. For the first time, all the available data are presented here and based on the findings from all available studies, and in the majority, alcohol clearly increases SWS in the first part of sleep at all doses, across gender and ages. Data for the impact of alcohol on total night SWS display a dose dependent effect with low doses showing no clear trend, moderate doses show a trend toward an increase in SWS and with high doses there is a significant and clear effect of increasing total SWS. This effect is consistent across gender and age groups. (Ebrahim et al., 2013, pp. 547–548)

Human sleep alternates between periods of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. Sleep and wakefulness are modulated by homeostatic and circadian regulatory mechanisms. Like most physiological systems, sleep and wakefulness are also governed by a circadian oscillator located in the suprachiasmatic nucleus (SCN) of the hypothalamus. Patients with sleep disorders often benefit from a general medical evaluation to investigate contributing factors. Fatigue and sleepiness may be associated with endocrine disorders such as hypothyroidism. The major symptom of Insomnia Disorder is dissatisfaction with the quantity or quality of sleep. Insomnia is associated with a wide variety of medical disorders, including pulmonary, cardiovascular, and metabolic disorder. Breathing-Related Sleep Disorders (BRSD) encompasses three entities: Obstructive Sleep Apnea Hypopnea (OSAH), Central Sleep Apnea (CSA), and Sleep-Related Hypoventilation (SRH).

Objective: The objective of this study was to determine the extent that confusional arousals (CAs) are associated with mental disorders and psychotropic medications. Methods: Cross-sectional study conducted with a representative sample of 19,136 noninstitutionalized individuals of the US general population aged 18 years or older. The study was performed using the Sleep-EVAL expert system and investigated sleeping habits; health; and sleep, mental, and medical conditions (DSM-IV-TR, ICSD-II, ICD-10). Results: A total of 15.2% (95% confidence interval 14.6%-15.8%) (n=2,421) of the sample reported episodes of CAs in the previous year; 8.6% had complete or partial amnesia of the episodes and 14.8% had CAs and nocturnal wandering episodes. Eighty-four percent of CAs were associated with sleep/mental disorders or psychotropic drugs. Sleep disorders were present for 70.8% of CAs. Individuals with a circadian rhythm sleep disorder or a long sleep duration (≥9 hours) were at higher risk of CAs. Mental disorders were observed in 37.4% of CAs. The highest odds were observed in individuals with bipolar disorders or panic disorder. Use of psychotropic medication was reported by 31.3% of CAs: mainly antidepressant medications. After eliminating possible causes and associated conditions, only 0.9% of the sample had CA disorder. Conclusions: CAs are highly prevalent in the general population. They are often reported allegedly as a consequence of the treatment of sleep disorders. For the majority of subjects experiencing CAs, no medications were used, but among those who were using medications, antidepressants were most common. Sleep and/or mental disorders were important factors for CAs independent of the use of any medication.