M. Zaubi

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healers’ help. They believed that he was possessed by devils. Family history revealed that his grandfather suffered from sleep arousal dysfunction including sleep-related eating disorder associated with depression. He was treated at “Bethlehem hospital” long ago. His childhood was uneventful. His school performance was average and completed first preparatory class. His first marriage failed after one year following marital disharmony. Then he remarried and is now living with his second wife, two sons and one daughter. He always maintained good relationships with his relatives and neighbours. He is a sergeant in the civil defence with 14 years service. His work record did not show any serious disturbance or significant court marshals. He is not a smoker and no history of drug or alcohol abuse. The psychiatric evaluation indicated the presence of reactive anxiety symptoms including despair, reduced awareness of the surrounding, restlessness and poor concentration. He had unremarkable physical examination. EEG and Computed Tomography of the brain were within normal limits. His IQ testing was within normal limits (IQ 97). The characteristics of this case are consistent with the DSMIV diagnosis of sleep walking disorder. (4) The patient was reassured and advised to avoid a stressful situation, alcohol, excessive consumption of coffee and maintain a regular sleep schedule. Safety issues were addressed including locking the windows and bedroom doors at night, sleeping on the ground floor and removing sharp and potentially dangerous object from the bedroom. Clonazepam was instituted at 0.5 mg and gradually increased to 1mg at bedtime. At follow-up visits for several months, the patient reported that his sleepwalking has subsided and that his sleep pattern had improved. Discussion Somnambulism is a benign condition, which takes place during the deep sleep (NREM sleep of stages III and IV) which are characterized by large amplitude very slow delta wave. If awakened from such an episode they remain confused, disoriented and distressed for short periods. Patients cannot recall the details of the event. (4) Sleep-walkers are generally more deep sleepers and it is more difficult to awake them during sleepwalking. They appear detached and are often noncommunicative, although they can become vocal, or even violent when confronted. (3) They may run, beat the walls and windows, or even leave the house. Response is reduced, although the patient may speak or scream. Behaviours which are more elaborate such as driving rarely occur. Reactions such as fleeing or defence against a threat may occur. Any attempt at restraint generally leads the patient to react violently and to attack using the hands or any object available. This patient became very violent at attempted restraint. They might attack and make chaos. Under such a condition, it is quite difficult to expect sleepwalkers passing their ways safe. On the contrary, self-injury (5) or injuries to others might be serious. (6) Variants of sleep-walking characterised by sexual activity or eating have been described. (7-8) Aggressive sexual behaviour includes disrobing, fondling, molesting the partner, or forced intercourse. This patient may have enacted serious sexual assault against the girls if was not confronted by their father. There is a strong genetic component in all parasomnia disorders demonstrated by both twin studies and in families, although the mode of transmission is not clear. (6) As mentioned earlier the patient’s grandfather was treated for sleep–related difficulties including nocturnal eating syndrome associated with depressive disorder. Furthermore, Restless Leg Syndrome (RLS) or Periodic Limb movement Syndrome (PLMS) or Sleep Disordered Breathing (SDB) in prepubertal children (9) can trigger it. Recurrence of sleepwalking in adulthood may be due to prior sleep deprivation, alcohol and recreational drugs (6) or excessive daytime anxiety and tension or regular intake of antiepileptic or psychotropic drugs. (5) It is clear in our case that anxiety and marital disharmony is significant factor in provoking this parasomnia disorder. This event appeared to both parties inexplicable and intensive police investigation and interrogations revealed nothing of significance and left no place to any doubt that a criminal motivation might have been involved. The court accepted the event as a sleep walking disorder and the charges were dropped on the ground of “non insane automatism” (6) or what suggested by Horn as an affirmative sleepwalking defence. (10) Conclusion This case illustrates the difficulty, which may be faced when assessing such a patient. The psychiatrists should give serious consideration to sleepwalking disorder (somnambulism) when 76 JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 16 No. 3 December 2009
they are dealing with violence toward others during sleep. References 1. Leong GB, Silva JA. Sleep-related violence. AAPL Newsletter 1999; 24(1): 23-27. 2. Ohayon M, Caulet M, Priest R. Violent behaviour during sleep. J Clin Psychiatry 1997; 58: 369-376. 3. Bradshaw D, Stafford CM. The sleep walking sailor. Navy Medicine 2003; 94 (6); 29-31. 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders, fourth edition. Washington DC: American Psychiatric Association 1994; 587-591. 5. Osman AA. Serious self stabbing with a knife during Sleep-Walking. Case report. Arab J of Psychiat 1990; 1(3): 225-230. 6. Cartwright R. Sleepwalking violence: A sleep Disorder, a legal dilemma, and a psychological challenge. Am J Psych 2004; 161: 1149-1158. 7. Poyares D, Almeida da CMO, Silva da RS, et al. Violent behaviour during sleep. Rev Bras Psiquiatr 2005; 27(1): 22-26. 8. Winkelman JW. Clinical and polysomnographic features of sleep-related eating disorder. J Clin Psy 1998; 59: 14-19. 9. Guilleminault C, Palombini L, Pelayo R, et al. Sleep walking and Sleep Terror in Prepubertal children: what triggers them? Pediatrics 2003; 111(1): e17-e25. 10. Horn M. A rude awakening: what to do with the sleepwalking defence? Boston College Law Review 2004; (46): 149-182. JOURNAL OF THE ROYAL MEDICAL SERVICES Vol. 16 No. 3 December 2009 77
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