Potentially Lethal Behaviors Associated With Rapid Eye Movement Sleep Behavior Disorder: Review of the Literature and Forensic Implications

Abstract

Rapid eye movement (REM) sleep behavior disorder (RBD) is characterized by loss of the muscle atonia of REM sleep, with release of complex and violent behaviors that are often attempted dream-enactments. This study reviewed the literature on RBD with regard to potentially lethal behavior. A total of 39-41 clinical cases of RBD associated with potentially lethal behaviors to self and/or others were found, involving a child and adults of all age groups, that manifested as choking/headlock (n = 22-24), defenestration/near-defenestration (n = 7), and diving from bed (n = 10). A total of 80.8% (n = 21) were males; 19.2% (n = 5) were females; mean age was 65.6 +/- (SD) 13.8 years (range: 27-81 years, and a child). (Gender/age data were not listed in the remaining cases.) An etiologic association of RBD with a neurologic disorder (or with pharmacotherapy of psychiatric disorders, n = 4) was present in 21-23 patients. Thus, RBD carries well-documented, potential forensic consequences during RBD episodes that could possibly have been misinterpreted as suicidal or homicidal behavior.

A Novel Therapy for REM Sleep Behavior Disorder (RBD)

“…[3][4][5] This study demonstrates that a customized bed alarm augments pharmacological treatment in refractory cases and prevents SRI. No SE have occurred over 63 patient-months since starting bed alarm treatment.…”

“…31 Also, case #1 demonstrates the importance of "host vulnerability factors" related to injuries resulting from RBD, as previously discussed in detail. 5 Although all of our patients had anticipatory anxiety about sleeping and sustaining SRI, it is intriguing that in cases #2 and #3, the spouse/boyfriend continued to sleep in the same bed despite sustaining repeated blows from DEB (in contrast, the wife of patient #4 eventually slept in a separate room). This is an impressive and apparently common phenomenon previously described, in which the spouses of patients with vigorous and violent RBD adamantly continue to sleep in the same bed, reportedly out of care and concern for the patient with RBD.…”

“…This is an impressive and apparently common phenomenon previously described, in which the spouses of patients with vigorous and violent RBD adamantly continue to sleep in the same bed, reportedly out of care and concern for the patient with RBD. 5 quetiapine, and clozapine. 6,13,15 The only agent that has been studied in a controlled, randomized, double-blind fashion is melatonin (see below).…”

“…Exiting the bed while acting out a dream is a particularly high-risk behavior and may result in severe traumatic injury. [3][4][5] Although clonazepam and melatonin are usually effective therapies, 6-8 they are often inadequate in the setting of neurodegenerative disease. RBD is often the cardinal fi nding among patients with impending synucleinopathies such as Parkinson disease, as well as other neurodegenerative disorders such as spinocerebellar ataxia.…”

Sleep Forensics: a critical review of the literature and brief comments on the Brazilian legal situation

“…As there is an obvious advantage to the defendant claiming they had no control over their actions, there has been much debate as to how to distinguish true cases of parasomniainduced violence from conscious actions. There are several guidelines available [41][42][43] , and most agree on the salient points: (a) previous history of parasomnia or at least truthful reports or sleep laboratory findings of similar (or not so similar) episodes; (b) the victim should have only been present by coincidence rather than being targeted; (c) a feeling of horror and guilt should be apparent once consciousness returns, with no attempt to escape or cover up the deed; (d) there should normally be some degree of amnesia regarding the event (or, in case of RBD, recalling vivid/violent dreams) and (e) the crime is out of character for the person in question. These factors are combined with the potential triggers listed above to assess the likelihood of a genuine parasomnia episode.…”