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Revista Brasileira de Psiquiatria

Print version ISSN 1516-4446

Rev. Bras. Psiquiatr. vol.31 no.3 São Paulo Sept. 2009

http://dx.doi.org/10.1590/S1516-44462009000300016 

CARTA AOS EDITORES

 

Violent sleepwalking in a general hospital ward: a case report

 

Sonambulismo violento em enfermaria de hospital geral: um relato de caso

 

 

Dear Editor,

Your journal recently published a case report of sleep terror disorder (ST), associated with emotional and behavioral disturbances at night.1 In a recent search, we found only one article2 in Brazilian journals with the uniterms "violence" and "sleepwalking" (SW) and, thus, we perceived the lack of publications on parasomnias and related behavioral disturbances.

We report the case of Mrs. A., a 25 year-old woman, who was accompanying her daughter at the pediatric ward at the University Hospital. After the 7th night of bad sleep, A. stood up, started to vigorously batter another accompanying mother (Mrs. B.) with a blanket and tried to strangle her. The nurses found A. with a blank stare and tried to wake her up. A. was confused for about three minutes and started crying. Before the event, A. and B. had had a good relationship. Two days after this episode, A. was sleeping during the afternoon when she suddenly stood up and vigorously shook her daughter's bassinet being witnessed by other person in the ward. After wakening up the confused mother, the psychiatric consultation-liaison was called. A. vaguely remembered fragmentary dream images of a fight for her life at the first event and an assault attempt at the second. She denied previous major psychiatric disorders or treatment, seizures, use of medication, alcohol or drugs abuse but affirmed SW through her eleven to thirteen years of age. Since ten months after her husband's death, A. had had repeated screaming night arousals. She presented with mild anxiety symptoms and normal EEG. Clonazepam 1mg per night was prescribed, with good improvement of sleep and no recurrence of confusional arousals. Her 16-channel polysomnographic study revealed only fragmented sleep with excessive movements on the bed, but inconclusive for parasomnias.

Unless a behavioral arousal from slow-wave sleep occurs during polysomnography, the sleep study is usually inconclusive for SW.3 Sleep deprivation and forced arousals during slow-wave sleep can induce SW episodes in predisposed adults, helping discriminate SW from REM sleep behavior disorder and Nocturnal Frontal Lobe Epilepsy.4 However, this proved to be more effective in children.3

REM sleep behavior disorder is frequently associated with neurodegenerative disorders and vivid dreaming recall, while amnesia or partial dream images recall is usual for SW.5 ST and SW are usually time-limited to childhood1,5 and may co-occur.5 However, SW can recur in early adulthood, especially when associated with predisposing factors such as substance abuse, sleep deprivation, and mood or anxiety disorders.2,5

The estimated rate of adults reporting current episodes of sleep-related aggression is 2.1%, which may be considered surprisingly high, given its potential seriousness and legal aspects.2,4

A preventive pharmacological treatment for parasomnia after relapse in childhood is not necessary. However, the treatment of predisposing factors should be seriously evaluated in order to prevent recurrence, especially violent behavior. It is still controversial if polysomnographic screening and preventive treatment is required in highly stressful moments of life of previous sleepwalkers. However, in these circumstances, a low dose of clonazepam seems to be the best choice.3

 

Bernardo de Mattos Viana
Psychiatry Service, Hospital das Clínicas,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil

Felipe Cunha Bawden
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil

Dirceu de Campos Valladares Neto
Clínica do SonoTM, Belo Horizonte (MG), Brazil

Paulo Caramelli
Behavioral and Cognitive Neurology Research Group,
Department of Internal Medicine, Medical School,
Universidade Federal de Minas Gerais (UFMG),
Belo Horizonte (MG), Brazil

 

 

References

1. Guzman CS, Wang YP. Sleep terror disorder: a case report. Rev Bras Psiquiatr. 2008;30(2):169.         [ Links ]

2. Poyares D, Almeida CM, Silva RS, Rosa A, Guilleminault C. Violent behavior during sleep. Rev Bras Psiquiatr. 2005;27(Suppl 1):22-6.         [ Links ]

3. Cartwright R. Sleepwalking violence: a sleep disorder, a legal dilemma, and a psychological challenge. Am J Psychiatry. 2004;161(7):1149-58.         [ Links ]

4. Joncas S, Zadra A, Paquet J, Montplaisir J. The value of sleep deprivation as a diagnostic tool in adult sleepwalkers. Neurology. 2002;58(6):936-40.         [ Links ]

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR®). Forth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.         [ Links ]