Sleepwalking with violence: A psychological defense against significant life trauma

Dear Editor,

Sleepwalking is a non-rapid eye movement sleep arousal disorder characterized by recurrent episodes of incomplete awakening from sleep. Such episodes are characterized by symptoms ranging from quietly moving out of bed to running and behaving inappropriately in a state of confusion and no recall of the episode when it is over after a few minutes to 1 hour.[1] The estimated lifetime prevalence of sleepwalking is 6.9% (95% CI: 4.6–10.3).[2] Sleepwalking is a relatively common phenomenon in children. However, adults present with sleepwalking uncommonly but with an increased chance of abnormal motor behaviors, including violence during the episodes. A search for specific etiologies such as obstructive sleep apnea, nocturnal fits, effects of medications, and significant life trauma should be sought in adults presenting with sleepwalking.[1] There are also sizeable effects of genetics in both childhood (66% in men and 57% in women) and adult (80% in men and 36% in women) sleepwalking.[3] We present a case with repeated episodes of sleepwalking with violence in an adult who had a background history suggestive of significant life trauma.

A 31-year-old married male patient of lower socioeconomic status and rural background presented to the Psychiatry outpatient department with chief complaints of repeated episodes of abnormal behavior during sleep for the last 2 years. Two years back, the patient was asymptomatic and working in Mumbai as a daily wage laborer when he developed his first episode of getting up from bed in the middle of the night and throwing things such as blankets, utensils, and stand-fans lying in the house. The fellow laborers sleeping in the same room were terrified by the patient’s abnormal behavior, and it was difficult to control him as he was attacking everyone who came to control him. He was unable to recognize his coworkers. His abnormal state lasted for an hour and thereafter he was unable to recall the event. After three similar episodes over the next month, the patient returned home to Bihar, where a psychiatrist prescribed risperidone 2 mg, trihexyphenidyl 2 mg, oxcarbazepine 600 mg, and clonazepam 0.5 mg per day. There was a reduction in sleepwalking and abnormal behavior. However, he discontinued the medications within 6 months due to financial constraints. Thereafter, the patient returned to Mumbai, where he developed another episode of sleepwalking with violent behavior toward roommates. He was seen by a psychiatrist and remained on psychotropic medications, though irregularly, for another 10 months. Meanwhile, he had four similar episodes, usually after discontinuation of the medications. Therefore, he decided to return home to Bihar. At home, he was off psychotropics for approximately 4 months when he had his last episode of illness where he attacked his spouse and mother and was throwing household items in anger within 2–3 hours of sleep. He was controlled with the help of neighbors. Then, the patient was brought to our clinic. The clinical workup suggested a history of unnatural death of the patient’s younger brother. The family believed that it was a murder and they started a legal battle against the accused and continued the legal proceedings for around 4 years, but justice was not done. The resultant financial crisis left the family in agony. This incident disturbed the patient to the core as he felt helpless. Being the principal earning member of the family, he moved to Mumbai to earn his livelihood. The patient’s clinical evaluation suggested no other psychiatric comorbidity or any significant morbidity. His CT scan (head), EEG, and ECG were within normal limits. As per ICD-10, a diagnosis of sleepwalking was made. The patient was prescribed divalproex 250 mg twice daily, melatonin 5 mg, and vortioxetine 5 mg at bedtime. He maintained improvement on review after a month, and divalproes was tapered to OD and vortioxetin was stopped. On the next review, divalproex was stopped and he was maintained with only melatonin.

In his 1974 landmark review of 50 forensic cases of sleepwalking with violence, Bonkalo observed a marked preponderance of males with an age range of 27–48 years. The onset of sleepwalking with violence was usually within 0.5–2 hours after sleep onset, and adult subjects showed more impulsive and goal-directed behaviors, which turned out to be negativistic, resistive, and assaultive when interfered with.[4] Similar clinical manifestations were observed in our patient.

Sleepwalking manifests typically during the initial 1–2 hours of the night, and it is usually not a psychologically based phenomenon in children as it has nothing to do with frequent daydreaming states of REM sleep.[5] However, certain intolerable impulses, feelings, and memories in adults with a history of major psychological trauma might escape into non-REM sleep as sleepwalking and night terrors. Such uncommon occurrences in non-REM sleep are supposed to be protective dissociative mechanisms with limited affective and motor manifestations, restricted awareness, and amnesia for the event subsequently.[6]

Sleepwalking with violence can be an uncommon defense to crimes and challenging to treat. During these episodes, the individual may be considered awake but not completely conscious with an alleged dissociative mechanism operating to produce amnesia.[6] It has long been hypothesized that serotonin may inhibit and dopamine may increase violent behavior;[7] thus, pharmacological interventions modulating neurotransmitters such as selective serotonin reuptake inhibitors,[8] mood stabilizers, and anticonvulsants that modulate glutamatergic or GABAergic balance help in the improvement of the symptoms.[8,9]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interests

There are no conflicts of interest.