10/16/2006 05:58 PMSleepwalking Violence: A Sleep Disorder, a Legal Dilemma, and a Psycho…allenge -- Cartwright 161 (7): 1149 -- American Journal of PsychiatryPage 1 of 16http://ajp.psychiatryonline.org/cgi/content/full/161/7/1149TOPAbstractIntroductionBackground on Sleepwalking...Promising New ResearchThe Case of Mr....ConclusionsReferencesThis ArticleAbstract Full Text (PDF)Alert me when this article is citedAlert me if a correction is postedCitation MapServicesEmail this article to a ColleagueSimilar articles in this journalSimilar articles in PubMedAlert me to new issues of the journalAdd to My Articles & SearchesDownload to citation managerCited by other online articlesGoogle ScholarArticles by Cartwright, R.Articles citing this ArticlePubMedPubMed CitationArticles by Cartwright, R.Related CollectionsMentally Ill Offenders Other Forensic Issues Sleep Disorders HomicideHOME HELP FEEDBACK SUBSCRIPTIONS ALL ISSUES SEARCH TABLE OF CONTENTSQUICK SEARCH: [advanced]GoAuthor: Keyword(s):Year: Vol: Page: Am J Psychiatry 161:1149-1158, July 2004© 2004 American Psychiatric Association Reviews and OverviewsSleepwalking Violence: A SleepDisorder, a Legal Dilemma, and aPsychological ChallengeRosalind Cartwright, Ph.D. Abstract OBJECTIVE: The purpose of this article is to further anunderstanding of the psychological state when aggression followsan episode of partial arousal from early non-REM sleep duringwhich some areas of the brain appear to be functioning as inwaking while others appear to remain in a state of sleep. Toillustrate this, the author examines a case of homicide for whichthe defense argued lack of responsibility due to sleepwalking. METHOD: A review of the forensicliterature on sleepwalking aggression and sleep studies suggests that these fall into one or both oftwo DSM-IV-TR diagnoses: sleepwalking disorder and sleep terror disorder. The new case, whichwould meet criteria for an overlap disorder in which sleepwalking is followed by sleep terror, iscompared to one previously published. RESULTS: These findings support sleepwalking violence10/16/2006 05:58 PMSleepwalking Violence: A Sleep Disorder, a Legal Dilemma, and a Psycho…allenge -- Cartwright 161 (7): 1149 -- American Journal of PsychiatryPage 2 of 16http://ajp.psychiatryonline.org/cgi/content/full/161/7/1149TOPAbstractIntroductionBackground on Sleepwalking...Promising New ResearchThe Case of Mr....ConclusionsReferencesas a distinct overlap disorder with common disturbed psychological functioning during and for aperiod up to 1 hour following an aggressive episode. CONCLUSIONS: Research clarifies thepathology of this disorder and highlights the need to both refine the differential diagnosis and testthe efficacy of treatment protocols. Introduction The recent public debate concerning the death penalty has centeredon the appropriateness of this punishment for violent crimes whencommitted by a person with "diminished capacity." This questionshifts the focus from whether the "punishment fits the crime" towhether it fits the criminal. Two types of exception to the rule ofbeing equal before the law have been raised: an accused personwho is mentally retarded and one who suffers from a mental disorder. This article is concerned withan additional category: a person accused of a violent act that was committed during an episode oftemporarily impaired consciousness due to a sleep disorder. While there are standardized tests forestablishing reduced mental capacity due to mental retardation and diagnostic criteria fordetermining the presence of a psychosis that limits rational thought, to my knowledge there is atthis time no agreed-on protocol for establishing that an accused adult suffers from a sleepwalkingdisorder. This presents a particularly difficult problem because of the episodic, time-limited natureof such episodes and their complete reversibility once the person is fully awake.Case reports of violence committed during a state of sleepwalking have appeared in the forensicliterature over many years (1–9). What appears to be the first such report was written by Yellowless(1) and appeared in 1878; it describes a 28-year-old man with a long history of night terrors with "avivid feeling that some dreadful evil is impending." He was tried for murder after smashing his 18-month-old son against the wall in the middle of the night, believing he was dealing with a wildbeast about to attack his family. He was found not guilty after a statement by Lord Justice Clerkthat the child was killed when the defendant was unconscious of the nature of the act by reason ofsomnambulism. Howard and d’Orban (9) quoted a case first reported in 1933 of a 31-year-oldfirefighter who "woke to find himself battering his wife’s head with a shovel. The shock was sogreat he fainted and, when he realized his wife was dead, attempted suicide. He had no memory ofgetting out of bed, fetching the shovel and there was an entire lack of motive as he lived amicablywith his wife" (p. 916).These early case reports often described the behavior as a curiously isolated incident, out ofkeeping with that person’s usual behavior, without apparent prior motivation and after which nomemory of the event was retained. This literature focuses on questions of responsibility for theharm done in light of the accused’s not having formed any prior intent, appearing not to have beenin a conscious state at the time, and proving afterward not to be insane.10/16/2006 05:58 PMSleepwalking Violence: A Sleep Disorder, a Legal Dilemma, and a Psycho…allenge -- Cartwright 161 (7): 1149 -- American Journal of PsychiatryPage 3 of 16http://ajp.psychiatryonline.org/cgi/content/full/161/7/1149TOPAbstractIntroductionBackground on Sleepwalking...Promising New ResearchThe Case of Mr....ConclusionsReferencesWhen such cases are brought to trial, the idea that it is possible to engage in complex injuriousbehavior while in a mixed state of sleep and wakefulness is usually met with considerableskepticism. As a result, there have been very different verdicts rendered in similar cases. There arealso differences in the law applied.This paper compares two cases of homicide in which I served as a sleep consultant pro bono;neither defendant was a patient of mine. In one case the defendant was judged under Canadian lawas innocent owing to the act being a noninsane automatism. This case has been fully published(10). The other defendant was judged guilty of murder in the first degree in a