Strangulation during the night: diagnosis of sleep-associated violence

Abstract

Background: Violent behaviors during sleep may be caused by various mental health and sleep disorders that require thorough investigation. A diagnosis could have significant implications in forensic medicine. Methods: We present the case of a 60-year-old truck driver with no history of sleep or mental health disorders, violent behavior during sleep or wakefulness, or marital discord. He developed insomnia after retiring. He was prescribed 0.25 mg of alprazolam at bedtime. Four days later, he woke up at 5:30 a.m. with his hands wrapped around his wife’s neck. He had severely strangled and choked her. She survived. The judge requested expertise in psychiatry and sleep medicine. The perpetrator was interviewed and underwent video-polysomnography with and without alprazolam. Results: The perpetrator had no identified psychiatric disorder. Video-polysomnography revealed no parasomnia, such as arousal disorder or rapid eye movement (REM) sleep behavior disorder, and no epilepsy. However, it did show severe obstructive sleep apnea (OSA), with apneas in REM sleep lasting 100 s. The OSA worsened after alprazolam administration. This event was diagnosed as sudden confusional arousal induced by apnea and exacerbated by severe hypoxemia and benzodiazepine use, which can lead to aggressive behavior. Charges against the perpetrator were dropped. He experienced no further behavioral episodes while undergoing treatment for OSA and after alprazolam withdrawal, and he now lives happily with his wife. Conclusion: This case illustrates the challenges of diagnosing violent nocturnal behaviors. In this case, it was only chance that prevented a tragic fatal outcome and made it possible to distinguish attempted murder from involuntary behavior. Clinical trial number: Not applicable.