pii: jc-00319-14 http://dx.doi.org/10.5664/jcsm.4220
Calls for an International Consensus on Sleep-Related Violence and Sexual Behavior in Sleep Are Premature John Rumbold, M.B.Ch.B., G.D.L.1; Ian Morrison, Ph.D.2; Renata L. Riha, M.D.3
Research Institute for Social Sciences, Keele University, Staffordshire, UK; 2Dept of Neurology, Ninewells Hospital, Dundee, UK; 3 Dept of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh UK
LETTER TO THE EDITOR
1
W
e note with interest the review article on the assessment of forensic sleep disorders as evidenced by case reports, some going back as far as the 1980s.1 While we agree with the conclusion that the uniform reporting of forensic sleep cases could facilitate analysis of such cases, there are severe limitations with this method. As an alternative, we would advocate more systematic research on the behaviors typically seen during disorders of arousal and other parasomnias. We believe that the current evidence base is not robust enough to support a useful set of international guidelines.2 A consensus statement would be prone to becoming an exercise in the politics of the field, given the paucity of evidence. Furthermore, an international consensus could not address the needs of different jurisdictions; subtly different legal questions may require different assessments for forensic sleep disorders. However, it could identify priorities for future research. It is important to emphasise that the jury (or the judge or bench of judges where appropriate) decides on a verdict, not a diagnosis. Furthermore, it is incorrect to state that the lack of full consciousness per se means the behavior occurred “without responsibility for the offender.” The issue of prior fault is relevant and very fact-specific. Also there is the issue of alcohol consumption and criminal responsibility. Although the presence of alcohol intoxication is problematic,3 the law in England and Wales, for instance, is quite clear that where multiple causes of incapacity are operating, the jury decides the cause of loss of capacity and thus, whether or not the defendant was criminally responsible (R v Stripp [1978] 65 Cr App R 318, R v Dietschmann [2003] 1 AC 1209). In addition, parasomnia triggered by alcohol might be considered by the courts to be distinct from alcohol intoxication (R v Harris [2013] EWCA Crim 223; cf Finegan v Heywood [2000] S.L.T. 905). The remit of expert witnesses is for the courts to decide, and any consensus must recognize that the legal questions of each jurisdiction differ. In fact, the often confusing legal terms utilised in this area would require scrutiny in the first 1253
instance and the jury (in common-law jurisdictions) be educated in the differences in rulings that are implied with respect to them.2 Finally, we would submit that it is not sufficient that an expert witness in these areas has credentials in sleep medicine (which presents a difficulty in the United Kingdom, where sleep medicine is not a recognized subspecialty). The expert should also have sufficient regular exposure to patients with parasomnias in that he/she is familiar with the very wide range of behaviors which can present. We therefore suggest that further research on the range and complexity of sleep behaviors be prioritized ahead of the development of international consensus statements in this area, to allow the expert witness to base their opinion on a sound evidence base.
CITATION Rumbold J, Morrison I, Riha RL. Calls for an international consensus on sleep-related violence and sexual behavior in sleep are premature. J Clin Sleep Med 2014;10(11):1253.
REFERENCES 1. Ingravallo F, Poli F, Gilmore EV, et al. Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports. J Clin Sleep Med 2014;10:927-35. 2. Morrison I, Rumbold JM, Riha RL. Medicolegal aspects of complex behaviours arising from the sleep period: a review and guide for the practising sleep physician. Sleep Med Rev 2014;18:249-60. 3. Rumbold JM, Riha RL, Morrison I. Alcohol and non-rapid eye movement parasomnias: where is the evidence? J Clin Sleep Med 2014;10:345.
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication August, 2014 Accepted for publication August, 2014 Address correspondence to: Dr Ian Morrison, Department of Neurology, Ninewells Hospital Dundee, Dundee, UK, DD1 9SY; Tel: +44 (0) 1382 632134; Fax: +44 (0) 1382 425739; E-mail: [email protected]
DISCLOSURE STATEMENT The authors have indicated no financial conflicts of interest.
Journal of Clinical Sleep Medicine, Vol. 10, No. 11, 2014
Calls for an International Consensus on Sleep-Related Violence and Sexual Behavior in Sleep Are Premature John Rumbold, M.B.Ch.B., G.D.L.1; Ian Morrison, Ph.D.2; Renata L. Riha, M.D.3
Research Institute for Social Sciences, Keele University, Staffordshire, UK; 2Dept of Neurology, Ninewells Hospital, Dundee, UK; 3 Dept of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh UK
LETTER TO THE EDITOR
1
W
e note with interest the review article on the assessment of forensic sleep disorders as evidenced by case reports, some going back as far as the 1980s.1 While we agree with the conclusion that the uniform reporting of forensic sleep cases could facilitate analysis of such cases, there are severe limitations with this method. As an alternative, we would advocate more systematic research on the behaviors typically seen during disorders of arousal and other parasomnias. We believe that the current evidence base is not robust enough to support a useful set of international guidelines.2 A consensus statement would be prone to becoming an exercise in the politics of the field, given the paucity of evidence. Furthermore, an international consensus could not address the needs of different jurisdictions; subtly different legal questions may require different assessments for forensic sleep disorders. However, it could identify priorities for future research. It is important to emphasise that the jury (or the judge or bench of judges where appropriate) decides on a verdict, not a diagnosis. Furthermore, it is incorrect to state that the lack of full consciousness per se means the behavior occurred “without responsibility for the offender.” The issue of prior fault is relevant and very fact-specific. Also there is the issue of alcohol consumption and criminal responsibility. Although the presence of alcohol intoxication is problematic,3 the law in England and Wales, for instance, is quite clear that where multiple causes of incapacity are operating, the jury decides the cause of loss of capacity and thus, whether or not the defendant was criminally responsible (R v Stripp [1978] 65 Cr App R 318, R v Dietschmann [2003] 1 AC 1209). In addition, parasomnia triggered by alcohol might be considered by the courts to be distinct from alcohol intoxication (R v Harris [2013] EWCA Crim 223; cf Finegan v Heywood [2000] S.L.T. 905). The remit of expert witnesses is for the courts to decide, and any consensus must recognize that the legal questions of each jurisdiction differ. In fact, the often confusing legal terms utilised in this area would require scrutiny in the first 1253
instance and the jury (in common-law jurisdictions) be educated in the differences in rulings that are implied with respect to them.2 Finally, we would submit that it is not sufficient that an expert witness in these areas has credentials in sleep medicine (which presents a difficulty in the United Kingdom, where sleep medicine is not a recognized subspecialty). The expert should also have sufficient regular exposure to patients with parasomnias in that he/she is familiar with the very wide range of behaviors which can present. We therefore suggest that further research on the range and complexity of sleep behaviors be prioritized ahead of the development of international consensus statements in this area, to allow the expert witness to base their opinion on a sound evidence base.
CITATION Rumbold J, Morrison I, Riha RL. Calls for an international consensus on sleep-related violence and sexual behavior in sleep are premature. J Clin Sleep Med 2014;10(11):1253.
REFERENCES 1. Ingravallo F, Poli F, Gilmore EV, et al. Sleep-related violence and sexual behavior in sleep: a systematic review of medical-legal case reports. J Clin Sleep Med 2014;10:927-35. 2. Morrison I, Rumbold JM, Riha RL. Medicolegal aspects of complex behaviours arising from the sleep period: a review and guide for the practising sleep physician. Sleep Med Rev 2014;18:249-60. 3. Rumbold JM, Riha RL, Morrison I. Alcohol and non-rapid eye movement parasomnias: where is the evidence? J Clin Sleep Med 2014;10:345.
SUBMISSION & CORRESPONDENCE INFORMATION Submitted for publication August, 2014 Accepted for publication August, 2014 Address correspondence to: Dr Ian Morrison, Department of Neurology, Ninewells Hospital Dundee, Dundee, UK, DD1 9SY; Tel: +44 (0) 1382 632134; Fax: +44 (0) 1382 425739; E-mail: [email protected]
DISCLOSURE STATEMENT The authors have indicated no financial conflicts of interest.
Journal of Clinical Sleep Medicine, Vol. 10, No. 11, 2014
