MEDICAL–LEGAL ASPECTS OF SLEEP MEDICINE

MEDICAL- LEGAL ISSUES FACING NEUROLOGISTS

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MEDICAL-LEGAL ASPECTS OF SLEEP MEDICINE Mark W. Mahowald, MD and Carlos H. Schenck, MD

"In all of us, even in good men, there is a lawless, wild-beast nature which peers out in sleep." PLATO-The Republic

"Acts done by a person asleep cannot be criminal, there being no consciousness."63 Increasingly, sleep medicine practitioners are asked to render opinions regarding legal issues pertaining to violent or injurious behaviors purported to have arisen from sleep or to have resulted from impaired performance caused by sleepiness on the roadway or in the workplace. This article addresses three issues: (1) violence arising from the sleep period, (2) injury or death resulting from sleepiness-induced impaired performance in the workplace or on the road or rail or in the air, and (3) disability determination for employees who have sleep disorders. VIOLENCE ARISING FROM THE SLEEP PERIOD

Automatic behaviors (automatisms) resulting in acts that may result in illegal behaviors have been described in many different medical, neurologic, or psychiatric conditions. Those arising from wakefulness are reasonably well understood and are not considered further in this article. Advances in sleep medicine have demonstrated that complex, violent, and potentially injurious acts can and do arise from the sleep period, without conscious awareness, and therefore, without re-

From the Minnesota Regional Sleep Disorders Center, Hennepin County Medical Center, and the Departments of Psychiatry (CHS) and Neurology (MWM), the University of Minnesota Medical School, Minneapolis, Minnesota

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sponsibility. These occasionally violent or injurious behaviors with forensic science implications are exquisitely state dependent, meaning that they arise exclusively or predominately from the sleep period. Such behaviors arising from the sleep period are more common than previously thought, being reported by 2% of the adult population. 141 Such acts, if having arisen from sleep without conscious awareness, would constitute an automatism. As discussed below, there is a striking and regrettable discrepancy between the medical and the legal concepts of automatism.

State-Dependent Violence

The concept that sleep is simply the passive absence of wakefulness (W) is erroneous. Not only is sleep an active rather than passive process, it is now clear that sleep consists of two completely different states: nonrapid eye movement sleep (NREM), and rapid eye movement sleep (REM). Our lives therefore, are spent in three entirely different states of being: W, REM sleep, and NREM sleep. The declaration of state is not necessarily all or none, and there may be incomplete declaration or rapid oscillation of the three states of being. 114, 116 Although the automatic behaviors of some mixed states are relatively benign (Le., shoplifting in narcolepsy204), others, particularly disorders of arousal, the REM sleep behavior disorder (RBD), and nocturnal seizures, may be associated with very violent or injurious behaviors. Such events likely are because highly complex emotional and motor behaviors can originate from more primitive structures-without involvement of higher neural structures such as the cortex.14, 18,40,43,74, 105, 177 These animal studies provide insights to sleep-related violent behaviors in humans: structural lesions at multiple levels of the nervous system may result in wakeful violence. 20,51,72,193

Sleep-Related Disorders Associated with Violence

Violent sleep-related behaviors have been recently reviewed in the context of automatized behavior in general. 114 There are well-documented cases of (1) somnambulistic homicide, filicide, attempted homicide, and suicide, (2) murders and other crimes with sleep drunkenness (confusional arousals), and (3) sleep terrors or sleepwalking with potentially violent or injurious consequences. A wide variety of disorders may result in sleep-related violence (Table 1).114,121,122 These conveniently fall into two major categories: neurologic (sleep-related) and psychiatric.

NEUROLOGIC (SLEEP-RELATED) CONDITIONS ASSOCIATED WITH VIOLENT BEHAVIORS Disorders of Arousal [Confusional Arousals, Sleepwalking or Sleep Terrors]

The disorders of arousal comprise a spectrum ranging from confusional arousals (sleep drunkenness) to sleepwalking (SW) to sleep terrors (ST).115,117 Although there is usually amnesia for the event62,188 vivid dreamlike mentation may occaSionally be experienced and reported. 165 Contrary to popular opinion, these disorders may actually begin in adulthood and are most often not associated with

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Table 1. SLEEP-MEDICINE-RELATED FORENSIC CONDITIONS

I. Sleep-related violence A. Neurologic

1. Sleep Disorders a. Disorders of arousal (confusional arousals [sleep drunkenness, automatic behavior] sleepwalking, sleep terrors) b. REM sleep behavior disorder c. Nocturnal seizures d. Compelling hypnagogic hallucinations e. Sleeptalking B. Psychogenic 1. Dissociative states (may arise exclusively from sleep) a. Fugues b. Multiple personality disorder c. Psychogenic amnesia 2. Posttraumatic stress disorder 3. Malingering 4. Munchausen syndrome by proxy II. Medico-legal Aspects of Sleepiness A. Motor vehicle accidents B. Workplace accidents III. Sleep Disorders and Workplace Disability Determination

psychopathology.BS.16S Recent population surveys indicate that disorders of arousal are far more prevalent in the adult population than commonly believed, being reported by 3% to 4% of all adults and occurring weekly in 0.4%.94 In susceptible individuals, febrile illness, alcohol, prior sleep deprivation, and emotional stress may serve to trigger disorders of arousaL22. 156. 190 Sleep deprivation is well known to result in confusion, disorientation, and hallucinatory phenomena.n.l •. 25.m.17•. 197 Medications such as sedative hypnotics, neuroleptics, minor tranquilizers, stimulants, and antihistamines, often in combination with each other or with alcohol may also playa role and have been involved in SW-related forensic cases. 37. 92. 111 Confusional arousals, a milder form of SW or ST, (also termed sleep drunkenness) occur during the transition between sleep and wakefulness and represent a disturbance of cognition and attention despite the motor behavior of wakefulness, resulting in complex behavior without conscious awareness.79.lOB.161 These may also be potentiated by prior sleep deprivation or the ingestion of alcohol or sedatives or hypnotics before sleep onset. l60 These episodes of automatic behavior occur in the setting of chronic sleep deprivation or other conditions associated with state admixture. (Shoplifting has been reported during a period of automatic behavior in a narcoleptic,11s.14s.204) Pathophysiology of Disorders of Arousal

There are striking behavioral similarities between documented SW or ST violence in humans and sham rage as seen in the hypothalamic savage syndrome?O

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Although it has been assumed that the sham rage animal preparations are awake, there is some suggestion that similar preparations are behaviorally awake, and yet (partially) physiologically asleep, with apparent hallucinatory behavior possibly representing REM sleep dreaming occurring during Wand dissociated from other REM state markers.98 The neural bases of aggression and rage in the cat also support an anatomic basis for some forms of violent behavior.ls.178 In humans, when there are confusional arousals that can result in confusion or aggression, there is clear electroencephalographic evidence of rapid oscillations between W and sleep.79.161 It is likely that such behaviors occurring in states other than Ware the expression of motor or affective activity generated by lower structures-unmonitored and unmodified by the cortex. Treatment of the disorders of arousal include both pharmacologic (benzodiazepines and tricyclic antidepressants) and behavioral (hypnosis) approaches. 120 Note that disorders of arousal may be triggered by other underlying sleep disorders such as obstructive sleep apnea.80·130.152 This is another reason to perform formal overnight polysomnographic (PSG) studies with extensive physiologic monitoring in the evaluation of problematic motor parasomnias. Disorders of Arousal and Human Violence

The commonly held belief that disorders of arousal are always benign is erroneous; the accompanying behaviors may be violent, resulting in considerable injury to the individual, to others, or in damage to the environment.47.114.165 Keeping in mind that sleep is a very active process, and that generators or effectors of many components of both REM and NREM sleep reside in the brain stem and other lower centers, it should be no surprise that, during sleep, prominent motoric and affective behaviors do occur. Specific incidents include 1. Somnambulistic homicide, attempted homicide, filicide." 2. Murders and other crimes with sleep drunkenness,22 including sleep apnea l56 and narcolepsy.204 3. Suicide, or fear of committing suicide.23.39.99.I04 4. STs or SW with potential violence or injury.38. 58. 84. 157 These episodes may be drug induced. 111. 167. 173 5. Inappropriate sexual behaviors during the sleep state, presumably the results of an admixture of wakefulness and sleep.5.34.56.95. 159. 175. 199 Very dramatic cases have come to trial with the confusional arousal defense. In one, the "Parks" case in Canada, the defendant drove 23 kilometers, killed his mother-in-law, and attempted to kill his father-in-law. He was acquitted, with somnambulism as the legal defense. 2B In the "Butler, PA" case, a confusional arousal attributed to underlying documented severe untreated obstructive sleep apnea was offered as a criminal defense for a man who fatally shot his wife during his usual sleeping hours. Contrastingly, he was found guilty.l40 REM Sleep Behavior Disorder

RBD represents an experiment of nature, predicted in 1965 by animal experiments97 and recently identified in humans.1I8 Normally, during REM sleep, there "References 3, 15, 23, 26, 52, 82, 88, 91, 109, 111, 134, 142, 143, 148, 149, 163, 185,201.

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is active paralysis of all somatic muscles (sparing the diaphragm and eye-movement muscles). In RBD, there is the absence of REM sleep atonia, which permits the acting out of dreams, often with dramatic and violent or injurious behaviors. These oneiric behaviors displayed by patients who had RBD are often misdiagnosed as manifestations of a seizure or psychiatric disorder. RBD is usually idiopathic but may be associated with underlying neurologic disorders. liB, 164 The overwhelming male predominance (90%) of RBDI66 raises interesting questions relating sexual hormones to aggression and violence. 71 ,135 The violent and injurious nature of RBD behaviors has been extensively reviewed elsewhere. 50,75, m, 166, 167 Treatment with clonazepam is highly effective. 1OO A related condition, the parasomnia overlap syndrome, which contains both clinical and PSG features of both disorders of arousal and RBD has been described. l70 Other sleep disorders such as disorders of arousal, underlying sleep apnea, and nocturnal seizures may perfectly simulate RBD, again underscoring the necessity for thorough formal PSG evaluation of these cases. 45 ,137

Nocturnal Seizures

The association between seizures and violence has long been debated. It is plain that, on occasion, seizures may result in violent, murderous, or injurious behaviors.87,114 Seizures originating in the orbital, mesial, or prefrontal region may result in bizarre behaviors, including episodic nocturnal wanderings.· Aggression and violence may be preictal, ictal, or postictal. Some postictal violence is often induced or perpetuated by the good intentions of bystanders trying to calm the patient after a seizure.53 Postictal wanderings (poriomania) may result in confused or violent behaviors. 24,127 Other sleep disorders such as obstructive sleep apnea or RBD may masquerade as nocturnal seizures. 45,76,9(l,I02 Compelling Hypnagogic Hallucinations

Recurrent sexually oriented hypnagogic hallucinations experienced by patients who have narcolepsy may be vivid and convincing. These hallucinations may be so vivid and convincing to the victim that they may serve as false accusations.56 Sleeptalking

Sleeptalking has also been addressed by the legal system. It is interesting to ponder if utterances made during sleep are admissible in courU PSYCHIATRIC CONDITIONS

Psychogenic Dissociative States

Waking dissociative states may result in violence. 128 It is now apparent that dissociative disorders may arise exclusively or predominately from the sleep ·References41, 112, 124, 146, 147, 155, 186, 189, 192, 198.

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period ...·lI • Most are victims of repeated physical or sexual abuse beginning in chiIdhood.172

Posttraumatic Stress Disorder and Limbic Psychotic Trigger Reaction

Dissociative states and injury related to nightmare behaviors have been reported in association with posttraumatic stress disorder (PTSD),19.44 and PTSD has been used (with varying degrees of success) to support an insanity defenseP The limbic psychotic trigger reaction in which motiveless unplanned homicidal acts occur is speculated to represent partial limbic seizures that are kindled by highly individualized and specific trigger stimuli, reviving past repetitive stress. ISO

Malingering

Malingering must also be considered in cases of apparent sleep-related violence. Our center has seen a young adult male who developed progressively violent behaviors directed exclusively at his wife and apparently arising from sleep. This behavior included beating her and chasing her with a hammer. After exhaustive neurologic, psychiatric, and PSG evaluation, it was determined that this behavior represented malingering.

Munchausen Syndrome by Proxy

In this recently described syndrome, a child is reported to have apparently medically serious symptoms, which, in fact, are induced by an adult, usually a caregiver and often a parent. The use of surreptitious video monitoring in sleepdisorder centers during sleep (with the parent present) has documented the true cause for reported sleep apnea and other unusual nocturnal spells.33.35.73.I07.I36.158. 162.179

MEDICOLEGAL EVALUATION Automatisms and the Law: Actus non tacit reum nisi mens sit rea-the deed does not make a man guilty unless his mind is guilty.""

In the United States and the United Kingdom, for a criminal act (actus rea) to be criminal, it must be paired with a culpable mental state (mens rea), which means a knowing intent to commit a crime. The legal definition of automatism is based on this doctrine. A recent book is devoted to the various forensic aspects of sleep medicine. 174 Most of the above-mentioned conditions resulting in violent or injurious behaviors are termed automatisms. Automatism is difficult to define. 54 •55.% Fenwick56 has proposed the following definition:

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"An automatism is an involuntary piece of behavior over which an individual has no control. The behavior is usually inappropriate to the circumstances, and may be out of character for the individual. It can be complex, coordinated, and apparently purposeful and directed, though lacking in judgement. Afterwards the individual may have no recollection or only partial and confused memory for his actions. In organic automatisms there must be some disturbance of brain function sufficient to give rise to the above features." The medical concept of automatism is relatively straightforward (complex behavior in the absence of conscious awareness or volitional intent); however, the judicial concept is quite different. Legally, there are two forms of automatism: sane and insane. The sane automatism results from an external or extrinsic factor, the insane from an internal or endogenous cause. This choice results in two very different consequences for the accused: commitment to a mental hospital for an indefinite period if insane or acquittal without any mandated medical consultation or follow-up if sane. For example, a criminal act resulting from altered behavior caused by hypoglycemia induced by injection of too much insulin would be a sane automatism, whereas the same act, if because of hypoglycemia caused by an insulinoma would be an insane automatism. By this unscientific paradigm, criminal behavior associated with epilepsy is, by definition, an insane automatism. 55.57 In the United States, the approach to automatism varies from state to state. 129 The current legal system unfortunately must consider a sleep-related violence case strictly in terms of choosing between an insane and noninsane automatism or without any stipulated deterrent concerning a recurrence of SW with criminal charges that were induced by a recurrence of the high-risk behavior. If SW is deemed an insane automatism, then a significant percentage of the general population is legally insane. Clearly, dialogue between the medical and the legal professions regarding this important area would be helpful to both professions and to those arrested during automatisms. 187 Two reasonable approaches have been suggested: 1. Add a category of acquittal that allowed for innocence based on lack of guilt consequent to set diagnoses-specific illnesses that could be categorized by a group of subspecialty clinicians in consultation with the legal professionY 2. Hold a two-stage trial, which would first establish who committed the act, and then deal separately with the issue of culpability. The first part would be held before a jury; the second in front of a judge with medical advisors present. 55 One fortunate, and unexplained, fact is that nocturnal sleep-related violence is hardly ever a reappearing phenomenon. 78 Rarely, recurrence is reported, and possibly should be termed a noninsane automatism. Thorough evaluation and effective treatment are mandatory before the patient can be regarded as no longer a menace to society.169 In some cases, clear precipitating events can be identified and must be avoided to be exonerated from legal culpability. This concept has led to the proposal of two new forensic categories: (1) "parasomnia with continuing danger as a non-insane automatism" and (2) "(intermittent) state-dependent continuing danger."I68.169,171 Role of the Sleep Medicine Specialist

With the identificati~n of the causes. and consequences of sleep-related violence comes an opportumty for neurologlsts and sleep medicine professionals to

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educate the general public and practicing clinicians as to the occurrence and nature of such behaviors and to their successful treatment or prevention. More important, the onus is on the sleep medicine professional to educate and assist the legal profession in cases of sleep-related violence that result in forensic medicine issues. This often presents difficult ethical problems, as most expert witnesses are retained by either the defense or the prosecution, leading to the tendency for expert witnesses to become an advocate or partisan for either one side or the other. Historically, this has been fertile ground for the appearance of junk science in the courtroom93 -from Bendectin to triazolam to breast implants. Junk science leads to junk justice and altered standards of care. l94 Recently, much attention has been paid to the existence and prevalence of junk science in the courtroom, with recommendations to minimize its occurrence. 59•65,110

Forensic Sleep Medicine Experts as Impartial Friends of the Court (amicus curae)

One infrequently used tactic to improve scientific testimony is to use a courtappointed impartial expert.93 When approached to testify, volunteering to serve as a court-appointed expert (whose primary function is scientific education), rather than one appointed by either the prosecution or defense, may encourage this practice. Other proposed measures include the development of a specific section in scientific journals dedicated to expert witness testimony extracted from public documents with request for opinions and consensus statements from appropriate specialists or the development of a library of circulating expert testimony that could be used to discredit irresponsible, professional, witnesses. 93 Good science should not be determined by the credentials of the expert witness, but rather, by scientific consensus. 194 To stem the flow of junk science in the courtroom, many professional societies have developed guidelines for expert witness qualifications and testimony.ll,21,42 The American Sleep Disorders Association and the American Academy of Neurology have adopted their own guidelines, which include6 ,8 A. Expert witness qualifications 1. Must have a current, valid, unrestricted license 2. Must be a Diplomat of the American Board of Sleep Medicine 3. Must be familiar with the clinical practice of sleep medicine and should have been actively involved in clinical practice at the time of the event B. Guidelines for expert testimony 1. Must be impartial: ultimate test for accuracy and impartiality is a willingness to prepare testimony that could be presented unchanged for use by either the plaintiff or the defendant. 2. Fees should relate to time and effort, not be contingent on the outcome of the claim. Fees should not exceed 20% of the practitioner's annual income. 3. Practitioner should be willing to submit such testimony for peer review. 4. To establish consistency, expert witnesses should make records from their previous expert witness testimony available to the attorneys and expert witnesses of both parties. 5. The expert witness must not become a partisan or an advocate in the legal proceeding.

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Familiarizing oneself with these guidelines may be helpful in a given case, as the expert witness from each side should be held to the same standards. 1l9 It is hoped that the legal profession will more often work with professional societies, and employ their guidelines to seek scientific truth, rather than employ hired guns who may attempt to win by perverting scientific evidence or selecting only that which supports their side. To this end, the use of an amicus curae would serve to educate the court and the jury impartially, with no stakes as to winning or losing.

CLINICAL AND LABORATORY EVALUATION OF WAKING OR SLEEP VIOLENCE

The history of complex, violent, or potentially injurious motor behavior arising from the sleep period should suggest the possibility of one of the above-mentioned conditions. Our experience with over 200 adult cases of sleep-related injury or violence has repeatedly indicated that clinical differentiation, without PSG study, among RBD, disorders of arousal, sleep apnea, and sleep-related psychogenic dissociative states, and other psychiatric conditions is often impossible.!23 It is likely that violence arising from the sleep period is more frequent than previouslyassumed.3! As mentioned above, the legal implications of automatic behavior have been discussed and debated in both the medical and the legalliterature.!·63.!53.!54.!95.!96 As with nonsleep automatisms, the identification of a specific underlying organic or psychiatric sleep or violence condition does not establish causality for any given deed. Two questions accompany each case of reportedly sleep-related violence: (1) is it possible for behavior this complex to have arisen in a mixed state of Wand sleep without conscious awareness or responsibility for the act? and, (2) is that what happened at the time of the incident? The answer to the first is often yes. The second can never be determined with certainty. To assist in the determination of the putative role of an underlying sleep disorder in a specific violent act, we have proposed guidelines, modified from Bonkalo22 (sleepwalking), Walker!9! (epilepsy), and Glasgowt'9 (automatism in general) and formulated from our clinical experience114 : 1. There should be reason (by history or by formal sleep laboratory evalua-

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tion) to suspect a bona fide sleep disorder. Similar episodes, with benign or morbid outcome, should have occurred previously. (Note that disorders of arousal may begin in adulthood.) The duration of the action is usually brief (minutes). The behavior is usually abrupt, immediate, impulsive, and senselesswithout apparent motivation. Although ostensibly purposeful, it is completely inappropriate to the total situation, out of (waking) character for the individual, and without evidence of premeditation. The victim is someone who merely happened to be present and who may have been the stimulus for the arousal. Immediately after return of consciousness, there is perplexity or horror, without attempt to escape, conceal, or cover up the action. There is evidence of lack of awareness on the part of the individual during the event. There is usually some degree of amnesia for the event, however, this amnesia need not be complete. In the c~se of ST o~ SW o~ sleep drunkenness, the act may (a) occur on awakenmg, (rarely Immediately upon falling asleep) and usually at least

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1 hour after sleep onset; (b) occur on attempts to awaken the subject; and (c) have been potentiated by alcohol ingestion, sedative or hypnotic administration or prior sleep deprivation.

Most of these conditions are both diagnosable and treatable. Clinical evaluation should include a complete review of sleep or wake complaints from both the victim and the bed partner (if available). This should be followed by a thorough general physical, neurologic, and psychiatric examination. The diagnosis may only be suspected clinically. Extensive polygraphic study employing an extensive scalp electroencephalogram (EEG) at a paper speed of 15 mm/s, electromyographic monitoring of all four extremities, and continuous audiovisual recording are mandatory for correct diagnosis in atypical cases." Establishing the diagnosis of nocturnal seizures may be particularly difficult. The proposition that sleep disorders may be a legitimate defense in cases of violence arising from the sleep period has been met with great skepticism. 77 For credibility, evaluations of such complex cases are best performed in experienced sleep disorders centers with interpretation by a veteran clinical polysomnographer. Because of the complex nature of many of these disorders, a multidisciplinary approach is highly recommended. 4,123

SLEEPINESS-INDUCED DISASTERS

Increasingly, the tragic consequences of impaired performance caused by sleepiness, be it caused by sleep deprivation or by an underlying sleep disorder, are resulting in legal action. This is particularly true in the case of fall-asleep motor vehicle accidents (MVAs), but also in sleepiness-induced malfeasance in the workplace. The magnitude of this serious problem is beginning to be appreciated, and the data are staggering. The National Commission of Sleep Disorders Research estimated that in 1998 in the United States, as many as 200,000 MVAs were caused by sleepiness behind the wheel. l38 Although this figure has been questioned, there is little doubt that the numbers are very high and that fall-asleep MVAs are one of the leading causes (as much as 25%) of fatal and nonfatal car crashes.89,103,113,125 Sleepiness in the workplace contributes significantly to between 30% and 90% of serious industrial accidents, including such memorable ones as Chernobyl, ThreeMile Island, Exxon-Valdez, Bopal, and the Challenger disaster. 49,138 The total cost of accidents related to sleepiness in the United States in 1988 was estimated to be between $43 billion and $56 billion. I06 Certain occupations are plagued with higher fall-asleep MVAs than others, particularly the trucking industry.126, 132, 182, 183 With these numbers, the amounts of money involved, and the resulting individual and societal tragedies, it is little surprise that the legal system is getting involved. No universally accepted guidelines are available for dealing with culpability. For instance, is falling asleep at the wheel in the same category of driving under the influence of alcohol? (After all, it has been shown that one night of sleep deprivation is as performance impairing as having a legally intoxicated blood alcoholleve1. 46 ) Or, is the fall-asleep MVA of a sleep-deprived shiftworker the fault of the worker or the employer who imposed the duty hours or requested a double shift? Because lawmakers are becoming interested in this important problem, with particular reference to limiting the driving privileges of some individuals with "References 10, 27, 32, 48, 80,81,117,146,151,181.

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sleep disorders, some of these disorders (sleep apnea and narcolepsy) are discussed further.

Driving and Sleep Apnea There is no question that MVAs are more frequent in people who have obstructive sleep apnea (OSA). This is likely caused by impairment of sustained attention or by frank falling asleep while driving. 60,66.67,83,131,200,202 The degree of impaired performance is similar to that of legal intoxication. 67 Effective treatment reduces the risk of sleepiness-related MVAs.36,IOO Objective measures of daytime sleepiness (Le., the multiple sleep-latency test) reflect the degree of improvement, and therefore may be used as a marker of treatment efficacy and compliance. l84 Given the 2% to 4% prevalence of significant OSA in the adult US population, it should be clear that the overwhelming majority of drivers with OSA remain undiagnosed and untreated. 203 Driving and Narcolepsy As with individuals who have OSA, MVAs are more common in patients who have narcolepsy (and other causes of hypersomnia such as idiopathic CNS hypersomnia) for the same reasons: impaired sustained attention or falling asleep while driving. 29,3Q,60,131 The degree of performance impairment is similar to that seen in individuals who have OSA.66 Regrettably, the currently available objective measures of daytime alertness often do not correlate with the subjective response, making treatment efficacy and compliance impossible to measure. 9

Legal Implications and Physician Responsibility

There is great confusion regarding the legal responsibility for patients who have sleep disorders reporting themselves or for their physicians for reporting them to authorities, and there are inconsistent and rapidly changing governmental policies that vary by state and country. Any listing of current guidelines and recommendations would be obsolete by the time of publication of this issue. Existing regulations are often not based on scientific data, and their effect on crashes or the practice of sleep medicine have not been assessed. I44 , 180 Common sense guidelines would be to report high-risk drivers (severe sleepiness from narcolepsy or apnea) who had already had a MVA and who insisted on driving prior to treatment or who failed to comply with treatment. 61 The American Medical Association (AMA) has published guidelines regarding commercial licences and sleep disorders. 7 It is the physicians' responsibility to know the laws of their jurisdiction, as in some states current laws could be interpreted as requiring clinicians to report all patients who have sleepiness caused by sleep disorder to health officials. Ignorance of the law is not a valid defense.131 For perspective, it is relatively easy to single out a specific group of patients who have identified sleep disorders and to restrict their driving privileges in the name of public safety. Keep in mind that, by far, the largest absolute number of sleepy drivers on the highways are those who are simply (and often severely) sleep deprived for social or economic reasons and who would be excluded from the reporting process and the legal consequences. Sanctions for patients who have

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narcolepsy or OSA would likely not only lack the desired effect but also would deter these patients from seeking medical attention for their symptoms. Legislated sanctions for patients who have sleep disorders should be undertaken with great thoughtfulness and caution and should be supported by scientific evidence. The analogous situation for patients who have epilepsy is a good reminder: subsequent to the enactment of reporting guidelines and sanctions for patients who have epilepsy, it has been shown that these patients do not have a higher MVA rate than other, nonreportable conditions.6B,tol Guidelines for the airline, railroad, and trucking industries are beyond the scope of this article.

EMPLOYMENT DISABILITY CONSIDERATIONS FOR WORKERS WHO HAVE SLEEP DISORDERS

Most sleep disorders resulting in excessive daytime sleepiness are diagnosable and respond well to appropriate treatment; however, some patients' symptoms remain severe and incapacitating despite aggressive therapeutic efforts. Those individuals may be eligible for consideration of disability under the Social Security Disability Insurance (SSDI) or for accommodations under The Americans With Disability Act (ADA). It continues to be difficult to obtain these benefits, as the pervasive attitude of our society that sleepiness represents a defect in character such as depression, laziness, slothfulness, boredom, or work-avoidance behaviors. Workers are not fired for the symptoms of asthma, diabetes, seizures, or other medical conditions, but losing one's job for falling asleep on the job is commonplace. To compound this problem, once a worker has been fired, health benefits are often lost, preventing or delaying appropriate diagnosis and treatment. The field of sleep medicine must continue to educate employers and administrators that unexplained sleepiness in the workplace is almost always the result of an underlying, diagnosable, and treatable sleep disorder and that early diagnosis and treatment benefit both the worker and the employer. Patients who have inadequately treatable sleep disorders should make every effort to establish care with an experienced sleep medicine professional to assure impeccable and credible documentation of the nature of their sleep disorder and its severity and the evidence of failure to respond to aggressive and appropriate treatments. Such information will be invaluable in the pursuit of ssm or ADA benefits. The medicolegal discussion regarding expert testimony after the "Sleep-Related Violence" section also applies to cases of sleepiness-induced MVAs or workplace accidents.

SUMMARY AND FUTURE DIRECTIONS Sleep-Related Violence

It is abundantly clear that violence may occur during anyone of the three states of being. That which occurs during REM or NREM sleep may have occurred without conscious awareness and is caused by one of a number of completely different disorders. Violent behavior during sleep may result in events that have forensic science implications. The apparent suicide (e.g., leap to death from a second-story window), assault or murder (e.g., molestation, strangulation, stabbing, shooting) may be the unintentional, nonculpable but tragic result of disorders of

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arousal, sleep-related seizures, RBD, or psychogenic dissociative states. The majority of these conditions are diagnosable and, more importantly, are treatable. The social and the legal implications are obvious. The field of sleep medicine must pursue further productive study and request adequate funding to study the following important questions objectively: What is the true prevalence of these disorders? How are they best and most accurately diagnosed? How can the usually present prodromes be taken seriously? Why the male predominance in many? How can they best be treated or, better yet, prevented? Are social stressors truly more prevalent in this population? What is the best way to deal with forensic science issues? What is to be done with the offender? What is the likelihood of recurrence? Is such behavior a sane or an insane automatism?26 How can the potential victim be protected? More research, both basic science and clinical, is urgently needed to identify and elaborate further on the components of both waking and sleep-related violence, with particular emphasis on neurobiologic, neuroplastic, genetic, and socioenvironmental factors. 20,51,n The study of violence and aggression will be greatly enhanced by close cooperation among clinicians, basic science researchers, and social scientists.

Sleepiness on the Roadway and in the Workplace

The dire consequences of sleepiness in these settings is slowly being appreciated. Massive educational campaigns must be undertaken to emphasize the fact that sleep is a biological imperative and that sleepiness is neither simply a minor annoyance nor the sign of a personality defect. There is growing interest in this problem by the transportation industry. More research on the identification, avoidance, and prevention of sleepiness in the workplace and behind the wheel is desperately needed. This provides an excellent opportunity for the close collaboration among sleep medicine clinicians, basic science researchers, and public policy makers to develop programs, policies, and guidelines that are evidence based and that will benefit individuals and society as a whole.

References 1. Forensic Psychiatry. In Camps FE (ed): Gradwohl's legal medicine, ed 3. Chicago, A John Wright and Sons, 1976, p 505 2. Regina v Warner 136 Ontario Reports (1995) 3. Sleepwalking and guilt. [editorial] BMJ 2:186, 1970 4. Aldrich MS, Jahnke B: Diagnostic value of video-EEG polysomnography. Neurology 41:1060,1991 5. Alves R, Aloe F: Sexual behavior in sleep, sleepwalking and possible REM behavior disorder: A case report (of parasomnia overlap disorder?). Sleep 21 (suppl):64, 1998 6. American Academy of Neurology: Qualifications and guidelines for the physician expert witness [newsletter]. Neurology 39:9A, 1989 7. American Medical Association: Medical Conditions Affecting Drivers. Chicago, American Medical Association, 1986, 8. American Sleep Disorders Association: ASDA Guidelines for expert witness qualifications and testimony. Association of Professional Sleep Societies Newsletter 8:23, 1993 9. American Sleep Disorders Association: Practice parameters for the use of stimulants in the treatment of narcolepsy. Sleep 17:348, 1994 10. Amir N, Navon P, Silverberg-Shalev R: Interictal electroencephalography in night terrors and somnambulism. Isr J Med Sci 21:22,1985

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