The FDA now requires a warning about sleep-driving for prescriptions of 13 different sedative-hypnotic drugs after quite a few reports associated with zolpidem (Ambien). Trouble is, the list includes barbituates, benzodiazepines, and a melatonin agonist with quite different mechanisms. While a pyrazolopyrimidine might increase incidents of somnambulism, a benzodiazepine may prevent them, an atypical antipsychotic can cause it, a mixed bag of GABAergic drugs may either treat or trigger sleep disorders... WTF?
What drives sleep-driving? surveys some of the issues.
The bigger issue behind this story isn't just which meds may cause or treat sleep-walking, sleep-driving, sleep-eating, and other parasomnias. It's the legal implications of the underlying mechanisms. Sleepwalking: Nightmare for the Courts is a sweet paper on neuroethics and sleep-murder. Who or what to blame when homicide is not a conscious act - or is it? Insanity, automism, disease, disorder, neurological, psychiatric or moral?
It's a tricky and fascinating business. What's your opinion?
Some self-contradictory expert testimony from R v. Parks, Supreme Court of Canada. Expert witness Dr. R. Billings, a psychiatrist is questioned by defence counsel:
Q. Do you have an opinion as to whether or not ... Mr. Parks was suffering from any medical illness?
A (Dr. Billings). No.
Q. Dealing now with sleepwalking, from the perspective of general psychiatry, is sleepwalking viewed as a neurological disease?
A. No.
Q. Is it viewed as something that is causally related to mental illness?
A. Can cause mental illness?
Q. No, is sleepwalking .. a result of mental illness?
A. No.
Q. Is sleepwalking a part of any mental illness?
A. No.
Q. In your opinion, ..., is sleepwalking a disease of the mind?
A. No, I would not call it a disease.
...Q. Is there any evidence that a person could formulate a plan while they were awake and then in some way ensure that they carry it out in their sleep?
A. No, absolutely not. Probably the most striking feature of what we know of what goes on in the mind during sleep is that it's very independent of waking mentation in terms of its objectives and so forth. There is a lack of control of directing our minds in sleep compared to wakefulness. In the waking state, of course, we often voluntarily plan things, what we call volition - that is, we decide to do this as opposed to that - and there is no evidence that this occurs during the sleepwalking episode. There usually is - well they are precipitated. They are part of an arousal, an incomplete arousal process during which all investigators have concluded that volition is not present.
Q. And assuming he was sleepwalking at the time, would he have the capacity to intend?
A. No.
Q. Would he have appreciated what he was doing?
A. No he would not.
Q. Would he have understood the consequences of what he was doing?
A. No, I do not believe that he would. I think it would all have been an unconscious activity, uncontrolled and unmeditated.
Parks was acquitted (read more, and even more) but surely not due to the clarity of Dr. Billings' testimony. If it's not neurological, mental or even medical, what IS a sleep disorder? Was it the Flying Spaghetti Monster who kept him asleep and walked him around like a puppet, or what??
Comments
Is it a disorder at all? It naturally occurs in a proportion of human population. Nobody is trying to treat it, except for making sure that habitual sleepwalkers have a safe environment in which to walk at night (multiple complicated locks on the doors, etc). Yes, you are completely unconscious, you cannot plan what to do once you are asleep and walking, you have no awareness of what you are doing while you are sleepwalking, and you have no recollection of what you did once you wake up. This would make asquittal a correct decision, without any need to invoke a disorder.
Posted by: coturnix | March 14, 2007 10:06 PM
Michael Rack does not much on the topic on his blog, and neither does Michael Breus, but there is more here.
Posted by: coturnix | March 14, 2007 10:16 PM