How the body got there was a mystery. More than 12 hours earlier, the man had emerged from successful back surgery. Now, clad only in underwear, he was outside, dead, wedged between a generator and a wall. He was six floors below the hospital rooftop. Had he jumped to his death? Had he been pushed? Neither, medical investigators concluded. He'd gone sleepwalking, and his stroll took an unfortunate turn.
"The autopsy showed that there were significant abrasions along this individual's back, which showed that he fell straight down," notes Michel Cramer Bornemann, an expert on sleep problems who is codirector of the Minnesota Regional Sleep Disorders Center in Minneapolis. "Suicide victims don't fall straight down. They jump." Moreover, the man had been barefoot yet not been deterred by the roof's layer of sharp stones. "Sleepwalkers don't sense pain; the sensory neural pathways are essentially off-line," says Cramer Bornemann, who was brought in by a family lawyer investigating the hospital's suggestion that the death was a suicide.
Cramer Bornemann heads up Sleep Forensics Associates, a group that lawyers and law enforcement officials have turned to when investigating crimes that may be explained by a sleep problem. Since they've been together—just over two years—he and his two colleagues have fielded approximately 150 requests for case evaluations, some from as far off as New Zealand. Murder, sexual assault, DUI, child abuse, and "suicide" are just a sampling of crimes they've encountered. All have been suspected of involving sleepwalking, sleep driving, or sleep sex, among other so-called parasomnias—inappropriate, unwanted behaviors that arise during sleep. (About one third of those case referrals involve the alleged influence of the sleep aid Ambien, he says.)
While Cramer Bornemann is noticing an increasing need for the group's input on court cases, he explains that it exists primarily to conduct scientific pursuits. These sleep-disorder cases provide an excellent window into the realm of parasomnias, he notes. Sleep Forensics Associates' approach, he said, isn't unlike that of animal-behavioral researchers who study primates in the wild, hoping to learn which behaviors are genetically determined and which are under conscious control.
Cramer Bornemann tracks every case, every call that comes in, collecting data so that years from now, perhaps in a decade or so, patterns might start to emerge that illuminate the physiologic mechanisms that underlie these bizarre sleep behaviors. "It's an attempt to see the breadth and depth of what's out there," says Sleep Forensics teammate Mark Mahowald, director of the Minnesota Regional Sleep Disorders Center and a professor of neurology at the University of Minnesota Medical School. So far, what's out there has proved "extraordinary," he marvels.
"Millions of Americans have some type of behavioral abnormality [during sleep], a parasomnia," says sleep medicine specialist Carlos Schenck, the third member of the Sleep Forensics group and a professor of psychiatry at the University of Minnesota Medical School. People have climbed out windows, driven for miles, and had sexual affairs in their sleep; they punch, kick, curse, and binge-eat in their sleep. Some of the strangest examples can be found in Schenck's books, Sleep and Paradox Lost, where he details stories—mostly his patients'—like that of the woman who dreamed she was cooking for a dinner party and awoke at 6:30 a.m. to find the table fully set and the meal ready. And that of the woman who woke to find she had sliced up her cat on a cutting board, the girl who sleepwalked to the top of a 130-foot crane without rousing, and the man who nearly snapped his wife's neck as he dreamed he was deer hunting with only his hands as a weapon.
"You don't have to extrapolate very far to connect what we see on a routine clinical basis weekly to saying that 'if this went a little bit further, this could easily have resulted in violent or injurious behavior with legal implications,' " says Mahowald.
Consider the experience of Ron Voegtli of St. Louis. Asleep, he'd fly out of bed, sometimes two times a night, and snap into "protective mode" against perceived intruders. He'd grab a knife or baseball bat and race around the house, often shrieking, while his wife and young kids stayed in their bedrooms. Never did he behave like that while awake.
"I always thought about . . . the possibility . . . like, what if I would have hurt my wife or one of my kids or something. I wouldn't be able to live with that," says Voegtli, now 63. "That's why I never had a gun in the house." In 1989, Schenck diagnosed Voegtli with sleepwalking and sleep terrors—frightened, hyperaroused behavior during sleep—and prescribed a nightly dose of an antipanic drug called clonazepam (Klonopin), which has cured his long-standing sleep problem.
Sometimes parasomnias do lead to something darker. A young Canadian man, Kenneth Parks, was acquitted for the 1987 murder of his mother-in-law using the "sleepwalking defense." He arose from sleep one night, drove 14 miles to the house of his in-laws—with whom he was said to be close—and strangled his father-in-law until the man passed out. He bludgeoned his mother-in-law with a tire iron and stabbed them both with a kitchen knife. The woman died; the man barely survived. Parks then arrived at a police station, reportedly confused over what had transpired. Police noted something odd: He appeared oblivious to the fact that he'd severed the tendons in both hands during the attack. That analgesia, along with other factors, including a strong family history of parasomnias, led experts to testify that Parks had been sleepwalking during the attack. Not conscious, not responsible, not guilty.
What explains such parasomnias? In the '70s, it was believed that all complex behaviors arising from sleep were some form of sleepwalking and that in adults, they were all indicative of serious underlying psychiatric disease. Not so, found Mahowald and Schenck; psychiatrically healthy adults could indeed do strange things at night. "Sleep is not a whole-brain phenomenon," says Mahowald. Neurophysiologic studies of sleepwalkers, for example, have shown that during sleepwalking episodes, brain-wave patterns indicate a state of neither full sleep nor full wakefulness: Part of the brain can be awake while the other part is asleep. In sleepwalkers, the part that's shut down governs judgment, says Schenck. "Their eyes are open, they can negotiate the environment; they can see their car keys, grab them, then go drive an automobile," he says. "The problem is, they don't consider the consequences."
They also don't feel pain. That explains how people can go on barefoot forays in the snow without awakening, even as their skin blackens and blisters from frostbite. "If the part [of the brain] that's awake can generate complex motor behaviors, yet the part that's asleep is the part that's normally laying down memories, monitoring what we're doing, then you have a situation where you can have extraordinarily complex behaviors without conscious awareness," says Mahowald. Like murder.
And the more closely the doctors examined these complex nighttime behaviors, the more they saw they weren't all forms of sleepwalking. There's REM sleep behavior disorder (RBD), for instance, which affects mostly men, age 50 and up. Unlike sleepwalking, RBD occurs during rapid-eye-movement sleep, the stage where most dreaming takes place. It's also the stage in which people should be paralyzed, a protective mechanism to guard against dream enactment.
The doctors noticed, however, that some people could leave the paralysis of REM sleep and become free to act out their dreams: dreams of running on a football field, then colliding with reality, into a dresser; dreams of diving through a window, then soaring headfirst into a wall. By following a group of their RBD patients, the doctors made a remarkable discovery. More than 75 percent of them went on to develop Parkinson's or Lewy body disease, which causes dementia. They now consider RBD an early harbinger of neurodegenerative disorders. (In other patients, RBD seems to be associated with antidepressant use, Mahowald says.)
Many of the cases coming to Sleep Forensics, of course, will turn out to be "Twinkie defenses," without scientific merit, from people trying to get off the hook. And even true parasomniacs can commit conscious crimes—and they have. "That's one of the major challenges for us in Sleep Forensics Associates—to work backwards to evaluate the evidence both in favor of a sleep disorder and in favor of criminal activity," says Schenck. "You can't assume that just because someone has a parasomnia, that's why the crime occurred."