Sherlock of Sleep Devoted to Understanding Parasomnias

This story was originally published in our Sept/Oct 2023 issue as “Sherlock of Sleep.” Click here to subscribe to read more stories like this one.

The elderly man woke up one night to find himself in a bed soaked with blood. His wife, lying next to him, was dead, stabbed with a letter opener.

The man was charged with murder, though he claimed to have no memory of what had happened. The defense attorney was stumped, because there was no plausible motive for his client to have killed his wife.

The couple had been together for decades, and everything suggested a harmonious, loving relationship with no signs of strife; nor were there mitigating factors like alcohol or drug intoxication.

Was it possible, the attorney wondered, that his client had been asleep when his wife was killed and thus was unaware of what he might have done?

While many might deem a scenario like that preposterous, it’s the kind of question Michel Cramer Bornemann addresses almost every day. Looking into cases like this is, for him, a full-time job with one goal: to educate a jury on whether there is consciousness (and therefore criminal intent) when a sleep-related incident occurs.

It’s a job for which Cramer Bornemann is uniquely qualified. He is the lead investigator for Sleep Forensics Associates (SFA), a St. Paul, Minnesota-based company founded to provide valid scientific information in criminal cases involving parasomnias — abnormal, unwanted and unintentional behaviors that can occur during sleep.

Unique expertise

Cramer Bornemann started the firm in 2006 with two internationally known authorities on sleep disorders: neurologist Mark Mahowald and psychiatrist Carlos Schenck, both professors at the University of Minnesota Medical School. (Mahowald died in March 2020.) SFA was initially part of the Minnesota Regional Sleep Disorders Center, where Mahowald was director and Cramer Bornemann co-director.

Although Cramer Bornemann confers regularly with Schenck and other experts, SFA is now a one-man operation. To date, he’s consulted on more than 400 parasomnia cases, and the work has taken him throughout the U.S. and Canada, as well as to Germany, Israel, Japan and New Zealand.

The demand for Cramer Bornemann and SFA’s unique expertise is due in large part to a simple fact: The division between sleep and wakefulness is not always clear. Consciousness is not a binary, on/off phenomenon, Cramer Bornemann insists. “It occurs on a spectrum,” he says. When sleep and wake states get mixed up, strange and sometimes violent circumstances can arise.

Multifaceted phenomenon

Another motivation for starting SFA, Schenck explains, was to help ensure that qualified scientists with decades of valid sleep research are the ones providing expert testimony in court. The firm, he adds, “represents clients without any bias toward the defense or prosecution.” Until SFA has reviewed the available evidence of any case, they won’t guarantee which side their assessments will ultimately favor. In a world where a wily culprit might be tempted to claim a “sleepwalking defense” to escape a conviction, Cramer Bornemann’s insight can make a crucial difference in serving justice.

“[SFA] has helped bring credibility to the task of differentiating between genuine parasomnias and deliberate criminal acts,” says Alon Avidan, director of the UCLA Sleep Disorders Center. Clete Kushida, director of the Stanford University Center for Human Sleep Research, agrees, calling the founders of SFA “well-established sleep researchers [who] have all written key articles on parasomnias and their forensic implications.”

Kushida does believe that the so-called sleepwalking defense is legitimate in some cases. “Almost anything you can do while you are awake, it is possible to do while you are asleep,” he says. Sleepwalking, or somnambulism, one of the most common and widely known types of parasomnias, occurs during the non-rapid eye movement (non-REM) phase of sleep. It’s a multifaceted phenomenon, where people may not merely walk in their sleep but could also consume vast quantities of food or perform otherwise strange and outrageous acts — such as relieving themselves in a bedroom closet or dresser drawer. In some cases, sleepers can even get into their cars and drive while technically still slumbering.

Far less common are parasomnias during REM or so-called dream sleep. REM sleep occurs about once every 90 minutes, lasting 10 to 15 minutes. During that time, the body is usually paralyzed, which serves as a protective mechanism.

But in the 1980s, Mahowald and Schenck discovered what they called REM sleep behavior disorder (or RBD), a condition that enables people to act out unpleasant or combative dreams, or at least attempt to do so. Individuals with RBD are not fully immobilized during REM sleep and can thus thrash, kick, punch — or much worse.

Schenck first documented this condition in a clinical setting in September 1982, when he joined the staff of the Minnesota Regional Sleep Disorders Center. On his very first day, he met with a 67-year-old patient, Donald Dorff, who complained about his “moving nightmares.” Dorff related a football dream he had in which he had smashed into a 280-pound lineman. In reality, he had crashed into his bedroom dresser, shattering a mirror and knocking everything off the top. Dorff eventually spent a night at the sleep lab, where he was observed jerking and kicking his limbs during REM sleep. “I was the first [scientist] to see someone who could act out his dream,” Schenck recalls.

After accumulating several cases like this, Mahowald and Schenck published a landmark 1986 paper that introduced RBD to the scientific world. Through subsequent research, they concluded that the temporary lifting of paralysis during REM sleep was usually caused by neurologic degeneration. Ninety percent of these patients — who were mostly older men — would go on to develop Parkinson’s disease or Lewy body dementia. (Dorff was among the lucky 10 percent who eluded those syndromes.)

Cramer Bornemann’s first foray into the field occurred in 1998, when he began research at the sleep center then run by Mahowald. Cramer Bornemann had earned his medical degree a few years earlier. He had decided to become a doctor in the hopes of earning respect, he says, something he had not received growing up as a half-Dutch refugee from Indonesia who came to the U.S. in 1969, at the age of eight.

The discrimination he continually faced propelled him to become the best student possible, even as he pushed himself to excel in any sport and job he undertook.

When Cramer Bornemann first arrived at the sleep lab, his specialty was in pulmonary medicine. Working alongside Mahowald, he discovered that the earliest signs of respiratory distress associated with Lou Gehrig’s disease show up during REM sleep. After that research was completed, Mahowald remarked: “You really enjoy working on sleep. How about another year or two of training?” Cramer Bornemann has been studying sleep disorders ever since.

The bizarre and exotic

In subsequent research, Cramer Bornemann, Mahowald and Schenck showed that parasomnias often arise during the transition from non-REM to REM sleep — as well as during shifts from wakefulness to non-REM sleep and from non-REM to dream sleep. During these abrupt alterations in brain activity, switching errors can occur when something goes awry among the brain’s network of 100 billion neurons, and an aberrant electrical signal is set off. If someone is startled during an episode like this, he or she may have instinctual, primal responses — defensive, predatory or even sexual in nature — that could be triggered because the prefrontal cortex, which is responsible for inhibiting such impulses, is offline (in “sleep mode,” so to speak). On rare occasions, the consequences can be deadly, especially if an object that could serve as a weapon is within reach.

After several years at the center, Cramer Bornemann couldn’t ignore how often he and his colleagues were fielding calls from attorneys or law enforcement officials asking for advice on bizarre, sleep-related cases. As Cramer Bornemann saw it, providing their medical expertise would fulfill a civic duty. Mahowald and Schenck agreed, especially after Cramer Bornemann persuaded them that income from forensic cases could help support the group’s studies of other sleep disorders. What’s more, he maintained, consulting work would provide access to many more cases of exotic nocturnal behaviors than they might typically encounter at their center.

Establishing a new specialty in sleep forensics was also important, Cramer Bornemann notes, because even though some clinicians are willing to speak up in court, “they may have no idea of the legal process. To secure a conviction, you need to establish both actus reus [the guilty act] and mens rea [the guilty mind],” he says. In the cases Cramer Bornemann consults on, the act itself normally is not in doubt; the accused party may have already admitted to assaulting someone, or touching them inappropriately, or even committing murder, but they may claim no memory of doing so. It’s the goal of sleep forensics, then, to determine the degree of consciousness. “We need to provide a comment on mens rea in order to assess culpability,” he says.

Mahowald and Schenck were happy to evaluate cases, but had no interest in going to court. Cramer Bornemann, on the other hand, relished the prospect. He had majored in philosophy in college and loved debating. He found that he enjoyed the challenge of explaining neuroscience in a way that lawyers — and especially juries — could understand. Cramer Bornemann’s medical training, clinical experience, and growing knowledge of case law would eventually give him a unique set of qualifications for his job.

“Nobody else in the world is so dedicated, has been involved in so many cases, and has so much expertise,” says Francesca Ingravallo, a medical legal expert at the University of Bologna in Italy. When a legal case involving sleep-related behavior arises, “Michel’s name is usually the first that comes up,” adds Susan Elizabeth Reese, an attorney based in Newport, Oregon, who has teamed up with Cramer Bornemann in the past.

In 2019, SFA’s founders published “A Review of Sleep-Related Violence,” an analysis of the 351 referrals they had investigated up to that point. “A key message of this study, Schenck says, “is that a variety of sleep disorders can lead to violence,” including murder and sexual assault (sexsomnia).

The SFA team, Ingravallo says, “has acquired a huge statistical base compared to other groups in this field” — one that affords a great opportunity to learn. “We’re not just providing a service to educate lawyers and the courts,” Cramer Bornemann says. “By capturing all these cases, and analyzing all the data, we’re furthering our own understanding of these rare and strange parasomnias.”

Secrets of the nocturnal realm

For the most part, Cramer Bornemann says, sleep medicine practitioners like himself are not starting with a grand theory. Learning comes by watching what people do and eventually finding patterns in their actions.

A distinction is commonly drawn between so-called hard science and soft science, he says. “Chemistry is considered a hard science: If you mix compound A with compound B and then heat that mixture to X degrees, you can quantify the results. But a lot of medicine isn’t hard science; a lot of it is based on more of an observational approach.” There is no blood test for schizophrenia, for example. Instead, over the years enough people were seen who shared common features and behaviors, suggesting they might have a similar disorder. And if enough people are studied over enough years, researchers may be able to predict what is likely to happen.

That’s what Cramer Bornemann and his SFA colleagues are attempting to do: uncover secrets of the nocturnal realm by observing populations of people, one patient at time.

As to the case of the elderly man charged with his wife’s murder, Cramer Bornemann’s investigation concluded that the client had “altered mental status” at the time of the incident. His unintended actions in this case were not the result of a parasomnia but were more likely due to a “neurological event that arose out of sleep” — a seizure that could also have caused switching errors during non-REM sleep. “We think parasomnias and seizures have a lot in common,” Cramer Bornemann says. “Both are electrical circuit problems.”

Conscious and unconscious

In the end, the man avoided further prosecution. The decision was just, says Cramer Bornemann, since in his assessment, the man “clearly did not intend to kill his wife.” And the punishment had already been meted out, Cramer Bornemann adds. “He had to live with this for the rest of his life.”

However, in another case, Cramer Bornemann was hired to defend a different man accused of killing his wife. This defendant had previously been treated at the Minnesota center and was actually observed experiencing a non-REM parasomnia. Despite this fact, the man’s behavior wasn’t consistent with parasomnia-related violence. Among other details, the man had followed his wife from room to room — stalking his prey — and changed his mind about what weapon to use before striking. This behavior pointed more to a deliberate conscious strategy than a spontaneous burst of violence more typical of a true parasomnia. In this case, the sleepwalking defense didn’t hold, and the husband was convicted.

About a third of the cases Cramer Bornemann takes on are for the prosecution, though sometimes he takes on pro bono work. For instance, a distraught mother once contacted him shortly after her 19-year-old son had been run over by a tractor-trailer at 2:00 AM, just outside his home, dressed only in underwear and a T-shirt. Although the coroner concluded the death was a suicide, Cramer Bornemann learned that the son had a history of sleepwalking and was able to have the ruling amended. That offered some relief to the grieving family.

While such work is rewarding, Cramer Bornemann’s motivations transcend a desire to help others, to see justice done, or even to ascertain the full range of parasomnias; he’s hoping to shed light on the workings of the brain itself.

There are times, normally of brief duration, when people can simultaneously be both conscious and unconscious — a fact that courts have been slow to appreciate, adhering instead to the notion that an individual is either conscious or not. In most instances, the overlap between these two states is inconsequential and goes without notice. But occasionally, the outcome can be perplexing. And in some situations, a person can end up hurt — or even dead.

The scores of cases investigated by SFA have made one thing abundantly clear to Cramer Bornemann: “We have less control over our behaviors than we think,” he says. “And when the behavior gets really bizarre, I usually get a call.”

Parasomnia Activity

Although many of the cases that Bornemann and Sleep Forensics Associates review tend to focus on violent parasomnias, this group of sleep disorders includes a wide range of unwanted and unintentional behaviors. They can occur in the transition to sleep, during sleep or while waking up.

It’s estimated that as many as 10 percent of Americans suffer regularly from some form of parasomnia, although research suggests that more than half of all sleepers have had at least one parasomnia event, often as children. Here are two of the most common types.

Sleepwalking (somnambulism) is the most widely known type of parasomnia, occurring during the non-rapid eye movement (non-REM) phase of sleep, and can include a lot more activities than walking. Eating excessively, going to the bathroom in inappropriate places, and even driving are all types of somnambulism.

By the way, it’s a myth that you should never wake a sleepwalker (you definitely should if they are doing something dangerous or could hurt themselves). But the best approach is to simply try to lead them back to bed.

Bed-wetting (sleep or nocturnal enuresis) or involuntary urination while sleeping is another common issue, especially in children, and it’s happened to almost everyone at some point in their lives.

Although inconvenient and embarrassing, it’s nothing to be ashamed of, and in most cases it’s a normal part of human development. To qualify as a true parasomnia, incidents of bed-wetting generally would occur at least twice a week in people age 5 or older, according to the American Academy of Sleep Medicine.

Find out more about these common (and many more uncommon) parasomnias at aasm.org.

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