Elsevier

Sleep Medicine

Volume 13, Issue 4, April 2012, Pages 327-334
Sleep Medicine

Review Article
Poor sleep as a potential causal factor in aggression and violence

https://doi.org/10.1016/j.sleep.2011.12.006Get rights and content

Abstract

Clinical observations suggest that sleep problems may be a causal factor in the development of reactive aggression and violence. In this review we give an overview of existing literature on the relation between poor sleep and aggression, irritability, and hostility. Correlational studies are supporting such a relationship. Although limited in number, some studies suggest that treatment of sleep disturbances reduces aggressiveness and problematic behavior. In line with this is the finding that sleep deprivation actually increases aggressive behavior in animals and angriness, short-temperedness, and the outward expression of aggressive impulses in humans. In most people poor sleep will not evoke actual physical aggression, but certain individuals, such as forensic psychiatric patients, may be particularly vulnerable to the emotional dysregulating effects of sleep disturbances. The relation between sleep problems and aggression may be mediated by the negative effect of sleep loss on prefrontal cortical functioning. This most likely contributes to loss of control over emotions, including loss of the regulation of aggressive impulses to context-appropriate behavior. Other potential contributing mechanisms connecting sleep problems to aggression and violence are most likely found within the central serotonergic and the hypothalamic–pituitary–adrenal-axis. Individual variation within these neurobiological systems may be responsible for amplified aggressive responses induced by sleep loss in certain individuals. It is of great importance to identify the individuals at risk, since recognition and adequate treatment of their sleep problems may reduce aggressive and violent incidents.

Introduction

It is well known that sleep loss can have serious detrimental effects on cognitive performance. For example, sleep deprivation reduces sustained attention, executive functioning, and memory [1], [2]. Moreover, sleep loss may also affect emotional function [3], and chronically disrupted sleep may even sensitize individuals to mood disorders [4], [5]. However, relatively little attention has been paid to the effects of sleep loss on other areas of affective functioning. Yet, many people have the experience that disturbed sleep is accompanied by emotional instability expressed, for instance, by a greater irritability and short-temperedness. In most people this will not result in physical outbursts of aggression. However, this may be different in vulnerable individuals, such as psychiatric patients, who often experience serious sleep problems. For example, about 80% of patients suffering from a depressive disorder experience sleep problems [6], and sleep disturbances are found in 30–80% of schizophrenic patients [7]. Similar numbers may apply to forensic psychiatric patients, but published data are lacking. Forensic psychiatric hospitals treat patients who have committed (violent) offences but have diminished responsibility due to a mental disorder. The most important treatment goal for this specific group of patients is to reduce the risk of (violent) recidivism. Based on clinical observations in forensic psychiatry, we have the impression that poor sleep may contribute to the loss of emotional control, including the regulation of aggression. If sleep problems are a potential risk factor for hostile and (reactive) aggressive behavior, treating sleep disturbances and promoting good sleep in mentally disordered offenders may be beneficial in crime-preventing treatment programs. Therefore, in this paper we present an overview of existing literature concerning the relationship between sleep and aggression/hostility.

Section snippets

Methods

A literature search was performed in PubMed and Ovid with the following search terms: sleep, sleep disturbances, sleep problems, sleep deprivation, sleep architecture, aggression and aggressive behavior. The search terms were used in different combinations. Cross-references were checked for relevant papers. We included studies that covered sleep and its effects on aggression, anger, and irritability.

With regards to the interpretation of relevant studies, it is important to bear in mind that

Childhood populations

In addition to the more obvious consequences – such as sleepiness, inattention, and poor cognitive performance and anxiety – poor sleep in children and adolescents appears to be associated with aggression and conduct problems [8], [9]. In a large group of 2- to 3-year-old children the number of night time awakenings was positively correlated with parent-rated aggressive behavior [10]. Parent-reported sleep problems in 3- to 4-year-old twins correlated positively with conduct problems, anxiety,

Correlations

The correlation between disturbed or short sleep and disturbed control of aggression could be even stronger in subjects with a high anger-trait as part of their character. A condition in which aggression and angriness are core symptoms and can be considered part of the subject’s character is antisocial personality disorder (ASPD). Individuals with ASPD probably suffer from sleep problems comparable to other psychiatric patients. In fact, in a group of Turkish male military subjects diagnosed

Effects of treatment of sleep problems

An interesting case report describes two boys (six and eight years old), both admitted to a psychiatric unit for increasingly aggressive and violent behavior towards peers and family members [36]. During admission, they were diagnosed with obstructive sleep apnea syndrome (OSAS), which in children is most often due to enlarged tonsils. After adenotonsillectomy, both children had, as expected, a significant reduction in their apneic episodes. More importantly, prominent reductions both in the

Animal studies

Various experimental studies in rats suggest that sleep deprivation may increase aggression: rats subjected to enforced wakefulness by placing them together on top of a rotating drum surrounded by water, died after 3–14 days, not directly from sleep loss per se, but from fighting [43]. These rats became so hyper-reactive that even slight physical contacts precipitated vicious, aggressive behavior. This behavior was not always directed against the actual offender, and occasionally several

Prefrontal cortical functioning

One hypothesis on the relationship between poor sleep and aggression is that sleep deprivation results in poor prefrontal cortical (PFC) functioning. When PFC functioning is reduced, the ability to anticipate, delay, and initiate behavioral responses based on cognitive and social context declines [69]. That sleep deprivation affects the PFC is supported by the finding that sleep deprivation as short as 24 h leads to significant declines in PFC metabolic activity [70]. In addition, after sleep

Individual vulnerability

It is possible that certain individuals are more susceptible to the emotional consequences of poor sleep. For example, individual differences in emotional intelligence predict the influence of sleep deprivation on written responses to cartoons displaying frustrating situations [62]. This could indicate that individuals with low emotional intelligence are more vulnerable to the negative effects of sleep deprivation on mental functioning. Speculatively, individuals with poor prefrontal

Conclusions

Clinical and anecdotal observations in forensic psychiatric patients suggest that sleep loss is a potential risk factor for impulsive, reactive aggression. The larger part of the reviewed literature concerning the relationship between poor sleep and emotional regulation supports this hypothesis. Yet, most studies measured correlations and, thus, did not provide information on causality: poor sleep may affect aggressiveness or aggressiveness may produce sleep problems. Another option is that

Conflict of Interest

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2011.12.006.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

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