By Melissa Bynes Brooks
March 26, 2012
No one could have ever predicted the massacre involving Staff Sgt. Robert Bales who was charged on Friday, March 23, 2012, with 17 counts of murder and six counts of attempted murder, along with other charges, in Afghanistan. Or could they? The warning signs were there in his history of traumatic brain injury and multiple deployments to Iraq.
Research findings at the Puget Sound Veterans Affairs hospital in Washington indicate providers should screen for anger and aggression among Iraq and Afghanistan War veterans who exhibit symptoms of Post-traumatic stress disorder (PTSD) and incorporate relevant anger treatments into early intervention strategies. PTSD is an anxiety disorder some people develop after seeing or living through an event that caused or threatened serious harm or death. Symptoms may include strong and unwanted memories of the event, bad dreams, emotional numbness, intense guilt or worry, angry outbursts, feeling “on edge,” and avoiding thoughts and situations that are reminders of the trauma.
The impetus for a review of the Army’s Post Traumatic Stress Disorder program comes after statistics showed staff at Madigan Medical Center on Joint Base Lewis McCord (JBLM), the home base of Staff Sgt. Robert Bales, had reversed the PTSD diagnoses of 40% of the troops they evaluated, according to Sen. Patty Murray, Washington-D, who recently raised the issue at a hearing on Capitol Hill.
It bodes well if the Army considers implementing a screening program that includes the use of a sleep study known as a polysomnogram (PSG). A PSG can confirm a diagnosis for the parasomnia, REM sleep behavior disorder (RBD), for soldiers with PTSD. REM sleep behavior disorder (RBD) is a frequent complaint in people who have suffered a traumatic brain injury. Traumatic brain injury (TBI) is acquired when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently hits an object, or when an object pierces the skull and enters brain tissue.
Sleep disorders are a common finding after the acute or sudden onset phase of TBI. This can result in daytime sleepiness, heightened anxiety, a poor individual sense of wellbeing, insomnia and depression. Sleep changes and disturbed sleep are common in chronic TBI, defined as 3 months to 2 years after an injury has occurred. Neuroimaging studies have shown highly significant relation¬ships between reduced prefrontal cortical size or prefrontal corti¬cal activity with increased aggression and violence. A large study of head injuries in combat veterans found damage to the frontal lobes was associated with an increased risk for violent behavior.
Head trauma may contribute to the development of REM sleep behavior disorder (RBD) during arousals from REM sleep when most dreams occur. RBD is noticeable by intense and frightening dreams. Normally, the muscles of the body are temporarily paralyzed while dreaming. With RBD, the muscles are not temporarily paralyzed and people can act out their dreams. This is when behaviors such as sleep walking, sleep talking, and vigorous, violent episodes occur that can cause serious bodily injury. Between 33% and 65% of RBD patients have been reported to have sleep related injury to self or bed partner. Persons experiencing RBD episodes are usually unaware of the events as they are taking place.
Violent behavior, in the case of sleepwalking, occurs only after the sleepwalking episode has been triggered and is underway. During the sleepwalking episode, while moving about the environment, the sleepwalking individual encounters someone else – most likely a family member. This person may approach, block, touch, or grab the sleepwalker, triggering a violent reaction.
Simultaneous video and sleep study (PSG) recording is essential for evaluating patients with suspected RBD, so that vocalizations and limb movements can be captured and viewed concurrently with PSG data. When vocalizations, excessive muscle activity in the chin and/or limb movements emerge during REM sleep, without associated seizure activity, the diagnosis of RBD is established.
John Henry Browne, the leading defense attorney for Army Staff Sgt. Robert Bales, said about Sgt. Bales, “He has an early memory of that evening, and he has a later memory of that evening, but he doesn’t have a memory of in between.” Because all persons with REM sleep behavior disorder have a history of acting out their dreams, one can only ponder whether a sleep study screening to evaluate RBD in Army Staff Sgt. Robert Bales, might have revealed a propensity for sleep violence, which could have thwarted such a wretched tragedy.
Melissa Bynes Brooks is the editor of BrooksSleepReview. She is the Clinical Coordinator of Coral Springs Medical Center Sleep Disorders Center, accredited by the American Academy of Sleep Medicine, in Broward County, Fl. She is a Registered Polysomnographic Technologist and Certified Respiratory Therapist with a B.S. in Respiratory Therapy from FAMU and MBA from Nova Southeastern University.
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[i] Raison, Charles (2012). What’s the link between PTSD, TBI and violence? Retrieved March 23, 2012, from
[ii] Jakupcak, M., Conybeare, D., Phelps, L., Hunt, S., Holmes, H. A., Felker, B., Klevens, M. and McFall, M. E.
(2007), Anger, hostility, and aggression among Iraq and Afghanistan war veterans
[iii] National Institutes of Health Fact Sheet (2010). Post-traumatic stress disorder (PTSD). Retrieved March 22,
2012, from http://report.nih.gov/NIHfactsheets/Pdfs/PostTraumaticStressDisorder(NIMH).pdf
[iv] Shaughnessy, Larry (2012). Army Reviewing PTSD Evaluation Program. Retrieved March 21, 2012, from
[v] Boeve, B. F. (2010), REM sleep behavior disorder. Annals of the New York Academy of Sciences, 1184: 15–
54. doi: 10.1111/j.1749-6632.2009.05115. National Institute of Neurological Disorders and Stroke (2012). NINDS Traumatic Brain Injury Information Page. Retrieved March 24, 2012, from http://www.ninds.nih.gov/disorders/tbi/tbi.htm
[vi] National Institute of Neurological Disorders and Stroke (2012). NINDS Traumatic Brain Injury Information
Page. Retrieved March 24, 2012, from http://www.ninds.nih.gov/disorders/tbi/tbi.htm
[vii] Verma A; Anand V; Verma NP. Sleep disorders in chronic traumatic brain injury. J Clin SleepMed 2007;3(4):357-362.
[viii] Brower MC, Price BH. Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a
critical review. Journal of Neu¬rology, Neurosurgery & Psychiatry 2001;71:720-6.
[ix] Aurora RN; Zak RS; Maganti RK; Auerbach SH; Casey KR; Chowdhuri S; Karippot A; Ramar K; Kristo DA; Mergenthaler TI. Best practice guide for the treatment of remsleep behavior disorder (rbd). J Clin Sleep Med
[x] Pressman MR. Disorders of arousal from sleep and violent be¬havior: the role of physical contact and proximity.
[xi] Boeve, B. F. (2010), REM sleep behavior disorder. Annals of the New York Academy of Sciences, 1184:
15–54. doi: 10.1111/j.1749-6632.2009.05115.
[xii] CNN Wire Staff (2012). Lawyer Suspect in Afghan Massacre Has Memory Loss, Lawyer Says. Retrieved
March 24, 2012, from