Wijdicks, Eelco F. M. MD, PhD
Sleep should provide rest and a dream does not usually make much sense, but, alas, not in the movies. For screenwriters there is a good reason to use dream sequences and sleep disorders. Serious screenwriters and film directors love the ethereal dream, and particularly night terrors, because they are a good storytelling device, but there are also the silly concoctions in horror movies such as “Eddie: The Sleepwalking Cannibal” (2012).
Sleep disorders have been depicted in film, but rarely have they been the sole focus. That has changed with the latest film by Steven Soderbergh, “Side Effects,” in which sleepwalking, or somnambulism, is prominently on display. Soderbergh, who announced that he would be ending his film career after the release of this film, has focused on medical themes in the past few years. “Side Effects” follows closely after his infernal “Contagion” (2011), which dealt with a fictitious virus loosely based on Nipah virus. “Side Effects” also has an associated [but made up] website (www.tryablixa.com) that is eerily similar to a real advertisement until Jude Law shows up as the psychiatrist Dr. Jonathan Banks. He asks questions about signs of depression. If all three questions are answered “yes,” he expresses concern and suggests the fictionalized antidepressant Ablixa. If all three questions are answered “no,” he still recommends a referral to a psychiatrist.
Ablixa is an antidepressant that causes violent sleepwalking in the main character Emily Taylor (Rooney Mara in a leading role). Emily is feeling hopelessly depressed, possibly set off by her husband's recent release from prison after serving four years for insider trading. Emily has tried to get her life back together but fails with the first social encounter. Next, she purposely drives her car into the wall of a parking garage and hospitalization leads to therapy sessions with Dr. Banks. Dr. Banks starts prescribing multiple antidepressants and, eventually, when all else fails — and after another attempt to throw herself under the train — treats her with Ablixa. The drug causes sleepwalking but also furnishes her with a cure. Stopping the medication, despite the seemingly innocent act of brief sleepwalking, is not an option she will consider. In the key scene she ends up committing a murder — not a spoiler here as the crime is already implied in the first minute of the film and prominently present in the trailer. This sets off the film's narrative, but “Side Effects” is one of those films in which nobody is what they seem.
After the murder, a brief courtroom drama ensues, but rather than presenting the difficulties with proving the relationship of violent behavior with sleepwalking, the discussion focuses on where the psychiatrist thinks the mind dwells in sleep. It is mentioned that consciousness provides a context for our actions, and that part does not exist when we sleep. The film does not mention video-EEG-polysomnographic assessment. It quickly goes to a plea bargain: case closed.
Dr. Banks' psychiatry practice suffers, his marriage almost falls apart, and he is grilled in a deposition asking about his workload and whether he can handle it. His colleague psychiatrists threaten to ostracize him for losing patients. The film has other not so subtle themes: psychiatrists discuss medication options (the “try-this–in-your patient-because-it worked-well-in mine” argument) and cavalierly prescribe for family members. Even Dr. Banks' decision to come to the US is used to imply that patients in UK who take medication are sick, while those who take medication in the US are getting better. It further caricaturizes a lavish lifestyle of specialists among other unsympathetic portrayals.
The film claims that violent behaviors during sleep can be caused by antidepressants, an exceedingly uncommon side effect. Violent behaviors during sleep are well known and may have dramatic implications including homicide, nonfatal assaults, and also sexual misconduct. Sleepwalking is usually benign in children but in adults it can become quite harmful, with not only destruction of property, but also serious injury to bed partners or others.
The American Academy of Sleep Medicine has clear criteria for somnambulism that include persistence of sleep or impaired judgment during ambulation and a disturbance that is not better explained by other disorders, drug use, or a substance use disorder. A recent textbook, Sleep Medicine, mentions that sleep specialists are increasingly asked to evaluate potential court cases where violent behavior might result from a sleep disorder.
Connecting violence with an underlying sleep disorder is far more difficult. However, the literature — reported in a December 2010 paper in the journal Brain — does suggest some criteria, including, for example: (1) previous episodes and documented sleep disorder; (2) arousal stimulus; (3) no attempts to escape; (4) horror and amnesia for the event; and (5) precipitating factors such as recent sleep deprivation and newly introduced medication.
Rooney Mara plays a very convincing sleepwalker — or, should I say, she kills it. Neurologists may find her portrayal — she performs the act of murder with bland emotion — truthful and accurate. We observe Emily as she wakes up at midnight, sets the breakfast table, and puts on music. The next scene is a murder on a clear day after a nap. This film effectively reflects how psychiatry and neurology may intersect and how the sleepwalker may be truly astonished that she has done such a horrifying deed — in this case, murder.
“Side Effects” brings to the forefront an interesting and disturbing phenomenon; that in itself makes the film worth watching. In the end, though, “Side Effects” is a disappointing mundane noir, with greed and conceit as a leading motif. Homicidal sleepwalking is baffling; the same can be said of this film.
Dr. Wijdicks is professor of neurology at Mayo Clinic in Rochester, MN.