AASM Membership Sections Newsletter Issue #3
16
American Academy
of Sleep Medicine
Force, Dr. Cramer Bornemann will be keeping the
membership informed about recommended updates
and revisions to the Diagnostic Criteria and Text
of the Parasomnia Section. Final recommendations
will require approval by both the
ICSD-3
Task Force
and the AASM Board of Directors. Work is ongoing
and will also incorporate the involvement of external
reviewers. The new
ICSD-3
is anticipated for release
in the fall of 2013.
Parasomnia Case of the Month
The Parasomnias Section is establishing a case of the
month to facilitate peer interaction among the mem-
bership through discussion of HIPPA-compliant case
presentations focusing on complex nocturnal behav-
iors. For the latest discussion, see the the Parasomnias
Section Discussion form located on the AASM web-
site at:
.
This month’s case is presented below.
REM Sleep Behavior Disorder Case
This is a 62 y/o white male with history of sleep apnea
who is presenting for initial consultation. He was
originally placed on CPAP of 15 cm of H
2
0,
which he
was unable to tolerate. The pressure was empirically
reduced down to 10 cm of H
2
0,
but due to continuous
intolerance, he presented for further work-up, includ-
ing a CPAP re-titration study. During the titration,
he was found to have REM sleep without atonia and
complex movements in REM sleep consisting of flail-
ing arm movements. In addition, he had an episode
that consisted of fighting movements of the arms in
which he tore off his CPAP mask. He had no recollec-
tion of these episodes on further questioning in the
morning. A bed partner interview was not available
as the patient lives alone.
The following representative epochs (Figures 1-3)
are recorded during the CPAP titration study that
showed REM sleep, RSWA and dream enactment.
Introduction
Parasomnias are defined by the
ICSD-2
as “undesir-
able physical events or experiences that occur during
entry into sleep, within sleep or during arousals from
sleep.” REM sleep behavior disorder is a parasomnia
that occurs during REM sleep, in which patients may
enact their dreams. During REM sleep, patients expe-
rience loss of muscle paralysis (LMP) or atonia that
leads to a wide spectrum of behavioral release dur-
ing sleep ranging form screaming to aggressive and
complex fighting behaviors. RBD may be associated
with neurodegenerative disorders such as Parkinson
disease and other neurodegenerative disorders such
as multiple system atrophy and Lewy body dementia.
Dream enacting behavior can occur in untreated
obstructive sleep apnea. In these cases the dream en-
actment is related to the apneas in REM sleep and the
condition is known pseudo RBD. Dream mentation
is also seen in Non-REM parasomnias (sleep walking,
sleep terrors, confusional arousals), nocturnal panic
attacks, nocturnal seizures, nightmares, nocturnal
wandering associated with dementia and post-trau-
matic stress disorder, alcohol or drug administration
or withdrawal.
Medications that can trigger RBD acutely include:
Tri-Cyclic Antidepressants, Selective Serotonin
Reuptake Inhibitors, Mono-Amine Oxidase Inhibi-
tors, Serotonin Norepinephrine Reuptake Inhibitors,
Mirtazapine, Selegiline, and Biperiden) or during
withdrawal of alcohol, barbiturates, benzodiazepine
or meprobamate. Selegiline may trigger RBD in pa-
tients with Parkinson disease. Cholinergic treatment
of Alzheimer’s disease may trigger RBD.
Diagnostic Criteria for REM Sleep Behavior
Disorder (ICSD-2):
1.
Presence of REM Sleep without Atonia
2.
At least one of the following is present:
a. Sleep related injurious, potential injurious, or
disruptive behaviors by history
ICSD-3 Parasomnia Updates continued