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Can You Diagnose This Sleep Disorder?
Author:
Joseph A. Diamond, MD
Mount Sinai West/St. Luke's
A 56-year-old man presents to your office with concern for multiple injuries at night. He has a medical history significant for hypertension that is well-controlled with amlodipine; depression, for which he is taking bupropion; chronic constipation; and a fall 6 months ago that had resulted in a rib fracture, which had been medically managed. During the current visit, he is accompanied by his partner, who reports that the man “seems as though he’s fighting people and yelling in his sleep.” This has resulted in multiple contusions and minor lacerations to the patient’s body, particularly his extremities, but no further serious injuries.
He once tried to hit his partner while screaming, “I’ll get you all!” but was able to be awakened and redirected. After this incident, the patient was alert, in no apparent distress, and reported, “I was boxing some aliens in my dream.” There is no reported snoring or witnessed apneas. He rarely has problems falling asleep; around times of large deals for his business, he has difficulty falling asleep because of “finances being on my mind.” He has 3 healthy children and a brother who is being treated for hallucinations. His parents died of old age, with some “shakiness” in his father shortly before his death, which was attributed to his being frail. There are no other known medical problems.
Which sleep disorder does this patient likely have?
Better luck next time
The correct answer is E. REM sleep behavior disorder (RBD).
The criteria1 for RBD include:
- Repetition of vocalizations and/or complex motor behaviors during sleep.
- Polysomnography (PSG) findings show that these behaviors occur during REM sleep.
- If documentation of these behaviors by PSG is not possible, they must at least be assumed to take place during REM sleep based on records of dream enactment.
- REM sleep without atonia (RWA) can be seen in polysomnographic recordings.
- Episodes cannot be explained by another mental disorder, sleep disorder, substance abuse, or medication.
Answer A is incorrect, because sleep terrors typically happen among children, occur during non-REM sleep, and the individual is confused if awakened during the events, with poor recollection the following morning. Answer B is incorrect, because the patient rarely has problems falling asleep; these problems are not reported to be chronic or prevalent. Answer C is synonymous with sleep talking, and while the patient does have vocalizations, they seem to be a part of dream-enactment behavior from RBD rather than a separate parasomnia. Answer D is incorrect, because while the patient does engage in violent altercations in his dreams, they do not appear to be distressing to him. It is only the subsequent injuries he sustains that are troubling.
Reference:
- International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
Nice job!
The correct answer is E. REM sleep behavior disorder (RBD).
The criteria1 for RBD include:
- Repetition of vocalizations and/or complex motor behaviors during sleep.
- Polysomnography (PSG) findings show that these behaviors occur during REM sleep.
- If documentation of these behaviors by PSG is not possible, they must at least be assumed to take place during REM sleep based on records of dream enactment.
- REM sleep without atonia (RWA) can be seen in polysomnographic recordings.
- Episodes cannot be explained by another mental disorder, sleep disorder, substance abuse, or medication.
Answer A is incorrect, because sleep terrors typically happen among children, occur during non-REM sleep, and the individual is confused if awakened during the events, with poor recollection the following morning. Answer B is incorrect, because the patient rarely has problems falling asleep; these problems are not reported to be chronic or prevalent. Answer C is synonymous with sleep talking, and while the patient does have vocalizations, they seem to be a part of dream-enactment behavior from RBD rather than a separate parasomnia. Answer D is incorrect, because while the patient does engage in violent altercations in his dreams, they do not appear to be distressing to him. It is only the subsequent injuries he sustains that are troubling.
Reference:
- International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
Joseph A. Diamond, MD, DABPN, DABSM, is an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai; Neurology Clerkship Site Director at Mount Sinai West/St. Luke's; and Neurohospitalist at Mount Sinai West/St. Luke's in New York, New York.
Which neurologic condition commonly develops 10 years after this diagnosis?
Author:
Joseph A. Diamond, MD
Mount Sinai West/St. Luke's
A 56-year-old man presents to your office with concern for multiple injuries at night. He has a medical history significant for hypertension that is well-controlled with amlodipine; depression, for which he is taking bupropion; chronic constipation; and a fall 6 months ago that had resulted in a rib fracture, which had been medically managed. During the current visit, he is accompanied by his partner, who reports that the man “seems as though he’s fighting people and yelling in his sleep.” This has resulted in multiple contusions and minor lacerations to the patient’s body, particularly his extremities, but no further serious injuries.
He once tried to hit his partner while screaming, “I’ll get you all!” but was able to be awakened and redirected. After this incident, the patient was alert, in no apparent distress, and reported, “I was boxing some aliens in my dream.” There is no reported snoring or witnessed apneas. He rarely has problems falling asleep; around times of large deals for his business, he has difficulty falling asleep because of “finances being on my mind.” He has 3 healthy children and a brother who is being treated for hallucinations. His parents died of old age, with some “shakiness” in his father shortly before his death, which was attributed to his being frail. There are no other known medical problems.
Which sleep disorder does this patient likely have?
Better luck next time
The correct answer is E. REM sleep behavior disorder (RBD).
The criteria1 for RBD include:
- Repetition of vocalizations and/or complex motor behaviors during sleep.
- Polysomnography (PSG) findings show that these behaviors occur during REM sleep.
- If documentation of these behaviors by PSG is not possible, they must at least be assumed to take place during REM sleep based on records of dream enactment.
- REM sleep without atonia (RWA) can be seen in polysomnographic recordings.
- Episodes cannot be explained by another mental disorder, sleep disorder, substance abuse, or medication.
Answer A is incorrect, because sleep terrors typically happen among children, occur during non-REM sleep, and the individual is confused if awakened during the events, with poor recollection the following morning. Answer B is incorrect, because the patient rarely has problems falling asleep; these problems are not reported to be chronic or prevalent. Answer C is synonymous with sleep talking, and while the patient does have vocalizations, they seem to be a part of dream-enactment behavior from RBD rather than a separate parasomnia. Answer D is incorrect, because while the patient does engage in violent altercations in his dreams, they do not appear to be distressing to him. It is only the subsequent injuries he sustains that are troubling.
Reference:
- International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
Nice job!
The correct answer is E. REM sleep behavior disorder (RBD).
The criteria1 for RBD include:
- Repetition of vocalizations and/or complex motor behaviors during sleep.
- Polysomnography (PSG) findings show that these behaviors occur during REM sleep.
- If documentation of these behaviors by PSG is not possible, they must at least be assumed to take place during REM sleep based on records of dream enactment.
- REM sleep without atonia (RWA) can be seen in polysomnographic recordings.
- Episodes cannot be explained by another mental disorder, sleep disorder, substance abuse, or medication.
Answer A is incorrect, because sleep terrors typically happen among children, occur during non-REM sleep, and the individual is confused if awakened during the events, with poor recollection the following morning. Answer B is incorrect, because the patient rarely has problems falling asleep; these problems are not reported to be chronic or prevalent. Answer C is synonymous with sleep talking, and while the patient does have vocalizations, they seem to be a part of dream-enactment behavior from RBD rather than a separate parasomnia. Answer D is incorrect, because while the patient does engage in violent altercations in his dreams, they do not appear to be distressing to him. It is only the subsequent injuries he sustains that are troubling.
Reference:
- International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
Joseph A. Diamond, MD, DABPN, DABSM, is an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai; Neurology Clerkship Site Director at Mount Sinai West/St. Luke's; and Neurohospitalist at Mount Sinai West/St. Luke's in New York, New York.
