Chronic behavioral disorders of human REM sleep: a new category of parasomnia.

Four men aged 67-72 with histories of injuring themselves or their spouses during sleep, often while enacting dreams, and a woman with disruptive but nonviolent sleep behaviors all showed REM sleep pathology on polysomnography: loss of chin muscle atonia, increased limb twitching, and elevated REM eye movements. Videotaped behaviors included punches, kicks, and dream movements. Slow-wave sleep was elevated for age; harmful behaviors did not occur during non-REM sleep. Four patients had serious neurological disorders (olivo-ponto-cerebellar degeneration, Guillain-Barré syndrome, subarachnoid hemorrhage, atypical dementia). Clonazepam and desipramine suppressed the behaviors, which returned when drugs were stopped. These REM sleep disorders replicate findings from cats with pontine lesions and offer insights into human behavior and dream phenomenology.

Study at a glance

Abstract

Four men, aged 67-72 years, had 4-month to 6-year histories of injuring themselves or their spouses with aggressive behaviors during sleep, often during attempted dream enactment. A 60-year-old woman had disruptive though nonviolent sleep and dream behaviors. Polysomnography did not detect seizures but did document REM sleep pathology with variable loss of chin atonia, extraordinarily increased limb-twitch activity, and increased REM ocular activity and density. A broad range of REM sleep behaviors was recorded on videotape, including stereotypical hand motions, reaching and searching gestures, punches, kicks, and verified dream movements. Stage 3-4 slow wave sleep was elevated for age in all patients. NREM sleep was devoid of harmful behaviors, although three men had periodic myoclonus. There was no associated psychiatric disorder, whereas serious neurologic disorder was closely associated in four cases: olivo-ponto-cerebellar degeneration, Guillain-Barré syndrome, subarachnoid hemorrhage, and an atypical dementia. Two patients had immediate and lasting sleep behavioral suppression induced by clonazepam, and another patient had the same response with desipramine. All instances of drug discontinuation prompted immediate relapse. In four cases there was associated dream hyperactivity, which resolved with behavioral control. These REM sleep neurobehavioral disorders constitute another category of parasomnia, replicate findings from 21 years ago in cats receiving pontine tegmental lesions, and offer additional perspectives on human behavior, neurophysiology, pharmacology, and dream phenomenology.