1450 Trauma-Associated Sleep Disorder with Dream Enactment Behavior
Zachary Sherman, Albert Vacheron, Rabin Shrestha, Amado Freire
Sleep May 1, 2025 DOI: 10.1093/sleep/zsaf090.1450 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Case study Case report Peer reviewed |
|---|---|
| Sample size | 1 |
| Population | 67-year-old male Gulf War veteran with 23 years of military service and active combat in 1990-1991 |
| Interventions | Melatonin Prazosin Doxazosin Amitriptyline Image rehearsal therapy |
| Dose | melatonin up to 15 mg |
| Key findings | TASD with dream enactment behavior is proposed as an under-recognized parasomnia, with mechanisms suggested to include hyperactivity in the locus coeruleus and peri-LC structures. In this patient, melatonin, prazosin, and doxazosin did not improve the parasomnia, and amitriptyline helped only sleep onset. The authors note that image rehearsal therapy's effect on dream enactment behavior is unclear, and that the risk of progression to RBD and alpha-synucleinopathies needs clarification. |
Abstract
Trauma-associated sleep disorder (TASD) is a proposed parasomnia that, while sharing criteria with REM-behavior disorder (RBD) remains under-recognized by clinicians. It is more common in the veteran population, and lacks clear guidelines on treatment, especially when accompanied by dream enactment behavior. A 67 year-old Gulf War veteran presented to sleep clinic with over 30 years of frequent dream enactment behavior (DEB). He has a concurrent history of insomnia, depression, and PTSD. Military service lasted 23 years, with active combat 1990-1991. DEB started then, as frequently as 5-7 times weekly. Behaviors include throwing nearby items, jumping out of bed, crawling on the floor, swinging, and yelling. The patient can only intermittently recall corresponding dreams. He has no tremor, shuffling gait, or change in handwriting. Neurological exam showed no cogwheel rigidity or resting tremor. He was diagnosed with trauma-associated sleep disorder and started on melatonin in 2017. Even with doses up to 15 mg there was no effect on parasomnia frequency or intensity, or any effect on sleep length or latency. He tried prazosin and doxazosin without improvement. These were stopped for side effects. Nighttime nausea and dizziness from other medication prevented starting clonazepam. He was later started on amitriptyline, which helped with sleep onset, but did not affect parasomnia. The patient is averse to group therapy because hearing others’ trauma has previously made his nightmares worse. The planned treatment is 1-on-1 image rehearsal therapy. TASD with DEB is a parasomnia not discussedin the ICSD-3-TR. Proposed mechanisms include hyperactivity in the locus coeruleus and peri-LC structures, as seen in PTSD, chronic stress, and psychiatric medications. TASD features nightmares that can occur in REM and NREM sleep and should be considered in any veteran with dream enactment. IRT is a non-pharmacologic treatment for PTSD-associated nightmares, but its effect on DEB is unclear, with only case reports. This patient has a decades-long history of DEB, but no signs of other neurological illnesses. The risk of evolution to true RBD and of developing alpha-synucleinopathies in these patients need to be clarified.