Fast Five Quiz: Sleep Disorders

Helmi L. Lutsep, MD; Zab Mosenifar, MD; Stephen Soreff, MD


August 03, 2020

The specific criteria for REM sleep behavior disorder from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include the following:

  • Recurrent episodes of arousal during sleep associated with vocalization and/or complex motor behaviors that arise during REM sleep

  • On waking from these episodes, the individual is not confused or disoriented and is completely alert

  • Either of the following is present: REM sleep without atonia on polysomnography recordings or a history suggestive of REM sleep behavior disorder and an established synucleinopathy diagnosis (eg, Parkinson's disease, multiple system atrophy)

  • The episodes cause significant distress or impairment in social, occupational, or other areas of functioning, which may include serious injury to self or the bed partner

  • The disturbance cannot be explained by the effects of a drug of abuse or medication

  • The episodes cannot be attributed to another mental disorder or medical condition

Routine medical history should include questions that screen for abnormal sleep movements and altered dreams. The presenting complaint is often violent dream-enacting behaviors during REM sleep, often causing self-injury or injury to the bed partner. The dream-enacting behaviors are usually nondirected and may include punching, kicking, leaping, crying out, or running from bed while still in REM sleep. The patient may be wakened or may wake spontaneously during an attack and vividly recall the dream that corresponds to the physical action. In some cases, an extended prodrome of prominent limb and body movements occurs before the development of REM sleep behavior disorder.

The most important diagnostic studies in REM sleep behavior disorder include the following:

  • Polysomnographic video recording: This is the most important diagnostic test in REM sleep behavior disorder. At least some tonic or phasic abnormalities of muscle tone are observed during REM sleep accompanying the attack, although usually patients have both.

  • Monitoring EOG

  • Electroencephalography

  • Electrocardiography

  • Polysomnography to evaluate respiration for OSA

  • Multiple electromyography channels using chin, bilateral extensor digitorum, and tibialis anterior muscles

REM sleep behavior disorder is treated symptomatically with various medications. However, the response varies in individual cases; therefore, all available medications should be tried before considering the patient's REM sleep behavior disorder as intractable.

Clonazepam is highly effective in patients with REM sleep behavior disorder. It demonstrates a complete benefit in most patients with the disorder. Little evidence suggests tolerance or abuse of this drug. Symptoms relapse promptly on discontinuation of medications in almost all patients; therefore, pharmacologic treatment should be continued indefinitely.

An important aspect of management of patients with REM sleep behavior disorder is environmental safety. Potentially dangerous objects should be removed from the bedroom, and the mattress should be placed on the floor or a cushion should be placed around the bed.

Read more clinical information about REM sleep behavior disorder.


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