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• W2914205268 abstract "Free AccessVeterans - Insomnia - Nightmares - EMG - Behavior - CommentaryDistinct Disorder? Or Mash Up of Several? Meagan Rizzo, MD, Brian Robertson, MD, Jacob F. Collen, MD Meagan Rizzo, MD Walter Reed National Military Medical Center, Bethesda, Maryland Search for more papers by this author , Brian Robertson, MD Walter Reed National Military Medical Center, Bethesda, Maryland Search for more papers by this author , Jacob F. Collen, MD Address correspondence to: Jacob F. Collen, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814 E-mail Address: [email protected] Uniformed Services University of the Health Sciences, Bethesda, Maryland Search for more papers by this author Published Online:February 15, 2019https://doi.org/10.5664/jcsm.7610Cited by:2SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONFeemster et al.1 present an outstanding case illustrating the complexities of parasomnias in combat veterans. The topic is timely given the high volume of veterans with sleep complaints as we approach two decades of war. Although public awareness and resources to diagnose and manage sleep disordered breathing have improved, we often miss the big picture (insufficient sleep, substance use, poly pharmacy, insomnia, nightmares, mood disorders).This case provides a more intimate look at the clinical controversy surrounding disruptive nocturnal behavior (DNB) in veterans. It is particularly compelling because the authors are leading experts in the field and still struggling with the challenges that all of us face in diagnosing and treating these patients. Response to therapy in trauma-associated sleep disorder (TSD) seems to be the exception, even in the best of hands. Several questions arise. Should the constellation of combat-related nightmares, dream enacting behavior (DEB) and DNB represent a formal single diagnosis (TSD)? Do these patients simply suffer from a subtype of REM sleep behavior disorder (RBD)? Or are we ineffective at managing multiple comorbid sleep and mood disorders?There are several differences between TSD and RBD. RBD tends to present in older adult males with DEB emerging from violent, aggressive, or confrontational dream content. RBD can present several years prior to overt neurodegenerative disease.2,3 The patient presented by Feemster et al.1 is over 50 years of age, which increases concern for RBD. However, some of the patient's behaviors were linked to combat-related dreams while others lacked dream recall (consistent with TSD).4–6 In general, patients with RBD do not have comorbid posttraumatic stress disorder (PTSD) confounding their presentation. They may have comorbid obstructive sleep apnea (like the case), however “pseudo-RBD” in the setting of sleep apnea,7 does not account for REM sleep without atonia (RWA). The authors comment that this patient meets the diagnosis of RBD based on the International Classification of Sleep Disorders, Third Edition.8 This is debatable, “the disturbance is not better explained by another sleep disorder, mental disorder, medication, or substance use.”TSD nightmares occur in both REM and NREM sleep, which contrasts with RBD. TSD polysomnography findings are notable for autonomic hyper-arousal (tachycardia, tachypnea and diaphoresis),4,6 unrelated to sleep-disordered breathing events, and which are not found in RBD. Many veterans from recent conflicts have engaged in nighttime operations due to technologies (night-vision) not utilized in prior wars. This may explain the burden of insomnia and nighttime hypervigi-lance. Assessing TSD as a unique and distinct disorder in its own right is reasonable given that the concurrent disturbances (DNB, DEB, nightmares, insomnia) feed off and perpetuate one another. There may be underlying neurophysiologic mechanisms whereby insomnia propagates further nightmares and DNB/DEB.4,6 Although TSD appears to emerge from a traumatic past event (war-related combat), these patients may not have daytime symptoms of PTSD. Patients with PTSD often have nightmares; however, nightmare disorder alone does not include RWA and DEB.9,10A significant issue for improving knowledge on this topic is heterogeneity in scoring RWA. A number of electromyography (EMG) montages exist for the evaluation of RWA. The standard recommended EMG montage from The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications (AASM Scoring Manual) uses a three-electrode placement for chin tone and a single electrode on the anterior tibialis muscle in each lower limb. Four-limb EMG is considered optional and can utilize either flexor digitorum superficialis or extensor digitorum communis in upper limbs.11 The Mayo group (Feemster et al.1) use the same montage as described by the AASM Scoring Manual, submentalis and anterior tibialis, and do not not require any upper limb EMG.12–14 In contrast, the SINBAR group's montage (Sleep Innsbruck Barcelona) does require upper limb leads (flexor digitorum superficialis) and also utilizes a limb lead different from that recommended by the AASM Scoring Manual: extensor digitorum brevis.15–17 The initial TSD case series used “any” EMG activity index on mentalis EMG alone and found a broad range from 13.7% to 37.6% of “any” EMG activity in mentalis muscle EMG per 3-second mini-epoch as a percentage of total REM sleep.5 The case published in this issue of the Journal of Clinical Sleep Medicine by Feemster et al.1 uses the methods described by the Mayo group. Because they use the standard EMG montage recommended by the AASM Scoring Manual (mentalis and anterior tibialis) these criteria may be more applicable for evaluating current populations with TSD, including observational cohorts that have already undergone polysomnography.This report does have some gaps, that provide a more realistic perspective and add to the educational value. The lack of information about alcohol intake (and tobacco) is glaring. The patient has a pattern of RWA more consistent with anti-depressant use, noted by the authors, and it is not clear how these therapies affected his condition. The patient tried prazosin up to 4 mg, without benefit; however, doses in excess of 10 mg may be needed, so it is not clear why the dose was not increased (ie, orthostatic symptoms).18 The patient also tried melatonin, presumably for RBD; however, the dose of 3 mg may also have been too low (doses exceeding 10 mg have been studied).2,3,19 The patient reportedly used continuous positive airway pressure, but objective data on efficacy and adherence are not listed. Sleep deprivation is common among service members with nearly two-thirds sleeping less than 6 hours per night.20 Actigraphy may be valuable to assess the relationship between habitual sleep deprivation and RWA in TSD.The impact of DNB and combative DEB on veterans can be devastating. Veterans with PTSD and poor sleep have an increased risk of suicide. Combative and disruptive behaviors that invade the bedroom risk alienating the patient from their support network (intimacy, spouse, bed partner, household). Sleep medicine as a specialty tends to focus more on sleep-disordered breathing, which can limit the depth of our care for these patients, who are refractory to management of each of their individual sleep problems. Recognition of TSD as a distinct diagnosis may help to provide more holistic care to veterans with sleep disorders.DISCLOSURE STATEMENTThe authors report no conflicts of interest.CITATIONRizzo M, Robertson B, Collen JF. Distinct disorder? Or mash up of several? J Clin Sleep Med. 2019;15(2):181–182.REFERENCES1 Feemster JC, Smith KL, McCarter SJ, St. Louis EKTrauma-associated sleep disorder: a posttraumatic stress/REM sleep behavior disorder mash-up?J Clin Sleep Med2019152345349 LinkGoogle Scholar2 Porter VR, Avidan AYClinical overview of REM sleep behavior disorderSemin Neurol2017374461470 CrossrefGoogle Scholar3 Rodriguez CL, Jaimchariyatam N, Budur KRapid eye movement sleep behavior disorder: a review of the literature and update on current conceptsChest20171523650662 CrossrefGoogle Scholar4 Mysliwiec V, Brock MS, Creamer JL, O'Reilly BM, Germain A, Roth BJTrauma associated sleep disorder: a parasomnia induced by traumaSleep Med Rev20183794104 CrossrefGoogle Scholar5 Mysliwiec V, O'Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJTrauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivorsJ Clin Sleep Med2014101011431148 LinkGoogle Scholar6 Rachakonda TD, Balba NM, Lim MMTrauma-associated sleep disturbances: a distinct sleep disorder?Curr Sleep Med Rep201842143148 CrossrefGoogle Scholar7 Iranzo A, Santamaria JSevere obstructive sleep apnea/hypopnea mimicking REM sleep behavior disorderSleep2005282203206 CrossrefGoogle Scholar8 American Academy of Sleep MedicineInternational Classification of Sleep Disorders20143rd edDarien, ILAmerican Academy of Sleep Medicine Google Scholar9 Husain AM, Miller PP, Carwile STREM sleep behavior disorder: potential relationship to post-traumatic stress disorderJ Clin Neurophysiol2001182148157 CrossrefGoogle Scholar10 Wallace DM, Shafazand S, Ramos AR, et al.Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory studySleep Med2011129850859 CrossrefGoogle Scholar11 Berry RB, Brooks R, Gamaldo CE, et al.for the American Academy of Sleep MedicineThe AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications2012Darien, ILAmerican Academy of Sleep MedicineVersion 2.0 Google Scholar12 McCarter SJ, St Louis EK, Duwell EJ, et al.Diagnostic thresholds for quantitative REM sleep phasic burst duration, phasic and tonic muscle activity, and REM atonia index in REM sleep behavior disorder with and without comorbid obstructive sleep apneaSleep2014371016491662 CrossrefGoogle Scholar13 McCarter SJ, St Louis EK, Sandness DJ, et al.Antidepressants increase REM sleep muscle tone in patients with and without REM sleep behavior disorderSleep2015386907917 Google Scholar14 McCarter SJ, St Louis EK, Sandness DJ, et al.Diagnostic REM sleep muscle activity thresholds in patients with idiopathic REM sleep behavior disorder with and without obstructive sleep apneaSleep Med2017332329 CrossrefGoogle Scholar15 Frauscher B, Ehrmann L, Hogl BDefining muscle activities for assessment of rapid eye movement sleep behavior disorder: from a qualitative to a quantitative diagnostic levelSleep Med2013148729733 CrossrefGoogle Scholar16 Frauscher B, Iranzo A, Gaig C, et al.Normative EMG values during REM sleep for the diagnosis of REM sleep behavior disorderSleep2012356835847 CrossrefGoogle Scholar17 Frauscher B, Iranzo A, Hogl B, et al.Quantification of electromyographic activity during REM sleep in multiple muscles in REM sleep behavior disorderSleep2008315724731 CrossrefGoogle Scholar18 Aurora RN, Zak RS, Auerbach SH, et al.Best practice guide for the treatment of nightmare disorder in adultsJ Clin Sleep Med201064389401 LinkGoogle Scholar19 Aurora RN, Zak RS, Maganti RK, et al.Best practice guide for the treatment of REM sleep behavior disorder (RBD)J Clin Sleep Med2010618595 LinkGoogle Scholar20 Mysliwiec V, McGraw L, Pierce R, Smith P, Trapp B, Roth BJSleep disorders and associated medical comorbidities in active duty military personnelSleep2013362167 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited bySleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported casesSchenck C, Cramer Bornemann M, Kaplish N and Eiser A Journal of Clinical Sleep Medicine, Vol. 17, No. 4, (803-810), Online publication date: 1-Apr-2021. Trauma Associated Sleep Disorder: Clinical Developments 5 Years After DiscoveryBrock M, Powell T, Creamer J, Moore B and Mysliwiec V Current Psychiatry Reports, 10.1007/s11920-019-1066-4, Vol. 21, No. 9, Online publication date: 1-Sep-2019. Volume 15 • Issue 02 • February 15, 2019ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationFebruary 4, 2019Submitted in final revised formFebruary 4, 2019Accepted for publicationFebruary 4, 2019Published onlineFebruary 15, 2019 Information© 2019 American Academy of Sleep MedicinePDF download" @default.
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