Parasomnia Overlap Disorder Research Articles

Update on Rapid-Eye-Movement Sleep Behavior Disorder (RBD): Focus on Its Strong Association with α-Synucleinopathies

REM sleep behavior disorder (RBD) is a parasomnia in which the customary generalized skeletal muscle atonia of REM sleep, “REM-atonia”, is compromised, allowing for the injurious acting-out of dreams. RBD can be idiopathic/isolated (iRBD) or symptomatic of neurological disorders, and can be triggered by most antidepressants. RBD mainly affects middle-aged and older adults, and is strongly linked with alpha-synucleinopathies, mainly Parkinson’s disease (PD) and dementia with Lewy bodies (DLB). iRBD is now known to be the earliest and strongest predictor of future PD/DLB, which has stimulated a major international clinical and basic science research effort to enroll iRBD patients for upcoming neuroprotective/disease-modifying trials and to identify the most promising interventions to test in these cohorts. This review will provide the latest pertinent information on the rapidly expanding field of RBD. The methods included a PubMed literature search that included PubCrawlers, which utilizes the NCBI (National Center for Biotechnology Information) E-utils tools for publication retrieval, using the keywords “REM sleep behavior disorder” and “RBD”. The results yielded the latest updates on iRBD as prodromal PD/DLB, with the most promising biomarkers for phenoconversion provided, along with a presentation of three clinical research consortiums that are systematically gathering patients in preparation for enrollment in upcoming clinical trials: (i) The International RBD Study Group; (ii) The North American Prodromal Synucleinopathy (NAPS and NAPS2) Consortium; and (iii) The FARPRESTO Italian multicenter RBD research consortium. In addition, updates on the Parasomnia Overlap Disorder (RBD + NREM parasomnia) and on narcolepsy-RBD are provided, along with new epidemiologic data, the latest RBD management guidelines, and updates on animal models of RBD. Emerging areas of critical RBD research are also highlighted. In conclusion, RBD is a notable example of clinical and translational neuroscience research.

REM sleep behavior disorder as a complex condition with heterogeneous underlying disorders: clinical management and prognostic implications [Commentary

To review how REM sleep behavior disorder (RBD) is a complex condition with heterogeneous underlying disorders; and to review clinical management issues and prognostic implications. PubMed literature search and contents from the first textbook of RBD (2018). RBD, with its core objective diagnostic feature of REM-without-atonia (RWA) documented by video-polysomnography, can emerge during the entire lifespan, and can initially present as an idiopathic (isolated) condition (iRBD), or can be associated with a broad spectrum of disorders including narcolepsy, alpha-synuclein neurodegenerative disorders (esp. Parkinson's disease [PD] and dementia with Lewy bodies [DLB]), paraneoplastic neurological syndromes and autoimmune disorders, CNS lesions (e.g., tumors, stroke), other neurological disorders, psychiatric disorders (PTSD, mood disorders), can be triggered by antidepressant/other medications, and can emerge acutely with drug withdrawal states, toxic-metabolic states, etc. Important clinical issues include the evolution of iRBD to PD/DLB in most middle-aged and older patients over a period of years to several decades, with compelling prognostic implications, along with the hope of enrolling these patients in future clinical trials to test promising disease-modifying therapies. Also, the strong link of RBD with narcolepsy needs further investigation. Parasomnia overlap disorder involves RBD and NREM parasomnias that can be idiopathic or linked with a broad range of clinical disorders. RBD usually responds to therapy consisting mainly of melatonin and/or clonazepam at bedtime. The complex associations of RBD with OSA are being increasingly investigated. RBD mimics with dream-enactment need to be recognized for diagnostic and management purposes, including severe OSA, NREM parasomnias, PLMD, nocturnal seizures, and other conditions. The clinical and research RBD fields span across the disciplines of neurology, pulmonary, psychiatry, psychology, and pediatric sleep medicine, along with physical medicine and rehabilitation medicine, other allied disciplines, and the basic and clinical neurosciences.

817 A Case of Parasomnia Overlap Disorder in a Patient on Lithium

Abstract Introduction The literature contains few case reports of parasomnia overlap disorder. There are also few case reports of lithium inducing sleep walking behaviors. Here we seek to present a case of a patient with multiple parasomnias, is taking a number of psychotropic medications for bipolar I disorder, and is on PAP for OSA. Report of case(s) The patient is a 43 year old male with a history of occasional mild sleep walking since childhood that remitted approximately 10 years prior to the onset of treatment, but returned when he traveled out of area for a family gathering approximately one year prior to presentation in the sleep clinic. He reported not only the return of sleepwalking, on a nightly basis, as well as more severe symptoms (including enuresis and violence/aggression). He also reported several episodes of dream enactment, as well as a history of sleep paralysis and vivid hypnogogic hallucinations, both of which had been improved in the last year. He denied any history of cataplexy. He did complain of symptoms of significant RLS symptoms. He was partially compliant with CPAP for obstructive sleep apnea, though the sleep behaviors continued regardless of CPAP usage. His psychiatrist had started him on clonazepam (titrated to 2mg/night) prior to his intake in the sleep clinic, but with minimal benefit. His other medications included propranolol 40mg BID, lithium 900mg/1200mg, oxcarbazepine 600mg bid, lamictal 225mg bid, lurasidone 80mg qday, and benztropine 2mg bid. Attended polysomnography demonstrated five episodes of sleep behaviors, as well as loss of atonia during REM, and severe obstructive sleep apnea (AHI of 61.2). Conclusion The patients various parasomnias could be due to the side effects of his psychotropic medications, represent a genetic or structural defect that is causing the various parasomnias, or be due to or worsened by his undertreated obstructive sleep apneas. His workup and treatment is still ongoing, but he has continued on clonazepam 2mg but taken 2 hours earlier, and has started a new APAP. Because of the severity of his bipolar disorder (including severe suicidal ideation), he is not a candidate to tapering the lithium or to taking serotonergic antidepressants. Support (if any):

Case Report: Parasomnia Overlap Disorder Induced by Obstructive Sleep Hypopnea Apnea Syndrome: A Case Report and Literature Review.

Obstructive sleep apnea hypopnea syndrome (OSAHS) and parasomnia overlap disorder (POD) are types of sleep disorders. When the symptoms of both conditions coexist, the POD symptoms are most likely caused by OSAHS. In these cases, the symptoms of POD will be relieved when OSAHS is effectively treated. We refer to these cases as symptomatic POD (related to OSAHS), which differs in pathophysiology, complications, and treatment from idiopathic POD. It is important to note that the treatment for idiopathic POD may aggravate the symptoms of OSAHS. In this case, we used video polysomnography (v-PSG) on a POD patient with suspected OSAHS to distinguish idiopathic POD from symptomatic POD, to inform the appropriate treatment course. The video results and clinical features lead us to diagnose symptomatic POD, and we treated the patient with auto-set continuous positive airway pressure to address their OSAHS. This course of treatment resolved all POD-related symptoms. Here, we discuss this case and review the relevant literature. This report highlights the importance of the use of v-PSG in the clinical diagnosis, differential diagnosis, and subsequent treatment of POD.

0815 Violent Parasomnias In Patients With REM Without Atonia. Parasomnia Overlap Disorder Vs Pure Rem Behavior Disorder

Abstract Introduction REM-Behavior-Disorder (RBD) patients are known for parasomnias causing self-injury. On literature review, harm to others using a weapon is not well established. Some opinions state REM-parasomnias do not consist of elaborate actions, such firing a gun. This has significant ramifications in forensic medicine when RBD is a consideration. We reviewed our RBD patients to identify instances in which a gun was used during a parasomnic event to characterize clinical features associated with such behaviors. Methods We reviewed over 57 RBD cases from Texas, between 2014-2017 seeking parasomnias in which a gun was used. Results We found two patients in whom a gun was used during a parasomnia, representing < 3.5% of cases. Case-1: 59 y/o F with a 5 year hx of parasomnias of screaming, thrashing, roaming and one instance in which she pointed an unloaded gun at her husband saying she was going to kill him. She had no recollection of the event. NPSG demonstrated REM without atonia, mild OSA (1a AHI of 11/hr) and frequent PLMS. Case-2 presented to a sleep center in 1989 at 33 y/o with 3 year Hx of EDS, found to have mild OSA unresponsive to PAP Tx, then diagnosed with narcolepsy. He later developed cataplexy and progressed to developing parasomnias 15 years later. He demonstrated REM without atonia on a CPAP re-titration NPSG study done in part for his parasomnias, 20 years after original assessment. PLMS were also demonstrated. His parasomnias consisted of yelling, screaming, roaming and one time he woke up finding bullet holes in his closet door with no recollection of firing his gun, which he kept near his bed. Conclusion RBD is associated with a wide range of parasomnic events, almost never captured in the laboratory. These patients had clear RBD findings. It is possible they had Parasomnia Overlap Disorder in which Non-REM parasomnias occur in patients with RBD. PLMS and or OSA may contribute by fragmenting sleep. Nonetheless, it is clear that RBD patients can have elaborate parasomnias involving the use of weapons. More attention of this is noteworthy since reports are lacking in the literature. Support N/A

Parasomnia overlap disorder with adolescent-onset presumed REM sleep behavior disorder converting to Parkinson's disease after 48 years

BackgroundIt is now recognized that the vast majority of individuals with typical RBD will develop a synucleinopathy; usually 11–16 years after symptom onset. Parasomnia Overlap Disorder (POD) with adolescent-onset dream enactment behavior with phenoconversion to neurodegenerative disease after a long latency has not been previously described. PatientWe present a case of a 65-year-old man with presumptive POD who had co-morbid childhood onset sleep walking and adolescent-onset dream enactment behavior beginning at age 17, with subsequent evolution to an increasingly troublesome REM sleep behavior disorder (RBD) at age 64 with Parkinson's Disease (PD) developing a year later. ResultsPolysomnography performed at age 64 was consistent with a diagnosis of RBD. Dream enactment behavior preceded PD diagnosis by at least 48 years. Our case represents the youngest reported RBD case who developed PD. ConclusionsWe report the first case of adolescent onset, presumed RBD in the context of presumptive POD developing neurodegenerative disease. Adolescent-onset RBD may have similar prognostic implications as typical RBD, where future phenoconversion to a synucleinopathy is expected.

Video polysomnographic findings in non-rapid eye movement parasomnia.

Although video polysomnography (vPSG) is not routinely recommended for the evaluation of typical cases of non‐rapid eye movement (NREM) parasomnias, it can aid diagnosis of unusual cases, other sleep disorders and complicated cases with REM behaviour disorder (RBD), and in differentiating parasomnias from epilepsy. In this study, we aimed to assess vPSG findings in consecutive patients with a clinical diagnosis of NREM‐parasomnia covering the whole phenotypic spectrum. Five hundred and twelve patients with a final diagnosis of NREM parasomnia who had undergone vPSG were retrospectively identified. vPSGs were analysed for features of NREM parasomnia and for the presence of other sleep disorders. Two hundred and six (40.0%) patients were clinically diagnosed with sleepwalking, 72 (14.1%) with sleep terrors, 39 (7.6%) with confusional arousals, 15 (2.9%) with sexsomnia, seven (1.4%) with sleep‐related eating disorder, 122 (23.8%) with mixed phenotype, and 51 (10.0%) with parasomnia overlap disorder (POD). The vPSG supported the diagnosis of NREM parasomnia in 64.4% of the patients and of POD in 98%. In 28.9% of the patients, obstructive sleep apnea (OSA) or/and periodic limb movements during sleep (PLMS) were identified, most commonly in older, male, sleepy and obese patients. vPSG has a high diagnostic yield in patients with NREM parasomnia and should be routinely performed when there is diagnostic doubt, or in patients where there is a suspicion of OSA and PLMS.

NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients

BackgroundNon-REM parasomnias are not uncommon conditions in the general population. Current treatment options are based on small case series and reports. In this study, we aimed to present the clinical experience from a large cohort of patients. PatientsFive hundred and twelve patients with Non-REM parasomnia or parasomnia overlap disorder (POD), who had undergone a video polysomnography and were exposed to treatment, were retrospectively identified. Treatment outcome was assessed based on patients’ reports, and treatment approach on a locally accepted hierarchy of interventions. ResultsForty percent of patients were diagnosed with sleepwalking, 23.8% with mixed-phenotype and 10% with POD. Ultimately, 97.2% reported adequate control of their symptoms. Moreover, 60.1% were treated with pharmacotherapy and 32.0% without, consistent across all phenotypes (p = 0.09). Benzodiazepines were the most common drugs prescribed (47.1%, p < 0.05). In the end, 37.7% of our patients were receiving a benzodiazepine as part of their successful treatment, 11.7% an antidepressant, 9.2% a z-drug, and 10.7% melatonin. Finally, 13.2%, 12.1%, and 5.8% of our patients reported good control of their symptoms with sleep hygiene, management of sleep-disordered breathing, and psychological interventions (cognitive behavioral therapy [CBT] or mindfulness-based stress reduction [MBSR]), as monotherapy, respectively. ConclusionThe treatment approach to effective treatment of the patients with Non-REM parasomnias or POD offering first sleep hygiene advice, next treatment of concurrent sleep disorders and management of other priming factors like stress and anxiety, and lastly pharmacotherapy for Non-REM parasomnia is supported by our results. Non pharmacological interventions were effective in one third of our patients, and CBT/MBSR and melatonin appeared promising new treatments.

Mirtazapine Induced Parasomnia Overlap Disorder

Mirtazapine Induced Parasomnia Overlap Disorder

Parasomnia overlap disorder, Parkinson\u2019s disease and subthalamic deep brain stimulation: three case reports

BackgroundParasomnia overlap disorder (POD) is a distinct parasomnia and characterized by concomitant manifestation of rapid-eye-movement (REM)- and non-REM (NREM)-parasomnias. Although not uncommon among patients with Parkinson’s disease, POD is often under-investigated.Case presentationThis is the first report of patients with PD and features of POD that underwent deep brain stimulation. Our patients exhibited different outcomes of POD features after subthalamic deep brain stimulation.ConclusionsWe expect that the reporting of these first patients will open the discussion about the need for more detailed and broad-spectrum assessments regarding parasomnias in PD patients that undergo deep brain stimulation. The implications of our observations are both clinical and neurobiological.

Parasomnia overlap disorder caused by paroxetine

We describe a case of parasomnia overlap disorder (POD) caused by paroxetine. Some reports have associated antidepressants such as selective serotonin reuptake inhibitors (SSRI) with rapid eye movement sleep behavior disorder. However, to the best of our knowledge, there have been no reports of POD caused by paroxetine. We diagnosed POD in a patient taking paroxetine using video-polysomnography (v-PSG) and then confirmed the improvement of POD symptoms by v-PSG after discontinuing the drug.

Parasomnia Overlap Disorder with Sexual Behaviors during Sleep in a Patient with Obstructive Sleep Apnea

Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of NREM sleep parasomnias. Sexsomnia has been reported as part of parasomnia overlap disorder (POD) in two other patients. We present the case of a 42-year-old male patient with video-polysomnography (vPSG) documented POD. The patient had sleepwalking, sleep-related eating, confusional arousals, sexsomnia, sleeptalking, and REM sleep behavior disorder (RBD). Confusional arousals and RBD were documented during the vPSG. This case had the added complexity of obstructive sleep apnea (OSA) playing a role in sleepwalking and sleep related eating, with good response to nasal continuous positive airway pressure (nCPAP). The sexsomnia did not respond to nCPAP but responded substantially to bedtime clonazepam therapy.

Video-polysomnographic documentation of non-rapid eye movement sleep parasomnia followed by rapid eye movement sleep behavior disorder: a parasomnia overlap disorder?

Video-polysomnographic documentation of non-rapid eye movement sleep parasomnia followed by rapid eye movement sleep behavior disorder: a parasomnia overlap disorder?

Parasomnias and isolated sleep symptoms in Parkinson's disease: A questionnaire study on 661 patients

BackgroundSleep disorders are among the most common non-motor symptoms in Parkinson's disease. MethodThe prevalence of parasomnias and their association with other symptoms were studied in a questionnaire study among 1447 randomly selected Parkinson patients, aged 43 to 89years. The response rate was 59.0% and of these 77% had answered to all questions that were used in the analyses (N=661). ResultsThe prevalence of REM sleep behavior disorder (RBD) evaluated by the RBDSQ ≥6 was 39.0%. The occurrences of other parasomnias (≥1/week) in patients with PD were: nightmares 17.2%, night terrors 3.9%, sleepwalking 1.8%, enuresis 21.0%, and hallucinations 15.3%. Occurrences (≥1/week) of the isolated sleep symptoms were: nocturnal sweating 28.8%, bruxism 4.7%, and sleep talking 21.7%. Association of RBD with sleepwalking (parasomnia overlap disorder) was found in 1.7% of all PD patients. Adjusted logistic regression analysis showed that weekly nightmares (OR 12.5; 95% CI 5.3 to 29.7), hallucinations (OR 5.1; 2.1 to 12.4), sleep talking (OR 11.6; 5.9 to 22.8), male gender (OR 1.9; 1.1 to 3.1), and restless legs syndrome (OR 4.7; 1.7 to 13.2) associated with the presence of RBD. ConclusionParkinson patients with RBD have often also other parasomnias and/or isolated sleep symptoms.

A Case of Successful Use of Hypnosis in the Treatment of Parasomnia Overlap Disorder

A young male patient was successfully treated for parasomnia overlap disorder (POD) using hypnosis. In 2006, this 16-year-old patient underwent a clinical evaluation for episodes of sleep talking, sleepwalking, and dream enactment. This initial assessment was followed by polysomnographic evaluation, a brain MRI, and three sessions of treatment using hypnosis. From the beginning, until the last contact in December 2011, benefits from the hypnotic suggestions were noted and documented.

Parasomnias in Parkinson’s disease

Sleep disturbances in patients with Parkinson’s disease (PD) are common. PD patients complain of insomnia and fragmented nocturnal sleep. Occurrence of different parasomnias have been largely overlooked and we have not found previous systematic studies on parasomnias. We studied occurrence of parasomnias and their association with other symptoms in PD patients. A structured questionnaire was sent to 1447 patients who were randomly selected from the registry of the Finnish Parkinson Association. The response rate of 59,0%. The questionnaire covered demographic items, and it included questions derived from the Basic Nordic Sleep Questionnaire and items about different parasomnias. The most common parasomnias occurring at least weekly were sleep talking (21.4%), nightmares (17.0%), hallucinations (11.2%), and bruxism (4.6%). At least monthly occurring parasomnias included night terrors (8.3%) and sleep walking (3.1%). Among other sleep related phenomena nocturnal sweating occurred weekly in 28.8%, nocturia (>3 times nightly) in 15.8% and bedwetting monthly in 28.5%. The prevalence of REM sleep behavior disorder (RBD) evaluated by the Marburg RBDSQ ⩾6 was 36.7%. Association of RBD with NREMsleep parasomnia (parasomnia overlap disorder) was found in 18.2% of all participants. Adjusted logistic regression analysis showed weekly nightmares (OR 7.1; 95% CI 3.2–15.5) and weekly sleep talking (OR 7.1; 95% CI 3.8–13.4) predicting the presence of RBD. In Parkinson’s disease the prevalence of RBD is overrepresented and it is often associated with other parasomnias. More attention should be paid to the detection and treatment of parasomnias. This study was supported by the Finnish Parkinson Foundation.

Parasomnia overlap disorder: a distinct pathophysiologic entity or a variant of rapid eye movement sleep behavior disorder? A case series

BackgroundParasomnia overlap disorder (POD) currently is classified by the International Classification of Sleep Disorders, Second Edition (ICSD-2) as a variant of rapid eye movement (REM) sleep behavior disorder (RBD), and therefore its diagnosis also implies counseling the patients on the increased risk for developing neurodegenerative disorders. POD pathophysiology is not clear to date. MethodsThe authors report 5 cases of POD, review the literature, and analyze previously published cases of POD. ResultsIn all 5 reported cases sleep-related activity was clearly demonstrated, though the RBD component was mild or incidentally discovered. None of the patients had Parkinsonian clinical features. Based on ICSD-2 criteria, there are 139 more POD cases reported in the literature and 69. 2% are idiopathic. The POD patients had an earlier age of onset than the patients with RBD. The RBD component was milder than the disorder of arousal (DOA) in most cases. Recently an updated classification was published, which included new categories of POD. The features mentioned above and the revised classification suggests that POD is not just a subtype of RBD. ConclusionsWe propose that POD is a distinct pathophysiologic parasomnia. Further research to identify the underlying mechanism is needed. Proper counseling is necessary for patients presenting with POD at a young age of onset.

Spectrum of rapid eye movement sleep behavior disorder (overlap between rapid eye movement sleep behavior disorder and other parasomnias)

Parasomnia Overlap Disorder (POD) was described and named in 1997 with a series of 33 cases of rapid eye movement (REM) sleep behavior disorder (RBD) combined with a disorder of arousal from non-rapid eye movement (NREM) sleep (sleepwalking, sleep terrors) that emerged idiopathically or symptomatically with neurological and other disorders. POD is a subtype of RBD in the International Classification of Sleep Disorders Diagnostic and Coding Manual, second edition (ICSD-2). An updated classification of POD also includes subclinical RBD-NREM parasomnia, RBD-sleep-related eating disorder, RBD-sexsomnia, RBD-rhythmic movement disorder, and status dissociatus (SD), which is another subtype of RBD in the ICSD-2. Similar to POD, a core feature of SD is sleep motor-behavioral dyscontrol, with release of dream-related behaviors suggestive of RBD, but with nearly continuous ambiguous polygraphic sleep precluding the identification of NREM/REM sleep states. SD exemplifies extreme state dissociation. SD is always a symptomatic disorder, and is causally associated with a broad range of neurologic disorders, often with thalamic, limbic, striatal, and pontine involvement. The parasomnia behaviors associated with POD and SD – typical RBD behaviors – can often be controlled with bedtime clonazepam therapy, including the abnormal dreaming.

Rapid eye movement sleep behavior disorder in adults younger than 50 years of age

Rapid eye movement (REM) sleep behavior disorder (RBD) occurring prior to age 50 is termed early-onset RBD. Early-onset RBD comprises a substantial minority of cases, and demonstrates the differences in demographics, comorbidities, and clinical considerations from previously described typical RBD with onset >50years. The world literature on RBD is reviewed with specific focus on features that distinguish early-onset RBD, including more gender parity, increased proportion of idiopathic cases, increased proportion of cases associated with narcolepsy, parasomnia overlap disorder, antidepressants, and possibly autoimmune disorders, and clinical presentation.

Sexual behaviors during sleep associated with polysomnographically confirmed parasomnia overlap disorder

Parasomnia overlap disorder (POD) refers to a sleep disorder characterized by the association of REM sleep behavior disorder (RBD) with NREM sleep parasomnia in the same patient. Sexual behaviors during sleep (SBS) can include most wakeful sexual activities and are classified in the ICSD-2 as a variant of confusional arousals and sleepwalking, both NREM parasomnias. A case of SBS associated with sleepwalking and possible RBD has been previously described, but it was not confirmed by polysomnography (PSG). We report two patients with SBS associated with POD documented by PSG. In one patient (60-year-old female) SBS was video-polysomnographically demonstrated: a few minute episode of masturbation occurring during slow-wave sleep (SWS) and preceded by hypersynchronous delta pattern. During the episode, the EEG pattern showed the persistence of delta rhythms with increasing alpha activity. When awoken by technicians, the patient was not aware of her sexual behavior and did not report any dream. The other patient, a 41-year-old male with a history of sleepwalking and RBD, was legally charged with repeatedly sexually fondling a young girl during the night. The POD was documented by PSG. The parasomnia defense, including sleepsex, was accepted by the Court and the patient was acquitted. This is an unprecedented report of SBS in patients with PSG-confirmed POD and of SBS documented during video-PSG.