Rem Behavior Disorder

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The second sleep disorder that may mimic convulsive epileptic seizures is REM behavior disorder (RBD) (58,59). RBD is characterized by recurrent episodes of vigorous motor activity occurring during REM sleep, movements that often awaken the patient or spouse. The primary presenting complaints are interrupted sleep or injuries during sleep. RBD is more common in older adults, usually beginning after the age of 50. It is two to five times more common in men than in women. It is possible that rare episodes such as these occur in a large percentage of the population. I am familiar with people who have had rare such episodes throughout their adult life.

The movements seen in RBD vary from minor movements of an individual extremity to complex behavior, such as laughing, shouting, or throwing one's self from the bed (58,59). Commonly, the movements are related to a dream the patient is having during REM sleep, and the patient is often able to describe the dream. The frequency of episodes varies from many per night to one every few weeks. If more than one episode occurs in a night, the episodes tend to occur at least 90 min apart, most likely during separate REM sleep cycles.

The exact mechanism of RBD is not known. During episodes of REM sleep in normal subjects, there is complete atonia. It is thought that RBD may be secondary to impairment of the normal inhibition of muscle activity during REM sleep (59). Consistent with this hypothesis, patients with RBD have been shown to have muscle activity present even during asymptomatic episodes of REM sleep. It is hypothesized that when the muscle activity during REM sleep is especially prominent, a clinical episode results.

RBD has been associated with brainstem lesions caused by vascular disease, trauma, and multiple sclerosis (59). In addition, RBD is common in patients with Parkinson's disease (60-62), and it has been reported in patients with narcolepsy (63). Schenk et al. followed patients who were diagnosed with RBD and found that 38% developed Parkinson's disease at an interval of 3.7 ± 1.4 years (60).

Treatment for RBD with clonazepam (0-5-2.0 mg.h.s) is successful in 80 to 90% of patients (59). Clonazepam does not completely suppress the motor activity during REM sleep, but it usually eliminates the vigorous, coordinated movements characteristic of RBD episodes. This allows the patient to sleep without disruption. If clonazepam is unsuccessful or causes drowsiness, tricyclics, levodopa/carbidopa, clonidine, or carbamazepine may be tried. Donepezil, an acetyl-cholinecterase inhibitor, has been effective in some patients (64).

1. Dorland's Pocket Medical Dictionary, 26th Ed. Philadelphia: W.B. Saunders, 2001.

2. Gastaut H, Broughton R. Epileptic Seizures: Clinical and Electro-graphic Features, Diagnosis and Treatment, Springfield, 1ll.: Charles C Thomas Publisher, 1972;26-37.

3. Zifkin B, Dravet C, Generalized convulsive seizures. In: Engel J, Pedley TA eds. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven, 1998;567-77.

4. Kotagal P, Lüders HO. Simple motor seizures. In: Engel J, Pedley TA eds. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven, 1998;525-32.

5. Wyllie E, Lüders HO, Morris HH, Lesser RP, et al. The lateralizing significance of versive head and eye movements during epileptic seizures. Neurology 1986;36:606-11.

6. Janz D, Durner M, Juvenile myoclonic epilepsy. In: Engel J, Ped-ley TA eds. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven, 1998;2389-2400.

7. Hamer HM, Lüders HO, Rosenow F, Najm I. Focal clonus elicited by electrical stimulation of the motor cortex in humans. Epilepsy Res 2002;51:155-66.

8. Verma S, Ahmed S, Gudapati S, King DW, et al. Arrhythmias in neurofibromatosis. Cardiology 2001;95:167-69.

9. Bleck TP. Syncope. In: Engel J, Pedley TA eds. Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven, 1998;2649-59.

10. Linzer M, Yang EH, Estes NAM 3rd, Wang P, et al. Diagnosing syncope: Part 1. Value of history, physical examination, and elec-trocardiography. Ann Intern Med 1997;126:989-96.

11. Schnipper JL, Kapoor WN. Diagnostic evaluation and management of patients with syncope. Med Clin North Amer 2001;85:423-56.

12. Lempert T. Seizures and syncopes. In: Schmidt D, Schachter SC eds. Epilepsy: Problem Solving in Clinical Practice. London: Martin Dunitz Ltd., 2000;19-28.

13. Benke T, Hochleitner M, Bauer G. Aura phenomena during syncope. Eur Neurol 1997;37:28-32.

14. Lempert T, von Brevern M. The eye movements of syncope. Neurology 1996;46:1086-88.

15. Duvoisin RC. Convulsive syncope induced by the Weber maneuver. Arch Neurol 1962;7:219-26.

16. Lin JTY, Ziegler DK, Lai CW, Bayer W. Convulsive syncope in blood donors. Ann Neurol 1982;11:525-28.

17. Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994;36:233-37.

18. Linzer M, Yang EH, Estes NA 3rd, Wang P, et al. Diagnosing syncope: Part 2. Unexplained syncope. Ann Intern Med 1997;127:76-86.

19. Wright RA, Kaufmann HC, Perera R, Opfer-Fehrking TL. A double-blind, doseresponse study of midodrine in neurogenic orthostatic hypotension. Neurology 1998;51:120-24.

20. Gulick TA, Spinks IP, King DW. Pseudoseizures: ictal phenomena. Neurology 1982;32:24-30.

21. Gates JR, Ramani V, Whalen S, Loewenson R. Ictal characteristics of pseudoseizures. Arch Neurol 1985;42:1183-87.

22. King DW, Gallagher BB, Murro AM, Campbell LR. Convulsive non-epileptic seizures. In: Rowan AJ, Gates JR eds. Non-Epileptic Seizures. Boston: Butterworth-Heinemann, 1993;31-37.

23. King DW, Gallagher BB, Murvin AJ, Smith DB, et al. Pseudo-seizures: diagnostic evaluation. Neurology 1982;32:18-23.

24. Williamson PD, Spencer DD, Spencer SS, Novelly RA, et al. Complex partial seizures of frontal lo be origin. Ann Neurol 1985;18:497-504.

25. Geyer JD, Payne TA, Drury I. The value of pelvic thrusting in the diagnosis of seizures and pseudoseizures. Neurology 2000;54:227-29.

26. Rowan AJ. Diagnosis of non-epileptic seizures In: Gates JR, Rowan AJ eds. Non-Epileptic Seizures, 2nd Ed. Boston: Butterworth-Heinemann, 2000;15-30.

27. Benbadis SR, Lancman ME, King LM, Swanson SJ. Preictal pseu-dosleep: a new finding in psychogenic seizures. Neurology 1996;47:63-67.

28. Trimble MR. Serum prolactin in epilepsy and hysteria. Br Med J 1978;2:1682.

29. Yerby MS, van Belle G, Friel PN, Wilensky AJ. Serum prolactins in the diagnosis of epilepsy: sensitivity, specificity, and predictive value. Neurology 1987;37:1224-26.

30. Oribe E, Amini R, Nissenbaum E, Boal B. Serum prolactin concentrations are elevated after syncope. Neurology 1996;47:60-62.

31. Wilkus RJ, Dodrill CB. Factors affecting the outcome of MMPI and neuropsychological assessments of psychogenic and epileptic seizure patients. Epilepsia 1989;30:339-47.

32. Loring DW, Meador KJ, King DW, Herman BP. In: Gates JR, Rowan AJ eds. Non-Epileptic Seizures, 2nd Edition. Boston: Butterworth-Heinemann, 2000;159-68.

33. Cohen RJ, Suter C. Hysterical seizures: suggestion as a provocative EEG test. Ann Neurol 1982;11:391-95.

34. Ramani SV, Quesney LF, Olson D, Gumnit RJ. Diagnosis of hysterical seizures in epileptic patients. Am J Psychiatry 1980;137:705-09.

35. Ramani V. Treatment of the adult patient with non-epileptic seizures. In: Gates JR, Rowan AJ eds. Non-Epileptic Seizures, 2nd Edition. Boston: Butterworth-Heinemann, 2000;311-16.

36. Lugaresi E, Cirignotta F. Hypnogenic paroxysmal dystonia: epileptic seizure or a new syndrome: Sleep 1981;4:129-38.

37. Lee BI, Lesser RP, Pippenger CE, Morris HH, et al. Familial paroxysmal hypnogenic dystonia. Neurology 1985;35:1357-60.

38. Lugaresi E, Cirignotta F, Montagna P. Nocturnal paroxysmal dystonia. J Neurol Neurosurg Psych 1986;49:375-80.

39. Meierkord H, Fish DR, Smith SJM, Scott CA, et al. Is nocturnal paroxysmal dystonia a form of frontal lobe epilepsy? Movement Disorders 1992;7:38-42.

40. Provini F, Plazzi G, Lugaresi E. From nocturnal paroxysmal dys-tonia to nocturnal frontal lobe epilepsy, Clin Neurophys 2000;111:Suppl 2:S2-S8.

41. Provini F, Plazzi G, Tinuper P, Vandi S, et al. Nocturnal frontal lobe epilepsy: a clinical and polygraphic overview of 100 consecutive cases. Brain 1999;122:1017-31.

42. Kertesz A. Paroxysmal kinesigenic choreoathetosis. Neurology 1967;17:680-90.

43. Lance JW. Familial paroxysmal dystonic choreoathetosis and its differentiation from related syndromes. Ann Neurol 1977;2:285-93.

44. Plant GT, Williams AC, Earl CJ, Marsden CD. Familial paroxysmal dystonia induced by exercise. J Neuro Neurosurg Psych 1984;47:275-79.

45. Demirkiran M, Jankovic J. Paroxysmal dyskinesias: clinical features and classification. Ann Neuro 1995;38:571-79.

46. Pellecchia MT, Cuomo T, Striano S, Filla A, et al. Paroxysmal dystonia in Behcet's Disease. Movement Disorders 1999;14:177-78.

47. Ondo WG, Verma A. Physiological assessment of paroxysmal dystonia secondary to subacute sclerosing panencephalitis. Movement Disorders 2002;17:154-57.

48. Dominguez-Moran JA, Callejo JM, Ferdandes-Ruiz LC, Martinez-Castrillo JC. Acute paroxysmal dystonia induced by fluoxetine. Movement Disorders 2001;16:767-69.

49. Sethi KD, Lee KH, Deuskar V, Hess DC. Orthostatic paroxysmal dystonia. Movement Disorders 2002;17:841-45.

50. Coleman RM, Periodic movements in sleep (nocturnal myoclonus) and restless legs syndrome. In: Guilleminault C ed. Sleeping and Waking Disorders: Indications and Techniques. Menlo Park: Addison-Wesley, 1982;265-95.

51. Coleman RM, Pollak CP, Weitzman ED. Periodic movements in sleep (nocturnal myoclonus): relation to sleep disorders. Ann Neurol 1980;8:416-21.

52. Aldrich MS. Restless legs syndrome and periodic limb movement disorder. Sleep Medicine. New York: Oxford University Press, 1999;175-85.

53. Allen RP, Earley CJ. Restless legs syndrome: a review of clinical and pathophysiologic features. J Clin Neuro 2001;18:128-47.

54. Bucher SF, Seelos KC, Oertel WH, Reiser M, et al. Cerebral generators involved in the pathogenesis of the restless legs syndrome. Ann Neurol 1997;41:639-45.

55. Brodeur C, Montplaiser J, Godbout R, Marinier R. Treatment of restless legs syndrome and periodic movements during sleep with L-Dopa: a double-blind, controlled study. Neurology 1988;38:1845-48.

56. Ohanna N, Peled R, Rubin AHE, Zomer J, et al. Periodic leg movements in sleep: effect of clonazepam treatment. Neurology 1985;35:408-11.

57. Kaplan PW, Allen RP, Buchholz DW, Walters JK. A double-blind, placebo-controlled study of the treatment of periodic limb movements in sleep using carbidopa/levodopa and propoxyphene. Sleep 1993;16:717-23.

58. Schenck CH, Bundlie SR, Etlinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep 1986;9:293-308.

59. Aldrich MS. Parasomnias, Sleep Medicine. New York: Oxford University Press, 1999;260-87.

60. Schenck CH, Bundlie SR, Mahowald MW. Delayed emergence of a parkinsonian disorder in 38% of 29 older men initially diag nosed with idiopathic rapid eye movement sleep behavior disorder. Neurology 1996;46:388-93.

61. Rye DB, Johnston LH, Watts RL, Bliwise DL. Juvenile Parkinson's disease with REM sleep behavior disorder, sleepiness, and daytime REM onset. Neurology 1999;53:1868-70.

62. Albin RL, Koeppe RA, Chervin RD, Consens FB, et al. Decreased striatal dopaminergic innervation in REM sleep behavior disorder. Neurology 2000;55:1410-12.

63. Schenck CH, Mahowald MW. Motor dyscontrol in narcolepsy: rapid-eye-movement (REM) sleep without atonia and REM sleep behavior disorder. Ann Neurol 1992;32:3-10.

64. Ringman JM, Simmons JH. Treatment of REM sleep behavior disorder with donepezil: a report of three cases. Neurology 2000;55:870-71.

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Healthy Sleep

Healthy Sleep

A Guide to Natural Sleep Remedies. Many of us experience the occasional night of sleeplessness without any consequences. It is when the occasional night here and there becomes a pattern of several nights in arow that you are faced with a sleeping problem. Repeated loss of sleep affects all areas of your life The physical, the mental, and theemotional. Sleep deprivation can affect your overall daily performance and may even havean effecton your personality.

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