Nightmares and sleep paralysis are the principal REM sleep disorders that may be confused with epilepsy. They are both common. Ten percent to 20% of individuals will have some experience of sleep paralysis. Waking from REM sleep without abolishing the physiological REM atonia that prevents us from "acting out" our dreams may lead to a frightening experience of paralysis. Nightmares are usually easier to distinguish from epileptic seizures than night terrors, as the child will have a memory of both waking and of the dream, and will then move into normal wakefulness rapidly. Nocturnal epileptic seizures rarely arise out of REM sleep.
Behavioral management and treatment of any comorbid medical conditions are the appropriate treatment strategies. The onset of a REM behavior disorder may rarely be the first clinical sign of a brainstem lesion, and neuroimaging may be appropriate. In adults REM behavior disorders and acting out of dreams, sometimes violent, may predate by many years other symptoms of serious neurological disorders such as Parkinsons disease, dementia with Lewy bodies, or multiple system atrophy.51
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