Increasing detection of disruptive nocturnal behaviors (DNB) and REM without atonia in trauma associated sleep disorder.

Trauma associated sleep disorder (TSD) manifests with trauma-related nightmares, disruptive nocturnal behaviors (DNB) including REM without atonia, and autonomic hyperactivity. Although patients with TSD frequently report DNB, events are infrequently identified during in-lab polysomnography (PSG).  We hypothesized that consecutive video PSG studies increase detection of DMB and REM without atonia.

Individuals were initially screened for TSD with the Pittsburgh Sleep Quality Index Addendum.  Those reporting trauma-related nightmares and DNB underwent a structured clinical interview to confirm the diagnosis. Patients with TSD completed 2 consecutive nights of attended in-lab PSG.  Video-PSG analysis was performed including detailed review of movements, excluding epochs with sleep disordered breathing.  REM sleep analysis included quantifying “any” electromyographic (EMG) activity as an objective measurement for REM without atonia.

We diagnosed 15 individuals (11 males; 14 Active Duty, 1 Veteran; average age 32.2 years) with TSD. Traumatic exposures were combat related in 40% and physical or sexual assault related in 60%.  Between the two nights there was a significant difference between proximal limb movements (1.0 ± 1.73 vs 10.3 ± 4.04; p=0.02) and the amount of EMG tone using 3 second REM mini epochs (153 ± 147.8 mini epochs vs 417 ± 35.1; p=0.04).  No difference was detected between vocalizations including total REM sleep time and percentage.  Nightmares were reported by 33% during their first night PSG vs 66% during their second PSG.

In patients with TSD, there was an increase in the number of proximal limb movements, total mini epochs of “any” REM EMG activity, and nightmares during the second night of consecutive in-lab PSG testing.  More than one night of in-lab PSG evaluation is likely required to best characterize the severe nocturnal disruptions of TSD.