The criteria for PTSD in the DSM-5 ( 7) include, among other symptoms, insomnia (difficulty falling or staying asleep) and nightmares (repeated, disturbing dreams of the traumatic experience). The contribution of sleep disturbances to PTSD severity, treatment resistance, and even suicide risk emphasizes the importance of identifying and addressing the nocturnal phenomena of PTSD ( 5, 6). Referred to as a hallmark of the disorder, sleep disturbances in PTSD are nearly ubiquitous ( 4).
general population, 10.2% of men and 15.5% of women seeking health care from the Veterans Health Administration, and 23% of veterans of Operation Enduring Freedom/Operation Iraqi Freedom ( 1– 3). PTSD is experienced by an estimated 8.3% of the U.S. The patient remains on clonazepam for the dream enactment behaviors, and his cognition and physical status continue to decline. A repeat polysomnogram is recommended by sleep medicine but not completed. Two separate attempts at PTSD-focused psychotherapy are thwarted by exacerbations of PTSD symptoms and cognitive decline. As a result, the psychiatrist increases prazosin to 2 mg at bedtime for nightmares. However, the nocturnal events decrease only to two or three times per week. In response, the sleep medicine clinician independently adds melatonin, titrating to 5 mg nightly, and increases clonazepam to 1.5 mg at bedtime for presumed RBD. Because the patient does not achieve REM sleep during this sleep study, polysomnographic confirmation of RBD is not possible.įollowing the sleep study, the patient continues to report dream enactment behaviors. There are no periodic limb movements and no dream enactment events. His respiratory disturbance index is 0, and his apnea-hypopnea index is 0.3. Total time in sleep stages includes 7.1% in stage N1, 70% in stage N2, 22.9% in stage N3, and 0% in REM. Total time asleep is 333 minutes with 73% sleep efficiency. Prior to this visit, the patient never had a sleep study.ĭiagnostic polysomnography is ordered to clarify the diagnosis.
A neurologist prescribed clonazepam for dream enactment behaviors and suspected REM sleep behavior disorder (RBD). Fluoxetine and prazosin were prescribed by a psychiatrist for PTSD symptoms and nightmares, respectively. to 8:00 p.m.) fluoxetine (40 mg daily) clonazepam (0.5 mg at bedtime) and prazosin (1 mg at bedtime). His current medications include carbidopa/levodopa (25/100 mg, two tablets alternating with 2.5 tablets every 2 hours from 8:00 a.m. The patient denies a past history of traumatic brain injury or epilepsy. In recent years, he began to discuss his sexually traumatic event with his wife, with the hope it would improve the dream enactment behaviors. He denies the experience of discrete nightmares that he can recall upon waking. Additionally, he avoids situations that remind him of the assault, tends to mistrust and detach from others, and demonstrates hypervigilance, an exaggerated startle response, and easy irritability. Since that assault, he has reported the experience of intrusive memories and fear, as well as hyperarousal, when reminded of the event. The patient assumes that his nocturnal episodes stem from him being sexually assaulted in his early twenties.
The patient denies excessive daytime sleepiness, sleep paralysis, sudden losses of muscle tone, or hallucinations upon waking or falling asleep. She also denies that he has ever walked out of bed or injured himself during an episode, but she sleeps in a separate bed for her own safety and sleep quality. His wife denies that he snores or stops breathing in his sleep. He does not recall the dreams or episodes. He is accompanied by his wife, who describes episodes of screaming and yelling while the patient is asleep that began nearly 10 years ago 2 years later, he started “acting out his dreams.” In a typical episode, according to his wife, the patient appears to run away from someone, punches the air, and repeatedly yells, “get away from me.” The episodes occur 2–3 hours after he falls asleep, four to five times per week. A 66-year-old right-handed male with a 5-year history of akinetic-rigid Parkinson’s disease is referred for neuropsychiatric consultation to evaluate nightmare symptoms and possible posttraumatic stress disorder (PTSD).
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