sleep

A Curious Case of Sleep Violence

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On September 11, 1982 I started my career in sleep medicine at the Minnesota Regional Sleep Disorders Center in Minneapolis. I had three new patients on my schedule for that day. The second patient was a 67-year-old gentleman from Golden Valley, Minnesota named Donald Dorff who presented with the complaint of “violent moving nightmares.” Don had bloodied himself several times from running into the bedroom furniture while enacting aggressive American football dreams or dreams in which he was escaping from unknown assailants and other menacing situations.

I was so curious about his enigmatic sleep problem that I spent the night of September 16 in the sleep lab to directly observe Don’s sleep and to view his physiologic sleep tracings, called polysomnography, monitoring his brain waves (EEG), eye movements, muscle activity, breathing, and heart rhythm. The sleep polygraph can reveal the truth about sleep, together with a simultaneous video recording. And indeed Don’s sleep polygraph revealed something unprecedented: during each of his four episodes of REM sleep, Don did not have the protective, physiological mammalian paralysis characteristic of REM sleep. Instead, Don’s electromyogram (electrodes monitoring the muscle tone and muscle twitching) showed the muscle activity ordinarily present in our waking lives—when we need to interact with our environment. For Don, though, his eyes were closed while he was dreaming and he was completely oblivious of his actual surroundings while he was talking, shouting, kicking, throwing punches, and trying to leap out of bed. Whenever he woke up from this activity, he immediately reported a dream to the sleep technologist and to me when we entered his room. What a dramatic night in the sleep lab! It was a night of discovery: we had just gathered objective evidence about a new, extreme sleep disorder.

Don turned out to be our index case of a newly recognized, extreme sleep disorder, or what is known as a “parasomnia.” We named the disorder RBD—REM Sleep Behavior Disorder.

Don’s dreams had changed radically since he developed the hazardous ability to simultaneously enact his dreams. He was not enacting his customary dreams, but rather aggressive and violent dreams. The enactment of distinctly altered dreams in RBD has been reported in the thousands of cases of RBD published from around the world. Moreover, Don was the nicest person, calm and pleasant without any tendency for irritability or temper displayed during his five decades of marriage. This contrast—calm during the day and aggressive and violent during dream-enactment at night—rings true for virtually all RBD patients. A study from Italy found that men with RBD were no more aggressive than control men without RBD, using formal research scales for aggression—even though these men with RBD had significantly more aggressive dreams than the controls. So the wild behavior of RBD is not mirrored by any wakeful tendency for emotional or behavioral dysfunction. That probably explains why not one case of marital separation or divorce has been reported with RBD, since the spouses, after decades of marriage, know that their husbands are acting completely out-of-character. But so much for fascinating science: Don was just interested in having me take care of his sleep problem, so that he could enjoy his retired life and play golf without sustaining any gash on his forehead or deep bruises in his arms or legs while he was dreaming.

At first I used good logic, which failed. I prescribed medications intended to suppress REM sleep: no REM sleep, no RBD. However, Don could not tolerate the untoward effects of these medications, and he was not happy about it. Fortunately, the next approach worked very nicely. I prescribed clonazepam, a benzodiazepine anticonvulsant known at the time to be effective in controlling leg jerking during non-REM sleep (which Don also had). In a week, Don called me very pleased to report that not only his RBD behaviors had been controlled, but also the disturbing dreams that he had been enacting had been controlled. And that provided a clue that the behavioral and dream problems of RBD, which had appeared in tandem and had been controlled in tandem, seemed to have a common cause—or what we refer to as “a common pathophysiology.” The science embedded in RBD is truly fascinating—but here is a real eye-opener: RBD commonly heralds the future emergence of Parkinson’s disease (and related conditions), a classic neurologic disorder. Imagine this: a dream-enacting behavior disorder during REM sleep can be the first indication of a future neurologic disorder. We made this discovery after following middle-aged and older men with RBD over a period of years. Other centers have documented the same pattern. A major research effort has been launched in this new convergent area of sleep medicine, neurology and the neurosciences.

My second patient with RBD was Mel Abel, a gregarious former real-estate agent with a winning smile, who almost strangled his wife Harriet to death one night while dreaming that he was “finishing off” a deer that he had just shot in his dream. That will be one of the stories that I will relate during The Mind after Midnight: Where Do You Go When You Go to Sleep? on June 3.

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