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Atypical Dream-Enacting Behaviors in REM Sleep Behavior Disorder (RBD), Involving Abuse/ Retaliation Dreams, Culture-Specific Dreams, and Religion-Specific Dreams
 
Schenck CH,1,2 Mahowald MW,1,3 Tachibana N,4 Tsai C-S5
 

1Minnesota Regional Sleep Disorders Center; Departments of  2Psychiatry & 3Neurology, Hennepin County Medical Center & University of Minnesota Medical School, Minneapolis; 4Kyoto University Hospital & Center for Sleep-Related Disorders, Kansai Electric Power Hospital, Osaka, Japan; 5Taichung Hospital Sleep Center & Central Taiwan University, Taiwan (Republic of China)

Introduction: RBD usually features enactment of altered dreams of fighting with unfamiliar people/animals, or of culture-specific sports dreams, such as American football or rugby.

Methods: Records at 3 sleep centers from 3different countries were reviewed for examples of atypical dream-enacting behaviors in PSG-documented RBD.

Results: 5 examples from 3 categories: I) Abuse/retaliation dreams (related to prior verbal/physical abuse-USA); II) Culture-specific dream (Japan); III) Religion-specific dream (Taiwan). I): i) A 43 y.o. female with narcolepsy/cataplexy (& bipolar disorder), on 110/day methylphenidate, developed RBD when imipramine was increased to 225 mg/day; her husband often observed defensive posturing, arm flailing, and punching that corresponded to dreams of her mother/sister berating her & hitting her during childhood—but she never retaliated in childhood, only later with RBD. Clonazepam controlled RBD and these dreams; ii) A 43 y.o. man with monosymptomatic narcolepsy (& alcohol abuse in remission; major depression controlled with 300 mg hs clomipramine) developed RBD with “fighting dreams”(observed by his wife) involving hitting back at his previously verbally/physically abusive alcoholic father; clonazepam partially contolled RBD; psychotherapy controlled most of these dreams & enactments; iii) Aa 58 y.o. married man (without psychopathology) developed idiopathic RBD & some of dream-enactments involved “punching out” a hypercritical father during his childhood (while actually hitting his wife in bed); in the a.m. he felt no remorse; prior to RBD he had no retaliation dreams, only dreams of his hypercritical father; clonazepam controlled dream-enactment & retaliation dreams. (II) A 51 y.o. Japanese man (without neurologic/psychiatric d/o), in a home sleep video recording had an episode from 2:43:58-2:45:59 a.m. in which he enacted a classic Samurai warrior dream. The sequence involved left arm motions while lying on his back, then abruptly sitting up & kneeling in bed, vocalizing, swinging his arms, throwing 3 punches with each arm, grabbing an imaginary sword with both hands and stabbing up and down 12 times in rapid succession. Moments of hypotonia (slumping forward) occurred during the sequence. He then went under the covers and lay quietly. III) A 26 y.o. Taiwanese man with a 10 yr history of narcolepsy/cataplexy (& no pychopathology) had 5 PSG-MSLTs over 10 years, with the latest PSG (at age 26 yrs) first-documenting RBD (while taking modafinil, methylphenidate, imipramine, trazodone). The pt. & mother reported that he was a devote Taoist; 3 times daily he enacted at home the “eight-general (wikipedia)”special Taoist religion temple worship ceremony lasting 4 min, 40 sec; during his latest PSG, in REM sleep he faithfully enacted this temple worship in bed, with sitting up, kneeling and fully bowing down, immobile, but with full muscle tone.

Conclusion: Narcolepsy/cataplexy(& treatment) and/or past abuse/psychopathology may be predisposing factors for atypical dream-enactment in RBD, along with intense religious devotion. Further search for atypical dream-enactment in RBD, including across cultures, is encouraged.

 

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