PURPOSE: The American Academy of Sleep Medicine (AASM) Manual for the Scoring of Sleep and Associated Events defines RBD PSG features as sustained muscle activity or excessive transient muscle activity in REM sleep. These scoring rules have not yet been validated in combat veterans with both PTSD and RBD.
METHODS: We undertook a retrospective cross-sectional analysis of history and PSG findings of veterans referred sleep center for polysomnography between September 28, 2010 and February 25, 2011. Patients with PTSD, with or without complaints of dream enactment, were included. We excluded patients with incomplete questionnaires; less than 5 minutes of REM sleep on PSG; or history of head injury or neurodegenerative disease. Criteria to classify a PSG as abnormal included tonic or phasic EMG activity, as defined by the AASM scoring manual, not associated with an arousal or obstructive respiratory event. We calculated the sensitivity and specificity of these scoring rules in the detection of RBD, as defined by the complaint of dream enactment on the pre-PSG questionnaire.
RESULTS: Records from 23 patients were included in this study. Twelve patients with PTSD composed the experimental group. Ten PTSD group reported dream enactments; 2 did not. Eleven patients without PTSD or dream enactment comprised the control group. None of the control group members reported dream enactment. Eight patients with dream enactment (80%) met criteria for abnormal EMG tone during REM sleep in the form of phasic type augmentation. Five patients without dream enactment (38%), including 1 of the 2 patients with PTSD, had abnormal EMG activity during REM sleep. The sensitivity and specificity of the current PSG scoring rules for detection of reported dream enactment are 80% and 62%, respectively. The positive predictive value (PPV) is 62% and the negative predictive value (NPV) is 80%. If only phasic muscle activity during REM sleep is used for the diagnosis the the sensitivity remains 80% but the specificity increases to 77%.
CONCLUSIONS: Dream enactment is very often reported in veterans with PTSD. Phasic EMG augmentation during REM sleep is a sensitive and specific marker of clinically diagnosed RBD in this population.
CLINICAL IMPLICATIONS: Augmented REM-related EMG activity should prompt a thorough evaluation for PTSD and dream enactment in combat veterans.
DISCLOSURE: The following authors have nothing to disclose: Jose Melendez, Sean Hesselbacher, Amir Sharafkhaneh, Max Hirshkowitz
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