Objective: 1. To determine the co-occurrence rate of PTSD in veterans with PD and RBD.

2. To evaluate severity of dream enactment behavior (DEB) and rate of injuries when PTSD and RBD coexist.

3. To evaluate DEB response to treatment in RBD patients with or without coexisting PTSD.

Background: Chronic post-traumatic stress disorder (PTSD) is common among veterans and causes substantial disability. PTSD and REM sleep behavior disorder (RBD) have overlapping pathophysiology and clinical features^1,2,3. Abnormal REM sleep atonia control in chronic PTSD have been documented in recent publications^1,4,5. In addition, PTSD has been implicated to increase the odds of RBD and other parasomnias in veterans⁶. However, whether the co-occurrence of PTSD and RBD increases injury risk due to dream enactment behavior (DEB) is unclear, so as RBD treatment response when PTSD coexists. This retrospective cohort study aims to address these unanswered questions.

Method: We reviewed charts of 230 PD patients followed in the Movement Disorders Clinic at Southern Arizona Veterans Affairs Healthcare System in Tucson, AZ (age 77.0 ± 8.4, female 4.3%). Atypical parkinsonism patients were excluded. PD patients with RBD were identified by the Single-Question Screen⁷. PTSD was diagnosed by board certified psychiatrists who co-manage these patients. Injury due to DEB is defined as bruising, laceration, or bone fractures to either self or bed partner. Chi Square analysis and Student T-test were used for data analysis.

Results: Among the 230 patients, 51% (118) has documented RBD; 21% (48) has PTSD. Among the RBD cohort, 29% (34) has coexisting PTSD. Patients with RBD and PTSD sustained injuries more frequently compared to RBD without PTSD (41% vs 13%, p<0.001); they were more likely to require pharmacological intervention using melatonin and/or clonazepam (84% vs. 61%, p = 0.02).  However, DEB improved similarly with treatment whether PTSD coexisted with RBD (81% vs 89%, p = 0.34).

Conclusion: PTSD is a common comorbid condition in veterans with PD and RBD. When PTSD and RBD coexist, patients are more likely to sustain DEB-associated injuries, and they require more aggressive pharmacological intervention. However, DEB treatment response to melatonin and/or clonazepam is favorable regardless of whether PTSD coexists with RBD.

References: 1. Husain AM, Miller PP, Carwile ST. REM sleep behavior disorder: potential relationship to post-traumatic stress disorder. J Clin Neurophysiol. 2001 Mar;18(2):148-57.
2. Jones MB, Agrawal R, Sharafkhaneh A, et al. Dream Enactment Behaviors Associated With Posttraumatic Stress Disorder. J Neuropsychiatry Clin Neurosci. 2022 Spring;34(2):124-131.
3. Barone DA. Dream enactment behavior-a real nightmare: a review of post-traumatic stress disorder, REM sleep behavior disorder, and trauma-associated sleep disorder. J Clin Sleep Med. 2020 Nov 15;16(11):1943-1948.
4. Feemster JC, Steele TA, Palermo KP, et al. Abnormal rapid eye movement sleep atonia control in chronic post-traumatic stress disorder. Sleep. 2022 Mar 14;45(3).
5. Feemster JC, Smith KL, McCater SJ, Louis EK. Trauma-Associated Sleep Disorder: A Posttraumatic Stress/REM Sleep Behavior Disorder Mash-Up? J Clin Sleep Med. 2019 Feb 15;15(2):345-349.
6. Elliott JE, Opel RA, Pleshakov D, et al. Posttraumatic stress disorder increases the odds of REM sleep behavior disorder and other parasomnias in Veterans with and without comorbid traumatic brain injury. Sleep. 2020 Mar 12;43(3):zsz237.
7. Postuma RB, Arnulf I, Hogl B, et al. A single-question screen for rapid eye movement sleep behavior disorder: a multicenter validation study. Mov Disord. 2012 Jun;27(7):913-6.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-effect-of-comorbid-chronic-post-traumatic-stress-disorder-in-dream-enactment-behavior-among-veterans-with-parkinsons-disease-and-rem-sleep-behavior-disorder/