Violent Sleep-Related Behavior
Leading to Subdural Hemorrhage
Mark E. Dyken, MD; Deborah C. Lin-Dyken, MD;
Peter Seaba, MSEE; Thoru Yamada, MD

Objective: To polysomnographically determine, using split-screen electroencephalographic-video analysis, the cause of violent sleep-related activity
in a patient whose differential diagnosis includes
sleep walking (somnambulism), pavor incubus (adult
night terrors), nocturnal seizures, psychogenic wan-

dering, and rapid eye movement sleep behavior disorder.

Setting: The patient was referred to the University of
Iowa, Department of Neurology Sleep Disorders
Center, Iowa City, from the local community to

The

evaluate a history of violent dreams associated with in-

jury. The subject presented with a subdural hemorrhage that was discovered with magnetic resonance imaging.
Outcome: The diagnosis of rapid eye movement sleep

behavior disorder was confirmed after a characteristic spell
of violent behavior, with an associated dream, was captured polysomnographically.

(Arch Neurol. 1995;52:318-321)

rapid eye movement

(REM) sleep behavior dis¬
order (RBD) was first de¬
scribed in humans in 1985.1
It is associated with vio¬
lent behavior arising from REM sleep, nor¬
mally a state of essential paralysis. The di¬
agnosis requires a history of potentially
harmful sleep-related body movements as¬
sociated with REM dreams.2"5 These be¬
haviors are rarely captured by polysom-

nography, as most patients experience a
major episode only once every 2 to 3

weeks,6 and, as yet, there exists no spe¬

cific diagnostic criteria based on polysom-

nographic findings.5,7

From the Departments of
Neurology Sleep Disorders
Center (Drs Dyken and

Yamada and Mr Seaba) and
the Department of Pediatrics,

Division of Developmental

Disabilities (Dr Lin-Dyken),
University of Iowa College of

Medicine, Iowa City.

After reviewing data from several dif¬
ferent groups, only seven (8.0%) of 87 pa¬
tients with possible RBD reported dreams
immediately following characteristic REMrelated behaviors captured polysomno¬
graphically. ·2·4·5·8"1'' Schenck et al20 per¬
formed sleep studies on 85 adult patients
with sleep-related injury. Although all RBD
patients were reported to be diagnosed
polysomnographically, the primary crite¬
rion for diagnosis was loss of REM atonia
and emergence of vigorous behaviors dur¬

ing REM sleep. No patients were re¬

ported to have typical, complex behav¬

iors associated with dream mentation
captured in the laboratory.
Although clinically RBD appears to

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be primarily associated with REM sleep,
frequent movements (periodic and nonperiodic) have been noted in non-REM

sleep.6 Therefore, polysomnographic sup¬

port for this disorder is usually based pri¬
marily on the observance of elevated

muscle tone in REM sleep with nonvio¬
lent movements occurring in both REM
and non-REM sleep. Subsequently, many
other phenomena associated with el¬
evated muscle tone during REM (narco¬
lepsy,21 drug use,19·22"24 Parkinson's dis¬
ease,25 and the posttraumatic stress
disorder26) or excessive movements dur¬

ing sleep (seizure,27 paroxysmal noctur¬

nal dystonia,27"29 somnambulism and night
terrors30), psychiatric conditions (such as
dissociative states,28 malingering,31 Munchausen syndrome by proxy,31 posttrau¬
matic stress disorder,6 and nocturnal panic
attacks6), and sleep drunkenness27·32 (be¬
havioral responses to arousals induced by
disorders such as sleep apnea and/or pe¬
riodic limb movements) may be misdiagnosed and inappropriate therapy can
occur.

REPORT OF A CASE

We describe a 73-year-old man with a his¬

tory of tobacco abuse (discontinued after
myocardial infarction suffered in 1976).

a

His only medication was ranitidine hy-

Figure 1. Superficial injury sustained to the right maxillary region during a
violent sleep behavior.

drochloride, 150 mg/d, taken for a remote history of pep¬
tic ulcer disease. He presented with a 10-year history of
violent dreams. He stated: "I act them out, sometimes I
hurt myself, I go through the motions of what I'm dream¬
ing about." His dreams occurred "almost every night."
On occasion, he unintentionally struck his wife. Re¬

Figure 2. Top, A brain magnetic resonance image of the patient revealed a
subdural hemorrhage outlined by the black arrows. Bottom, A 6-month
follow-up study demonstrates resolution of the hematoma.

cently, he dreamed of working on a loading dock and he
had seen a man running. He reported: "Someone yelled,
'stop him.' I tried." His wife reported that he jumped off
the end of the bed and awoke on the floor with "a bloody
lip, head, and knee."
During another episode, the patient leaped from his
bed, fell, and struck the right side of his face on a corner
of a chest (Figure 1 ). He immediately awoke and com¬
plained of a headache and nausea and vomited. He ap¬
peared confused for a 3-hour period, after which he was
alert and had no complaints.
Results of the neurologic examination were nor¬
mal, and RBD was suspected clinically. A magnetic
resonance imaging scan of the brain revealed a leftsided subdural hemorrhage, which had completely
resolved by the time of a second study 9 months later
(Figure %).

A standard polygraph (Nicolet [Madison, Wis] 1A97)
used to record the electroencephalogram, electrooculogram, electromyogram (chin, bilateral anterior tibialis, and intercostal muscles), electrocardiogram, and res¬
piratory air flow and effort parameters. The study was
recorded and sleep was scored according to the crite¬
rion of Rechtschaffen and Kales." The analog outputs of
the 1A97 were input to a reformatter (W/TV-16B, Telefactor Corp, Conshohocken, Pa) that converted the ana¬
log inputs to a video signal, simulating the paper record¬
ing. This simulation was then mixed with a video image
of the patient. The combined video image (patient and
data) was displayed on a video monitor while being re¬
corded on the video track of a standard videocassette re¬
corder. Audio from the patient's room was recorded on
the audio track of the tape. The video image of the pa¬
tient was obtained using a low-level black-and-white video
camera and infrared light.
The overnight polysomnogram was remarkable
for significant periodic limb movements (with a movewas

Figure 3. Polysomnographic tracing generally revealed the classic
electromyographic augmentation that is associated with rapid eye
movement (REM) sleep in the REM sleep behavior disorder. LOG indicates
left outer canthus; ROC, right outer canthus; temporal; C, central; ET,
ears tied; 0, occipital; LA, left arm; RA, right arm; LL, left leg; RL, right
leg; IC, intercostal electromyogram; NA, nasal airflow; OA, oral airflow; and
TM, thoracic movement.

ment index of 52.0 events per hour and a movement-

arousal index of 3.0 events per hour) and an increase
in phasic limb movements throughout most REM
sleep periods (Figure 3). There was no evidence of
sleep apnea or epileptiform activity. Over a 5-month
period, a trial of oral clonazepam, 0.5 mg taken orally
every evening before sleep, was instituted. The patient
reported marked improvement, without complete
resolution of his violent nocturnal behavior.
Subsequently, clonazepam was discontinued for a
3-day period, after which three consecutive nights of

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Figure 4. These split-screen polysomnogaphic tracings of our patient (left, center, and right) temporally document the course (before, during, and after,
respectively) of a typical violent rapid eye movement (REM) behavior followed by a spontaneous dream report. LOG indicates left outer canthus; ROC, right
outer canthus; T, temporal; C, central; ET, ears tied; 0, occipital; LA, left arm; RA, right arm; LL, left leg; RL, right leg; IC, intercostal electromyogram; NA,
nasal airflow; OA, oral airflow; and TM, thoracic movement.

polysomnography were performed. Each study
revealed significant periodic limb movements and a
general loss of atonia during REM sleep. In the third
night study, during one REM episode, after a pro¬
longed period of uncharacteristically quiet electromyographic activity, the patient suddenly exhibited
explosive running movements, followed by an arousal
(Figure 4). Subsequently, he was coherent and dem¬
onstrated no evidence of confusion. The patient spon¬
taneously reported "one of them dreams. As it started
out, I was chasing cattle," after which the animals
reportedly turned and pursued him. It should be noted
that the patient is a cattle farmer. He was subsequently
treated with 1.0 mg of oral clonazepam taken before
sleep, with complete resolution of all violent dream
activity over the following year.
COMMENT

appear similar in dream interruption insomnia,36·37
somnambulism/night terrors,27·38·39 seizures, and RBD.
Subsequently, RBD has frequently been mlsdiagnosed as nocturnal seizure, psychiatric disorder,27 and
sleep apnea.2·6 In addition, there has been a recent pro¬
posal for the existence of "overlapping syndromes"
that exhibit characteristics suggestive of both RBD and
sleepwalking/night terrors. In the two cases presented
by Hurwitz et al,40 complex violent behavior with
reported dream imagery was not captured polysomno¬

graphically.

Up to 77.1% of patients with RBD present with mildto-moderate sleep-related injuries, including bruises, lac¬
erations, dislocations, and fractures.6 Rarely is the RBD
reported to be associated with serious injury, but, ow¬
ing to the limited use of appropriate monitoring tech¬
niques, the true magnitude of these problems may be un¬
derestimated.7·27,28

There has been only one other documented case of

associated violent, directed behavior, followed by the

RBD causing subdural hematoma.8 A 73-year-old man, with
a 2-year history of almost nightly violent movements in
sleep, reportedly hit his head on a table "in a dream." A

Therefore, few of these patients have polysomno¬

to be associated with dream mentation.

Our case is important because we have documented a
typical spell of RBD that arises from REM sleep with

spontaneous, nonprompted report of a detailed dream
that corresponds with observed movements. In the
sleep laboratory, videotaped actions, felt to be charac¬
teristic for RBD,are rarely followed by full arousals.4·6·16

computed tomogram of the head revealed bilateral subdu¬
ral hematomas, while polysomnography demonstrated vio¬
lent movements during REM sleep. The nature of the vio¬
lent movements was not described, and none were reported

graphically documented violent behavior associated
with the report of dreaming, and, to our knowledge,
no published studies provide split-screen, videotaped
evidence of such a spell, where temporally related
behavior and electroencephalographic activity can be
appreciated simultaneously.

Using advanced split-screen video-imaging tech¬
niques, we were able to capture a classic REM episode

sleep other than REM.2·4·26·3435 In addition, violent
behaviors associated with dreams have been reported
not only in RBD but in nightmares associated with the

Accepted for publication November 1, 1993.
We acknowledge the comments and technical assis¬
tance given by Harold Adams, MD, and Christine Glenn,
REEGT, RPSGT, of the Department of Neurology, Uni¬
versity of Iowa College of Medicine, Iowa City, in the prepa¬
ration of this article.
Reprint requests to Department of Neurology, Uni¬
versity of Iowa College of Medicine, Iowa City, IA 52242
(Dr Dyken).

Dreamlike mentation can occur from stages of

posttraumatic stress disorder,26·35 somnambulism,
night terrors, and sleep apnea.27 Schenck et al28 point
out that the diagnosis of sleep-related injury cannot be
determined only from clinical characteristics of the

behavior, the time of night the behavior occurs, or the
degree of event or dream recall, as these features can

of violent behavior followed by a dream report. These tech¬
nical capabilities allowed us to confidently diagnose and
successfully treat RBD in a patient with an associated sub¬
dural hemorrhage.

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