1120 Parasomnia Trifecta: RBD, nightmares and somnambulism

Abstract

Introduction: Case of mirtazapine treatment resulting in REMbehavior disorder, nightmares and somnambulism in a patient without Parkinsonism. Report of Case: 67-year-old male Vietnam Veteran on treatment for major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) was found to have mild OSA (AHI 13.9) with poor compliance on autoPAP therapy due to claustrophobia with the mask and frequent episodes of dream enactment. The patient reported a temporal relationship with his nocturnal disruptive behaviors and commencement of mirtazapine. The mirtazapine dose had recently been increased to 45mg which the patient associated with worsening somnambulism, RBD and nightmares. Additionally, worsening insomnia was associated with twice daily bupropion SR use. In consultation with the psychiatrist, we recommended bupropion XL once daily in the morning, which resulted in significant and swift improvement in insomnia, and initiated a mirtazapine taper, with goal to discontinue the medication. As the mirtazapine dose was reduced, the patient reported significant reduction in nocturnal disruptive behaviors, including dramatic improvement of RBD and significant reduction in nightmares and somnambulism. Additionally, low-dose clonazepam was initiated transiently to prevent withdrawal symptoms such as rebound anxiety and irritability from the alpha-2 antagonist taper, to decrease arousals and to improve CPAP compliance. Conclusion(s): Medications used to treat mood disorders can result in significant sleep comorbidities. Identifying appropriate medications that can treat the mood and administering them at appropriate times can result in maximal benefit with minimal side effects to the patient.