Violent dreaming and antidepressant drugs: or how paroxetine made me dream that I was fighting Saddam Hussein.

A 50-year-old man was referred for consultation because of disrupted sleep. He complained of a 10-year history of nonrestorative sleep, loud snoring, and a history of “restless leg syndrome.” Ten years previously he developed symptoms of depression. His physician prescribed fluoxetine, a selective serotonin reuptake inhibitor (SSRI) agent. His symptoms of depression improved, however he subsequently developed disrupted and nonrestful sleep with frequent awakenings and disturbing body movements. His physician prescribed clonazepam 0.5 mg. He reported improvement in his sleep. Five years previously he stopped using fluoxetine and clonazepam. He subsequently had no significant difficulties with sleep. Three years previously, his symptoms of depression returned, and he was treated with paroxetine. Shortly after starting treatment with paroxetine, his symptoms of disrupted sleep again recurred. At that time, his physician restarted clonazepam and his sleep improved. However, he experienced daytime grogginess and tried to stop clonazepam, but his sleep disturbance worsened again and at that point was referred for sleep consultation. When asked to provide a detailed account of his symptoms of disrupted sleep, he reported that he fell asleep quickly at bedtime and slept well the first part of the night. His spouse stated that his nocturnal symptoms began by his legs kicking. Then he would wake up flailing or thrashing his arms and legs, often striking the spouse vigorously. The patient reported that these episodes were associated with dreams; often there was a theme of violence or that he was being attacked. He said he had recently dreamed he had engaged in hand-to-hand combat with Saddam Hussein. He specifically denied experiencing an irresistible urge to move or stretch his legs that occurred primarily in the evening. Over the past year his weight had increased by 15 pounds. His wife reported occasional snoring but no witnessed apneas. He reported no daytime sleepiness. His Epworth Sleepiness Scale score was 6/24. He denied tremor and muscular rigidity. His past medical history was pertinent for Crohn disease, which was now inactive. His medications were paroxetine 30 mg per day, clonazepam 1 mg per day, sulfasalazine 1 gm once a day, and folic acid 1 mg per day. His physical examination was unremarkable and specifically showed no signs of Parkinson’s disease or other neurological disease. Polysomnography showed periodic limb movements occurring 27 times per hour; 10% were associated with arousal. The apnea-hypopnea index was 3 events per hour. Lowest oxygen saturation was 90%. Phasic increases in submental muscle activity were observed during REM sleep (Figure 1). Vocalizations were observed during REM sleep, but there were no overt behaviors. The study was otherwise unremarkable.