Case report Polysomnographic study of sleeplessness and oneiricisms in the alcohol withdrawal syndrome Giuseppe Plazzi * , Pasquale Montagna, Stefano Meletti, Elio Lugaresi Institute of Clinical Neurology, University of Bologna, via Ugo Foscolo 7, 40123 Bologna, Italy Received 9 July 2001; received in revised form 25 October 2001; accepted 25 October 2001 Abstract We describe a polysomnographic observation of the acute phase of the alcohol withdrawal syndrome, characterized by an alteration of the sleep–wake cycle and by the absence of non-rapid eye movement sleep. An atypical transitional state between rapid eye movement sleep and wake with hallucinations and enacting-dream behaviors represented the sole sleep pattern. Analogies of alcohol withdrawal syndrome with fatal familial insomnia and Morvan’s fibrillary chorea suggest a common pathophysiological mechanism in these conditions. q 2002 Elsevier Science B.V. All rights reserved. Keywords: Polysomnograpy; Alcohol withdrawal syndrome; Recovery; Rapid eye movement sleep behavior disorder; Oneiricism; Fatal familial insomnia; Morvan’s fibrillary chorea; Clonazepam 1. Introduction Alcohol withdrawal is a complex syndrome that ranges from anxiety to insomnia to delirium tremens [1]. Typically, insomnia is one of the heralding aspects, followed by an agitated sleepless state with hallucinations (oneiricism): the patient, especially during the night, can experience frag- mentary or global dream-like hallucinations with partial or even absent awareness of reality [1]. A close link between dream activity and hallucinations in delirium tremens was hypothesized in 1881 [2], but the neurophysiological studies of this condition, mostly performed in the 1970s and 1980s [3,4], did not offer a unanimous interpretation. We studied the acute phase and recovery from alcohol withdrawal syndrome on video-polysomnography (PSG). The absence of non-rapid eye movement (NREM) sleep and the presence of an atypical transitional state between rapid eye move- ment (REM) sleep and wake, associated with hallucinations and enacting-dream behaviors, represented the main find- ings of the acute phase and this condition promptly responded to clonazepam administration. 2. Case report A 56-year-old man, an alcohol abuser since the age of 30, spontaneously withdrew from alcohol. He had a normal family and personal history, in particular any premorbid sleep parasomnia and excessive daytime sleepiness (i.e. narcolepsy), were clinically excluded. Within a few days, his wife and daughters reported abnormal motor and verbal activities appearing during the night: jerks, fragmented movements, violent fighting behavior, talking and mimick- ing daytime actions such as shaving or hair combing. When- ever awakened from these episodes, the patient reported a vivid dream content. Episodes became more intense and prolonged day by day, with a cluster in the early morning hours. In 2 weeks, when the patient was admitted to a General Hospital, the enacting dreams spread throughout the night and appeared also during the daytime, as soon as the patient lapsed into drowsiness. During the rest of the day, the patient was lucid and oriented. Hyperthermia and profuse sweating completed the picture. The patient under- went thiamine, glucose, and electrolyte treatment. One month after alcohol withdrawal, the patient was admitted to our observation for persisting symptoms. Neurological examination showed signs of lower limb poly- neuropathy and mild cerebellar ataxia. When awake, the patient was cooperative, well oriented in time and space. Left alone, he lapsed into drowsiness and oneiricisms. Formal neuropsychological evaluation by means of a Sleep Medicine 3 (2002) 279–282 1389-9457/02/$ - see front matter q 2002 Elsevier Science B.V. All rights reserved. PII: S1389-9457(02)00014-X www.elsevier.com/locate/sleep * Corresponding author. Tel. 1039-051-585158; fax: 1039-051- 6442165. E-mail address: plazzi@neuro.unibo.it (G. Plazzi).