1255 An Unusual Clinical Presentation of a Parasomnia

Abstract

Parasomnias are defined as undesirable physical events or experiences that occur during entry to sleep, within sleep, or during arousals from sleep. The non REM (NREM) parasomnias include confusional arousals, sleepwalking, and sleep terrors. In children, NREM parasomnias occur out of stage N3 (first part of the night) but in adults can occur out of stages N1 or N2 during any part of the night. We describe a case of NREM parasomnia with atypical clinical presentation. A 21-year-old female with history of depression and anxiety was evaluated for sleep terrors, sleep walking and sleep eating since age 5. Over the period of past 4 years, her sleepwalking subsided, and was substituted with hallucinations. Patient woke up with loud screams and hallucinations, “living the dream” and was able to explain it to her parents with her eyes open, who eventually “woke her up out of the episode”. Dreams were violent with “death” as the usual theme, approximately 2 hours after sleep onset with complete recollection after waking up. She also endorsed excessive daytime sleepiness with adequate sleep time on actigraphy. Patient denied history of head trauma, encephalitis, epilepsy or family history of sleep disorders. She was treated with Alprazolam and Sertraline in the past 3 years without improvement. She underwent a carefully conducted PSG and MSLT, which was negative for sleep disordered breathing or hypersomnia disorders. Extended Video EEG monitoring captured multiple stage 2 screaming and looking under the bed episodes with patient describing, “dead dogs around and under her bed”. No epileptiform activity was seen. Patient was started on Protriptyline HCL 10 MG twice daily, which resolved her symptoms. Sleep hallucinations are relatively common in teens and young adults, usually visual and reduce with aging. This case highlights an unusual presentation of hypnopompic hallucinations in stage 2, patient opening her eyes and being able to describe her hallucinations before she is “woken out of her sleep”. Differential diagnosis includes disorders of NREM sleep arousals vs. epileptiform activity. Latter was ruled out with an extended video EEG monitoring. It’s also interesting to note that her symptoms resolved with tricyclic antidepressant (TCA), which was used due to failure of SSRI and benzodiazepine therapy in the past. TCA use has been described to control sleep hallucinations in narcolepsy, our case delineates their possible use in NREM hallucinations.