1150 Isolated Nightmares: An Unusual Presentation of Narcolepsy?
Katherine Moawad, David M. Raizen
Sleep April 20, 2024 DOI: 10.1093/sleep/zsae067.01150 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Case study Case report Peer reviewed |
|---|---|
| Sample size | 1 |
| Population | A 21-year-old female with daily nightmares for five years |
| Measures | Polysomnography (PSG), Multiple sleep latency test (MSLT) |
| Topics | Dreaming |
| Key findings | The authors report that polysomnography and a multiple sleep latency test in a patient whose only presenting complaint was near-sleep-onset nightmares supported a diagnosis of narcolepsy without cataplexy, despite her reporting no sleepiness. They argue this is an atypical presentation and recommend that clinicians treating narcolepsy also inquire about dream and nightmare activity. |
Abstract
A nightmare involves an internally generated conscious experience of negative emotional valence. Nightmares typically occur during REM sleep, which is most prevalent during the second half of the night. A young female presented with isolated nightmares, occurring near sleep onset and raising suspicion for narcolepsy. A 21-year-old female presented to the sleep center due to experiencing daily nightmares for five years. Nightmares were described as “super realistic”, “distressing”, and occurred minutes after sleep onset. Nightmare content varied. Some of her nightmare themes included an apocalypse, family members dying, and animals chasing her. She had a remote history of anxiety and was previously prescribed sertraline, which had been discontinued two years ago. She reported no hallucinations, cataplexy, sleep paralysis, dream enactment or excessive sleepiness. She had been using a hormonal transdermal patch for about 2 years. On physical exam, she was noted to have mild bilateral proptosis with white sclera visible above the iris on primary gaze. Polysomnography (PSG) revealed a sleep onset latency of 30.5 minutes, N1 1.5%, N2 47.5%, N3 20.9%, and REM 30.1%. REM sleep latency was short at 63.5 minutes. There were 21.6 arousals per hour. The apnea-hypopnea index was of 0.3 events per hour. The PSG was followed by a multiple sleep latency test (MSLT), which measured a mean sleep latency of 5 minutes 42 seconds during five nap opportunities. The patient experienced REM sleep in both the first and third nap, with a REM sleep latency of 4.5 minutes. The patient’s MSLT revealed pathological sleepiness, which supported a diagnosis of narcolepsy without cataplexy, although the patient reported nightmares and not sleepiness. This is an atypical presentation for narcolepsy, which is characterized by REM sleep abnormalities. Further research, classifications, and diagnostic criteria for clinical REM phenomena associated with narcolepsy should be investigated. Clinicians who treat patients with narcolepsy should monitor not only the characteristic symptoms of narcolepsy, such as cataplexy or sleepiness, but also inquire about oneiric activity.