We present a case of a woman suffering from violent recurrent non-REM parasomnias with co-morbid obstructive sleep apnea that responded to treatment with nocturnal non invasive mechanical ventilation.
A 54 yr female with a history of seizure disorder, systemic hypertension and “blackouts” was referred to our sleep center. Her seizure disorder had been well controlled on valproic acid with no signs of seizure activity by EEG evaluations. Her blood pressure had been closely monitored and was well controlled on atenolol and enalapril. She had no history of childhood parasomnias. Her nighttime symptoms had started 5 years prior to her presentation. She had been taking a nap in the car while her daughter went to the grocery store. She awoke to find herself driving her car into the middle of a busy intersection 3 miles away. She promptly returned to the store to meet her daughter. Approximately 5 times a month over the next five years the patient experienced similar episodes while “sleeping”. Several times she would awaken to horn sounds while driving her car, often miles away from her house. Other times she awoke to find herself barefoot in the snow in a neighbor’s backyard and at a convenient store 3 blocks from her home in her pajamas. Once she was found by police wandering in a neighboring town. Although she was apparently initially confused, she awoke while they were driving her to the station and was able to tell them where she lived. The patient was coerced by her daughter to see medical attention after her most recent disturbing incident. She describes herself falling asleep around 10 PM while watching a horror movie. She awoke extremely fatigued around 6 AM. She found her hands covered in dried blood. She was then horrified to find blood stains on a cutting board in the kitchen and her cat’s remains next to the trash can. A detailed sleep history revealed non-restorative nighttime sleep and excessive daytime sleepiness. She was noted be a loud snorer. She had been experiencing increased frequency of daytime dozing over the past several years which correlated with a period of increased weight gain. Split-night polysomnography revealed severe OSA with marked oxygen desaturations (Figure 1). She received CPAP titration, which significantly reduced the number apneas and hypopneas. She noted that this was her first restful night of sleep in years. In the four months after starting treatment for OSA she has not suffered any further parasomnias.
Parasomnias secondary to OSA have been described in the literature (1). Increased parasomnias following treatment with CPAP in previously untreated patients have also been well described (2). No violent parasomnias have been linked to OSA. To our knowledge, this is the first case report of a violent parasomnia that responded to effective treatment for OSA.
This case report suggests that violent non-REM parasomnias may be linked to untreated OSA and that effective OSA control may improve symptoms of the parasominias. Sleep deprivation has been shown to be an effective tool for inducing somnambulistic episodes in the laboratory, thereby facilitating the diagnosis of sleepwalking in predisposed individuals (3). We theorize the contrary is true, that by decreasing sleep deprivation by decreasing sleep fragmentation using CPAP, a person is less likely to have parasomnias.
Omar Lateef, None.