Sleep-related Dissociative Disorders Research Articles

Two Cases of Sleep-Related Dissociative Disorder with Episodes of Nocturnal Eating

AbstractSleep-related dissociative disorder (SRDD) is a female-predominant psychiatric parasomnia that was first identified as a condition that mimics sleepwalking in 1989, and was included in the International Classification of Sleep Disorders, 2nd edition, in 2005, with a subsequent expanding literature of case series and case reports. The objective hallmark of SRDD, found in about half of the reported cases, is sustained electroencephalogram (EEG) wakefulness during dissociative episodes emerging during wake-sleep transitions or after awakenings from light non-rapid eye movement (NREM) sleep or rapid eye movement (REM) sleep. Herein are reported two additional cases of SRDD in two female patients aged 53 and 40 years with prominent histories of multimodal abuse (typical of SRDD), with childhood emotional and food deprivation abuse in Case 1, and childhood emotional, sexual, and physical abuse in Case 2. Both patients were affected by “sleep phobia” and had recurrent nocturnal eating episodes. Major findings from the cumulative literature on SRDD are reinforced by these cases, with additional findings being described, particularly nocturnal eating behaviors and priming/triggering factors.

Sleep-isolated trichotillomania as an ictal symptom of complex partial seizure in a 12-year-old girl: a case report

Sleep-isolated trichotillomania (TTM) is the unconscious and automatic pulling of one's hair only while sleeping. In previous case reports, sleep-isolated TTM has been categorized as a sleep-related disorder or a sleep-related dissociative disorder in case reports, and a treatment strategy in this direction has been implemented. However, to our knowledge, no reports have been published describing hair pulling during sleep as a symptom of epilepsy and its pharmacological treatment. In this case report, we present the hair-pulling behavior during sleep as an ictal manifestation of complex partial seizure in a 12-year-old girl and its successful treatment with levetiracetam. We suggest that epilepsy should be suspected in addition to parasomnias and sleep-related dissociative disorder in the differential diagnosis, especially in cases presenting with isolated TTM behavior during sleep.

A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria.

To identify the most relevant clinical and video-polysomnographic characteristics of patients with sleep-related dissociative disorders (SRDDs) and to propose a framework for new diagnostic criteria. We searched potential SRDD cases from the scientific literature and from a database of patients referred for clinical and video-polysomnographic assessment in a single sleep disorders center for disruptive nocturnal behaviors (n = 731). The most relevant clinical and neurophysiological characteristics of the cases were extracted and a descriptive analysis was performed. Twenty-six SRDD cases (8 new and 18 previously published cases) were reviewed. Almost all cases of SRDDs occurred in a context of past traumatic events or abuse and were associated with at least 1 comorbid psychiatric disorder. We highlighted 4 relevant clinical characteristics of SRDD useful for the differential diagnosis with parasomnias: episodes of long duration of more than 1 hour (90.9%), self-inflicted injuries (83.3%), occurrence while awake close to bedtime (35.7%), and the presence of daytime dissociative symptoms (72.7%). The video-polysomnography documented typical episodes of SRDD with prolonged wakefulness before, during, and after the event in 11/26 cases. New diagnostic criteria for SRDD were proposed, with 3 levels of certainty for the diagnosis based on clinical, video-polysomnographic, and homemade video findings. More than 30 years after its formal identification, SRDD is not currently recognized as an official diagnostic entity. We better delineate the clinical and neurophysiological features of SRDD and propose a framework for its reinstatement in the next revisions of the sleep and psychiatric disorders classifications. Lopez R, Lefevre L, Barateau L, Micoulaud-Franchi J-A, Dauvilliers Y, Schenck CH. A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria. J Clin Sleep Med. 2022;18(2):563-573.

Sleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported cases

To update the literature on the diagnostic category of sleep-related dissociative disorders (SRDDs), involving psychogenic dissociation, since the time of their inclusion in the parasomnias section of the International Classification of Sleep Disorders, second edition, in 2005; to summarize the most salient clinical and video-polysomnographic (vPSG) findings and typical clinical profile from all reported cases; and to provide the rationale for the re-inclusion of the group of SRDDs in future editions of the International Classification of Sleep Disorders. A systematic computerized literature search was conducted searching for SRDDs, nocturnal dissociative disorders, and nocturnal dissociation. Nine additional cases were identified, with sufficient clinical history and vPSG findings to justify the diagnosis of SRDDs, supplementing the 11 cases cited in the International Classification of Sleep Disorders, second edition, for a total of 20 cases. Twenty-six other cases with vPSG testing were found, with 18 cases reported in abstracts and 8 cases reported in a publication with compelling histories of SRDDs and 2 consecutive vPSG studies, but without the vPSG findings explicitly reported for any case. In more than half of all reported cases, there was objective diagnostic confirmation for SRDDs consisting of the hallmark finding of abnormal nocturnal behaviors arising from sustained electroencephalography wakefulness, or during wake-sleep transitions, without epileptiform activity. These nocturnal behaviors often replicated daytime psychogenic dissociative behaviors. A history of trauma (physical, sexual, emotional) was an almost universal finding, along with major psychopathology. All patients, except for one, had prominent histories of daytime dissociative disorders. Many of the patients were referred on account of a presumed parasomnia. Cases of SRDDs continue to be reported, often as a "parasomnia mimic," with psychogenic dissociation being clearly distinguished from physiologic sleep-wake dissociation as found in primary sleep disorders such as narcolepsy, rapid eye movement sleep behavior disorder, etc. Eleven reasons are provided for why the category of SRDDs should be re-included in future editions of the International Classification of Sleep Disorders, and in the parasomnias section.

Sleep-related dissociative disorders (SRDD)

Sleep-related dissociative disorders (SRDD)

Milton G. Ettinger, MD (1930–2008)

MILTON ETTINGER, LONG-TIME CHIEF OF NEUROLOGY AND FOUNDER OF THE MINNESOTA REGIONAL SLEEP DISORDERS CENTER AT HENNEPIN COUNTY Medical Center in Minneapolis, died May 2, 2008 of meningitis. He was a graduate of St. Paul Central High School and completed his medical studies at the University of Minnesota Medical School in 1954. Following an internship in Los Angeles he completed a neurology residency at the University of Minnesota under Dr. A. B. Baker. After a stint in the Air Force he returned to Minneapolis, to become the first full-time neurology staff member at the Minneapolis General Hospital (later to become Hennepin County Medical Center). He and a few colleagues were instrumental in the transformation of the old “General Hospital” to its current status as a major clinical, teaching, and research facility—while continuing to serve as one of the few remaining true “safety-net” hospitals. Milton G. Ettinger, MD (1930–2008) Beyond his legendary clinical, teaching, and administrative skills, he will be remembered as a visionary and mentor extraordinare. He helped create one of the first medical ethics committees in the country, and established a multidisciplinary Huntington's Disease Clinic. In the mid-1970s, he foresaw the clinical importance of sleep medicine as a discipline, leading to the establishment of the Minnesota Regional Sleep Disorders Center in 1978. Realizing that clinical and research aspects of Sleep Medicine ideally involved numerous medical specialties, he emphasized the importance of a truly multidisciplinary approach. From the onset, the importance of sleep medicine training for medical students, residents, and fellows was emphasized, as was clinical research. He appreciated the fact that thoughtful and thorough clinical evaluation combined with long-term, careful, and systematic follow-up of patients was paramount, not just for patient care, but also for clinical discovery. He encouraged close collaboration between clinicians and basic science researchers. Under his watch, a number of previously unidentified or unrecognized sleep disorders were identified, including REM sleep behavior disorder, parasomnia overlap disorder, status dissociatus, sleep-related eating disorder, sleep-related dissociative disorders, and epic dreaming. Following his “retirement” in 1995, he continued to provide clinical and educational activities, along with mentorship, at the Minnesota Regional Sleep Disorders Center. At the time of his death, he was actively promoting the development of the first academically based sleep medicine forensics unit. Throughout his career, he maintained non-negotiable priorities of teaching and serving the underserved, disadvantaged, and less fortunate. His teaching skills did not go unnoticed: in 1990 he was bestowed the prestigious A. B. Baker award for excellence in neurological education by the American Academy of Neurology. His vision of developing a multidisciplinary sleep medicine program has well-served the field—not only as a model to be emulated, but also as a source of a large number of trainees who continue to contribute to the field. He was a true visionary and mentor who received his own personal joy and satisfaction never by being in the limelight himself, but rather by allowing others to enjoy the limelight he helped create for them. He was a proud husband and father, who enjoyed fishing and spending time with his children and grandchildren. He is survived by his wife Jeanne, son David, daughter Adrienne, and two grandchildren. His influence on our field is immeasurable

Sleep-Related Dissociative Disorder in a 6-Year-Old Girl

Sleep-related dissociative disorders are parasomnias that can emerge at any point during the sleep period and are associated with traumatic life experiences. No reports to date have described this parasomnia in a school-age child. This case report discusses presentation, diagnosis, and treatment of a 6-year-old girl with this diagnosis. Sleep-related dissociative disorder should be considered in young children who have experienced traumatic life events and who present with abnormal sleep patterns and bizarre behavior. Early identification and intensive psychotherapy can be efficacious for these children.

Sleep and sex: what can go wrong? A review of the literature on sleep related disorders and abnormal sexual behaviors and experiences.

To formulate the first classification of sleep related disorders and abnormal sexual behaviors and experiences. A computerized literature search was conducted, and other sources, such as textbooks, were searched. Many categories of sleep related disorders were represented in the classification: parasomnias (confusional arousals/sleepwalking, with or without obstructive sleep apnea; REM sleep behavior disorder); sleep related seizures; Kleine-Levin syndrome (KLS); severe chronic insomnia; restless legs syndrome; narcolepsy; sleep exacerbation of persistent sexual arousal syndrome; sleep related painful erections; sleep related dissociative disorders; nocturnal psychotic disorders; miscellaneous states. Kleine-Levin syndrome (78 cases) and parasomnias (31 cases) were most frequently reported. Parasomnias and sleep related seizures had overlapping and divergent clinical features. Thirty-one cases of parasomnias (25 males; mean age, 32 years) and 7 cases of sleep related seizures (4 males; mean age, 38 years) were identified. A full range of sleep related sexual behaviors with self and/or bed partners or others were reported, including masturbation, sexual vocalizations, fondling, sexual intercourse with climax, sexual assault/rape, ictal sexual hyperarousal, ictal orgasm, and ictal automatism. Adverse physical and/or psychosocial effects from the sleepsex were present in all parasomnia and sleep related seizure cases, but pleasurable effects were reported by 5 bed partners and by 3 patients with sleep related seizures. Forensic consequences were common, occurring in 35.5% (11/31) of parasomnia cases, with most (9/11) involving minors. All parasomnias cases reported amnesia for the sleep-sex, in contrast to 28.6% (2/7) of sleep related seizure cases. Polysomnography (without penile tumescence monitoring), performed in 26 of 31 parasomnia cases, documented sexual moaning from slow wave sleep in 3 cases and sexual intercourse during stage 1 sleep/wakefulness in one case (with sex provoked by the bed partner). Confusional arousals (CAs) were diagnosed as the cause of "sleepsex" ("sexsomnia") in 26 cases (with obstructive sleep apnea [OSA] comorbidity in 4 cases), and sleepwalking in 2 cases, totaling 90.3% (28/31) of cases being NREM sleep parasomnias. REM behavior disorder was the presumed cause in the other 3 cases. Bedtime clonazepam therapy was effective in 90% (9/10) of treated parasomnia cases; nasal continuous positive airway pressure therapy was effective in controlling comorbid OSA and CAs in both treated cases. All five treated patients with sleep related sexual seizures responded to anticonvulsant therapy. The hypersexuality in KLS, which was twice as common in males compared to females, had no reported effective therapy. A broad range of sleep related disorders associated with abnormal sexual behaviors and experiences exists, with major clinical and forensic consequences.