Sleepwalking Research Articles

Exploring Digital Biomarkers for Depression Using Mobile Technology

Introduction & BackgroundWith the advent of ubiquitous sensors and mobile technologies, wearables and smartphones offer a cost-effective means for monitoring mental health conditions, particularly depression. These devices enable the continuous collection of behavioral data, providing novel insights into the daily manifestations of depressive symptoms. Objectives & ApproachThe present study summarizes findings from our five recent investigations that explored the relationships between depression severity and digital biomarkers captured by wearables and smartphones. These studies analyzed data from RADAR-MDD, a multinational mobile health program, involving 623 participants and tracked for up to two years. Participants' depression severity was measured biweekly using the PHQ-8 questionnaire conducted via smartphones. Concurrently, participants’ Fitbit and smartphone data were also collected. Given the longitudinal nature and repeated measurements for each participant, multilevel modeling techniques were employed to analyze the data. Relevance to Digital FootprintsOur approach involved extracting features from passive data that reflect various aspects of daily behavior—such as sleep quality, social interaction, physical activity, and walking patterns—akin to digital footprints. ResultsWe found several significant links between depression severity and various behavioral biomarkers: elevated depression levels were associated with diminished sleep quality (assessed through Fitbit metrics), reduced sociability (approximated by Bluetooth), decreased levels of physical activity (quantified by step counts and GPS data), a slower cadence of daily walking (captured by smartphone accelerometers), and disturbances in circadian rhythms (analyzed across various data streams). Conclusions & ImplicationsLeveraging digital biomarkers for assessing and continuously monitoring depression introduces a new paradigm in early detection and development of customized intervention strategies. Findings from these studies not only enhance our comprehension of depression in real-world settings but also underscore the potential of mobile technologies in the prevention and management of mental health issues.

Enhanced external counterpulsation treatment improves multi-organ hemodynamics for postoperative liver transplantation patient. A case report

IntroductionPost liver transplantation (LT) patients endure high morbidity rate of multi-organ ischemic symptoms following reperfusion. We hypothesize that enhanced external counterpulsation (EECP) as a typical non-invasive assisted circulation procedure, which can efficiently inhibit the relative ischemic symptoms via the systemic improvement of hemodynamics.Case presentationA 51-year-old male patient, 76 kg, 172 cm, received orthotopic LT surgery for viral hepatitis B induced acute-on-chronic liver failure hepatic failure. His medical records revealed ischemic symptoms in multi-organ at the time of hospital discharge, including headache, refractory insomnia, abdominal paralysis, and lower limb pain. The EECP treatment was introduced for assisted rehabilitation and to improve the postoperative quality of life. Doppler Ultrasound examination showed significant augmentation of blood flow volume in the carotid arteries, the hepatic artery, the portal vein and the femoral artery during EECP intervention. A standard 35-hour EECP treatment led to significant improvement in quality of life, e.g. sleep quality and walking ability.ConclusionWe report a case of multi-organ ischemic symptoms in a post LT patient. EECP treatment can significantly improve the quality of life via the systematic promotion of hemodynamics.

Temporal dynamics of awakenings from slow-wave sleep in non-rapid eye movement parasomnia.

Non-rapid eye movement parasomnia disorders, also called disorders of arousal, are characterized by abnormal nocturnal behaviours, such as confusional arousals or sleep walking. Their pathophysiology is not yet fully understood, and objective diagnostic criteria are lacking. It is known, however, that behavioural episodes occur mostly in the beginning of the night, after an increase in slow-wave activity during slow-wave sleep. A better understanding of the prospect of such episodes may lead to new insights in the underlying mechanisms and eventually facilitate objective diagnosis. We investigated temporal dynamics of transitions from slow-wave sleep of 52 patients and 79 controls. Within the patient group, behavioural and non-behavioural N3 awakenings were distinguished. Patients showed a higher probability to wake up after an N3 bout ended than controls, and this probability increased with N3 bout duration. Bouts longer than 15 min resulted in an awakening in 73% and 34% of the time in patients and controls, respectively. Behavioural episodes reduced over sleep cycles due to a reduction in N3 sleep and a reducing ratio between behavioural and non-behavioural awakenings. In the first two cycles, N3 bouts prior to non-behavioural awakenings were significantly shorter than N3 bouts advancing behavioural awakenings in patients, and N3 awakenings in controls. Our findings provide insights in the timing and prospect of both behavioural and non-behavioural awakenings from N3, which may result in prediction and potentially prevention of behavioural episodes. This work, moreover, leads to a more complete characterization of a prototypical hypnogram of parasomnias, which could facilitate diagnosis.

Probable Parasomnias and Mortality: A Prospective Study in US Men

ObjectiveTo examine the association between parasomnias, including rapid eye movement sleep behavior disorder (RBD) and sleep walking (SW), and mortality risk in a large-scale population-based cohort. MethodsThis prospective cohort study was based on 25,695 participants from the Health Professionals Follow-up Study, a population-based cohort of male health professionals in the United States. Probable SW (pSW) and probable RBD (pRBD) were measured by questions adapted from the Mayo Sleep Questionnaire in 2012. All-cause mortality and cause-specific mortality were ascertained through the national registry, reports by the families, and the postal system from January 1, 2012, through June 30, 2018. ResultsOf the studied population, 223 reported pSW and 2720 reported pRBD. During 6 years of follow-up (2012 to 2018), 4743 mortality cases were documented. The co-occurrence of both probable parasomnias was associated with higher all-cause mortality risk (Ptrend=.008), and the adjusted hazard ratio (HR) of mortality was 1.65 (95% CI, 1.20 to 2.28) compared with participants without either probable parasomnia after adjustment for major lifestyle, sleep, and metabolic risk factors, and chronic diseases. Significant associations were found for mortality attributed to neurodegenerative diseases (adjusted HR for both parasomnias vs none, 4.57; 95% CI, 2.62 to 7.97) and accidents (adjusted HR for both parasomnias vs none, 7.36; 95% CI, 2.95 to 18.4). Having pSW alone was associated with all-cause mortality, and pSW and pRBD were individually associated with mortality attributed to neurodegenerative diseases and accidents too (P<.05 for all). ConclusionProbable parasomnia was associated with a higher risk of all-cause mortality and mortality attributed to neurodegenerative diseases and accidents.

Science and the 'emancipation of the mind': dreams, the mind, and slavery.

Dreams were a subject of interest to philosophers thinking about the connection between the mind and the body in the nineteenth century. Many scholars have pointed out that the mind and the body were intimately linked and affected each other. Although science was on its way to becoming more technical and numbers focused in its investigatory practices, medical students and other physician-philosophers investigated the nature of sleep and dreams. Medical students and advanced researchers speculated on the nature of consciousness and mused on where the mind travels to during the sleep processes. Other romantic figures like Dr Polydori speculated on the nature of sleep walking in their medical dissertations. Dreams also had a powerful moral and motivational component, as dreams and activities in dreams, drove people like Benjamin Rush to embrace abolition. Other promoters of abolition used the nature of dreams to discusses the dreadfulness and suffering of slavery.

Clozapine-Induced Somnambulism in a 55-year-old Lady with Psychotic Depression: A Case Report

Sleep walking disorder or somnambulism is a parasomnia that occurs in non-rapid eye movement sleep (NREM) characterized by an individual arising from bed and ambulating without fully awakening. It is known to be associated with multiple medications and has been reported with atypical antipsychotics. Here, we report a case of sleep walking induced by clozapine; before this, there have only been two reported cases of clozapine induced somnambulism.

1036 Traumatic Complications of Unrecognized Somnambulance in a Pediatric Patient

Abstract Introduction Parasomnias are unusual, disruptive, and abnormal verbal or motor events that occur during sleep or between wake and sleep transitions. They can occur in non-rapid eye movement (NREM) or rapid eye movement (REM) sleep stages. NREM parasomnias are typically more prevalent in pediatric populations. One such NREM parasomnia is sleep walking or somnambulance. One study estimates somnambulance has a prevalence of 17% in ages 3-13 years¹. Somnambulance typically occurs during stage 3 sleep which is clustered in the first half of sleep when REM is less prevalent Report of case(s) A 4-year-old previously healthy male presented to clinic for a somnambulance consult. Around 6 months prior, his parents awoke around 3 AM to check on their crying infant, a sibling of our patient, and noticed the patient was missing. They noticed the back door open. Two blocks away they saw police lights and found he had been hit by a vehicle. He was admitted to the hospital for polytrauma, including bilateral pulmonary contusions with acute respiratory failure, grade 4 liver and kidney lacerations, grade 3 adrenal injury, and right parietal lobe parenchymal and subarachnoid hemorrhages. He was later discharged in stable condition with persistent but improved spasticity, impaired mobility, and cognition. His parents had not noticed any prior episodes of somnambulance. However, they did report other frequent parasomnias: somniloquy and confusional arousals. These episodes were worse following late evenings. There was a strong family history of somnambulance in the parent’s siblings. They denied any sleep disordered breathing symptoms. Parents were reassured and educated about parasomnia's self-limited nature but to keep a safe environment and avoid sleep deprivation. Conclusion The majority of parasomnia in children have benign outcomes and eventual self-resolution with age. However, rare circumstances arise where these events can be hazardous including sleep-cooking, risking fire and burns or, as in this case, unknowingly walking into traffic. A sleep study is not always needed as parasomnias are a clinical diagnosis. However, it’s important to note that if a patient has a history of parasomnias parents should be educated on the importance of keeping a safe environment to prevent possible harm. Support (if any)

Prevalence and pattern of sleep disorders in childhood

Background: Sleep disorders are very common in the population of children, with prevalence rates ranging from 25-40%, and they are often persistent. The aetiology of sleep problems is very complicated and depend on many varied factors. Psychological factors concerning family life and general state of health have a significant impact on children. Methods: A hospital based descriptive study was carried out among 1024 children visiting the paediatric outpatient departments of Madras medical college, Chennai and Al-Ameen medical college and hospital, Vijayapura over a period of 1 year from March 2022 to March 2023. An appropriate questionnaire was formulated that had to be filled by parents and those children with sleep problems interviewed and assessed using appropriate statistical methods. Results: Out of 1164 questionnaires, 1024 (88.97%) were filled completely and returned. The 497 (48.54%) boys and 527 (51.46%) girls were included in this study. Of the 1024 children, 621 (60.64%) had no sleep related problems. The 403 (39.36%) had one or more sleep related problem, which included 211 (52.36%) boys and 192 (47.64%) girls. Male children were more commonly affected with sleep disorders and there is statistically significant difference at 5% level among males and females in having sleep disorders (p&lt;0.05). Conclusions: Most of the children studied had only 1 of sleep disorders of which males outnumbered females. Sleep disorders were predominantly found in the age group of 7-10 years among which most common sleep related disorder was nocturnal enuresis. The study also showed that sleep walking is usually associated with another sleep disorder.

Retrospective Analysis of Walking Distance and Use of Medication After Bariatric Surgery

Aim: The objective of this study was to ascertain the drug use and walking distance of individuals after bariatric surgery.&#x0D; Material and Methods: The sample of the study consisted of 165 individuals. Individuals who underwent bariatric surgery were examined retrospectively after their operations. Data were collected using the Personal Information Form and the Walking Impairment Questionnaire.&#x0D; Results: The mean age of the individuals included in the study was 40.22±9.63. 52.1% of individuals were female. The body mass index of individuals was 39.63±4.69 before bariatric surgery and 23.94±2.57 in the first year follow-up after bariatric surgery. Forty percent of individuals did not have any chronic illnesses. Among individuals who had been on medication before surgery, 72.4% of those taking psychiatric medications, 57.5% of those taking diabetes medications, and 16% of those taking heart medications discontinued medications after their operations. 81.8% of individuals reported improved sleep quality compared to the period before the operation. The walking distance level of the individuals showed a significant increase in the first year after bariatric surgery compared to the period&#x0D; before the surgery.&#x0D; Conclusion: The study showed that bariatric surgery is an effective method for weight loss and reduction of comorbidities, as well as leading to a statistically significant reduction in chronic drug use and an increase in sleep quality and walking distance of individuals

0646 Sleep Disorders and Sleep Medication Use in Youth with Persistent Tic Disorders

Abstract Introduction Sleep disturbance is present in 80% of youth with persistent tic disorders (PTD). However, studies examining rates of sleep disorders in youth with PTD are limited, and reports on sleep medication use in this population are lacking. Such knowledge would inform understanding of assessment and treatment needs of youth with PTD. Therefore, the present study examined rates of sleep disorders and sleep medication use among youth with PTD, and their associations with tic severity and ADHD symptoms. Methods Participants were 52 parents of youth with PTD who responded to an internet survey evaluating sleep-wake patterns. Youth were predominantly male (n = 37, 72.5%); and 88.5% (n = 46) were reported to have Tourette’s disorder and 11.5% (n = 6) were reported to have persistent motor tic disorder. Parents provided demographics and medical history, including lifetime sleep disorder diagnosis by a health professional and current prescription or over-the-counter sleep medication use. Parents rated youth tic severity (Parent Tic Questionnaire) and ADHD symptom severity (Swanson, Nolan, and Pelham-IV Parent Rating Scale). Results Descriptive statistics and independent samples t-tests were performed. Per parent report, 39.2% (n = 20) of youth with PTD had one or more lifetime sleep disorders. Insomnia (n = 9, 17.3%), nightmares (n = 9, 15.7%), sleep walking (n = 5, 10.0%), bruxism (n = 5, 10.0%), and restless leg syndrome (n = 5, 10.0%) were most commonly endorsed. Fifty percent of parents of youth with PTD endorsed youth sleep medication use. The most commonly endorsed sleep medications were melatonin (n = 23, 44.2%), valerian (n = 6, 11.5%), and diphenhydramine (n = 5, 9.6%). There were no significant group differences in tic severity or ADHD symptom severity. Conclusion Findings highlight the presence of disorders of sleep initiation and maintenance, parasomnias, and sleep-related movement disorders in youth with PTD. Results indicate that sleep medication use, particularly melatonin, is common in this population. Future research is needed to test the efficacy of melatonin use for addressing sleep problems in youth with PTDs. Support (If Any) NIMH K23 MH113884 funding to Dr. Ricketts.

Genetic Variant (rs2304672) in 5’ UTR region in PER2 gene and its association to Parasomnias and other sleep disorders in Puerto Rico

Sleeping is one of the main physiological processes of cellular and physiological restoration. Inadequate sleep patterns can impede adequate systemic restoration and can lead to the development of chronic health conditions. In 2014, both World Health Organization (WHO) and the Central Disease Control (CDC) in the United States categorized inadequate sleep patterns as a public health crisis. Both entities majorly agree that, approximately 40% of the general population suffers from sleep disorders, with 60% of these opt for medication to induce sleep. Researchers from Epidemiologist suggest that a series of external factors, have been theorized to contribute to lack in sleep quality. Including high levels of stress, sounds, and light quality. Alternatively, there has been a limitation regarding studying internal factors affecting sleep quality and sleep behavior. Parasomnia is an abnormal sleep behavior in any of the five sleep stages characterized by sleep walking, sleep talking, bedwetting, nightmare disorders, and sleep paralysis principally. To date, little is known about this sleep abnormality and its origins. In this study, we referenced data from the 1000 Genome Project to study the genetic variant (rs2304672) of the PER2 gene in Puerto Rico, whose general population houses the highest percentage of the variant in all the America’s. Provided data suggests that this genetic variant is linked to poor sleep quality and parasomnias. In Puerto Rico, modern demographics evidence that the population is comprised of three main ethnic groups. We theorize that a bottleneck effect is an influential factor in the distribution and prevalence of said genetic variant in the island. Our results found that the genetic variant is common in the southwestern and southeastern coastal regions of Puerto Rico. Additionally, we found that the genetic variant frequency in the entire island is of 3.83% in the general population of Puerto Rico.

The Association Between Gait Speed and Sleep Problems Among Chinese Adults Aged 50 and Greater

ObjectiveThe relationship between sleep problems and walking speed has been less explored. The present cross-sectional study was to investigate the association between sleep quality and sleep duration and gait speed in Chinese adults.MethodsA total of 13,367 participants were recruited in this cross-sectional study, retrieving the data from the Global Aging and Adult Health Survey (SAGE). Gait speed was measured using the 4-m walking test. Age, sex, education years, smoking status, alcohol consumption, physical activity, chronic disease, sleep problems were self-reported by participants. To explore the association between sleep problems and gait speed, multivariate linear regression models were employed.ResultsIn the adjusted model, poor sleep quality and longer sleep duration were significantly associated with slower normal walking speed in Chinese adults (p < 0.001). Moreover, there were negatively significant associations between normal gait speed and sleep quality in male adults (p < 0.01).ConclusionThe findings suggest that slower normal walking speed was associated with poor sleep quality and longer sleep duration (>8 h) in Chinese male adults.

Validation of the Dutch translation of the Paris Arousal Disorders Severity Scale for non-REM parasomnias in a 1-year and 1-month version.

We created a Dutch version of the Paris Arousal Disorders Severity Scale (PADSS), which assesses non-rapid eye movement (NREM) parasomnia symptoms over the past year (PADSS-year). This questionnaire was previously validated in patients with sleep walking and/or sleep terrors (SW/ST). We validated the questionnaire in SW/ST patients, and in a broader population, including patients with confusional arousals, comorbidities, and medication users ("other NREM parasomnias"). Furthermore, we introduced a version covering the past month (PADSS-month), with the potential purpose of evaluating symptom evolution and treatment response. We compared PADSS scores among 54 SW/ST patients, 34 age-matched controls, and 23 patients with other NREM parasomnias. We evaluated discriminative capacity, internal consistency, and construct validity. Furthermore, we assessed the test-retest reliability and treatment response of PADSS-month. Healthy controls scored significantly lower than both patient groups. We found an excellent diagnostic accuracy (area under the curve PADSS-year 0.990, PADSS-month 0.987) and an acceptable internal consistency. Exploratory factor analysis identified 3 components: "behaviors outside the bed," "behaviors in/around the bed," and "violent behaviors," with the former 2 factors reflecting the distinction between SW and ST. PADSS-month showed an acceptable test-retest reliability (0.75). Additionally, PADSS-month significantly decreased after pharmaceutical and/or behavioral treatment. This change was correlated with the clinical impression of the caregiver, implying that PADSS-month is sensitive to treatment effects. The Dutch PADSS questionnaire can be used as a screening tool in a broad population of patients with NREM parasomnia, not only SW/ST. Furthermore, we validated a PADSS-month version to assess the evolution of symptoms and treatment effect. van Mierlo P, Hermans L, Arnulf I, Pijpers A, Overeem S, van Gilst M. Validation of the Dutch translation of the Paris Arousal Disorders Severity Scale for non-REM parasomnias in a 1-year and 1-month version. J Clin Sleep Med. 2022;18(4):1135-1143.

Combination of Obstructive and Central Sleep Apnea as a Non-Sleepy Phenotype of Obstructive Sleep Apnea (OSA): A Case Report and Literature Review

Background and Objective: Co-occurring central sleep apnea (CSA) and obstructive sleep apnea (OSA) are a developing apprehension because many patients referred to sleep studies have co-morbidities such as cardiovascular and/or neurological disorders which increase the possibility of central and obstructive episodes. Here, we report a patient without excessive daytime sleepiness and a combination of CSA and OSA. Case Report: We present a 16-year-old boy with a history of snoring, poor quality of sleep, nightmare, sleep walking, and sleep talking since he was two-years old. His STOP-Bang score was 7. Standard attended polysomnography (PSG) with audio-video monitoring was performed. The PSG results contained Apnea Hypopnea Index (AHI): 30.2 (number of OSAs was 50 and number of CSAs was 49 during sleep). Then, a titration study was performed and continuous positive airway pressure (CPAP) setting as low as eight cmH2O was effective in eliminating obstructive events, but there was emerging CSAs in favour of Treatment Emergent CSA (TCSA). Conclusion: This case represents a non-sleepy phenotype of OSA in combination with many CSAs in PSG. We suggest that further studies be performed on the association between the concomitant presence of CSA and OSA among nonsleepy patients with OSA.

Polysomnography Is an Important Method for Diagnosing Pediatric Sleep Problems: Experience of One Children's Hospital.

In this study, we collected and analyzed polysomnography (PSG) data to investigate the value of PSG in diagnosing sleep problems in children. The results of PSG studies of children (<18 years old) with sleep problems conducted from April 2015 to May 2017 at a children’s hospital in Taiwan were collected and analyzed retrospectively. Data for 310 patients (209 males and 101 females) who underwent PSG were collected. The final diagnoses were as follows: obstructive sleep apnea in 159 (51.3%), snoring in 81 (26.4%), limb movement sleep disorder in 25 (8.1%), hypersomnias in 12 (3.9%), central apnea in 8 (2.9%), enuresis in 7 (2.3%), bruxism in 5 (1.6%), sleep terrors in 5 (1.6%), narcolepsy in 3 (1.0%), sleep seizures in 3 (1.0%), sleep walking in 1 (0.3%), and insomnia in 1 (0.3%). PSG may help detect significant sleep-related problems in children and is useful for making therapeutic decisions regarding children. Obstructive sleep apnea syndrome (OSAS) was the primary sleep problem for most of the children (51.3%); however, only 7.4% of them underwent surgery for OSAS. We therefore suggest that children with sleep problems should undergo PSG.

Effective Treatment of Adult Parasomnias with Keishikaryukotsuboreito in Four Cases.

Parasomnias are undesirable behaviors or experiences during sleep that manifest clinically as abnormal behavior, emotions, and nightmares. We herein report four elderly parasomnia patients who were successfully treated for abnormal nocturnal behaviors, including rapid eye movement (REM) sleep behavior disorders, with Keishikaryukotsuboreito (KRB), a Japanese traditional herbal medicine. KRB resolved nocturnal violent behaviors and sleep walking without any adverse effects. In one patient, occipital dominant spike-wave complexes induced by 3-Hz photic stimulation were reduced after KRB treatment, suggesting that KRB has inhibitory effects on brain irritability. KRB may represent a safe therapeutic option for treating parasomnias in the elderly.

Olanzapine-Related Somnambulism: A Systematic Review of Literature and a Case Report of Anorexia Nervosa.

Somnambulism, or sleepwalking (SW), is one of the most common forms of arousal parasomnias. It is characterized by different complex motor behaviors leading to unwanted movements in bed or walking during sleep. It can be the consequence of psychological stress, abnormal breathing during sleep, high fever, or drug adverse effects. There is evidence of an association between antipsychotic treatment, including olanzapine, and SW. We present the case of a patient experiencing treatment-resistant anorexia nervosa whose somnambulism re-exacerbated after the addition of a low dose of olanzapine, following the CARE (CAse REport) Statement and Checklist. We also conducted a systematic review of the literature on olanzapine-induced somnambulism following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, PsychINFO, and the Cochrane Library databases were independently reviewed up to January 2021 for articles reporting olanzapine-related somnambulism cases, without language or time restriction. We describe a case of somnambulism in a patient initially admitted to our hospital for anorexia nervosa and treated with a low dose of olanzapine. This is the first case of SW induced by olanzapine in eating disorders to be reported. Up-to-date olanzapine-related somnambulism was described in 8 patients experiencing psychiatric disorders (ie, schizophrenia and bipolar disorder). To provide a reliable estimate of incidence and prevalence for olanzapine-related somnambulism, large-scale, pharmacovigilance studies are required, to allow for comparisons of overall clinical characteristics, outcomes, including time to recovery, between different treatment options. Clinician awareness should be enhanced, and attention should be given to such infrequent adverse effects associated with antipsychotics.

Relative frequency of drug-induced sleep disorders for 32 antidepressants in a large set of Internet user reviews.

It is known that antidepressant drugs can induce sleep disorders in patients, but little data exist about high or low-risk molecules. The aim was to study the frequency of antidepressant drug-induced sleep disorders (DISD) by molecule. 77,391 patient comments for 32 antidepressant drugs were collected from drug review websites and screened for DISD. Association between drugs and nightmare disorder, restless legs syndrome, sleep paralysis, sleep terrors, sleep-related hallucinations, or sleep walking was expressed as relative proportion [proportional reporting ratio (PRR)]. A detailed analysis of the content of the dreams was also carried out. Amitriptyline, doxepin, fluvoxamine, mirtazapine, nortriptyline, trazodone, venlafaxine, and vilazodone were associated with a greater frequency of DISD compared to other antidepressants. Vilazodone heavily increased the probability of developing 5 of the 6 studied DISD (PRR 3.3 to 19.3) and mirtazapine increased the probability of developing 4 DISD (PRR 2.4 to 6.4). Bupropion and citalopram were associated with lower probabilities for 5 DISD (PRR 0.2 to 0.7). Sentiment analysis showed that patients described disturbing dreams for vilazodone or mirtazapine and strange but less negative dreams for bupropion, citalopram, or duloxetine. Relative frequencies of sleep disorders were obtained for a vast panel of antidepressant drugs through an original analysis of user's drug reviews on drug rating websites. Our results could guide clinicians in the appropriate choice of antidepressant drugs for high DISD-risk patients in need of such treatment. These results may however be cautiously taken, considering the uncertain reliability and generalizability of web-based data.

863 When sleep takes you to unwanted places?

Abstract Introduction Somnambulism is a parasomnia occurring in non-rapid eye movement sleep, and is characterized by ambulation as a disorder of arousal regulation. Sleep deprivation, alcohol abuse, fragmented sleep and certain medications can increase the risk of sleep walking. Report of case(s) Here we present a 35-year-old man with multiple triggers for sleep walking, resulting in recurrent parasomnia events over fifteen years. He had a history of bipolar disorder, post-traumatic stress disorder (PTSD), chronic insomnia, moderate untreated obstructive sleep apnea (OSA), anxiety with violent daytime behaviors, and prior alcohol abuse status post six years of sobriety. He was sent to our clinic due to increased frequency and severity of events, with nightly events for the last five years. Episodes were characterized by walking around the home, leaving the home, and driving on occasion. He reported at least one minor car accident as a result of sleep driving. He also reported an injury resulting from a fall in his home while sleep walking. Several security measures were implemented, including door gates, door alarms, and hiding car keys. His family slept in different bedrooms with locked doors for safety. The patient’s chronic insomnia improved with cognitive behavioral therapy, leading to an average sleep time of five hours per night with no reported hypersomnia or daytime fatigue. After his initial evaluation, he was referred for a mandibular advancement device for treatment of his OSA, due to prior poor compliance with positive airway pressure therapy related to his PTSD. Optimizing his OSA helped decrease arousals that might trigger sleep walking events. He also maintained close follow up with mental health for pharmacotherapy and psychological therapy. Treatment with clonazepam 0.25 mg at bedtime was initiated given the severity of his somnambulism. Conclusion The use of a benzodiazepine can reduce slow wave sleep duration by its effect on the inhibitory neurotransmitter gamma aminobutyric acid (GABA). Our patient had multiple risk factors for parasomnias, with severe, frequent episodes of sleepwalking leading to self-injury. His treatment involved both pharmacotherapy as well as optimization of underlying triggers. Support (if any):

817 A Case of Parasomnia Overlap Disorder in a Patient on Lithium

Abstract Introduction The literature contains few case reports of parasomnia overlap disorder. There are also few case reports of lithium inducing sleep walking behaviors. Here we seek to present a case of a patient with multiple parasomnias, is taking a number of psychotropic medications for bipolar I disorder, and is on PAP for OSA. Report of case(s) The patient is a 43 year old male with a history of occasional mild sleep walking since childhood that remitted approximately 10 years prior to the onset of treatment, but returned when he traveled out of area for a family gathering approximately one year prior to presentation in the sleep clinic. He reported not only the return of sleepwalking, on a nightly basis, as well as more severe symptoms (including enuresis and violence/aggression). He also reported several episodes of dream enactment, as well as a history of sleep paralysis and vivid hypnogogic hallucinations, both of which had been improved in the last year. He denied any history of cataplexy. He did complain of symptoms of significant RLS symptoms. He was partially compliant with CPAP for obstructive sleep apnea, though the sleep behaviors continued regardless of CPAP usage. His psychiatrist had started him on clonazepam (titrated to 2mg/night) prior to his intake in the sleep clinic, but with minimal benefit. His other medications included propranolol 40mg BID, lithium 900mg/1200mg, oxcarbazepine 600mg bid, lamictal 225mg bid, lurasidone 80mg qday, and benztropine 2mg bid. Attended polysomnography demonstrated five episodes of sleep behaviors, as well as loss of atonia during REM, and severe obstructive sleep apnea (AHI of 61.2). Conclusion The patients various parasomnias could be due to the side effects of his psychotropic medications, represent a genetic or structural defect that is causing the various parasomnias, or be due to or worsened by his undertreated obstructive sleep apneas. His workup and treatment is still ongoing, but he has continued on clonazepam 2mg but taken 2 hours earlier, and has started a new APAP. Because of the severity of his bipolar disorder (including severe suicidal ideation), he is not a candidate to tapering the lithium or to taking serotonergic antidepressants. Support (if any):