Things That Go Bump in the Night

A 32-year-old woman with a history of bipolar disorder presented in clinic with 10 years of unusual sleep behaviors. She had a history of uncategorized epileptiform activity in childhood while awake and sleeping; a prior sleep study showed alpha activity in posterior channels during these episodes consistent with wakefulness, possibly psychogenic disorders. Initial differential also included nocturnal seizures, REM sleep behavior disorder (RBD), and NREM parasomnias. Ultimately polysomnogram with extended EEG montage confirmed presence of motor activity consistent with NREM parasomnias, with multiple arousals from stage N3 sleep associated with these episodes. While there are clinical features that differentiate nocturnal seizures, NREM parasomnias, and RBD, extended EEG montage is necessary as NREM parasomnias often show a mix of awake and N3 sleep waveforms. In addition, general psychiatric comorbidity should not automatically predispose to psychogenic disorder diagnosis, as they are more specifically correlated with a history of trauma or abuse.