Sleep Disorders

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Nocturnally occurring seizures may resist antiepileptic therapy. Both seizure-related sleep disruption and antiepileptic drugs may produce excessive daytime sleep and mental sluggishness. Several nonepileptic parasom-nias share features with epileptic conditions by interrupting sleep. These also lead to daytime fatigue and sleepiness, possibly compounded by unnecessary antiepileptic medication. Sleep deprivation from para-somnias could aggravate a true epileptic tendency. The foregoing considerations require that the investigation and management of possible seizure disorders include a description of such somnogenic events and scrutiny for symptoms of sleep deprivation (see also Chapter 16).

Broughton (102) described three phenomena that superficially resemble dyscognitive (formerly known as complex partial) seizures: confusional awakenings (CA), sleep terrors (ST), and sleep walking (SW). CA develop from sleep stages 3 or 4 in the early night (103). The EEG consists of diffuse medium voltage theta, possibly with V-waves superimposed, or unreactive alpha. Arousal from rapid eye movement (REM) sleep may be accompanied by a visual hallucination, a possible dream remnant. ST principally afflicts children, developing in stages 3 or 4 of non-REM sleep. Inconsolable anxious behavior occurs, occasionally with screaming and subjective "single frame" imagery. The EEG during such an event depicts a transition from stage 3 to 4 non-REM sleep to low-voltage, high-frequency nonepileptic activity. SW, manifested by stereotyped behavior, such as dressing or eating while remaining inattentive to stimuli, also emerges from non-REM sleep in otherwise normal children. Diffuse theta or nonreactive alpha appear on EEG.

Emotional stress, alcohol and drugs (prescription or illicit), depriving the subject of sleep may evoke REM rebound on a succeeding night, thus producing terrifying dreams. REM-onset sleep or a higher than normal REM sleep proportion is the EEG reflection of this circumstance.

REM sleep without atonia may develop in the elderly or in disease states, allowing kicking, diving from bed, punching, or rapid walking to occur in the second half of the night, presumably in response to dream content. The EEG discloses REM sleep and low-amplitude patterns that may evolve to features of wakefulness.

Nocturnal enuresis, head banging, and hypnogenic paroxysmal dystonia are other nonepileptic parasomnias.

If not unraveled by a careful history, nocturnal polysomnography may disclose the patterns described above and thus yield a diagnosis. The unlikely possibility of epilepsy lurking in an occult frontal lobe surface may linger. However, untreated, the occurrence of a secondarily generalized tonic-clonic seizure would ultimately unravel the mystery.

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