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FRONTIERS IN MEDICAL CASE REPORTS - Volume 2; Issue 2, (Mar-Apr, 2021)

Pages: 1-04

Date of Publication: 30-Mar-2021

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Clinical Alteration of Sleep Related Dissociative Disorder into Psychogenic Nonepileptic Seizure in an Adolescent Girl with The History of Physical Abuse in Early Childhood

Author: Aylin Yetim, Alper Alnak, Yesfa Sebnem Aydin, Kemal Gudek, Ismail Yildiz, Firdevs Bas, Ayse Kilic

Category: Medical Case Reports


Sleep related dissociative disorder is a parasomnia and may be related to childhood adverse events including sexual and/or physical abuse. In this case report, we present a 15-year-old girl with a history of multiple episodes of somnambulism and a family history of multiple relatives with somnambulism, who was admitted to our emergency unit after attempting suicide during sleep. In her 5-year follow-up, parasomnias were replaced by psychogenic non-epileptic seizure attacks. An experience of severe physical abuse in early childhood was uncovered.

Keywords: Sleep Related Dissociative Disorder, Somnambulism, Dissociative Identity Disorder, Suicide Attempt


Full Text:


Sleep related dissociative disorder (SRDD) is defined as a parasomnia in the third edition of the International Classification of Sleep Disorders (ICSD) and accepted as a variant of dissociative disorders (American Academy of Sleep Medicine, 2014; American Psychiatric Association, 2013). Five subtypes of dissociative disorders are defined in Diagnostic and Statistical Manual of Mental Disorders 5. Edition (DSM-5): dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder. In SRDD, dissociative experiences tend to emerge during periods of sleep-wake transitions and, unlike other parasomnias, it is accompanied by full wakefulness on electroencephalogram (EEG) (Genchi, 2017). SRDDs are considered to be psychogenic in etiology, and are sometimes referred to as “dissociative pseudoparasomnia”. They are characterized as psychiatric parasomnias, are usually related to childhood sexual or physical abuse and are often recognized during adolescence (Hartman et al., 2001). Somnambulism (sleepwalking) may also be seen as a part of SRDD (Genchi, 2017; Hartman et al., 2001).

Psychogenic non-epileptic seizures (PNES) are paroxysmal events without corresponding electrophysiological changes on EEG. PNES are seen mostly in adolescents with psychoemotional difficulties, with a psychogenic etiology (Heyer, 2018).

In this case report, we describe a 15-year-old adolescent girl with the diagnosis of other specified dissociative disorder, along with a history of multiple episodes of somnambulism, who was admitted to an emergency unit because of a suicide attempt by taking multiple pills during sleep. During her five year follow-up there was a transition of symptoms from SRDD to PNES.


A fifteen-year-old girl who had taken a large amount of medication, was admitted to our emergency unit by her parents. In her statement, she reported that she was not aware of taking pills and did not remember anything about this event. Her parents stated that she was asleep and regained consciousness after stimulation. In her detailed history, when she was three years old, her father had observed her talking during sleep, reportedly saying 'kill me, I want to die'. Parents also reported that she continued to have episodes of sleep talking and sleepwalking at intervals. Her family history was also remarkable for episodes of somnambulism in multiple relatives.

On examination she had a good general condition, was fully conscious and cooperative. Her physical systemic examination was normal. Her biochemical and metabolic tests were normal. There was no thyroid dysfunction. Electroencephalogram (EEG) and cranial magnetic resonance imaging were also normal. There was a dissociative episode after awakening from a period of rapid eye movement (REM) sleep during polysomnography. Along with symptoms of dissociative disorder, including amnesia and fugue, depressive symptoms were noted in her psychiatric assessment. On careful questioning, it was discovered that the patient had been abused physically and emotionally and had lived in a high-risk environment for sexual abuse during early childhood.

The patient was diagnosed with SRDD and followed-up by psychiatric and adolescent centers. During her five years of follow-up, she received intensive psychotherapy treatment along with pharmacological intervention, including antidepressants and antipsychotics (fluoxetine up to 40 mg/day, sertraline up to 100 mg/day and risperidone up to 1 mg/day). While her episodes of somnambulism gradually decreased in number and had resolved completely at the end of the first year, she began to experience episodes of PNES during daytime, mostly in school. During this period, she had continued to receive weekly individual supportive psychotherapy without any change in her medical treatment regimen. While PNES attacks were frequent in the first years, the frequency of PNES episodes has decreased over time.


In the presence of somnambulism and self-injurious behaviour without conscious awareness, it is important to keep the possibility of SRDD in mind (Genchi, 2017). In a recent study comparing patients with dissociative disorders (DID), those with other psychiatric disorders and healthy subjects, experiences of somnambulism, trance and possession were found to be higher in the DID group than the other two groups (Ross, 2011). While somnambulism is common in the general population with a prevalence of up to 5% in children (Stallman and Kohler, 2016), and may be even higher in those with family history of somnambulism, self-harming behaviour is rarely seen. In our patient, a suicide attempt during the somnambulism episode led us to consider other types of parasomnia and, consequently, the diagnosis of SRDD was initially assigned. During her follow-up, her symptom phenomenology evolved and attacks of daytime PNES emerged, immediately after complete resolution of SRDD. While nocturnal episodes of PNES have been previously reported in subjects with SRDD (Genchi, 2017), to the best of our knowledge, this is the first case to be reported in which daytime PNES emerged after resolution of SRDD symptoms.

In the presence of unusual symptoms and/or accompanying psychiatric symptoms in SRDD patients, it is important to consider psychogenic causes, since these patients may benefit greatly from psychopharmacological, psychotherapeutic and/or counseling intervention. In conclusion, complaints of patients with SRDD may be replaced by other psychogenic disorders during the natural history of the clinical process. Obtaining a detailed history of the patient and careful monitoring of clinical progress and the treatment process is important, as was demonstrated in the case presented here.

Consent: Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Competing Interests: The author(s) declare that they have no competing interests.


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