Trichotillomania and Non-Epileptic Seizures as Sleep-Related Dissociative Phenomena

271 Journal of Clinical Sleep Medicine, Vol. 11, No. 3, 2015 The occurrence of non-epileptic seizures (NES) and trichotillomania during sleep is rare. We describe the case of an adult woman with a personal history of childhood maltreatment and psychiatric morbidity (major depression, trichotillomania, and conversion disorder), who was referred to the sleep unit because of nocturnal hair-pulling and psychomotor agitation during sleep. An all-night PSG recording with audiovisual monitoring docu- mented seven episodes of trichotillomania and one NES, all of which arose from unequivocal wakefulness. Improvement of nocturnal behaviors was observed after long-term psychotherapy. This case illustrates that nocturnal trichotillomania and NES may be symptoms of a sleep-related dissociative disorder. Keywords: trichotillomania, dissociative disorder, parasomnia, convulsion, non-epileptic, sleep Citation: Angulo-Franco M, Bush-Martínez A, Nenclares- Portocarrero A, Jiménez-Genchi A. Trichotillomania and non-epileptic seizures as sleep-related dissociative phenomena. J Clin Sleep Med 2015;11(3):271–273. pii: jc-00331-14 http://dx.doi.org/10.5664/jcsm.4542 S leep-related dissociative disorders (SRDD) are defined as dissociative disorders that can arise throughout the sleep period during well-established wakefulness. 1 Nocturnal behavior of patients with SRDD may correspond to the behaviors observed in dissociative disorders (DD; ≥ 2 distinct personality states or a nocturnal fugue). However, some patients have presented nocturnal behaviors that represent reenactments of past traumatic incidents, self-mutilating behaviors, violent behavior, and psychogenic events. 1,2 This suggests that behaviors in SRDD may resemble daytime DD but are not limited to them. Herein we describe the case of a patient with sleep-related trichotillomania and psychogenic non-epileptic seizures (NES) as symptoms of nocturnal dissociation. REPORT OF CASE Mrs. B is a 41-year-old woman with a personal history of se- vere childhood maltreatment. In association to childhood abuse, she experienced episodes of intense anxiety, which sometimes triggered seizure-like events characterized by tremor-like movements of the jaw, then in the arms and legs, and finally in the whole body. After these events, she frequently presented a distinctive hair-pulling behavior. First, she pulled hair out from her scalp one by one until she had approximately 40 in her hand. Then she felt the urge to introduce them into the ear; after this, she manipulated them trying to separate them into two halves. The ritual ended when she swallowed hair or threw it away. When she was 39 years old, she came to our institution because of persistent anxiety and depressive symptoms and frequent seizure-like events. A major depressive disorder, conversion disorder and trichotillomania were identified. A routine EEG and a brain CT scan showed no abnormali- ties. Treatment with sertraline, clonazepam, and supportive Trichotillomania and Non-Epileptic Seizures as Sleep-Related Dissociative Phenomena Melina Angulo-Franco, MD; Alejandra Bush-Martínez, MD; Alejandro Nenclares-Portocarrero, MD; Alejandro Jiménez-Genchi, MD, MS Servicios Clínicos, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Tlalpan, México C ASE R EPORTS psychotherapy produced significant improvement. After two years, she was referred to the sleep clinic because on wak- ing up in the morning she discovered she was holding hairs in her hands and there were also many hairs over the bed. According to her daughter, Mrs. B would often show hair- pulling during the night but had no recollection whatsoever of this behavior; however, sometimes she would dream about the hair-pulling act. She also complained of insomnia, night- mare-related psychomotor agitation, and exhibited violent behavior. A polysomnographic recording with audiovisual monitoring was performed. Ninety minutes after sleep onset, she had an arousal, and 90 sec later the patient initiated a distinctive hair- pulling behavior (Figure 1 and Video 1 ). First she selected one hair and pulled it out from her scalp; she then put the hair in front of her face and tried to straighten it up; afterwards, she placed it inside her left ear for a few seconds before finally throwing it away. She had 7 hair-pulling events of similar char- acteristics throughout the night. All of the events arose from an EEG wakefulness state with alpha rhythm preceding the episodes; no epileptiform activity was noted. These awakenings were preceded by different NREM sleep stages (Figure 2), and they were not associated with respiratory events or leg movements (both the apnea-hypopnea index of 1.6/h and the peri- odic limb movements of sleep index 1.3/h were normal). Six hours 50 minutes after sleep onset she presented an episode characterized by flailing movements, beginning with the legs, then the arms, and finally the whole body; the episode finished with head-banging movements. Moaning and cries were pres- ent during the entire 143-sec attack. This episode arose from a wakefulness state, and no epileptic discharges were observed. During the follow-up, NES and hair-pulling showed very slow improvement until remission after two years in psychotherapy and attendance to a self-help group. Downloaded from jcsm.aasm.org by 27.79.76.86 on May 11, 2023. For personal use only. No other uses without permission. Copyright 2023 American Academy of Sleep Medicine. All rights reserved.

Trichotillomania and Non-Epileptic Seizures as Sleep-Related Dissociative Phenomena

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