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To investigate clinical and video-polysomnography (VPSG) findings of hallucinatory experiences in patients suffering from disorders of arousal (DOA) in the absence of other pathologies.The authors retrospectively reviewed the records of 370 adults with DOA. Thirty (8.1%) patients concomitantly reported complex nocturnal visual hallucinations. VPSG recordings were scrutinized, and motor behavioral and electroencephalogram (EEG) patterns were classified according to previous descriptions of DOA.Thirty DOA patients reported seeing images of objects, people, and animals; either distorted, static, or mobile. The images disappeared with increased illumination in 80% of patients, and 23.3% reported preceding dream imagery. In addition to the classical DOA patterns on VPSG, a distinct pattern of behavioral and EEG manifestation associated with complex hallucinatory episodes was identified in 16 (53.3%) DOA patients. This consisted of low-voltage mixed-frequency EEG activity before eye opening that persisted while patients were observed staring or visually tracking before the onset of motor behavior.A novel, distinct behavioral and EEG pattern in patients with DOA and history of reported complex nocturnal visual hallucinations was identified. This may represent a unique phenotype of dissociation between sleep states that merits further investigation.

Introduction We aim to quantify adherence of positive airway pressure (PAP) initiated during the COVID-19 pandemic and compare the effects of remote versus face-to-face (FTF) education in patients with obstructive sleep apnoea (OSA). Methods Prospective cohort study in a tertiary National Health Service (NHS) hospital sleep disorders centre in London, United Kingdom, involving 141 patients aged >18 years with newly diagnosed OSA initiating PAP during the first national coronavirus (COVID-19) lockdown in 2020. We compare 70 patients educated on PAP remotely to 71 patients receiving standard FTF education. We measured adherence over a continuous 30-day period within the first three months of PAP usage, including average nightly usage, usage per nights used, percentage of nights used, and percentage of nights used for >4 hours. Results Of 141 patients, there was a two-thirds male predominance, and half of the patients (56%) above 45 years of age and sleepy at baseline (Epworth Sleepiness Score >10, 48.9%). 114 patients (81%) were diagnosed with moderate or severe OSA. 54 patients (38.3%) achieved good adherence (≥70% of nights with ≥4 hours usage), with an average of 4.7 hours of PAP usage per night used. Patients receiving FTF PAP education had a comparable level of good adherence (38.03% versus 38.57%, p=0.915), and hours per nights used (4.76 versus 4.61 h/night, p=0.711) to remotely educated patients. More severe OSA, lower mask leak, and a nasal mask were associated with achieving good PAP adherence. Discussion PAP adherence of newly diagnosed individuals with OSA during the COVID-19 pandemic was modest at 38.30%, and not significantly affected by remote PAP education delivery, but rather the effects of the COVID-19 pandemic.

Copyright © 2021 O’Regan, Nesbitt, Biabani, Drakatos, Selsick, Leschziner, Steier, Birdseye, Duncan, Higgins, Kumari, Stokes, Young and Rosenzweig. Background: Following the success of Cognitive Behavioral Therapy (CBT) for insomnia, there has been a growing recognition that similar treatment approaches might be equally beneficial for other major sleep disorders, including non-rapid eye movement (NREM) parasomnias. We have developed a novel, group-based, CBT-program for NREM parasomnias (CBT-NREMP), with the primary aim of reducing NREM parasomnia severity with relatively few treatment sessions. Methods: We investigated the effectiveness of CBT-NREMP in 46 retrospectively-identified patients, who completed five outpatient therapy sessions. The outcomes pre- and post- CBT-NREMP treatment on clinical measures of insomnia (Insomnia Severity Index), NREM parasomnias (Paris Arousal Disorders Severity Scale) and anxiety and depression (Hospital Anxiety and Depression Scale), were retrospectively collected and analyzed. In order to investigate the temporal stability of CBT-NREMP, we also assessed a subgroup of 8 patients during the 3 to 6 months follow-up period. Results: CBT-NREMP led to a reduction in clinical measures of NREM parasomnia, insomnia, and anxiety and depression severities [pre- vs. post-CBT-NREMP scores: P (Insomnia Severity Index) = 0.000054; P (Paris Arousal Disorders Severity Scale) = 0.00032; P (Hospital Anxiety and Depression Scale) = 0.037]. Improvements in clinical measures of NREM parasomnia and insomnia severities were similarly recorded for a subgroup of eight patients at follow-up, demonstrating that patients continued to improve post CBT-NREMP. Conclusion: Our findings suggest that group CBT-NREMP intervention is a safe, effective and promising treatment for NREM parasomnia, especially when precipitating and perpetuating factors are behaviorally and psychologically driven. Future randomized controlled trials are now required to robustly confirm these findings. National Institute for Health Research (NIHR) Biomedical Research Centre at South London; Maudsley NHS Foundation Trust and King's College London; National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London

Unlike sleep-walkers, patients with rapid-eye-movement-behaviour disorder (RBD) rarely leave the bed during the re-enactment of their dreams. RBD movements may be independent of spatial co-ordinates of the ‘outside-world’, and instead rely on (allocentric) brain-generated virtual space-maps, as evident by patients’ limited truncal/axial movements. To confirm this, a semiology analysis of video-polysomnography records of 38 RBD patients was undertaken and paradoxically restricted truncal/thoraco-lumbar movements during complex dream re-enactments demonstrated.

Unpleasant dreamlike mentation can occur during non-rapid eye movement parasomnias, leading to associated panic attacks. The mentations are rarely remembered and are likely underreported. However, they may lead to significant personal distress and, if not addressed, may contribute to poorer clinical outcomes. Cotard le délire de negation are very rare nihilistic delusions, historically described with psychotic disorders. Their association with a variety of neurologic disorders, including migraine and cluster-headache, has also been reported. Here we present three cases of Cotard parasomnia during which distinct states of consciousness defined by nihilistic ideation occurred. Patients described believing they are dead or dying, while unable to perceive or experience their bodies in whole, or in part, as their own. A source analysis of the electroencephalographic fingerprint of these mentations suggests right-hemispheric hypoactivity subsequent to confusional arousals. Mechanistically, an aberrant activation of two major intrinsic brain networks of wakefulness, the salience network and the default mode network, is argued. CITATION: Gnoni V, Higgins S, Nesbitt AD, et al. Cotard parasomnia: le délire de negation that occur during the sleep-wake dissociation? J Clin Sleep Med. 2020;16(6):971–976.

Although video polysomnography (vPSG) is not routinely recommended for the evaluation of typical cases of non-rapid eye movement (NREM) parasomnias, it can aid diagnosis of unusual cases, other sleep disorders and complicated cases with REM behaviour disorder (RBD), and in differentiating parasomnias from epilepsy. In this study, we aimed to assess vPSG findings in consecutive patients with a clinical diagnosis of NREM-parasomnia covering the whole phenotypic spectrum. Five hundred and twelve patients with a final diagnosis of NREM parasomnia who had undergone vPSG were retrospectively identified. vPSGs were analysed for features of NREM parasomnia and for the presence of other sleep disorders. Two hundred and six (40.0%) patients were clinically diagnosed with sleepwalking, 72 (14.1%) with sleep terrors, 39 (7.6%) with confusional arousals, 15 (2.9%) with sexsomnia, seven (1.4%) with sleep-related eating disorder, 122 (23.8%) with mixed phenotype, and 51 (10.0%) with parasomnia overlap disorder (POD). The vPSG supported the diagnosis of NREM parasomnia in 64.4% of the patients and of POD in 98%. In 28.9% of the patients, obstructive sleep apnea (OSA) or/and periodic limb movements during sleep (PLMS) were identified, most commonly in older, male, sleepy and obese patients. vPSG has a high diagnostic yield in patients with NREM parasomnia and should be routinely performed when there is diagnostic doubt, or in patients where there is a suspicion of OSA and PLMS.

Background: Continuous positive airway pressure (CPAP), the best available treatment for obstructive sleep apnea (OSA), requires long-term compliance to be effective. Behavioral interventions may be used to improve adherence to CPAP. We aimed to investigate whether positive or negative message framing impacts on CPAP compliance in patients with OSA, when compared to standard care. Methods: Consenting patients with confirmed OSA were randomly allocated to receive along with their CPAP either positively or negatively framed messages (Pos; Neg), or standard care (Con). Standardized motivational messages were read out to patients during an initial teaching session and through weekly telephone calls. Patients' compliance data were reviewed 2 and 6 weeks following CPAP initiation. Results: We randomized 112 patients to groups that were matched for age, BMI, and OSA severity. The positively framed group (Pos) showed greater CPAP usage after 2 weeks (total use 53.7±31.4 hours) as compared to the negatively framed and the control group (35.6±27.4 and 40.8±33.5 hours, P < 0.05); however, no differences were seen at 6 weeks. There were more dropouts in the control group than in either framed groups (Pos n=5; Neg n=8; Con n=11; P < 0.05). Conclusions: Positively framed messages can improve CPAP adherence in patients with OSA in the shortterm; however, strategies for implementing its long-term use need to be developed.

Catathrenia is an uncommon and poorly understood disorder, characterized by groaning during sleep occurring in tandem with prolonged expiration. Its classification, pathogenesis, and clinical relevance remain debated, substantially due to the limited number of cases reported to date. We report a series of consecutive cases of catathrenia, their clinical and polysomnographic characteristics, and their subsequent management.Consecutive patients with catathrenia who had undergone full polysomnography in our institution over a 5.5-year period were included. Catathrenia events (CEs) were examined in clusters, which formulated catathrenia periods (CPs). The relationships between CPs, sleep stage distribution, electroencephalogram (EEG) arousals, and other sleep parameters were assessed, along with the clinical presentation and management of catathrenic patients.A total of 427 CPs were identified in 38 patients, 81% arising from rapid eye movement (REM) sleep. EEG arousals preceded or coincided with the onset of 84% of CPs, which were of longer duration than those not associated with an arousal (57.3 ± 56.8 vs. 32.2 ± 29.4 s, p 0.001). Each CE had a characteristic airflow signal, with inspiration preceding a protracted expiration and a brief more rapid exhalation, followed by deep inspiration. Although the majority of patients were referred on the basis of bed partner complaints, 44.7% complained of daytime sleepiness. Continuous positive airway pressure therapy and sleep-consolidating pharmacotherapy led to subjective improvement, but were limited by poor long-term adherence.In the largest series of catathrenia patients reported to date, we found that this rare disorder is characterized by a distinct breathing pattern and arises predominantly from REM sleep, with arousals almost uniformly preceding or coinciding with the onset of CPs.

Background Obstructive sleep apnoea (OSA) is the most common form of sleep-disordered breathing, and the standard treatment is continuous positive airway pressure (CPAP). Emerging treatments for OSA, including electrical hypoglossal nerve stimulation (HNS) and non-invasive electrical stimulation (nES), are currently being developed. To involve patients in the development of research projects, we evaluated patients’ preference for different treatments of OSA using a short survey. Patients and methods We recorded patients’ age, gender, body-mass-index (BMI), Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ10), severity of OSA, and current treatment. We showed pictures of existing (CPAP, mandibular advancement device (MAD)) and emerging treatments (HNS and nES). We then asked 1) whether they were interested in further information about HNS/nES, 2) if they would be willing to try HNS/nES, and 3) if they were to choose only one of the four listed treatments, which one would they prefer to use every night. Results 162 patients completed the survey (81 males, mean age 52 (12) years, BMI 34 (7.3) kg/m2, ESS 10.2 (6.0) points, FOSQ10 28.5 (8.1) points). The majority of the respondents (89.5%) had been diagnosed with OSA, with 95.4% of those being treated with CPAP. 91.3% of the respondents were interested in more information and were willing to try HNS/nES. Most respondents preferred the potential use of nES (56.7%), while 21.7% chose HNS, 17.8% CPAP, and 3.8% the MAD. There were no differences in the characteristics of the patients who preferred nES compared to those who preferred other treatments; however, a regression analysis showed that a low ESS score was a predictor of patients choosing nES (p Conclusion Although the CPAP is the established treatment for OSA, most patients would prefer alternatives for long-term treatment. The majority of the respondents were interested in emerging technologies, with less sleepy patients more likely to choose less invasive treatment options.