Bed crumbs and sleepiness.

An 11-year-old male with history of well-controlled asthma and attention deficit hyperactivity disorder was referred for evaluation of insomnia. Bedtime is at 9 pm with sleep onset latency of about 30 minutes. He wakes up at 8 am on his own in a good mood. His routine leading to bedtime has been stable for many years, and his mother does not report any bedtime resistance. She reports having found him in the kitchen looking for food during hours of sleep. He appears disoriented during these times and has minimal recollection of the events. He has also been found with food crumbs in his bed in the morning. He has had behavioral issues at school with poor performance. Daytime somnolence has also been reported with an Epworth Sleepiness Scale score of 13. No snoring or pauses in respiration while asleep have been noted. There is no caffeine intake. He takes 30 milligrams of lisdexamfetamine at 9 am and 12 noon. Physical examination reveals a child who is developmentally normal for his age with no tonsillar hypertrophy. The only notable finding was a body mass index in the 85th percentile for his age. He underwent an overnight polysomnography which demonstrated no sleep related breathing events. An arousal was noted to occur from stage N2 sleep (Figure 1) when he began eating food placed at his bedside and then returned to stage N1 sleep. Figure 1 QUESTION 1: Which of the following is not part of the diagnostic criteria for this disorder? Recurrent episodes of eating and drinking occurring during the main sleep period Adverse health consequences from recurrent binge eating of high caloric food Lack of anorexia during the daytime Consumption of peculiar forms or combinations of food or inedible or toxic substances Insomnia related to sleep disruption from repeated episodes of eating, with a complaint of non-restorative sleep, daytime fatigue, or somnolence QUESTION 2: Which of the following pharmacologic agents is least likely to be beneficial in the treatment of this disorder? Fluoxetine Topiramate Pramipexole Zolpidem Clonazepam QUESTION 1 ANSWER: c. Lack of anorexia during the daytime QUESTION 2 ANSWER: d. Zolpidem This patient has sleep-related eating disorder (SRED). According to the International Classification of Sleep Disorders, the diagnostic criteria must include recurrent episodes of eating and drinking occurring during the main sleep period. In addition to this, one of the following must also be present: consumption of peculiar forms or combinations of food or inedible or toxic substances, insomnia related to sleep disruption from repeated episodes of eating with a complaint of non-restorative sleep or daytime fatigue or somnolence, sleep-related injury, dangerous behaviors performed while in pursuit of food or while cooking food, morning anorexia, or adverse health consequences from recurrent binge eating of high caloric food. Lack of anorexia during the daytime is not a criterion. Finally, the sleep disturbance cannot be better explained by any other sleep disorder, medical or neurologic disorder, mental disorder, and medication use or substance use disorder.1 SRED may be accompanied by either clear or clouded consciousness. Patients often report an inner compulsive desire to eat but deny feeling hunger. Events can occur from any stage of sleep but appear more commonly from stage N1 and N2 sleep. Recurrent electromyelogram (EMG) activity of the masseter and orbicularis oris muscle representing repetitive masticatory and swallowing behavior may be seen.2 There is an association with periodic limb movement disorder, restless leg syndrome, narcolepsy, sleepwalking, and sleep talking, as well as depression. The association with these conditions suggests a common pathway in the dopaminergic system, which plays roles in both reward mechanisms and compulsive behaviors. This may explain the potential therapeutic role of pramipexole and other dopaminergic medications in SRED. Medications like fluoxetine, which modify serotonin activity, and antiepileptics like topiramate may also be effective in treating SRED. Clonazepam or other benzodiazepines is most effective in SRED associated with sleepwalking. Zolpidem, on the other hand, is the agent most commonly associated with SRED and is therefore least likely to be beneficial for this patient.3