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Valentina Guzman (she, her, hers), a 29-year-old Latina woman, presents at your clinic. Vitals Name: Valentina Guzman Sex assigned at birth: Female Gender: Woman Height: 5 ft, 6 inHeight: 5 feet 6 inches Weight: 222 pounds Age: 29 Chief Complaint: “If I had a better handle on my night-time eating, I could lose enough weight to have this bariatric surgery.” HPI Patient complains of unconscious nocturnal eating behaviors that started 10 years ago. Initially, she was able to partially recall the nocturnal binges (reportedly would eat peanut butter and uncooked spaghetti), but over the past year she has no recollection of these episodes the following morning. Has had chronic insomnia for 5 years and has been taking zolpidem (Ambien) for 5 years, which has been helpful. Denies binge episodes during the day. Denies compensatory behaviors such as purging, laxatives, or excessive exercise. History Medical history: GERD, PCOS Surgical history: Gall bladder removal Psych history: Was treated for a single major depressive episode in the past. Took quetiapine (Seroquel) for sleep, which worked well, but weight loss doctor advised against it so stopped. Family psych history: Mother: bulimia Social history: Divorced 10 years ago, no children, works full-time; no current or previous alcohol use, illicit substance use, or tobacco use Reproductive: Has Nexplanon implant, no period in over a year Current Medications Zolpidem (Ambien) 10 mgMilligram at bedtime Omeprazole (Prilosec) 40 mgMilligram daily Tests Overnight polysomnography: Recurrent confusional arousals arising from non-REM sleep and eating binges while asleep with no subsequent recall Thyroid panel: WNL What is the likely diagnosis for Valentina? Nocturnal Eating with Amnesia: Valentina reports unconscious nocturnal eating behaviors, initially with partial recall, but recently with no subsequent recall. This aligns with SRED, where individuals have little or no memory of the eating episodes. Feedback: Sleep-related eating disorder is the most likely diagnosis. What is one differential diagnosis for Valentina? Zolpidem-Induced Parasomnia: Zolpidem (Ambien) can sometimes cause complex sleep-related behaviors, including sleep-eating, which may be unusual or dangerous, and occur with amnesia of the event. This could be essential in Valentina’s case, as she has been using zolpidem for five years and her symptoms started around the time she began using it. Feedback: Differentials include nocturnal eating disorder and complex sleep related behavior secondary to zolpidem (Ambien) use. How do you distinguish your primary diagnosis from your differential diagnosis? Temporal Relationship with Medication: Zolpidem-Induced Parasomnia: If Valentina’s nocturnal eating behaviors started or significantly worsened around the time she began taking zolpidem, and these behaviors occur only while using the medication, it may suggest a causal relationship. Discontinuing or altering the dosage of zolpidem under medical supervision might reduce or eliminate the sleep-eating episodes. SRED: If Valentina’s nocturnal eating behaviors were present before starting zolpidem or persist unchanged despite changes in zolpidem usage, it would more strongly suggest SRED, which is not necessarily related to medication use. Nature and Pattern of Episodes: Zolpidem-Induced Parasomnia: Zolpidem can cause various complex sleep-related behaviors beyond eating, such as sleepwalking, sleep-driving, or engaging in other activities while asleep. The presence of a broader range of parasomnias would lean toward zolpidem-induced issues. SRED: The primary behavior is eating during sleep, often without other types of sleep-related activities. Response to Medication Adjustments: A trial discontinuation or a switch to an alternative sleep aid (under medical supervision) and monitoring the impact on nocturnal eating episodes can provide diagnostic clarity. A significant improvement or resolution of symptoms after changing zolpidem would suggest medication-induced parasomnia. Evaluation of Other Medication Use: Reviewing Valentina’s history of other medications, such as quetiapine, and their impact on sleep behaviors may provide insights. If nocturnal eating persisted despite using other medications, it may indicate SRED. Feedback: Sleep-related eating disorder is similar to other disorders of arousal. It occurs due to a mixture of being awake and being in NREM sleep. Sleep-related eating disorder is characterized by episodes of recurrent involuntary and amnestic eating during the sleep period. Patients often consume peculiar forms of food (such as raw hamburger, cake mix, etc.) with partial or no memory of the event. In many cases, sleep-related eating disorder may be related to treatment with a sedative/hypnotic agent (such as zolpidem) or a comorbid sleep disorder like restless leg syndrome. Night eating syndrome is characterized by recurrent episodes of evening hyperphagia and middle-of-the-night eating, which results in a delay in the circadian pattern for eating. This distinguishes it from sleep-related eating disorder. For more information, see: Vaughn, B. V. (2023). Approach to abnormal movements and behaviors during sleep. UpToDate. Retrieved May 7, 2024. What psychiatric medication(s) do you prescribe Valentina?

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