{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T06:12:32Z","timestamp":1788502352156,"version":"build-2803163510"},"reference-count":38,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T00:00:00Z","timestamp":1788480000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Psychiatry"],"abstract":"<jats:p>Excessive daytime sleepiness (EDS), nocturnal impaired-awareness episodes, and abnormal sleep-related behaviors have complex and overlapping etiologies. Narcolepsy, obstructive sleep apnea (OSA), and epileptic nocturnal events may present with similar clinical manifestations. In patients with intellectual disability (ID), restricted self-reporting, incomplete caregiver observations, and diagnostic overshadowing may lead clinicians to misattribute underlying neurological or sleep disorders to preexisting cognitive impairment or psychiatric and behavioral problems, resulting in delayed diagnosis or misdiagnosis. We present an illustrative case of a 34-year-old woman with lifelong cognitive and adaptive impairments who was referred for long-standing snoring, EDS, and two nocturnal impaired-awareness episodes. An outside emergency department had previously considered \u201csleep apnea?\u201d and \u201cnarcolepsy?\u201d as possible diagnoses. After detailed collateral history-taking, overnight polysomnography (PSG), the Multiple Sleep Latency Test (MSLT), and two 24-hour ambulatory electroencephalography (EEG) recordings, she was diagnosed with epilepsy with focal to bilateral tonic-clonic seizures, moderate OSA, and mild ID. At the 6-month follow-up after concurrent initiation of levetiracetam (LEV) and continuous positive airway pressure (CPAP) therapy, no further nocturnal impaired-awareness episodes, limb jerking, or cyanosis of the lips were reported; her EDS also improved, with the Epworth Sleepiness Scale (ESS) score decreasing from 18\/24 at baseline to 6\/24. Rather than reporting a rare comorbidity alone, this case-based diagnostic analysis uses the index case to clarify the differential diagnostic approach to EDS and nocturnal events in patients with ID, highlights the key distinctions among narcolepsy, OSA-related sleepiness, and epileptic nocturnal events, and emphasizes the need for integrated management when OSA and epilepsy coexist.<\/jats:p>","DOI":"10.3389\/fpsyt.2026.1919011","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T05:29:11Z","timestamp":1788499751000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Narcolepsy-like presentations in intellectual disability with comorbid epilepsy and obstructive sleep apnea: a case-based diagnostic analysis and literature-informed discussion"],"prefix":"10.3389","volume":"17","author":[{"given":"Shuning","family":"Hong","sequence":"first","affiliation":[{"name":"Affiliated Mental Health Center & Hangzhou Seventh People\u2019s Hospital, Zhejiang University School of Medicine","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lili","family":"Yang","sequence":"additional","affiliation":[{"name":"Affiliated Mental Health Center & Hangzhou Seventh People\u2019s Hospital, Zhejiang University School of Medicine","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lishan","family":"Ren","sequence":"additional","affiliation":[{"name":"Affiliated Mental Health Center & Hangzhou Seventh People\u2019s Hospital, Zhejiang University School of Medicine","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Haisi","family":"Chen","sequence":"additional","affiliation":[{"name":"Affiliated Mental Health Center & Hangzhou Seventh People\u2019s Hospital, Zhejiang University School of Medicine","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuping","family":"Zheng","sequence":"additional","affiliation":[{"name":"The Fifth People\u2019s Hospital of Lin\u2019an District","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wenjuan","family":"Liu","sequence":"additional","affiliation":[{"name":"Affiliated Mental Health Center & Hangzhou Seventh People\u2019s Hospital, Zhejiang University School of Medicine","place":["Hangzhou, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,4]]},"reference":[{"key":"B1","volume-title":"International Classification of Sleep Disorders","year":"2023"},{"key":"B2","doi-asserted-by":"publisher","DOI":"10.5664\/jcsm.9620","article-title":"Recommended protocols for the multiple sleep latency test and maintenance of wakefulness test in adults: guidance from the American Academy of Sleep Medicine","volume":"17","author":"Krahn","year":"2021","journal-title":"J Clin Sleep Med"},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.5664\/jcsm.10974","article-title":"Recommended protocols for the multiple sleep latency test and maintenance of wakefulness test in children: guidance from the American Academy of Sleep Medicine","volume":"20","author":"Maski","year":"2024","journal-title":"J Clin Sleep Med"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1016\/j.neurol.2023.08.001","article-title":"Narcolepsies, update in 2023","volume":"179","author":"Barateau","year":"2023","journal-title":"Rev Neurologique"},{"key":"B5","doi-asserted-by":"publisher","first-page":"15015","DOI":"10.1038\/nrdp.2015.15","article-title":"Obstructive sleep apnoea syndrome","volume":"1","author":"L\u00e9vy","year":"2015","journal-title":"Nat Rev Dis Primers"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1007\/s13311-021-01021-w","article-title":"Sleep and epilepsy: a focused review of pathophysiology, clinical syndromes, co-morbidities, and therapy","volume":"18","author":"Moore","year":"2021","journal-title":"Neurotherapeutics"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1038\/s41582-019-0226-9","article-title":"Narcolepsy \u2014 clinical spectrum, aetiopathophysiology, diagnosis and treatment","volume":"15","author":"Bassetti","year":"2019","journal-title":"Nat Rev Neurol"},{"key":"B8","doi-asserted-by":"publisher","DOI":"10.1111\/epi.18338","article-title":"Updated classification of epileptic seizures: position paper of the International League Against Epilepsy","volume":"66","author":"Beniczky","year":"2025","journal-title":"Epilepsia"},{"key":"B9","doi-asserted-by":"publisher","first-page":"687","DOI":"10.1016\/j.neurol.2023.07.006","article-title":"Sleep and epilepsy: a clinical and pathophysiological overview","volume":"179","author":"El Youssef","year":"2023","journal-title":"Rev Neurologique"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1007\/s11940-024-00801-x","article-title":"Sleep disorders in adults with intellectual disability: current status and future directions","volume":"26","author":"Perera","year":"2024","journal-title":"Curr Treat Options Neurol"},{"key":"B11","doi-asserted-by":"publisher","first-page":"479","DOI":"10.5664\/jcsm.6506","article-title":"Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline","volume":"13","author":"Kapur","year":"2017","journal-title":"J Clin Sleep Med"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1016\/j.clinph.2021.07.016","article-title":"Minimum standards for inpatient long-term video-EEG monitoring: a clinical practice guideline of the International League Against Epilepsy and International Federation of Clinical Neurophysiology","volume":"134","author":"Tatum","year":"2022","journal-title":"Clin Neurophysiol"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1352\/1944-7558-129.2.116","article-title":"Diagnostic overshadowing of psychological disorders in people with intellectual disability: a systematic review","volume":"129","author":"Dell\u2019Armo","year":"2024","journal-title":"Am J Intellectual Dev Disabil"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1037\/pas0001367","article-title":"How intellectual disability may bias psychologists\u2019 clinical impressions: an examination of diagnostic overshadowing","volume":"37","author":"Dell\u2019Armo","year":"2025","journal-title":"Psychol Assess"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1192\/bjb.2021.122","article-title":"Sleep: the neglected life factor in adults with intellectual disabilities","volume":"47","author":"Korb","year":"2023","journal-title":"BJPsych Bull"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1136\/thorax-2023-220032","article-title":"Sleep-disordered breathing in children and adults with intellectual disability: mind the gap","volume":"79","author":"Riha","year":"2024","journal-title":"Thorax"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1002\/pnp.12010","article-title":"Delirium or mood disorder: the role of relative in correcting the misdiagnosis in an intellectual disability patient","volume":"28","author":"Javaid","year":"2024","journal-title":"Prog Neurol Psychiatry"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.3390\/jcm11072063","article-title":"Effects of obstructive sleep apnea on epilepsy, and continuous positive airway pressure as a treatment option","volume":"11","author":"Jo","year":"2022","journal-title":"JCM"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1080\/14737175.2025.2546866","article-title":"The impact of sleep apnea on epilepsy treatment outcomes","volume":"25","author":"Pavlova","year":"2025","journal-title":"Expert Rev Neurother"},{"key":"B20","article-title":"Obstructive sleep apnea and epilepsy: understanding the pathophysiology of the comorbidity","volume":"15","author":"Goyal","year":"2023","journal-title":"Int J Physiol Pathophysiol Pharmacol"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.3389\/fphar.2023.1230313","article-title":"Intermittent hypoxia: linkage between OSAS and epilepsy","volume":"14","author":"Ma","year":"2023","journal-title":"Front Pharmacol"},{"key":"B22","doi-asserted-by":"publisher","DOI":"10.1172\/jci.insight.172423","article-title":"Failure to breathe persists without air hunger or alarm following amygdala seizures","volume":"8","author":"Harmata","year":"2023","journal-title":"JCI Insight"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.3390\/jpm14010118","article-title":"The reciprocal relationship between sleep and epilepsy","volume":"14","author":"Krutoshinskaya","year":"2024","journal-title":"JPM"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1111\/epi.14006","article-title":"The incidence and significance of periictal apnea in epileptic seizures","volume":"59","author":"Lacuey","year":"2018","journal-title":"Epilepsia"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000006785","article-title":"Postconvulsive central apnea as a biomarker for sudden unexpected death in epilepsy (SUDEP)","volume":"92","author":"Vilella","year":"2019","journal-title":"Neurology"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000214603","article-title":"Brainstem respiratory center dysfunction in persons with epilepsy: an fMRI study","volume":"106","author":"Ciumas","year":"2026","journal-title":"Neurology"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000006920","article-title":"Limbic and paralimbic structures driving ictal central apnea","volume":"92","author":"Lacuey","year":"2019","journal-title":"Neurology"},{"key":"B28","doi-asserted-by":"publisher","DOI":"10.1016\/S1474-4422(13)70214-X","article-title":"Incidence and mechanisms of cardiorespiratory arrests in epilepsy monitoring units (MORTEMUS): a retrospective study","volume":"12","author":"Ryvlin","year":"2013","journal-title":"Lancet Neurol"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000213856","article-title":"Persistent postictal central apnea in focal seizures: incidence, features, and imaging findings","volume":"105","author":"Meletti","year":"2025","journal-title":"Neurology"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.5603\/PJNNS.a2022.0036","article-title":"Effect of levetiracetam on nocturnal sleep in patients with epilepsy","volume":"56","author":"Chaneva","year":"2022","journal-title":"Neurol Neurochir Pol"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.5935\/1984-0063.20220045","article-title":"Effects of antiepileptic drugs on sleep architecture parameters in adults","volume":"15","author":"Carvalho","year":"2022","journal-title":"Sleep Sci"},{"key":"B32","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1155\/2013\/670682","article-title":"Epilepsy, antiseizure therapy, and sleep cycle parameters","volume":"2013","author":"Shvarts","year":"2013","journal-title":"Epilepsy Res Treat"},{"key":"B33","doi-asserted-by":"publisher","DOI":"10.1212\/CONT.0000000000001521","article-title":"Update on antiseizure medications 2025","volume":"31","author":"Abou-Khalil","year":"2025","journal-title":"Continuum (Minneap Minn)"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1007\/s40263-023-01058-9","article-title":"Effect of levetiracetam on cognition: a systematic review and meta-analysis of double-blind randomized placebo-controlled trials","volume":"38","author":"Lin","year":"2024","journal-title":"CNS Drugs"},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.3389\/fphar.2025.1584566","article-title":"Adverse effects of antiseizure medications: a review of the impact of pharmacogenetics and drugs interactions in clinical practice","volume":"16","author":"De Bellis","year":"2025","journal-title":"Front Pharmacol"},{"key":"B36","doi-asserted-by":"publisher","DOI":"10.3389\/fneur.2026.1783559","article-title":"Overview of psychiatric and behavioral adverse effects of levetiracetam","volume":"17","author":"Alkhotani","year":"2026","journal-title":"Front Neurol"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.1212\/wnl.44.11.2060","article-title":"Epilepsy and sleep apnea syndrome","volume":"44","author":"Devinsky","year":"1994","journal-title":"Neurology"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsmc.2022.07.012","article-title":"The relationship between epilepsy, obstructive sleep apnea, and treatment outcome","volume":"17","author":"Sethi","year":"2022","journal-title":"Sleep Med Clinics"}],"container-title":["Frontiers in Psychiatry"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1919011\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T05:29:13Z","timestamp":1788499753000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpsyt.2026.1919011\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,4]]},"references-count":38,"alternative-id":["10.3389\/fpsyt.2026.1919011"],"URL":"https:\/\/doi.org\/10.3389\/fpsyt.2026.1919011","relation":{},"ISSN":["1664-0640"],"issn-type":[{"value":"1664-0640","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,4]]},"article-number":"1919011"}}