In 2008 a WISC-IV (Wechsler Intelligence Scale for Children, version IV) was completed to clarify the nature of his difficulties retaining information. Physical History and Other Additional Investigations At discharge he was given a diagnosis of hebephrenic schizophrenia. His compliance was erratic, with clear deterioration of his symptoms when noncompliant. However, due to complaints of sleepiness the medication was changed to aripiprazole. In his admission in 2009 his presentation appeared different, with paranoid symptoms and auditory hallucinations, which responded to haloperidol. The opinion then was that the underlying narcolepsy could explain his psychotic experiences so his antipsychotic medication (amisulpride) was subsequently reduced without any evidence of deterioration in his mental state. The patient had several prior admissions to psychiatric wards in 20.ĭuring his admission in 2008 his psychotic symptoms appeared to be present mostly at bedtimes in the form of hypnagogic and hypnopompic hallucinations with little evidence of psychosis during the day. While in our unit, arranging further tests (i.e., PSG, Multiple Sleep Latency Testing-MSLT) was considered but put on hold due to the young man’s mental health deterioration. He was receiving followup from a sleep disorder service and was not on any medication for narcolepsy or cataplexy. Polysomnography (PSG) had not been considered necessary at that stage nor Human Leukocyte Antigen (HLA) typing as studies on Hong Kong Chinese narcoleptics had found out that all patients were HLA DR2- and DQ1-positive so the view then was that it would not provide any additional relevant information for the diagnosis. The diagnosis had initially been made on clinical grounds following the ICSD (International Classification of Sleep Disorders) criteria B and C (B = Recurrent daytime naps for >3 months and C = Sudden bilateral loss of muscle tone in association with intense emotion (cataplexy)). In 2007 the patient had been diagnosed with narcolepsy and cataplexy after a history of recurrent episodes of loss of muscle tone related with high emotions (i.e., strong laughter) and daytime somnolence. He had a comorbid diagnosis of narcolepsy. Case ReportĪ 17-year-old man of Chinese ethnicity was admitted to our unit in 2009 after presenting with auditory and somatic hallucinations and paranoid delusions, which resulted in an incident of aggression at home.
We report on a 17-year-old man with narcolepsy complicated by psychotic symptoms and the therapeutic approach followed. These look at adults, with anecdotal references to younger patients. Narcolepsy and psychosis can share common features and age of onset, leading to challenges for diagnosis and subsequent management, as illustrated in case reports and case control studies. However, the precise prevalence of hypersomnia in children is unknown.
Narcolepsy was considered a disorder of adulthood, but accumulating evidence indicates that narcolepsy may start during childhood. Narcolepsy is a chronic neuropsychiatric disorder characterized by severe, irresistible daytime sleepiness and symptoms described as rapid eye movement (REM) sleep-related symptoms, including sudden loss of muscle tone (cataplexy), hypnagogic hallucinations, and sleep paralysis.
Our report illustrates the relevance of a thorough differential diagnosis as well as the need to explore treatment avenues based on the evidence available for both narcolepsy and psychosis symptoms to try and maximise the therapeutic impact. The prevalence of both conditions is low and the reports in young people are scarce. Psychotic features can be present in both narcolepsy and psychosis, which can result in challenges in diagnosis and management.
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