Pseudo-narcolepsy: case report Jane A. Hicks, MA, MRCPsych; Colin M. Shapiro, PhD, MRCPsych University of Toronto, Department of Psychiatry, The Toronto Hospital, Western Division, Toronto, Ont. This report describes the case of a 44-year-old woman presenting to a Sleep and Alertness clinic with symptoms of narcolepsy. The patient had clinical and polysomnographic features of narcolepsy, which dis- appeared after disclosure of severe psychological stress. Following a discussion of the differential diagnosis of narcolepsy, alternative diagnoses are considered. The authors suggest that the patient had a hysterical conversion disorder, or "pseudo-narcolepsy." Careful inquiry into psychological factors in unusual cases of narcolepsy may be warranted. Ce rapport decrit le cas d'une femme agee de 44 ans qui s'est presentee a une clinique de traitement des troubles du sommeil et de l'eveil avec des sympt6mes de narcolepsie. La patiente avait les caracteristiques cliniques et polysomnographiques de la narcolepsie, qui sont disparues apres qu'on a decouvert un stress psychologique grave. Apres une discussion sur le diagnostic differentiel de narcolepsie, les auteurs envi- sagent d'autres diagnostics. Is indiquent que la patiente avait un trouble de conversion hysterique ou une ((pseudonarcolepsie»>. Une analyse attentive des facteurs psychologiques qui jouent dans des cas inusites de narcolepsie peut etre justifiee. Case report cataplectic attacks consisted of a sudden bilateral loss of motor tone in her facial muscles and upper limbs, her A 44-year-old married woman with a history of a recur- head dropping forward and her eyes closing, and her not rent depressive illness was referred to our Sleep and responding to her name being called. These attacks last- Alertness clinic by a neurologist. In the past, her depres- ed minutes and were triggered suddenly by intense peri- sion had required antidepressant treatment and individ- ods of emotion such as fear and anxiety. She did not have ual psychotherapy. Details of her family psychiatric or sleep paralysis or any automatic behaviours. In the initial family medical history were difficult to obtain because consultation it was noted that "she likes to be ill." The she had been adopted at birth, but it was known that her neurologist was treating her headaches with an anti- biological mother had suffered from depression. migraine medication. Computer-enhanced tomography She gave an 18-month history of excessive daytime and an electroencephalogram were normal. sleepiness (EDS), hypnogogic and hypnopompic halluci- An overnight polysomnographic sleep study with a nations, cataplectic attacks and migraine headaches. Her Multiple Sleep Latency Test (MSLT) had been per- Correspondence to: Dr. Colin M. Shapiro, Department of Psychiatry, The Toronto Hospital, Western Division, EC 3D-040, 399 Bathurst St., Toronto ON MST 2S8; fax 416 603-5292 Medical subject headings: conversion disorder; diagnosis; narcolepsy; stress, psychological J Psychiatry Neurosci 1999;24(4):348-50. Submitted Aug. 18, 1998 Revised April 19, 1999 Accepted April 20, 1999 © 1999 Canadian Medical Association Vat. 24,n0 4, 1999 34800 Revue de psychiatrie et de neuzoscience-Jence W;.i,*irs j .i0I Pseudo4.arcotpy formed. The sleep study showed several polysomno- breached, but that she would disclose the information graphic features suggestive of narcolepsy: (1) a to the nurses as soon as she felt comfortable.) decreased total sleep time (5.8 hours); (2) 97 minutes of A repeat sleep study, following the disclosure, intervening wakefulness; (3) an impaired sleep efficien- showed a MSLT with no REM intrusions but mild cy (78%); and (4) rapid eye movement (REM) sleep hypersomnolence. She fell asleep in all 4 naps with within 30 seconds of sleep onset. In the MSLT, the sleep latencies of 9.0, 12.0, 8.0, and 7.0 minutes, giving a patient had REM intrusions in naps 2, 3, and 4 (all with- mean sleep latency of 9.0 minutes. The overnight in 2 minutes from lights out). She fell asleep in all 4 naps polysomnogram showed a shortened REM latency con- with a mean sleep latency of under 2 minutes. The pres- sistent with depression. She was discharged without ence of cataplexy and 2 or more REM onsets during the medication but received a course of cognitive behaviour MSLT is considered diagnostic of narcolepsy.' therapy as an outpatient, concentrating on psychologi- Consequently, a diagnosis of narcolepsy was made, and cal issues secondary to relationships and her depressive the patient was treated with methylphenidate (20 mg illness. She continued to make good progress but still twice a day) and clomipramine (100 mg at night). suffered from migraine headaches. Upon follow-up 2 Initially, treatment was effective and a Maintenance years later there was no evidence of any narcoleptic fea- of Wakefulness Test showed a good improvement in tures. The patient's mood is euthymic, and the migraine the patient's alertness. However, after 6 months of treat- attacks have also abated. ment the patient began to experience side effects. Consequently, she stopped her medication. This result- Discussion ed in a return of her sleep problems and coincided with a recurrence of her depressive illness. This report summarizes the case of a 44-year-old She presented at the clinic, together with her hus- woman presenting with symptoms of narcolepsy to the band, with hysterical symptoms and hypophonia. The Sleep and Alertness clinic. After disclosure and subse- staff interviewed the couple, and then had a discussion quent treatment of severe psychological stress (sexual with her husband alone, during which admission was abuse by a treating physician), her symptoms disap- discussed. The patient was also then seen alone, at peared. which point she disclosed that she had been having a The evidence supporting a diagnosis of narcolepsy sexual relationship with her general practitioner thera- included clinical symptoms (i.e., EDS, cataplexy, pist (a hypnotherapist), which had placed her under hypnogogic and hypnopompic hallucinations), over- severe stress for some time. night polysomnographic data, and an MSLT of less than She was admitted to a psychiatric ward. On admis- 5 minutes with REM intrusion in 3 out of 4 naps.' sion she had a labile mood, with underlying depression The more unusual features of this case, less support- and poor concentration. Throughout the day she had ive of a diagnosis of narcolepsy, were, first, the age of regular cataplectic attacks, similar to the attacks she had onset of symptoms. The onset of narcolepsy can often had before admission. They now included sudden falls be traced back to a specific stressful life event.2 to the ground. Her migraine headaches had returned, However, this trigger usually coincides with an onset in and resulted in slurred speech and posturing of her left the late teens or early 20s, and the narcolepsy is usually arm. These migrainous attacks lasted at least 20 minutes lifelong. Forty-four years of age is a relatively late age of and often longer. The most likely diagnosis was still onset, although onset has been reported to range from thought to be narcolepsy, but a focal epilepsy or 12 years to 65 years of age, and a second smaller peak is migraine variant were also considered. An electroen- observed in women nearing menopause.3 Second, the cephalogram showed normal results. diagnosis of cataplectic attacks was complicated by the One week after admission, she disclosed the details of patient's similar migraine episodes. Finally, the most the affair with the hypnotherapist to the nurses on the conclusive evidence against the diagnosis of narcolepsy inpatient unit. This disclosure to ward staff and her was the cessation of symptoms following the disclosure husband coincided with complete cessation of the cata- of her relationship with the hypnotherapist. As well, plectic attacks and an improvement in her mood. (Her human leukocyte antigen (HLA) testing, performed agreement to enter the inpatient unit was based on an with oligotyping, was negative for both DRw15 and understanding that her confidence would not be DQw6. Only a very small percentage of patients with V4,a*Voow,$ H|icksfL ,;and Shapiro narcolepsy test negative for these HLA types.3 with methylphenidate and clomipramine are, therefore, Alternative diagnoses or explanations for the not fully accounted for. patient's sleep symptoms included hypersomnolence On first presentation, the patient was not clinically secondary to depression, hysterical conversion symp- depressed, although her response to medication could toms, false-positive or false-negative MSLT results, or have been due to the treatment of her hypersomnolence side effects from the anti-migraine medication. Hyper- secondary to a masked depression. However, she had somnolence, rather than insomnia, is reported to be no polysomnographic evidence of depression on her present in some 20% of patients with depression.4 initial overnight sleep study. It was initially assumed, However, most reports of hypersomnolence in depres- when she was prescribed methylphenidate and sion have not been based on objective evidence. In a clomipramine, that the improved alertness on a study that did report objective evidence, a group of Maintenance of Wakefulness Test and the disappear- patients with hypersomnia associated with mood disor- ance of the cataplectic attacks supported a diagnosis of ders were compared with a group of patients with idio- narcolepsy. If this indeed was solely a conversion dis- pathic hypersomnia.