Identifying the Current Guidelines for Evaluating and Treating Psychosis and Behavioral Manifestations in a Child With Narcolepsy: A
Case Report and Literature Review
• Psychotic symptoms in children are challenging for
clinicians to identify, interpret, and treat
• The interaction between sleep disorders and
psychosis has been moderately studied in adults,
but rarely in the child and adolescent population.
• Treatments of psychosis usually require a
component of sedation, while treatments of
narcolepsy usually require a stimulant
• If a patient presents with both symptoms,
treatment appears to be contradictory and can
present with complications in optimal treatment
1. To investigate the relationship between
psychosis and narcolepsy and their
respective evaluations and treatment
modalities in the C&A population
2. Encourage further research and
discussion on psychosis and narcolepsy
in C&A population
A retrospective review of the patient’s chart was
performed and a pub med search was conducted
using the keywords “evaluation and treatment”
“narcolepsy,” “psychosis,” and “children” and
“adolescents.”
Marie Rodriguez, MD; Sara Hong, MD; Audrey Rossowski, DO; Chioma Iheagwara, DO
Department of Psychiatry
Einstein Medical Center and Belmont Behavioral Health, Philadelphia PA
A 10 year old Haitian-American male with recently diagnosed narcolepsy presented to inner city inpatient unit with new-onset
• This patient presents a case where he initially presented with
narcolepsy, was treated with stimulants, but then developed
psychosis. Several months prior to admission, he was diagnosed with narcolepsy by outpatient Neurology due to excessive psychosis
daytime sleepiness, falling asleep in class, and by polysomnogram with multiple sleep latency testing. He was prescribed • He was discontinued from stimulants, but psychosis remained
Adderall, then Modafinil, after which he began exhibiting auditory and visual hallucinations and paranoid delusions that "Satan is • This case had several treatment limitations due to the family’s
mistrust of medical professionals and prohibition of doing further
coming" and that he will "turn into a snake." He also started to neglect activities of daily living. He then was hospitalized medically
tests, treatment
for change in mental status and psychosis. Medical workup, including urinalysis, urine drug screen, CBC with diff, EBV, ammonia,
• Studies have shown that in narcolepsy there is increased risk of
CRP, a.lactate, comprehensive metabolic
. panel, thyroid, pyruvic acid, ANA, heavy metals, amino acid profile, vital signs, EKG, and psychotic symptoms or other comorbid psychiatric conditions
head CT all were within normal limits. The patient was discontinued from the stimulants, but the psychosis remained. However, • Studies have also shown that psychosis and narcolepsy may
when the hospital team also recommended MRI and lumbar puncture, the family refused. They also began refusing other share an autoimmune pathology
recommended blood tests. It was later ascertained that the parents' objections were spiritually driven. After several days of • Stimulants may trigger or exacerbate psychosis, and it may be
hospitalization, he was deemed medically cleared, and the child was transferred to inpatient psychiatry for further management of more beneficial to discontinue them and treat psychosis
• Stimulant induced psychosis: transient psychotic states that occur
persistent psychosis despite his parents not believing their son’s problem was psychiatric. in 0.25% children on stimulants, but tend to wane after
Inpatient Psychiatric Hospitalization Course: The patient’s behavior upon admission was noted to be bizarre, agitated, as discontinuation of stimulant, although 1-15% continue to have
evidenced by disrobing, masturbating, talking, and laughing to himself. He needed prompts to perform activities of daily living. psychosis
Over the course of both the medical, then subsequent psychiatric hospitalization, the family’s spiritual and cultural beliefs • Patients can be encouraged nondrug management for narcolepsy
influenced the child’s treatment and proved as a barrier. A previous differential of anti-NMDA encephalitis versus was considered such as sleep hygiene, dietary changes, scheduled napping
but parents continued to refuse MRI and LP for diagnosis. He was initially started on Zyprexa for psychosis during his stay but
switched to Risperdal as the Zyprexa was causing excess daytime sedation. He continued to have occasional aggression, yelling,
and was defiant. He was noted to have poor sleep at night, sleepiness during the day, and poor hygiene. He was encouraged
• Sleep disturbances complicate the course of treatment for
sleep hygiene to avoid naps and avoided re-starting stimulants. At times he was still noted to have symptoms of narcolepsy and
psychosis
daytime sleepiness. Eventually over the course of his stay, he was noted to have more episodes of clarity, interacted more, • Limited literature available but most recommend
attended more groups but was still noted to have defiance at times. His antipsychotic was titrated up to his discharge dosage. He discontinuing stimulants and starting an antipsychotic to
was eventually discharged back home with his family and recommended partial hospitalization and psychiatric follow up. reduce psychosis
• Continued antipsychotic treatment at low doses may
prevent development of chronic, persistent psychosis
Suggested Work Up for Narcolepsy: Treatment Options for Narcolepsy: • There are limited studies discussing treatment of
-Structured sleep schedules narcolepsy and psychosis in the C&A population, more
-History and Physical -Dietary factors, avoiding simple sugars, vitamin research and studies should be conducted to come up
-Laboratory tests supplementation with proper guidelines for evaluation and treatment of
-Polysomnography -Exercise these conditions
-Multiple Sleep Latency Testing -Modafinil
-LP- Hypocretin 1 -Stimulants
-HLA DQB1*0602 -Sodium Oxybate
-Neuroimaging • Moturi, Sricharan MD, MPH; Ivanenko, Anna. Psychiatry
Treatment Options for Psychosis:
Suggested Work Up for Psychosis: (Edgemont) 2009 Jun;6(6):38-44. Complex Diagnostic and
-typically multimodal treatment Treatment Issues in Psychotic Symptoms Associated with
-History and physical -Therapy: CBT, outpatient, community programs Narcolepsy
-laboratory tests: CBC w/ diff, UA, UDS, EBV, ammonia, CRP, -psychopharmalogical: typical vs atypical • Sikich, L. (2013). Diagnosis and Evaluation of Hallucinations and
lactate, CMP, Thyroid panel, pyruvic acid, ANA, heavy metals, antipsychotics Other Psychotic Symptoms in Children and Adolescents. Child and
Adolescent Psychiatric Clinics of North America, 22(4), 655-673.
B12, HIV, RPR, amino acid profile -psychotherapeutic
DOI: 10.1016/j.chc.2013.06.005
-EKG -psychoeducational
-head imaging such as CT/MRI -case management services
-LP -family support
-genetic testing/chromosomal analysis -specialized education programs
-screening for metabolic disorders, storage diseases, infectious -vocational/rehab assistance
diseases, autoimmune encephalitis -ECT
The authors have nothing to disclose
-EEG rodrigm1@einstein.edu