Narcolepsy and automatic behavior: a case report

Narcolepsy is characterized by excessive daytime sleepiness and cataplexy, which may be accompanied by hypnogogic or hypnopompic hallucinations and sleep paralysis. Automatic behavior is a relatively newly recognized symptom of the narcolepsy syndrome. This case report describes a particularly troublesome sort of automatic behavior--shoplifting--in a narcoleptic patient. It illustrates how a sleep-laboratory evaluation was used to confirm the diagnosis of narcolepsy and considers aspects of the treatment of the problem.

The treatment of narcolepsy-cataplexy with nocturnal gamma-hydroxybutyrate

Sixteen patients with narcolepsy and cataplexy were treated with gamma-hydroxybutyrate (GHB) given at night and tailored to achieve as continuous a night's sleep as possible. The dosage usually consisted of 1.5-2.25 gm orally at bedtime and then one or two further 1.0-1.5 gm doses with awakenings during the night, and totaled about 50 mg/kg. Apart from one patient who took only the bedtime dose, the subjective quality of night sleep improved in all patients and the number of irresistible daytime attacks of sleep and cataplexy substantially diminished. Some residual daytime drowsiness remained and this usually responded well to low doses of methylphenidate. Improvement has been maintained for up to 20 months without the development of tolerance. Two patients experienced adverse side effects necessitating withdrawal of GHB treatment, but no serious toxic effects have occurred.

[Use of substances modifying serotonin metabolism in the treatment of narco-cataplexy (considerations on 5 cases)]

The AA., after a critical analysis of the new proposed treatments for the narco-cataplexy, report their experience about the therapeutic possibilities of this syndrome with particular manipulations of cerebral serotonin (5-HT). In 5 patients they tried to act on the two sides of the sleeping-waking cycle by using a diurnal administration of Methysergide (5-HT inhibitor) and an evening loading of L-Tryptophan combined with Benserazide (dopa-decarboxilase inhibitor). The immediate and long term results on the nercoleptic as well as cataplectic symptoms can be considered good. Conversely treatments with Clomipramine alone exerted poor beneficial effects in these patients. The AA. discuss the physiopathogenetic mechanisms which are thought to be involved in this disease.

Narcolepsy with tinnitus aura: interpretation

A fifty-five year old man was admitted to our ward for evaluation of narcoleptic-cataplectic attacks which were signaled by a "hissing sound like high pressure steam leaking out of a pipe." This tinnitus was exclusively localized to the right ear. It started about sixty-to-ninety seconds before the cataplectic episode (affecting mostly the jaw muscles) and lasted through part of it as it became progressively louder toward the end and ceased abruptly. It is postulated that, along with the collapse of tonic musculature of the mandible, a decrease of proprioceptive tone also affected the tensor tympani muscle leaving the middle ear vulnerable to internally generated noise. We further postulate that tinnitus was finally arrested by the generation of phasic bursts of contraction of the tensor tympani and/or the stapedius muscle at a later stage of cataplexy.

Clinical and polygraphic effects of d.1 5 HTP on narcolepsy-cataplexy

d.1 5 hydroxy-trytophan (600 mg a day) or a placebo were administered during 4 weeks following a double blind cross over design to 11 narcoleptic-cataplectic patients. Daily number of cataplectic and narcoleptic attacks did not vary. The 36 hours polygraphic recordings performed at the end of each treatment exhibit: a trend toward a decrease of the duration of the day time sleep and a significant increase of the duration of the night sleep.

Narcolepsy, paranoid psychosis, and tardive dyskinesia: a pharmacological dilemma

The case history of a 54-year-old man with concomitant narcolepsy, paranoid psychosis, and tardive dyskinesia is presented. These disorders may all result from alteration in catecholamines, serotonin, and/or acetylcholine in the central nervous system. The interactions of the various psychopharmacological agents usually used to treat the disorders when they occur separately are considered in terms of current neurotransmitter hypotheses. The management of this case creates a pharmacological dilemma; the agents used for treatment of each of the disorders separately exacerbate one or both of the other two syndromes.

The effects of gamma-hydroxybutyrate on sleep

Sodium gamma-hydroxybutyrate (GHB) is a remarkably safe and nontoxic hypnotic agent which is reported to be free of addicting properties. It is also a normal metabolite of the mammalian nervous system. We examined its effects on the sleep-EEG of eight patients with histories of impaired sleep, as a prelude to a more detailed study of its clinical potential. Sleep induced with GHB was indistinguishable subjectively from natural sleep as well as by behavioral and electroencephalographic criteria. Unlike most synthetic hypnotics, GHB increased delta sleep and did not suppress REM sleep. It shortened the REM sleep latency and shifted REM sleep into the first third of the night. On one occasion it induced a sleep onset REM period which was experienced as an attack of sleep paralysis. Withdrawal was simple; there was no REM sleep rebound and sleep patterns immediately returned to their pre-drug form. Its major clinical drawback was its short duration of action: its hypnotic effect lasting only 2 to 3 hr. We suggest that GHB may serve as the prototype for a new class of hypnotic compounds derived from natural sources and capable of activating the neurological mechanisms of normal human sleep.

Protriptyline: an effective agent in the treatment of the narcolepsy-cataplexy syndrome and hypersomnia

The authors present five case reports illustrating that 10-20 mg of protriptyline in a single dose at bedtime can effectively control arousal dysfunction (sleep drunkenness and hypersomnia) and the narcolepsycataplexy syndrome without the apparent development of tolerance and without the side effects that are frequent complications of treatment with other agents. Although protriptyline was efficacious in controlling symptoms, it was found to have relatively poor REM sleep-suppressing properties.

Narcolepsy. Diagnosis and treatment

Narcolepsy may affect as many as 200,000 Americans. The illness involves a neurologic defect in the regulation of sleep and wakefulness. The chief symptoms are sleepiness, inappropriate sleep episodes, and cataplexy. A characteristic history of cataplexy establishes the diagnosis. Narcoleptic patients also frequently complain of hypnagogic hallucinations, sleep paralysis, blackouts (or automatic behavior), and disturbed nocturnal sleep. Narcolepsy usually develops in adolescence and is a life-long illness. Symptoms may also appear in young children who may be misdiagnosed as hyperactive or psychotic. No completely satisfactory treatment is available at the present time. The current treatments of choice are methylphenidate (for sleepiness and sleep episodes) and imipramine (for cataplexy). Medication dosages must be adjusted for individual patients. A careful history of the illness can rule out hypothyroidism, hypoglycemia, and epilepsy. Sleep apnea is a serious complication of narcolepsy and may be life threatening.

Problems in the differential diagnosis of narcolepsy versus schizophrenia

The authors discuss the problems of accurately diagnosing narcolepsy when patients manifest the auxiliary symptoms of this disorder, i.e., cataplexy, hypnagogic hallucinations, and sleep paralysis, which conclude that misdiagnosis of narcolepsy can be avoided if clinicians are aware that this illness can simulate a psychiatric disorder and if they give careful attention to the histroy of the patient's illness.

Evaluation of short-term and long-term treatment of the narcolepsy syndrome with clomipramine hydrochloride

Clinical examinations, questionnaires, and 24- or 36-hour polygraphic recordings were performed on 21 adult patients with the narcolepsy syndrome to investigate the short- and long-term effects of clomipramine HCL. Cataplexy was improved by the medication, but tolerance was observed 4 1/2 months of treatment. Clomipramine HCL induced significant changes in the sleep EEG, chin EMG, and EOG. In two patients, clomipramine HCL caused a nocturnal myoclonia that produced insomnia. Sexual side effects were seen with clomipramine HCL, particularly in males. A combination of clomipramine HCL and L-Dopa apparently prevented this difficulty in one patient. A rebound of cataplexy was seen during the 15 days following withdrawal of the drug. Methysergide maleate was found to be ineffective on cataplexy in four patients.

Narcolepsy in seven dogs

Narcolepsy in 7 dogs was tentatively diagnosed on the onset of cataplexy, before or during young adulthood. Confirmatory polygraphic sleep recordings were done in 3 of the dogs. In 2 dogs, treatment with neostigmine did not cause the signs to disappear, thus ruling out myasthenia gravis; trials with imipramine reduced catapletic attacks. Data from case histories, polygraphic recordings, drug trials, and clinical tests were used to compare and contrast the disease in man and in the dog.

Natural history, symptoms and treatment of the narcoleptic syndrome

This study describes the clinical features, natural history and treatment of 100 patients with narcolepsy. Over half had one or more affected relatives. Symptoms commenced in adolescence or early adult life in most patients, and remissions were uncommon. Narcolepsy occurred several times each day, often in unusual circumstances and sometimes with little warning. The mean total sleep time of narco-leptics was a little over 9 hours in each 24 hour period, as compared with under 8 in normal subjects. Cataplexy occurred in 93 patients, most commonly when subjects were tired. Attacks were similar in nature to physiological weakness with laughter, although other sudden sensory or emotional stimuli did not cause paralysis of voluntary movement nor loss of muscle tone in normal subjects. Half these patients had frequent dreams before the onset of proper sleep, and 62 had sleep paralysis. This was often frightening, with feelings of suffocation, accompanied by dreams, and of uncertain length. A minority of patients with narcolepsy had muscle aches and jerks before sleep, double vision or loss of focus during cataplexy, went sleep-walking by day, and had daytime hallucinations. Amphetamines had been given to 71 patients for periods of up to 33 years with adequate, but rarely complete, control of narcolepsy. Side effects were common and almost half these patients became tolerant, needing higher dosage to control symptoms. Three patients had a cerebrovascular accident whilst taking amphetamines. Imipramine or clomipramine had ben given in combination with amphetamines to 33 patients for periods of up to 6 years with considerable improvement in both cataplexy and sleep paralysis, and few side effects. Sustained or paroxysmal hypertension as a result of amphetamines or combined treatment did not occur.