“Mrs. X,” a 60-year-old, right-handed, graduate housewife, a known hypertensive patient controlled on enalapril 2.5 mg per day for 2 years, was referred to psychiatric services of our hospital on Day 3 of medical intensive care unit admission in October 2010 with the chief complaints of irresistible desire to sleep “in attacks” anytime during day hours, repetitive forward head droops and jaw sags, and persistent obsessive impulses of killing of her only grandson. She had an otherwise-negative medical and psychiatric history and was admitted with a first episode of transient right-sided hemiparesis and hemiballismic movements of the right half of her body, both of which lasted only for a few hours, due to left thalamo-striatal stroke. Her arterial blood gas analysis, liver function tests, and renal function tests were normal, but a recent MRI was noted to be significant for two small, lacunar infarcts in the left basal ganglia. Just a few weeks before admission, she had history of sore throat, fever, productive cough, and elevated antistreptolysin O (ASO) titres (610 IU/ml), which were treated with amoxicillin 500 mg tid for 7 days. She was provisionally diagnosed with organic narcolepsy and was given a morning dose of modafinil 200 mg/day before she was discharged from the hospital. Because her obsessive symptoms were only of 3 days’ duration, we had not put her on anti-OCD drugs. For the next 2 weeks, her attacks of daytime sleepiness progressed and began occurring anytime: sitting and reading, watching television, traveling in a car for a short distance to attend social ceremonies or the hospital, and even while talking, and continued to increase initially in frequency, then in duration, but she had been reasonably alert between the attacks for an hour or so, and she described that she was fighting a constant battle against this unusual drowsiness. Her nighttime sleep was impaired. A few times, after awakening from sleep, she felt that she could neither speak nor move, but could open her eyes and was completely aware of her surroundings; she also experienced hypnogogic hallucinations now and then. The latter episodes never lasted more than a minute or so. Also, there were recurrent, persistent episodes of periodic loss of sudden muscular tone, especially of the head and neck region, as well as shoulder and hip-girdle region, which would be very transient, 2–3 times per day, varying in duration, and analogous to newer changes of her old personality, which has made family members more concerned about her. Her Epworth Sleepiness Score was 17, and polysomnography showed 3 to 4 minutes of mean sleep latency time (MSLT) and four-to-five episodes of rapid eye movement (REM) sleep during MSLT in three separate and serial evaluations.
Interestingly and simultaneously, from October 2010 onward, she had progressively worsening anxiety, provoking repetitive, intrusive, and absurd thoughts and impulse of taking her grandson to the terrace and pushing him down from the second floor. She never liked these thoughts, rather resisted them with internal will and prayed and dreamt that this should never happen to her, and felt guilty that these were her own thoughts about her beloved and only grandson. She described recurrent obsessions of “needing to know” information about her grandson, with resultant checking rituals. This “need to know” was primarily related to the fear of losing control of her own thoughts and impulses. Nevertheless, she never acted on her thoughts and would rather ask her son and grandson to stay away from her. The storming emotions and anxiety would frequently precipitate previously described cataleptic attacks. She had no history of sleep apnea, excessive snoring, epilepsy, head injury, parkinsonism, hepatic or renal encephalopathy, tic disorder, psychosis, mood disorder, drug intoxication, other drug abuse, substance-induced disorder, or family history of psychiatric disorders. Modafinil 200 mg/day did not help in any of these features. She took traditional Ayurvedic treatment for about 2 months on firm insistence of her son and returned to us about 3 months later, in January 2010, disillusioned and frustrated. She recovered dramatically in her unintended sleep episodes and daily naps within 3 weeks with 20 mg of sustained-release formulation of methylphenidate divided in two doses. Cataplexy and obsessive thoughts and impulses almost returned to her premorbid state with 25 mg per day of sustained-release paroxetine by Week 4, and she has been symptom-free for about the last 7–8 months without relapse.