Clinical impressions of the case of patient no. 1

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Thomas E. Scammell, MD: Dr. Moawad, let us turn to you for your general impressions of this case and what stands out to you.

Heidi Moawad, MD: In fact, this patient’s story is, in many ways, so typical because he attempts to explain his symptoms with the things that are going on in his life. He is not doing well at school. He misses his classes. And so he’s describing the depression, the drowsiness, all those things based on the events that are happening to him. Especially at this age, it’s a normal way for a young person to describe what’s going on with them. One thing that I think stands out is that he’s been on medication for a while and it can really have a lot of side effects and can change things that he doesn’t seem to have been warned about maybe what side effects to look for . I think that colors what’s going on here. But the other thing that really stands out is how persistent it all is. Often when young people in particular try to explain the symptoms by what is going on in their life, it shouldn’t take that long. In this case, we’re talking about a 19-year-old, and he’s been dealing with this since he was 16. This is definitely something to delve into.

Thomas E. Scammell, MD: He sleeps problematically. How would you sort out this question of depression and narcolepsy in this guy?

Heidi Moawad, MD: Well, I think I really think ladders would be helpful in this type of situation. One thing is that it opens the discussion. It helps him to consider drowsiness independent of mood and to consider how much he has slept, how much he has fallen asleep. Plus, it allows for a discussion that this isn’t necessarily normal and he really needs to start tracking this a bit more. I think it’s just an opening for sleep studies, which would be more definitive for him.

Thomas E. Scammell, MD: It seems that just with this kind of story, after taking a good story, you would definitely move on to do an overnight polysomnogram and a multiple sleep latency test.

Heidi Moawad, MD: Yeah. Given how long he’s been dealing with this and it seems like the conditions in his life that he’s blaming it all on aren’t becoming – because things probably fluctuate over summer vacation and things like that – his symptoms do not appear to improve during these times.

Phyllis C. Zee, MD, Ph.D.: One thing I notice is that we focus heavily on excessive daytime sleepiness, daytime functioning, and there were no questions about his nighttime sleep, being a student, regularity some sleep. I think Dr. Benca brought up the issue of sleep deprivation which is very common in this group. I think that’s probably something I would be really interested in knowing about the quality of his sleep, the regularity too, because it’s important not to miss that in the story.

Thomas E. Scammell, MD: I think you’re highlighting the fact that far more common than narcolepsy is lack of sleep, delayed circadian phase, things like that are really what most often cause these kinds of problems in this stage group . Dr. Benca, were you going to say something?

Ruth Benca, MD, Ph.D.: Yeah. Certainly, all of this is true, but this is also an age range where narcolepsy sometimes appears. We have to keep that in mind, but I agree with Dr. Zee that, especially in young people like this, we need to get a very thorough sleep history. Does he have classes early in the morning and stay up very late at night? Does he have irregular social jet lag, whatever contributes to his drowsiness? The other concern I have about him is his history of substance abuse. Again, is he self-medicating because he’s sleepy, or is he sleepy because he’s prone to addiction to using stimulants that have their side effects when you stop a drowsy excessive, like cocaine? And although he says he hasn’t used in a month or two, that doesn’t really indicate that he’s recovered from drug addiction, and he smokes a pack a day. It also raises concerns about how we are going to deal with him, as he is clearly someone with a tendency to abuse substances.

Thomas E. Scammell, MD: Yeah. I think it’s obvious, but do you want to comment on caffeine and nicotine and his sleep patterns?

Heidi Moawad, MD: I just have one more thing to add is that a kid that age who is having trouble in school could potentially have ADHD or an undiagnosed learning disability and that can contribute to their drug use as a means of dealing with these difficulties.

Transcript edited for clarity

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