Hallucination Question

[zenman]

21 yr old African American male soldier. Sleep difficulties for 2 yrs. He complains of visual(demons, sometimes human form), auditory (screams), tactile (like somebody heavy lying on top of him and he is paralyzed), and occasional olfactory (like a garbage dump) hallucinations which only occur when he is sleeping. He denies that these are hypnopompic or hypnogogic although they might well be. He does report an episode since his last visit where he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again." Reports his Auntie had some symptoms except that she was "physically moved around the room). He denies migraines or auras but does have occasional headache about once a week which is a 7/10. He had an MRI of the brain w/wo contrast yesterday which was unremarkable. Referred for neuro consult. It that's negative I'm going for sleep consult and/or priest! Any thoughts?

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[danielmd06]

21 yr old African American male soldier. Sleep difficulties for 2 yrs. He complains of visual(demons, sometimes human form), auditory (screams), tactile (like somebody heavy lying on top of him and he is paralyzed), and occasional olfactory (like a garbage dump) hallucinations which only occur when he is sleeping. He denies that these are hypnopompic or hypnogogic although they might well be. He does report an episode since his last visit where he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again." Reports his Auntie had some symptoms except that she was "physically moved around the room). He denies migraines or auras but does have occasional headache about once a week which is a 7/10. He had an MRI of the brain w/wo contrast yesterday which was unremarkable. Referred for neuro consult. It that's negative I'm going for sleep consult and/or priest! Any thoughts?

Is he hypersomnolent? Does he have sleep attacks? Does he have a history of head trauma (with LOC) or PTSD? What medications is he taking? Is he wanting disability? Does he have additional family history of narcolepsy, hallucinations, psychiatric disease, or anything like this? Does he have cataplexy? Does he ever lose continence with these spells? Bite his tongue or the inside of his cheek with them? Wake up and note blood on his pillow or have very sore muscles in the morning? Are the spells stereotyped? How often are they occurring each night/week/month? Was there an antecedent psychiatric or physical trauma (or drug use) before the events started?

What you're desribing sounds like a mixture of potentially normal sleep-related phenomenon, plus headaches. Also, you need to at least think about narcolepsy (http://en.wikipedia.org/wiki/Narcoleptic), seizures, psychiatric problems like schizophrenia, just plain nightmares, or PTSD. I'd be most curious about narcolepsy.

1) The paralysis is called "sleep paralysis," and it may be either hypnopompic or hypnogogic. It should properly be a full paralysis, save for preserved diaphragm and extraocular muscle activity. It should pass spontaneously within seconds to minutes. The hallucinations may be occurring during the paralysis. The SP may be seen in the setting of narcolepsy, fragmented sleep (like medical residents/college students), or occur in isolation of other symptoms. It is not unusual to feel that something heavy is on your chest during these spells, and it is also not unusual to sense a dark/evil presence in the room during these events. Many ancient cultures have described this, and it has given rise to myths about witches or "mares" riding on people's chests at night. If combined with hallucinations, the effect can be quite terrifying for the uninitiated. People may also have kinetic sensation (falling, or even rising off the bed a la alien abduction stories) with this.

This is where the term "night-mare" orginally came from. Note the interesting pieces of artwork in the article: http://en.wikipedia.org/wiki/Sleep_Paralysis

2) The hallucinations all depend on context. You say that these are only during sleep and are not before or after falling asleep or waking up? They may simply be dreams, but they sound more like sleep hallucinosis from what you've typed. If they are during the day (and not related to sleep), then they may or may not be related to narcolepsy. Olfactory hallucinations are rare (and suggest the possibility of an epileptic origin), and auditory ones should be thoroughly questioned so you rule out psychiatric disease.

Typically with narcolepsy and with very fragmented sleep in college kids etc you have hypnopompic or hypnogogic hallucinations. They are most often visual. You see them with your eyes open. Usually phosphenes, shadows, shapes, scenes (like looking through a window into a meadow), silhouettes of people/men standing at the foot of your bed, ghosts, demons, animals like spiders and bats and the like (http://en.wikipedia.org/wiki/Hypnagogia). More rarely, you can have kinetic, auditory, tactile, or olfactory hallucinations. Also, you need to be sure that your patient is not just describing dreams...which are a separate entity altogether.

3) Be sure to ask about cataplexy. http://en.wikipedia.org/wiki/Cataplexy

4) Again, it sounds like the guy may have anything along a gamut from psychiatric disease, very fragmented sleep only, narcolepsy, migraine, or even seizures. What you are describing sounds most consistent with narcolepsy, or at the very least, extremely fragmented sleep with interspersed sleep hallucinosis and sleep paralysis.

I'd recommend an EEG (remember the olfactory hallucinations, and also are any of the hallucinations stereotyped?), possibly a psych consult (depending on those voices, possibility of nightmares, and possibility of PTSD), screen his medications (anticholinergics or antidepressants?), give him a full neuro exam, and take a thorough history of these hallucinations and sleep patterns.

He likely will need a PSG (with MSLT and urine drug screen) to check for OSA, nocturnal seizures, other disturbances of sleep, and to rule out narcolepsy.

 

[zenman]

Is he hypersomnolent? Does he have sleep attacks? Does he have a history of head trauma (with LOC) or PTSD? What medications is he taking? Is he wanting disability? Does he have additional family history of narcolepsy, hallucinations, psychiatric disease, or anything like this? Does he have cataplexy? Does he ever lose continence with these spells? Bite his tongue or the inside of his cheek with them? Wake up and note blood on his pillow or have very sore muscles in the morning? Are the spells stereoptyped? How often are they occurring each night/week/month? Was their an antecedent psychiatric or physical trauma (or drug use) before the events started?

Great, thanks. Denies drugs, occasional ETOH, no trauma, no meds (I just started him on hydroxyzine for sleep till neuro/sleep consults), no seizure hx. No other symptoms of schizophrenia. Don't think he's malingering. He likes the military. Interesting fellow. I'll keep you posted.

What you're desribing sounds like a mixture of potentially normal sleep related phenomenon, plus headaches. Also, you need to at least think about narcolepsy (http://en.wikipedia.org/wiki/Narcoleptic), seizures, psychiatric problems like schizophrenia, just plain nightmares, or PTSD. I'd be most curious about narcolepsy.

1) The paralysis is called "sleep paralysis," and it may be either hypnopompic or hypnogogic. It should properly be a full paralysis, save for preserved diaphragm and extraocular muscle activity. It should pass spontaneously within seconds to minutes. The hallucinations may be occurring during the paralysis. The SP may be seen in the setting of narcolepsy, fragmented sleep (like medical residents/college students, or occur in isolation of other symptoms). It is not unusual to feel that something heavy is on your chest during these spells, and it is also not unusual to sense a dark/evil presence in the room during these events. Many ancient cultures have described this, and it has given rise to myths about witches or "mares" riding on people's chests at night. If combined with hallucinations, the effect can be quite terrifying for the uninitiated. People may also have kinetic sensation (falling, or even rising off the bed a la alien abduction stories) with this.

This is where the term "night-mare" orginally came from. Note the interesting pieces of artwork in the article: http://en.wikipedia.org/wiki/Sleep_Paralysis

2) The hallucinations all depend on context. You say that these are only during sleep and are not before or after falling asleep or waking up? They may simply be dreams, but they sound more like sleep hallucinosis from what you've typed. If they are during the day (and not related to sleep), then they may or may not be related to narcolepsy. Olfactory hallucinations are rare, and auditory ones should be thoroughly questioned so you rule out psychiatric disease.

Typically with narcolepsy and with very fragmented sleep in college kids etc you have hypnopompic or hypnogogic hallucinations. They are most often visual. You see them with your eyes open. Usually phosphenes, shadows, shapes, scenes (like looking through a window into a meadow), silhouettes of people/men standing at the foot of your bed, ghosts, demons, animals like spiders and bats and the like. http://en.wikipedia.org/wiki/Hypnagogia More rarely, you can have kinetic, auditory, tactile, or olfactory hallucinations. Also, you need to be sure that your patient is not just describing dreams...which are a separate entity altogether.

3) Be sure to ask about cataplexy. http://en.wikipedia.org/wiki/Cataplexy

4) Again, it sounds like the guy may have anything along a gamut from psychiatric disease, very fragmented sleep only, narcolepsy, or even seizures. What you are describing sounds most consistent with narcolepsy, or at the very least, extremely fragmented sleep with interspersed sleep hallucinosis and sleep paralysis.

I'd recommend an EEG (remember the olfactory hallucinations, and also are any of the hallucinations stereotyped?), possibly a psych consult (depending on those voices, possibility of nightmares, and possibility of PTSD), screen his medications (anticholinergics or antidepressants?), give him a full neuro exam, and take a thorough history of these hallucinations and sleep patterns.

He likely will need a PSG (with MSLT and urine drug screen) to check for OSA, nocturnal seizures, other disturbances of sleep, and to rule out narcolepsy.

 

[neglect]

21 yr old African American male soldier. Sleep difficulties for 2 yrs. He complains of visual(demons, sometimes human form), auditory (screams), tactile (like somebody heavy lying on top of him and he is paralyzed), and occasional olfactory (like a garbage dump) hallucinations which only occur when he is sleeping. He denies that these are hypnopompic or hypnogogic although they might well be. He does report an episode since his last visit where he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again." Reports his Auntie had some symptoms except that she was "physically moved around the room). He denies migraines or auras but does have occasional headache about once a week which is a 7/10. He had an MRI of the brain w/wo contrast yesterday which was unremarkable. Referred for neuro consult. It that's negative I'm going for sleep consult and/or priest! Any thoughts?

My thinking is that demonic possession is a superseded theory. Sleep paralysis. The guy needs nothing except reassurance and good sleep habits. Nearly every resident I've ever spoken to during my residency had at least one attack, so IMO, this is a human phenomenon brought on by sleep pressure. If there are other sleep problems, like daytime sleepiness or features of cateplexy, then a sleep study would be warranted.

My partner was fascinated by a young man who came to him and described lucid dreaming, of course without knowing the name. Sleep is so interesting, other than the 99% of the insomniacs and sleep apnea patients.

 

[michaelrack]

If work up unrevealing, can try low dose tricyclic (elavil 10-25 qhs). The meds that are effective for cataplexy/auxiliary symptoms of narcolepsy are sometimes also effective for isolatd sleep paralysis/sleep hallucinosis.

 

[neurodoc]

21 yr old African American male soldier: 1) Sleep difficulties for 2 yrs. 2) visual(demons, sometimes human form), auditory (screams), tactile (like somebody heavy lying on top of him and he is paralyzed), and occasional olfactory (like a garbage dump) hallucinations which only occur when he is sleeping. (i.e. hallucinations, and 3)He denies that these are hypnopompic or hypnogogic although they might well be. He does report an episode since his last visit where he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again." .... Any thoughts?

Well, the normal brain MRI and unremarkanle neuro exam (presumably a good one) are reassuring that there is no significant structural pathology. here's my 2 cents:

1) "Sleep difficulties" needs to be further specified. We could be dealing with a specific sleep disorder such as sleep apnea, narcolepsy/cataplexy, sleep paralysis, etc. Or maybe it's just "insomia," which could be due to many other things, including depression, anxiety, or PTSD. You mentioned that the patient is a soldier.

2) "Hallucinations" can be due to many things. Visual hallucinations are often viewed as "organic" whereas "auditory" hallucinations are often thought to be "psychiatric." Actually they may be either. Well-formed specific visual hallucinations can be seen in lesions affecting the basilar/PCA distribution (such as the "top-of-the-basilar" syndrome. Specific visual "distortions" such as micropsia, macropsia, and paliniopsia can be due to lesions involving the PTO circuitry. Olfactory hallucinations, if organic, are due to lesions affecting the mesial temporolimbic circuitry, and ar common in temporal lobe epilepsy. Tactile hallucinations (e.g. "formications") are commonly felt to be due to metabolic delirium (e.g. alcoholic delirium. However, any and all of these specific hallucinoses may also be due to psychiatric disorders. Is there a good way to sort out whether or not the hallucinatory symptoms are "organic" or "psychiatric?"

The sorting out is difficult but there are a couple of strategies I've found useful. "Psychiatric" hallucinations tend to "make sense" in terms of some plausible psychological disorder. For example, the belief that one is "possessed" by a demon, or if the hallucination fits into some psychotic delussional scheme. I've found that it is often possible to distinguish other "psychiatric" versus "organic" neurologic symptoms, such as dysphasia, using a similar strategy. For example, Wernicke's aphasia can often be distinguished from schizophrenic "word salad" aphasia by an astute clinician who notices that the psychotic's "word salad" fits some psychotic delusional scheme, whereas the "neurologically" dysphasic patient's speech makes different sorts of "mistakes." Being able to make such clinical judgements it not easy. It requires that the clinican have a very good sense of the patient's language.

3) I don't know what to make of the patient's report that he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again. This is an unusual symptom for sleep paralysis, which doesn't usually include pitch-black blindness. It makes me suspect a psychiatric condition.

At this point I think that polysomnography/EEG would be the best next study to clarify the diagnosis.

 

[LimbicResponse]

Call the family / roommates / with his permission and ask about strange behavior /comments during the daytime . If so , send him over to psych.

 

[Mattchiavelli]

21 yr old African American male soldier. Sleep difficulties for 2 yrs. He complains of visual(demons, sometimes human form), auditory (screams), tactile (like somebody heavy lying on top of him and he is paralyzed), and occasional olfactory (like a garbage dump) hallucinations which only occur when he is sleeping. He denies that these are hypnopompic or hypnogogic although they might well be. He does report an episode since his last visit where he dozed off during the daytime and when he opened his eyes it was pitch black and he was paralyzed, and then "everything cleared up and it was daylight again."

2 things-

1) why couldn't all those sensory disturbances have been... you know... dreams?

2) if it was pitch black and he was paralyzed how did he know his eyes actually opened?

I am usually a big fan of occam's razor especially when the history is kind of all over the place like this. THis is the type of referral where I initially always think "well this history obviously overloaded whoever referred this person and it could be something pretty benign." I'm pretty skeptical of patients having these crazy zebras people referring think they might have- it goes with the old adage that it's likely a weird presentation of something common rather than a really rare pathology.

Seeing as the guy is in the military I can imagine that his sleep hygiene might not be the greatest and the reason he hasn't had issue with this as much before is his sleep schedule was more regular so these things weren't coming out