Daytime Parahypnagogia?

[Zenman1]

The patient is a 22-year-old married Caucasian female National Guard member. She was initially seen in June 2014 for anxiety attacks which were related to her National Guard drills. She also had a history of miscarriage March 2014 with her first pregnancy and was sexually assaulted October 2012. Her anxiety initially start in 2012 when her parents divorced. At her first visit she complained of occasionally seeing bugs floating across her field of vision which ranged from "dark spots to actual bugs." She also thought she saw a dead deer in the road but when she got closer nothing was there. She was also hearing her name being called about twice a week. This has been going on for almost a year. On 06 Jun 2014 she traveled 11 hours by car for a National Guard drill. After arriving and resting for a while she went to the latrine and noticed that scratches on the floor started moving around. Then she saw a red exit sign move around the room. She then noticed that dark figures like poorly defined people started coming out of the fluorescent lights. These figures then went to each person’s bunk in the barracks and just look down at them. One figure then came towards her and she pulled the covers up over her head. She also noticed that her dress blue uniform shirt started rocking back and forth with one sleeve trying to reach out to her. She also reported on 24 June 2014 that her ceiling fan at home moved down near her and then moved back up to the ceiling. She also saw eyes and a face in the ceiling which looked like her in a mirror and which repeated any movement she made with her eyes and face. She then saw miniature people coming out of the same mirror in the ceiling. That same day she also heard neighbors talking but her spouse did not hear anything. She has also heard the door bell ringing but her dog did not respond so she knows that it was not real. At another time she saw a black bear moving around which then turned into a miniature gorilla. She has also seen sheep on her dresser top and then 2 alligators fighting with the sheep. She then saw a full grown person squatting and jumping up and down beside her bed. She got up and rearranged her dresser top to see if that would help but then saw 2 gorillas and a sheep on her dresser top. On another night she heard 3 people, male and female, laughing and talking when she was about to fall asleep. Then she saw a third female holding her hands on her face yelling in distress. On another day, in the daytime, she heard 2 males having a conversation in her living room and then she heard someone yelling for help outside. Her dog, who notices any slight noise, did not react. She denies noxious smells or olfactory hallucinations but does have tactile hallucinations of bugs on her forearms. Normally she feels the bugs either early morning or around 6 to 7 PM. Some of her hallucinations are probably hypnagogic but other visual and auditory hallucinations have occurred during the daytime. She was initially placed on Sonata for sleep but was waking up in the middle of the night and having difficulty falling back asleep. Sonata was discontinued for a while to see if there were any effects on her hallucinations. Apparently it had no effects. She was then started on Lunesta 3 mg q.h.s. p.r.n. insomnia. She had been on phentermine at one point in the past but was not on it during any of these episodes and she denies any other drugs. On the way to her last National Guard drill, and prior to starting Lunesta, she kept hearing sirens and screeching brakes. She then fell asleep and ran into a ditch where her dog woke her up by licking her face. She did not feel tired prior to this incident. Currently she denies falling asleep at other times. Due to the nature of her hallucinations she was worked up for organic hallucinosis. MRI with and without contrast was negative. A consult for sleep study has been placed but there have been difficulties getting approval for it.

Meds: At her first visit she was placed on Celexa 20 mg daily for anxiety, Sonata 5 mg 1-3 caps q.h.s. p.r.n. insomnia, melatonin 3 mg q.h.s. p.r.n. insomnia, Klonopin 0.5 mg 1/2-1 tab daily p.r.n. severe anxiety. Sonata was ineffective and she was started on Lunesta 3 mg q.h.s. p.r.n. insomnia.

Labs: ESR, glucose fasting, B12, B6, liver function tests, comprehensive metabolic panel, folate, ESR, and urine drug screen were ordered. UDS was negative and the only abnormal results were bilirubin of 0.1 and ESR of 24.

Any thoughts or recommendations?

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[Shikima]

Sleep medicine consult would be ok IMO, however I'm thinking that there is quite a bit of psychosis from a primary mood disorder and I'm wondering about Axis II? It's great that you got a comprehensive medical work-up regarding the hallucinations, and I'm glad they've come back negative. I'd discontinue the Klonopin along with any Z-BZD hypnotics in exchange for an atypical (Start with Seroquel and work towards Risperdal). If she is having hypnagogic hallucinations, the 3 most common causes are lack of sleep, OSA and/or use of a BZD/Z-BZD (ie: Zolpidem) and getting a PSG (not a home test) to rule out of primary seizure disorder would be good to investigate - could even include a seizure montage with possible MSLT. Getting the PSG/MSLT cleared/approved would be easy after seeing an sleep physician who does a complete history on her.

 

[hamstergang]

Paragraphs make that monstrosity readable.

 

[nitemagi]

I agree on the sleep consult, as well as getting an EEG. If all else is negative, consider in the differential of this being pseudohallucinations (a psychiatric conversion disorder -- meaning a conversion disorder manifesting in hallucinations rather than neurological symptoms). See the DSM handbook of differential diagnosis under trees for hallucinations. Reqments include hallucinations that are in multiple sensory modalities, can fantasy-like or childish in nature, and with retained insight.

Essentially if that's the case then it would be expected that this person has other characteristics of someone susceptible to a conversion disorder, which might include natural propensity for dissociation or a trance, response to hypnosis, and ability to turn on/off symptoms simply with a hypnotic suggestion. If there's anyone in your hospital hypnosis trained, I'd consider getting a standardized exam such as the Hypnotic Induction Profile (Spiegel & Spiegel), or the Stanford Hypnotic Susceptibility Scale.

 

[Zenman1]

Sleep medicine consult would be ok IMO, however I'm thinking that there is quite a bit of psychosis from a primary mood disorder and I'm wondering about Axis II? It's great that you got a comprehensive medical work-up regarding the hallucinations, and I'm glad they've come back negative. I'd discontinue the Klonopin along with any Z-BZD hypnotics in exchange for an atypical (Start with Seroquel and work towards Risperdal). If she is having hypnagogic hallucinations, the 3 most common causes are lack of sleep, OSA and/or use of a BZD/Z-BZD (ie: Zolpidem) and getting a PSG (not a home test) to rule out of primary seizure disorder would be good to investigate - could even include a seizure montage with possible MSLT. Getting the PSG/MSLT cleared/approved would be easy after seeing an sleep physician who does a complete history on her.

Sleep study approved today ...in about a month and a half...unless there's a cancellation. She only takes the klonopin 1-2 times every other week. I just don't see Axis II on her. Heck, I can get psych testing a lot faster than sleep studies. I guess United Healthcare is on a "deny every sleep study" month.

 

[Zenman1]

Paragraphs make that monstrosity readable.

Not my usual short one, lol!

 

[Zenman1]

I agree on the sleep consult, as well as getting an EEG. If all else is negative, consider in the differential of this being pseudohallucinations (a psychiatric conversion disorder -- meaning a conversion disorder manifesting in hallucinations rather than neurological symptoms). See the DSM handbook of differential diagnosis under trees for hallucinations. Reqments include hallucinations that are in multiple sensory modalities, can fantasy-like or childish in nature, and with retained insight.

Essentially if that's the case then it would be expected that this person has other characteristics of someone susceptible to a conversion disorder, which might include natural propensity for dissociation or a trance, response to hypnosis, and ability to turn on/off symptoms simply with a hypnotic suggestion. If there's anyone in your hospital hypnosis trained, I'd consider getting a standardized exam such as the Hypnotic Induction Profile (Spiegel & Spiegel), or the Stanford Hypnotic Susceptibility Scale.

Thanks. EEG and neuro consult placed today.

 

[vistaril]

Thanks. EEG and neuro consult placed today.

You have to wonder and question the utility of some of these work ups I think....she has already had MRI and a bunch of labs probably. You know that the neuro consult, EEG, and sleep study are very unlikely to show anything. Np testing isn't going to be much help probably.

I'm not saying I wouldn't do the same thing(also not saying I would)....it just appears that there isn't a lot of easy to find data on how cost effective things like an EEG are for this....not neccessarily in terms of what the EEG findings will be, but in how it affects treatment.

 

[Shikima]

You have to wonder and question the utility of some of these work ups I think....she has already had MRI and a bunch of labs probably. You know that the neuro consult, EEG, and sleep study are very unlikely to show anything. Np testing isn't going to be much help probably.

I'm not saying I wouldn't do the same thing(also not saying I would)....it just appears that there isn't a lot of easy to find data on how cost effective things like an EEG are for this....not neccessarily in terms of what the EEG findings will be, but in how it affects treatment.

This is from your vast experience with neurological disorders and sleep medicine?

 

[Ceke2002]

I'm not sure if this will be of any help, because obviously it's more from the point of view of maintenance/treatment of pre-existing symptomology rather than diagnosis, but I'm just trying to think of what sort of check lists my Psychiatrist goes through with me when I'm symptomatic in this regard.

Ah, okay let's see...

In no particular order:

Frequency
Time of Occurrence
Duration
Type (Auditory/Visual/Olfactory/Sensory)
Content
Description (in colour, black and white, solid, transparent, clearly audible, faint, loud, etc)
Any Changes in Functioning
Speech/Language Issues and/or Deficits
Reported Observations by Third Parties
Changes in Mood
Medication Changes (dosage increase/decrease, additional medications recently started, etc)
Any Increase in Alcohol Consumption
Generalised Anxiety
Emotional Disregulation
Sleep Disturbances
Dissociative Episodes (possibility of)
Triggers for Past Trauma Recall
Any Other Recent Stressors

I have to say the only time I've ever had what I'd consider 'bizarre' or 'atypical' hallucinations, like your patient seems to be reporting (including Lilliputian hallucinations), was when I stopped taking a high dose of Seroquel (1200 mgs per day) and my brain basically turned around, stuck two fingers up at me, and went, "Eff you".

You seem to have an interesting case on your hands, that's for sure.

 

[Zenman1]

I'm not sure if this will be of any help, because obviously it's more from the point of view of maintenance/treatment of pre-existing symptomology rather than diagnosis, but I'm just trying to think of what sort of check lists my Psychiatrist goes through with me when I'm symptomatic in this regard.


You seem to have an interesting case on your hands, that's for sure.

That's why the more consults/tests than usual.

 

[smalltownpsych]

I agree it's a good idea to rule out some of the physiological but I concur with Nitemagi. I wouldn't be surprised if there was an earlier trauma than the sexual assault. Also, look for dissociative symptoms and memory gaps, but if this patient is highly suggestible, be wary of induction of symptoms. I had a patient recently who was very similar and had been diagnosed with multiple disorders by multiple providers. As she described her vast array of bizarre symptoms, she would watch me intently to gauge my reaction. Unfortunately, she didn't feel validated by my lack of response to her symptoms and my tendency to focus on the more concrete aspects of her life so only had the intake.

 

[nitemagi]

smalltown, from that brief paragraph, malingering/factitious would be higher on my differential in your case (the pursuing a specific response).

Which can of course be possible in the OP's case as well, but more of diagnosis of a exclusion.

 

[vistaril]

This is from your vast experience with neurological disorders and sleep medicine?

from my experience in reading their consult reports(and subsequent recs) in cases like this.

 

[smalltownpsych]

smalltown, from that brief paragraph, malingering/factitious would be higher on my differential in your case (the pursuing a specific response).

Which can of course be possible in the OP's case as well, but more of diagnosis of a exclusion.

Malingering wouldn't make sense because no secondary gain. Factitious would also have more of a conscious or intentional component if my memory serves (too lazy to look it up), not sure if that was the case, and didn't see patient enough to differentiate.

 

[michaelrack]

"She then fell asleep and ran into a ditch where her dog woke her up by licking her face" This is the key history point that would support the need for a PSG (followed the next am by an MSLT if negative for significant apnea). Of course, you would want to ensure good sleep hygiene for at least the week prior to the test. It will probably be difficult to get the patient off of her sedating/REM altering meds prior to the MSLT, so sleep testing is likely to be nonconclusive. In addition to the med changes Shikima recommended, an empiric trial of a low-dose tricyclic could be considered to help suppress any hypnagogic phenomena. Unless the PSG is being read by a sleep-neurologist, sz activity may be missed so a full EEG should be obtained. The patient is on a lot of hypnotics, and I would probably try to lower or eliminate melatonin, unless it was clearly helpful.

 

[Ceke2002]

Malingering wouldn't make sense because no secondary gain.

Sometimes the validation is the secondary gain though. I know I don't have any level of professional training, but I have spent a lot of time in various patient support groups and been able to observe the behaviours of other patients. I remember one girl in particular - past history of CSA, abandonment issues, low self esteem, lack of concrete self image, self harming and impulsive behaviours etc etc - who suddenly began endorsing psychotic like symptoms. She actually ended up finding a Psychiatrist who was willing to diagnose her with Schizophrenia and placed her on Haloperidol (which she admitted she never took, because something about the CIA operatives), which was after she'd burnt through umpteen dozen other doctors, but the interesting thing with her was if she reported having an episode, and she didn't get a certain level of concern and/or a myriad of people rushing in to validate/comfort her, suddenly the reported episode would start becoming increasingly bizarre. 'I'm hearing voices, and I'm scared' would end up being 'I'm hearing voices coming from a UFO that is hovering around my room, and a witch has just teleported out of the craft, and now she's clinging to my ceiling and cackling at me because she's telling me to go kill my family'. She'd only stop embellishing once enough people had given her the validation she required, at which point of course she'd report that the entire episode itself had now ceased. You could almost set your watch by when she was going to have another 'episode', because several hours prior she'd always start talking about how no one was hearing her, and she didn't feel 'seen' or 'listened to', and she couldn't make anyone understand, and she felt like no one was ever really going to be there for her - and then fast forward 3 or 4 hours, suddenly!Psychosis. I know she eventually ended up with a really good Psychotherapist who was able to get her past all this, and she's doing really well now - stable, completed university studies, gainfully employed, little to no symptomology present.

I guess my point is some patients might feel as if the only way they'll be heard and/or receive the validation they're looking for is to basically shout, and to them endorsing bizarre symptoms of psychosis might just be their version of shouting.

 

[smalltownpsych]

Sometimes the validation is the secondary gain though. I know I don't have any level of professional training, but I have spent a lot of time in various patient support groups and been able to observe the behaviours of other patients. I remember one girl in particular - past history of CSA, abandonment issues, low self esteem, lack of concrete self image, self harming and impulsive behaviours etc etc - who suddenly began endorsing psychotic like symptoms. She actually ended up finding a Psychiatrist who was willing to diagnose her with Schizophrenia and placed her on Haloperidol (which she admitted she never took, because something about the CIA operatives), which was after she'd burnt through umpteen dozen other doctors, but the interesting thing with her was if she reported having an episode, and she didn't get a certain level of concern and/or a myriad of people rushing in to validate/comfort her, suddenly the reported episode would start becoming increasingly bizarre. 'I'm hearing voices, and I'm scared' would end up being 'I'm hearing voices coming from a UFO that is hovering around my room, and a witch has just teleported out of the craft, and now she's clinging to my ceiling and cackling at me because she's telling me to go kill my family'. She'd only stop embellishing once enough people had given her the validation she required, at which point of course she'd report that the entire episode itself had now ceased. You could almost set your watch by when she was going to have another 'episode', because several hours prior she'd always start talking about how no one was hearing her, and she didn't feel 'seen' or 'listened to', and she couldn't make anyone understand, and she felt like no one was ever really going to be there for her - and then fast forward 3 or 4 hours, suddenly!Psychosis. I know she eventually ended up with a really good Psychotherapist who was able to get her past all this, and she's doing really well now - stable, completed university studies, gainfully employed, little to no symptomology present.

I guess my point is some patients might feel as if the only way they'll be heard and/or receive the validation they're looking for is to basically shout, and to them endorsing bizarre symptoms of psychosis might just be their version of shouting.

True, but when we speak of malingering we are generally referring to direct results such as either monetary gain or to evade prosecution. What you are describing is more in line with a Factitious Disorder. It's a fine line between the two, but thinking of intentional scam verses real patient exaggerating symptoms can help. Patients will exaggerate or minimize their symptoms to different degrees for a variety of reasons, that's fairly normal behavior and not just for psych, medical doctors see it all day long.

 

[Ceke2002]

True, but when we speak of malingering we are generally referring to direct results such as either monetary gain or to evade prosecution. What you are describing is more in line with a Factitious Disorder. It's a fine line between the two, but thinking of intentional scam verses real patient exaggerating symptoms can help. Patients will exaggerate or minimize their symptoms to different degrees for a variety of reasons, that's fairly normal behavior and not just for psych, medical doctors see it all day long.

Thanks for the differential, that does make sense.

 

[Shikima]

from my experience in reading their consult reports(and subsequent recs) in cases like this.

There is a difference with sleep physicians like Dr. Rack and I and the others whom I'll refer to as 'reportologists'.

 

[Catilina]

There might be an ongoing process somewhere.
However: There is a phenomenon we can call e.g. "daytime parahypnagogia". We are not very common. Some suffer from it, some don't, sometimes it can be enjoyable even. Sometimes it is irritating. I have never met anyone with an adolescent or adult onset, but then we are rare and meet by chance only. It is rather a property and follows one from the childhood on.
Visual hallucinations usually bespeak a very organic origin rather than so called "psychiatrical".

 

[Zenman1]

Follow-up. Patient's sleep study was normal. After psych testing the psychologist diagnosed her with Bipolar II Disorder and Psychotic Disorder NOS. She did this due to patient being able to function at work and in school during hypomanic episodes. However, a few days later the patient called in from the road side after driving 400 miles on way to her NG unit, not sure where she was or how she got there. She also had pressured speech according to the nurse who talked to her. Do you think this is Bipolar II superimposed on a psychotic disorder or has she now "earned" manic status? She doesn't have disorganized thinking or behavior seen in schizophrenia. Interesting that she never disclosed history of hypomania since 17-18 yrs of age plus mother with paranoid delusions and maternal GM with psychosis, even when questioned. Dang it!

 

[Shikima]

Sounds like she bought herself a Type I, manic with psychotic features.

 

[Zenman1]

Sounds like she bought herself a Type I, manic with psychotic features.

Yep, and I was so hoping for a sleep disorder. If she had been more forthcoming she would already be on meds.

 

[Shikima]

Good job working her up!

 

[hamstergang]

After psych testing the psychologist diagnosed her with Bipolar II Disorder and Psychotic Disorder NOS.

Now that I actually read the OP, it does feel a lot like an Axis II/conversion-y thing to me. And I feel it's not uncommon for that to look like Bipolar II. The driving 400 miles seems like dissociation, which also fits. And if we believe the nurse about the pressures speech, I wouldn't be so fast to mark it off as a manic symptom instead of the speech pattern of someone in distress.

With what's been written here, I would not be comfortable calling this Bipolar Disorder.

 

[Ceke2002]

Now that I actually read the OP, it does feel a lot like an Axis II/conversion-y thing to me. And I feel it's not uncommon for that to look like Bipolar II. The driving 400 miles seems like dissociation, which also fits. And if we believe the nurse about the pressures speech, I wouldn't be so fast to mark it off as a manic symptom instead of the speech pattern of someone in distress.

With what's been written here, I would not be comfortable calling this Bipolar Disorder.

Hmm, yeah, if I was a Doctor, which I'm obviously not, I'd probably want to see these 'pressured speech' patterns for myself before I made a clear diagnosis. I've known someone who was Type 1 Bipolar, manic with psychosis, and I've also known a few people with Axis II diagnosis, the pressured speech displayed in both cases was considerably different. I couldn't even begin to describe it in any sort of medical terms, it was just one of those thing that when you saw it you knew it wasn't even close to being the same thing.

 

[Zenman1]

Now that I actually read the OP, it does feel a lot like an Axis II/conversion-y thing to me. And I feel it's not uncommon for that to look like Bipolar II. The driving 400 miles seems like dissociation, which also fits. And if we believe the nurse about the pressures speech, I wouldn't be so fast to mark it off as a manic symptom instead of the speech pattern of someone in distress.

With what's been written here, I would not be comfortable calling this Bipolar Disorder.

I talked with yhe nurse this morning and she said she was able to calm the patient down quickly so it was most likely distress.

 

[gabafan]

Hi Zen Man. Are antipsychotics helpful for the pt? I currently am seeing an adult who has A/V hall's in the evening (not just prior to sleep). She has had them since childhood, but they have been more frequent and bothersome since she entered a residential tx center for polysubstance abuse. She has a trauma hx. So far, two atypicals have not helped.

 

[Zenman1]

Haven't seen her since sleep study and psych testing as she is going to another country with her mlitary spouse and will start treatment then.