Abstract Introduction Narcolepsy is a chronic sleep disorder characterized by excessive daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis. Its symptoms may overlap with psychiatric disorders, resulting in delayed or incorrect diagnoses. This case highlights a patient initially diagnosed with schizophrenia whose psychotic-like symptoms resolved after confirmation and treatment of narcolepsy. Case Presentation A 38-year-old man with schizophrenia, hypertension, diabetes, gastroesophageal reflux disease, and hyperlipidemia presented with loud snoring, excessive daytime sleepiness, witnessed apneas, and fragmented sleep. Four years earlier, polysomnography (PSG) had shown mild abnormalities, but symptoms worsened after a 100-lb weight gain (current weight 295 lbs, neck circumference 19¼ in). Neurology evaluation for “seizure-like” spells prompted repeat sleep testing.He reported bedtime around 11 PM, sleep talking, hypnagogic hallucinations, transient weakness at sleep onset, and multiple nocturnal awakenings. His wife observed frequent daytime “sleep attacks,” vivid dreaming, and episodes resembling cataplexy. He routinely napped two to three times daily for 1-2 hours. Medications included multiple antipsychotics and anticonvulsants (aripiprazole, quetiapine, olanzapine, haloperidol, levetiracetam, valproate), along with antihypertensives and diabetic therapy.Repeat overnight PSG confirmed moderate obstructive sleep apnea (OSA) with oxygen desaturation to 70% and periodic limb movements. Continuous positive airway pressure (CPAP) at 16 cm H2O improved snoring but not hypersomnia (Epworth Sleepiness Scale = 11). Multiple Sleep Latency Testing (MSLT) on CPAP demonstrated four sleep-onset REM periods, confirming narcolepsy.Treatment with modafinil and sodium oxybate led to complete resolution of sleep attacks, hallucinations, and cataplexy. The schizophrenia diagnosis was reconsidered, and symptoms were reattributed to narcolepsy-related phenomena. Discussion This case underscores the importance of considering narcolepsy in patients with persistent hypersomnia despite treated OSA or apparent psychiatric illness. Overlap between narcoleptic hallucinations and psychotic symptoms can lead to misdiagnosis and prolonged inappropriate treatment. Comprehensive evaluation, including MSLT, is critical for accurate diagnosis. Early recognition and targeted therapy can dramatically improve symptoms and restore quality of life. This abstract is funded by: n/a
Smith et al. (Fri,) studied this question.