![]() ![]() During the event deep tendon reflexes were 2+ at the biceps tendons bilaterally, 2+ at the patellar tendons bilaterally, and 1+ at the Achilles' tendons bilaterally. Video recording of a typical drop attack showed backward collapse from a seated position, without emotional precipitant ( Video 1). This finding was consistent with a diagnosis of psychogenic non-epileptic attacks. EEG showed neither epileptiform activity nor changes in the normal waking background activity during the convulsive event. Typical generalized convulsive event capture on video-electroencephalogram (EEG) recording. The video-EEG recording was consistent with a diagnosis of psychogenic non-epileptic seizures. Neither epileptiform activity nor changes in the normal waking background EEG were noted during the event ( Figure 1). During a 30-min video-EEG recording, multiple typical generalized convulsive episodes with eyes closed and maintained ability to communicate were captured ( Video 2). The patient was on levetiracetam during the PSG-MSLT. After sleep physician review, a single epoch of REM sleep was noted in the first nap and the average sleep latency was 1 minute. The MSLT was interpreted as having no SOREMPs and was terminated after 4 naps. The patient reported nightly CPAP use, but downloadable data was not available and patient did not complete sleep diaries as requested.Ī repeat PSG-MSLT on 9 cm of CPAP was performed. ![]() Continuous positive airway pressure (CPAP) PSG titration revealed a pressure requirement of 9 cm H 2O. A repeat PSG showed an apnea hypopnea index of 28. Obstructive sleep apnea (OSA) was highly suspected. Physical exam revealed a body mass index (BMI) of 42 with Mallampati IV and large tongue. The patient reported snoring and waking up gasping for air. His current medications are sodium γ-hydroxybutyrate (GHB) 6 grams at bedtime and 6 grams at 2 AM levetiracetam 500 mg twice per day and venlafaxine 150 mg once per day. The patient fulfilled criteria of the Diagnostic and Statistical Manual of Mental Disorders IV for paranoid-type schizophrenia. Auditory hallucinations occurred in the context of paranoid ideation that others were going to harm him. The patient started hearing voices at age 19 while not on any stimulant medications. Clomipramine and venlafaxine were added with no improvement noted. With complaints of daytime sleepiness, the patient was diagnosed with narcolepsy with cataplexy and started on sodium γ-hydroxybutyrate (GHB) with no improvement in drop attack frequency. A polysomnogram (PSG) followed by multiple sleep latency testing (MSLT) performed at an outside institution while on AEDs was interpreted as showing 5 out 5 sleep onset REM sleep periods (SOREMPs), with an average sleep latency of 1.2 minutes (data from PSG was not available). Magnetic resonance imaging of the brain, and 3 routine electroencephalograms (EEGs) without video monitoring were normal. A typical drop attack is shown in Video 1. The drop attacks, referred to as “cataplexy” by the patient, always occurred in public, have no clear trigger and have never resulted in injury to the patient. At age 17 he started having daily drop attacks consisting of full body weakness followed by collapse. He has been on multiple anti-epileptic drugs (AEDs) including phenobarbital, valproic acid, and levetiracetam without decrease in event frequency. ![]() The patient's typical convulsive events started at 8 years of age, occur daily, and consist of jerking in all extremities with preserved consciousness. A 29-year-old white man presents for evaluation of refractory daily generalized convulsions and drop attacks previously diagnosed as cataplexy. ![]()
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