A pediatrician presented a medical case:
40 year-old man unable to sleep since 7 years-old, sleeping 2-4 hours a night and having unusual dreams. Why, and could it be epileptic.....?
40 year-old man who has been unable to sleep since he was 7 years old, sleeping 2-4 hours a night, and having unusual dreams. Why does he not sleep, and could he be having epileptic activity at night.....?
Close details
Patient demographics
Gender
male
Age
40
Ethnicity
Occupation
self employed roofing estimator
Chief complaint or problem to solve
Started 7-8 years of age. Never fell asleep. stayed up all night. If something was going on it would keep him up.
Gets really bad bouts of a month or so.
2 hours a night to 4 hours a night of sleep. Stress dreams. About almost anything. He sometimes wakes with a sense general unease. He sometimes has “dreamlike” experiences during which he is disoriented and unable to go completely to sleep. He has the sense that when he does fall asleep he dreams immediately. He experiences “dreamlike” states associated with repetition of thinking about a song, lasting hours, not a specific song-can be any one.

At times gets dizzy when hasn’t slept. Is impaired to the extent that he cannot formulate sentences and cannot keep balance, cannot operate a car or stand well, feels like he is ”under water.”

hx when 10-11 years old would get panic attacks when walking into restaurants. That changed Came back when 19 for a little bit.
No sleep medications have helped except for lorazepam which he feels he should not take regularly.

amitryptiline no benefit

seroquel side effects not worth it. made him a zombie
trazodone- neither here nor there
nyquil did not work although is made him
“kinda drowsy”

melatonin no effect
ativan works

never had a sleep study.
never had an EEG

Does he have sleep induced subclinical electrical activity? Would he benefit from Gabapentin? Does he need an EEG, sleep study?

Case history
No family history of sleep disorders. Smokes. Limited alcohol intake. No FH seizures. Stable lifestyle. Travels often.
Purpose of case discussion
Is this sleep induced subclinical seizures
Supplemental Materials

Dr. Isak Isakov
Psychiatry
12 doctors agree

In brief: Case does not have all necessary test results to give recommendation

Need imaging study of the brain,EEG and Sleep study Before recommendation given for treatment.

In brief: Case does not have all necessary test results to give recommendation

Need imaging study of the brain,EEG and Sleep study Before recommendation given for treatment.
Dr. Isak Isakov
Dr. Isak Isakov
Thank
Dr. Yash Khanna
Family Medicine
6 doctors agree

In brief: Seizure Unlikely

It is a sleep disorder and unlikely to be a subclinical seizure.
Ativan is working.Needs Sleep studies and try 10mgm of Melatonin if not tried.Also may need Psychiatric evaluation to rule out underlying psychiatric condition.And consult with a sleep specialist

In brief: Seizure Unlikely

It is a sleep disorder and unlikely to be a subclinical seizure.
Ativan is working.Needs Sleep studies and try 10mgm of Melatonin if not tried.Also may need Psychiatric evaluation to rule out underlying psychiatric condition.And consult with a sleep specialist
Dr. Yash Khanna
Dr. Yash Khanna
Thank
Dr. Edward Workman
Pain Management
6 doctors agree

In brief: Needs EEG & sleep study for starters

It is possible that a seizure disorder could yield such a picture, esp.
if a seizure typically occurred just after REM sleep and just before stage 4 deep sleep. This would yield almost exactly the type of situation he is experiencing, esp with vivid dreams and what appears to be low grade atypical night terrors. He needs a full evaluation by a Neurologist who is also boarded in sleep medicine; otherwise a referral to each specialty in sequence would be a reasonable course of action. He needs an EEG with photic stimulation and NG leads to increase sensitivity to SZ activity. Then a sleep study to see whats going on in terms of sleep architecture. Gabapentin might help at decent dosages (e.g. 1800mg and above) if the culprit is atypical electrical activity set of by REM sleep. Interesting case.

In brief: Needs EEG & sleep study for starters

It is possible that a seizure disorder could yield such a picture, esp.
if a seizure typically occurred just after REM sleep and just before stage 4 deep sleep. This would yield almost exactly the type of situation he is experiencing, esp with vivid dreams and what appears to be low grade atypical night terrors. He needs a full evaluation by a Neurologist who is also boarded in sleep medicine; otherwise a referral to each specialty in sequence would be a reasonable course of action. He needs an EEG with photic stimulation and NG leads to increase sensitivity to SZ activity. Then a sleep study to see whats going on in terms of sleep architecture. Gabapentin might help at decent dosages (e.g. 1800mg and above) if the culprit is atypical electrical activity set of by REM sleep. Interesting case.
Dr. Edward Workman
Dr. Edward Workman
Thank
Dr. Milton Alvis, jr
Preventive Medicine
2 doctors agree

In brief: Impossible to solve

complex human problems with single molecule medications, regardless how many; usual medical nonsense.
What might help? Usual low-tech medical body mechanic stuff? Of course not. On the other hand, human sensitivity, commitment, basic logic & recognizing human/spiritual purpose(s) underlying the behaviors nearly always help & can be radically trans-formative, yet rare among physicians who typically want & will only consider simplistic mechanistic answers; ideas vastly below the reality/complexity of embodied Souls in a complex violent world of practice Heaven, practice Hell. I would expect the pseudo "diagnostic" tests suggested would end up of zero value to client, only billing opportunities. For starters suggest study http://goo.gl/Blh6rW & work of: Gavin deBecker, Flanders Dunbar, Richard Bach, George Ritchie, Vilayanur Ramachandran for clues. Dreams are essential for memory integration & problem solving. Yet, for some, the problems, in their perception, are unacceptable to face.

In brief: Impossible to solve

complex human problems with single molecule medications, regardless how many; usual medical nonsense.
What might help? Usual low-tech medical body mechanic stuff? Of course not. On the other hand, human sensitivity, commitment, basic logic & recognizing human/spiritual purpose(s) underlying the behaviors nearly always help & can be radically trans-formative, yet rare among physicians who typically want & will only consider simplistic mechanistic answers; ideas vastly below the reality/complexity of embodied Souls in a complex violent world of practice Heaven, practice Hell. I would expect the pseudo "diagnostic" tests suggested would end up of zero value to client, only billing opportunities. For starters suggest study http://goo.gl/Blh6rW & work of: Gavin deBecker, Flanders Dunbar, Richard Bach, George Ritchie, Vilayanur Ramachandran for clues. Dreams are essential for memory integration & problem solving. Yet, for some, the problems, in their perception, are unacceptable to face.
Dr. Milton Alvis, jr
Dr. Milton Alvis, jr
Thank
Dr. Holly Maes
Pediatrics
2 doctors agree

In brief: You need...

A SLEEP STUDY and a sleep professional!

In brief: You need...

A SLEEP STUDY and a sleep professional!
Dr. Holly Maes
Dr. Holly Maes
Thank
Dr. Djamchid Lotfi
Neurology
2 doctors agree

In brief: Sleep study

Needs a proper sleep study and a psychiatric evaluation!

In brief: Sleep study

Needs a proper sleep study and a psychiatric evaluation!
Dr. Djamchid Lotfi
Dr. Djamchid Lotfi
Thank
Dr. Judith Tellerman
Clinical Psychology
1 doctor agrees

In brief: Panic Attacks

It would be important to have a sleep study and a neurological exam conducted by Doctors.
Once physical illness is treated or ruled out then it would be good to a consult with a Clinical Psychologist for Panic Disorder and have an evaluation by a Psychiatrist for possible medication in addition to psychotherapy.

In brief: Panic Attacks

It would be important to have a sleep study and a neurological exam conducted by Doctors.
Once physical illness is treated or ruled out then it would be good to a consult with a Clinical Psychologist for Panic Disorder and have an evaluation by a Psychiatrist for possible medication in addition to psychotherapy.
Dr. Judith Tellerman
Dr. Judith Tellerman
Thank
Dr. Jon Ahrendsen
Family Medicine
1 doctor agrees

In brief: There are a couple of other things to try and help him sleep.

I certainly would have him have a sleep study first.
Doesn't sound like he has sleep apnea, but they can help gauge the quality of his sleep. Look for a sleep center that does these in the clinic. One near me offers it for a much lower co-pay that the hospital which can run for upwards of $2,000. I have had different people respond to these pharmacologic aids: zolpidem, tempazepam, ramelton, cyproheptadine. One man in my practice never slept well until we tried a low dose of ritalin at night. Using a stimulant at night? Think of it this way, it helps him focus on sleep. It's worked for a couple of my patients. Also consider a Fischer-Wallace neurostimulator. An FDA approved device for insomnia that uses two AA batteries to deliver a low level electrical impulse to the temples like a tens unit. Nice thing to try as there really are no side effects and the company offers a 30 day money back guarantee.

In brief: There are a couple of other things to try and help him sleep.

I certainly would have him have a sleep study first.
Doesn't sound like he has sleep apnea, but they can help gauge the quality of his sleep. Look for a sleep center that does these in the clinic. One near me offers it for a much lower co-pay that the hospital which can run for upwards of $2,000. I have had different people respond to these pharmacologic aids: zolpidem, tempazepam, ramelton, cyproheptadine. One man in my practice never slept well until we tried a low dose of ritalin at night. Using a stimulant at night? Think of it this way, it helps him focus on sleep. It's worked for a couple of my patients. Also consider a Fischer-Wallace neurostimulator. An FDA approved device for insomnia that uses two AA batteries to deliver a low level electrical impulse to the temples like a tens unit. Nice thing to try as there really are no side effects and the company offers a 30 day money back guarantee.
Dr. Jon Ahrendsen
Dr. Jon Ahrendsen
Thank
Dr. Bert Liang
Neurology
1 doctor agrees

In brief: Sleep evaluation needed

There are a number of possibilities here, but what is unusual is with a patient complaining of such prolonged history of sleep abnormalities, he's never had a sleep study.
Regardless, that's where one could start to evaluate whether he has anything from true insomnia, pseudo-insomnia, or other etiologies which might include epilepsy (albeit a distinctly uncommon presentation) or narcolepsy. One could speculate on a number of organ systems being involved, toxic-metabolic causes, congenital, etc etc, but would need additional history and exam findings to firmly establish a differential diagnosis. The sleep study should include at least some level of EEG monitoring, so prior to doing either an ambulatory or more prolonged evaluation I'd start there. Good luck.

In brief: Sleep evaluation needed

There are a number of possibilities here, but what is unusual is with a patient complaining of such prolonged history of sleep abnormalities, he's never had a sleep study.
Regardless, that's where one could start to evaluate whether he has anything from true insomnia, pseudo-insomnia, or other etiologies which might include epilepsy (albeit a distinctly uncommon presentation) or narcolepsy. One could speculate on a number of organ systems being involved, toxic-metabolic causes, congenital, etc etc, but would need additional history and exam findings to firmly establish a differential diagnosis. The sleep study should include at least some level of EEG monitoring, so prior to doing either an ambulatory or more prolonged evaluation I'd start there. Good luck.
Dr. Bert Liang
Dr. Bert Liang
Thank
Dr. Kathryn Seifert
Clinical Psychology
1 doctor agrees

In brief: Could be anxiety

Anxiety, depression, bipolar disorder and a history of trauma which occurred at night can disturb sleep.
The fact that Ativan works implicates anxiety. Have a psychologist evaluate for the above. Have him explore meditation to manage anxiety and sleep. Biofeedback can also potentially help.

In brief: Could be anxiety

Anxiety, depression, bipolar disorder and a history of trauma which occurred at night can disturb sleep.
The fact that Ativan works implicates anxiety. Have a psychologist evaluate for the above. Have him explore meditation to manage anxiety and sleep. Biofeedback can also potentially help.
Dr. Kathryn Seifert
Dr. Kathryn Seifert
Thank
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