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. 2021 Jul;144(1):28-41.
doi: 10.1111/acps.13300. Epub 2021 May 5.

Narcolepsy and psychosis: A systematic review

Cyril Hanin  1   2 , Isabelle Arnulf  3 , Jean-Baptiste Maranci  3 , Michel Lecendreux  4 , Douglas F Levinson  5 , David Cohen  1   2   6 , Claudine Laurent-Levinson  1   2
Affiliations

Narcolepsy and psychosis: A systematic review

Cyril Hanin et al. Acta Psychiatr Scand. 2021 Jul.

Abstract

Objective: Narcolepsy is a rare sleep disorder in which psychotic-like symptoms can present diagnostic and therapeutic challenges. We aimed to review the association between, and medical management of, narcolepsy and psychosis in children and adults.

Methods: We reviewed the full text of 100 papers from 187 identified by a PubMed search on narcolepsy plus any of these keywords: psychosis, schizophrenia, delusion, side effects, safety, and bipolar disorder.

Results: Three relevant groups are described. (i) In typical narcolepsy, psychotic-like symptoms include predominantly visual hallucinations at the sleep-wake transition (experienced as "not real") and dissociation because of intrusion of rapid eye movement (REM) sleep phenomena into wakefulness. (ii) Atypical patients ("the psychotic form of narcolepsy") experience more severe and vivid, apparently REM-related hallucinations or dream/reality confusions, which patients may rationalize in a delusion-like way. (iii) Some patients have a comorbid schizophrenia spectrum disorder with psychotic symptoms unrelated to sleep. Psychostimulants used to treat narcolepsy may trigger psychotic symptoms in all three groups. We analyzed 58 published cases from groups 2 and 3 (n = 17 and 41). Features that were reported significantly more frequently in atypical patients include visual and multimodal hallucinations, sexual and mystical delusions, and false memories. Dual diagnosis patients had more disorganized symptoms and earlier onset of narcolepsy.

Conclusion: Epidemiological studies tentatively suggest a possible association between narcolepsy and schizophrenia only for very early-onset cases, which could be related to the partially overlapping neurodevelopmental changes observed in these disorders. We propose a clinical algorithm for the management of cases with psychotic-like or psychotic features.

Keywords: delusion; hallucination; narcolepsy; psychosis; schizophrenia; side effects.

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Conflict of interest statement

During the last two years, David Cohen reported past consultation for or the receipt of honoraria from Otsuka, Shire, Lundbeck, and IntegraGen. All other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Flow chart of review process. The systematic literature search was conducted on 27 April 2020, using the following Search Builder: narcolepsy[MeSH Major Topic] AND (psychosis OR schizophrenia OR delusion OR bipolar disorder OR safety OR side effect, yielding 187 records. An additional 48 records were identified via reference lists from the 187 selected records, or from supplementary Medline searches (15 papers on mechanisms or adverse effects of drugs used to treat narcolepsy; 12 with relevance to the discussion of the relationship between narcolepsy and psychosis; and 21 with more relevance to discussion of narcolepsy or to psychosis but not their relationship). None of the additional records were cohort or case reports. We list as excluded records those that were identified by systematic search but not selected as eligible for inclusion in the qualitative or quantitative analyses for the reasons cited
FIGURE 2
FIGURE 2
Algorithm for evaluating and treating narcolepsy patients with psychotic symptoms
See this image and copyright information in PMC

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