Brit. 3. Psychiat. (1976), 128, 562—5

Psychiatric Aspects of Narcolepsy By ALEC ROY Summary.

Among

twenty

patients

with

narcolepsy

intelligence

was normal

and no characteristic personality or psychopathology was found. A family history of psychiatric disorder was present in five and a past personal history in ten. Eight had a current psychiatric disorder and twelve either a current or past psychiatric disorder. Chronic sexual disorder was present in eleven. Arousal appeared to be the mechanism by which emotions precipitated symptoms. Ten patients were found to have had difficulties at work, in marriage or in social life.

IN'rRoDucrloN ‘¿anxiety, schizoid and paranoid reactions' in a Gelineau'ssyndrome isa tetrad—narcolepsy,further 25. Thus two thirds had a psychiatric

cataplexy,

sleep paralysis

hypnopompic

@

hallucinations.

and hypnagogic

and

Pond (1952) found

that ‘¿narcoleptics have a considerably higher intelligence level than normal'. Daniels (i@@) considered that before the onset of narcolepsy patients had shown ‘¿neurotic and psychopathic tendencies' in their personality, and that the condition led to a change of personality charac terized by ‘¿sensitivity', ‘¿an air of reserve and gravity', and ‘¿irritability'. Pond (1952), on the basis of interview, Rorschach and TAT tests, reported a passive personality. Smith (i@@@) found that five of his seven patients had signi ficantly high neuroticism scores on the MPI, while on the MMPI the only significant finding was high depression scores in five subjects. His Rorschach testing revealed no common personality profile. Sours' (1963) impression was

that

the

‘¿personality configuration

was

predominantly passive-aggressive'. Among the 30 cases reported by Adie (1926), Wilson (1928) and Levin (1929), none had a personal history of psychiatric disorder. Daniels (1934)

reported

147

cases

and

concluded

that

‘¿althoughpatients become discouraged, real attacks of depression are exceptional'. Smith (i@@@)

found

no

formal

psychiatric

disorder

of

schizophrenic

‘¿reaction'

in

10,

Scoville,1938; Brock and Wiesel, 1941; Smith,

1958). After Council's monograph (1958), many of these later reports may be reformulated as amphetamine psychoses secondary to the stim ulant medication. Sours (1963) claimed that 10 of his patients ‘¿developed frank schizophrenic reactions which required prolonged hospitali zation' and that in only 3 could this be attrib uted to stimulants. Daniels (i@@) found impaired sexual function in 15 of his 97 men but in only one of his women patients. Of Sours' (1963) 75 ‘¿primary' narcoleptics 45 were men, and impotence occurred in 5 of them. Four of his 75 patients were homosexual. Pond (1952) reported all his seven male patients ‘¿suffered from ejaculatio praecox at some stage of their illness'. The one woman was frigid. He explained this is terms of unresolved Oedipal problems. There have been reports of cataplexy provoked by anger (Levin, 1935,

among his seven cases. Of Sours' (1963) 75 cases, he reported a diagnosis of depression in 15,

diagnosis but, as Cooper, Kendell et al, (1972) have shown, different diagnostic habits in the United States may .partly account for this. There have been many reports of schizo phrenia-like psychosis associated with nar colepsy (Dods Brown, igo8; Young and

and 56*

1963;

Barker,

1948;

Smith,

1958)

and

by orgasm (Langworthy and Betz, ‘¿@; Sleep paralysis precipitated by fearful dreams and nightmares has been reported (Daniels,

BY ALEC 1934;

Brock

and

Wiescl,

1941;

Dement,

ROY

563 T@

1966).

The present study aimed to examine these psy chiatric aspects.

EysenckPersonalityQyestionnairescoresin narcoleptic patients (scoresfor normal population in brackets) Mean ncuroticism

METHOD

Twenty patients with Gelineau's syndrome were seen. There were three diagnostic criteria: the presence of narcolepsy and cataplexy, and the absence of organic cerebral pathology. Eighteen of the twenty were drawn randomly from the neurological clinic of a general teaching hospital. Sixteen were seen as out-patients and two as in-patients. Two of the ten males were drawn from the out-patients of a psychiatric teaching hospital. The average age of onset was 19

years,

and

the

average

I

age

of

the

scoreFemales

RESULTS

score

(N = zo) .. (‘3@o±4i)Males

@3.3 (I2@7±5@I)

(N = IC))

.. IO@7 I2@7 (‘3@'±5@o)TABLE (9i±5@') II

Effect of stimulants scoresMeanon personality N score;

patients

when seen was 40 years. All the patients were given a psychiatric interview, an intelligence test and a personality questionnaire, and their neurological case notes were examined.

Mean cxtraversion

Mean

E score;

patientsOn patients stimu-

Not on On stimu— stimu-

lantsFemales

lants

lants

lants

13@3Males (N = io)

14•5

I5@8

I3@3

(N = io)

io@8

IO@5

Not on stimu

Intelligence

Intelligence was measured by the Mill Hill Vocabulary Scale—Set A and Set B. The highest score was 126 and the lowest 77; the mean IQwas 96@4. Personality and psychopathology The Eysenck Personality Questionnaire was used. The results are presented in Table I. The scores in brackets are those for normals (Eysenck, S., 1974). Four women and eight men were taking prescribed stimulant drugs when seen. In Table II the scores for these patients are compared with those not taking stimulants. The results show that the neuroticism and extraversion scores of all these different groups are within the normal range. Family history of psychiatric disorder

The definition of a psychiatric case used was that suggested by Shepherd (i@)@). A current psychiatric evaluation was made and where possible any psychiatric notes were examined. A family history was found in five cases. The diagnosis was depressive neurosis in two first degree relatives and sexual deviation in the

@3.4

io@c@

third. In the two third-degree relatives the diagnoses were unknown—one had committed suicide and the other was a long-stay mental hospital

patient.

Past personal history Ten patients had a past personal history of psychiatry abnormality. In four, this was a

depressive neurosis, in one an anxiety neurosis, and in one an obsessive-compulsive neurosis. In two, the diagnosis was personality disorder, in one a marital problem, and in one a psychosis. Currentpsychiatric disorder Eight of the twenty were diagnosed as having a current disorder. In five, this was a personality disorder, in one a depressive neurosis, in another a schizophreniform psychoses with Schneiderian first-rank symptoms, and in the last a marital problem. Four of the ten with past personal disorder were found to have no current abnormality. Two of the eight with current disorder had no past personal history. Among the six with a past history, the diagnosis re

PSYCHIATRIC

564

ASPECTS

mained the same in four; in two this was personality disorder, in one a marital problem, and in one, psychosis. Thus a diagnosis of

psychiatric was found

disorder—either in twelve

past or current

of the twenty.

Ten

of the

twenty—five with and five without any psy chiatric disorder—had had difficulties at work, in marriage and in their social life.

OF NARCOLEPSY

priate. Eysenck (1964) suggested the action of amphetamines on the reticular formation as a possible means of treatment, by facilitating social conditioning and learning of some criminal psychopaths. However, there was no significant difference in either the neuroticism or extraversion

scores between

them and those

not being treated with amphetamines. Among the five patients who had a family

Sexual disorder

history

Sexual disorder was only counted if it had persisted for at least one year. Two of the ten men gave a history of sexual dysfunction. One had a long-lasting history of premature ejacu lation; the other had been impotent for the last ten years but during that time he had also had a post-traumatic syndrome. Nine of the ten women had been frigid for many years and the tenth had had two periods of frigidity lasting three years each. In all ten the frigidity

past or current psychiatric disorder, and in the remaining three cases there was no con cordance of diagnosis between the patient and relative. Nine of Sours' (1963) 75 patients had a family history, but there was no concordance of diagnosis between any case with disorder and any relative with disorder. Davison and Bagley (1969) found i8 case reports of schizo phrenia-like psychosis, and in only one was there a family history of schizophrenia. It seems unlikely that narcolepsy, which may be familial, should be associated with any psychia tric disorder in which there is a marked genetic factor. Five of the eight patients found to have a current psychiatric disorder had a personality disorder.

was anorgasmia. Influence of emotions

All twenty patients reported that laughter provoked cataplexy; five of the twenty recog nized that anger provoked cataplexy, and two reported orgasmic cataplexy. Sleep paralysis occurred in thirteen; in four the preceding affect was fear associated with a dream, and another three described their affective state at the time as ‘¿frightened'. DIscussIoN The group suffered from the condition for, on average, 2! years. Pond (1952) reported high intelligence in his narcoleptics seen at a teaching hospital. The patients here were seen in a similar setting, but the mean IQ was within the normal range, at 96.4. The Eysenck Personality Questionnaire mean scores fell within the normal range for both neuroticism and extraversion, and at interview no specific personality traits were noted. The personality findings of Smith (i@@@)and Pond (1952) were not found. No specific dynamic psychopathology or family constellation was found; rather, it seemed that each individual was unique in background, personality and psychopathology, and Sours' (1963) observations about individual ways of coping and adapting seemed appro

of psychiatric

Gelineau's

syndrome

disorder,

two

had

no

begins in early adult life,

and the symptoms occur at inappropriate times, causing distress and difficulties at home, at work and in relationships. As with epilepsy, distorted self-image, social withdrawal, exclu sion by peer groups, difficulties in maintaining employment and heterosexual contacts may lead to the development of a personality dis order. Ten of the twenty ‘¿patients had a past personal history of psychiatric disorder. In five, this had been an affective disorder and two of these had a current diagnosis of per sonality disorder. The affective disorder may be seen as reaction to the subject's personality or life difficulties or it may be that disorder of the arousal system plays a part in the patho genesis. The relationship to schizophrenia-like psychosis may have been overstated. The patient with such a psychosis, unrelated to stimulant medication, also had a familial tremor—and there have been reports of schizophrenia-like psychosis related to this condition. Co-existing personality disorder, organic cerebral disorder or amphetamine

BY ALEC

intoxication

are often present in the reported

cases with schizophrenia-like

psychosis.

The anorgasmia found in all ten women may be a chance

finding.

All ten were married,

on

average for i8 years, and all had regular sexual intercourse. Some had had intercourse with other men before or during marriage, or after divorce, and had been anorgasmic with them also. Personaifty and selection factors relating to women who seek referral to a physician with a special interest in their condition might be relevant. Only five of the ten had a past or current history of psychiatric disorder. None of them had been taking any drugs, let alone the same drug, for the duration of their symp toms, and none thought that drugs had played a part. There may be a yet unrecognized neuro physiological explanation. Guilleminault (ig7@) has also noted sexual disorder among his patients and thinks that this may be due to disorder of the neurotransmitters in the brain stem. Aversive learning producing a phobia of orgasm may be the explanation; orgasm being avoided in order to prevent cataplexy (Roy, 1975).

One

had

cataplexy

during

her

BROCK & WIESEL BROWN,

a disease sui generzs.

of

Oxford

Psychiatric

: Oxford

L.

(‘934)

University Narcolepsy.

1—122. DAVISON & BAGLEY (i@6g)

associated nervous

with

system;

Medicine

Diagnosis

Monograph. (Baltimore),

Schizophrenia-like

organic a review

disorders

i@,

psychoses

of the

of the literature.

central

Chapter

i8

in Current Problems in Xeuro-psychiatty. British Journal of Psychiatrj Special Publication. Ashford, Kent: Headley Brothers Ltd. DEMENT,W., RECHTSCHAPFEN A., eta! (i g66) The nature of the narcoleptic sleep attack. Neurology, i6, 18—33.

EYSENCK,H. (1964) Crime and Personality. Routledge & Kegan Paul. EYSENCK,S. (1974) Personal communication. GU1LLEMINAULT,

C.

(1975)

Personal

communication.

LANGWORTHY& BETZ (i@44) Narcolepsy as a type of response to emotional conflicts. Psychosomatic Medicine, 6, 211. LEVIN, M. (1929)

other

Narcolepsy

varieties

(Gelineau's

of morbid

syndrome)

somnolence.

and

Archives of

Neurologyand Psychiatry,22, I 172—1200. (1935)

The

pathogenesis

of

cataplexy

on

anger.

Journal of Neurology and Psychopathology, z6, 140.

(1963) Aggression, guilt and cataplexy. Archivesof Neurology and Psychiatry, 69, 224.

Po,w, D. (1952) Narcolepsy; a brief critical review and study of eight cases. Journal of Mental Science, 98, 595—604.

Roy, A. (ig75) Psychiatric aspects of narcolepsy. thesis. University of London. SHEPHERD, M. (1973) Research report: Practice research unit at the Institute

M.Phil.

The General of Psychiatry.

Psychological Medicine, 3, 525. C.

(1958)

Psychosomatic

aspects

of narcolepsy.

Journal of Mental Science, 104, 593—607. —¿

(,g@@)

Psychological

cataplexy

factors

syndrome.

in

Psychosomatic

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narcolepsy

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SouRs, J. (1963) Narcolepsy and other disturbances in rhythm:

a study

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review of the literature. Journal of Nervous and Mental Disease, 137, 525—42. WILSON, K. (1928) Brain,49, 257.

pattern,

situational

stress,

B.A., M.B. B.Chir., M.Phil., M.R.c.P.(U.K.),

Denmark Hill, London SE5 8AZ (Received 23 July;

Journal

Amphetamine Ps@hosis. London:

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SMrrll,

and the symptoms of narcolepsy. Psychosomatic Medicine, I, 193. Roy,

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@8)Personality

A case

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BA.mR,

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CONNELL, P. (1958)

I wish to thank Dr A. Lishman, Reader in Psychiatry, Institute of Psychiatry, London, for the idea and Dr D. Parkes, Consultant and Senior Lecturer in Neurology,

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sexual experience and had been anorgasmic ever since, and others gave similar histories of avoiding and fearing orgasm. Reports of anger precipitating cataplexy were confirmed. Seven gave a history, similar to previous reports, of sleep paralysis associated with fearful affects and dreams. All these emotional precipitants of cataplexy may have arousal as their common pathogenetic mechanism (Roy, 1975).

Ania

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revised 2 October 1975)

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A Roy BJP 1976, 128:562-565. Access the most recent version at DOI: 10.1192/bjp.128.6.562

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