A Case of Hashimoto's Encephalopathy Manifesting as Psychosis

Abstract

Two Cases of Somnambulism Induced by QuetiapineSir: Somnambulism reflects an impairment in the normal mechanisms of arousal from sleep in which motor behaviors initiated during deep, non-rapid eye movement or slow-wave sleep are activated without full consciousness.Somnambulism, a previously unreported side effect of quetiapine, is described in 2 cases.Both cases described here involved individuals with attention-deficit/hyperactivity disorder (ADHD).The possible significance of this will be discussed.Case 1.Mr. A, a 52-year-old white man with no history of somnambulism, was undergoing treatment for DSM-IV panic disorder and schizoaffective disorder.He reported attention problems and hyperactivity since childhood and restless legs syndrome for 35 years.He was admitted to the medical unit in February 2006 to rule out myocardial infarction after falling off his porch while sleepwalking.The patient reported that somnambulism had begun 18 months previously, after his quetiapine dose was increased to 200 mg at bedtime.This dose was later titrated to a maximum of 1000 mg during the month prior to admission.At that time, mirtazapine 30 mg at bedtime was added.This combination further aggravated the patient's somnambulism, which occurred almost nightly.The patient was witnessed by his roommate to wander in a confused state, manipulate various belongings, open the refrigerator and eat, and visit the bathroom.He was easily redirected back to bed, but did not appear to awaken.A polysomnogram done when Mr. A was taking 800 mg of quetiapine showed no significant respiratory obstruction.Electroencephalogram (EEG) showed no epileptiform activity.Leg electromyogram findings were significant for frequent leg jerks.Quetiapine treatment was discontinued, and methylphenidate and clonazepam were started.Quetiapine 25 mg nightly was reinitiated later.No recurrence of somnambulism was reported at 8-month follow-up.Case 2. Mr. B, an 18-year-old white man with DSM-IV diagnoses of ADHD and pervasive developmental disorder, sought consultation for episodes of somnambulism and nocturnal combativeness.At the time of presentation in June 2003, he was receiving quetiapine 400 mg nightly and dextroamphetamine sulfate 35 mg daily in divided doses.The patient gave a history of starting quetiapine 8 months previously for onset of command auditory hallucinations.Shortly thereafter, he began to have nightmares associated with shouting, jumping from bed, property destruction, and assaults on family members.Mr. B awakened in the mornings with a headache but had no recollection of the events of the night before.Neurologic examination findings were unremarkable, and results of a 24-hour EEG study were normal.The patient's quetiapine dose was reduced to 350 mg nightly, resulting in the return of auditory hallucinations.Dextroamphetamine sulfate was then tapered over a period of 4 months and discontinued with good result and resolution of hallucinations.The patient continued to have nocturnal outbursts, though these were less frequent and less intense, occurring approximately once every 2 weeks.Quetiapine was tapered by 50-mg decrements over several months.These symptoms resolved below a dose of 150 mg nightly.Quetiapine was discontinued, with no recurrence of somnambulism during 1 year of follow-up.These cases suggest that quetiapine, like many other psychotropic medications, may induce somnambulism in certain individuals, possibly due to its impact on central serotonin activity. 1,2 This effect may be dose dependent.Both individuals had ADHD, which is interesting in view of recent evidence linking ADHD to polymorphism in the serotonin transporter gene and the genes for tryptophan hydroxylase and various serotonin receptors. 3,