A 16 year old adolescent girl (let’s call her Jane) came to see me with her mother. The primary concern was daytime sleepiness. Jane was falling asleep in class and sleeping all day on the weekends. Jane’s mother was concerned she might have narcolepsy. Jane was otherwise healthy and had no abnormal physical exam findings. A query for other features of narcolepsy such as cataplexy, sleep paralysis, or hypnagogic hallucinations was negative. Her PCP had ruled out low thyroid, anemia, low vitamin D, etc.
The vibe between Jane and her mother was very tense. Jane wasn’t happy about being at the doctor’s office and was rolling her eyes, crossing her arms, and just generally being uncooperative with her mother’s questions.
I went through Jane’s sleep history and I couldn’t explain her daytime sleepiness. Whenever I have a minor with excessive daytime sleepiness it is narcolepsy until proven otherwise. I had Jane keep sleep logs and then ordered an overnight sleep study followed by an MSLT. MSLT is a daytime nap test that allows us to objectively quantify sleepiness since people will both under or over exaggerate sleepiness.
Jane’s MSLT was normal showing no hint of narcolepsy or any other sleep disorder to explain her symptoms. So then I decided to order an actigraphy study, because sleep diaries don’t always tell the entire story.
Jane’s actigraphy showed that she was staying up to 2-3 am every night, even on weekdays and she was only getting 4-5 hours of sleep per night. Jane didn’t volunteer this information during our visit or on her sleep diaries.
When I met with Jane and her mother to go over the results I had to deliver the information delicately. But now the whole story made sense, including Jane’s annoyance for being at the sleep clinic. It turned out that the main problem was that Jane was on her smartphone in bed until the wee hours.
It took creativity to solve this one but we did. Check out my stories for details.
Do you know the diagnosis? How would you have solved it?