Mania in a Boy Treated With Modafinil for Narcolepsy

Albert was a 17-year-old boy who was diagnosed with narcolepsy at age 14. He was first prescribed modafinil, 400 mg/day for 1 year, switched to methylphenidate, 40 mg/day for 2 years, then returned to modafinil, 400 mg/day. The switching was because of complaints of irritability and of a lack of efficacy for sleep attacks. Albert then experienced flight of ideas, sexual excitation, and increased irritability. These manic symptoms resulted in friction with family members and a fight for which he could have been put on trial. Then, free of psychostimulant treatment, Albert was described as sad, anhedonic, and withdrawn. Following reintroduction of modafinil, the same manic symptoms reoccurred. After a meeting with a judge, Albert experienced self-referential thinking and suspiciousness. Later, a full manic episode developed within 3 days, including insomnia, tachypsychia, logorrhea, psychomotor agitation, and mood-incongruent psychosis. There was no grandiosity but delusion of persecution, based on auditory hallucinations (his uncle reproaching him for his past sexual behavior), complex visual hallucinations (a vampire hiding in his bedroom and trying to bite him), and a feeling of being talked to through the television. Albert was hospitalized, and the modafinil was stopped. The mania required pharmacological treatment that started after written consent was obtained from both Albert and his parents.