Medical Challenge Case
S: Patient is a 32 year-old female referred to you by her cardiologist for severe anxiety, dyssomnia, and possible paranoid schizophrenia. She suffers from anxiety which worsens as the day progresses and becomes near panic at night near bed time. She claims that demons must possess her when she goes to sleep so she doe not want to ever go to sleep.
O: Cardiac exam was normal. Testing and stress ECG were both normal. All blood tests were WNL and she had a normal arteriogram. The cardiologist concluded that her problem had to be psychiatric. There is a family history of heart disease. Her sleephad been normal for many years prior to the onset of her psychiatric and sleep problems. She described that at the very beginning of her problem she would start waking from sleep with chest pain and felt some anxiety. Her physical and psychological symptoms disappeared as soon as she would wake up. As time went on, her chest pains became worse and she would wake from sleep with more and more severe pain and anxiety each night of sleep until she became afraid to go to sleep. As various medications to make her sleep or treat her anxiety failed to help, she became more and more afraid to sleep and began to believe that she was becoming possessed by some sort of demons. She had even requested that her priest perform an exorcism to rid her of these demons. A polysomnogram was ordered and the all electrophysiological parameters measured were basically normal with the primary exception of the ECG. As soon as she reached stage 2 of sleep she began to enter REM sleep after only 20-30 minutes following sleep onset. At this time, she began to exhibit abnormal ECG characterized by an average of 16 of the arrythmias illustrated below per minute.
A: What is your diagnosis of this patient?
P: What is your recommended plan of treatment?