Narcolepsy

Could you imagine standing around chatting with friends, and then suddenly you see
someone drop to the floor and fall asleep. Most people would laugh, but narcolepsy is not a
laughing matter; it is a severe, life changing illness. Narcolepsy is classified as a chronic sleep
disorder that is characterized by three groups of symptoms: cataplexy, which is an unexpected
failure of muscle tone set off by strong emotions, excessive daytime sleepiness, and abnormal
rapid eye movement sleep manifestations, such as parasomnias (Billiard, 2008). According to
the DSM-IV, in order for a person to become diagnosed with narcolepsy, they must have
irresistible attacks of refreshing sleep that occur daily over at least three months. The person
must also have either repeated disruptions of rapid eye movement (REM ) sleep into the
transition between wakefulness and sleep, which is manifested by either hypnagogic
hallucinations, sleep paralysis, or hypnopompic at the beginning or end of sleep episodes, or
cataplexy. Also the disturbance of sleep must not be due to any direct physiological effects of a
substance (BehaveNet.)
Patients who suffer from this disorder typically present different types of behaviors
depending on the symptoms that they have. People who have the symptom cataplexy normally
show signs of slurred speech and sometimes their body will totally collapse which may cause
them to fall to the ground and lye there for a few seconds. This is known as a sleep episode and
is due to the sudden loss of muscle tone. These episodes can last for 20 minutes or less and can
be brought on by strong emotions such as laughter, anger, or surprise. Patients with narcolepsy
can experience up to six episodes a day. Other behaviors that might be observed would be a
person showing signs of sleepiness, lack of energy and concentration, or exhaustion due to EDS.

About 40 percent of the people who have been diagnosed with narcolepsy also show signs of
another DSM disorder, most commonly anxiety, substance use conditions, and mood (Lyons &
Martin 2009).
According to Lyons and Martin (2009), a reported 1 in 2000 people in the United States
are diagnosed with the condition, and it is equally common in males and females and has an
onset beginning before the age of 40. Also about one half of first degree relatives of patients with
narcolepsy show symptoms of sleepiness, and about 15% of them have the disorder. Most
patients who have the condition do not sleep regularly, meaning the person does not progress
through a series of stages into slow wave sleep followed by a periodic rapid eye movement or
REM sleep. Patients who have narcolepsy go into REM sleep more quickly than usual. This can
sometimes happen immediately after the patient fall asleep (Robinson & Keating, 2007). There is
no cure for narcolepsy, but for patients suffering from this condition, treatment is available in the
form of medication that treats its three cardinal symptoms.
Conventional treatments, such as amphetamines, methylphenidate, mazindol, selegiline,
pemoline, and behavioral treatment, have been used to treat the three cardinal symptoms of
narcolepsy. In a study conducted by Billiard (2008), he discusses these types of treatments and
how they are used. For the treatment of excessive daytime sleepiness and sleep attacks, Billiard
first suggested the drug mazindol, but later found out that the drug modafinil was best to use to
treat EDS. This was based on a double blind with placebo controlled trials, which showed that
the drug was significantly effective on EDS at a dose of 300 mg. Modafinil also replaced
amphetamines and methylphenidate as the first line treatment of EDS. For the treatment of
cataplexy and other REM sleep manifestations, Billiard illustrates how these symptoms were
primarily treated using a tricyclic antidepressant called imipramine, which are norepinephrine

uptake inhibitors. These days mazindol, selefiline, SSRS, and behavior treatments have been
established as new forms of treatments for cataplexy and other REM sleep manifestations. The
drug Viloxamine is also used to treat cataplexy. It is administered at a dose of 100-300 mg per
day. The main treatment Billiard discusses for treating REM sleep are benzodiazepine and nonbenzodiazepines. In a single study done by MJ Thorpy, revealed were both drugs were shown to
improve sleep efficiency and overall sleep quality in patients, by administering a .25 mg dosage
of the drug triazolam, which is a type of benzodiazepine (Billiard, 2008).
Sodium oxybate is the form of treatment that has be proven to be an effective method in
treating the symptom cataplexy, in patients with narcolepsy. Sodium oxybate can be obtained
through prescription only because it contains sodium salt that is found in the CNS depressant hydoxybutric acid (GHD). According to Robinson and Keating (2007), they believed this type of
medication to be highly effective in treating the symptom cataplexy. To prove their theory, they
constructed a double blind placebo-controlled trial where they administered a 9g dose of sodium
oxybate for 4 weeks to 717 patients with narcolepsy. Their results showed a 69% decrease in
cataplexy attacks in patients with narcolepsy. After 8 weeks, the 9g dosage reduced the number
of cataplexy attacks by 57-85%. Also while conducting the trials, they found sodium oxybate to
be a quickly absorbable substance by the human body, and that it would had to be taken with
food in order to slow down its processing time. That gives it more time to work. Out of the 717
patients, 91% of them experienced certain side effects; 22% experienced headaches, 17%
dizziness, 21% nausea, 8% somnolence, 8% urinary incontinence, 7% vomiting, and 8%
nasopharyngitis. During withdrawal, these side effects were said to have sometimes caused the
return of narcoleptic symptoms instead of withdrawal symptoms (Robinson & Keating, 2007).

Future treatments for narcolepsy, according to Thorpy (2007) consist of neurotransmitter

and receptor systems. He believes the existing treatments for narcolepsy are symptomatically
based, and symptomatic neurotransmitters (e.g. armodafinil), immunotherapy, and manipulation
of skin temperature are future therapeutic approaches for treating the symptoms of narcolepsy.
Armodafinil is the r- enantiomer, or the drug that binds to the retinoid X receptor of the drug
modafinil. In a double-blind, randomized, placebo-controlled trail that consisted of 196 patients
with narcolepsy, armodafinil extensively enhanced the patients ability to stay awake throughout
the day. It also improved the patients overall attention, fatigue, and memory. Thorpy (2007)
explains the immunotherapy treatment as a treatment that attempts to modify the immune
process because he believed narcolepsy to be an autoimmune disorder, which is a disorder that
comes from an excessive immune reaction of the body that acts against tissues normally present
in the body. Also in his article, he illustrates how skin temperature regulation is changed in
patients with narcolepsy. According to Thorpy (2007), distal skin cooling and proximal skin
warming increase REM and slow wave sleep, as well as decrease wakefulness. This finding
raises a new possibility that temperature manipulation could set up new methods that would
improve nocturnal sleep in narcolepsy patients.
The current medicines for the treatment of narcolepsy have all shown to reduce
symptoms in patients with the condition. In all the resources I have researched, sodium oxybate
has been the most effective treatment for the symptom of cataplexy. The drug modafinil was
most effective in treating EDS and different types of benzodiazepine medications have been
shown to be most effective in treating REM sleep in narcoleptic patients. As for future
approaches that might be used in treating the patients with this condition, hypocretin-based

therapies are said to be the most challenging, but according to Billiard (2008) it is still too early
to tell.

Reference
BehaveNet Clinical Capsule: Narcolepsy. (n.d.). BehaveNet. Retrieved November 16, 2010,
from http://www.behavenet.com/capsules
Billiard, M. (2008). Narcolepsy: Current treatment options and future approaches.
Neuropsychiatric Disease and Treatment, 4(3), 557-566.
Lyons, C., & Marin, B. (2009). Abnormal psychology: Clinical and scientific perspective (3rd.
ed.). Redding, CA: BVT Publishing
Robinson, D., & Keating, G. (2007). Sodium oxybate: A review of its use in the management of
narcolepsy. CNS Drugs, 21(4), 337-354.
Thorpy, M. (2007). Therapeutic advances in narcolepsy. Sleep Medicine, 8(4), 427-440.