Narcolepsy is a chronic neurological condition with impairments of the sleep-wake cycle. Narcolepsy manifests with four symptoms, the so-called classical tetrad:
|a) Episodic irrepressible uncontrollable Day-Time Sleepiness (DTS) is the key feature, and
b) Abnormal bilateral episodes of muscle tone loss with clear consciousness (cataplexy) make the diagnosis definitive. Common but not necessarily required symptoms are
c) Sleep onset distortions (hypnagogic hallucinations), and
d) Awareness of being paralyzed when waking during the night (sleep paralysis).|
*This series of articles focuses on the areas where the mythology may need to be broken and where limitations may not necessarily be recognized. This article has several parts, each interrelated yet independent. As with all publications, information such as this must be considered only after consultation with physicians and any medical information recorded here should not substitute for such consultations.
Diplopia and nocturnal insomnia are two other often ignored common symptoms.
The classical standard narcolepsy research criteria confirming a narcolepsy diagnosis consist of either a positive multiple sleep-latency tests (MSLT), or an abnormally low cerebrospinal fluid (CSF) Orexin (hypocretin) level. I focus on some controversies:
|a) First, the genes for narcolepsy have been largely ignored when applying the recognized criteria for diagnosing narcolepsy. These genes include particularly DQB1*06:02. However, the DQA1*01:02 gene should also be measured 1:02.
b) Secondly, the multiple sleep-latency test (MSLT) may be overemphasized for definitive diagnosis, because the genetic test is as important or even more relevant. This is pertinent because, in the USA, insurance approval of costly medications such as modafinil, armodafinil and sodium oxybate are often dependent on the insurances applying a positive MSLT as a requirement; when it is negative, the insurances might tragically deny coverage of these medications: This might deprive many in the narcolepsy population of their essential life-sustaining treatment, even though they might have definite clinical features plus the gene expression, and often, already, response to wakefulness drugs.
c) Third, clinical evaluations must be standardized. At this stage, we, at the PNI b2 apply modifications of the Epworth Sleepiness Scale in conjunction with the Fatigue Severity Scale, and the Neppe Narcolepsy Questionnaire, as fundamental ways to evaluate narcolepsy clinically. These historical rankings and screens combined with proper HLA screening may be adequate for more than 90% of diagnoses.
d) Fourth, the comorbidities of narcolepsy might include psychosis, anxiety, depression, impaired functioning, and seizure phenomena. These may reflect multifactorial etiologies: some of these may be linked with narcolepsy, and others unassociated.|
I suggest a new model of hypocretin deficiency being slightly down-stream from the actual cause of narcolepsy-cataplexy. This accentuates the need for proposing two new terms, namely ???primary narcolepsy??? for the most common narcolepsy condition that appears to be hypothalamically linked to an auto-immune process involving hypocretin, and ???symptomatic narcolepsy??? due to infectious or tumor or trauma events involving the hypocretin / reticular activating system/ hypothalamus. On the others hand, some
old classifications have used the previous terms "Type 1
Narcolepsy" for narcolepsy with cataplexy, and "Type 2
Narcolepsy" for narcolepsy without demonstrated cataplexy:
this classification appears redundant and has ambiguities
(e.g. some require proof by MSTL or Orexin levels and some
do not). The various ICSD and DSM criteria are re-examined.
Keywords: Age; Armodafinil; Auto-Immune; Bilateral;
Bipolarity; Cataplexy; Cerebrospinal Fluid; Children;
CSF; Crying; Day-Time Sleepiness; Diplopia; DSM-V; DTS;
Dyssomnia; EEG; Ego-Boundary; Emotion; Episodes;
Epworth Sleepiness Scale; ESS; False Negative; False Positive;
FISS; FISS-1; FISS-2; Gold Standard; HLA; HLA DR; DQB2
06:02; HLA-DQ6; DQA1*01:02; DQB1*06:02; Hallucination;
HCRT; H1N1; Hypersomnia; Hypothalamus; Hypnagogic
Hallucinations; Hypnopompic Hallucinations; Hypocretin;
Hypocretin (Orexin); Neuropeptide Precursor; ICSD; Illusion;
International Classification of Sleep Disorders; Laughing; Loci;
Modafinil; Modified Epworth Sleepiness Scale; MESS; "Multiple
Sleep-Latency Test"; Muscle Tone; Mythology; Narcolepsy;
Narcolepsy Type 1; Narcolepsy Type 2; Neppe; Neppe
Narcolepsy Questionnaire; NNQ; NNQ-4R; Neuro-Excitatory;
Neurological; Neuropsychiatry; Nocturnal Polysomnography;
Nortriptyline; NPSG; Nuvigil; Oxybate; OSA; Orexin; Periodic
Leg Movements; PLM; Pharmacological Responsiveness; PNI
Modified Fatigue Severity Scale; Primary Narcolepsy; Provigil;
Rapid Eye Movement; RAS; Reticular Activating System, REM;
Schizophrenia; Sleep; Sleep Apnea; Sleep-Onset; Sleep-Onset
REM Period; Seizure; SOREMP; Sleep Paralysis; Sleep-Wake
Cycle; Symptomatic Narcolepsy; Tetrad; Transition; Tricyclic;
Uncontrollable Sleepiness; Venlafaxine; Wakefulness;
b "PNI" refers to the Pacific Neuropsychiatric Institute in Seattle, WA. "We" is used here to include application at the PNI; "we" is also used generically, for example, in broader recognitions of symptoms by researchers.
Narcolepsy: The condition: Part 1
The classic clinical tetrad
Narcolepsy is a chronic neurological condition resulting
from impairments of the sleep-wake cycle, in which patients
necessarily uncontrollably fall asleep during the day. (Day
Time Sleepiness or DTS). They might also often have symptoms
pertaining to abnormal muscle tone episodes (cataplexy). When
the DTS is combined with the cataplexy, the clinical diagnosis is
definitive. There are two other frequent symptoms, namely sleep
onset distortions ("hypnagogic hallucinations"), and waking up
during the night from sleep and experiencing paralysis ("sleep
Day-time sleepiness (DTS) involves recurrent periods of an
irrepressible need to sleep: This is uncontrollable and even may
occur while driving, when patients learn to quickly go to the side
of the road, but where they are at major risk for car accidents.
They then lapse into sleep, and they may nap several times within
the same day.
Cataplexy involves brief episodes of sudden bilateral loss of
muscle tone, most often linked with intense emotion.
This therefore constitutes the classical clinical Narcolepsy
tetrad (four major symptoms) of:
|i) Day time sleepiness (DTS) and cataplexy, particularly,
ii) Plus the two other accessory features of hypnagogic
hallucinations and sleep paralysis.|
These two accessory features are, at times, elicited and
sometimes documented, even at a lab level, but they are clinically
pertinent, though often neglected.
The standard research criteria applied to confirm a narcolepsy
diagnosis consist of either the multiple sleep-latency test (MSLT),
and / or measures of cerebrospinal fluid (CSF) Orexin.
The data in this Part 1 points to some key information, yet
because it is highly concentrated, some concepts may seem
difficult to follow, at this point. But this broad overview might
provide a perspective when later on I cover each concept in more
detail and accentuate two key points:
|i) I illustrate specifically a controversy of the gene for narcolepsy
largely being ignored, even in the criteria for narcolepsy, and
yet a possible overvaluation of multiple sleep-latency test
(MSLT) sleep tracings being used for definitive diagnosis.
This is important because in the USA insurance approval of
expensive medications is often dependent on the MSLT being
positive and when negative it might deprive many in the
population of essential life-sustaining treatment.
ii) I also emphasize the need for clinical evaluations to be
standardized, and point to modifications of the Epworth
Sleepiness Scale in conjunction with the Fatigue Severity
Scale, and the Neppe Narcolepsy Questionnaire.|
The usual clinician does not have access to such specialized
tests, yet every clinician can ask for the Narcolepsy gene test (e.g.
the main one is HLA DR DQB2 06:02), and this correlates very
highly with Orexin in narcoleptic patients (90% or higher e.g.
92%) [1,2]. The problem is it has false positives in about one tenth
to one third of patients depending on the population.
In our clinical experience spanning over two decades of
evaluating such narcolepsy patients, these false positives
expressing the narcolepsy gene (usually "DQB 06:02") are not
just "control" normal patients. Every one of these controls in
our neuropsychiatric population, has had some kind of sleep
disturbance. But detailed history shows that these "controls"
exhibit lifelong symptoms of different sleep disorders though not
clinical narcolepsy. Because other symptoms like depression or
anxiety may not be sufficient in many of these cases, it is that likely
that many of these patients have other "primary dyssomnias"
and often such conditions have not been well delineated. Yet,
commonly the families of these "controls with positive narcolepsy
gene expression", have classical narcolepsy, also with their HLA
"DQB 06:02" gene being expressed.
The utility of genetic testing for narcolepsy was recognized
even by 2002 , and the specific HLA DR2 "narcolepsy" gene was
reported in 1984 [4,5].
But narcolepsy gene testing has remained extremely underrated
by many experts who have preferred the far more expensive,
specialized, and time-consuming "multiple sleep-latency test"
(MSLT) test instead. Yet, in our experience, the HLA typing for
the narcolepsy gene can be performed as a simple genetic blood
test that provides powerful confirmatory data when used as an
addition to the clinical data Indeed, in our experience the gene
plus clinical data, as shown later in this article, provides as strong
or even stronger diagnostic support than the MSLT test.
More complex testing
Whereas the sleep-onset MSLT, and the Orexin CSF tests are
valuable to have available as extras in cases of further diagnostic
query after detailed clinical plus gene evaluation, they are
specialized because of their costs (MSLT) or invasiveness (CSF)
and require specialty involvements.
I know now that narcolepsy is regarded as due to Orexin
deficiency  in the hypothalamus. This may or may not be
an auto-immune process, as sometimes trauma or infection
can induce it in predisposed individuals. But that can only be
measured using cerebrospinal fluid: So this is not something
easily accessible to many clinicians.
Orexin deficiency correlates strongly with the most commonly
used standard sleep lab test, the MSLT (possibly 95% ref). The
MSLT involves a measure of how often patients go directly into
rapid eye movement sleep within say 8 minutes of going to sleep
during the day under standard precautions. This is an expensive
test, but when it is positive and applied with all its required
stringencies, such as not having sleep for (say) six hours before,
and not having taken confounding medication, it provides strong
support for the diagnosis the narcoleptic condition. Moreover,
the MSLT can be applied sequentially to monitor medication
responses.. But, there is commonly a tragic problem in the USA.
When the MSLT results are negative and yet the clinician based
on structured questionnaires, gene testing and pharmacological
response regards the narcolepsy diagnosis as definite because
these same patients may not be authorized to receive their very
expensive wakefulness medications from the insurance company.
This is because the insurance industry have taken the criteria of
diagnosis of MSLT as the most definitive.
A negative MSLT, in the presence of positive other testing and
even medication sample response, is not a rarity, unfortunately, in
our experience. This is because only slightly more that one fifth of
narcoleptics have a positive MSLT on the first run of the test :
Usually 2 such positive tests out of four, five or six, are required.
Moreover, some researchers that there are false positive MSLT
results: Depending on the population this may be as much as
about 3 in 10 positive MSLT cases not even having narcolepsy .
Positive MSLT test results vary with age, specific symptoms in
populations, and other confounding factors [1,8]. Yet, proponents
of the MSLT, and this includes most sleep laboratories, claims
the MSLT is the most definitive test for narcolepsy, so that this is
conflict with the above:
The data suggests that the MSLT cannot be used purely in
isolation to confirm or exclude narcolepsy. Many experts believe it
is now indicated only in selected patients with excessive daytime
sleepiness. And almost every specialist agrees it is most valuable
when interpreted in conjunction with clinical findings . It may
be that a useful, but as yet unperformed definitive controlled
study would be the proportion of patients expressing Clinical
features plus HLA-DQ2-06:02 typing who have positive MSLTs
and what proportion are of MSLT patients do not express any of
the implicated HLA-DQA and DQB genes.
Narcolepsy usually has an onset at an early age (childhood,
adolescence or young adulthood), but is often missed till late ,
the mean delay to diagnosis is up to 15 years, with rare individual
cases being delayed even for 60 years, though with education,
there might now be a shorter delay to diagnosis.
The delay in diagnosing narcolepsy may sometimes be linked
with the frequent association with other sleep-wake disorders
In my opinion, many cases are never diagnosed. Misdiagnosis
or absence of diagnosis is a key problem. Early diagnosis of
narcolepsy has the possibility to offer affected persons an adequate
medication to lead an almost normal life and the future possibility
to cure narcolepsy through immunomodulation therapy .
Lack of symptom recognition is unfortunate, because narcolepsy
has a high comorbidity burden. Many disorders manifest with
symptoms that overlap with narcolepsy and patients are labeled
bipolar, schizophrenic, depressed and anxious. These detrimental
effects impact on proper health-care being used, employment,
and quality of life. Education and awareness of narcolepsy and its
symptoms might assist .
Moreover, particularly in the young, the symptoms can be
disabling enough to interfere with functioning of the child, and
therefore compromise his/her education. That in turn leads to
further stigmata and impairments.
Men and women have very similar narcolepsy related
symptoms. But women may be more likely to be diagnosed later:
85% of men were diagnosed by 16 years after symptom onset
(still a long time), compared to a 28 year delay in women (a very
long time). One wonders whether the large gray area are those
who are undiagnosed .
Interestingly, despite being more objectively sleepy (e.g. on
MSLT), women were far less likely to report lifestyle impairments
in the areas of personal relationships and physical activity, but
were also slightly more likely to self-medicate with caffeine .
However, most important may be a way for clinicians to easily
and cheaply make the diagnosis clinically without having to resort
to tests such as MSLT, and CSF Orexin levels.
This is what this paper is about.
No real gold standard currently exists for the diagnosis of
narcolepsy. Conventional diagnostic criteria are unwieldy and
arbitrary. Clearly defined criteria for case selection are needed to
compare the results of different studies .
However, these criteria require highly specialized evaluations,
and therefore are limiting.
Currently, the International Classification of Sleep Disorders
(ICSD) Revised 4 represents the research "gold standard" for the
diagnosis of narcolepsy. It begins with the classical association of
recurrent daytime naps and cataplexy and this has now become
sufficient for a definite diagnosis, because the cataplexy symptom
is so specific.
But there are many patients without cataplexy, who have
daytime sleepiness and other associated features. In a specialized
setting, sleep studies may greatly contribute.
The criteria have changed minimally over the years. For
example, in DSM 4TR is very close . DSM-V  has improved
this a little and now recognizes Sleep Paralysis. It also emphasizes
co-morbidity of Narcolepsy diagnoses with Schizophrenia
and Bipolarity. Whereas, in my opinion, this might be true, it
also might not be, because narcolepsy experiences manifest in
different ways and may be misdiagnosed. One measure may be
pharmacological responsiveness to appropriate neuroleptic, for
example, in appropriate dosage [14,15].
However, the linkage may be pertinent, as well, in some patients:
Preliminarily, there is a higher frequency of DQ B1(*)-03:01/06:02
antigens in N-C children with narcolepsy and cataplexy who
develop what Huang is calling "secondary schizophrenia". This
linkage is a therapeutic challenge where there may be long-term
persistence of severe psychotic symptoms .
Importantly, diagnoses are also by exclusion so DSM 4R
included, as it does for almost every other condition: The
classic phrase for all Diagnostic and Statistical Manual of Mental
Disorders comments is: "The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a
medication) or another general medical condition".
Interestingly, at one point, we spoke of narcolepsy, type 1 (with
cataplexy) and narcolepsy, type 2 (without). This is really extra
verbiage, unnecessary particularly as some have tried to suggest
special criteria for qualifying for Type 1 and Type 2-eventually
very few would qualify.
Let's now list minima that are usually mentioned
Remarkably there are amazing omissions such as sleep
paralysis in the clinical DSM criteria and genetic components in
the ICSD criteria. Let's examine this in the light of recent history:
|1. Day-time sleepiness frequency at minimum should be at least three times per week over the past 3
2. The presence of at least one of real cataplexy or cataplexy equivalent in children should occur at least a
few times per month:
a. In individuals with long-standing disease, cataplectic events can be brief (seconds to minutes) episodes
of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or
b. In children or in individuals within 6 months of onset, spontaneous grimaces, or jaw-opening episodes
with tongue, thrusting or a global hypotonia, without any obvious emotional triggers, are allowed.
3. Recurrent intrusions of elements of rapid eye movement (REM) sleep into the transition between sleep
and wakefulness, as manifested by either hypnopompic or hypnagogic hallucinations or sleep at the
beginning or end of sleep episodes
4. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication) or another general medical condition.
Table 1A: Criteria for Narcolepsy .|
a) The International Classification of Sleep Disorders (ICSD)
ICSD 4R is the current gold standard for the diagnosis of
narcolepsy and reflects the criteria for the sleep association.
The classical association of recurrent daytime naps and
cataplexy is sufficient for a definite diagnosis, the latter symptom
being specific. That appears logical.
However, there is a wide spectrum of cases without cataplexy,
where daytime sleepiness and other associated features
are evocative but not specific, then according to the ICSD
polysomnographic studies are mandatory. As you will see in this
paper, with due respect, I regard, in a clinical practice, genetic
studies as not only adequate, but mandatory with or without
|347.00 (G47.419) Narcolepsy without cataplexy but with hypocretin
deficiency: Criterion B requirements of low CSF hypocretin-1 levels and
positive polysomnography/ multiple sleep latency test are met, but no
cataplexy is present (Criterion B1 not met). NOTE there is no mention of genetics!
347.01 (G47.411) Narcolepsy with cataplexy but without hypocretin
deficiency: In this rare subtype (less than 5% of narcolepsy cases),
Criterion B requirements of cataplexy and positive polysomnography/
multiple sleep latency test are met, but CSF hypocretin-1 levels are
normal (Criterion B2 not met).
347.10 (G47.429) Narcolepsy secondary to another medical condition:
This subtype is for narcolepsy that develops secondary to medical
conditions that cause infectious (e.g., Whipple's disease, sarcoidosis),
traumatic, or tumoral destruction of hypocretin neurons.
Mild: Infrequent cataplexy (less than once per week),
need for naps only once or twice per day, and less
disturbed nocturnal sleep.
Moderate: Cataplexy once daily or every few days,
disturbed nocturnal sleep, and need for multiple naps
Severe: Drug-resistant cataplexy with multiple attacks
daily, nearly constant sleepiness, and disturbed nocturnal
sleep (i.e., movements, insomnia, and vivid dreaming.
Table 1B: ICD 9 and ICD 10 diagnoses.|
There are confounders with sleepiness in patients with
narcolepsy without cataplexy, idiopathic hypersomnia,
and Obstructive Sleep Apnea Syndrome creating needs for
Interobserver Reliability in the ICSD Diagnostic Criteria for
The ICSD-3 of 2014 provides new terminology, classifications,
and diagnoses for this disorder that's characterized by daily
periods of irrepressible need to sleep or daytime lapses into sleep.
This change was made because some patients demonstrate what
they consider the fundamental cause for narcolepsy type 1 namely
hypocretin deficiency but without cataplexy. The data presented
in this article may suggest however that that fundamental cause
is an early result of hypothalamic change and that the genetic
elements may even be more relevant to causality. I do not see
this classification as bringing anything further to the table, except
limiting the diagnosis profoundly to MSLT, polysomnography and
CSF Orexin, and possibly incorrectly excluding genetic testing, or
even pharmacological responsiveness, and excluding most of the
population with narcolepsy because they do not qualify on testing.
However, this classification at least widens clinical criteria
to include both daily periods of irrepressible need to sleep or
daytime lapses into sleep, but may narrow patient diagnosis,
in terms of episodes not being daily. This to me, with respect, is
The ICSD has revised the classification of narcolepsy and this is
more sensible: ICSD Revised 4 represents the new gold standard
for the diagnosis of narcolepsy. Now the classical association of
recurrent daytime naps and cataplexy is sufficient for a definite
diagnosis, the latter symptom being specific. On the other hand,
if there is doubt, in the wide spectrum of cases without cataplexy,
where daytime sleepiness and other associated features are
elicited, but not specific, polysomnographic studies are then
We can go back in time: There is an extended history across
these cultures attributing these symptoms to supernatural
causes. These involve entities "incubi" dating back to the times
of Martin Luther, or the Newfoundland "Ag-Rog" or "Old Hag" or
by the 1970s, "alien abduction". This mythology is usually linked
to nocturnal sleep episodes either the sleep paralysis which is
non-specific and not diagnostic, or the hypnagogic (sleep-onset)
or hypnopompic (sleep awakening) hallucinatory experiences.
This may lead to further distressing dynamics, and these beliefs
might partly relate to the "true nightmare" . Interestingly,
these kinds of interpretations with altered consciousness are not
unusual, particularly in a related episodic condition with defect of
consciousness, epilepsy .
Narcolepsy: the Key Clinical Features: Day-time Sleepiness and Cataplexy. Part 2
In this section, I discuss the two key features of Narcolepsy
|i) Daytime Sleepiness and
Without Daytime Sleepiness there can be no diagnosis of
Narcolepsy. It is a sine qua non. There can be narcolepsy without
cataplexy, and sometimes is in about a third of cases. % But if
there is cataplexy, with classical Daytime Sleepiness the diagnosis
effectively is indisputable.
Let's examine both of these briefly:
Day Time Sleepiness (DTS)
Daytime sleepiness attacks in narcolepsy involve recurrent
periods of an irrepressible need to sleep, lapsing into sleep, or
napping occurring within the same day.
One description is "Irresistible attacks of refreshing sleep".
Another conceptualization is these attacks are short-lived.
Frequently, they may last half an hour and then the patient is
refractory to another such attack for several hours e.g. 2 hours.
The patient After the DTS attack, the patient feels remarkably
refreshed. An essential component of this classical DTS is
the episodic element. That differentiates them from chronic
maintained states of sleepiness.
The minimum frequency varies for these to be considered
narcoleptic: The ICSD requires occurrence at least three times
per week over the past 3 months. DSM 4 R required at least daily.
More pertinent may be the associated activities: For example,
post-prandially an hour after a high carbohydrate lunch, patients
prone to hypoglycemia may become sleepy.
Clinically, in narcolepsy, I distinguish between physical
tiredness and true uncontrolled daytime sleepiness with the
onset or REM sleep.
|i) The patient still only sleeps 7 or 8 hours per 24 hours. This
means patients have insomnia at night. They do not sleep
7-8 hours at night but less to make up for their micro-sleeps
during the day. Narcolepsy is often classified, in my opinion
incorrectly, as a "hypersomnia". This would refer to a disorder
of increased sleep in the 24-hour day. It is not a hypersomnia,
but a "dyssomnia" with breakage of sleep distribution: the
disorder of increasing short nap sleeps during the day is
countered by insomnia at night to make up the 7 or 8 hours
required for mean sleep during the 24-hour period.
ii) Almost every narcoleptic I've seen has had motor vehicle
accidents where they've fallen asleep. This is not quite as
dangerous as seizure disorders with loss of consciousness
when there is no warning. But narcoleptics often can pull
over to the side of the road (a few seconds warning) but this is
still dangerous, requires medical review, and unless the DTS
is excellently controlled these patients should not be driving,
and even if well-controlled should recognize that driving is
their responsibility and should be for short trips only under
medical and prescription supervision.
iii) Therefore, when they take appropriate medicines e.g.
Modafinil and Armodafinil they are much better and may
not be dangerous. Epileptics are sometimes completely
controlled on anti-convulsants and the criterion for driving
there varies with jurisdictions e.g. 3, 6, or 12 months or
How do I measure the DTS in a clinically standard way? The
best way, I think, is applying two scales such as the Modified
Epworth Sleepiness Scale (MESS) [20-22] with the PNI Fatigue
Severity Scale (PFISS) . If there are any clues to narcolepsy,
such as a MESS score of 10 or more, with a FISS-1 score of 20
or less, we then apply a standardized questionnaire, such as
The Neppe Narcolepsy Questionnaire (NNQ) [23-25]. These are
Cataplexy is a medical condition involving sudden and transient
episodes of usually bilateral muscle weakness is accompanied by
full conscious awareness. This is due to a sudden loss of muscle
tone, and is most often associated with intense emotion (although
there are exceptions). The fact that this is bilateral-on both
right and left sides together-and occurs in clear consciousness,
differentiates cataplexy from seizure disorders.
Cataplectic attacks vary in severity depending on the incident
and the individual:
Sometimes cataplectic attacks involve sudden minimal
weakness, such as barely perceptible slackening of the
facial muscles; alternatively, a cataplectic attack might manifest
marked physical collapse with loss of muscle tone and strength,
where the body falls helplessly, though remaining conscious.
A basic diagnostic issue is that cataplectic attacks are almost
invariably triggered by strong emotions such as laughing, crying,
Cataplexy affects about 70% of people who have narcolepsy
. Occasionally, cataplexy precedes the classical EDS. The
extent of severity varies.
Cataplexy as a symptom is sometimes difficult to conceptualize.
When trained, raters are "almost perfect" in observing the
videotaped physical signs after training . But ordinary mental
health specialists don't have that training and don't see such
attacks: Therefore a standardized question series such as the NNQ
should be useful. Again the NNQ is valuable in this [23,24].
Cataplexy manifests as muscular weakness attacks that are
brief, and most last from a few seconds to a couple of minutes.
Typically, attacks could involve any or all of dropping of the
jaw, neck weakness, and/or buckling of the knees. Complete fullblown
muscle paralysis with postural collapse may occur [27-29].
Speech may be slurred and vision may be impaired (double vision,
inability to focus) , but hearing and awareness remain normal.
Cataplexy attacks are self-limiting and resolve without the
need for acute medical intervention [27-29]. If the person is
reclining or lying down comfortably, the patient may transition
into one of the other narcoleptic features namely, sleepiness,
hypnagogic hallucinations, or a sleep-onset REM period .
Cataplexy worsens with fatigue, and it might rarely not
be triggered by the usual strong emotional reactions such
as laughter, anger, surprise, awe, and embarrassment. Sudden
physical effort may trigger it, and being caught unawares or off
guard may trigger it or it may be quite spontaneous with no
identifiable emotional trigger.
Cataplexy is very varied and more difficult to assess.
It varies from minimal muscle tone-hardly noticed, to
major episodes e.g. drop attacks. It often is bilateral, on both
sides. Cataplexy may develop only later, particularly when the
narcolepsy begins, in children. The cataplexy does not respond as
well to Modafinil and requires often something else, e.g. oxybate
or tricycles or venlafaxine. Some patients try to avoid emotional
situations and these may require prophylaxis.
Almost invariably cataplexy is associated with narcolepsy.
Cataplexy without narcolepsy is rare and the cause is unknown.
Even in a collapse, people are usually able to avoid injury
because they learn to notice the feeling of the cataplectic attack
approaching and the fall is usually slow and progressive. In
children, cataplexy and muscle weakness episodes triggered by
emotions such as laughing and joking are often atypical. They
may be without triggers and affect the face with mouth opening,
tongue protrusion. This might occur often with very abrupt
sleepiness and weight gain.
As in REM sleep, the person continues to breathe and is able to
control eye movements .
Cataplexy presence is almost diagnostic clinically for
narcolepsy, yet I have seen a patient with definite cataplexy
expressing the HLA DQB1 06:02 gene but with no classical
daytime sleepiness, but severe chronic fatigue instead. It could
be argued that the daytime sleepiness will come but the fatigue
severity in the absence of other conditions is notable.
This would be an example of the value of using a standard
clinical measure. The best way is applying a standardized
questionnaire, such as The Neppe Narcolepsy Questionnaire
(NNQ) [23-25]. These are discussed later.
Sleep paralysis is regarded as associated with REM sleep
atonia intruding into wakefulness. This produces impaired
maintenance of REM sleep atonia and might manifest with dream
imagery intruding into wakefulness  at the start of sleep (e.g.
hypnagogic hallucinations) and on awakening (hypnopompic
hallucinations). In my opinion, these are often visual and
sometimes illusory phenomena, but not hallucinations themselves
as they are distortions, not images seen or voices that are heard
without any sensory stimulation so the term "hallucination" may
be inaccurate sometimes.
Attention to periodic leg movements (PLM), sleep apnea and
REM sleep behavior disorder (RBD) is particularly important in
the management of the older narcoleptic patient, in whom these
conditions are more likely to occur .
Differentiating Fatigue and Sleepiness. Part 3
Fatigue is a general term which refers to any of exhaustion,
tiredness, weariness, drowsiness, low energy, sleepiness during the
day when you are supposed to be awake.
At the PNI, we have used the PNI Fatigue Severity Scale
(FISS) for about 2 decades and found it useful. It is a self-scored
evaluation of fatigue designed to differentiate from clinical
depression, as both share fatigue symptoms. However, it's also
particularly useful as well in narcoleptics to differentiate from
sleep apnea and other dyssomnias. We actually use it as part of
a series of 10 tests that we call the Diagnostic-Screen 10. The
Epworth is another one of these ten tests.
The ratings for the PNI Fatigue Severity Scale (FISS) are based
on a 0 to 6 scale (our PNI scoring system) scored over the last
There are two tests.
The FISS-1 previously just the Fatigue Severity Scale (FISS)
contains 9 items so the minimum score is 0 and maximum is 6.
Range is therefore 0 from 54.
Scoring 10 or above is significant. 19 or above reflects
The FISS-1 first item is different My motivation is lower when
I an fatigued is scored as a subset decimal point.
Reference is http://www.mult-sclerosis.org/
fatigueseverityscale.html but this scale uses a 1-7 range. This
was the only test we used till 2012.
In 2012, the PNI added an accessory 5 point scale-the FISS-2
was added. This was based on feedback from patients and it could
be regarded as the activation component. We sometimes combine
the scores. This adds 30 more points to the score. We separate
the FISS-1 which is the official score, from the FISS-2 which is the
extra item score. Our preliminary impression is the FISS-2 might
correlate better with features such excessive daytime sleepiness,
and also motivational features particularly on awakening. But this
needs to be properly analyzed.
Surprisingly, I could not find studies of FISS (here the FISS-
1) with ESS. Yet it is logical because patients with many causes
for fatigue (systemic e.g., anemia, cardiac, renal, hepatic, Lyme
disease; brain related e.g. sleep apnea; psychiatric e.g. depression,
anxiety; general e.g. chronic fatigue syndrome) should have their
higher FISS scores correlated with the ESS to measure comparative
daytime sleepiness. The initial clue for going towards the NNQ
is when ESS scores are >11 for narcolepsy daytime sleepiness
and also fatigue is only mildly elevated (averaging 1 or 2 per
item) as opposed to very high. We have found this clue valuable.
As indicated, now, it looks like a relatively high FISS-2 score
compared with FISS-1 may also provide an excellent clue to other
ongoing investigations. With any of these clues being abnormally
high, we then do the Narcolepsy gene blood screen.
There are other approaches as well. For example, The Sustained
Attention to Response Task is a valid and easy-to-administer
measure to assess treatment effects in narcolepsy, enhanced by
combining it with the Epworth Sleepiness Scale .
PNI FATIGUE SEVERITY SCALE (FISS) (FISS-R 2012) ?? PNI 2012
Name: __________________________________ Date: __________________________
Instructions: This questionnaire contains nine statements that attempt to explore the severity of fatigue
Fatigue is a general term which refers to any of exhaustion, tiredness, weariness, drowsiness, low energy,
sleepiness during the day when you are supposed to be awake.
Please read each statement and circle a number from 0 to 6. As a guide-line, base your answer on how you've
felt over the last week.
A low value indicates that the statement is not very appropriate whereas a high value indicates agreement with
In the past week:
0 means "I do not have this" ;
1 = this is present but very mild or occasional;
2 = This has been mild;
3 = "This has been moderate";
4 = This has been moderately severe;
5 = This has been severe
6 = This has been extremely severe".
FISS -1 direct fatigue
1. My motivation is lower when I an fatigued 0 1 2 3 4 5 6
2. Exercise brings on my fatigue. 0 1 2 3 4 5 6
3. I am easily fatigued. 0 1 2 3 4 5 6
4. Fatigue interferes with my physical functioning. 0 1 2 3 4 5 6
5. Fatigue causes problems for me. 0 1 2 3 4 5 6
6. My fatigue prevents sustained physical functioning. 0 1 2 3 4 5 6
7. Fatigue interferes with carrying out certain duties and responsibilities. 0 1 2 3 4 5 6
8. Fatigue is among my three most disabling symptoms. 0 1 2 3 4 5 6
9. Fatigue interferes with my work, family, or social life. 0 1 2 3 4 5 6
FISS -1 total __________________________________________
10. It is difficult for me to get out of bed in the morning. 0 1 2 3 4 5 6
11. It is difficult for me to get going in the morning. 0 1 2 3 4 5 6
12. I lack energy. 0 1 2 3 4 5 6
13. I lack enough energy to perform even routine tasks. 0 1 2 3 4 5 6
14. I have episodes of significant tiredness during the day. 0 1 2 3 4 5 6
FISS -2 total
FISS Grand Total
The Epworth sleepiness scale (MESS)
This is an 8 item self-scored report. It reflects how much
patients fall asleep under normal circumstances, and it is
sometimes based on imagining what would have happened.
The original measures on the Epworth Sleepiness Scale
(ESS) that we first encountered was 1 (normal, never) to 4, but
it appears that is seldom used today, though many publications
don't describe what they're using.
We have scored based on 0 to 3 scores with 0= never, 1=
slight, 2= moderate, 3= high chance of dozing. The original scale
Statistical analysis is much easier when looking at 0 to 3, and this
also helps "eyeball" results quickly.
However, we wanted to have a broader severity indication.
Therefore we modified the ESS:
All our scoring is 0 for never and applies a 0 to 4 so we apply a
5-point scale. Range therefore 0 to 24. We still obtain two scores
so our data can be compared with others using the ESS 0-3 scale.
Scores of 5 or above are clinically relevant. Scores of 8 to 10
reflect major symptoms.
Adapted from http://www.stanford.edu/-dement/epworth.
The Epworth Sleepiness Scale score calculates the presence
of residual sleepiness. The key series of questions are: "Under
normal circumstances, how likely are you to doze off or fall asleep
in the following situations, in contrast to just feeling tired? Even
if you have not done some of these things recently, try to imagine
how they would affect you. Use the following scale to choose the
most appropriate number for each situation."
|0 = would never doze: you never or almost never doze when
1 = Slight chance of dozing: you have a slight chance of dozing
2 = Moderate chance of dozing: you have a moderate chance of
3 = High chance of dozing: you have a high chance of dozing
4 = always dozing: you're almost always dozing when that's
For statistical reasons, we obtain the 2 scores (based on the
original 4 point scale of 0-3) MESS R3 and the MESS R4 score
based on the later 5 point scale (0-4).
The data in the literature is exclusively the 4 point scale with a
maximum of 8*3= 24.
It is here that scores of 11 or 12 are suggestive for narcolepsy
particularly if the FISS-1 fatigue score is not very high (e.g. <20).
But given that a score of 4 is relatively rare, and would most
commonly push the items below 11 or 12, we could technically
use MESS R4 in any event.
The MESS and FISS gives us the clue to ask the patient to
complete the NNQ below, and whenever we do this for the first
time, we perform HLA testing for narcolepsy.
These clinical tools help prioritize individuals with the most
severe illness regarding whom we should prescribe medication
for. They are not perfect but at least standardized for each patient.
We consider polysomnography (PSG) but it is rare for this to be
needed because more than 90% of our patients are clear-cut.
Additionally, the modern media facilitate reaching out to the
general population to raise awareness of the other conditions
associated with EDS such as sleep apnea .
And it is this combination, Narcolepsy plus Sleep Apnea, that
we see quite frequently.
We return to the ESS: There are over a hundred peer reviews
publications on the Epworth in many countries, and translated
into several languages.
|1. There is good agreement on all the items totaled together
between the patients and their close relatives, but not always
within individual items.
2. The correlation of objective sleepiness as measured by the
ESS and the close relatives is high, and this also correlates
on MSLT .
3. The cut-off for EDS (MESS >10 points) was chosen in line
with the traditional ESS.
4. Data scores before and after interventions correlated with
improvement in predicting OSA in patients with COPD .
5. ESS answers differ according to sociocultural and economic
conditions. For example, a score of 8 or higher on the ESS
would seem a more appropriate cutoff score than 10 or 11,
that many others use, to suspect clinically relevant sleepiness
in the Turkish population .
6. Men and women reported similar degree of subjective
sleepiness as measured by the Epworth Sleepiness Scale,
though women demonstrated significantly more severe
objective sleepiness on multiple sleep latency testing (MSLT)
7. Epworth Sleepiness Scale scores appear to be an indication
of personal sleep debt that varies depending on one's
individual sleep requirement .
8. Interestingly, ESS scores were considerably more sensitive
than MSLT scores in documenting efficacy of the most
common treatment, modafinil  (and presumably, it
would be the same for its very close cousin, armodafinil).
On the other hand, the improvements in MSLT scores were
minimal and remained in the pathologically sleepy range
. These findings suggest that the ESS is a more sensitive
and clinically meaningful tool to evaluate the efficacy of
modafinil in narcolepsy .
9. By measuring a clinically useful and well-used fatigue
scale, the FISS-1, we are able to better gauge the relevance
of the patient's sleepiness at a clinical level. Although we
have added the FISS-2 to it, and cannot officially analyze it
because there is no other standard for these questions, we
have found that it is clinically useful appreciating the success
of the interventions because the real world seldom contains
a single individual diagnosis.|
We now list our version of the MESS-R. At this point, any
collaborations would be excellent for this and the PNI-FISS. We
also welcome clinicians at this point using this in their practice
provided they let us know at firstname.lastname@example.org that they're doing so.
Modified Epworth Sleepiness Scale (MESS-R) ?? PNI 2016
Please between 0 and 4 for the degree (how much?) it's been happening in the past week.
0 = you never or almost never doze when that's happening
1 = you have a slight chance of dozing
2 = you have a moderate chance of dozing
3 = you have a high chance of dozing
4 = you're almost always dozing when that's happening
Under normal circumstances, how likely are you to doze off or fall asleep in the following situations (in
contrast to just feeling tired)?
If you have not been in the situation in the past week, please imagine how it would affect you.
1. Sitting and reading 0 1 2 3 4
2. Watching TV 0 1 2 3 4
3. Sitting, inactive in a public place (e.g. a theater or a meeting) 0 1 2 3 4
4. As a passenger in a car for an hour without a break 0 1 2 3 4
5. Lying down to rest in the afternoon when circumstances permit 0 1 2 3 4
6. Sitting and talking to someone 0 1 2 3 4
7. Sitting quietly after a lunch without alcohol 0 1 2 3 4
8. In a car, while stopped for a few minutes in traffic 0 1 2 3 4
Adapted from http://www.stanford.edu/-dement/epworth.html VMNeppe 2003, revised 2014
Please do not write here:
MESS R3 Score (1-3) = ; MESS-R4 score =
The Neppe Narcolepsy Questionnaire (NNQ): Part 4
The Neppe Narcolepsy Questionnaire (NNQ)
The Neppe Narcolepsy Questionnaire is a copyrighted
screening questionnaire . This developed out of necessity
because as far as we're aware there is now equivalent.
It was needed in the running of the Pacific Neuropsychiatric
Institute (PNI), as it would be for any Neuropsychiatric Institute.
Vernon Neppe authored an early version of this test in the
1982 while working in a Sleep-Wake Lab at the Division of
Chronobiology, Cornell University, NY. Dr Neppe then adapted it
in the early 1990s. This has become critically important because
there remains no test to screen for possible narcoleptic symptoms
. Recently, Dr Neppe updated the NNQ (2016) to include
the latest criteria and ideas on narcolepsy and cataplexy. These
were purely additions, with no subtractions so that our previous
We have used the Neppe Narcolepsy Questionnaire (NNQ)
at the PNI in Seattle, WA  as a screen in every patient who
exhibits any clues to narcolepsy, significant day time sleepiness
on the modified PNI Modified Epworth Sleepiness Scale (MESS)
or disproportionate sleepiness compared with fatigue on the
modified PNI Fatigue Severity Scale Questionnaire (FISS).
|So that we can manage the narcolepsy appropriately.
We can differentiate the non-narcolepsy primary dyssomnias with genetic positive HLA expression.
We can motivate use of wakefulness agents.
We can, in a structured fashion, speed up the evaluation as the patient records their symptoms which can
We know what extra symptoms the patient has clinically.
We also are able to build a reservoir of experience and knowledge for the future.
We can also save significant expense because it almost always eliminates the need for polysomnography in
narcolepsy (not sleep apnea), or for MSLT or CSF Orexin levels provided it is performed with genetic HLA
testing (which is a simple blood test).
Table 4A: Why is the Neppe Narcolepsy Questionnaire used? [23,25].|
The NNQ has been used regularly clinically (at the PNI)
since 1992 for all patients in which the diagnosis of Narcolepsy
or a narcoleptic syndrome is queried.
Patients complete this open answer questionnaire in
Microsoft Word. The numbers of questions per item have
changed over time including 2014 and 2016. The patients
usually complete this in a short w hile (such as a hour0.
The NNQ covers the areas of:
|a) Nocturnal sleep (20 was 12 items),
b) Day-time sleepiness (34 was15 items plus subitems),
c) Cataplexy (20 was 10 items),
d) Sleep paralysis (13 was 9+ items),
e) Special Tests (new only: subitems),
f ) Diplopia (18 was 5 items).|
There are several extra items:
|a) Automatic Behavior (32 was 16 items with subitems),
b) Perceptions (33 was 20+ items), Dreams (24 was18+
c) Nocturnal Sleep Disorders (11 was 12 items) and
d) Ego-Boundaries (23 was 12 items with subitems).|
We cannot present comparative data because there is no
other questionnaire. But it has proven extremely sensitive
and specific in screening for symptoms of Narcolepsy based
on measures of diagnosis and also of clinical response to
medication. (In twenty years we have not had patients where
eventually we prescribed wakefulness agents and found the
patients did not respond as expected. On the other hand we
did not use these agents when not indicated, and managed
with alternative medications. We can therefore argue that the
use of the NNQ is pr oven.
In practice, the NNQ has always been combined with the
HLA Narcolepsy screen and HLA-DS15 (DRB1*15), HLADQ6
(DQA1*0102/DQB1*0602). This has proven useful in
supporting our expectations (clinical hypotheses) that the
NNQ is valuable. As a point of interest, at the PNI, we might see
more narcolepsy than anywhere else in WA state. Consequently,
we have over the past two plus decades had the opportunity to
see many variants. At times we see more patients because of
loaded family histories. Our comments here are based on this
The NNQ together with HLA have proven very useful.
The utility is well documented on response to appropriate
medications particularly wakefulness agents, such as
Modafinil. Usage of these criteria differentiates two groups:
A Narcolepsy diagnostic group and a Primary Dyssomnia
(without Narcolepsy) syndrome.
Interestingly, a high proportion of these patients has
temporolimbic instability and also r equire anticonvulsants.
I provide below the key aspects of the NNQ. Those wishing
to use it in research or clinically should contact us at admin@
Neppe Narcolepsy Questionnaire???4R (NNQ???4R) 
I. SLEEP HABITS:
1. Do you have difficulty sleeping?
If so, in w hat way?
Please describe approximate times when you sleep:
a. During work days
b. During off days e.g. weekends.
2. How long does it tak e you to fall off to sleep?
3. What time do you wake up in the morning?
4. Do you wake during the night?
a. How often?
5. How many hours a night are you sleeping?
a. During work days?
b. During off days e.g. weekends?
6. Do you remember your dreams (on waking)?
7. Do you sleep the same number of hours over
8. Do your sleeping habits change?
a. In what way?
9. Do you feel tired when you wake up in the morning?
10. Do you wake up naturally or by other methods?
For example, alarm clocks?
11. Do you snore when you sleep?
12. Do you have any other experiences any time while you
are sleeping at night? Describe.
13. Do you take any medications to go to sleep or any
medicines at night?
14. Have you ever been given sleeping pills to take?
a. Which ones?
c. Frequency? Every night.
d. Please go through each and indicate how they
help or hinder you.
15. For how long do you sleep?
a. Per night?
16. Have you ever been diagnosed with an y of the following:
If yes, please answer when it was diagnosed and whether
this is so?
a) sleep apnea?
c) delayed sleep phase syndrome?
d) advanced sleep phase syndrome?
e) Sleep wake disorder associated with work?
f ) Sleep wake disorder associated with anything else?
g) Seizures or epilepsy?
h) Depression, anxiety or other mental related condition?
If yes to any of the above, please give details.
17. Do you use any kind of CPAP or other mask or nasal
method while sleeping? If yes: Please amplify which
one, what level, how frequently, and the success you've
18. How tall are you (in feet and inches or centimeters)?
19. What do you weigh? (in pounds or kg)
20. What was your maximum weight ever?
II. Daytime sleepiness (Uncontrolled DTS)
1. Do you fall asleep during the da y?
2. How frequently is this on purpose?
3. How often is this against your will (you cannot control
4. Is there a particular circumstances associated with your
falling asleep? Describe.
5. How often during the day do you nap/sleep on the
a. Per 24-hour day?
b. Per night?
6. How often during the day do you nap/sleep on the
7. How many times in the past month have you napped on
average each day?
8. a. How many day-time naps do you average per day?
b. What is the most?
c. What is the least number?
9. Is this about the same over the past three months, or is
it increasing or decreasing?
10. At what age did these episodes begin?
11. Was there ever a break period during this time when
you didn't have these times of naps dur ing the day?
Is there any reason you can think of ?
12. Has there been other reasons like sleep apnea,
recreational or other non-prescription drug use,
prescription medications, or changes in your sleepwake
cycle during work? Please clarify and indicate if
this made the condition w orse or better.
13. When you nap during the day, do you have difficultly
sleeping at night?
14. Can you control your going off to sleep during the da y?
15. If you fall asleep during the day, do you feel refreshed
a. How long do you feel refreshed for?
16. Can you return to sleep again or do you have difficulties
getting to sleep once you have slept during the da y?
17. Has this problem caused any difficulties in the past?
18. Have you ever fallen asleep while driving?
a. How often?
b. Have you had any serious accidents?
c. Any near misses?
d. Any car accidents where you might have fallen asleep
or not been aware?
19. Have you ever fallen asleep while standing?
20. Have you ever fallen asleep while writing something?
21. Do you find that falling asleep relates to whether you
are bored with the activity you are involved in?
22. Are you more likely to fall asleep doing something
passively; like watching something or during periods of
23. Are there any pointers for you that make you know that
you are going to fall asleep during the da y?
24. Have you any warning of any kind, or do such episodes
take you by surprise?
25. After napping how do you feel when you wake up?
26. Are you usually alert between naps?
27. Are you ever fully alert?
a. At al times other than napping?
b. Just after napping?
28. Do you sleep whenever you feel sleepy, or do you
postpone or try to avoid sleep?
a. In what way?
29. At what age did your narcolepsy/uncontrollable
30. When was the last time y ou had this?\
31. Describe an example that is clearest to you or
remembered best or the most se vere one?
32. a. Which medications recreational drugs or alcohol
help and in what dose?
b. Which medications or recreational drugs or alcohol
or other make these worse, and in what dose?
33. Does anyone in your family have episodes of
uncontrollable sleeping during the da y?
1. Do your muscles sometimes feel weak or wobbly when
you laugh or get angry?
2. Have you ever had episodes where parts of your body,
for example, your face, start quivering, and you cannot
control this? These are examples and please check any
of these sudden symptoms that present:
b. Head drop
c. Facial sagging and twitching
d. Slurred speech
e. Jaw weakness
f. Head drop
g. Weakness in arms shoulders and hands
h. Buckling of knees
i. Have any doctors or professionals regarded
this as sudden and transient loss or reduction of muscle
3. When mild, do episodes involve legs, neck, face, eyelids,
arms, or breathing, all or most of above? Please check
4. When severe, do episodes involve legs, neck, face,
eyelids, arms, or breathing, all or most of above? Please
check which ones.
5. Do you notice these features coming on in any particular
6. a. When was the last time an y of these occurred?
b. When was the first time an y of these occurred?
c. How frequently do these events happen now?
d. At worst, how frequently did these events happen?
7. In your own words, please describe
a. a typical (cataplexy or equivalent) event like the ones
b. The most severe ones.
c. The most minor ones.
8. Which medications help and in w hat dose?
9. Which medications or recreational drugs or other make
these worse, and in what dose?
10.Does anyone in your family have cataplexy episodes or
anything like this? If so, w hom?? Who? Please describe.
11.Have you ever found that while awake you've suddenly
become paralyzed in terms of action or have sudden
weakness in a part of your body or other kind of possible
a) Does this occur under an y "particular circumstance"?
b) Have you ever had these symptoms while laughing?
while crying, while surprised, while elated?
c. While having strong emotions?
d. While under stress?
e. While angry?
f. While surprised?
g. Doing nothing in particular?
h. Can you stop any of these symptoms?
i. as a child at an y point even without triggers?
j. as an adult, at any point even without triggers?
12. How often does it happen? Almost e veryday
a. When was the first time?
b. When was the last?
13. Have you ever found that while awake you've just fallen
to the ground?
14. a Have you ever felt drained of strength?
b. Do you ever feel lightheaded?
c. Have you ever lost consciousness with any of these
d. Do the symptoms (cataplexy) end in sleep?
e. If so: without dreams, with dreams, with day-dreams
f. Have you ever found that while awake you've just
fallen to the ground?
15. Are you more likely to have these symptoms (cataplexy)
when you are sleepy?
16. a. Have you ever hurt yourself with these attacks?
b. Are you able to avoid injury because you've learnt
to notice the feeling of these (cataplectic) attacks
c. Is the fall is usually slow and progressive over short
periods like seconds? Please amplify if needed.
17. How long do these attacks last? (seconds, minutes,
b. Shortest time?
c. Longest time?
18. Do you lose control of your eye movements during
these episodes? Please explain if you do.
19. Some basics:
a. At what age did your symptoms begin?
b. When was the last time y ou had this?
c. Describe an example that is clearest to you or
remembered best or the most se vere one?
d. Does anyone in your family have episodes like this?
e. Which medications help and in w hat dose?
f. Which medications or recreational drugs or other
make these worse, and in what dose?
g. Which medications or recreational drugs or alcohol
help and in what dose?
h. Which medications or recreational drugs or alcohol
other make these worse, and in what dose?
i. Does anyone in your family have such episodes or
anything like this? If so, w hom?? Who? Please describe.
IV. Sleep Paralysis SP
1. Do you sometimes while during sleep wake up to find
yourself paralyzed, unable to move?
a) How often does this happen?
b) When was the last time?
c) Does this involve your whole body?
d) If so, which part?
e) How long does this last?
f) When did it first occur?
g) Do you experience this feeling as pleasant or
Indicate this proportion unpleasant to
2. Do you find that during these experiences you have any
3. Do these experiences seem to lead on from any particular
kind or dream?
4. Are they associated with hallucinations or strange
5. At what age did your symptoms begin?
6. When was the last time y ou had this?
7. Describe an example that is clearest to you or remembered
best or the most se vere one?
8. Does anyone in your family have episodes like this?
9. Which medications help and in w hat dose?
10. Which medications or recreational drugs or other make
these worse, and in what dose?
11. Which medications or recreational drugs or alcohol help
and in what dose?
12. Which medications or recreational drugs or alcohol other
make these worse, and in what dose?
13. Does anyone in your family have such episodes or
anything like this? If so, w hom?? Who? Please describe.
V Special tests:
Please give the results of any of the tests you've had relating
to sleep difficulties.
If you know the results, please record these. Also give dates,
a) Any kind of sleep r ecordings?
b) Nocturnal polysomnogram-a measure of sleep during
the night. (check: at home/ in a lab)?
c) MSLT (multiple sleep latency test) (do you know how
many times they measured this in one da y)?
d) Sleep apnea testing (check: at home/ in a lab)?
e) Gene test for narcolepsy?
f) Any other gene test?
g) Spinal tap? (also called Lumbar puncture? CSF /
cerebrospinal fluid/ Orexin test).
1. Do you ever see double?
a) How frequently does this occur?
b) Do you see double with both e yes or with one eye?
c) Does this occur on medication?
d) Does this occur off of medications?
e) At what age did this begin?
f) At what age did your symptoms begin?
g) When was the last time y ou had this?
h) Describe an example that is clearest to you or
remembered best or the most se vere one?
i) Does anyone in your family have episodes like this?
j) Which medications help and in w hat dose?
k) Which medications or recreational drugs or other
make these worse, and in what dose?
l) Which medications or recreational drugs or alcohol
help and in what dose?
m) Which medications or recreational drugs or alcohol
other make these worse, and in what dose?
n) Does anyone in your family have such episodes or
anything like this? If so, w hom?? Who? Please describe.
VI. Automatic Behavior
1. Have you ever done something unusual and yet you
were not aware of it until afterwards? (Elaborate: drove a car,
had a strange conversation; walked a dog, or did something
a. How often?
2. Have you found that you have continued to drive your
car and not been a ware of it?
3. Have you ever been vaguely aware of carrying out an
4. Would this awareness be like a dream?
a. In what way?
b. How often?
5. Have you ever performed any antisocial acts without
6. Have you ever been violent without being a ware of it?
7. Have you ever walked during sleep (= Experienced
a. When was the first time?
b. When last?
8. Have you ever carried on writing doing something and
not been aware of it?
9. Has your handwriting changed in any way during that
10. What was the content of what you were writing?
11. Did that change in some w ay?
12. Then these episodes of beha ving automatically occur?
a. How long did they last?
c. What is the longest the y have ever lasted?
d. What is the shortest they have ever lasted?
e. What time of day do they occur?
f. Are they more common when sleepy?
13. Are these episodes of strange/unusual/'amnesic/
dreamlike behavior more likely to occur when you're very
sleepy, such as when you've postponing or avoiding sleep?
14. Are these specific triggers or associated events?
15. What other features are associated?
16. Do you have any memories at all of them?
17. Are these memories at the beginning, the middle, or
18. Do these memories come back?
19. Do you ever find that these lead from daydreams or
lead into some kind of da ydream?
20. Do you find that they occur more frequently when
associated with particular symptoms?
21. Do they occur more frequently when associated with
a. With laughing?
b. With crying?
c. With shame?
22. Afterwards how you feel?
23. Do you have a headache?
a. If so, of what kind?
24. Do you feel sleepy or tired?
25. Do you feel confused in that you have difficulty being
aware of where you are, or what day or date it is?
26. Have people ever told you that you were acting
27. What about nausea/vomiting?
29. Any pains?
30. Have you ever found yourself shaking uncontrollably
during these other episodes?
a. If so, describe.
31. Has anyone in your family ever had symptoms of this
a. At what age did these s ymptoms begin?
b. When was the last?
32. Describe an example that is clearest to you, or
VIII Perceptions No hypnopompic or hypnogogic
1. Do you ever find that you have strange unusual or
frightening experiences or voices, dreams or visions before
going to sleep?
a. How often do you have them?
b. When was the last time?
c. At what age did they start?
2. Do you ever find that you have strange experiences
a. While awake?
b. Or in association with an y daytime naps?
3. Do you have strange experiences at any other time?
4. Which of your senses have been involved; seeing,
hearing, your sense or touch, temperature, your sense of self,
your sense of taste, your sense of balance?
5. Do they involve any kind of pain?
6. Any kind of sensation within y our body?
7. Temperature change?
8. Do they relate to any form of stimulus or which you can
experience or see, or is there nothing which has stimulated the
9. Is what you perceive (experience) a distortion of
something actually in the environment?
10. Are they pleasant or unpleasant?
a. What is the ratio?
11. Have others also experienced these with you?
12. How long do they last?
13. Does anything else sometimes happen while you're
having these experiences?
a. And after?
14. Do they occur only in one perception, for example,
seeing or hearing, or do they have many different kinds of
sensations, for example, seeing and hear??ing together
a. What do they mean?
15. Do they have a ???knowledge' component?
16. Do they specifically refer to you?
17. Would you please describe what happens?
18. Is the experience mild or intense?
19. Do you experience these from outside?
20. Can you recognize who it is or what it is that you may
be seeing or hearing?
21. Are there any other associated features?
22. Would you please describe when these occur?
23. Are they before sleep, after sleep, during the day, other
24. Are you frightened of objects, shadows, or sounds in
your darken bedroom?
25. Are you intrigued by them?
26. Do you sleep in the dar k?
a. If so, do these objects change in an y way?
b. If not, do you perceive them as changed?
27. Do you at other times see or hear or in other ways
experience a person or a thing which is a distortion of
something which is present?
28. Have you ever found yourself outside of your body or
feeling outside your body?
29. Have you ever experienced that your consciousness is
outside yourself ?
30. Have you ever seen yourself or felt yourself outside
31. Have you found that during these times when you hear
or see things, you cannot move?
32. Have you ever had the experience that somehow you
felt paralyzed during this ( you couldn't move your body)?
a. What do you feel causes it? I'm focused on what's
outside of my not my body
b. Have these occurred during periods of hig h emotion?
33. Any family history?
For all the following experiences, indicate whether they
occur during daytime
naps or during the night, so that they are in fact two series
1. Do you dream? (remember dreaming)
2. Do you dream in:
b. black and white?
3. Are there any particular colors you find yourself
4. Have you ever had the impression that you know you
are dreaming but you feel you are awake even though you are
asleep and dreaming?
5. Have you ever been aware of yourself dreaming while
you were dreaming?
a. When last?
b. How often?
c. When was the first time?
d. Are your dreams very clear?
e. Are your dreams vivid or lifelike?
f. More so then before?
6. Is there any special quality to any of your dreams?
7. How frequently do you recall your dreams?
a. Immediately upon on waking?
b. At lunch-time the same da y?
c. The next day?
8. Do you dream during the daytime?
9. Do you dream about any particular events?
10. Do you feel that most of your dreams relate to the
events of the previous day?
11. Have you ever had dreams where you felt you've had
a special knowledge about something or been able to predict
12. How long do you feel your dreams last?
13. Do you ever have the same dream repetitively?
14. Do you ever find that if you wake up, you can recontinue
your dream where you left off ?
a. In what detail are you able to recall your dreams?
15. Do you ever have dreams where you feel you are
16. Do you ever have dreams where you are very active?
17. Don't have any weight, you feel weightless?
18. Do you have strange kinds of dreams during the day
where you would not have felt you were sleeping, but you
seem you must have?
19. Do you daydream?
20. Have you ever dreamed about something and you later
learned that what you dreamed really happened?
21. Have you ever had a rather clear and specific dream
which matched in detail an event which occurred before,
during or after your dream and which you did not know about
and did not expect at the time of this dr eam?
a. How many times have you had this dream?
b. Please describe separate instances.
22. Do you believe your dreams can foretell the future?
a. Or allow special knowledge for you?
23. Have you ever had a dream involving someone and
later learnt that that person had the same dream as you did at
the same time?
a. If so, describe separate instances.
24. When you awake from dreaming, how long does it take
to reorient yourself ?
IX. Sleep Disorders of Any Kind During the Night:
Daytime Sleepiness; Hallucinations of Any Kind; Illusions
of Any Kind; Sleep Paralysis; Cataplexy; Diplopia; Strange
Dream Experiences; Automatic (For all of these questions
please describe at what age each one of these features began).
1. Are there any members of your family who have any of
a. Please list:
2. Which medications have you been taking?
3. What is the pr esent frequency of each symptom?
4. What was the greatest frequency when they were worst?
5. What effect do your medications have on each symptom?
6. Have you ever abused any non-prescribed drugs?
7. What medications have you been on for your problem?
8. Which medications do y ou find work best?
9. Have you ever had a sleep test that the doctors called an
10. Have you ever had a sleep r ecording at night?
11. Have you any other sleep related conditions or behaviors
or sleep apnea
The following questions have subsections and may seem
unusual. You need not fear answering positively to them.
1. Have you ever had "psychic" or paranormal experiences?
a. How many?
b. Were these of everyday things or of major e vents?
c. Were these proven right?
d. What did they mean?
2. How psychic are you?
a. Why you specifically?
3. Have you ever had telepathic or ESP experiences? (i.e.,
the strong feeling" or knowledge that something unexpected
was happening or had happened or would happen.)
a. Please describe.
b. Were you right?
c. What did it mean?
d. Why to you?
4. Have you ever healed someone?
5. Do you have special healing powers?
a. Please describe.
b. What success have you had?
c. What does this mean?
6. Have you ever:
a. made something move from afar?
b. bent something with your mind?
c. stopped a watch?
d. found your watch cannot run for no apparent reason?
a. What does this mean t o you?
b. Why can you do it?
8. Have you ever had a memory of a previous existence?
(i.e., as if you've lived before or had another lif e)
a. Please describe.
b. Have you ever recognized yourself as someone
important or famous?
c. How is this possible?
d. Do you think it is lik ely?
9. Have you ever been in a tr ance?
10. Have you ever found somebody else controlling your
thoughts or your thinking?
a. Or your writing?
b. Or your speech?
d. Who was this?
e. What does it mean?
f. Why does it happen t o you?
11. Have you ever had the impression (or awareness or saw
or heard or smelt or sensed) that someone or something not
physically or really present was there?
12. Or have you felt colors or lights or an aura around
someone or part of them?
a. Were you awake?
b. What does it mean?
c. Why you?
13. Does someone or something, known or unknown to you
sometimes control your thoughts or your thinking?
a. What about your feelings - your emotions?
b. Is someone or something from outside controlling
14. Can you control your actions fully at all times?
a. Or does someone or something influence them by
b. What about parts of your body?
15. Do you find that an outside force does things using you
as a vehicle?
a. Or thinks some things?
b. Or feels (experiences an emotion) in a particular
16. Does an outside force or influence sometimes do things
which actually look like it's being done b y you?
c. What does it mean?
17. Can others read your thoughts?
b. Why do they do it?
c. Is it only your thoughts that can be r ead?
d. Do they extract (take or steal) your thoughts (out of
18. Can you communicate by telepathy?
19. Can you read their thoughts?
20. Does everyone have these powers?
a. Why you?
21. Do you sometimes hear your own thoughts?
a. Where do you hear them?
22. Do you sometimes feel alien?
23. a. Do your thoughts sometimes stop?
b. Or you suddenly experience nothing?
c. Or do your thoughts sometimes feel unclear?
d. Like they are falling over each other?
e. Or they cannot connect?
f. Or they are like wool?
The Genetics of Narcolepsy: Part 5
No gold standard currently exists for the diagnosis of
narcolepsy. Conventional diagnostic criteria have often been
unwieldy, requiring low CSF orexin (same as "hypocretin"),
or 2 positive SORMPS out of 4 or 5 or 6 under strict MSLT
conditions. The criteria are often arbitrary and varies. Yet,
in research, defined criteria for case selection are needed to
compare the results of different studies . Even more so real
interpretation is required clinically.
Most importantly, it seems that based on the data available,
we can ensure a diagnosis of narcolepsy that is appropriate
in the high 90% range. This can be easily done by clinically
applying careful evaluations and structured questionnaires.
This allows making sure the patient's day-time sleepiness
conforms to the narcolepsy label, that the patient has cataplexy
features which makes the diagnosis more specific, and that the
patient expresses HLA DQB1*0602. If this happens, and this
triad of features based on research occurs in some 85% of
cases, we can be reasonably certain that the patient will also
have a CSF hypocretin/ orexin deficiency. We will therefore
know the cause biologically is due to the disease state of
narcolepsy. This data is not new, but has been known since
MSLT may be valuable in the small proportion of patients
who fail in this assessment: this will include either or both
of narcolepsy without cataplexy, or those who do not express
HLA DQB1*0602, but they might even include those who on
CSF do not have a hypocretin state. I humbly submit that at
this point, these exceptions are at best unproven entities
and that biologically they might not be narcoleptic and may
reflect more than one condition or subtype. Yet, we don't have
studies, at this point, proving different conditions or subtypes.
Let's look at the information available on the HLA gene. We
|i) Even as long ago as 2002, new research diagnostic
criteria for narcolepsy were based on HLA typing. These
possessed high interrater reliability and appeared
valid descriptors of the syndrome. These results may
be useful in providing consistent criteria to compare
different research studies . Why?
ii) The key, most common gene involved in narcolepsy is
HLA DQB1*0602: depending on the study, about seven
eighths  or even 12/13  of cataplexy patients,
but only 33% of those with narcolepsy features
without cataplexy, express the gene . The question
is: Are these figures of the those who do not express
the correct HLA gene reflecting poor clinical diagnoses
and not representing narcolepsy, or are they accurate?
Clinically, this is unanswered completely, but they
likely accurately reflect different diagnoses based on
rankings of narcolepsy diagnoses . Why?
iii) The HLA-DQB1*02 frequency is also increased in the
population with hypersomnia when compared with
the control population (p = 0.004) But enough with
hypersomnia without narcolepsy are positive that we
need other tests. This means effectively that the *0602
expression reveals potentially more than narcolepsy
and therefore that it may encompass any dyssomnia.
My own impression is that if one is very careful in a
neuropsychiatric population: We have found that even
those "controls" who express *0602 have, in every
case, expressed some kind of sleep disturbance. A 34%
figure of "controls" from this study . is the highest
in the literature  with 16% being a more common
estimate , and there may even be only 10% or less
so-called false positives depending on the population
. I argue that the difference is an epidemiological
one, depending on how skewed and symptomatic the
population is. But, I humbly submit that we could
be talking about the far more common "primary
narcolepsy", with the usual gene expression, and if
tested this would imply low orexin and likely autoimmune
components, and "symptomatic narcolepsy",
with secondary brain damage at the hypothalamic RAS
level. This can manifest in many ways: I've even seen a
case mobilized by cysticercosis.
iv) The evidence is so strong that if DQB1*06:02 is
positive, subjects are at a 251-fold increase in risk for
narcolepsy ! An overwhelming portion of genetic
risk for narcolepsy with cataplexy is found at this DQB1
locus , but importantly other loci such as DQA may
also be relevant and therefore tests should be for both
loci, particularly as expression at both loci might show
higher penetrance of symptoms.
v) Without HLA-DQB1*02 expression, it is very unlikely
that narcolepsy exists . My impression is that,
yes, narcoleptic syndrome could exist but this is due
to possible damage to the Orexin or hypothalamoreticulo-
activating system dysfunction due to trauma,
tumor or infection. So the absence of genes does not
then exclude narcolepsy, but the clinical situation must
provide much stronger evidence.
vi) We generally need not demonstrate low CSF
hypocretin-1 levels. This is because we know, based
on other research, that low hypocretin will likely
be present in about 85% of cases with DQB1*06:02
expression and cataplexy. However, if the patient does
not have cataplexy, only about one fifth of such patients
will have low CSF hypocretin-1 levels: This is a curiosity,
because cataplexy sometimes takes some years to
develop after the narcolepsy day time sleepiness. This
might mean that the low CSF hypocretin-1 levels are
not primary but secondary to progression of the illness.
vii) However, rare cases (about one in sixty) are
DQB1*06:02 negative with low CSF hypocretin-1. These
occur equally with or without cataplexy: Therefore,
even hypocretin does not correlate fully. There are
rare HLA negative subjects with severe cataplexy, but
often without clear triggers . This might suggest
that another gene could be involved, so we need to look
viii) Although HLA-DQB1*06:02 is the strongest
predisposing genetic factor for narcolepsy, the effect
of this gene must therefore be considered alongside
that of others, and that turns out to be its polymorphic
partner, DQA1 .
ix) HLA-DQB1*06:02 allele with narcolepsy and cataplexy
is clearly a major predictor of cataplexy in narcoleptic
patients. We argue that the literatures' supports it
could be used as an additional diagnostic marker
alongside Hypocretin . This may seem obvious but
bears mention because the literature seldom points
x) The genetic basis for narcolepsy may also be linked
increased susceptibility to infectious factors or an
immune cytotoxic mechanism in narcolepsy, potentially
targeting hypocretin neurons: this may be linked not
only with DQB1 gene but DQ A .
xi) A secondary HLA-DP association may be present
in rare cases representing particularly difficult
diagnostic challenges: The rare subtype DPB1*0901,
and homologous DPB1*10:01 subtype . However,
it does point out that occasionally there are other ways
of narcolepsy expression.
xii) The HLA-DQB1*06:02 involves a functional HLADQ
molecule consists of a DQ alpha and a DQ beta
chain. The HLA-DQB1*06:02 (DQ beta) has a strong
preference for binding to HLA-DQA1*01:02 (DQ alpha
), and together they form the functional DQ0602 dimer
xiii) In individuals homozygous for HLA-DQB1*06:02-
DQA1*01:02, a dosage effect would be expected if the
HLA-DQ0602 dimer itself is directly involved in the
etiology. This does occur. An increased expression
of the HLA-DQ0602 dimer is expected in individuals
homozygous for HLA-DQB1*06:02-DQA1*01:02, but is
also hypothesized in individuals heterozygous for HLADQB1*
06:02 and homozygous for HLA-DQA1*01:02. A
Dutch study showed importantly, a significantly higher
prevalence of homozygosity for DQA1*01:02 was found
in HLA-DQB1*06:02 heterozygous patients compared
to controls (O.R. 2.37, p < 0.001). The latter finding
clearly supports a direct role of the HLA-DQ molecule
in the development of disease. 44 It also suggests
that all studies should include DQA1*01:02 as well as
DQB1*06:02. This is supported by other genetic studies
xiv) HLA genes likely function under an incomplete
penetrance model, with possible influences from
environmental factors or other genes different to HLA
genes . This may explain why patients from the
same family, and with the same main gene expressions
like 0602, still vary markedly in symptoms. 46 At least
some of these patients have markedly loaded family
histories and autosomal dominant inheritance is likely
xv) Few sleep disorders have an established genetic basis
including four rare diseases that may result from a
single gene mutation: fatal familial insomnia, familial
advanced sleep-phase syndrome, chronic primary
insomnia, and narcolepsy with cataplexy. However, most
sleep disorders are complex in terms of their genetic
susceptibility together with the variable expressivity
of the phenotype even within a same family . The
extent of penetrance of genes is pertinent her e.
xvi) Finally, reanalyzing the genes, it may be even more
complex. There may be protective genes based on
Chinese work. HLA-DPA1(*)01:03-DPB1(*)04:02
(DP0402; . They also found an independent
predisposing effect of DQB1*03:01 predisposes
via a currently unknown mechanism which might
explain the few that are not due to the 06:02 gene.
They also reported strong protective effects of
HLA-DPA1(*)01:03-DPB1(*)04:02 (DP0402 and
HLA-DPA1(*)01:03-DPB1(*)04:01 (DP0401 and
predisposing effects of HLA-DPB1(*)05:01 . It is
clear that both DQA1 and DQB1 influence narcolepsy
xvii) Moreover, genome wide association studies have
subsequently been able to prove that autoimmune
mechanisms are responsible for the manifestation of
narcolepsy with the HLA association being the most
important for susceptibility and protection .
xviii) Unlike the case of canine narcolepsy, where mutations
in the hypocretin (orexin) neuropeptide precursor
(HCRT) receptor have been found, it has been argued
that Orexin deficiency is the cause of human narcolepsy
[31,53]. The recent advances in the elucidation of the
genetics of canine narcolepsy and the pathophysiologic
role of hypocretin, in animals and humans, enhances
current diagnostic capability and will ultimately
provide better treatment modalities in the future ,
as well as clarify etiological and diagnostic issues.
xix) Data also suggests that narcolepsy may be the result of
an autoimmune reaction triggered by H1N1 vaccination
in susceptible individuals .
xx) Given these differences, and the above data, it might
support the possibility of HLA genes and associated
receptor expressions being fundamental.
xxi) Moreover, Mignot's analysis could explain increased
disease heterogeneity in a non-cataplexy group and a
direct effect of the HLA DQB1*0602 genotype on the
clinical expression of narcolepsy supports this .
xxii) Based on this data, it appears that the gene expression
may be even more basic than the low orexin / hypocretin
levels which may be secondary: This is a new Neppe
hypothesis using this data. Effectively, the current
idea has been that hypocretin deficiency causes the
narcolepsy. I propose that based on the HLA data the
cause is higher up the stream, and orexin deficiency is a
consequence, albeit an early consequence downstream,
but not a cause. A way to test this is to find patients
with HLA DQB1 * 06-02 gene expression, with any early
symptoms of narcolepsy, but which has normal orexin,
and then with progression, later deficient orexin.
|a. Further characterization of the HLA genes could
potentially enhance differential diagnosis among
those expressing different kinds of excessive daytime
sleepiness and this may correspond with diverse entities
with different biological mechanisms . But this is
too specialized. Let's just remember the rules, not the
b. We must test both for the DQA and DQB genes. A recent and
changed but common habit, certainly in our geographical
area, is labs just doing the HLA-DQB1*06:02. This misses
the other genes involved and may provide insufficient
data for clinical assessment and later comparative
clinical research, too. At minimum, DQA1*01:02 should
c. In my experience over the past 20 years, in my
neuropsychiatric populations, every patient expressing
the gene has on careful analysis had some kind of
dyssomnia: This is not a "normal" control population by
Management of narcolepsy: Part 6
Two conditions are treated in narcolepsy.
The first is day-time sleepiness.
Current treatment recommendations suggest that these
wakefulness drugs (also called wakefulness-promoting agent
or eugeroics) should be used as a first-line treatment ahead
of conventional stimulants such methylphenidate or sodium
The advent of modafinil (Provigil in USA) and armodafinil
(Nuvigil in USA) (it's daughter effectively with a longer
half-life allowing daily not BID management at times) has
revolutionized management of narcolepsy . It is indicated
for narcolepsy, shift work sleep disorder, and excessive
daytime sleepiness associated with obstructive sleep apnea
. It is not indicat ed in cataplexy.
Modafinil and Armodafinil is a schedule IV controlled
substance with restricted availability and usage in the USA,
though in many countries it is a prescription drug, but not
Although the mechanism of action of modafinil and
armodafinil was initially unknown, we do know it does act
as a selective, relatively weak, atypical dopamine reuptake
inhibitor, possibly as a dopamine transporter reuptake
Modafinil produces wakefulness reportedly without the
need for compensatory sleep, and shows a relatively low, if any
, potential for abuse, through mechanisms e.g. cholinergic
may be pertinent.
What is useful in follow up is the ability of sleep-stage
sequencing of sleep-onset rapid eye movement periods in the
multiple sleep latency test to predict treatment response, in
narcolepsy, with cataplexy or without, applying clinical and
polysomnographic criteria. This can be used in monitoring
response to medications . However, as indicated, the
Epworth Sleepiness Scale appears more effective when using
modafinil in narcolepsy  and also in obstructive sleep
The second medication approach is in the management of
Sodium oxybate and gamma-hydroxybutyrate has been
found to be effective at reducing the number of cataplexy
episodes. Sodium oxybate is generally safe and typically the
recommended treatment for some clinicians as the most
Sodium oxybate (USAN) (Xyrem from Jazz Pharma USA)
is designated as an orphan drug, a pharmaceutical drug
developed specifically to treat an orphan disease, cataplexy
and narcolepsy. It is FDA approved for the treatment
of excessive daytime sleepiness (EDS) associated with
narcolepsy, and for the treatment of cataplexy associated with
narcolepsy. and under the name Alcover, it is used in Italy for
treatment of alcohol withdrawal and dependence. Therefore,
it's the only drug marketed for narcolepsy EDS and cataplexy.
It is generally well tolerated by most patients. The drug has
been safely used by patients with narcolepsy since 2002, with
surprising low rates of abuse, dependence, and withdrawal,
and very rare sexual assault cases.
The active metabolite of sodium oxybate, gammahydroxybutyric
acid, acts as an agonist at the GABA-B receptor
complex and the GHB receptor. This likely contributes to some
part of sodium oxybate's therapeutic effects.
However, it is a central nervous system depressant and
must be taken exactly as prescribed. My biggest problem with
oxybate is a practical one: patients must take it at night and
wake in the night to take the second dose. A lesser irritation is
simply that and patients should not eat for two hours before
Instead, my own preference is for tricyclic antidepressants.
I have been using nortriptyline but others use imipramine,
clomipramine or protriptyline; venlafaxine is possible,
although it can be argued that the benefit is not as good. I have
seen recommendations pertaining to SSRIs, but I have no proof
all are effective, and if so that the effect will be maintained for
prolonged periods. Because tricyclics have been available for
up to 60 years, we know they do not appear to lose efficacy
certainly in depression.
These compounds work to manage both cataplexy and the
REM sleep-onset symptoms of sleep paralysis and hypnagogic
Non-pharmacological management of narcolepsy is
important: Patients should maintain a strict regular wakesleep
schedule and good sleep hygiene. They should benefit
from voluntary afternoon naps and a program of regular
exercise . Importantly, many cataplectics try to avoid
highly emotionally charged situations such as laug hter.
Treatment is highly individualized, depending on the
severity of daytime sleepiness, cataplexy and sleep disruption.
Patients with narcolepsy should respond to modafinil or
armodafinil. Dosage varies greatly.
Patients with cataplexy need tricyclic antidepressants like
nortriptyline in low to medium doses.
atients with hypnagogic hallucinatory phenomena
sometimes respond to small doses of atypical neuroleptics like
aripiprazole 2mg to 5mg daily (but this is an out of label use).
Mechanisms of Narcolepsy: Part 7
The current postulated cause of narcolepsy is due to an
autoimmune destruction of the neurotransmitter hypocretin,
which regulates arousal and wakefulness. This leads to a
low level of CSF hypocretin. We know further that damage
to orexin-secreting neurons in the hypothalamus can lead to
inhibition of motor neurons, thus lowering muscle tone.
The neurological process behind the lesion of narcolepsy
is the impairment of descending pathways controlling the
normal inhibition of muscle tone, consequently, cataplexy
results with muscle atonia .
This loss of tonus is caused by massive inhibition of motor
neurons in the spinal cord. When this happens during waking,
the victims of cataplectic attacks lose control of their muscles.
However, even though it is not apparent, muscle tone
paralysis occurs at inappropriate times, but, nevertheless, the
patient still continues to breathe and is able to control eye
movements . This is postulated and likely to be because
this phenomenon is linked with Rapid Eye Movement (REM)
The hypothalamus region of the brain regulates basic
functions of hormone release, emotional expression and
sleep. The absence of neuro-excitatory properties of the
hypothalamic hypocretin-peptidergic system 33 appears
linked with the neurochemical hypocretin (Orexin), which is
regulated by the hypothalamus. Hypocretin is significantly
reduced in almost all patients with the symptoms of cataplexy,
and is the primary chemical important in regulating sleep and
states of arousal. Hypocretin deficiency is further associated
with decreased levels of histamine and epinephrine, which are
chemicals important in promoting wakefulness, arousal and
Substitution of the deficient neuropeptides by hypocretin
agonists  is a possible causal treatment strategy if this
is, indeed, the etiology, or even if this is an early result of
cataplexy and EDS.
The Reticular Activating System
The reticular activating system involves up and down
The muscular paralysis can be perceived as the reverse
effect of the sleepiness. The Reticular Activating System (RAS)
goes to sleep in the other direction at an inappropriate timeso
to say when RAS phenomena occur upwards. When this
upward component happens during waking, we argue that the
patient falls asleep and the kind of firing results in rapid-eyemovement
sleep almost immediately with or without stage 1
When the downward component happens during waking,
the patient with a cataplectic attack loses control of some of
their muscles [32,63]. This loss of tone is caused by massive or
limited inhibition of motor neurons in the spinal cord.
Hypocretin levels can be measured using cerebrospinal
fluid (CSF) hypocretin-1 immunoreactivity values: Deficiency
is currently regarded as a level of less than or equal to onethird
of values obtained in healthy subjects tested using the
same assay, and this usually works out to less than or equal to
110 pg/mL. Nevertheless, some argue that the optimal cutoff of
CSF hypocretin-1 for narcolepsy without cataplexy diagnosis
should be as high as 200 pg/ml rather than 110 pg/ml. .
A limitation is that CSF levels of hypocretin-1 should not be
assessed in the context of acute brain injury, inflammation, or
Patients with narcolepsy possess a reduced number of
hypocretin-producing neurons in the hypothalamus and
accordingly the hypocretin level in the cerebrospinal fluid is
Anatomically, hypocretinergic axons make asymmetric
synapses with neurons within the locus cerulean, ventral
tegmental area, dorsal raphe nucleus and laterodorsal
tegmental nucleus that target the medial frontal cortex.
Hypocretins could facilitate wakefulness and cortical
activation, therefore, by activation of those neurons with
cortical projections in these four reticular nuclei .
The neuropeptide hypocretin (orexin) has functions, such
as the regulation of the sleep-wake cycle, the autonomous
nerve system, motor system and metabolic processes .
Imaging studies have revealed neurodegenerative changes,
making a multifactorial etiopathogenesis probable. The
frequent occurrence of metabolic disorders has not yet been
clarified. 10 And certainly puzzling are those few cases with
normal hypocretin levels in the CSF. Does this imply a second
process such as resistance to the receptor, or another cause,
or as indicated, that the hypocretin deficiency certainly is
an important result, but minimally downstream and not the
How do low hypocretin patients compare with normal
hypocretin measures on NPSG and MSLT? These patients
have far more frequent short rapid-eye movement (REM)
sleep latency during polysomnography, as well as shorter
sleep latencies and more sleep-onset REM periods during the
Multiple Sleep Latency Test (MSLT) .
In essence, current thinking is that measuring CSF
hypocretin-1 is a definitive diagnostic test, provided that it
is interpreted within the clinical context . It has limited
use when the MSLT is difficult to interpret as in subjects who
are already treated with psychoactive drugs or with other
concurrent sleep disorders .
The question is "how far down in the narcolepsy cycle is the
orexin data"? A small proportion of cataplectics have normal
orexin levels yet express abnormal DQB genes . Could it be
that the damage is reflecting hypothalamic abnormalities and,
as seen in the HLA discussion, based on this data, it appears
that the gene expression may be even more basic than the
slightly downstream low orexin / hypocretin levels, which
then may be secondary? In this paper, I have suggested this as
a feasible and possible new hypothesis, because the HLA data
as a whole supports this line of reasoning.
Multiple Sleep Latency Test (MSLT): Part 8
The Multiple Sleep Latency Test (MSLT) test has become a
routinely recommended evaluation to be performed in Sleep
Labs for the diagnosis of nar colepsy .
Without doubt, the test has some strong virtues in assisting
difficult diagnoses and in monitoring changes after treatment,
but that must be put in a perspective.
In essence, there are some major difficulties, as well, about
performing the MSLT:
|a. first, the test works out as very expensive;
b. secondly, it is a specialized test where ordinary clinicians
in psychiatry, neurology or family practice are effectively
c. thirdly, it does not yield an adequat ely high positive rate;
d. fourthly, a good proportion of those without narcolepsy
have false positives;
e. fifthly, in my opinion, the MSLT is not necessary in most
instances because the diagnosis is clear without it but
with a good evaluation; and amplifying this,
f. sixthly, and possibly most importantly, we argue that
g. simply good clinical information (based on structured
historical responses such as the Modified Epworth Sleep
Scale and the PNI Fatigue Severity Scale as an initial
screen, followed by the Neppe Narcolepsy Questionnaire,
all combined with an e xperienced clinician in the ar ea)
h. combined with HLA testing of both the DQ-B and DQ-A
i. monitoring pharmacological response is usually adequate.
j. Only then, if there are questions, the MSLT should be
performed, with or without CSF Orexin (Hypocretin)
The problem might be more complex. MSLT is expensive,
and when narcolepsy is diagnosed or suspected, but MSLT does
not prove the condition, then often the insurance companies
will not approve the costs of wakefulness drugs treatment,
which on an extended lifetime basis, using today's prices, is
extraordinarily expensive. If this happens, patients may not be
able to afford their treatment and they might deteriorate, be
unable to work, have disruptive family lives, and suffer a great
deal and compromise their families. And therefore, if they
have a narcolepsy diagnosis, and are already responding to
modafinil or armodafinil, this creates a major risk for them, as
their medical record might say that they do not have a positive
MSLT. That is potentially tragic.
In other words, I argue that there must another acceptable
route for the medical insurances in the USA, certainly, to
approve what the treating physicians regard as appropriate
diagnoses of narcolepsy with or without cataplexy, when
these patients have been evaluated even without MSLT. That
acceptable route should be clinical and scoring data e.g.
Epworth, plus NNQ or other historical standard protocol, plus
expression of HLA-DQB-0602.
The problem may be more insidious. Why not just get an
MSLT even though the diagnosis is relatively certain, including
marked family histories? The difficulty is the "normal" MSLT
result because at that point the patient who merits treatment
on the basis of the previous narcolepsy evaluation (as listed in
the sixth point above) may be denied costly pharmacological
interventions by the medical insurances, and may not be able
to afford the medications. This can be catastrophic for their
future. Sadly, we personally have seen this happening on a
number of occasions, and see as this as very tragic: Patients
have literally lost their livelihood because they could not work
and the insurances would not approve what for them are lifesaving
Additionally, as Mayer points out, the MSLT is a poor gold
Effectively, the ICSD-4 is, in any event, easily applicable
in cases with typical cataplexy and narcolepsy where with
the MSLT, further evaluations are almost always positive and
may thus not always be needed . The main conundrum lies
with patients without cataplexy who are difficult to classify
. These patients' results might demonstrate difficulties in
interpreting the MSLT, particularly in the presence of sleep
apnea or reduced sleep.
Let's briefly examine the utility of the Multiple Sleep
Latency Test (MSLT).
The most common criteria used is a multiple sleep latency
test involves examining for Sleep Onset Rapid Eye Movement
periods (SOREMPs). The MSLT test consists of four or five or
even six 20-minute nap opportunities set two hours apart.
The patient is monitored to measure the time elapsed from
the start of a daytime nap period to the first signs of sleep and
sleep latency. For a SOREMP to be positive, it should showing
a mean sleep latency less than or equal to 8 minutes. For an
MSLT there should be two or more SOREMPs. Technically,
therefore, there should be two episodes of almost REM onset
sleep for diagnosis or close to that, with up to a few minutes
of a little stage 1 sleep beforehand, being acceptable. This
criterion might be too stringent and diminish yield, but if
there was only one SOREMP that might be too easy. This view
is supported: Dauvilliers argues that the MSLT criteria indeed
are too stringent certainly in the older population .
An alternative that counts for one SOREMP in the American
Academy of Sleep Medicine (AASM) classification, is a
SOREMP (this time showing latency to rapid eye movement
(REM) sleep of less than or equal to 15 minutes of sleep
onset) on the preceding nocturnal polysomnogram (PSG) and
this may replace one of the SOREMPs on the MSLT. Nocturnal
polysomnography (NPSG) sometimes precedes they multiple
sleep latency testing (MSLT).
The NPSG of a narcoleptic patient may be totally normal,
or demonstrate the patient has a short nocturnal REM sleep
latency (suggesting narcolepsy), or the patient may exhibit
separate unexplained arousals or periodic leg movements
Based on sleep wave measurements, the diagnosis of
narcolepsy is therefore supported by the presence of two or
more sleep onset REM periods (SOREMPs) in the MSLT, or
sleep onset REM periods (SOREMPs). Let's re-examine this.
Sansa et al examined the distribution of SOREMPs
throughout the MSLT in narcolepsy with and without cataplexy.
They applied the common five-nap test in MSLT, which requires
at least two such tests to be positive. On average, about one
fifth of these nap tests showed SORMPS and the fourth test in
that sample was about a sixth. Shortening the MSLT to three
or four naps decreased the capability of the test even more to
support the diagnosis of nar colepsy .
Sleep laboratory testing should be performed according
to standard techniques, and results should be carefully
interpreted in the context of the patient's clinical history in
the presence of EDS. At least 1 week of Actigraphy assessment
with a sleep log is strongly recommended prior to MSLT to
determine factors that may bias results (e.g., insufficient sleep,
shift work, or other circadian rhythm disorder). These reflect
stringencies in the MSLT procedure (as behooves any logical
test), for example, the patient should not have slept less than 6
hours prior to MSLT, and the issues of medication will vary: for
example, on what one is monitoring e.g. response to treatment
is one parameter.
Hypersomnolence and/or MSLT findings should not be
better explained by other causes such as insufficient sleep,
obstructive sleep apnea, delayed sleep phase disorder, or the
effect of medication or substances or their withdr awal.
On the other hand, in another study, patients with definitive
orexin findings, and proven narcolepsy with cataplexy, have
much higher sensitivity of 96% with specificity of 74%, whereas
two SOREMPs had a sensitivity of 75%, with a specificity of
95% for a pathological REM sleep propensity at MSLT. In this
population, which likely does not require clinical selection at
all because it is definitive, the multiple spontaneous SOREMPs
during daytime clearly identified patients with narcolepsy
MSLT can also prognosticate: The presence of this specific
sleep-stage sequence in all sleep-onset rapid eye movement
periods was associated with worse treatment response and
aid the prediction of treatment response in narcoleptics
and provide a useful prognostic tool in clinical practice
. However, we could logically hypothesize that simply
monitoring severity of clinical episodes e.g. by Epworth
score, or the presence of HLA genes both DQA and DQB ,
or pharmacological response, might provide an even more
adequate monitoring test, as well, but the research has not
adequately explored that.
These tests MSLT, Orexin, HLA are controversial in their
interpretation: As I regard the literature currently including
much of the research, routine MSLT is not required to prove
diagnoses of narcolepsy when clinical (including structured
histories) and HLA confirmation confirms the diagnosis of
both narcolepsy and cataplexy. Technically, classifications
have varied with what has been called Narcolepsy Type
1 involving both excessive daytime sleepiness (EDS) and
cataplexy as core features, and Narcolepsy Type 2 requiring
the excessive daytime sleepiness as the essential feature but
where cataplexy is absent. These criteria seem reasonable
except one can say ""Narcolepsy with Cataplexy instead
of Type 1, and "without Cataplexy" instead of Type 2. The
problem comes when some classifications add additions such
as MSLT and / or CST orexin as mandatory criteria: Those
additions exclude most conditions from being either Type 1 or
Type 2 because those tests have not been done. Additionally, if
we examine the literature carefully, it is astonishing that HLA
testing for narcolepsy has just been excluded in almost every
list of fundamental criteria.
Without cataplexy, MSLT for narcolepsy may be useful but
should not be overvalued because it is not a gold standard, as
in the real world there are often complicating features, such as
additional obstructive sleep apnea.
Perspective on Narcolepsy and Cataplexy: Part 9
This final section is best illustrated with tables. First, I
describe, again, the classical narcolepsy quartet where daytime
sleepiness and cataplexy are far more important clinically
than the other symptoms which may be non-specific and so
not diagnostic and are difficult to conceptualize.
Day-time sleepiness: This involves uncontrolled sleepiness. Very commonly has a history of falling asleep
while driving. After a 20 minute nap with or without remembered dreams, there is an episode of several
hours of refractoriness during which the patient is very refreshed.
Cataplexy: This loss of tone often occurs with high emotion. It can involve small groups of muscles and
sometimes involves dropping objects, or the knees buckling. It can manifest with any group, but in our
experience may be consistent for that individual. Cataplexy is very common and leads to a classification of
Narcolepsy with cataplexy and Narcolepsy without cataplexy.
Sleep paralysis: This is likely associated with the hypotonia in REM sleep with awakenings. The patient
awakens from sleep during the night, was in a REM phase, and cannot move because he/she continues
to be hypotonic. But respiration is ostensibly unaffected, and eye movements can occur, and males may
be erectile. Patients should be reassured about the mechanism and that they are not safe during these
episodes and not about to die, because such happenings otherwise could be very frightening.
Hypnagogic and hypnopompic phenomena: Again, hypnagogic experiences may be linked up with the
onset of REM prior to fully sleeping. I seldom encounter hypnopompic phenomena. These both are often
predominantly visual, do not respond to atypical neuroleptic, and involve more distortions with illusions
than hallucinations. The patient may have had them before, and education about them can take away the
sense of fright, they may otherwise experience.
Table 9A: Features of Narcolepsy: Classically there is a quartet.
Next I describe features that are often not asked about.
Double vision is again non-specific, but so is insomnia.
However, the insomnia is a key symptom if patients are
having narcoleptic sleepiness during the day, they must have
insomnia. Therefore, treatment for insomnia at night with
medications must be carefully considered.
Importantly, these are often not recognized.
Diplopia: Double-vision is a common accessory symptom. But eye movements should be spared and this
therefore should not be associated with cataplexy, so the symptom is strange [23,30,70,71].
Nocturnal insomnia: This is very common and classically explained by the narcoleptic still having 7-8
hour per day sleep cycles but their micro-sleeps during the day produce less need for sleep at night .
Table 9B: Secondary features of narcolepsy.
The difficulty with narcolepsy is the concurrent morbidity.
Often the hallucinatory (usually visual) episodes or visual
illusory distortions are misinterpreted. Patients are then
given high doses of neuroleptic and get worse. Some end up in
mental hospitals, sometimes for prolonged periods, because
they get worse. And they are theoretically far more likely to
be at higher risk then for tardive dyskinesia because they are
biologically receiving inappropriate doses of neuroleptic for
what are not true psychoses [14, 72-75].
Psychotic or psychopathological features: This occurs in about a quarter of patients and manifest
differently from what one would expect. Narcolepsy is the great mimicker and we have several patients who
were misdiagnosed and even may have ended up in mental hospitals .
Primary Dyssomnia. Commonly we see patients with gene expression and often with a loaded family history,
yet no history of narcoleptic symptoms. Yet, we have never seen a patient who has no sleep disturbance
after taking a detailed history, and yet this genetic expression. This leads us to postulate that there is a
gene positive, primary dyssomnia group who manifests extreme fatigue, yet still responds to wakefulness
drugs. The genetic expression is, therefore. non-specific primary dyssomnia with narcolepsy as the primary
condition, but never in our experience has the patient been entirely without sleep disturbance. But then we
do not evaluate "normal" individuals, usually so this is a biased population! 
Strange experiences: Though claimed otherwise, we have not seen more patients than the average
population with out-of-body , near-death, or subjective paranormal experiences [23,77].
Table 9C: Variant extra features of narcolepsy.
Variants with gene expression
|a. About one third of our patients exhibit significant sleep
disturbance. They may even have loaded family histories
of narcolepsy (based on our experience and with the data
available, this may be autosomal dominant). These patients
might have significant primary sleep disturbances other
than exhibiting narcolepsy. The gene then would reflect a
dyssomnia, predominantly narcolepsy, but in these cases,
b. Some of our patients require a second hit (e.g. meningitis,
in one instance, cysticercosis of the brain, head injury) to
c. Many of our patients with narcolepsy but not cataplexy,
have had MSLTs. However, they have had multiple sleep
latency tests with a negative test. In our experience, and
also at Cornell where I developed the NNQ in 1982-1983,
it was not common to have a clean positive MSLT for
narcolepsy, because patients' conditions are, in practice,
d. We've seen two patients who are MSLT positive and
yet genetically negative. This suggests there is more to
Narcolepsy than just the gene, as w ell.|
|a. Invariably these patients respond to Wakefulness
agents such as modafinil, armodafanil and sometimes
to psychostimulants, partly and incompletely such
as methylphenidate on its own, or as adjunct to the
b. Unlike the early literature that claimed that the
electroencephalogram is invariably normal, about half
our patients with narcolepsy have temporal lobe foci,
or are loaded with temporal lobe symptomatology and
respond to anticonvulsants, in addition.
c. The psychopathology commonly is controlled by additive
buspirone for the agitation and anxiety, and/or atypical
neuroleptic in low doses such as aripiprazole for the
psychotic or paranoid features.
d. The cataplexy responds well to tricyclics such as
nortriptyline or clomipramine (sometimes obsessionality
Finally I create Table 9D, effectively a flow chart to approach
the possible narcoleptic patient.
Criteria sequence: Medical history taking then ESS + FISS, NNQ, HLA,
responses, EEG if needed, MSLT and CSF unlikely unless atypical
1. Clinical symptoms
a. Key features:
1. EDS (excessive day-time sleepiness)
c. Extra likely
2. Clinical questionnaires to complete:
PNI Fatigue Severity Scale. (FISS-M) with Modified Epworth
If scores are on MESS are >10 (using the 8 questions 0 to
3 range) or if the MESS score is half or more of the FISS-1, then the
Neppe Narcolepsy Questionnaire is completed.
Neppe Narcolepsy Questionnaire (NNQ)
3. HLA measures
Blood taken for narcolepsy HLA gene screening. It should include
HLA DQB1* 0602 but also HLA DQA1*01:02 at minimum. If
there are other issues, other HLA DQ protective genes should be
prescribed. Supposedly the correlation of genetic HLA is in the
90%+ range with cataplexy with DQB1*0602 alone. But there are
other genes: HLA-DQ6 (DQA1*0102) appears important and others
such as HLA-DS15 (DRB1*15).
4. Pharmacological responsiveness if the diagnosis is clear or
a. Modafinil and armodafinil are mainstream treatments
b. Methylphenidate or other stimulants if modafinil or
armodafinil are not available and they are occasionally used
as adjunct to them.
c. Xyrem (oxybate), unusually, is prescribed, simply because it
requires awakening at night to take a dose. Xyrem when used
appears effective, and then used on its own.
d. If cataplexy: Tricyclic antidepressant like nortriptyline e.g.
50mg to 75mg daily.
5. The Limitations of Esoterica:
a. CSF Orexin or Hypocretin: Very rarely needed because it will
just confirm what I know unless questions about etiology.
Useful in research though and might lead to new drug
b. MSLT and /or polysomnography: Useful in unusual cases, but
expensive and low-yield in our group. But do not use this to
decide whether wakefulness drugs are necessary.
c. Electroencephalograms. In our experience at the PNI over 20
years, possibly one half of these patients have temporal lobe
foci on extended monitoring. This contrasts with folk-lore
where narcoleptic patients are supposed to have normal EEGs.
If so the patients may require treatment e.g. Anticonvulsants.
Table 9D: The Practical Narcolepsy Ingredients (PNI).
I clearly see a loaded population. But it is difficult for me
to believe the incidence of Narcolepsy is only one in 5000
patients. I suspect maybe 90% of narcoleptic patient diagnoses
are missed and if so the likelihood is the incidence is closer
to 1 in 500. This marked underestimation of the narcoleptic
population is also an opinion shared by Manzaneda 
and also by Chakravorty who argues that "only 15-30% of
narcoleptic individuals are ever diagnosed or treated, and
nearly half first present for diagnosis after the age of 40 y ears
Applying the unified approach
Classifications of old are a problem: Type 1 Narcolepsy
of old is now Narcolepsy with Cataplexy. Type 2 Narcolepsy
of old is now Narcolepsy without cataplexy. Fortunately, the
Type 1 and Type 2 labeling seems to not be as fashionable. As
indicated, I would argue for a primary narcolepsy condition
and for one that is symptomatic narcolepsy due to other causes
such as infection or tumor impacting hypothalamic function.
Thank you for the valuable suggestions of Psychiatrists,
Biagio Longano, Michael Norden and Dale Sobotka, of
psychologist, Suzan Wilson, and of Lis Neppe and Shauna
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