Posted by Ayushi Desai, MSIV, Drexel University College of Medicine
Fatigue. I imagine it ranks highly among the most unifying experiences shared by Americans in this day and age. Amidst torturously busy schedules, sleep deprivation, taxes, and the unyielding restraints of a day comprised of only 24 hours, I can blame no one for being tired, just, ALL the time.
Sometimes I wonder whether those of us who are affected by this obnoxious, unremitting daily fatigue secretly have undiagnosed narcolepsy.
Let’s be serious — how many of us can really sit through some performance in a dark theater without catching even a few Zs? And aren’t we all jealous of kindergarteners, whose workday includes a mandatory scheduled nap?
I’m embellishing, of course, but I may not be too far off. As we delve further into the study of sleep, we are starting to realize that narcolepsy is, indeed, hopelessly underdiagnosed.
Down to the basics, narcolepsy is a sleep disorder characterized by the early intrusion of REM in the sleep cycle, which eventually translates into excessive daytime fatigue and resultant episodes of irrepressible need to sleep.
How this happens is slightly complicated and represents an unfortunately vicious cycle:
In a nutshell, restful sleep occurs during stages 3 and 4 — at this time brain waves are slow, and we are allowed to recuperate in so-called “deep sleep.” In contrast, brain waves seen on polysomnography during the REM stage are fast and essentially the same as those seen when someone is awake with their eyes closed… Which means that in REM, our brains act as if we are awake. It becomes easier, then, to imagine how (8 hours or not) a night spent predominantly in REM equates to extremely poor sleep quality. This poor sleep quality in a narcoleptic leads to the aforementioned characteristic excessive daytime fatigue, and suddenly, we have a person who is almost involuntarily taking REM naps and doing other sorts of REM things throughout the day, everyday.
These other REM things? During REM, we have “awake” brains, we have dreams, and our bodies lose all muscle tone (USUALLY rendering us completely unable to move). Those suffering from narcolepsy manifest the latter two during the day and undergo peculiar experiences: Cataplexy, HypnaGOgic Hallucinations (vivid dream-like hallucinations experienced while GOing to sleep), and the ever-terrifying Sleep Paralysis.
Sleep Paralysis (yikes)
As we can imagine, these key sleep pathologies are likely a source of significant embarrassment and suboptimal quality of life in sufferers of narcolepsy.
So how do we treat it? The most important aspect is, of course, in diagnosing it! Which means recognizing when a patient might have it — a ballgame in which it seems we have been falling behind. Unless the disease process is frank and severe, it may be difficult for a narcoleptic patient to recognize the characteristic “buzzword” signs and symptoms (or even that there may actually be something underlying their round-the-clock tiredness). So perhaps it might be prudent to consider the diagnosis of narcolepsy in a person experiencing chronic daily fatigue, with the first step being simply to ask if our perpetually half-awake patient sometimes experiences symptoms that sound somewhat like cataplexy, hypnagogic hallucinations, or sleep paralysis. We can throw in an Epworth Sleepiness Scale to get a baseline of how terribly the tiredness affects activities of daily living, and after that, sleep studies are the way to go.
Besides the obvious, though, traditional treatments are aimed largely at helping to improve symptoms (as we’ve not yet struck the gold in finding a cure). CNS stimulants such as methylphenidate (Ritalin), amphetamine (Adderall), modafinil (Provigil), and armodafinil (Nuvigil) have achieved moderate success in eliminating the chronic fatigue. We’ve even used tricyclic antidepressants (clomipramine/imipramine) and other medications with anticholinergic side effects to alleviate cataplexy. However, I am most intrigued by the eventual advent of an orexin-receptor agonist. While we aren’t yet quite sure how exactly narcolepsy develops, it is widely believed that the neurotransmitter orexin (aka hypocretin) is deficient in narcoleptics. It is hypothesized that finding a way to upregulate the production of orexin in narcoleptic patients may lead to disease remission without all the nasty side effects of medications.
So… are most of us realistically secret narcolepsy victims? Probably not. But here’s a link to the Epworth Sleepiness Scale in case you want to assess how well you’ve fared in the fight against fatigue.
Based on my results, I’ve likely been asleep during this entire blogging experience.