"Sleep and sleep" sleep disorder, a table tells you how to treat it

*Only for medical professionals to read for reference.
Rational use of drugs is the key to the treatment of diseases.

The 16-year-old student's grades plummeted, irresistible daytime sleep! When a 16-year-old boy laughs, his limbs become weak and fall to his knees.
Do you know what it is? The patient was a 16-year-old student in junior high school.
Since the age of 14, he has had irresistible paroxysmal daytime sleep, which occurred more than 10 times a day, ranging from a few minutes to ten minutes each time, which seriously affected the life and study of the patient.

There were 2 crashes caused by falling asleep on the way home by bike.

Although a variety of methods were adopted to intervene, none of them worked.

Later, I gradually appeared 1.
Sleep paralysis, feeling limbs unable to move when I fell asleep, and struggling hard after being awake, but still unable to move for several minutes; 2.
Sleep hallucinations, when I was half asleep and half awake, it seemed that I heard someone talking to him, and I saw more This is a horrible and weird picture; 3 cataplexes, the patient does not dare to laugh, a laugh, especially a big laugh, will cause weakness, and will kneel to the ground in severe cases.

His academic performance dropped sharply for 2 years after the onset of illness and he was repetitive for 1 year.
He was unable to attend classes normally, was depressed, and lost his temper.

At the outpatient clinic of the Institute of Mental Health of Peking University, there were no positive signs on the physical examination.
Based on the patient's symptoms and previous examination results, he was diagnosed as "narcolepsy".

Clomipramine 75mg/d was given for 6 weeks, but there was no obvious effect.

Switch to methyl methacrylate 5mg, 3 times/d, the narcolepsy symptoms disappeared, the mood is stable, he can go to class normally, and his academic performance is significantly improved.

The dose was gradually reduced to 2.
5mg, 2 times/d, and it has been maintained so far [1].

Narcolepsy is a type of sleep disorder, manifested as pathological sleep (also called excessive daytime sleepiness) or a group of clinical syndromes accompanied by cataplexy, sleep hallucinations, and sleep paralysis.
It is mainly characterized by multiple sleep disorders , The core symptom is sudden and irresistible sleep attacks during the day. The third edition of the International Classification of Sleep Disorders issued by the American Academy of Sleep Medicine (AASM) divides narcolepsy into 2 types, including narcolepsy 1 (narcolepsy with cataplexy) and narcolepsy 2 (Narcolepsy is not accompanied by cataplexy).

It is estimated that the prevalence of narcolepsy type 1 is 25-50 per 100,000, and the incidence rate is 0.
74 per 100,000 per year [2-4]; the prevalence of narcolepsy type 2 is still uncertain, and currently lacks Sufficient research makes diagnosis difficult, but it is estimated that 20-34 people per 100,000 people suffer from this disease [5-6].

There is no difference in incidence between men and women.
Narcolepsy usually starts at 10+ years old, and occasionally can occur earlier than 5 years old or more than 40 years old [7].

The clinical manifestations of narcolepsy can be defined as a sleep-wake disorder, in which sleep factors invade awake factors, and awake factors invade sleep.

The result is pathological sleep during the day, accompanied by various degrees of cataplexy, sleep hallucinations, and paralysis.

All patients will have excessive daytime sleepiness, but only 1/3 of patients will have these symptoms.
Therefore, when patients only have excessive daytime sleepiness, the diagnosis should also be considered.

These symptoms usually worsen during the first few months to several years and last for life [8].

1.
Excessive daytime sleepiness (EDS) is the main symptom of narcolepsy.
It is mainly manifested as an uncontrollable sleep attack that occurs suddenly during the day, which can occur at rest or during exercise.
The duration varies from a few minutes to several hours.

Unlike normal people’s fatigue, it cannot be relieved by adequate sleep.

The Epworth Sleepiness Scale score of patients with narcolepsy is usually greater than 15.

2.
Cataplexy is a characteristic symptom of this disease.
It is manifested as a sudden loss of tension in the voluntary muscles of the body during awakening and falls.
It lasts for a few seconds to a few minutes.
It is often induced by strong emotional changes, including laughter, Nervousness, excitement, etc.
[9].
In 60% of narcolepsy patients, decomposing paralysis occurs within three to five years after the onset of sleepiness [7]. 3.
Sleep hallucinations.
This symptom is not common.
It occurs during the transition from sleep to awakening or at the beginning of sleep.
At this time, there may be dream-like hallucinations.

4.
Sleep paralysis, mainly manifested as limb inability, inability to speak, and clear consciousness during the attack.
The patient often has a sense of suffocation.
The suffocation may be related to a slight decrease in tidal volume during sleep paralysis.
This attack can be terminated by slight stimulation.

Diagnosis criteria Diagnosis of type 1 narcolepsy (narcolepsy with cataplexy) needs to meet the following two requirements at the same time (Figure 1): 1.
Irregular sleepiness occurs every day, lasting ≥3 months.

2.
One or both of the following: MSLT test average sleep latency ≤ 8 minutes, 2 or more sleep-initiated rapid eye movement sleep; rapid eye movement sleep that occurs within 15 minutes of sleep start can replace the MSLT test REM sleep initiated by 1 sleep.

Cerebrospinal fluid Hcrt-1/Orexin-1 level ≤110pg/mL or lower than 1/3 of the average value of normal controls.

Diagnosing type 2 narcolepsy (narcolepsy without cataplexy) needs to meet the following five requirements at the same time (Figure 2): 1.
Intractable drowsiness occurs every day, lasting ≥3; 2.
MSLT test average sleep latency ≤8 minutes, REM sleep initiated by sleep 2 or more times; REM sleep that occurred within 15 minutes of sleep start can replace REM sleep initiated by 1 sleep in the MSLT test; 3.
No cataplexy; 4.
No cerebrospinal fluid Hcrt-1/Orexin-1 was measured, or the measured cerebrospinal fluid Hcrt-1/Orexin-1 level>110 pg/ml, or more than 1 of the average value of normal controls tested by the same standard /3; 5.
Somnolence and/or MSLT test results cannot be better explained by other reasons, such as lack of sleep, obstructive sleep apnea (OSA), delayed sleep phase, use of drugs or drugs. Figure 1: Diagnostic criteria for type 1 narcolepsy (International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014) Figure 2: Diagnostic criteria for type 2 narcolepsy (International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014) Non-pharmacological treatments The following non-pharmacological interventions may be effective for excessive narcolepsy, but most patients still need drugs to reduce sleepiness and cataplexy.

1.
Nap and regular sleep.
Generally speaking, sleeping for 20 minutes at 1-2 o'clock in the afternoon is usually very helpful.

Because it can improve the awakening of 1-3h and reduce the demand for central stimulants in the afternoon [10].

2.
Avoid using drugs, such as benzodiazepines, opioids, antipsychotics and alcohol.

3.
Social and psychological support.

4.
Treatment of other concurrent diseases: such as sleep apnea syndrome, cardiovascular disease, diabetes, etc.

Drug treatment mainly includes traditional central stimulants and new central stimulants.
Other drugs include antidepressants, including selective 5-HT reuptake inhibitors (SSRI) and/or adrenaline reuptake inhibitors (SNRI), etc.
.

See Figure 3 for drugs to improve narcolepsy targeting specific neurochemical systems, and Figure 4 for a summary of drug treatments.

Figure 3: Drugs for improving narcolepsy target specific neurochemical systems Figure 4: Summary of drug treatment for narcolepsy: For patients with severe sleepiness that require medical treatment, it is recommended that modafinil is the first choice instead of vinegar Methyl ester or amphetamine (grade 2 C); when giving central nervous system stimulants, clinicians should remind patients of the risk of serious cardiovascular side effects.
It is recommended that patients should monitor their heart rate and blood pressure at each visit.
Because hypertension is common in patients with narcolepsy, and most drugs will increase blood pressure; it is recommended to use drugs that inhibit REM sleep (such as venlafaxine, fluoxetine, amoxetine, etc.
) as first-line drugs To treat patients with drowsiness and cataplexy, it is best to use a sustained-release dosage form; for patients whose drowsiness or cataplexy cannot be improved by one of the drugs, it is recommended to add sodium oxybate (grade 2B) for treatment [11]. Reference materials: [1] Zhao Zhenhai, Cheng Xiang, Duan Hongqiu Zhao Zhenhai, Cheng Xiang, Duan Hongqiu A case of narcolepsy tetralogy "Chinese Journal of Psychiatry" 2004, 37 (03) 10.
3760/j: issn: 1006-7884.
2004.
03.
023[ 2] Longstreth WT Jr, Koepsell TD, Ton TG, et al.
The epidemiology of narcolepsy.
Sleep 2007; 30: 13.
[3] Nohynek H, Jokinen J, Partinen M, et al.
AS03 adjuvanted AH1N1 vaccine associated with an abrupt increase in the incidence of childhood narcolepsy in Finland.
PLoS One 2012;7:e33536.
[4]Partinen M, Saarenpää-HeikkiläO, Ilveskoski I, et al.
Increased incidence and clinical picture of childhood narcolepsy following the 2009 H1N1 pandemic vaccination campaign in Finland.
PLoS One 2012; 7: e33723.
[5] Silber MH, Krahn LE, Olson EJ, Pankratz VS.
The epidemiology of narcolepsy in Olmsted County, Minnesota: a population-based study.
Sleep 2002; 25: 197.
[6 ]Shin YK, Yoon IY, Han EK, et al.
Prevalence of narcolepsy-cataplexy in Korean adolescents.
Acta Neurol Scand 2008; 117:273.
[7] Ohayon MM, Priest RG, Zulley J, et al.
Prevalence of narcolepsy symptomatology and diagnosis in the European general population.
Neurology 2002; 58: 1826.
[8] Okun ML, Lin L, Pelin Z, et al.
Clinical aspects of narcolepsy-cataplexy across ethnic groups.
Sleep 2002; 25: 27.
[9] Overeem S, van Nues SJ, van der Zande WL, et al.
The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin -1 deficiency.
Sleep Med 2011;12:12.
[10]Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16:444.
[11]Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11, 2020.
https: //www.
uptodate.
com/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkPrevalence of narcolepsy symptomatology and diagnosis in the European general population.
Neurology 2002; 58: 1826.
[8] Okun ML, Lin L, Pelin Z, et al.
Clinical aspects of narcolepsy-cataplexy across ethnic groups.
Sleep 2002; 25: 27 .
[9]Overeem S, van Nues SJ, van der Zande WL, et al.
The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12:12.
[10] Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11, 2020.
https: //www.
uptodate.
com/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkPrevalence of narcolepsy symptomatology and diagnosis in the European general population.
Neurology 2002; 58: 1826.
[8] Okun ML, Lin L, Pelin Z, et al.
Clinical aspects of narcolepsy-cataplexy across ethnic groups.
Sleep 2002; 25: 27 .
[9]Overeem S, van Nues SJ, van der Zande WL, et al.
The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12:12.
[10] Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11, 2020.
https: //www.
uptodate.
com/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_link[8] Okun ML, Lin L, Pelin Z, et al.
Clinical aspects of narcolepsy-cataplexy across ethnic groups.
Sleep 2002; 25: 27.
[9] Overeem S, van Nues SJ, van der Zande WL, et al.
The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12: 12.
[10]Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11,2020.
-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_link[8] Okun ML, Lin L, Pelin Z, et al.
Clinical aspects of narcolepsy-cataplexy across ethnic groups.
Sleep 2002; 25: 27.
[9] Overeem S, van Nues SJ, van der Zande WL, et al.
The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12: 12.
[10]Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11,2020.
-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkThe clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12: 12.
[10]Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11,2020.
-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkThe clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency.
Sleep Med 2011; 12: 12.
[10]Mullington J, Broughton R.
Scheduled naps in the management of daytime sleepiness in narcolepsy-cataplexy.
Sleep 1993; 16: 444.
[11] Thomas E Scammell, MD.
Clinical features and diagnosis of narcolepsy in adults.
UpTo Date.
Aug 11,2020.
-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkcom/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_linkcom/contents/clinical-features-and-diagnosis-of-narcolepsy-in-adults?topicRef=7681&source=see_link