SLEEP

INSOMNIA is the lack of quality sleep. The cause is usually environmental (stress, medications, crying baby, night shifts). The 1st line treatment is  with lifestyle modifications that cultivate healthy sleep hygiene. If the cause is stress, then therapy is helpful. Sleep medications, like Melatonin / Ramelteon or the ZZZ drugs are often warranted. 

PARASOMNIAS - disorders during sleep. Two broad categories.

Non-REM Parasomnias are treated with Benzos (which decreases the duration of N3)

• Bed wetting (nocturnal diuresis)

• Sleepwalking

• Sleep terrors - the patient (usually a kid) wakes up in the middle of the night screaming. They won’t remember it in the morning. 

REM Parasomnias are harder to treat. 

• • Nightmare disorder - lots of nightmares. Prazosin is helpful with comorbid PTSD, but the non-PTSD cases are treated with therapy.

  • Sleep Paralysis

  • Hypnagogic / Hypnopompic Hallucinations

NARCOLEPSY is the inability to regulate sleep. 

Sleep regulation? What does that mean?

The sleep cycle is a highly regulated process, akin to a well-oiled machine. Instead of the gradual descent from N1 to N2 to N3 to REM over 90 minutes, the sleep cycle pattern in Narcolepsy is out of order. That particular progression from N1 to REM is crucial to restorative effects of sleep. Patients with Narcolepsy often jump into REM very quickly, which is termed a decrease in REM Latency. 

What are the symptoms of Narcolepsy?

(1) Sleepy during the day. Although patients get 8 to 10 hours of sleep in a day, they feel exhausted all the time. They’ll fall asleep during the middle of a conversation.

(2) Sleep Paralysis. The patient’s brain can’t control REM. If the patient is still in REM when they wake up, then the patient will wake up in a state of paralysis (because muscle tone is zero during REM). This is pretty scary. 

(3) Hypnagogic / Hypnopompic Hallucinations. This is also due to the dreams of the REM stage overlapping with  awake time. 

(4) Cataplexy. Strong emotions (laughter, fury) trigger a loss of muscle tone, and the patient falls to the ground. They remain awake the whole time. It wears off after a few minutes. These patients shouldn’t drive.

Diagnosis? 

Diagnosis is made by a sleep specialist, who records a video EEG while the patient sleeps. 

Treatment?

There is no cure. During the day, the patient should take Stimulants such as Amphetamines or Modafinil. At night, the patient should take Sodium Oxybate before falling asleep. This is essentially GHB, the date rape drug. It works really well at restoring both the quantity and quality of their sleep, in addition to helping with Cataplexy.