A 23-year-old man comes to the office with symptoms of daytime sleepiness. The patient initially attributed his sleepiness to the frequent travel required by his job, but he grew more concerned when he fell asleep in the middle of a business meeting last week. At night, the patient initially falls asleep quickly, but then wakes up frequently throughout the night. He couldn't move when he first woke up one morning this week, and he has recently begun to hear "demonic" voices at night as he lies in bed. The patient has a history of remitted major depressive disorder. The patient's brother has schizophrenia.
Vital signs and physical examination are within normal limits.
A daytime, multiple sleep latency test shows a short sleep latency of 4 minutes (normal 10 minutes).
Which of the following is the most appropriate therapy?

Question

A 23-year-old man comes to the office with symptoms of daytime sleepiness.  The patient initially attributed his sleepiness to the frequent travel required by his job, but he grew more concerned when he fell asleep in the middle of a business meeting last week.  At night, the patient initially falls asleep quickly, but then wakes up frequently throughout the night.  He couldn't move when he first woke up one morning this week, and he has recently begun to hear "demonic" voices at night as he lies in bed.  The patient has a history of remitted major depressive disorder.  The patient's brother has schizophrenia.
Vital signs and physical examination are within normal limits.
A daytime, multiple sleep latency test shows a short sleep latency of 4 minutes (normal >10 minutes).
Which of the following is the most appropriate therapy?

Quizplus · Accepted Answer

11ec193a_98e3_66c5_853d_f333c1983ca9_MD0002_00 This patient's daytime somnolence, sleep paralysis, hypnagogic hallucinations (ie, occurring during sleep onset), and disrupted nocturnal sleep are consistent with narcolepsy. Other common features include cataplexy (ie, sudden loss of muscle tone associated with laughing or intense emotions) and low cerebrospinal fluid hypocretin-1 (also known as orexin-A) levels. Narcolepsy usually presents around age 20. Patients with suspected narcolepsy should undergo an overnight polysomnogram followed, the next day, by a multiple sleep latency test (MSLT), in which patients are given several opportunities to nap and time to sleep onset (sleep latency) is measured. Patients with narcolepsy demonstrate shorter sleep latency on the MSLT than normal controls and have evidence of rapid eye movement (REM) shortly after falling asleep. First-line treatment for daytime somnolence in narcolepsy is the novel stimulant modafinil. It is generally preferred over methylphenidate or amphetamines due to its favorable side effect/safety profile. If cataplexy causes functional impairment, REM sleep-suppressing agents (eg, venlafaxine, fluoxetine, atomoxetine) are considered first-line pharmacotherapy; if cataplexy symptoms are initially resistant to treatment, sodium oxybate may be effective as a second-line agent. (Choice A) Although obstructive sleep apnea is a common cause of excessive daytime somnolence treated with continuous positive airway pressure, the presence of hypnagogic hallucinations and the lack of any history of snoring or apneic spells make narcolepsy a more likely diagnosis. (Choice B) Patients with narcolepsy actually have the same total sleep time during a 24-hour period as unaffected individuals and would not benefit from increased sleep time. Increasing sleep time is indicated when excessive daytime sleepiness is due to insufficient sleep. (Choice C) Melatonin is not indicated for the treatment of narcolepsy. (Choice E) This patient's report of hearing voices while falling asleep is consistent with hypnagogic hallucinations found in narcolepsy. Antipsychotics (eg, quetiapine) are not indicated for the treatment of hypnagogic hallucinations. Educational objective: Narcolepsy is characterized by excessive daytime somnolence, cataplexy, sleep paralysis, and low cerebrospinal fluid hypocretin-1 levels. The diagnosis is confirmed with a multiple sleep latency test. First-line treatment for daytime somnolence is modafinil. __________ References: Narcolepsy: clinical features, co-morbidities & treatment. (http://www.ncbi.nlm.nih.gov/pubmed/20308759) Narcolepsy. (http://www.ncbi.nlm.nih.gov/pubmed/28179647)

A 23-Year-Old Man Comes to the Office with Symptoms of Daytime