Why am I sleepy all the time?

Often, when we see people falling asleep—standing in a line or attending a meeting or even working at their desks—we laugh at them. Anybody rarely takes it seriously. But if this is habitual for the person, s/he may be suffering from narcolepsy.

What is narcolepsy?

Narcolepsy is a term for a disorder of the part of our brain that controls sleep and wakefulness. As a result, sleep or parts of sleep intrude into periods when a person is awake, often at inappropriate times. Typically, individuals with narcolepsy get sleep attacks anytime during the day. They also feel sleepy all the time and suffer from tiredness [like they haven’t slept enough] no matter how much they sleep. If severe, the condition seriously affects a person’s quality of life. Although there is no cure for it, the good news is that it can be effectively managed with proper treatment.

What causes narcolepsy?

Although the exact cause is not known, it is certain that narcolepsy is not caused by psychiatric or psychological problems. Recent studies have found low levels of a brain chemical called hypocretin in people with narcolepsy. Some researchers have suggested that a problem with the gene responsible for making hypocretin, combined with other factors in a person’s life may cause the disorder.

Probable causes include:

• Autoimmune mechanisms
• Deficiency of hypocretin/Orexin
• HLA subtypes HLA-DQBI*0602 linked
• Other factors like infections/toxin stress/ hormonal/ dietary.

Symptoms of narcolepsy

The four cardinal features of narcolepsy are:

1. Excessive daytime sleepiness
2. Cataplexy
3. Sleep paralysis
4. Hypnagogic hallucinations.

These symptoms are now thought to include disrupted or non-refreshing sleep.

In most cases, excessive daytime sleepiness is the most bothersome symptom.

Excessive daytime sleepiness

This is usually the first symptom of narcolepsy that shows up. Narcoleptics report feeling continually sleepy and tired all the time, seemingly without any reason. The drowsiness or grogginess is felt at times when we are usually fully awake and alert or in situation where alertness is required, for instance while driving.

Sleep specialists access excessive daytime sleepiness using various scales such as the Epworth Sleepiness Scale. On the scale, 0= no chance of dozing, 1= slight chance of dozing, 2= moderate chance of dozing and 3= high chance of dozing.

Patients are asked to rate the everyday situations in their lives such as: sitting and reading, watching TV, sitting inactive in a public place [a theater or a meeting], as a passenger in a car for an hour without a break, lying down to rest in the afternoon when circumstances permit, sitting and talking to someone, sitting quietly after lunch without alcohol, in a car, while stuck in traffic. A score of more than 10 on this scale is worrisome.

Cataplexy

It is a condition in which strong emotions, laughter, anger, fear or surprise cause a person to suddenly feel weak. The mild form is characterised by a brief feeling of weakness, while the severe form is characterised by a complete physical collapse, resulting in fall and, sometimes, even injury.

Sleep paralysis

Sleep paralysis too is a brief loss of muscle strength. However, it occurs when a person is either falling asleep or waking up. The person may be somewhat aware of his or her surroundings, but is unable to move or speak—feels powerless and paralysed.

Hypnagogic hallucinations

These are vivid dreams—complete with disturbing images and sounds—that occur when a person is drowsy. These hallucinations may be frightening because the person is partly awake but has no control over the events.

How is narcolepsy diagnosed?

The first step in diagnosing this disorder would be an evaluation by your physician to eliminate other medical illness as the cause. The next step is usually a visit to a physician specialising in sleep disorders.

At a sleep disorders centre, the specialist will thoroughly review your medical history and give you a complete physical examination. If the specialist suspects narcolepsy, s/he will ask you to undergo the following steps:

1. Maintaining a sleep log over a period of two weeks.
2. Review of the antidepressants such as SSRI, TCAs and other medicines you have been taking
3. Polysomnogram [sleep study].
4. Multiple sleep latency test [MSLT] to confirm the diagnosis of narcolepsy.

Cerebrospinal fluid levels of ‘hyprocretin’ are also used to diagnose narcolepsy.

How is narcolepsy treated?

Narcolepsy cannot be cured but its symptoms can usually be controlled or improved. If you are diagnosed with narcolepsy your treatment plan would likely to have a multidisciplinary approach.

1. Medication
2. Behaviour modification
3. Environment management

Medications

Prescription medications effectively help control excessive daytime sleepiness, cataplexy,hallucinations, and sleep disruptions. These include:

1. Stimulants like methylphenidate and amphetamines
2. Wakefulness-promoting agents like modafinil
3. Medications to suppress the cataplexy sleep paralysis and hypagogic hallucinations— tricyclic anti-depressants.

Lifestyle modifications

• Following a regular sleep/wake schedule.
• Taking regular short naps.
• Following your healthcare professional’s instructions regarding medications.

Managing your environment

• Keep family, friends, co-workers, employers and other individuals with whom you have frequent contact informed about your condiion
• Make sure you plan ahead and stay prepared for the potential impact of your condition on family and work
• Seek help from the community and support groups like narcolepsy support groups

With the help of some modifications, medicines and positive attitude, narcoleptics can learn to effectively manage their situation.