Behavioral Sleep Medicine Services for Hypersomnia Disorders: A Survey Study

Effectiveness of an intervention program on physical activity in children with narcolepsy type 1

OBJECTIVES

Physical activity (PA) is recommended as part of the management of narcolepsy type 1 (NT1). This study aimed at 1) characterizing PA in children and adolescents treated for NT1 using objective and subjective measurements, 2) evaluating how PA is associated with NT1 symptoms and comorbidities, and 3) evaluating the effects of an Adapted Physical Activity (APA) program on PA and clinical characteristics.

PATIENTS/METHODS

Patients with NT1 from the National Reference Center of Narcolepsy (Lyon, France) were consecutively included in an APA intervention protocol. Narcolepsy symptoms and comorbidities were collected using standardized questionnaires and sustained attention was evaluated using the Bron-Lyon Attention Stability Test before and after the four-week APA intervention. PA was measured objectively using actigraphy throughout the study.

RESULTS

Twenty-seven NT1 patients were included (median age 14.7 years [8.3-18.4], cataplexy 88.9%, obesity 37.0%). At baseline, 52.4% of the patients had satisfactory PA levels according to international recommendations. Patients with leisure-time PA (LTPA) showed higher quality of life than patients without. 45% of the patients increased PA during the intervention compared to baseline. These responsive patients had more depressive feelings and tended to have lower objective PA than non-responsive patients at baseline. No significant correlation was found between PA levels before and during the intervention and other clinical data.

CONCLUSIONS

Most children with NT1 showed satisfying PA levels despite their daytime sleepiness. LTPA engagement was associated with higher quality of life. An APA intervention could be effective in children with narcolepsy, especially for those with depressive feelings.

Prevalence and Course of Idiopathic Hypersomnia in the Wisconsin Sleep Cohort Study

BACKGROUND AND OBJECTIVES

Idiopathic hypersomnia (IH) is a CNS disorder of hypersomnolence of unknown etiology. Due to the requirement for objective sleep testing to diagnose the disorder, there are currently no population-based estimates of the prevalence of IH nor data regarding the longitudinal course of IH in naturalistic settings.

METHODS

Subjective and objective data from the Wisconsin Sleep Cohort study were used to identify cases with probable IH from participants with polysomnography and multiple sleep latency test data. Demographic, polysomnographic, and symptom-level data were compared between those with and without IH. Longitudinal trajectories of daytime sleepiness among those with IH were assessed to evaluate symptom persistence or remission over time.

RESULTS

From 792 cohort study participants with available polysomnography and multiple sleep latency test data, 12 cases with probable IH were identified resulting in an estimated prevalence of IH of 1.5% (95% CI 0.7-2.5, p < 0.0001). Consistent with inclusion/exclusion criteria, cases with IH had more severe sleepiness and sleep propensity, despite similar or longer sleep times. Longitudinal data (spanning 12.1 ± 4.3 years) demonstrated a chronic course of sleepiness for most of the cases with IH, though pathologic somnolence remitted in roughly 40% of cases.

DISCUSSION

These results demonstrate IH is more common in the working population than generally assumed with a prevalence on par with other common neurologic and psychiatric conditions. Further efforts to identify and diagnose those impaired by unexplained daytime somnolence may help clarify the causes of IH and the mechanisms underlying symptomatic remission.

The Role of Sodium Oxybate in Idiopathic Hypersomnia: A Case Report Showing Improvement of Excessive Daytime Sleepiness and Reduced Symptoms

Our aim is to report the clinical profile and outcome of patients diagnosed with idiopathic hypersomnia (IH). Idiopathic hypersomnolence is a complex, debilitating, and uncommon sleep disorder manifested mainly by chronic excessive daytime sleepiness (EDS). This paper reports on the treatment of a patient with idiopathic hypersomnia who was treated with low sodium oxybate (LXB) due to a lack of response to the first-line drug modafinil. This patient, who presented with worsening excessive daytime sleepiness, sleep drunkenness, and sleep disturbances, was diagnosed with idiopathic hypersomnia by overnight polysomnography (PSG) and a multiple sleep latency test (MSLT). Stimulant agent modafinil was prescribed along with sleep hygiene education. Her symptoms did not respond to modafinil, and she was switched to a recently approved newer medication, i.e., low sodium oxybate.

Impairment in Functioning and Quality of Life in Patients with Idiopathic Hypersomnia: The Real World Idiopathic Hypersomnia Outcomes Study (ARISE)

Purpose

Idiopathic hypersomnia is a debilitating neurologic sleep disorder characterized by excessive daytime sleepiness, sleep inertia, and prolonged sleep. Its impact on patients' quality of life and daily functioning has not been fully elucidated. The Real World Idiopathic Hypersomnia Outcomes Study (ARISE) evaluated the daily functioning, relationships, cognition, emotional well-being, and productivity/employment of participants with idiopathic hypersomnia.

Patients and Methods

ARISE was a US-based virtual cross-sectional survey comprising multiple patient-reported outcome measures (Functional Outcomes of Sleep Questionnaire, short version [FOSQ-10], Quality of Life in Neurological Disorders [Neuro-QoL] Social Roles and Stigma domains, British Columbia Cognitive Complaints Inventory [BC-CCI], Patient Health Questionnaire [PHQ-9], and the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem [WPAI:SHP]). Participants were adults 21-65 years of age with idiopathic hypersomnia. Data were analyzed for all participants and for subgroups with/without long sleep time (LST; self-reported sleep ≥11 hours in 24 hours).

Results

Of 75 participants enrolled, most were female (81.3%) and the mean (SD) age was 34.1 (10.7) years. Participants' scores on the FOSQ-10 (mean [SD] score: 10.7 [2.8]) and the Neuro-QoL Social Roles (43.4 [4.2]) and Stigma (57.3 [5.9]) domains reflected impairments in daily functioning and quality of life. More than half of participants reported moderate to severe cognitive complaints (BC-CCI; 62.7%) and moderate to severe depressive symptoms (PHQ-9; 66.7%). Scores on the WPAI:SHP showed substantial impairments in absenteeism, presenteeism, overall work productivity, and overall regular daily activity (mean percent [SD]: 12.3 [23.6], 47.6 [22.7], 51.4 [24.7], and 64.0 [21.9], respectively). These considerable impairments were found in participants with and without LST.

Conclusion

ARISE participants with idiopathic hypersomnia demonstrated poor quality of life and impaired functioning across multiple symptom domains.

Sleep Disorders in Childhood

OBJECTIVE

This article provides a comprehensive review of pediatric sleep disorders including the clinical features, diagnosis, and treatment of sleep-disordered breathing, insomnia, parasomnias, restless sleep disorder, restless legs syndrome, narcolepsy in childhood, and Kleine-Levin syndrome.

LATEST DEVELOPMENTS

Our understanding of pediatric sleep pathophysiology continues to evolve, and diagnostic and treatment modalities have expanded. A low-sodium oxybate formulation was approved in July 2020 in the United States to treat cataplexy and excessive daytime sleepiness in patients 7 years old and older with narcolepsy. A validated pediatric hypersomnolence survey for pediatric narcolepsy and idiopathic hypersomnia with high sensitivity, specificity, and interrater reliability is now available.

ESSENTIAL POINTS

The clinical presentation, diagnostics, and treatment of children with sleep disorders differ from those of adults. Untreated sleep disorders in childhood can lead to adverse physical and psychological consequences in adults. Correctly diagnosing and treating sleep disorders in youth can prevent a significant burden of disease in adulthood.

Update on the treatment of idiopathic hypersomnia: Progress, challenges, and expert opinion

Idiopathic hypersomnia is a central hypersomnolence disorder of unknown origin characterized by excessive daytime sleepiness despite normal or long sleep time, and frequent severe sleep inertia. Management strategies have been largely derived from expert consensus, due to a lack of disease-specific assessments and reliance on case series and rare randomized controlled studies. Guidelines recommend treatment with off-label medications. Modafinil, which was approved for idiopathic hypersomnia until 2011 in Europe, is the most commonly used treatment and improved sleepiness in two recent randomized placebo-controlled trials. In 2021, low-sodium oxybate (LXB) was approved in the United States for idiopathic hypersomnia. In a placebo-controlled, double-blind, randomized withdrawal study, LXB reduced daytime sleepiness and sleep inertia, and improved daily functioning. Here, treatment options are reviewed considering the authors' professional experience, current guidelines, and the latest research developments. The choice of pharmacotherapy should be guided by symptom profile, age, comorbidities (eg, depressive symptoms, cardiovascular problems), and concomitant medications (eg, oral contraceptives). Nonpharmacologic approaches have a role in management. An instrument (idiopathic hypersomnia severity scale) has been validated in idiopathic hypersomnia specifically, opening a path to better assessment of symptoms, impact, and response to treatment. Continued research on idiopathic hypersomnia is needed to support treatment algorithms.

Approach to a sleepy child: Diagnosis and treatment of excessive daytime sleepiness in children and adolescents

The aim of this review is to give updated information to pediatric neurologists on the correct diagnostic approach and treatment of excessive daytime sleepiness (EDS) in children and adolescents. Due to the change in the society habits, EDS is becoming an emerging problem for the health system. At the present there are few articles specifically devoted to the evaluation of EDS. EDS is often reported in several manuscripts as a side effect of other sleep disorders (obstructive sleep apnea, circadian disorders, etc.) or of the use of drugs or of the substance abuse or as a consequence of bad sleep habits and poor sleep hygiene. EDS, especially in children, may manifest with paradoxical symptoms like hyperactivity, inattention, and impulsiveness. However, common sign of EDS in children are the propensity to sleep longer than usual, the difficulty waking up in the morning, and falling asleep frequently during the day in monotonous situation. The diagnosis should include subjective (sleep diaries, questionnaires) and objective (polysomnography, multiple sleep latency test, etc.) instruments to avoid misdiagnosis. Narcolepsy is the most studied central disorder of hypersomnolence, and it is a predominantly pediatric disease with a peak age of onset in prepuberty but the diagnosis is often delayed especially in mild forms. The early and correct treatment of narcolepsy and of other form of EDS is extremely important since late and inappropriate treatments can affect the psychosocial development of the children and adolescents.

Symptom Severity and Treatment Satisfaction in Patients with Idiopathic Hypersomnia: The Real World Idiopathic Hypersomnia Outcomes Study (ARISE)

Objective

Idiopathic hypersomnia is a debilitating sleep disorder characterized by excessive daytime sleepiness, sleep inertia, and prolonged sleep duration. The patient burden of idiopathic hypersomnia is poorly understood. The Real World Idiopathic Hypersomnia Outcomes Study (ARISE) evaluated symptoms and treatment effectiveness/satisfaction in participants with idiopathic hypersomnia.

Methods

ARISE was a United States-based virtual cross-sectional survey. Participants were adults 21-65 years of age with idiopathic hypersomnia recruited from social media, the Hypersomnia Foundation website, and a patient panel. Self-assessments included the Epworth Sleepiness Scale (ESS), Idiopathic Hypersomnia Severity Scale (IHSS), Treatment Satisfaction Questionnaire for Medication, version II (TSQM-vII), and additional treatment questions. Data were analyzed for all participants and for subgroups with/without long sleep time (LST; ≥11 hours in 24 hours).

Results

Of 75 participants enrolled, most were female (81.3%). The mean (SD) age was 34.1 (10.7) years and 49% had LST. Most participants took off-label prescription medications (89.3%) and/or used other measures (93.3%) to manage their symptoms. The mean (SD) ESS score was 14.5 (3.5) and the mean IHSS score was 35.2 (7.6). Treatment satisfaction was low (mean [SD] TSQM-vII score: overall, 61.9 [21.2]; with LST, 57.9 [21.4]; without LST, 66.7 [20.3]), primarily driven by dissatisfaction with treatment effectiveness. The most common classes of prescription medications used were stimulants (61.3%), wake-promoting agents (28.0%), and antidepressants (18.7%); non-prescription measures used to manage symptoms included caffeine (73.3%), planned naps (34.7%), and individual accommodations (32.0%).

Conclusion

Overall, participants with idiopathic hypersomnia, with or without LST, had substantial symptom burden despite most of the study population taking off-label medications and using nonprescription measures to manage symptoms.

Narcolepsy Treatment: Voices of Adolescents

INTRODUCTION

Narcolepsy, characterized by excessive daytime sleepiness, is a debilitating lifelong sleep disorder for which there is no cure. Current pharmacological and nonpharmacological treatments directed toward symptom management may be suboptimal. This qualitative study explores the perspective of adolescents on therapeutic interventions for narcolepsy.

METHODS

Semi-structured interviews with adolescents with narcolepsy were conducted from May to August 2019 at The Hospital for Sick Children in Toronto, Canada. Qualitative thematic analysis was utilized to generate themes emerging from the data.

RESULTS

Eighteen adolescents with narcolepsy (age range = 10-17, mean age = 14.4 ± 2.0 years, 72% male) participated and 56% had cataplexy. Four prominent themes arose regarding therapeutic interventions for narcolepsy. Firstly, participants described that pharmacotherapy was moderately effective but did not fully relieve symptoms associated with narcolepsy. Secondly, while medications are the first line treatment for narcolepsy, many participants reported frustration regarding medication dependence and side effects. Thirdly, nonpharmacological strategies including scheduled sleep times and exercise were accepted and often employed. Lastly, adolescents desired more psychosocial support to address mental health sequelae of narcolepsy that were not fully managed by current treatment modalities.

CONCLUSIONS

Medications were perceived as moderately effective for managing narcolepsy but almost all participants expressed concerns with taking medications due to side effects. Adolescents valued the importance of more holistic care for their narcolepsy treatment such as psychosocial support and nonpharmacological modalities. Further anticipatory guidance regarding pharmacological side effect profiles and better integration with nonpharmacological modalities are needed to improve disease control in adolescent patients.

Idiopathic Hypersomnia and Depression, the Challenge for Clinicians and Researchers

The review deals with idiopathic hypersomnia, focusing mostly on the research findings about the presence, onset and severity of excessive daytime sleepiness and depressive symptoms in patients with idiopathic hypersomnia.

Treatment and care delivery in pediatric narcolepsy: a survey of parents, youth, and sleep physicians

STUDY OBJECTIVES

To describe the most commonly used treatments in pediatric narcolepsy and their perceived effectiveness, as well as to elicit key stakeholder perspectives on the most optimal manner in which care ought to be delivered to youth with narcolepsy.

METHODS

A cross-sectional survey of youth with narcolepsy, parents, and sleep physicians.

RESULTS

Complete survey results were available for 35 youth with narcolepsy, 116 parents, and 30 sleep physicians. Overall there was general agreement among family and physicians regarding most effective treatments, including both pharmacologic (stimulants, sodium oxybate, and modafinil/armodafinil) and nonpharmacologic (sleep schedule, exercise, diet) approaches. There was a stronger interested in cannabidiol oil (CBD) from families compared to physicians. Both families and physicians also endorsed a need for multispecialty care, ideally delivered in a same day setting and including specialists in mental health, social work, and nutrition. Quality measures were felt to be important but are not currently tracked by most sleep physicians. Qualitative responses highlight the value families place on providers who listen well and remain open-minded.

CONCLUSIONS

Our results suggest strong support by key stakeholders for an interdisciplinary approach to care for youth with narcolepsy.

Perceived challenges in pediatric narcolepsy: a survey of parents, youth, and sleep physicians

STUDY OBJECTIVES

To clarify the most common and problematic symptoms, psychosocial challenges, and comorbidities among youth with narcolepsy based on input from key stakeholders.

METHODS

A nationwide cross-sectional survey of youth with narcolepsy, parents, and sleep physicians.

RESULTS

Overall, 116 parents, 35 youth, and 30 providers completed the entire survey. Symptoms that were rated as most common and problematic by both parents and youth were (in descending order) as follows: daytime sleepiness, disturbed nighttime sleep, mood challenges, cataplexy, sleep-related hallucinations, and sleep paralysis. Most of the 18 queried psychosocial concerns were identified as substantial challenges by both adults and youth, including difficulty focusing and memory, school, worry and anxiety, diet and nutrition, lack of motivation, mood problems, and relationship problems. In contrast, while physicians did recognize some of these challenges, they rated medication side effects and driver's license issues as relatively greater challenges.

CONCLUSIONS

These data highlight the high prevalence of psychosocial challenges, discordance between physician and family ratings of challenges, and a high rate of medical comorbidities in youth with narcolepsy and support the application of a biopsychosocial framework in the assessment and treatment of pediatric narcolepsy.

Developing a cognitive behavioral therapy for hypersomnia using telehealth: a feasibility study

STUDY OBJECTIVES

The purpose of this study was to evaluate the feasibility and acceptability of a novel cognitive behavioral therapy for hypersomnia (CBT-H) in people with central disorders of hypersomnolence and co-occurring depressive symptoms using a telehealth model for delivery and assessment.

METHODS

Thirty-five adults with narcolepsy or idiopathic hypersomnia received a 6-session CBT-H delivered individually or in small groups using videoconferencing. The clinical impact of CBT-H was evaluated using the Patient Health Questionnaire, Patient-Reported Outcomes Measurement Information System measures, Epworth Sleepiness Scale, and other patient-reported outcomes collected online at baseline and posttreatment. Feasibility and acceptability of the intervention and telehealth model was also evaluated using qualitative data collected from exit interviews conducted through videoconferencing.

RESULTS

Forty percent of the sample achieved a clinically significant baseline to posttreatment change in depressive symptoms (decrease in Patient Health Questionnaire ≥ 5), which is below the prespecified efficacy benchmark (50% of the sample). The prespecified benchmark for a minimal clinically important difference (Cohen's d > 0.5) on other psychosocial measures was met only on the Patient-Reported Outcomes Measurement Information System global self-efficacy (d = 0.62) in the total sample. Qualitative data revealed enthusiasm for the accessibility of telehealth delivery and the usefulness of several cognitive and behavioral modules but also revealed opportunities to refine the CBT-H program.

CONCLUSIONS

These findings indicate that this new CBT-H program can potentially reduce depressive symptoms and improve self-efficacy in people with central disorders of hypersomnolence. Furthermore, telehealth is a promising model for remote delivery and data collection to enhance participant accessibility and engagement.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Psychosocial Adjunctive Treatment for Hypersomnia (PATH); URL: https://clinicaltrials.gov/ct2/show/NCT03904238; Identifier: NCT03904238.

Who Is Seeking Help for Sleep? A Clinical Profile of Patients in a Sleep Psychology Clinic

BACKGROUND

The present study outlines a clinical profile of an ecologically valid population consulting for sleep difficulties at the Sleep Psychology Clinic of the Consultation service of the School of Psychology of Université Laval .

METHOD

Patients self-report to the sleep clinic. Following a phone screening interview, patients present to the clinic for a semi-structured clinical interview for sleep and psychopathology, which is conducted by psychologists and doctorate psychology students. A chart review of adult patients (56% female, M_age = 43.6 years) was conducted (between 2015 and 2018) to record diagnosed sleep, psychiatric, and medical conditions.

RESULTS

There was a high level of comorbidity with an average of 2.85 diagnoses (any diagnosis combined) per patient (SD = 1.76), with 27% of the patients having at least four diagnoses. Reviewing specific types of disorders, 58.5% of patients presented with at least one comorbid psychiatric disorder, 27.5% with one medical comorbidity, or 39.5% with another sleep disorder alongside their primary sleep concern. Insomnia was the main sleep disorder (76%). Anxiety (77.8%) and depression (53.8%) were the predominant psychiatric disorders, while fibromyalgia (10.9%), hypertension (10.9%), and head trauma (9.1%) were the main medical conditions. Of patients with five diagnoses and more, 77.8% were taking on average 3.2 different types of medications. The number of diagnoses predicted the use of prescribed hypnotics and the use of any type of medications.

CONCLUSION

This clinical profile emphasizes the reality of multiple morbidities, which may have implications for clinical decisions. Future research is required to evaluate transdiagnostic approaches for the sleep disorder patient with multiple morbidities.

Potential Maladaptive Sleep-Related Cognitions in Depression with Comorbid Hypersomnolence: An Exploratory Investigation

Objective/Background: Dysfunctional sleep-related cognitions (SRCs) have been demonstrated in both insomnia and depression, but have not been evaluated in patients experiencing depression with co-occurring hypersomnolence. Given the prominence of maladaptive thinking in depression with comorbid insomnia, dysfunctional SRCs may also exist in depressed persons experiencing hypersomnolence. Identifying potentially maladaptive SRCs may assist development of cognitive-behavioral strategies to alleviate hypersomnolence and its related impairment, particularly when comorbid with depression. Participants: Twenty-two unmedicated persons with major depressive disorder (MDD) with comorbid hypersomnolence (MDD+/HYP+), as well as age- and sex-matched persons with MDD without hypersomnolence (MDD+/HYP-) and healthy controls (HC). Methods: Participants completed the Dysfunctional Beliefs and Attitudes About Sleep-16-item (DBAS-16) and underwent overnight polysomnography. Groups were compared across clinical and sleep domains, as well as DBAS-16 global, subscale, and individual item scores. Additional analyses evaluated DBAS-16 components while controlling for depression severity. Results: Groups significantly differed across all collected sleep and mood metrics consistent with diagnostic classification. MDD+/HYP+ DBAS-16 global score was significantly elevated, relative to HC, and was comparable to MDD+/HYP-. A DBAS-16 global score significant group effect was maintained while controlling for depression symptom severity, however only individual DBAS-16 items related to quantity and quality of sleep demonstrated particular relevance to MDD+/HYP+ compared to other groups. Conclusions: Results suggest potentially maladaptive SRCs in MDD+/HYP+. Further efforts are needed to clarify whether these beliefs and attitudes about sleep in persons with hypersomnolence are in fact dysfunctional, as well as identify relevant content for development of a novel hypersomnolence-related SRC metric.

A practical guide to the pharmacological and behavioral therapy of Narcolepsy

Narcolepsy is a rare, chronic, and disabling central nervous system hypersomnia; two forms can be recognized: narcolepsy type 1 (NT1) and narcolepsy type 2 (NT2). Its etiology is still largely unknown, but studies have reported a strong association between NT1 and HLA, as well as a pathogenic association with the deficiency of cerebrospinal hypocretin-1. Thus, the most reliable pathogenic hypothesis is an autoimmune process destroying hypothalamic hypocretin-producing cells. A definitive cure for narcolepsy is not available to date, and although the research in the field is highly promising, up to now, current treatments have aimed to reduce the symptoms by means of different pharmacological approaches. Moreover, overall narcolepsy symptoms management can also benefit from non-pharmacological approaches such as cognitive behavioral therapies (CBTs) and psychosocial interventions to improve the patients' quality of life in both adult and pediatric-affected individuals as well as the well-being of their families. In this review, we summarize the available therapeutic options for narcolepsy, including the pharmacological, behavioral, and psychosocial interventions.

Quality of life and procrastination in post-H1N1 narcolepsy, sporadic narcolepsy and idiopathic hypersomnia, a Swedish cross-sectional study

OBJECTIVE/BACKGROUND

A cross-sectional study of health-related quality of life (HRQoL), procrastination and the relation to sleepiness, depression and fatigue in post-H1N1 narcolepsy type 1 (NT1), sporadic NT1 and idiopathic hypersomnia (IH).

PATIENTS/METHODS

Participants with NT1 and IH were enrolled from the Department of Neurology, Sahlgrenska University Hospital in Gothenburg (Sweden). All participants completed questionnaires about medication, employment, studies, transfer income, sleepiness, HRQoL, depression, fatigue and three questionnaires for procrastination.

RESULTS

Post-H1N1, sporadic NT1 and IH all scored higher than healthy controls on Epworth Sleepiness Scale (ESS), Patient Health Questionnaire (PHQ-9) and Fatigue Severity Scale (FSS), whereas EQ-5D-5L index and VAS was lower than for healthy individuals, but with no difference between groups. Post-H1N1 NT1 had a larger proportion of participants prescribed with sodium oxybate (44% vs. 9%, p = 0.003) and dexamphetamine (62% vs. 17%, p = 0.03) compared to sporadic NT1. The latter also in significantly higher doses than in sporadic NT1 (46 ± 12 vs. 25 ± 10 and 47.5 ± 21 mg, p < 0.0001). Post-H1N1 NT1 also had significantly higher scores on Pure Procrastination Scale (PPS), Irrational Procrastination Scale (IPS) and Susceptibility to Temptation Scale (STS), indicating a higher degree of procrastination. Multivariate analysis showed that depression, and to some extent fatigue, were predictors in NT1 for both HRQoL and procrastination.

CONCLUSIONS

The results show that health-related quality of life is impaired and tendency to procrastinate is higher in patients suffering from NT1 and both attributes can in part be explained by depressive symptoms. These findings highlight the impact of symptoms other than sleep and wakefulness regulation in patients with NT1.

Cannabidiol Partially Blocks the Excessive Sleepiness in Hypocretindeficient Rats: Preliminary Data

BACKGROUND

Excessive daytime sleepiness and cataplexy are among the symptoms of narcolepsy, a sleep disorder caused by the loss of hypocretin/orexin (HCRT/OX) neurons placed into the Hypothalamus (LH). Several treatments for managing narcolepsy include diverse drugs to induce alertness, such as antidepressants, amphetamine, or modafinil, etc. Recent evidence has shown that cannabidiol (CBD), a non-psychotropic derived from Cannabis sativa, shows positive therapeutic effects in neurodegenerative disorders, including Parkinson´s disease. Furthermore, CBD provokes alertness and enhances wake-related neurochemicals in laboratory animals. Thus, it is plausible to hypothesize that excessive somnolence observed in narcolepsy might be blocked by CBD.

OBJECTIVE

Here, we determined whether the systemic injection of CBD (5mg/kg, i.p.) would block the excessive sleepiness in a narcoleptic model.

METHODS

To test this idea, the neurotoxin hypocretin-2-saporin (HCRT2/SAP) was bilaterally injected into the LH of rats to eliminate HCRT leading to the establishment of narcoleptic-like behavior. Since excessive somnolence in HCRT2/SAP lesioned rats has been observed during the lights-off period, CBD was administered at the beginning of the dark phase.

RESULTS

Hourly analysis of sleep data showed that CBD blocked the sleepiness during the lights-off period across 7h post-injection in lesioned rats.

CONCLUSION

Taking together, these preliminary findings suggest that CBD might prevent sleepiness in narcolepsy.

Development and validation of the hypersomnia-specific beliefs scale

OBJECTIVE/BACKGROUND

Patients with Central hypersomnia, especially Narcolepsy type 1 and Idiopathic Hypersomnia (NT1 and IHS) often have psychological frustration in their daily lives. We aimed to develop the first scale of hypersomnia-specific beliefs (HSB).

PATIENTS/METHODS

We developed the HSB scale consisting of three factors ("aversion toward doze", "hypersensitivity toward others" reactions about my doze", and "sense of defeat caused by doze") with 12 items through interviews to 11 patients with NT1 and IHS. Validity and reliability of the HSB were evaluated cross-sectionally with 166 patients with NT1 and IHS and 375 controls. Simultaneously, scores of patient health questionnaire -2(PHQ-2), mini-Social Phobia Inventory (mini-SPIN), and Epworth Sleepiness Scale (ESS) were obtained.

RESULTS

This 3-factor model had enough fitness (χ2 = 60.25, df = 51, p = 0.18, TLI = 0.99, CFI = 0.99, RMSEA = 0.03), Cronbach's α coefficient being 0.90. The intraclass correlation coefficient was 0.76. Also, the area under the receiver operating characteristic curve (AUC = 0.88) confirmed good discrimination ability. A cut-off score of 38 resulted in a sensitivity of 90% and a specificity of 75%. Multiple linear regression analyses showed that these scales were independently associated with the HSB score; the PHQ-2 (β = 0.24, p = 0.002), mini-SPIN (β = 0.29, p < 0.001) and ESS (β = 0.15, p = 0.048).

CONCLUSIONS

Our data suggest that the HSB scale measured beliefs in NT1 and IHS patients with good validity, reliability, and discrimination ability. The HSB scale assesses the negative beliefs specific to patents with NT1 and IHS. This scale could be applied to the development of novel psychotherapeutic approach to patients with NT1 and IHS.

Topical Review: A Biopsychosocial Framework for Pediatric Narcolepsy and Idiopathic Hypersomnia

OBJECTIVE

Provide an overview of current research findings in pediatric central disorders of hypersomnolence (CDH) and propose a biopsychosocial model for clinical management, with a focus on interdisciplinary care and future directions for research and clinical practice.

METHODS

Literature review drawing from pediatric and adult narcolepsy, as well as pediatric sleep and chronic pain research to develop an integrative biopsychosocial model for pediatric CDH.

RESULTS

Youth with CDH are vulnerable to impairments in academics, emotional, and behavioral functioning, activity engagement and quality of life (QOL). There is a complex interrelationship between neurobiological features of disease, treatment-related factors, and psychological, sleep-related, and contextual factors across development. Research is limited largely to adults and pediatric narcolepsy type 1 and the mechanisms and evolution of morbidity remain poorly understood.

CONCLUSIONS

In addition to first-line treatment (pharmacotherapy), routine screening of bio-behavioral and psychosocial functioning and QOL is needed to identify risk for compromised functioning warranting adjunctive interventions with behavioral health specialists.

Narcolepsy in Children and Adults: A Guide to Improved Recognition, Diagnosis and Management

Narcolepsy is a rare condition that affects children and adults, and commonly has an onset in childhood. Time to appropriate diagnosis frequently is at least a decade. Unrecognized or misdiagnosed symptoms of narcolepsy contribute to increased morbidity, disability and socioeconomic liability in these patients. Delays in diagnosis may be related to variability in presentation in childhood, lack of familiarity with symptoms or appropriate diagnostic testing or misdiagnosis with accidental introduction of treatment that may modify or mask narcolepsy features. Improved awareness about the diagnosis and tailored therapies improve clinical and socioeconomic outcomes by reducing time to effective treatment. Application of effective treatment results in long-term benefits by improving clinical outcomes, potentially enabling improved education, increased employment opportunity, and improved work productivity and quality of life. This review provides a comprehensive stepwise approach to improve knowledge and comfort for recognition of symptoms, diagnostic strategies and management considerations of narcolepsy in children and adults.

Update on the Treatment of Idiopathic Hypersomnia

Purpose of Review

Idiopathic hypersomnia is an incapacitating disorder with a profound impact on daytime performance and quality of life. The most commonly used treatment modalities are lifestyle advice and pharmacological therapy. We present an update on the evidence concerning treatment options for idiopathic hypersomnia.

Recent Findings

Evidence for non-pharmacological interventions is lacking; improvement in symptoms on introducing these interventions is often less pronounced than in narcolepsy. Additional pharmacological treatment is therefore usually initiated. The few treatment studies that have been performed are hampered by small sample sizes and the use of variable and often insufficiently validated outcome parameters for the whole spectrum of idiopathic hypersomnia symptoms.

Conclusion

Evidence on treatment is scarce. Since the efficacy of modafinil is consistently described and there is much experience with this substance, it is reasonable to start with modafinil as a first choice treatment. Methylphenidate and dexamphetamine are good alternatives. In the future, newer drugs such as sodium oxybate, pitolisant, and solriamfetol might be authorized for use in idiopathic hypersomnia.

Clinical Sleep-Wake Disorders I: Focus on Hypersomnias and Movement Disorders During Sleep

Central disorders of hypersomnolence are characterized by daily periods of irrepressible need to sleep or daytime lapses into sleep, as defined in the current version of the International Criteria of Sleep Disorders. Thus, the unifying symptom is excessive daytime sleepiness which is not caused by any other sleep-wake disorder. Relevant disorders including narcolepsy type 1 and 2, idiopathic hypersomnia, Kleine-Levin syndrome, and insufficient sleep syndrome will be discussed. Other central disorders of hypersomnolence include hypersomnias due to medical or psychiatric disorders or because of medication or substance use.In sleep-related movement disorders, the cardinal symptom consists of simple, often stereotyped movements occurring during sleep. The most frequent disorder in this category of sleep-wake disorders is restless legs syndrome, which is often associated with period limb movements during sleep.

Idiopathic Hypersomnia

Idiopathic hypersomnia (IH) is a chronic neurologic disorder of daytime sleepiness, accompanied by long sleep times, unrefreshing sleep, difficulty in awakening, cognitive dysfunction, and autonomic symptoms. The cause is unknown; a genetic predisposition is suggested. Autonomic, inflammatory, or immune dysfunction has been proposed. Diagnosis involves a clinical history and objective testing. There are no approved treatments for IH, but modafinil is typically considered first-line. A substantial fraction of patients with IH are refractory or intolerant to standard treatments, and different treatment strategies using novel therapeutics are necessary. Even with current treatment options, quality of life and safety may remain impaired.