“I become more frustrated and then have another cataplexy attack.”– Nicki

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Evaluating for Cataplexy and Other Symptoms

In all patients with excessive daytime sleepiness, evaluate for possible cataplexy and other symptoms.1-3

Evaluating for Cataplexy

Cataplexy can be difficult to recognize in clinical settings,4,5 and patients may not report cataplexy.3 Cataplexy may also appear years after the onset of excessive daytime sleepiness, so it is important to explore cataplexy with patients on more than one occasion.6,7 Having someone who knows the patient well present during the clinical evaluation can help, as this person may have noticed less obvious signs of cataplexy.4,5

  • Partial cataplexy attacks can involve almost any muscle, but the neck and head are most commonly affected.4,6,8-11 Complete attacks can involve the whole body.9
    • More obvious complete cataplexy: knees buckling, collapse to the ground, head drops, slurred speech, sagging of the face or jaw4,6,8,9,11
    • Less obvious partial cataplexy: numbness, tingling, twitching, dropping things or clumsiness4,6,8-11
  • Emotional triggers include happiness, laughter/humor, anger, excitement, stress or anxiety, tension, anticipation, embarrassment.4,5,9
    • Ask patients if they suppress emotions or are withdrawn from family and friends.9,12
  • Situational triggers include telling or hearing a joke, making a witty remark, being tickled, being the center of attention, unexpectedly encountering a friend or acquaintance, being startled, remembering happy or emotional events, intimate moments, a romantic thought or moment, experiencing an orgasm.4,5,9
    • Ask patients if they avoid any situations that may trigger a cataplexy attack.2,9,13-15

Evaluating for Other Signs or Symptoms of Narcolepsy

Other symptoms or manifestations of narcolepsy can also have a substantial impact on patients.2,4,6 Ask patients about the presence and impact of:

  • Sleep paralysis4
  • Hypnagogic/hypnopompic hallucinations4,11,16
  • Vivid dreams at night2,6
  • Vivid dreams during daytime naps2
  • Bizarre dream content2
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  1. Green PM, Stillman MJ. Narcolepsy: signs, symptoms, differential diagnosis, and management. Arch Fam Med. 1998;7(5):472-478.
  2. Thorpy MJ, Dauvilliers Y. Clinical and practical considerations in the pharmacologic management of narcolepsy. Sleep Med. 2015;16(1):9-18.
  3. Overeem S, Reading P, Bassetti C. Narcolepsy. Sleep Med Clin. 2012;7:263-281.
  4. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.
  5. Anic-Labat S, Guilleminault C, Kraemer HC, Meehan J, Arrigoni J, Mignot E. Validation of a cataplexy questionnaire in 983 sleep-disorders patients. Sleep. 1999;22(1):77-87.
  6. Thorpy M, Morse AM. Reducing the clinical and socioeconomic burden of narcolepsy by earlier diagnosis and effective treatment. Sleep Med Clin. 2017;12(1):61-71.
  7. Sturzenegger C, Bassetti CL. The clinical spectrum of narcolepsy with cataplexy: a reappraisal. J Sleep Res. 2004;13(4):395-406.
  8. Dauvilliers Y, Siegel JM, Lopez R, Torontali ZA, Peever JH. Cataplexy—clinical aspects, pathophysiology and management strategy. Nat Rev Neurol. 2014;10(7):386-395.
  9. Overeem S. The clinical features of cataplexy. In: Baumann CR, Bassetti CL, Scammell TE, eds. Narcolepsy: Pathophysiology, Diagnosis, and Treatment. Springer-Verlag New York; 2011:283-290.
  10. Overeem S, van Nues S, van der Zande WL, Donjacour CE, van Mierlo P, Lammers GJ. The clinical features of cataplexy: a questionnaire study in narcolepsy patients with and without hypocretin-1 deficiency. Sleep Med. 2011;12(1):12-18.
  11. Pelayo R, Lopes MC. Narcolepsy. In: Lee-Chiong, TL, ed. Sleep: A Comprehensive Handbook. Hoboken, NJ: John Wiley & Sons; 2006:145-149.
  12. Broughton R, Ghanem Q, Hishikawa Y, Sugita Y, Nevsimalova S, Roth B. Life effects of narcolepsy: relationships to geographic origin (North American, Asian or European) and to other patient and illness variables. Can J Neurol Sci. 1983;10(2):100-104.
  13. de Zambotti M, Pizza F, Covassin N, et al. Facing emotions in narcolepsy with cataplexy: haemodynamic and behavioural responses during emotional stimulation. J Sleep Res. 2014;23(4):432-440.
  14. Ahmed I, Thorpy M. Clinical features, diagnosis and treatment of narcolepsy. Clin Chest Med. 2010;31(2):371-381.
  15. Daniels E, King MA, Smith IE, Shneerson JM. Health-related quality of life in narcolepsy. J Sleep Res. 2001;10(1):75-81.
  16. Dauvilliers Y, Lopez R. Parasomnias in narcolepsy with cataplexy. In: Baumann CR, Bassetti CL, Scammell TE, eds. Narcolepsy: Pathophysiology, Diagnosis, and Treatment. Springer-Verlag New York; 2011:291-299.

Performance of routine tasks without awareness.

Sudden and brief loss of muscle tone, often triggered by strong emotions or certain situations. Narcolepsy with cataplexy is known as narcolepsy type 1.

Complete collapse to the ground; all skeletal muscles are involved.

Only certain muscle groups are involved.

Biological clock mechanism that regulates the 24-hour cycle in the physiological processes of living beings. It is controlled in part by the SCN in the hypothalamus and is affected by the daily light-dark cycle.

Frequent awakenings and inappropriate transitions between states of sleep and wakefulness during nighttime sleep.

The inability to stay awake and alert during the day.

A neurotransmitter in the brain that supports wakefulness.

Vivid, realistic, and frightening dream-like events that occur when falling asleep.

A neuropeptide that supports wakefulness and helps suppress non-REM sleep and REM sleep.

Primary brain region for regulating the timing of sleep-wake states.

Unintentionally falling asleep due to excessive daytime sleepiness. Also known as “sleep attacks.”

Brief, unintentional lapses into sleep, or loss of awareness.

A validated objective measure of the tendency to fall asleep in quiet situations.

People with narcolepsy type 1 have low levels of hypocretin.

Narcolepsy without cataplexy; the cause of narcolepsy type 2 is unknown.

A state of sleep characterized by slower-frequency, more synchronized neuronal activity and decreased muscle tone. Deep stages help to restore the body.

A multiparameter test that monitors physiologic signals during sleep; used as a diagnostic tool in sleep medicine.

A state of sleep characterized by low-amplitude, fast-frequency EEG, vivid dreams, and loss of muscle tone. Normally occurs 60-90 minutes after sleep onset. Also known as “paradoxical sleep.”

Brief loss of control of voluntary muscles with retained awareness at sleep-wake transitions.

Sleep-onset REM period.