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Case 3: Volume 1, Case #5: The sleepy woman with anxiety
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NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology
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Case 3: Volume 1, Case#5: The Sleepy Woman with Anxiety
Helpful Questions to Ask
1. What time do you generally go to bed and what time do you wake up?
Asking this is important as it helps to rule out night-time insomnia as the cause of the patient’s day time sleepiness. In order to diagnose her with a sleep/wake disorder, it has to be clear that her condition is being caused by an underlying issue that has nothing to do with the sleep itself.
1. What happens when you fall asleep?
Asking this allows the patient to explain in detail all the symptoms that she has been experiencing, with regard to her disorder. This information is crucial in helping to correctly diagnose a particular sleep/wake disorder.
1. Are you taking any medications? If so, which ones?
A number of health issues, including some sleep/wake disorders are have a lot to do with pharmacodynamics. The patients day time sleepiness may be caused by certain drug actions or interactions and as such would require a restructuring of their medication or dosages.
The person that would be most helpful in evaluating the patient’s sleep patterns in this case would be the husband. Given that she has no children and keep little contact with her family or friends, the husband is the only person who has stayed with the patient long enough to properly observe the quantity and quality of her sleep. In sleep evaluation cases, getting a second person’s assessment is important as the patient may not be able to correctly or exhaustively explain what happens when they fall asleep. In this case, specific questions to the patient’s husband would include the following:
1. What happens when your wife falls asleep? (This allows the husband to explain in his own words what he has observed in his wife’s sleep pattern.
2. What do you think causes her sleep to be this way? (This may help bring new information which the patient may have deliberately or unintentionally left out.)
In order to diagnose narcolepsy, a number of physical and diagnostic tests can be done. Physical tests generally involve learning the patient’s medical history, analyzing the patient’s symptom self-assessment, checking the patient’s vitals and observing their general appearance. A physical test reveals symptoms and patterns which may help the health practitioner diagnose the patient with a particular sleep/wake disorder. For instance, a narcoleptic patient’s physical exams would entail such symptoms as excessive daytime sleepiness, hallucinations, sleep paralysis and cataplexy. The physical test can also include an Epworth Sleepiness Scale (ESS) questionnaire, which is employed in many sleep clinics to evaluate patients’ sleep quantity and quality. In an ESS, patients are asked to rate a range of activities in which they are likely to fall asleep, with the scale generally being from 0-24. Patients who score 0-10 are generally considered non-narcoleptic while those with score of above 11 are considered possible cases for narcolepsy. Diagnostic tests may include the polysomnogram (PSG) test and the multiple sleep latency test (MSLT) (Abad & Guilleminault, 2017; Bhattarai & Sumerall, 2017). The PSG test electronically evaluates a patient’s quality of sleep at night while the MSLT test measures a patient’s sleep latency during the day. Narcolepsy can also be diagnosed by conducting a hypocretin level test. Most narcoleptic patients are deficient in the chemical hypocretin, produced in the brain (Abad & Guilleminault, 2017; Bhattarai & Sumerall, 2017).
Differential Diagnoses
1. Narcolepsy (Most likely)
2. Hypersomnia /Excessive Sleepiness
3. Insomnia
Narcolepsy is the most likely diagnosis in this case owing to the patient’s excessive daytime sleepiness, which points to a deficient daytime arousal (Stahl, 2013). In addition to that, the patient has also been taking a range of medications including bupropion for depression, gabapentin for anxiety and lamotrigine for stabilizing her mood. These medications cause her heavy sedation which may bring about narcolepsy as a side effect (Stahl, 2013).
Two pharmacological agents to prescribe in this case would be methylphenidate (54mg/day) and sodium oxybate (9mg/day. Of the two, methylphenidate is more suitable as sodium oxybate has been seen to cause sleep walking, exacerbate nervousness in patients with anxiety and cause urinary incontinence (bedwetting) (Bhattarai & Sumerall, 2017)
From this case, we learn that it is important to establish whether a patient’s daytime sleepiness is a symptom of narcolepsy or simply hypersomnia, which is an underlying symptom of depression. It is also highly important to evaluate a patient’s medication, as it could be the main reason why they are experiencing sleep disturbances. A patient with anxiety and depression is most likely to develop sleep/wake disorders owing to their normal symptoms and the effect of the drugs they are taking (Abad & Guilleminault, 2017; Bhattarai & Sumerall, 2017).
References
Abad, V. C., & Guilleminault, C. (2017). New developments in the management of narcolepsy. Nature and science of sleep, 9, 39.
Bhattarai, J., & Sumerall, S. (2017). Current and future treatment options for narcolepsy: a review. Sleep Science, 10(1), 19.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge University Press.
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