Psychiatric Comorbidities & Differential Diagnosis in Narcolepsy


In this custom video series, experts discuss medical and psychiatric illnesses that can be confused with narcolepsy as well as the presence and treatment of psychiatric comorbidities.

Debra Stultz, MD: There are different medical and psychiatric illnesses that can be confused during your work-up with narcolepsy. What do you think about that?

Stephen Stahl, MD, PhD: The big 1, of course is OSA, obstructive sleep apnea. As you say, you can have it with narcolepsy, but you need to do that sleep EEG [electroencephalogram] to see if people are having apneic periods at night to make that diagnosis. That’s the big 1.

Debra Stultz, MD: Right. Or for any other sleep disorder, like restless leg or circadian rhythm.

Stephen Stahl, MD, PhD: How about those acting out at night during sleep episodes, which you get with the onset of Parkinson disease. Or some hypnotic agents that make you act out weird stuff—you go down and eat from the refrigerator, come back to bed, and don’t know it.

Debra Stultz, MD: REM [rapid eye movement] behavior disorder. Other psychiatric disorders are also part of the differential if it’s depression, anxiety, bipolar depressed fatigue, anxiety, thyroid problems. There are a lot of things to consider. Medications that cause excessive sleepiness and timing. Are they taking their blood pressure medicine in the morning? Is it causing extreme sedation or substance abuse, or other substances?

Stephen Stahl, MD, PhD: Absolutely. Antipsychotics are a big 1. A lot of people fall asleep with these agents that we give them in the daytime. They think, “Oh, I got narcolepsy because I’m falling asleep in the daytime all the time.”

Debra Stultz, MD: It could be just the medicines. But it’s common for people with narcolepsy to have psychiatric disorders, especially depression and social anxiety. But patients with narcolepsy are 16 times more likely to have anxiety. Just because they have those symptoms, it’s not 1 or the other. I had a provider say, “I’m going to treat the depression before I start working on the narcolepsy.” That, to me, doesn’t make sense. If you had a patient who had high blood pressure, diabetes, or COPD [chronic obstructive pulmonary disease] you would go in and treat their blood sugar, give them a medicine for their blood pressure and an inhaler. You would treat all 3. You wouldn’t say, I’ll just treat the diabetes, and we’ll see what happens with the rest. Having depression in narcolepsy, you’ve got to treat them both and treat them aggressively. The ongoing frustration with narcolepsy—having job problems, relationship problems, problems with your children—can lead to depression.

One other important point I’d like to make is sometimes people with severe cataplexy are trying hard to suppress their symptoms that they look flat and emotionless and seem depressed, but they’re not. I had a patient just like that, and I kept asking her about depression. I kept asking her, and she had significant cataplexy. She knew that if she got angry, or looked depressed, or suddenly got sad, then she was going to have this severe cataplexy. She was really blank and flat. And her kids knew that, so they knew they could get her frustrated and manipulate her. That was a really sad situation because you think of a mother trying to raise kids being completely flat.

Stephen Stahl, MD, PhD: That it was restricting the effect.

Debra Stultz, MD: Yes. It may not be depression. It may just be they’re trying to suppress their symptoms. But there’s certainly coexisting depression just because you have the narcolepsy.

Stephen Stahl, MD, PhD: Pretty common.

Debra Stultz, MD: Yes. If you think they have narcolepsy and they have depression, then 1 treatment alternative would be to use 1 of the antidepressants we’ve used to help cataplexy to treat the depression. We would use something like an SSRI [selective serotonin-reuptake inhibitors] or SNRI [serotonin-norepinephrine reuptake inhibitors] that could help with cataplexy and treat their depression.

Transcript edited for clarity.


Dr Stephen Stahl is clinical professor of psychiatry and neuroscience at the University of California Riverside, adjunct professor of psychiatry at the University of California San Diego, and honorary fellow in psychiatry at the University of Cambridge. Over the past 12 months (January 2020 - December 2020), Dr Stahl has served as a consultant to Acadia, Alkermes, Allergan, AbbVie, Arbor Pharmaceuticals, Axovant, Axsome, Celgene, Concert, Clearview, EMD Serono, Eisai Pharmaceuticals, Ferring , Impel NeuroPharma, Intra-Cellular Therapies, Ironshore Pharmaceuticals, Janssen, Karuna, Lilly, Lundbeck, Merck, Otsuka, Pfizer, Relmada, Sage Therapeutics, Servier, Shire, Sunovion, Takeda, Taliaz, Teva, Tonix, Tris Pharma, and Viforpharma; he is a board member of Genomind; he has served on speakers bureaus for Acadia, Lundbeck, Otsuka, Perrigo, Servier, Sunovion, Takeda, Teva, and Vertex; and he has received research and/or grant support from Acadia, Avanir, Braeburn Pharmaceuticals, Eli Lilly, Intra-Cellular Therapies, Ironshore, ISSWSH, Neurocrine, Otsuka, Shire, Sunovion, and TMS NeuroHealth Centers.

Dr Debra Stultz is the Director and Owner of Stultz Sleep and Behavioral Health in Barboursville, West Virginia. Dr Stultz earned her medical degree from Marshall University School of Medicine in Huntington, West Virginia. She completed a residency in psychiatry and a fellowship in child and adolescent psychiatry through West Virginia University at their Charleston Division through Charleston Area Medical Center in Charleston, West Virginia. She is board certified in psychiatry, sleep medicine, and behavioral sleep medicine. With a special interest in Narcolepsy, she treats a variety of sleep disorders and psychiatric issues. She is also the editor for the Clinical TMS Society newsletter, on their Board of Directors, and the chairman of the TMS and Sleep Disorders Affinity Group. Dr Stultz is on the advisory committee for Harmony Biosciences and is a speaker for Harmony Biosciences and Jazz Pharmaceuticals.

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