What does it really mean?
For a long time when I heard the word “narcolepsy” I imagined an unfortunate person who would fall unconscious in the middle of the sentence and wake up the next day – an image based on River Phoenix character from the early 90s movie “My Private Idaho”. There was surprisingly little education on the subject of sleep disorder in medical school but fortunately I have opted to do a three- week elective at a sleep center during my residency where I have learned the truth about this condition.
How is it diagnosed?
Narcolepsy is suspected when a person is suffering from excessive sleepiness despite adequate amount of sleep and the diagnosis is made by performing a sleep study (polysomnogram) that is done during the night and then MSLT (multiple sleep latency test) which measures tendency to fall asleep during the day. The whole thing amounts to a rather involved and cumbersome test, the patients get a couple dozen electrodes glued to their heads and get to hang out in a hotel-like sleep suite for almost 24 hours.
Narcoleptics are all around us.
You too have probably seen quite a few people affected by narcolepsy – it may be the girl in your college class who used to sleep through most of the lectures, the guy at your work who tends to nod off during most of the conferences, the uncle who falls asleep on the couch watching a football game, a friend who is always complaining of being tired and not being able to get a refreshing sleep… It never occured neither to any of these people nor to anyone around them that their brains simply doesn’t function normally when it comes to sleep. Narcolepsy is one of the most under-diagnosed medical conditions, partially because the sleep deprivation – an alternative explanation to symptoms is so common that people accept their symptoms as part of life and may never find out that they are affected.
What causes narcolepsy?
The modern science of genetics attributes narcolepsy to a mutant gene that codes for a specific neutrotransmitter region. The disruption of proper function leads to abnormal regulation of sleep cycle sequences and often intrusion of REM sleep into wakefulness. People with narcolepsy also are prone to sleep paralysis, they are uncomfortably aware of not being able to move or see when they are asleep. They can also experience hallucinations when they either fall asleep or waking up. While helpful at hinting toward epilepsy, neither one of these symptoms is required to be present in order for diagnosis of epilepsy to be established, and they also can occur on occasion in perfectly healthy individuals.
How do you treat it?
For many years, the traditional medication for treatment of narcolepsy were amphetamine derived drugs, such as Ritalin. Lately, however there has been a surge of new drugs on the market, that are more specifically directed at the sleep wake cycle regulation (Nuvigil) and are less prone to abuse. Also there is a medication called GHB (the substance with a tainted past of a popular date rape drug in the 80s). It is sold under the brand name Xyrem. This medication induced deep stages of sleep, which are deficient in narcoleptics, and has been extremely effective in controlling the symptoms. The downside is that it is very tightly regulated and quite expensive.
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What is dopamine so important? Dopamine is the molecule that acts in the brain to promote the feeling of pleasure and makes us look forward to enjoying things and activities. Without dopamine on board, we can not experience positive feelings.
Dopamine is the neurotransmitter that is pivotal to motivation, creativity and sexual desire. Drugs like cocaine and amphetamines act in the opposite way. They cause a burst of dopamine to be released which leads to euphoria – an exaggerated feeling of happiness which is very addictive to humans because it makes all other experience dwarfed in comparison.
Too little dopamine. People with Parkinson’s disease also suffer from a lack of dopamine but it is limited to a very specialized part of the brain where it is responsible not for the mood but for the movement. Low levels of dopamine levels has also been linked to ADHD and social anxiety disorder.
Too much dopamine. On the other end of the spectrum, there can be too much of a good stuff too. Schizophrenia and paranoid behavior are believed to be caused by excess of dopamine in certain parts of the brain.
Dopamine medications. Anti-Parkinsonian medications such as Sinemet, Requip, Mirapex and others raise levels of dopamine in the brain. You would think that giving these drugs to people who already have normal levels will also cause euphoria but it is not the case. The change in dopamine level caused by this medications is much more gradual and the brain has time to adjust. Nevertheless, these medication have a potential to create a whole slew on unpredictable side effects related to dopamine. The Mirapex is implicated in turning previously very responsible and monogamous people into sex addicts and obsessive-compulsive gamblers. The main character in the movie “Awakening” played by Robert DeNiro who wakes up from severe Parkinsonian coma in the end goes crazy from paranoia and grandiosity caused by incorrect dosing of levodopa, which was still an experimental drug at that time.
Dopamine myths. An Ayurvedic herb called Mucuna pruriens that contains a small amount of levodopa. The amount is likely too small to cross the blood brain barrier in a quantity large enough to impact any changes but there are some people who claim that their mood and concentration get better when they take it. Some, on other hand only report jittery feeling akin drinking five cups of coffee and others feel nothing at all.
The wide spread belief that eating brown spots on bananas raises dopamine levels is incorrect. While eating overly ripe bananas is probably not going to harm you, it won’t make you happy either.
For more information about the role neurotransmitters play in our mood go to my blogs:
Everybody knows that coffee is a stimulant drug but most people simply prefer to think of it as a drink that has become a staple of contemporary lifestyle. Drugs always sell, and therefore caffeine, being the least regulated drug, is easy to sell – just count the number of Starbucks on your street.
We live in the world where a large part of the population is dependent on coffee and addicted to caffeine in a various forms – without even realizing it or feeling the least concerned about it. It does not mean that it is normal or that it will always be like that. After all, there was a time in the twentieth century when doctors advertised cigarettes on the TV.
There is nothing wrong with enjoying an occasional coffee after lunch, or using it to stay up late and study for an exam. However, if you feel tired on a regular basis, that means your body is sending you a message that you have depleted your energy stores. Your body is asking you for a break because it needs to regenerate and refuel itself. Your brain feels groggy because it requires more sleep in order to restore itself (see Sleep Revelations). Unfortunately, because of the demands of today’s busy life, these kind of pleas are often ignored. Instead, people are drinking their daily dose of a mild stimulant drug, which creates the energy that was not supposed to be there and thus enables them to keep going.
Caffeine blocks adenosine receptors in your brain, and adenosine is believed to be responsible for the feeling of mental fatigue. Now, all that adenosine is not going anywhere, it is just piling up in your brain, waiting for the receptors to be freed up and then attack them with much more power than it would have initially. Also, the brain tends to up-regulate receptors when there is a high demand to them. That is the basis for all drug withdrawal syndromes.
In more simplistic terms, think of it as a credit analogy. While credit cards are convenient and cause no harm for people who use them wisely, those who use it without having sufficient funds to pay them off, find themselves over time in a big financial trouble. Same, with caffeine users, the cumulative effects of living on borrowed energy and sleep deprivation over a long period of time begin to take its toll. The combination of coffee and sugar, which most people prefer, is shown to be particularly habit forming (see Tale of Hypoglycemia).
The coffee addicted scientists have been enthusiastic about finding justification for coffee use. There have been many poorly executed studies that aimed to prove positive effects of coffee (from kidney stones to cancer). Even if those findings are true, it appears that the positive properties are mainly linked to the anti-oxidative substances found in coffee leaves and not the caffeine itself. Therefore, drinking decaf would have the same benefits without the adverse effects on your energy stores.