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Prior uncontrolled studies of nonsmokers with major depressive disorder (MDD) indicate rapid reduction in depressive symptoms with nicotine patch therapy. This randomized, double-blind, placebocontrolled pilot study examined the effect of nicotine patch therapy on depressive symptoms in non-medicated nonsmokers with current MDD. Due to recruitment difficulties, only 7 were enrolled and of these 6 (5 females, 1 male) completed the study. Participants received either placebo (n = 4) or active (n = 2) patch therapy for 8 days. They completed daily clinic visits during patch therapy and a final visit on Day 12. Depressive symptoms were assessed using the Hamilton Rating Scale for Depression (HRSD). The mean change in HRSD scores of all participants decreased (p = 0.021) from baseline by Day 1 of patch use. Similar decreases in HRSD scores were observed for placebo and active patch groups. Among the placebo participants, the mean HRSD score decreased (p = 0.038) by Day 2. The study needs replication with a larger sample and utilizing novel recruitment strategies. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To estimate long-term survival of unselected patients with anorexia nervosa from Rochester, Minn. PATIENTS AND METHODS: In this population-based retrospective cohort study, all 208 Rochester residents who presented with anorexia nervosa (193 women and 15 men) for the first time from 1935 through 1989 were monitored for up to 63 years. Subsequent survival was compared with that expected for Minnesota white residents of similar age and sex, and standardized mortality ratios were determined on the basis of age- and sex-specific death rates for the US population in 1987. RESULTS: Survival was not worse than expected in this cohort (P = .16). The estimated survival 30 years after the initial diagnosis of anorexia nervosa was 93% (95% confidence interval, 88%-97%) compared with an expected 94%. During 5646 person-years of follow-up (median, 22 years per patient), 17 deaths occurred (14 women and 3 men) compared with an expected 23.7 deaths (standardized mortality ratio, 0.71; 95% confidence interval, 0.42-1.09). One woman died of complications of anorexia nervosa, 2 women committed suicide, and 6 patients (5 women and 1 man) died of complications of alcoholism. Other causes of death were not increased. CONCLUSIONS: Long-term survival of Rochester patients with anorexia nervosa did not differ from that expected. This finding suggests that overall mortality was not increased among the spectrum of cases representative of the community. [ABSTRACT FROM AUTHOR]

Study Objectives: To evaluate for potential interactions between magnetic positive airway pressure (mPAP) masks and cardiac implantable electronic devices (CIEDs) for patients with sleep apnea., Methods: Adult patients with a CIED who used an mPAP mask were recruited from our sleep clinic to undergo a safety visit at our pacemaker clinic. We tested whether the mPAP interacted with the implanted device at home during normal use and in the clinic during simulated normal use and with direct contact. The magnetic field strength of 6 mPAP masks was tested with a gaussmeter., Results: Of 13 patients tested, 1 (8%), wearing a full face mask (ResMed AirFit F30 [ResMed, San Diego, California]), had a magnet response event (interaction) with direct contact, but no interactions were identified during normal or simulated normal use in any patient. The magnetic field strength of the mPAP masks increased the closer the mask got to the CIED, from 0.4 mT (4 G) at the mask manufacturer's recommended 5.1-cm (2-inch) distance from an implanted medical device up to 291 mT (2,910 G) at 0 cm (0 inches; direct contact)., Conclusions: An mPAP mask may interact with a CIED if placed directly on the skin overlying the CIED. The use of Philips Respironics (Philips, Cambridge, Massachusetts) mPAP masks is now contraindicated in patients with a CIED. Until additional studies are conducted to better document the risks and benefits of mPAP masks, we recommend discouraging patients with CIEDs from using any mPAP mask., Citation: Ruoff CM, Tashman YS, Cheema KPK, et al. Interaction of positive airway pressure mask magnets with cardiac implantable electronic devices. J Clin Sleep Med . 2023;19(5):941-946., (© 2023 American Academy of Sleep Medicine.)

Objective/background: Home sleep apnea tests utilizing peripheral arterial tone (PAT HSAT) detect sleep disordered breathing by measuring various physiologic measures including changes in arterial volume in the finger. Validation tests comparing PAT HSAT to simultaneous polysomnography (PSG) have demonstrated a high correlation. Alcohol increases peripheral vasodilation, which may alter arterial tone in the finger. Validation studies have not evaluated for an interaction between alcohol consumption and PAT HSAT measures., Patients/methods: We describe an in-depth evaluation of a 53-year-old man who consumes alcohol on nightly basis. He underwent a series of 5 diagnostic studies under different conditions: three PAT HSATs (two nights with and another without alcohol) and two polysomnograms (one night with and another without alcohol)., Results: Obstructive sleep apnea (OSA) was found on both polysomnograms but only on the PAT HSAT without alcohol, raising the possibility of two false negative PAT HSAT results after alcohol consumption., Conclusions: This report demonstrates the need for further investigations into the performance of PAT HSATs with and without alcohol. In the meantime we recommend that testing be done without alcohol and over the course of multiple nights., Competing Interests: Declaration of competing interest No conflicts exist for any of the authors., (Copyright © 2022. Published by Elsevier B.V.)

Narcolepsy is a chronic neurologic disorder associated with the dysregulation of the sleep-wake cycle that often leads to a decreased quality of life and results in a considerable health burden. There is often a delay to diagnosis of narcolepsy, mainly due to the lack of recognition of this disorder. One of the main factors hindering the diagnosis of narcolepsy is the association of comorbidities, which include other sleep disorders, psychiatric disorders, cardiovascular disorders, and metabolic disorders. The signs and symptoms of these comorbidities often overlap with those of narcolepsy, and some of the medications used for their treatment may obscure the symptoms of narcolepsy, leading to a delay in diagnosis. This review is targeted to clinicians unaccustomed to working with sleep disorders and aims to increase recognition and improve the management of narcolepsy., (© 2021. The Author(s).)

This article updates the American Academy of Sleep Medicine protocols for the administration of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. The American Academy of Sleep Medicine commissioned a task force of clinical experts in sleep medicine to review published literature on the performance of these tests since the publication of the 2005 American Academy of Sleep Medicine practice parameter paper. Although no evidence-based changes to the protocols were warranted, the task force made several changes based on consensus. These changes included guidance on patient preparation, medication and substance use, sleep before testing, test scheduling, optimum test conditions, and documentation. This article provides guidance to providers who order and administer the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test., Citation: Krahn LE, Arand DL, Avidan AY, et al. Recommended protocols for the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2021;17(12):2489-2498., (© 2021 American Academy of Sleep Medicine.)

Study Objective: To evaluate the efficacy of pitolisant, a histamine 3 (H 3 )-receptor antagonist/inverse agonist, in adult patients with high burden of narcolepsy symptoms., Methods: Data were pooled from two randomized, placebo-controlled, 7- or 8-week studies of pitolisant (titrated to a potential maximum dose of 35.6 mg/day) in adults with narcolepsy. Analyses included three independent patient subgroups: Epworth Sleepiness Scale (ESS) baseline score ≥16, Maintenance of Wakefulness Test (MWT) sleep latency ≤8 min, and ≥15 cataplexy attacks per week., Results: The analysis populations included 118 patients for ESS (pitolisant, n = 60; placebo, n = 58), 105 for MWT (pitolisant, n = 59; placebo, n = 46), and 31 for cataplexy (pitolisant, n = 20; placebo, n = 11). On the ESS, least-squares mean change from baseline was significantly greater for pitolisant (-6.1) compared with placebo (-2.3; P < 0.001). Significantly more pitolisant-treated patients were classified as treatment responders: ESS score reduction ≥3, 69.0% in the pitolisant group versus 35.1% in the placebo group (P = 0.001); final ESS score ≤10, 36.2% versus 10.5%, respectively (P = 0.005). On the MWT, mean sleep latency increased from 3.5 min to 10.4 min with pitolisant and from 3.4 min to 6.8 min with placebo (P = 0.017). Least-squares mean change in the weekly rate of cataplexy was significantly greater for pitolisant (-14.5; baseline, 23.9; final, 9.4) compared with placebo (-0.1; baseline, 23.1; final, 23.0; P = 0.004). Headache was the most common adverse event with pitolisant., Conclusions: Pitolisant, at once-daily doses up to 35.6 mg, was efficacious for reducing excessive daytime sleepiness and cataplexy in patients with severe narcolepsy symptom burden., (Copyright © 2021 The Authors. Published by Elsevier B.V. All rights reserved.)

Study Objectives: Scleroderma is associated with abnormal skin thickening, interstitial lung disease, pulmonary hypertension, and abnormalities of the upper airway. These changes can cause cardiopulmonary complications, potentially including sleep-disordered breathing. The objective of this study is to examine the risk of sleep-disordered breathing in patients with scleroderma., Methods: We retrospectively identified patients with documented scleroderma. We abstracted data from their electronic health records, including findings from antibody tests, serial pulmonary function tests, transthoracic echocardiography, high-resolution computed tomography, and overnight forehead oximetry., Results: We identified 171 patients with scleroderma. Mean age at the time of initial consult was 56.5 years (range, 18-96 years), and 150 (86.7%) were women. Scleroderma was categorized as limited disease for 108 (62.4%), diffuse disease for 59 (34.1%), and mixed connective tissue disease for 6 (3.5%). Fifty-four patients (31.2%) had abnormal overnight forehead oximetry results, defined as an oxygen desaturation index greater than 5 or a baseline mean arterial oxygen saturation level less than 90%., Conclusions: Cardiopulmonary complications are common in patients with scleroderma, one of which may be sleep-disordered breathing. In our cohort, approximately one-third of individuals with scleroderma had evidence of sleep-disordered breathing. Moreover, the rate of sleep-disordered breathing in our population of scleroderma patients was twice the rate of pulmonary hypertension and was approximately the same as the rate of interstitial lung disease. Future prospective studies are needed to further assess the role of sleep-disordered breathing in scleroderma clinical outcomes., (© 2019 American Academy of Sleep Medicine.)

Objective: To objectively assess whether a dog in the bedroom or bed disturbs sleep., Participants and Methods: From August 1, 2015, through December 31, 2015, we evaluated the sleep of humans and dogs occupying the same bedroom to determine whether this arrangement was conducive to sleep. The study included 40 healthy adults without sleep disorders and their dogs (no dogs <6 months old). Each participant wore an accelerometer and their dog a validated dog accelerometer for 7 nights., Results: The mean ± SD age of the participants (88% women) was 44±14 years and body mass index was 25±6. The mean ± SD age of the dogs was 5±3 years and weight was 15±13 kg. Mean ± SD actigraphy data showed 475±101 minutes in bed, 404±99 minutes total sleep time, 81%±7% sleep efficiency, and 71±35 minutes wake time after sleep onset. The dogs' accelerometer activity during the corresponding human sleep period was characterized as mean ± SD minutes at rest, active, and at play of 413±102, 62±43, and 2±4. The dogs had mean ± SD 85%±15% sleep efficiency. Human sleep efficiency was lower if the dog was on the bed as opposed to simply in the room (P=.003)., Conclusion: Humans with a single dog in their bedroom maintained good sleep efficiency; however, the dog's position on/off the bed made a difference. A dog's presence in the bedroom may not be disruptive to human sleep, as was previously suspected., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

The presence of pets in the bedroom can alter the sleep environment in ways that could affect sleep. Data were collected by questionnaire and interview from 150 consecutive patients seen at the Center for Sleep Medicine, Mayo Clinic in Arizona. Seventy-four people (49%) reported having pets, with 31 (41% of pet owners) having multiple pets. More than half of pet owners (56%) allowed their pets to sleep in the bedroom. Fifteen pet owners (20%) described their pets as disruptive, whereas 31 (41%) perceived their pets as unobtrusive or even beneficial to sleep. Health care professionals working with patients with sleep concerns should inquire about the presence of companion animals in the sleep environment to help them find solutions and optimize their sleep., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Abstract: The American Academy of Sleep Medicine (AASM) commissioned a Workgroup to develop quality measures for the care of patients with narcolepsy. Following a comprehensive literature search, 306 publications were found addressing quality care or measures. Strength of association was graded between proposed process measures and desired outcomes. Following the AASM process for quality measure development, we identified three outcomes (including one outcome measure) and seven process measures. The first desired outcome was to reduce excessive daytime sleepiness by employing two process measures: quantifying sleepiness and initiating treatment. The second outcome was to improve the accuracy of diagnosis by employing the two process measures: completing both a comprehensive sleep history and an objective sleep assessment. The third outcome was to reduce adverse events through three steps: ensuring treatment follow-up, documenting medical comorbidities, and documenting safety measures counseling. All narcolepsy measures described in this report were developed by the Narcolepsy Quality Measures Work-group and approved by the AASM Quality Measures Task Force and the AASM Board of Directors. The AASM recommends the use of these measures as part of quality improvement programs that will enhance the ability to improve care for patients with narcolepsy., (© 2015 American Academy of Sleep Medicine.)

Introduction: Carisoprodol is a centrally acting muscle relaxant used in the treatment of various musculoskeletal disorders whose main metabolite, meprobamate, is a controlled substance in the United States due to its sedative properties and potential for abuse., Case Description: We report a case of a 51-year-old man with cognitive impairment and tremor who developed worsening tremor, anxiety, myoclonus, ataxia, and psychosis on abrupt cessation of carisoprodol. At hospital discharge, his cognitive function significantly improved compared with when he was on carisoprodol., Conclusion: Carisoprodol withdrawal is an important and under-recognized syndrome that should be considered in patients presenting with neurologic symptoms who are taking the medication. Carisoprodol withdrawal can be successfully treated with the use of benzodiazepines, although further studies are needed to identify the most appropriate treatment protocol.

Background: Factitious and somatoform-disorder patients are alike in that they both organize their lives around seeking medical services in spite of having primarily a psychiatric condition. In DSM-IV, the key difference is that factitious-disorder patients feign illness, and somatoform-disorder patients actually believe they are ill. Although patients may not be conscious of their motivation or even their behaviors, deliberately embellishing history or inducing symptoms exemplifies behaviors designed to enhance a self-concept of being ill., Conclusion: For DSM-V, we propose reclassifying factitious disorder as a subtype within the somatoform-spectrum disorders or the proposed physical-symptom disorder, premised on our belief that deliberate deceptions serve primarily to portray to treaters the sense of being ill.

Patients with insomnia may develop suicidal ideation; however, we know of no reports of suicidal ideation associated with obstructive sleep apnea. We report on a 74-year-old man who presented to his primary care physician with excessive daytime sleepiness, poor quality nocturnal sleep, depressed mood, and suicidal ideation with active suicide plans. An emergency outpatient psychiatry consultation was arranged. The patient declined psychiatric hospitalization. He agreed to a trial of continuous positive airway pressure, using a self-titrating machine, followed by an urgent sleep study. Polysomnography revealed an apnea hypopneaindex of 64, arousal index of 91 and minimum oxygen saturation of 65%. The patient's sleep and excessive daytime sleepiness responded to nCPAP. The patient declined antidepressant medication but had excellent adherence to nCPAP. Suicidal ideation and depression resolved promptly and at 4-month followup were in remission. Further studies examining the relationship among untreated obstructive sleep apnea, depression, and suicidal ideation are warranted.

Objective: Selective serotonin reuptake inhibitors (SSRIs) are used to treat interferon-associated depression in patients receiving hepatitis C virus therapy. Prior studies have cautioned against the combined use of SSRIs and interferon due to increased risk of hemorrhage. Given the morbidity of depression and its impact on interferon compliance, we sought to reexamine the data., Method: In a retrospective analysis of our database of hepatitis C virus patients, a consecutive series of 303 patients (receiving treatment between January 2001 and January 2005) were evaluated for any evidence of bleeding. On the basis of our standard practice of care, patients were treated prophylactically with antidepressants for 3 to 4 weeks before beginning combination therapy with interferon and ribavirin. Patients were evaluated every 4 weeks during antiviral treatment with physical examinations and complete blood cell counts with differentials and platelets., Results: The overall rate of bleeding in our study was 0.3%, representing a single case of hemophilia., Conclusions: The bleeding risk of SSRIs is lower than previously reported.

Interferon (IFN) is an effective agent in the treatment of chronic viral hepatitis C. A variety of adverse neuropsychiatric effects including anxiety, depression, delirium, psychoses, and mania complicates its usage. IFN-alpha-induced depression is presumed to be composed of two overlapping syndromes: a depression-specific syndrome characterized by depressed mood, anxiety, and cognitive complaints, and a neurovegetative syndrome consisting of fatigue, anorexia, somatic pain complaints, and psychomotor retardation [1]. Our results show that depression-specific symptoms peak at 12 weeks of IFN therapy and respond well to serotoninergic antidepressants [2]. We conclude that neurovegetative symptoms are relatively treatment refractory to antidepressants, occur early in the course of treatment, and tend to persist for the duration of therapy [1].

Study Objectives: This pilot study explored the sensitivity and specificity of a brief survey to determine the presence of cataplexy. We hypothesized that the brief questionnaire could provide a quick, sensitive, and specific screening tool to identify those patients with cataplexy, which would result in more timely referrals for further diagnostic testing., Design: The pilot study utilized a brief questionnaire that was developed by including 5 questions that were found to be strong positive predictors of cataplexy from a previous 51-item cataplexy questionnaire., Setting: Participants with a laboratory-confirmed diagnosis completed the questionnaire via mail correspondence or at the time of scheduled appointments in the Mayo Clinic Sleep Disorder Center, Rochester, Minn., Participants: Seventy-eight patients with narcolepsy and cataplexy and 78 patients with obstructive sleep apnea completed the questionnaire., Interventions: NA., Measurements and Results: The sensitivity, specificity, area under the curve, positive predictive value, and negative predictive value/were computed for each question individually, along with appropriate 95% confidence intervals., Conclusions: The first item of the cataplexy emotional trigger questionnaire (CETQ) discriminates patients with cataplexy from controls with excellent sensitivity and specificity. The addition of the other 4 questions, in the context of question 1, did not improve specificity, area under the curve, positive predictive value, or negative predictive value but did provide useful confirmatory data. Thus, a single question provides a brief practical tool that could improve the recognition of cataplexy in the clinical setting. Depending on the circumstance, users may be interested in utilizing 1 or all 5 questions.

Cataplexy is an intriguing example of how emotions can trigger muscle weakness by activating neural pathways. When associated with excessive daytime sleepiness, cataplexy is considered pathognomonic of narcolepsy. A questionnaire was administered to 55 patients with narcolepsy-cataplexy and 47 comparison subjects with obstructive sleep apnea. The area under the receiver-operating curve was 0.94 for the combination of muscle weakness with laughter and ability to hear during the episode. A 51-item questionnaire succeeds in identifying cataplexy in narcolepsy-cataplexy patients measured up against a comparison group. In the future, an abbreviated survey with these two questions should identify cataplexy with high sensitivity and specificity. These selected questions could subsequently be included into screening tools for use with different patient populations.

Background and Purpose: Cataplexy, transient episodes of bilateral muscle weakness with areflexia provoked by emotions, is a state highly specific to narcolepsy. Cataplexy is diagnosed based on clinical interview. Two screening tools have been developed recently but their usefulness has been limited because of length or current lack of psychometric data. Used effectively even these screening tests require the interpreting physician to have an understanding of the typical features of cataplexy. Most physicians encounter patients with cataplexy fairly infrequently, making it difficult to gain proficiency in detecting cataplexy based on clinical interview alone. Relatively little attention has been given to the differential diagnosis of cataplexy, which increases the likelihood of unnecessary sleep testing or false positive diagnosis., Patients and Methods: This case series describes six cases where cataplexy was initially diagnosed. In all cases the weakness spells were eventually not attributed to cataplexy. The presentation and characteristics of these cases will be presented as a means to discuss the differential diagnosis of cataplexy., Results: These cases represent a diverse set of medical disorders including bradycardia, migraine, delayed sleep phase syndrome, conversion disorder, malingering and a chronic psychotic disorder., Conclusions: A more in-depth understanding of the classic features of cataplexy should improve recognition of this fascinating state. Improved cataplexy recognition will enhance the appropriate usage of sleep tests and eventually increase the timeliness and accuracy of the diagnosis of narcolepsy with cataplexy.

Background: Canine models for narcolepsy have mutations of the hypocretin receptor 2 gene, and preprohypocretin knockout murine lines exhibit narcoleptic-like behaviors. Human narcolepsy with cataplexy is associated with human leukocyte antigen DQB1*0602 and reduced hypocretin levels in cerebrospinal fluid, suggesting an autoimmune diathesis. We tested the hypothesis that DQB1*0602-positive narcoleptic subjects with cataplexy have immunoglobulin (Ig)G reactive to human preprohypocretin and its cleavage products., Methods: Serum samples of 41 DQB1*0602-positive narcoleptic subjects with cataplexy and 55 control subjects were studied, as were 19 narcoleptic and 13 control samples of cerebrospinal fluid. We tested for IgG reactive to preprohypocretin and its major cleavage products (including hypocretin 1 and 2), using immunoprecipitation assays (IP), immunofluorescence microscopy (IF) of Chinese hamster ovarian cells expressing preprohypocretin, and Western blots., Results: There was no evidence for IgG reactive to preprohypocretin or its cleavage products in CSF of subjects with narcolepsy as measured by IPs, Western blots, and IF. Although the IP with CSF and the C-terminal peptide showed significant differences by two methods of comparison, the control subjects had higher counts per minute than narcoleptic subjects, which was opposite to our hypothesis., Conclusions: The hypothesis that DQB1*0602-positive narcoleptic subjects with cataplexy have IgG reactive to preprohypocretin or its cleavage products was not supported.

This study characterizes the type and timing of psychiatric manifestations in sporadic Creutzfeldt-Jakob disease (sCJD). Historically, sCJD has been characterized by prominent neurological symptoms, while the variant form (vCJD) is described as primarily psychiatric in presentation and course: A retrospective review of 126 sCJD patients evaluated at the Mayo Clinic from 1976-2001 was conducted. Cases were reviewed for symptoms of depression, anxiety, psychosis, behavior dyscontrol, sleep disturbances, and neurological signs during the disease course. Eighty percent of the cases demonstrated psychiatric symptoms within the first 100 days of illness, with 26% occurring at presentation. The most commonly reported symptoms in this population included sleep disturbances, psychotic symptoms, and depression. Psychiatric manifestations are an early and prominent feature of sporadic CJD, often occurring prior to formal diagnosis.

Disturbed sleep is a feature of many psychiatric disorders. When clinicians are investigating insomnia, excessive daytime sleepiness, as well as parasomnia, they need to consider whether these complaints might be secondary to a psychiatric process. The association that is best supported by scientific evidence is between insomnia and mood disorders. Nonetheless, other psychiatric conditions including anxiety, psychosis, chemical dependency, and attention deficit hyperactivity disorder are closely linked with alteration in sleep quality and quantity. Treatment plans should take into account the nature of sleep symptomatology as well as the effect of medications on sleep. Ideally, management should include a combination of medications and behavioral treatment.

Background and Purpose: While there have been anecdotal observations of binge eating in childhood-onset narcolepsy, the possible relationship between increased weight gain and childhood-onset narcolepsy has not been evaluated., Patients and Methods: A retrospective, case-control design was used to compare the body mass index (BMI) of 31 narcolepsy children at the time of diagnosis with that of healthy, age- and gender-matched controls., Results: The median BMI in the narcolepsy subjects was 22.93 as compared to that in controls of 20.36 (P=0.001). BMI did not differ significantly between narcolepsy subjects who had received prior psychotropic medications and those who had not. The mean BMI of 22 of 31 narcolepsy subjects who had not received psychotropic medications prior to diagnosis was also significantly higher than that of controls (25.1, SEM 1.53 versus 21.1, SEM 0.56; P=0.008 )., Conclusion: The tendency for increased weight gain is intrinsic to childhood narcolepsy and is manifested relatively early in the course of the disorder. Correlation of this finding with hypocretin and leptin metabolism may further understanding of the pathogenesis of narcolepsy.

Patients with sleep disorders present with a variety of complaints including excessive daytime sleepiness, daytime spells, inability to sleep, uncomfortable sensation in the extremities, and unusual night time behaviors. This article provides eight vignettes on patients with sleep disorders including narcolepsy, idiopathic hypersomnia, obstructive sleep apnea, restless legs syndrome, and rapid eye movement behavior disorder. The discussion provides data regarding the epidemiology, pathophysiology, and diagnostic approach for these conditions. The various treatment options for these sleep disorders are also identified.

Objective: Factitious disorder with physical symptoms characterizes patients who strive to appear medically ill and assume the sick role. Clinical suspicion is highest for female health care workers in the fourth decade of life. This study was designed to analyze the diagnosis of factitious disorder, the demographics of affected patients, and intervention and treatment., Method: Retrospective examination was of 93 patients diagnosed during 21 years. Two raters agreed on subject eligibility on the basis of DSM-IV criteria and absence of a somatoform disorder and a plausible medical explanation., Results: The group included 67 women (72.0%); mean age was 30.7 years (SD=8.0) for women and 40.0 years (SD=13.3) for men. Mean age at onset was 25.0 years (SD=7.4). Health care training or jobs were more common for women (65.7%) than men (11.5%). Most often, inexplicable laboratory results established the diagnosis. Eighty had psychiatric consultations; 71 were confronted about their role in the illness. Only 16 acknowledged factitious behavior. Follow-up data were available for only 28 patients (30.1%); maximum duration of follow-up was 156 months. Two patients were known to have died. Few patients pursued psychiatric treatment. Eighteen left the hospital against medical advice., Conclusions: Factitious disorder affects men and women with different demographic profiles. Diagnosis must be based on careful examination of behavior, motivation, and medical history and not on a stereotype. Laboratory data and outside medical records help identify suspicious circumstances and inconsistencies. Confrontation does not appear to lead to patient acknowledgment and should not be considered necessary for management.

Psychiatrists have made significant contributions to the sleep field, but over time the visibility of psychiatrists within this field may be decreasing. A brief survey to evaluate sleep education, faculty, resident recruitment trends, and career prospects in sleep medicine for graduating psychiatrists was sent to the 177 directors of U.S. general psychiatric residency programs. Responses were received from 98 (66%). Most programs (82%) offer didactic lectures about sleep. Fifty-two programs (44%) provide a sleep medicine rotation; 10 programs had previously discontinued sleep electives. Most program directors (73%) agreed that sleep medicine was a viable career option for graduating psychiatric residents. Nonetheless, few recent psychiatry graduates have entered the field. Fewer psychiatric residency programs offer sleep electives than in the past, although most still provide didactics. Over time, this decrease in educational opportunities may result in few newly trained psychiatrists entering the sleep field.

Study Objectives: Hypocretin (orexin) deficiency (< 40 pg/ml) is highly associated with narcolepsy with cataplexy (89.5%) and more specifically with patients with cataplexy who are HLA DQB1*0602 positive (95.7%). The relationship between hypocretin-1 levels and narcolepsy without cataplexy or the DQB1*0602 allele is less clear., Methods/design: This study compared cerebrospinal (CSF) hypocretin-1 in 13 patients with HLA DQB1*0602 allele and cataplexy to 4 HLA negative patients with cataplexy, 3 HLA positive patients without cataplexy, and 6 HLA negative patients without cataplexy, plus 15 neurologic controls., Setting: Data were collected at a sleep disorders center., Patients/participants: Twenty-six patients with narcolepsy, with and without HLA DQB1*0602 and with and without cataplexy, as well as 15 neurologic controls., Interventions: N/A., Measurement & Results: Using analysis of variance techniques, statistically significant differences were found between the CSF hypocretin-1 levels in HLA positive patients and all other groups (P < 0.01). Although the sample size was small, subjects with the DQB1*0602 allele without cataplexy had lower hypocretin-1 levels than did other groups (other than the HLA and cataplexy positive group). Hypocretin-1 levels were not associated with age at diagnosis, age at lumbar puncture, body mass index at time of diagnosis, or body mass index at time of lumbar puncture., Conclusion: This data confirms the previous finding that undetectable hypocretin-1 levels are highly specific for HLA positive narcolepsy with cataplexy. The data suggests that the pathophysiology and, by extension, etiology of this disorder are distinctly different from the other conditions studied. The relationship of the DQB1*0602 allele and reduced hypocretin-1 levels needs further study.

Narcolepsy secondary to other neurologic processes has been recently associated with hypocretin (orexin) deficiency. We present a patient who developed a narcoleptic-like sleep disorder after receiving treatment for a choroid plexus carcinoma of the pineal gland. She underwent a pinealectomy, chemotherapy, and radiation treatment. The primary features of this condition were excessive daytime sleepiness, sleep paralysis and hypnagogic hallucinations. Increased percentage of rapid eye movement (REM) sleep and sleep onset REM periods were seen during the multiple sleep latency test. Circadian rhythmicity was preserved for melatonin and cortisol. She was negative for human leukocyte antigen DQB1*0602 and had a detectable cerebrospinal fluid hypocretin level (518 pg/ml). We emphasize that the narcoleptic-like disorder likely resulted from the surgical intervention or radiation therapy. Her symptoms are caused by an unknown mechanism unrelated to hypocretin depletion which merits more research.

Study Objectives: Narcolepsy is strongly associated with the presence of HLA DQB1*0602. This and other evidence suggests that human narcolepsy is an autoimmune disease. This is in distinction to that found in canine models where hypocretin receptor 2 mutations are etiologic. We decided to test for the presence of several neuron-specific and organ-specific autoantibodies to see if they were present in HLA DQB1*0602-associated or cataplexy-associated narcolepsy or could serve as a serologic marker of the illness., Design: We tested for N-type and P/Q-type voltage-gated calcium-channel antibodies, neuronal nicotinic acetylcholine receptor alpha3 subunit, acetylcholine receptor-binding antibodies, striated muscle antibodies, Type 1 Purkinje cell cytoplasmic antibodies, types 1 and 2 antineuronal nuclear antibodies and amphiphysin antibodies, GAD-65 antibody, and thyroid microsomal and thyroglobulin antibodies in the serum of 43 patients with or without cataplexy, 41 with known HLA status., Setting: Narcoleptic subjects were recruited from the Mayo Sleep Disorders Center., Participants: N/A., Interventions: N/A., Measurements and Results: No antibody test yielded significantly positive results for the group as a whole or for subgroups of patients with cataplexy or positive HLA DQB1*0602 status., Conclusions: These results do not support the hypothesis that narcolepsy is an autoimmune disease. However, it is possible that the autoimmune attack is very selective and does not involve the epitopes measured in this study. Recent findings that the hypocretin neurotransmission system is involved in animal models of narcolepsy should lead to research to look for antibodies directed against components of the hypocretin neurotransmission system in narcolepsy.

Study Objectives: To determine the age- and sex-specific incidence rates and prevalence of narcolepsy in a United States community., Design: The records-linkage system of the Rochester Epidemiology Project was utilized to ascertain all patients with narcolepsy seen in Olmsted County, Minnesota between 1960 and 1989. Age- and sex-specific incidence rates were calculated, using census data. Prevalence of narcolepsy on January 1,1985 was calculated., Setting: N/A., Patients or Participants: Community patients diagnosed with narcolepsy by a validated set of diagnostic criteria., Interventions: N/A., Measurements and Results: The incidence rate per 100,000 persons per year was 1.37 (1.72 for men and 1.05 for women). The incidence rate was highest in the 2nd decade, followed in descending order by the 3rd, 4th and 1st decades. The prevalence on January 1, 1985 was 56.3 per 100,000 persons. Approximately 36% of prevalence cases did not have cataplexy., Conclusions: Narcolepsy is not a rare disorder. It appears to be commoner in men. It originates most commonly in the 2nd decade. Narcolepsy without cataplexy is an important subgroup, warranting further study.

This pilot study compares standardized and actual psychiatric patients used to teach introductory psychopathology. In a blinded manner, students and psychiatric faculty interviewed both types of patients, using a small group format. Before and after the course, students and faculty completed a questionnaire about expectations and effectiveness. Students were divided in their opinions of standardized patients but generally preferred actual patients. Faculty were initially noncommittal, but after the course they strongly preferred actual patients. Although standardized patients offer some advantages over actual patients, limitations included difficulty developing empathy. Standardized patients could potentially be trained to convey emotions realistically, but further study of this is needed.

Background and Purpose: No gold standard currently exists for the diagnosis of narcolepsy. Conventional diagnostic criteria are unwieldy and arbitrary. Clearly defined criteria for case selection are needed to compare the results of different studies., Methods: We developed new clinical and neurophysiologic criteria for narcolepsy using four categories, based on the degree of diagnostic certainty. Category A is Definite Narcolepsy, Category B is Probable Narcolepsy (Laboratory Supported; two subgroups B1 and B2) and Category C is Probable Narcolepsy (Clinical). We assessed the charts of 69 new or established patients with narcolepsy seen consecutively in the Mayo Sleep Disorders Center and classified them according to our system. The human leucocyte antigen (HLA) DQB1*0602 status was determined for each patient as an indirect measure of validity. Two investigators independently assessed 30 charts to assess interrater reliability. We assessed additional 337 charts of patients with other hypersomnolence states to assess the specificity of our definitions., Results: Seventy-four percent were positive for HLA DQB1*0602 (including 85% of those with cataplexy). Only 33% of those without cataplexy were HLA DQB1*0602 positive. The two investigators agreed on the classification of 29/30 patients (0.97 reliability). None of the 337 additional patients fulfilled criteria for narcolepsy, and specifically not for cataplexy., Conclusions: We conclude that our new research diagnostic criteria for narcolepsy possess high interrater reliability and appear valid descriptors of the syndrome, based on HLA typing. They may be useful in providing consistent criteria to compare different research studies.

Introduction: The prevalence and treatment outcome of smokeless tobacco (ST) use among hospitalized addiction patients is unclear., Methods: Using initially a retrospective and then a prospective study design, data were collected about patients who described "other tobacco use." The data examined included demographics, medical disorders, psychiatric conditions, nicotine treatment and outcome., Results: The data from the two samples were consistent. All subjects were Caucasian males, mean age 38.5 years, with daily ST use for at least one year. Most had alcohol dependence. The prevalence rate was 3% retrospectively and 7% prospectively. Interventions included nicotine gum and patches. All subjects abstained from ST use during hospitalization but follow-up data were limited., Conclusion: These observations are consistent with reports of ST use being more common in males in the general population and its association with alcohol dependence. Further research is needed into effective long-term treatment for ST use among addiction or psychiatric patients.

The authors identified patients with the coexistence of narcolepsy and another CNS disorder seen between 1975 and 1998 at their institution. Eighteen patients were identified, nine with narcolepsy commencing within 1 year before or after the other disorder. Seven patients (39%) had hypothalamic-pituitary syndromes. When they occur together, narcolepsy and other CNS disorders frequently emerge at about the same time, suggesting a causative relationship. Hypothalamic-pituitary pathology was the most common association.

Velo-cardio-facial syndrome (VCFS) has been associated with schizophrenic symptoms in some patients and is caused by a deletion of 22q11.21--q11.23. The voltage-gated calcium channel (VGCC) gamma 2 subunit is located on chromosome 22 and is telemeric to the most commonly observed VCFS deletion region but is near a putative marker for schizophrenia (D22S278). Metaphase spreads of four controls, four patients with VCFS, and one patient with VCFS and schizophrenia were evaluated for the VCFS deletion using the VCFS-diagnostic probe, TUPLE 1, and for deletion of VGCC gamma 2 subunit gene using probes for that gene's exon 1 and exons 3 and 4. All of the VCFS patients had deletion of the TUPLE 1 probe on one chromosome of the chromosome 22 pair. None showed deletion of the gamma 2 subunit exons studied. The location of the gamma 2 subunit gene at 22q13.1 was confirmed by FISH in all cases. This study did not show a deletion of the gamma 2 subunit gene as a distinguishing feature of our patient with VCFS and schizophrenia.

Objective: Originating from the pituitary gland, TSH secretion is regulated predominantly by thyroid-releasing hormone (TRH) neurons located in the hypothalamus. Norepinephrine and dopamine have important effects in modulation of TSH secretion. An inhibitor of catecholamine synthesis, alpha-methyl-para-tyrosine (AMPT) has been used in several studies of the regulation of human TSH secretion. The short-term effects (<8 hours) of low doses of AMPT include stimulation of pituitary TSH secretion by selective lowering of brain dopamine levels. After prolonged administration of AMPT (>24 hours), theoretically both dopamine and norepinephrine levels are lowered significantly in the brain, although this has not been reported previously., Methods: Nine subjects (five women and four men) received a total of five 1-g doses of AMPT or five 50-mg doses of promethazine (active placebo) over 28 hours in a randomized, double-blind, placebo-controlled crossover design in which the active and control tests were separated by 4-6 weeks. Blood samples were obtained over 24 hours (18 time points) on day 2 of each condition., Results: Changes in prolactin secretion and 6-hydroxymelatonin sulfate excretion indirectly showed the effects of AMPT on dopamine and norepinephrine. The typical circadian rhythm of TSH secretion was blunted by AMPT throughout the night; at ten time points, the difference between the two groups was statistically significant (P <.01). The long-term effects of repeated doses of AMPT were inhibition of TSH secretion and significant attenuation of the circadian rhythm of TSH. Additionally, AMPT induced low norepinephrine levels, which counteracted the stimulatory effect of low dopamine levels on TSH., Conclusion: Through its inhibitory effect on TRH, norepinephrine appeared to be involved in the regulation of TSH.

Objectives: To evaluate the efficacy of a brief, intense treatment program for fibromyalgia and to determine which patient characteristics are associated with a better treatment response., Patients and Methods: Two self-report measures, the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory (MPI), were administered before patients completed treatment and 1 month after participating in the program. The main outcome measure was the difference in FIQ score and MPI scale before and after program participation., Results: Of 139 patients who met the American College of Rheumatology criteria for fibromyalgia, 100 chose to participate in the 1 1/2-day Fibromyalgia Treatment Program at the Mayo Clinic, Rochester, Minn. Of these 100 patients, 74 completed the follow-up surveys. Patients were less affected by fibromyalgia after participation in the treatment program. This was demonstrated by a posttreatment improvement in the total FIQ score (P<.001), the MPI pain severity score (P<.001), and the MPI interference score (P=.01). The 1 patient characteristic found to be significantly associated (P<.001) with a better response to treatment was a high pretreatment level of impairment from fibromyalgia, as measured by the pretreatment FIQ score., Conclusions: A brief interdisciplinary program for treating fibromyalgia reduced some associated symptoms. Patients more severely affected by fibromyalgia may benefit most from this approach. Clinicians may apply these findings to develop beneficial and convenient treatment programs for patients with fibromyalgia.