What is Cataplexy?

Many individuals report feeling very weak or even losing control of their muscles and body when they experience strong emotions. This condition is called cataplexy and it is almost always a feature of the sleep disorder called narcolepsy.

Cataplexy: What does it mean?

Cataplexy is a condition characterized by a sudden and transient loss of voluntary muscle tone triggered by strong and, often pleasant emotions such as laughter and happiness. The loss of muscle tone, typically, affects both sides of the body and the attack lasts between a few seconds to less than 2 minutes after which normal muscle tone and function returns.

Cataplexy usually occurs during waking hours and it may range from mild to severe. While laughter is the most common trigger of cataplexy, it may also be triggered by other emotions such as excitement, anger, fear, stress, and surprise. It may also occur after abrupt discontinuation of an antidepressant medication.

Stats: How many People suffer from this Disorder?

Cataplexy is a common feature of Narcolepsy, however, it may be seen in other rare disorders including Wilson’s disease, Prader-Willi syndrome, and Niemann-Pick disease. Additionally, some patients with stroke, multiple sclerosis, traumatic brain injury, and encephalitis may also develop this condition.

Narcolepsy is a neurological disorder characterized by excessive daytime sleepiness and it occurs in 2 in 100 adults worldwide, however, the incidence of cataplexy is a little lower than this as not all persons with narcolepsy have cataplexy. Cataplexy which occurs with narcolepsy typically begins in childhood and early adulthood with an age of onset between 7 and 25 years, although it may begin at any time.

How many episodes of cataplexy people with the condition experience varies from as small as one per year to as many as several attacks in a day. However, on average, a person with cataplexy will experience at least one attack every week.

What Causes Cataplexy?

The exact cause of cataplexy is not clearly understood, however, scientists suggest that it may occur as a result of an inability of the brain to regulate the sleep-wake cycle. The stage of sleep called the rapid eye movement (REM) sleep is characterized by normal loss of muscle tone. In cataplexy, this feature occurs during wake hours, suggesting that there is an overlap between sleep and wake phases.

The cause of this intrusion of sleep into waking hours is unknown, however, a contributing factor is a loss of brain cells which produce a chemical substance called hypocretin (or orexin) which is involved in keeping an individual awake and alert within a sleep-wake cycle. Some studies have suggested that this loss of brain cells that produce hypocretin is caused by an autoimmune process in which antibodies destroy these cells.

Signs and Symptoms of Cataplexy

Symptoms of a cataplectic episode vary widely and may be mild and undetectable or severe. These symptoms include:

  • Jaw tremor
  • Nodding of the head, in partial loss of muscle tone.
  • Drooping of the eyelids
  • Difficulty speaking
  • Trembling of the knees
  • Muscle twitching
  • Making unusual tongue movements
  • Facial twitching and grimacing
  • In severe cases, the person may collapse and develop a transient inability to move.

During a cataplectic attack, an individual is usually conscious and able to breathe. These symptoms usually last a few minutes or less and resolve without any intervention. Some persons may fall asleep afterward.

Testing: What are the Diagnostic Criteria per the DSM-5

Cataplexy is the diagnostic feature of narcolepsy and its presence typically suggests that an individual has narcolepsy. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Narcolepsy is defined as recurrent episodes of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day. These must have been occurring at least three times per week over the past 3 months. There also must be the presence of at least one of the following: 

  • Episodes of cataplexy occurring at least a few times per month
  • Hypocretin deficiency
  • REM sleep latency ≤15 minutes, or a mean sleep latency ≤8 minutes and two or more sleep-onset REM periods (SOREMPs)

Cataplexy and other Conditions

There are a number of conditions which are characterized by or which presents similarly to cataplexy and which should be distinguished clinically.

Cataplexy vs. Narcolepsy

Narcolepsy is a sleep disorder that is characterized by the tetrad of excessive daytime somnolence, sleep paralysis, hallucinations just before falling asleep, and cataplexy. However, cataplexy is the diagnostic symptom of narcolepsy, such that if an individual develops excessive daytime sleepiness with cataplexy, they likely have narcolepsy. Cataplexy occurring without narcolepsy is rare and its cause is unknown. Narcolepsy is also associated with trouble sleeping at night and nocturnal compulsive behavioral patterns such as sleep-eating and night smoking.

Cataplexy vs. Catatonia

Catatonia is a state of unresponsiveness to external stimuli and it is characterized by an apparent inability to move in a person who is apparently awake. Catatonia often occurs in severely ill individuals with certain psychiatric or medical conditions.

Individuals with catatonia present with mutism, opposition or no response to instructions or external stimuli, agitation that is not influenced by an external trigger, grimacing, mimicking another’s speech, and mimicking another’s movements. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classifies catatonia into three types: (i) catatonia associated with another mental illness, (ii) catatonia resulting from a medical condition, and (iii) unspecified catatonia.

Cataplexy vs. Stroke

Cataplexy may be distinguished from stroke by the short timeline of the symptoms of the former. While symptoms of muscle paralysis in cataplexy lasts for a few minutes or less and resolve without intervention, symptoms of stroke typically last longer and requires treatment. However, in the case of transient ischemic attacks, symptoms may last for several hours but resolve within 24 hours.

In addition, stroke presents typically with convulsions, sudden severe headache, numbness in one half of the body and face, trouble speaking, transient blindness in one or both eyes, and difficulty walking.

Related Conditions

Sleep paralysis is a condition related to cataplexy but which usually occurs during awakening or when falling asleep. In sleep paralysis, the patient is typically unable to move when they wake, however, unlike in cataplexy, hallucinations are associated with this paralysis.

A severe form of cataplexy may be mistaken for convulsions, however, the difference is that, unlike in convulsions, the individual remains conscious during a cataplectic episode and is able to recount all that happened during the attack.

Cataplexy in Adults and Children

Cataplexy with narcolepsy typically begins in childhood and early adulthood between the ages of 7 and 25. However, children with cataplexy may also manifest some atypical movement disturbances, such as repetitive movement patterns which resolve later in the course of the disease. Also, children with cataplexy develop an unusual facial appearance during each attack, characterized by repetitive mouth opening, drooping of the eyelids, and tongue protrusion. In addition, the emotional triggers of cataplexy, such as laughter or excitement, are not always present in children.

Example Case of Cataplexy

John, a 14-year-old college student is referred to the sleep clinic by his primary care physician on account of his excessive daytime sleepiness which has been occurring on most days of every week for the past three months. John notes that these symptoms began with recurrent episodes of falls to the ground from his seat whenever he laughs or jokes with his classmates. He claims that he remains conscious during each attack and can remember what happens. He notes that each “attack” typically begins with drooping of his eyelids, inability to continue with whatever he was doing at the time before he falls to the ground.

How to Deal/Coping with Cataplexy

Cataplexy may be a debilitating condition, impairing a person’s daily activities, interpersonal relationships, and productivity at work or school. It is essential to consult a physician or expert before it causes serious complications. Certain lifestyle changes may help to reduce the symptoms and frequency of cataplexy and to reduce the risk of developing serious injuries.

Look out for these Complications/Risk Factors

Complications of Cataplexy include:

  • Since cataplexy can occur without any notice and at any time, an episode may cause injuries and even death if the individual is driving or doing an activity that involves dangerous objects.
  • An individual may avoid both pleasant and unpleasant emotions for fear of an attack.
  • A strain on interpersonal and social relationships
  • Poor work or school performance as a result of the intermittent disruption of activities cataplexy causes.

Although cataplexy has been associated with reduced levels of the chemical substance, hypocretin in the brain, there are other factors which may increase the risk of this disorder. These include:

  • Traumatic brain injuries
  • Brain tumors around the areas of the brain that regulate sleep.
  • Autoimmune conditions – characterized by overactive immune cells which mistake normal cells for foreign objects, destroying them in the process.
  • Viral infections and vaccinations against viral infections.

Cataplexy Treatment

Treatment of cataplexy includes the use of medicines, lifestyle modifications, and dietary changes. People with cataplexy need emotional support at work/school and at home and should be provided with their special academic needs and other social requirements such as insurance and driver’s license.

Possible Medications for Cataplexy

Common medications for treating cataplexy, with or without narcolepsy, include antidepressants such as tricyclic antidepressants such as clomipramine, and selective serotonin reuptake inhibitors including Fluoxetine. Sodium oxybate is another medication commonly used to treat cataplexy. Individuals that have narcolepsy with cataplexy may also be treated with modafinil and stimulant drugs such as Ritalin.

Home Remedies to Help Cataplexy

Lifestyle changes and dietary modifications may help in reducing the frequency and intensity of cataplexy. Sleep hygiene is an important factor which may help reduce the intensity and frequency of cataplexy.

Practicing the following sleep hygiene measures may help reduce the symptom of cataplexy:

  • Keep a regular sleep schedule which ensures that you get up and go to bed at the same time every day.
  • Ensure you aim at getting a minimum of 7 to 8 hours of sleep daily.
  • Make the bedroom quiet and keep the temperature cool to allow for comfortable sleep.
  • Limit your exposure to light in the evening to prevent a delayed sleep onset.

Other lifestyle changes which help reduce these symptoms include:

  • Engage in regular exercise
  • Avoid consuming alcohol
  • Avoid taking caffeine in the afternoon or close to bedtime.
  • Take at least one short nap during the day.
  • Maintain a healthy diet.

Living with Cataplexy

People with cataplexy need to take extra precautions because of the nature of the condition:

  • Inform your friends and loved ones that you have the condition and tell them how to identify the symptoms. This will help them better understand the condition and help you to cope with it.
  • Ensure you drive with a companion or have them drive you as often as possible.
  • Be prepared for situations which may provoke strong emotions and have a friend keep a close eye on you in those situations.
  • Ensure you get as much sleep as possible – a short nap in the afternoon and seven to eight hours of sleep each night.
  • Be aware of potential dangers such as sharp objects, heights, and glass
  • Practice relaxation techniques such as yoga.
  • Avoid driving a car or operating machinery until you have been cleared by a medical professional.

Insurance Coverage for Cataplexy

Check your plan benefits for coverage of sleep therapy or neurological services. You may inquire through your human resources unit for employer-sponsored health coverage for treatment of this condition or you may contact your health insurance company directly. Also, find out about the out-of-pocket costs and deductibles you will pay to access the mental health services under your insurance plan.

How to Find a Therapist

Your primary care physician, after a thorough evaluation of your symptoms, will refer you to a neurologist or a sleep medicine specialist for treatment. You may also check through online resources and directory to find the right therapist for you.

What should I be looking for in a Licensed Mental Health Professional (LMHP)?

Qualities you should look for in an LMHP or sleep specialist include:

  • Good Communication Skills – Your LMHP should be able to effectively communicate their expert ideas and thoughts about your symptoms.
  • Empathy: You do not want a counselor who would rush through medical facts and treatment protocols without considering your emotional needs. You need an LMHP that is considerate, patient, calm, and compassionate with you.
  • Problem-Solving Skills: Your chosen LMHP must be knowledgeable enough to help you through to a satisfactory reduction of your symptoms. While your complete relief is not entirely up to your counselor, they must demonstrate ample ability to help manage your symptoms effectively.
  • Good multicultural Relationship: Your counselor must be able to strike a strong patient-therapist relationship with you regardless of any racial, ethnic, or cultural differences. Therapy must be devoid of such prejudices which may hamper the effectiveness of treatment.

Questions to ask for Potential Therapist

You should ask your therapist the following questions to help you gain more insight into your symptoms and the scope and potential effectiveness of available treatment options.

  • What may be causing these symptoms?
  • Do I have cataplexy?
  • Should I inform my school/employer/colleagues about the condition?
  • What is the treatment approach you recommend?
  • What medications will I be on?
  • What side effects should I expect from those drugs?
  • Are there effective home remedies I can employ?
  • What precautions should I take in living with this condition?
  • How will you monitor my treatment progress?
  • Are there any resources or websites you recommend?

Cataplexy is a brief, sudden loss of muscle control and tone triggered by strong emotions such as laughter, excitement, fear, and anger. Cataplexy is almost exclusively associated with narcolepsy, a sleep disorder characterized by excessive daytime sleepiness. Although cataplexy has no cure, its intensity and symptoms may be reduced with medications, sleep hygiene practices, and dietary changes.

References:

https://sleepfoundation.org/narcolepsy/content/cataplexy

https://www.medicalnewstoday.com/articles/307668.php

https://www.sleepassociation.org/sleep-disorders/narcolepsy/about-narcolepsy-cataplexy-2/

https://www.livestrong.com/article/83013-diet-therapy-narcolepsy/

https://www.researchgate.net/publication/262813425_Cataplexy_-_Clinical_aspects_pathophysiology_and_management_strategy

https://emedicine.medscape.com/article/1188433-overview#a1

https://emedicine.medscape.com/article/1154851-overview#a1

author avatar
Angel Rivera
I am a Bilingual (Spanish) Psychiatrist with a mixture of strong clinical skills including Emergency Psychiatry, Consultation Liaison, Forensic Psychiatry, Telepsychiatry and Geriatric Psychiatry training in treatment of the elderly. I have training in EMR records thus very comfortable in working with computers. I served the difficult to treat patients in challenging environments in outpatient and inpatient settings
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