Running head: CASE STUDY ON HYPERSOMNIA Case Study on Hypersomnia Student’s Name Institutional Affiliations 1 CASE STUDY ON HYPERSOMNIA 2 Table of Contents Case Study on Hypersomnia ........................................................................................................... 3 Introduction ................................................................................................................................. 3 Diagnosis ..................................................................................................................................... 4 Etiology ....................................................................................................................................... 6 Biological Causes .................................................................................................................... 7 Psychological Causes .............................................................................................................. 8 Social Causes ........................................................................................................................... 8 Treatment .................................................................................................................................. 10 Prognosis ................................................................................................................................... 13 Conclusion................................................................................................................................. 13 References ................................................................................................................................. 15 CASE STUDY ON HYPERSOMNIA 3 Case Study on Hypersomnia Introduction Hypersomnia or sleep-wake disorder is a sleep disorder characterized by excessive sleepiness, leading to reduced functioning, which impacts on performance negatively. Patients with this order often experience problems staying awake and attentive during major waking episodes, leading to an uncontrolled sleeping pattern. Hypersomnia can be categorized into primary hypersomnia and the recurrent hypersomnia (Ohayon, 2009). The former is characterized by excessive sleepiness over months or years but does not occur within regular periods. In the latter, the symptoms last for many years, but there are times when an individual is free from all the symptoms. However, the two types of hypersomnia are both characterized by long nap periods during the day, thus interrupting the schedules of the affected (Ohayon, 2009). Also, the frequent naps and more than seven hours of sleep during the night do not seem to refresh the individual. For hypersomnia, the symptoms present themselves gradually and may either worsen or get better with time. It is essential to diagnose and treat the disorder as soon as it is discovered because of its severe impacts. For instance, people with the disease may be involved in car accidents if they fall asleep in traffic. They could also sustain injuries from tripping, falling, and other forms of disasters. Prolonged hypersomnia can also impede the ability of an individual to fulfill their professional duties and maintain good social relationships. The disorder can also affect an individual’s well-being due to insecurity concerning their health. The case study seeks to highlight the symptoms and causes of the disorder by conducting a review of a twenty-year-old male, who is my brother named JM. I recently noticed that he might be suffering from the sleep-wake disorder, also known as hypersomnia. I can relate his symptoms CASE STUDY ON HYPERSOMNIA 4 to the condition because he has been complaining of the inability to control daytime sleepiness even after sleeping for more than seven hours at night. Moreover, he always looks tired, confused and unable to perform simple mental and physical tasks. Diagnosis In the past month, I had noticed a significant reduction in my brother’s functioning, in terms of his social interactions and overall work performance. He has also had difficulties remembering information, always fatigued, and seems confused most of the time. However, before I could conclude that JM is suffering from hypersomnia, I had to ask him several questions centered on the time he first noticed the drowsiness, his overall sleeping pattern and environment and an evaluation of current medication that could be contributing to the sleepiness. From my questioning, I deduced that he had five main symptoms. I categorized the symptoms using the DSM 5 method as follows: • Symptom 1 – falling asleep severally during the day. • Symptom 2 – feelings of confusion or combativeness when trying to wake up from sleep • Symptom 3 – Experiencing difficulties when trying to wake up from sleep • Symptom 4 – Feeling tired even after sleeping for more than nine hours • Symptom 5 – taking naps to counter the sleepiness but failing to wake up refreshed JM noted that he still felt unrested even after sleeping for long hours. Thus, upon waking up, he always felt sleep deprived. Further, he also experienced sleep drunkenness, which barred him from thinking clearly each time he woke up. He stated that he experienced a “foggy” feeling upon awakening and experienced difficulties performing simple physical and mental tasks. CASE STUDY ON HYPERSOMNIA 5 Additionally, JM often experienced sleep inertia, which caused him to have problems waking up accompanied by confusion and dizziness. During the questioning, I created a possible sleeping diary which showed his sleep and awake times both during the day and at night. However, it was necessary to ascertain the information, and I, therefore, asked him to keep a sleeping diary for the next seven days. I asked him to record the time he went to bed, the number of hours he sleeps and the waking time. I discovered that his sleeping pattern was characterized by long sleeping times during the day and at night. Apart from the diary, I also utilized the Epworth Sleeping Scale, which is a scale containing eight items essential in measuring sleepiness (Banerjee, 2007). I asked him to rate his probability of sleeping on a scale of 1 to 3 while engaged in specific activities. The scale would determine if he had a normal or abnormal sleeping pattern (Banerjee, 2007,). A score of 3 means that one has a high chance of falling asleep while a score of I points to a slight chance. Upon filling the form, the following were his test results Situation Score Sitting and reading 3 Watching television 3 Sitting inactive in a public place (e.g. a theatre/meeting) 3 As a passenger in a car for an hour with no break 3 Lying down in the afternoon (when possible) 3 Sitting and talking to someone 1 Sitting quietly after lunch without alcohol 3 CASE STUDY ON HYPERSOMNIA 6 In a car, while stopped for a few minutes in traffic 1 Total 20 From his test results (20), it was evident that he had an exceedingly high level of daytime sleepiness that required medical intervention. Though I had already performed the two self-examines tests, I felt the need to complete a Multiple Sleep Latency Test, which would make a clear distinction between fatigue and hypersomnia (Waihrich, Rodrigues, Silveira, Fróes, & Rocha, 2006). Ordinarily, people confuse between the two, but the latter denotes the ability to fall asleep. The test was performed in a clinic, and it sought to determine how fast JM fell to sleep with little simulation (Waihrich et al., 2006). The test was also to establish how soon he would enter REM sleep. During the test, JM was allowed to fall asleep, but the clinicians would often wake him up after twenty-minute intervals. After the test, it was established that JM had an MLST of under seven minutes, pointing to possible excessive daytime sleepiness. Apart from the tests, I noted that JM had been involved in an accident at his workplace. He had been accidentally hit by a blunt object, during one of the breaks. As such, he had been taking medication to relieve the pain. Furthermore, his sleeping environment was in no way related to his sleeping patterns because he fell asleep randomly in various places. Therefore, for the diagnosis, the three tests utilized were sleeping diary, Multiple Sleep Latency Test and the Epworth Sleeping Scale. Backed by the symptoms, the three results indicated that JM was suffering from hyper insomnia. I then sought to understand the causes of the sleep disorder. Etiology CASE STUDY ON HYPERSOMNIA 7 Biological Causes One of the primary causes of hypersomnia is a Traumatic Brain Injury (TBI). Such injuries tend to alter the functioning and output of the nucleus suprachiasmatic, causing disruptions in the circadian rhythm, which then leads to both insomnia and hypersomnia (Viola-Saltzman & Musleh, 2016). These injuries are often caused by motor vehicles and construction accidents, physical assault, and impact from objects. TBI can be categorized as either mild, moderate or intense depending on the severity of the symptoms. In this case, however, the conclusion is that the brain injury was severe because of the results acutely or develop as a long-lasting problem during the recovery period, which could be years after the injury (Viola-Saltzman & Musleh, 2016). Further, sleep disorders can also deter the recovery process after the TBI. Apart from hypersomnia, other sleep disorders associated with TBI are circadian rhythm and sleep-related breathing disorders. Apart from TBI, sleep disorders have a genetic element (Charrier, Olliac, Roubertoux, & Tordjman, 2017). Therefore, clinicians often acquire information concerning possible hypersomnia in the family before making a diagnosis. Other disorders occurring in the family should also be noted particularly those related to the nervous, endocrine and mental systems. Additionally, clinicians often enquire on the history of obesity, suicidal tendencies, and psychological disorders. Apart from the family history, it is also essential to obtain the personal history of the patient, which could be contributing to hypersomnia. Thus, illnesses related to the brain, endocrine system and use of toxic substances are often noted. Therefore, the biological causes of hypersomnia are not limited to TBI because there are those related to the family and personal history of the patient. In this case, the biological factor contributing to Jm’s hypersomnia is the brain injury sustained at his workplace. Therefore, the interruption in the functioning of his brain could be CASE STUDY ON HYPERSOMNIA 8 adding to daytime sleepiness, drowsiness, and confusion. However, his family and personal history are in no way linked to his sleep disorder. That means that the clinicians did not establish complications connected to the nervous system or psychological dysfunction. Psychological Causes Hypersomnia is also associated with mental disorders such as depression, Parkinson’s disease, and Alzheimer’s disease. For instance, individuals suffering from depression often experience severe symptoms of both insomnia and hypersomnia (Dauvilliers, Lopez, Ohayon, & Bayard, 2013). Thus, chronic sleepiness becomes a form of escape from the harsh world. Further, these psychological disorders cause patients to feel weak and physically ill, leading to more extended hours of sleep. Additionally, hypersomnia emanates from the fact that individuals with various mental disorders often experience feelings of unhappiness and emptiness, causing to sleep exceedingly. Thus, these people sleep most of the days, take many naps during the day, retire to bed early and are late to wake up. In some patients, hypersomnia can be mistaken for depression (Dauvilliers, Lopez, Ohayon, & Bayard, 2013). Thus, the chronic sleeping causes one to miss appointments, fail to finish simple tasks and unavailable for loved ones. The isolation coupled with depression causes an individual to desire long sleeping hours. Though psychological causes are a common cause of hypersomnia, they were not mentioned in JM’s case. The health professionals established that JM does not have psychological disorders such as depression, Alzheimer’s and Perkinson’s disease. With this discovery, it was easier for them to identify the best treatment methods for his condition. Social Causes CASE STUDY ON HYPERSOMNIA 9 Use of addictive substances such as alcohol, marijuana, and cocaine tends to increase the severity of hypersomnia symptoms (Mahfoud, Talih, Streem, & Budur, 2009). Individuals with a history of substance abuse and hypersomnia tend to have a substantial sleep time during the night, while drowsiness and frequent naps characterize their day time. There are drugs which cause negative impacts on the Central Nervous System by increasing sleepiness. However, withdrawal from these stimulants also activates hypersomnia symptoms. Continued use of these substances may trigger additional sleep problems, resulting in daytime sleepiness. Further, continued use or withdrawal can result in hypersomnia. For starters, alcohol consumption impedes with the chemicals found in the brain. The central role of these chemicals is controlling sleep and subduing REM sleep, a stage that is connected to sleep restoration (Mahfoud et al., 2009). Further, alcohol not only causes individuals to sleep for long hours but also interferes with their sleeping patterns. Therefore, alcohol is a major cause of hypersomnia because its consumers experience sleeping problems, awake several times during the nights, experience sleepiness during the day and generally have a poor quality of sleep. The impacts of alcohol are more pronounced when the drink is consumed late in the evening or during bedtime. Apart from alcohol, abuse of marijuana causes hypersomnia because the drug affects the normal sleeping patterns and further impacts brain chemicals associated with inducing sleep (Mahfoud, et al., 2009). Therefore, just like alcohol, marijuana use tends to overpower REM sleep. Though marijuana starts by promoting sleep, consistent or discontinuation of use can affect the sleep quality of an individual negatively. In addition to marijuana and alcohol, some stimulants lead to hypersomnia. These substances enhance the release of the dopamine hormone in the brain, which is crucial for remaining awake. CASE STUDY ON HYPERSOMNIA 10 Chronic use of addictive substances such as marijuana, alcohol, cocaine and some stimulants often trigger the symptoms of hypersomnia. Alternately, the withdrawal from the same can also lead to the disorder. However, JM admitted to the clinicians that he only consumes alcohol occasionally and therefore cannot be deemed as addicted to either of the drugs. Thus, as an occasional drinker, his symptoms do not have any correlation with the substance because the signs have been occurring continuously. I also noted that JM spends most of his time at work or at home, where he performs minimal activities. Treatment There are several recommended Treatments of hypersomnia depending on the severity and etiology of the problem. For instance, therapies and counseling alter the behavior, nonpharmacologic options, pharmacologic regimens, and lifestyle changes are some of the methods that cure the sleeping disorder. For starters, patients without primary conditions such as narcolepsy and apnea, may get help by applying nonpharmacologic options, which might help to normalize the pattern of the sleep (Siegel, Badr, & Krieger, 2005). For instance, people with voluntary sleep challenges may need to alter their sleep hygiene. Sleep hygiene approach is most suitable for treating people with work disorder. In this case, de-harmonization happens between the quotidian rhythm and existing chances to rest within the daily plan of the patient. The most affected with this disorder are the people working night shifts, although it may also affect those working in irregular shifts. Excellent sleep hygiene calls for a well-structured tactic and timing of sleeping and waking up. An individual should ensure that they rest in an environment that is conducive to sleep. For example, a dark room or use of eye masks may create such a setting. At the same, one may use earplugs and dulling loud sounds. Another CASE STUDY ON HYPERSOMNIA 11 approach to good sleep hygiene is ensuring that one is exposed to light during the waking hours, while also avoiding excessive exposure to light, which may result in a delayed period of sleep (Siegel, Badr, & Krieger, 2005). Also, going to bed at a specific time every night, while avoiding sleeping during the day is another solution to hypersomnia. Also, one should avoid depressant such as alcohol because it disrupts sleep. Additionally, medications and tobacco, which stimulate wakefulness should be avoided, mainly when one is about to sleep. Although exercise is an excellent recommendation for treating this problem, one should avoid it when they are almost headed to bed (Siegel, Badr, & Krieger, 2005). Therefore, exercising is advised because it helps a person to remain in excellent shape, as studies have revealed there is a strong relationship between apnea and obesity. Light therapy and chronotherapy are the two primary recommended nonpharmacologic therapy available for patients with delayed sleep syndrome (Siegel, Badr, & Krieger, 2005). The latter involved altering the bedtime hours forward by some hours until the time when one will reach the desired sleep time. After entering this time, a disciplined approach is used to lock the bedtime through having wake-up calls, alarms, cohabitants helping to enforce a consistent sleep regimen. Though a less radical approach, light treatment occurs through exposing an individual to bright light during their waking hours. The technique has an alerting effect, which is impacting the circadian rhythm. Another treatment for the sleep disorder involves the use of drugs after the nonpharmacologic approach fails. All the medicines of the patients should be reviewed to determine whether they are affecting the sleeping pattern of the affected person. Some of the suggested treatments include the use of stimulants, antidepressants, hypnotics, modafinil, and melatonin. The hypnotics are used to standardize the sleep schedule because they treat over a CASE STUDY ON HYPERSOMNIA 12 short period. The most employed treatment is Benzodiazepine receptor agonists because they have a positive impact on the day and night symptoms (Siegel, Badr, & Krieger, 2005). Patients that need to be alert in the day may be prescribed Short-acting benzodiazepines. However, those with sleep disorders that experience anxiety may be recommended to use longer-acting medications. However, long term exposure to hypnotic to treat sleep disorder is not endorsed, in part, because they may have side effects, and only mask the disorder instead of curing it entirely. Stimulants are another treatment that can help bring sporadic symptom reprieve. For instance, to treat narcolepsy, Dextroamphetamine and methylphenidate are the recommended medications. The former may be divided into doses of between five and sixty mg/d, while the latter may be used up to 60 mg/d, bid or lid (Siegel, Badr, & Krieger, 2005). There is a need to monitor patients using these medications to avoid cases of drug abuse. Concomitant insomnia associated with depression may also be addressed through sedative antidepressants. However, the issued antidepressants should be tailored to meet the needs of the patients. Melatonin, a hormone found in the pineal gland, has a different reaction to the circadian rhythm as compared to bright light. Therefore, it is a treatment approach for those experiencing delayed sleep period signs. One may be prescribed to use 3-mg early dosage, which may increase to reach 10-mg (Siegel, Badr, & Krieger, 2005).Patients trying to sleep early can consume it in the evening. The final treatment approach is the use of modafinil with a dosage of 100 mg/d to 200 mg/d consumed in the morning as one starts to use this medication (Siegel, Badr, & Krieger, 2005). However, depending on the response of the patients, some clinicians may increase the dosage to 400 mg/d. However, there is a concern of abuse of all these dosages, which calls for monitoring of patients. Other drugs for sleep disorders are RLS because it responds to gabapentin, opiates, and dopamine agonists. CASE STUDY ON HYPERSOMNIA 13 Prognosis Apart from the suggested medical treatments, patients like JM can benefit from nonmedical treatments, which can address hypersomnia symptoms partially. Therefore, treatments that are both psychological and behavioral can reduce the effects of the disorder and further counter other conditions that intensify the sleepiness. However, in JM’s case, I noted that it was not possible to introduce napping as a mitigation strategy because he would experience problems awakening. Therefore, the clinicians advised him to engage himself in tasking activities that would keep his brain engaged and prevent him from sleeping. It was, therefore, suggested that he avoids activities that increased the chances of taking a nap such as watching television, reading books, listening to music. JM was also supposed to keep his sleeping diary as a tool for determining improvements in his sleeping patterns. Thus, he was to engage in activities that require both physical and mental energy. These strategies were to be accompanied by alternative medical forms of treatment. Conclusion From the case study, it is evident that hypersomnia, as a sleeping disorder, causes excessive sleepiness during the day and at night. The affected often have long sleeping times and never get refreshed. Their normal functioning is also hindered by consistent drowsiness, confusion, and irritability. Therefore, these people experience challenges both in their professional and social lives. As in the case of JM, I noted that he was no longer engaging in physical activities and ordianr working hours; he often spent most of his time sleeping. However, the diagnosis of the disorder may vary from simple strategies such as keeping a sleep diary to more complex processes such as CASE STUDY ON HYPERSOMNIA 14 the Multiple Sleep Latency Test. These tests are essential in distinguishing between fatigue and hypersomnia. The case study also established that causes of the sleeping disorder vary among individuals. Some of the common causes include biological factors such as brain injury and genetic elements. The disorder could also be a result of psychological factors such as depression, Alzheimer’s and Parkinson’s disease. That is why it is essential for clinicians to obtain the complete family and personal history of a patient before treating the disorder. Other causes of the daytime sleepiness are social factors such as excessive consumption of alcohol and abuse of substances such as alcohol and marijuana. Moreover, the treatment of the disorder depends on its causes though treatment may be either medical or non-medical. However, failure to treat this order soonest possible may cause the patient to suffer severe injuries resulting from motor vehicle and construction accidents, falls and trips. It is, therefore, essential for patients like JM to seek help once they notice the symptoms of the daytime sleepiness. CASE STUDY ON HYPERSOMNIA 15 References Banerjee, D. (2007). The Epworth Sleepiness Scale. Occupational Medicine, 57(3), 232-232. doi:10.1093/occmed/kqm009 Charrier, A., Olliac, B., Roubertoux, P., & Tordjman, S. (2017). Clock Genes and Altered Sleep–Wake Rhythms: Their Role in the Development of Psychiatric Disorders. International Journal of Molecular Sciences, 18(5), 938. doi:10.3390/ijms18050938 Dauvilliers, Y., Lopez, R., Ohayon, M., & Bayard, S. (2013). Hypersomnia and depressive symptoms: methodological and clinical aspects. BMC Medicine, 11(1). doi:10.1186/1741-7015-11-78 Mahfoud, Talih, Streem, & Budur. (2009). Sleep Disorders in Substance Abusers How Common Are They? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2766287/ Ohayon, M. M. (2009). From wakefulness to excessive sleepiness: What we know and still need to know. Sleep Medicine Reviews, 12(2), 129-141. doi:10.1016/j.smrv.2008.01.001 Siegel, Badr, & Krieger. (2005). When sleep is the enemy. Retrieved from https://www.semel.ucla.edu/sites/default/files/sleep/publications/Hypersomnia.pdf Viola-Saltzman, M., & Musleh, C. (2016). Traumatic brain injury-induced sleep disorders. Neuropsychiatric Disease and Treatment, 12, 339. doi:10.2147/ndt.s69105 Waihrich, E. S., Rodrigues, R. N., Silveira, H. A., Fróes, F. D., & Rocha, G. H. (2006). Comparative analysis of multiple sleep latency tests (MSLT) parameters and occurrence of dreaming in patients with daytime sleepiness of narcoleptic and non-narcoleptic origin. Arquivos de Neuro-Psiquiatria, 64(4), 958-962. doi:10.1590/s0004282x2006000600014
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