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  • Adjunct Faculty, Department of Clinical Pharmacy Practice, Butler University College of Pharmacy and Health Sciences
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Often gastritis diet buy motilium 10 mg cheap, such individuals take a wait-and-see attitude and do not employ problem-solving or efective management techniques gastritis diet 80 order motilium 10 mg line. Efective maintenance includes:??Acceptance of the lapse and a willingness to syarat diet gastritis discount motilium 10 mg with mastercard re-engage in problem solving and reinstate the use of techniques that have been successful in the past gastritis diet handout cheap motilium 10 mg online. There are some treatments that may have worked for a few people, yet no scientifcally valid studies support their efcacy and therefore they are not typically recommended by expert clinicians. Diets, electric stimulation, massage, acupuncture and hypnosis are all approaches which lack adequate research to be recommended by expert clinicians. Some of these approaches might prove useful as an adjunctive or additional treatment to use with cognitive behavioral treatment, but they cannot be recommended as stand-alone treatments. Remember, any treatment that might work for one person, may not work for most or all people. The treatment approaches endorsed in this booklet are derived from cognitive behavioral principles and behavioral and medical research. Many individuals have been reticent to establish close interpersonal relationships or have not pursued vocational interests. If too much attention is paid to the picking or pulling and none to these life issues, the individual has a much higher chance of relapse. Well-meaning friends and family members often wish to be helpful, yet at times their eforts can actually 20 Maintaining a supportive role and making eforts to communicate directly, but in a sensitive manner with the person you are trying to help can be benefcial. Books, self-help groups and other resources are available to family members who need extra support. To be a supportive, helpful, and fully invested resource, it is important that you are strong, informed, empathic and calm when helping your loved one. Foundation members receive discounted event pricing, free admission to live webinars, exclusive access to our members-only website content, and our quarterly InTouch newsletter. If you are a mental health professional: Attend our training programs to improve your ability to identify and efectively treat hair pulling, skin picking, and related body-focused repetitive behaviors. Become a professional member to stay up to date on research, treatment developments, and to obtain a referral listing on our website. Partner with leading scientists from around the world on truly cutting-edge research. We take a comprehensive approach to helping people overcome and heal from body-focused repetitive behaviors by: Connecting afected individuals and their families with each other, thereby helping to end their isolation and providing a community of support. Referring people to appropriate treatment providers, services, and educational resources so that they can take better control of their recovery. We conduct outreach to healthcare providers and educators, teaching them how to recognize these disorders, and train qualifed mental health professionals in the latest evidence-based cognitive behavioral treatment approaches. We design and fund research projectsaimed at understanding the neurobiology of these disorders and identifying pharmacological and behavioral treatments, as well as possibilities for prevention. Census Idiocy/Insanity Also in the 1840s, southern alienists discovered a malady called Drapetomania the inexplicable, mad longing of a slave for freedom. Census Mania mostly as defined today, a condition characterized by severely elevated mood. The difference between monomania and passion can be very subtle and difficult to recognize. Only one diagnosis, Adjustment Reaction of Childhood/Adolescence, could be applied to children. Increased attention was given to the problems of children and adolescence with the categorical addition of Behavior Disorders of Childhood-Adolescence. Its reliability was improved with the addition of explicit diagnostic criteria and structured interviews. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers. These persistent drug effects may benefit from long term approaches to treatment. Motor or sensory sx suggest a neurologic or general medical problem (?pseudoneurologic?) B. Psychological factors are key, as stressors precede onset of deficit/symptoms (a symbolic resolution that keeps psychological conflict out of conscious awareness) C. Deafness, hallucinations The Grief that has no vent in tears Makes other organs weep. Age 14, she saw a church play about the end of the world and became terrified of earthquakes or signs from God that the world was ending. Was the presence of any Personality Disorder at baseline associated with a poor treatment response? The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item required in children. The anxiety, worry, or physical symptoms cause clinically signifcant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological efects of a substance. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). I see other woman on fears, fear of harm to self or others, and scrupulosity (Abramowitz, the street or on Facebook and I can t stop thinking whether I will0 McKay, & Taylor, 2008). Relationship obsessive compulsive dis be happier with them, or feel more in love with them. Jane, a 28 year-old of the relationship experience (relationship-centered; Doron, academic in a 2-year relationship, recently moved in with her Derby, Szepsenwol, & Talmor. She describes a different preoccupation: I love my phenomena may also include disabling preoccupation with the partner, I know I can t live without him,0 but I can t stop thinking0 perceived? We argue that consideration of this obsessional theme may lead to a 2211-3649/$-see front matter & 2013 Elsevier Ltd. We also argue that socio-cultural factors, ing when experienced in the course of an ongoing romantic early childhood environments, and parent?child relationships, in? Such cases are frequently associated with extreme fear of anticipated regret and 2. Other regarding romantic relationships and compulsive behaviors per people report avoiding romantic relationships altogether for dread formed in order to alleviate the distress associated with the of hurting others. Measures of relationship obsessive?compulsive symptoms viors to others,0 visualizing or recalling positive experiences or feelings, reassurance seeking and self-reassurance (see Table 1). Guilt and shame may also be associated with lized in terms of dimensions rather than categories. Typical triggers Intrusion Appraisal Typical responses Contextual Romantic cues Relationship-centered. Shame Physical attraction (or lack thereof) Urge to leave Cognitive-behavioral responses Talk of commitment Partner-focused Reassurance seeking, monitoring feelings, Emotional She is unattractive? I will regret this forever comparisons avoidance. Finally, checking and reassurance seeking) on three relational dimensions: we evaluate the potential role of other personality factors, societal one s feelings towards a relationship partner. For instance, over obsessive?compulsive phenomena, small to moderate correlations estimation of threat may bias individuals0 interpretations of are expected between these measures and tools assessing other others0 feelings towards them. The belief that one can and should control one s0 thoughts may promote suppression efforts of relationship doubts or negative thoughts 4. Adams and Jones (1997) proposed a three dimensional conceptualization of relational commitment, includ 4. In support of these hypoth shield them from the temptation of attractive alternatives (see eses, studies have found that, as compared to participants with Lydon, 2010 for a review). Moreover, these doubts may further reduce tension, and (b) rely more on external feedback in assessing these personal commitment, which, in turn, may decrease the effective internal states (Lazarov, Dar, Oded, & Liberman, 2010, Lazarov, Dar, ness of temptation-shielding mechanisms and then intensify the Liberman, & Oded, 2012). Liberman, and Dar (2013) have recently found that intense the normative and constraining dimensions of relational com monitoring of one s feelings of emotional closeness in an intimate0 mitment may be heavily in? For instance, one client may magnify fears of making the wrong decision?, leading to quanti? Another client reported time spent crying0 following An additional relationship-related factor that may be involved a relationship breakup as a retrospective indicator of his feelings. More often, however, clients gage relationship quality or rightness Regret is experienced when we realize that our current situation by referring to the cognitive.

Because they are primarily evolutionarily determined gastritis ruq pain cheap motilium 10mg fast delivery, the basic emotions are experienced and displayed in much the same way across cultures (Ekman gastritis symptoms livestrong discount 10mg motilium fast delivery, 1992; [2] Elfenbein & Ambady treating gastritis with diet buy 10 mg motilium fast delivery, 2002 gastritis nsaids motilium 10 mg with amex, 2003; Fridland, Ekman, & Oster, 1987), and people are quite accurate at judging the facial expressions of people from different cultures. Video Clip: the Basic Emotions Not all of our emotions come from the old parts of our brain; we also interpret our experiences to create a more complex array of emotional experiences. For instance, the amygdala may sense fear when it senses that the body is falling, but that fear may be interpreted completely differently (perhaps even as excitement?) when we are falling on a roller-coaster ride than when we are falling from the sky in an airplane that has lost power. The cognitive interpretations that accompany emotions?known as cognitive appraisal?allow us to experience a much larger and more complex set of secondary emotions, as shown in Figure 10. Although they are in large part cognitive, our experiences of the secondary emotions are determined in part by arousal (on the vertical axis of Figure 10. They are determined by both their level of arousal (low to high) and their valence (pleasant to unpleasant). When you succeed in reaching an important goal, you might spend some time enjoying your secondary emotions, perhaps the experience of joy, satisfaction, and contentment. But when your close friend wins a prize that you thought you had deserved, you might also experience a variety of secondary emotions (in this case, the negative ones)?for instance, feeling angry, sad, resentful, and ashamed. You might mull over the event for weeks or even months, experiencing [3] these negative emotions each time you think about it (Martin & Tesser, 2006). Our response to the basic emotion of fear, for instance, is primarily determined by the fast pathway through the limbic system. When a car pulls out in front of us on the highway, the thalamus activates and sends an immediate message to the amygdala. Secondary emotions are more determined by the slow pathway through the frontal lobes in the cortex. When we stew in jealousy over the loss of a partner to a rival or recollect on our win in the big tennis match, the process is more complex. Information moves from the thalamus to the frontal lobes for cognitive analysis and integration, and then from there to the amygdala. We experience the arousal of emotion, but it is accompanied by a more complex cognitive appraisal, producing more refined emotions and behavioral responses. In some cases we take action after rationally processing the costs and benefits of different choices, but in other cases we rely on our emotions. Emotions become particularly important in guiding decisions when the alternatives between many complex and conflicting alternatives present us with a high degree of uncertainty and ambiguity, making a complete cognitive analysis difficult. In these cases we often rely on our emotions to make decisions, and these decisions may in many cases be more accurate than those produced by cognitive processing (Damasio, 1994; Dijksterhuis, Bos, Nordgren, & van Baaren, 2006; Nordgren & Dijksterhuis, [5] 2009; Wilson & Schooler, 1991). The Cannon-Bard and James-Lange Theories of Emotion Recall for a moment a situation in which you have experienced an intense emotional response. Perhaps you woke up in the middle of the night in a panic because you heard a noise that made you think that someone had broken into your house or apartment. Or maybe you were calmly cruising down a street in your neighborhood when another car suddenly pulled out in front of you, forcing you to slam on your brakes to avoid an accident. I?m sure that you remember that your emotional reaction was in large part physical. Perhaps you remember being flushed, your heart pounding, feeling sick to your stomach, or having trouble breathing. You were experiencing the physiological part of emotion?arousal?and I?m sure you have had similar feelings in other situations, perhaps when you were in love, angry, embarrassed, frustrated, or very sad. If you think back to a strong emotional experience, you might wonder about the order of the events that occurred. Certainly you experienced arousal, but did the arousal come before, after, or along with the experience of the emotion? Psychologists have proposed three different theories of emotion, which differ in terms of the hypothesized role of arousal in emotion (Figure 10. According to the theory of emotion proposed by Walter Cannon and Philip Bard, the experience of the emotion (in this case, I?m afraid?) occurs alongside our experience of the arousal (?my heart is beating fast?). According to the Cannon-Bard theory of emotion, the experience of an emotion is accompanied by physiological arousal. Thus, according to this model of emotion, as we become aware of danger, our heart rate also increases. Although the idea that the experience of an emotion occurs alongside the accompanying arousal seems intuitive to our everyday experiences, the psychologists William James and Carl Lange had another idea about the role of arousal. According to the James-Lange theory of emotion, our experience of an emotion is the result of the arousal that we experience. This approach proposes that the arousal and the emotion are not independent, but rather that the emotion depends on the arousal. The fear does not occur along with the racing heart but occurs because of the racing heart. As William James put it, We feel sorry because we cry, angry because we strike, afraid [6] because we tremble? (James, 1884, p. A fundamental aspect of the James-Lange theory is that different patterns of arousal may create different emotional experiences. The emotional circuits in the limbic system are activated when an emotional stimulus is experienced, and these circuits quickly create corresponding physical [7] reactions (LeDoux, 2000). The process happens so quickly that it may feel to us as if emotion is simultaneous with our physical arousal. On the other hand, and as predicted by the James-Lange theory, our experiences of emotion are weaker without arousal. Patients who have spinal injuries that reduce their experience of arousal [8] also report decreases in emotional responses (Hohmann, 1966). There is also at least some support for the idea that different emotions are produced by different patterns of arousal. People who view fearful faces show more amygdala activation than those who watch angry or joyful [9] faces (Whalen et al. The Two-Factor Theory of Emotion Whereas the James-Lange theory proposes that each emotion has a different pattern of arousal, the two-factor theory of emotion takes the opposite approach, arguing that the arousal that we experience is basically the same in every emotion, and that all emotions (including the basic emotions) are differentiated only by our cognitive appraisal of the source of the arousal. Because both arousal and appraisal are necessary, we can say that emotions have two factors: an arousal factor and a cognitive factor (Schachter & Singer, [12] 1962): emotion = arousal + cognition In some cases it may be difficult for a person who is experiencing a high level of arousal to accurately determine which emotion she is experiencing. That is, she may be certain that she is feeling arousal, but the meaning of the arousal (the cognitive factor) may be less clear. Some romantic relationships, for instance, have a very high level of arousal, and the partners alternatively experience extreme highs and lows in the relationship. One day they are madly in love with each other and the next they are in a huge fight. In situations that are accompanied by high arousal, people may be unsure what emotion they are experiencing. In the high arousal relationship, for instance, the partners may be uncertain whether the emotion they are feeling is love, hate, or both at the same time (sound familiar? The tendency for people to incorrectly label the source of the arousal that they are experiencing is known as the misattribution of arousal. When he had finished, she wrote her name and phone number on a piece of paper, and invited him to call if he wanted to hear more about the project. More than half of the men who had been interviewed on the bridge later called the woman. In contrast, men approached by the same woman on a low solid bridge, or who were interviewed on the suspension bridge by men, called significantly less frequently. The idea of misattribution of arousal can explain this result?the men were feeling arousal from the height of the bridge, but they misattributed it as romantic or sexual attraction to the woman, making them more likely to call her. Research Focus: Misattributing Arousal If you think a bit about your own experiences of different emotions, and if you consider the equation that suggests that emotions are represented by both arousal and cognition, you might start to wonder how much was determined by each. That is, do we know what emotion we are experiencing by monitoring our feelings (arousal) or by monitoring our thoughts (cognition)? The bridge study you just read about might begin to provide you an answer: the men seemed to be more influenced by their perceptions of how they should be feeling (their cognition) rather than by how they actually were feeling (their arousal). Schachter and Singer believed that the cognitive part of the emotion was critical?in fact, they believed that the arousal that we are experiencing could be interpreted as any emotion, provided we had the right label for it. Thus they hypothesized that if an individual is experiencing arousal for which he has no immediate explanation, he will label? this state in terms of the cognitions that are created in his environment. On the other hand, they argued that people who already have a clear label for their arousal would have no need to search for a relevant label, and therefore should not experience an emotion. In the research, male participants were told that they would be participating in a study on the effects of a new drug, called suproxin,? on vision. On the basis of this cover story, the men were injected with a shot of the neurotransmitter epinephrine, a drug that normally creates feelings of tremors, flushing, and accelerated breathing in people.

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This is confirmed and reinforced by Figures B1a to uremic gastritis definition motilium 10 mg mastercard B9a in the Appendix that show the same flat graphs for the full sample gastritis dieta buy generic motilium on-line, heart attacks gastritis location generic 10 mg motilium, respiratory gastritis symptoms home remedies buy line motilium, metabolic, neoplastic and infectious admissions. The effect is most pronounced on the Monday after the clocks are turned back by one hour, and then decreases smoothly over the next three days before they disappear on day five. The decrease for cardiovascular admissions equals about 1 admission per 100,000 population for four days, or about 40 admissions per 1 million residents over the entire week. In our set of robustness checks, in Figures B1b to B6b, one obtains exactly the same pattern using the full sample (Figure B1b), heart attacks (Figure B2b), injuries (Figure B3b), respiratory and metabolic admissions (Figure B4b and B5b) as well as neoplastic admissions (Figure B6b). There is little room for interpretation whether these patterns could be 10 due to voluntary behavioral responses when it comes, for example, to heart attacks. Some readers may become suspicious since the pattern look surprisingly similar across different disease categories. We solely see the primary diagnosis in the data and know that the patient stayed overnight, which excludes ambulatory elective surgeries. Also recall that these daily estimates are not nonparametric plots but stem from the rich fixed effects specification in equation (1). Moreover, the coefficients compare the relative admission rates for the 15 days plotted to the admission rates in the prior and post two weeks. Lastly, note that we identify exactly the same four-day pattern using American survey data (see Figures 2b, A3 and A5). We interpret the similarity of these four-day pattern across different disease groups as strong support for our identification strategy. Moreover, the implication in terms of content would be that additional sleep is protective across a broad range of disease groups for people who are on the margin to getting admitted to a hospital. The medical advice for most people on the margin to getting admitted to a hospital is certainly to lay down and rest, which is essentially what one hour of additional sleep represents. Note that the medical literature provides support of our notion that sleep matters and crucially affects patients in critical health conditions. For example, it is well know that cancer patients suffer from fatigue and sleep disorders that is not well defined or well understood at present (Ancoli-Israel et al. Stepanski and Burgess (2007) note that patients with cancer commonly report disturbed sleep, fatigue [?]? and that the overall significance of poor sleep as it relates to fatigue, pain, depression, or other health outcomes would be unknown. Furthermore, they state that the evaluation and treatment of sleep disturbance in patients undergoing treatment for cancer was important. First, Figures B7 to B9 plot the results of the daily approach for the diagnoses (i) suicide attempts, (ii) drug overdosing, and (iii) infectious diseases. While all three diagnoses could, in principle, be affected by sleep we consider it less likely in these cases, since (i) and (ii) should be driven by very time-persistent individual issues such as depression or addiction and not be triggered by one hour more or less sleep. All curves are very flat around the zero line in the week following the change in clocks. If anything, one might observe the characteristic four-day decrease in admissions for infectious diseases. Again, each column of Table 4 represents one independent model and the outcome variable is displayed in the column header. The coefficient estimates carry unsystematic positive or negative signs throughout and have a magnitude of about 1-2% of the mean. Increases of 3-4% can be excluded with 95% statistical certainty (see also Figures 4a-5a, B1a-B8a). Two exceptions are the neoplastic admission rate which carries a coefficient size of 3. Similar is the case for suicide attempts with a marginally significant, positive, and relatively large coefficient. Taken at face value, these estimates would suggest that one hour less sleep in spring does matter for these subgroups which is not totally unreasonable. However, inspecting the according Figures B6a and B7a, one 11 does not find a convincing systematic pattern that could drive the results. Hence, we interpret these effects very carefully and keep in mind how powerful our data are and that even small random shocks could lead to significant daily coefficient estimates. For example, Figure 5b shows significant decreases of heart admissions by about 1. One also obtains exactly the same figure when multiplying the coefficient estimate of -0. Next, we move the six week window one week further into February and repeat the approach. The weekly coefficient estimates are plotted in Figures B10a and B10b along with the true spring and fall estimates (rightmost coefficients #23 and #24). First, our empirical approach is sophisticated enough to eliminate most seasonal confounders that may affect admissions. Except for one estimate in the first half of the year, in Figure B10a, all weekly coefficient estimates are close to the zero line, fluctuate very little, and lie between the boundaries of -2ppt and +2ppt (relative to a mean of 59. Since we do not specifically st control for May 1 in the specification, the weekly decrease by -4 could be entirely explained by st a May 1 decrease of 28 admissions. When interpreting the placebo estimates, this fact simply has to be considered when interpreting the estimates. It could simply be noise and related to weather effects?admissions decrease on sunny days and mid-October typically provides the last nice days of the year?or due to vacation effects. Even though we control for school vacations, Germans without kids typically go on fall vacation for one to two weeks in rd October. October 3 is a national holiday in Germany (German Reunification Day) and often leads to a long? weekend. Many Germans take advantage of this long weekend and extend it for their fall vacation. One explanation for this asymmetry is that people react differently to spring and fall time changes, perhaps in ways consistent with the notion of loss aversion. The biological sleep rhythm of humans and intuition might also provide an explanation for the asymmetric effects. Without behavioral adjustments, most people would sleep one hour less in the night from Sunday to Monday. However, to the extent that such behavior leads to tiredness on the Monday, most people would probably simply go to bed one hour earlier Sunday night. In fall, by contrast, people would feel relaxed and well-rested on Monday due to the extra hour of sleep. To the extent that those people do not fully adjust their bedtime to wintertime but keep on going to bed at summertime 11pm, the sleep extension would even carry over to the next days. Another explanation for asymmetric behavioral sleep adjustments could be media exposure. Figure 6 shows that result of a google search request using the keywords daylight savings time? and heart attack. In addition, column (2) shows that share of American who unintentionally fell asleep during the day decreases by a significant 4. The analogous graphical representation with the plotted daily effects is in Figure A5. Again we observe that the characteristic drop in fall lasts for four days (Figure A5b). This finding is in line with the relatively large, albeit impressively estimated, sufficient rest? coefficients in columns (5) and (6) of Table A5. One could hypothesize that the effects differ depending on how time and schedule-constrained people are. If someone has the possibility to adjust their bed and their wake-up times flexibly, one would expect the potential health effects to be smaller. The most constrained individuals with respect to their wake-up time are employees without flexible working schedules. This is also the societal subgroup among which we would expect to find most sleep deprived people. Overall, the findings are in line with what we already found: the triple interaction terms are mostly non-significant and small in size. However, if there is a pattern to observe, then it is a pattern that confirms the hypothesis above, namely that subgroups which 27 are likely to be time-constraint, sleep deprived, and inflexible in their daily schedules are more affected. Investigating Mechanisms using Daily Variation in Weather and Pollution Lastly, we investigate effect heterogeneity by weather and pollution conditions using the German Hospital Census.

A diagnostic and therapeutic trial of sleep extension for 10-14 days can often clarify the diagnosis gastritis symptoms nhs direct order motilium 10mg online. Hypersomnoience disorder should be distinguished from excessive sleepiness related to diet during gastritis best motilium 10mg insufficient sleep quantity or quality and fatigue gastritis diet order motilium with a mastercard. Excessive sleepiness and fatigue are difficult to gastritis diet cost of motilium differentiate and may overlap considerably. Individuals with hypersomnoience and breathing related sleep disorders may have similar patterns of excessive sleepiness. Breathing related sleep disorders are suggested by a history of loud snoring, pauses in breathing during sleep, brain injury, or cardiovascular disease and by the presence of obesity, oro? pharyngeal anatomical abnormalities, hypertension, or heart failure on physical examina? tion. Polysomnographie studies can confirm the presence of apneic events in breathing related sleep disorder (and their absence in hypersomnolence disorder). Circadian rhythm sleep-wake disorders are often characterized by daytime sleepiness. A history of an abnormal sleep-wake schedule (with shifted or irregular hours) is present in individuals with a circadian rhythm sleep wake disorder. Parasomnias rarely produce the prolonged, undisturbed nocturnal sleep or daytime sleepiness characteristic of hypersomnolence disorder. Hypersomnolence disorder must be distinguished from mental disorders that include hypersomnolence as an essential or associated feature. In particular, complaints of daytime sleepiness may occur in a major depressive episode, with atypical fea? tures, and in the depressed phase of bipolar disorder. Assessment for other mental disorders is essential before a diagnosis of hypersomnolence disorder is considered. A diagnosis of hyper? somnolence disorder can be made in the presence of another current or past mental disorder. Many individu? als with hypersomnolence disorder have symptoms of depression that may meet criteria for a depressive disorder. This presentation may be related to the psychosocial consequences of persistent increased sleep need. Individuals with hypersomnolence disorder are also at risk for substance-related disorders, particularly related to self-medication with stimulants. This general lack of specificity may contribute to very heterogeneous profiles among indi? viduals whose symptoms meet the same diagnostic criteria for hypersomnolence disorder. Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping oc? curring within the same day. These must have been occurring at least three times per week over the past 3 months. Episodes of cataplexy, defined as either (a) or (b), occurring at least a few times per month: a. In individuals with long-standing disease, brief (seconds to minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness that are precipitated by laughter or joking. In children or in individuals within 6 months of onset, spontaneous grimaces or jaw-opening episodes with tongue thrusting or a global hypotonia, without any obvious emotional triggers. Moderate: Cataplexy once daily or every few days, disturbed nocturnal sleep, and need for multiple naps daily. Severe: Drug-resistant cataplexy with multiple attacks daily, nearly constant sleepi? ness, and disturbed noctumal sleep. Subtypes In narcolepsy without cataplexy but with hypocretin deficiency, unclear 'cataplexy-like" symptoms may be reported. Seizures, falls of other origin, and conversion disorder (functional neurological symptom disorder) should be excluded. In other cases, the destruction of hypocretin neurons may be secondary to trauma or hypothalamic surgery. Diagnostic Features the essential features of sleepiness in narcolepsy are recurrent daytime naps or lapses into sleep. Sleepiness typically occurs daily but must occur at a minimum three times a week for at least 3 months (Criterion A). Narcolepsy generally produces cataplexy, which most commonly presents as brief episodes (seconds to minutes) of sudden, bilateral loss of mus? cle tone precipitated by emotions, typically laughing and joking. Muscles affected may include those of the neck, jaw, arms, legs, or whole body, resulting in head bobbing, jaw dropping, or complete falls. To meet Criterion Bl(a), cataplexy must be triggered by laughter or joking and must occur at least a few times per month when the condition is untreated or in the past. Cataplexy should not be confused with 'weakness" occurring in the context of athletic activities (physiological) or exclusively after unusual emotional triggers such as stress or anxiety (suggesting possible psychopathology). Episodes lasting hours or days, or those not triggered by emotions, are unlikely to be cataplexy, nor is rolling on the floor while laugh? ing hysterically. In children close to onset, genuine cataplexy can be atypical, affecting primarily the face, causing grimaces or jaw opening with tongue thrusting ("cataplectic faces"). Alter? natively, cataplexy may present as low-grade continuous hypotonia, yielding a wobbling walk. Criterion Bl(b) can be met in children or in individuals within 6months of a rapid onset. Narcolepsy-cataplexy nearly always results from the loss of hypothalamic hypocretin (orexin)-producing cells, causing hypocretin deficiency (less than or equal to one-third of control values, or 110 pg/mL in most laboratories). These tests must be performed after the individual has stopped all psychotropic medications, following 2weeks of adequate sleep time (as documented with sleep diaries, actigraphy). Associated Features Supporting Diagnosis When sleepiness is severe, automatic behaviors may occur, with the individual continuing his or her activities in a semi-automatic, hazelike fashion without memory or conscious? ness. Approximately 20%-60% of individuals experience vivid hypnagogic hallucinations before or upon falling asleep or hypnopompic hallucinations just after awakening. These hallucinations are distinct from the less vivid, nonhallucinatory dreamlike mentation at sleep onset that occurs in normal sleepers. Approximately 20%-60% of indi? viduals experience sleep paralysis upon falling asleep or awakening, leaving them awake but unable to move or speak. However, many normal sleepers also report sleep paralysis, especially with stress or sleep deprivation. Nocturnal sleep disruption with frequent long or short awakenings is common and can be disabling. Individuals may appear sleepy or fall asleep in the waiting area or during clinical ex? amination. During cataplexy, individuals may slump in a chair and have slurred speech or drooping eyelids. If the clinician has time to check reflexes during cataplexy (most attacks are less than 10seconds), reflexes are abolished?an important finding distinguishing gen? uine cataplexy from conversion disorder. Development and Course Onset is typically in children and adolescents/young adults but rarely in older adults. Severity is highest when onset is abrupt in children, and then decreases with age or with treatment, so that symptoms such as cataplexy can oc? casionally disappear. Abrupt onset in young, prepubescent children can be associated with obesity and premature puberty, a phenotype more frequently observed since 2009. Onset in adults is often unclear, with some individuals reporting having had excessive sleepiness since birth. In 90% of cases, the first symptom to manifest is sleepiness or increased sleep, followed by cataplexy (within 1 year in 50% of cases, within 3 years in 85%). Excessive sleep rapidly progresses to an inability to stay awake during the day, and to maintain good sleep at night, without a clear increase in total 24-hour sleep needs. Sleep paralysis usually develops around puberty in children with prepubertal onset. Exacerbations of symptoms suggest lack of compliance with medications or devel? opment of a concurrent sleep disorder, notably sleep apnea. Young children and adolescents with narcolepsy often develop aggression or behav? ioral problems secondary to sleepiness and/or nighttime sleep disruption. Workload and social pressure increase through high school and college, reducing available sleep time at night.

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