Narcolepsy type 1 is typically diagnosed years after it starts, and the delay is usually a history-taking problem rather than a testing problem. The sleepiness gets attributed to depression, poor sleep hygiene, obstructive sleep apnoea or adolescence, and the feature that would settle it is never asked about, because patients do not volunteer it and rarely have a word for it.
Cataplexy is a sudden, brief loss of muscle tone triggered by emotion, most reliably by laughter, and it is specific enough to change the whole differential. Ask about it concretely rather than by name: when you laugh hard, do your knees go, does your jaw sag, does your head drop, do you have to sit down? Ask whether it happens when they are surprised, or angry, or telling a joke. Ask whether they stay fully aware throughout, which separates it from syncope and from seizure.
The other three questions take a minute between them: sleep paralysis on waking or falling asleep, vivid dream-like hallucinations at sleep onset, and whether daytime naps are refreshing, which they characteristically are in narcolepsy and are not in obstructive sleep apnoea. A patient with excessive daytime sleepiness who answers yes to laughter-triggered weakness needs a sleep study and a specialist opinion, not another lecture about screen time.
- Ask about emotion-triggered weakness in concrete terms, not by the word cataplexy
- Confirm that awareness is preserved throughout, which separates cataplexy from syncope and seizure
- Ask whether naps are refreshing: they usually are in narcolepsy and usually are not in sleep apnoea
- Screen for sleep paralysis and hypnagogic hallucinations in the same minute
- Refer for a sleep study rather than treating presumed depression when sleepiness dominates the picture
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