Avoiding Common Pitfalls When Managing Excessive Daytime Sleepiness

Distinguishing excessive daytime sleepiness (EDS) from other overlapping psychiatric and medical conditions can get tricky. In this interview, psychiatrist and sleep medicine expert Nishi Bhopal, MD, founder and medical director of telepsychiatry practice Pacific Integrative Psychiatry, provides a thorough overview of some of the obstacles that may prevent EDS diagnosis. She shares practical clinical strategies, like the importance of a comprehensive sleep history, that can help clinicians screen for, diagnose, and treat EDS in a more efficient manner.

For more expert insights, visit the Sleep Disorders Excellence Forum here on Neurology Learning Network.

Don't miss the other videos in this series:

>>A Brief Overview of Excessive Daytime Sleepiness

>>A Guide to Diagnosing and Treating Excessive Daytime Sleepiness

Read the Transcript

Nishi Bhopal, MD: I'm Dr Nishi Bhopal. I am a physician. I'm board certified in sleep medicine, psychiatry, and Integrative holistic medicine. I'm the founder of Pacific Integrative Psychiatry. We're an online telehealth practice seeing patients across the state of California. I'm also the founder of Intra Balance, which is an online platform teaching physicians, therapists, and other healthcare practitioners about clinical sleep medicine. I do that through a YouTube channel and online courses.

Neurology Learning Network: What are some of the most common comorbid conditions that can either contribute to or mimic EDS, and how can clinicians differentiate between them?

Dr Bhopal: So some of the most common conditions that can contribute to or mimic EDS include sleep disorders, psychiatric disorders, medical conditions, medications, and neurological disorders. Sleep disorders include conditions like obstructive sleep apnea, restless leg syndrome, circadian rhythm disorders, narcolepsy, central disorders of hypersomnolence as well. Psychiatric disorders that are frequently associated with EDS include depression and anxiety. Here you want to do a thorough psychiatric evaluation, and you can use standardized screening tools to help differentiate between depression and anxiety and EDS.

In this category, I'm just going to share a quick story that might help with this differentiation. When I was in my sleep medicine fellowship, the first time I saw a patient in the sleep clinic who had narcolepsy, I would've thought he had depression. As a psychiatrist, if I were seeing that patient, I would've diagnosed him with depression. However, some of the key differentiating features with this patient were that he was struggling with this excessive daytime fatigue and sleepiness. He worked in tech, so he was on a computer all day working from home, and he noted just having no energy to go out and do things. His wife was getting frustrated with him because all he wanted to do was rest and sleep on the weekends. So, it looked like depression. His psychiatrist had trialed a number of different antidepressants, none of which were helping. So he was referred to the sleep medicine clinic. It turned out this patient had narcolepsy. He looked like he had depression, but he actually had excessive daytime sleepiness from a diagnosis of narcolepsy.

So there is a lot of symptom overlap, but the key features were that he wanted to go out. He didn't have anhedonia. He wasn't really struggling with concentration just to the effect that he was feeling sleepy. So that was impairing his cognition, but he wanted to get up and do things. He was interested in life. He wasn't experiencing some of the classic symptoms of depression. His PHQ-9 score was low. However, another key point here is that there can be overlap in the conditions, so patients can have more than one thing, but I just wanted to highlight that story just so you have that idea of what narcolepsy or EDS could look like in clinical practice.

Now, I mentioned medical conditions as another common comorbid condition or symptoms that could mimic EDS. So this includes chronic illnesses like diabetes, hypothyroidism, chronic obstructive pulmonary disease (COPD), and heart failure. So of course, you want to do comprehensive medical history and the appropriate laboratory tests to rule out those conditions.

Certain medications like sedatives can contribute to EDS, antihistamines, some antidepressants as well can cause or exacerbate EDS. So you want to do a thorough review of the patient's medication history and then neurological conditions as well. We want to consider things like Parkinson's disease, multiple sclerosis (MS), traumatic brain injury—all of these things can present with EDS likely in those patients that that's the diagnosis. And so it's more likely that you would know that EDS is from those conditions, whereas with psychiatric conditions or some of the other more subtle sleep disorders, it may be harder to tease those out.

Neurology Learning Network: What are the biggest pitfalls or biases in diagnosing EDS that may lead to mismanagement or delayed treatment?

Dr Bhopal: Some of the biggest pitfalls are symptom overlap, taking an inadequate sleep history, a bias towards psychiatric diagnosis, limited use of objective tests, and then medication side effects. Let me go through each of those.

As I've mentioned, EDS and psychiatric conditions overlap a lot. There's a lot of common symptoms like fatigue, like lack of energy and poor concentration. This overlap can lead to misdiagnosis where the EDS may be incorrectly attributed solely to psychiatric conditions.

The second biggest pitfall that I see is taking an inadequate sleep history. This is no fault of the clinicians or the practitioners because most of us don't really get much training in how to take a proper sleep history. We want to be looking at things like symptoms of obstructive sleep apnea that may be more subtle than what you would find on a STOP-bang questionnaire typically. Looking at symptoms of narcolepsy, but also getting a really good understanding of what the patient's sleep schedule is like, their wake time versus their rise time, their bedtime versus their sleep onset time, how much sleep they're getting, if there's any other sleep disruptors that may be at play, and so on.

The third pitfall I mentioned was a bias towards psychiatric diagnosis, and of course, as psychiatrists, we're going to have that bias. So we're going to be prioritizing psychiatric diagnoses over sleep disorders, especially in patients with known psychiatric conditions. So this is where you want to take a step back and just look at the bigger picture and ask yourself what else might be going on. So just approaching it with some curiosity. I mentioned limited use of objective tests. We want to be using things like the rating scales that I mentioned, the Epworth sleepiness scale, although that is a subjective scale, but we can use technology that's available with home sleep testing, with longitudinal sleep testing, or using polysomnography or multiple sleep latency test as I mentioned.

I also discussed medication effects. So looking at medications that might be sedating or exacerbating EDS, again, this is where we just want to get curious, reevaluate what the patient's taking, both from a medication standpoint and from a supplement standpoint as well. Many patients are taking supplements without thinking of the side effects or without thinking that the doctor needs to know about them. So I really like to take a comprehensive look and ask the patient what medications they're taking and also what supplements they're taking and looking at those effects and potential interactions that could be exacerbating their symptoms of EDS.

Neurology Learning Network: Which misconceptions about EDS would you like to clarify for our audience?

Dr Bhopal: One misconception is that EDS is not just fatigue. So as I mentioned earlier, EDS is characterized by a propensity to fall asleep during the day, whereas fatigue is more of a broader sense of tiredness and lack of energy that doesn't necessarily involve sleepiness. A second misconception is that EDS is often misattributed to psychiatric conditions. As we've been discussing, there is a lot of overlap between symptoms of EDS and psychiatric conditions, but this overlap can lead to misdiagnosis where EDS is incorrectly attributed only to the psychiatric condition. Another misconception is that you need to figure it out all on your own, and the beauty of a multidisciplinary approach is that we can get different perspectives and expert consultation. So I recommend if you're struggling with a patient who has EDS involving a sleep specialist or even a behavioral sleep specialist or a psychologist who has training in sleep medicine for accurate diagnosis and management. So using this multidisciplinary approach helps to address the complex interplay between sleep disorders and psychiatric conditions.

Interested readers can explore Dr Bhopal's YouTube Channel here.

Nishi Bhopal, MD, is board-certified in psychiatry, sleep medicine, and integrative holistic medicine. She graduated from the University College Cork School of Medicine, completed her psychiatric residency at Henry Ford Health System, and a fellowship in sleep medicine at Harvard Medical School. She is the founder and medical director of Pacific Integrative Psychiatry, an online practice in California where patients receive a whole-person approach to anxiety, depression, and sleep disorders, including nutrition, psychotherapy, and integrative and functional medicine. In addition to her private practice, Dr Bhopal is the founder of IntraBalance, an educational platform for physicians and therapists that includes a YouTube channel and online courses on clinical sleep medicine for healthcare practitioners. Her passion is making clinical sleep medicine easy to understand and accessible to all.

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