Case Study: Darius “DJ” Coleman (DSM-5-TR: Narcolepsy Type 1)

Demographics

• Name: Darius “DJ” Coleman

• Age: 27

• Gender: Male

• Occupation: Long-haul truck driver for a logistics company

• Background: U.S. Army veteran; discharged after four years of service due to excessive daytime sleepiness

Clinical Presentation

Course of Symptoms

Darius first noticed “zoning out” during conversations and brief episodes of suddenly nodding off during his final year in the Army. Initially attributed to irregular sleep schedules and stress, his symptoms worsened over time. After several near-miss accidents at work, he underwent a sleep evaluation and was diagnosed with Narcolepsy Type 1.

Darius experiences daily episodes of irresistible sleep attacks, occurring multiple times a day despite getting 8 hours of sleep at night. He reports cataplexy—sudden loss of muscle tone triggered by strong emotions such as laughter or anger—during which he remains conscious but unable to move. He also describes hypnagogic hallucinations, seeing vivid images as he falls asleep, and sleep paralysis upon waking.

He feels constant embarrassment and anxiety about his symptoms, particularly cataplexy episodes that have occurred during social events and work breaks.

DSM-5-TR Diagnostic Features

Criterion A:

Recurrent periods of an irrepressible need to sleep, lapsing into sleep, or napping occurring within the same day, at least three times per week over the past 3 months.

Darius reports uncontrollable “sleep attacks” several times per day for over two years, even during active conversations or meals.

Criterion B:

Presence of at least one of the following:

1. Episodes of cataplexy, defined as either:

   • Brief (seconds–minutes) episodes of sudden bilateral loss of muscle tone with maintained consciousness, precipitated by laughter or joking (in individuals with long-standing illness), or

   • Spontaneous grimaces or jaw-opening episodes with tongue thrusting or global hypotonia without emotional triggers (in children or recent onset).

   Darius experiences sudden knee buckling and loss of strength in his neck when laughing hard, forcing him to brace against furniture.

2. Hypocretin deficiency, measured in cerebrospinal fluid (CSF), not due to acute brain injury or infection.

   His CSF hypocretin-1 concentration is 15 pg/mL (normal >110 pg/mL).

3. REM sleep latency ≤15 minutes or two or more sleep-onset REM periods during a multiple sleep latency test (MSLT).

   Sleep study confirmed average sleep latency of 4 minutes with two REM-onset episodes.

Specifier:

Narcolepsy Type 1 (with cataplexy and hypocretin deficiency).

Psychological and Behavioral Features

• Cataplexy triggered by laughter, anger, and surprise.

• Sleep paralysis lasting up to 2 minutes, described as “feeling awake but frozen.”

• Hypnagogic hallucinations involving shadowy figures or hearing footsteps while falling asleep.

• Daytime fatigue leads to irritability, low motivation, and declining job performance.

• Social withdrawal from fear of public embarrassment.

Differential Diagnosis (DSM-5-TR Guidance)

Functional Impairment

• Occupational: Loss of driver’s license; employer reassigned him to a desk-based dispatch role.

• Social: Avoids social gatherings due to fear of collapsing during laughter.

• Emotional: Reports embarrassment, isolation, and mild depressive symptoms.

• Safety: History of two minor vehicle accidents attributed to microsleeps.

Treatment Considerations (DSM-5-TR Aligned)

• Pharmacologic:

  • Modafinil or armodafinil to promote wakefulness.

  • Sodium oxybate for cataplexy and disrupted nighttime sleep.

  • SSRIs or SNRIs (e.g., venlafaxine) to reduce cataplexy frequency.

• Behavioral Interventions:

  • Scheduled daytime naps (10–20 minutes) to manage sleep attacks.

  • Sleep hygiene education—consistent bed/wake times, avoidance of alcohol.

  • Counseling for emotional and social adjustment.

• Occupational Counseling:

  • Transition to roles that minimize driving and operating heavy machinery.

  • Support from the Veterans Affairs (VA) system for accommodations.

Cultural and Psychosocial Context

• Darius grew up in a family that viewed excessive sleep as laziness, making it difficult for him to seek help early.

• Military culture emphasized toughness, so he minimized his symptoms until they interfered with his duties.

• His transition to civilian life was complicated by the loss of independence and the stigma of an “invisible disorder.”