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The evaluation of a patient with excessive sleepiness requires that a detailed sleep history is taken with medical, psychiatric, and psychosocial factors considered, and a differential diagnosis developed. This chapter deals with the important elements in the clinical evaluation of patients with excessive sleepiness. The social history should be elicited, particularly relationships with other family members, and including determination of any financial, personal or social stresses that may contribute to sleep disturbance. Some sleep disorders including sleep apnea syndrome, narcolepsy, recurrent hypersomnia as well as restless legs syndrome, have a familial tendency. The physical examination ideally should be comprehensive and focus on respiratory, cardiovascular, gastrointestinal, endocrine and neurological evaluation. The patient who is sleepy may be asked to complete various tests of performance, such as a psychomotor vigilance test (PVT), or other tests of cognitive ability.
Many of the parasomnias are manifestations of central nervous system activation and autonomic nervous system changes with skeletal muscle activity. Parasomnias can contribute to impaired academic or occupational performance, disturbances of mood and social adjustment. Identification of the presence of any psychological trauma or history of such trauma is important when trying to understand the possible sources of parasomnia. There is a predisposition to sleep-related dissociative disorder in victims of physical or sexual abuse or post-traumatic stress disorder (PTSD). Secondary sleep enuresis is also noted in these patients. This chapter begins with a thorough history-taking, keeping in mind the Parasomnia Classification in the International Classification of Sleep Disorders, 2nd edition (ICSD-2) and the differential diagnosis of abnormal behaviors and events during sleep. Seizures should always be considered in the differential of parasomnias, and formal EEG studies should be performed with appropriateness.