Sexual excitation induces courtship ultrasonic vocalizations and cataplexy-like behavior in orexin neuron-ablated male mice.

Cataplexy is triggered by laughter in humans and palatable food in mice. To further evaluate mice's cataplexy, we examined courtship behavior in orexin neuron-ablated mice (ORX-AB), one of the animal models of narcolepsy/cataplexy. Wild-type female mice were placed into the home cage of male ORX-AB and cataplexy-like behavior was observed along with ultrasonic vocalizations (USVs), also known as the "love song". ORX-AB with a female encounter showed cataplexy-like behavior both during the dark and light periods, whereas ORX-AB with chocolate predominantly showed it during the dark period. During the light period observation, more than 85% of cataplexy-like bouts were preceded by USVs. A strong positive correlation was observed between the number of USVs and cataplexy-like bouts. Cataplexy-like behavior in narcoleptic mice is a good behavioral measure to study the brain mechanisms behind positive emotion because they can be induced by different kinds of positive stimuli, including chocolate and female courtship.

Involvement of the Nucleus Accumbens in Chocolate-induced Cataplexy.

Happiness is key for both mental and physical well-being. To further understand the brain mechanisms involved, we utilized the cataplexy that occurs in narcoleptic animal models as a quantitative behavioral measure because it is triggered by actions associated with happiness, such as laughter in humans and palatable foods in mice. Here we report that the rostral part of the nucleus accumbens (NAc) shell is strongly activated during the beginning of chocolate-induced cataplexy in orexin neuron-ablated mice. We made a local lesion in the NAc using ibotenic acid and observed the animals' behavior. The number of cataplexy bouts was negatively correlated to the lesion size. We also examined the hedonic response to palatable food by measuring the number of tongue protrusions in response to presentation of honey, which was also found to be negatively correlated to the lesion size. Next, we used clozapine N-oxide to either activate or inactivate the NAc through viral DREADD expression. As expected, the number of cataplexy bouts increased with activation and decreased with inactivation, and saline control injections showed no changes. Hedonic response in the DREADD experiment varied and showed both increases and decreases across mice. These results demonstrated that the rostral part of the NAc plays a crucial role in triggering cataplexy and hedonic orofacial movements. Since the NAc is also implicated in motivated behavior, we propose that the NAc is one of the key brain structures involved in happiness and is a driving force for positive emotion-related behaviors.

Neuroimaging correlates of narcolepsy with cataplexy: A systematic review.

Recent developments in neuroimaging techniques have advanced our understanding of biological mechanisms underpinning narcolepsy. We used MEDLINE to retrieve neuroimaging studies to compare patients with narcolepsy and healthy controls. Thirty-seven studies were identified and demonstrated several replicated abnormalities: (1) gray matter reductions in superior frontal, superior and inferior temporal, and middle occipital gyri, hypothalamus, amygdala, insula, hippocampus, cingulate cortex, thalamus, and nucleus accumbens, (2) decreased fractional anisotropy in white matter of fronto-orbital and cingulate area, (3) reduced brain metabolism or cerebral blood flow in middle and superior frontal, and cingulate cortex (4) increased activity in inferior frontal gyri, insula, amygdala, and nucleus accumbens, and (5) N-acetylaspartate/creatine-phosphocreatine level reduction in hypothalamus. In conclusion, all the replicated findings are still controversial due to the limitations such as heterogeneity or size of the samples and lack of multimodal imaging or follow-up. Thus, future neuroimaging studies should employ multimodal imaging methods in a large sample size of patients with narcolepsy and consider age, duration of disease, age at onset, severity, human leukocyte antigen type, cerebrospinal fluid hypocretin levels, and medication intake in order to elucidate possible neuroimaging characteristic of narcolepsy and identify therapeutic targets.

Anterior hippocampus volume loss in narcolepsy with cataplexy.

Narcolepsy with cataplexy is a lifelong disease resulting from the loss of hypocretin neurons in the hypothalamus; structural changes are not, however, limited only to the hypothalamus. We previously revealed an overall hippocampal volume loss in narcolepsy with cataplexy. The aim of this study is to describe the volume reduction of the anterior and posterior parts of the hippocampus in patients with narcolepsy with cataplexy in comparison with a control group. The anterior hippocampus is more involved in episodic memory and imagination, and the posterior hippocampus in spatial memory. Manual magnetic resonance imaging hippocampal volumetry was performed in 48 patients with narcolepsy with cataplexy and in 37 controls using the manual delineation technique in the ScanView program. All participants were examined on the same 1.5 T MR scanner; measurement was carried out as T1W 3D image with a slice thickness of 1.0/0 mm. There was a significant absolute loss of the total volume of the anterior hippocampus (sum of left and right) in patients with narcolepsy with cataplexy as compared with the controls (10.5%, p = .03 ANCOVA after correcting for total brain volume and multiple testing). We found a negative correlation between the total anterior hippocampus volume and the duration of the disease (R = -0.4036, p = .016-corrected for multiple testing).

White matter alterations in narcolepsy patients with cataplexy: tract-based spatial statistics.

Functional imaging studies and voxel-based morphometry analysis of brain magnetic resonance imaging showed abnormalities in the hypothalamus-thalamus-orbitofrontal pathway, demonstrating altered hypocretin pathway in narcolepsy. Those distinct morphometric changes account for problems in wake-sleep control, attention and memory. It also raised the necessity to evaluate white matter changes. To investigate brain white matter alterations in drug-naïve narcolepsy patients with cataplexy and to explore relationships between white matter changes and patient clinical characteristics, drug-naïve narcolepsy patients with cataplexy (n = 22) and healthy age- and gender-matched controls (n = 26) were studied. Fractional anisotropy and mean diffusivity images were obtained from whole-brain diffusion tensor imaging, and tract-based spatial statistics were used to localize white matter abnormalities. Compared with controls, patients showed significant decreases in fractional anisotropy of white matter of the bilateral anterior cingulate, fronto-orbital area, frontal lobe, anterior limb of the internal capsule and corpus callosum, as well as the left anterior and medial thalamus. Patients and controls showed no differences in mean diffusivity. Among patients, mean diffusivity values of white matter in the bilateral superior frontal gyri, bilateral fronto-orbital gyri and right superior parietal gyrus were positively correlated with depressive mood. This tract-based spatial statistics study demonstrated that drug-naïve patients with narcolepsy had reduced fractional anisotropy of white matter in multiple brain areas and significant relationship between increased mean diffusivity of white matter in frontal/cingulate and depression. It suggests the widespread disruption of white matter integrity and prevalent brain degeneration of frontal lobes according to a depressive symptom in narcolepsy.

Narcolepsy-Associated HLA Class I Alleles Implicate Cell-Mediated Cytotoxicity.

STUDY OBJECTIVES: Narcolepsy with cataplexy is tightly associated with the HLA class II allele DQB1*06:02. Evidence indicates a complex contribution of HLA class II genes to narcolepsy susceptibility with a recent independent association with HLA-DPB1. The cause of narcolepsy is supposed be an autoimmune attack against hypocretin-producing neurons. Despite the strong association with HLA class II, there is no evidence for CD4+ T-cell-mediated mechanism in narcolepsy. Since neurons express class I and not class II molecules, the final effector immune cells involved might include class I-restricted CD8+ T-cells. METHODS: HLA class I (A, B, and C) and II (DQB1) genotypes were analyzed in 944 European narcolepsy with cataplexy patients and in 4,043 control subjects matched by country of origin. All patients and controls were DQB1*06:02 positive and class I associations were conditioned on DQB1 alleles. RESULTS: HLA-A*11:01 (OR = 1.49 [1.18-1.87] P = 7.0*10(-4)), C*04:01 (OR = 1.34 [1.10-1.63] P = 3.23*10(-3)), and B*35:01 (OR = 1.46 [1.13-1.89] P = 3.64*10(-3)) were associated with susceptibility to narcolepsy. Analysis of polymorphic class I amino-acids revealed even stronger associations with key antigen-binding residues HLA-A-Tyr(9) (OR = 1.32 [1.15-1.52] P = 6.95*10(-5)) and HLA-C-Ser(11) (OR = 1.34 [1.15-1.57] P = 2.43*10(-4)). CONCLUSIONS: Our findings provide a genetic basis for increased susceptibility to infectious factors or an immune cytotoxic mechanism in narcolepsy, potentially targeting hypocretin neurons.

Histamine Transmission Modulates the Phenotype of Murine Narcolepsy Caused by Orexin Neuron Deficiency.

Narcolepsy type 1 is associated with loss of orexin neurons, sleep-wake derangements, cataplexy, and a wide spectrum of alterations in other physiological functions, including energy balance, cardiovascular, and respiratory control. It is unclear which narcolepsy signs are directly related to the lack of orexin neurons or are instead modulated by dysfunction of other neurotransmitter systems physiologically controlled by orexin neurons, such as the histamine system. To address this question, we tested whether some of narcolepsy signs would be detected in mice lacking histamine signaling (HDC-KO). Moreover, we studied double-mutant mice lacking both histamine signaling and orexin neurons (DM) to evaluate whether the absence of histamine signaling would modulate narcolepsy symptoms produced by orexin deficiency. Mice were instrumented with electrodes for recording the electroencephalogram and electromyogram and a telemetric arterial pressure transducer. Sleep attacks fragmenting wakefulness, cataplexy, excess rapid-eye-movement sleep (R) during the activity period, and enhanced increase of arterial pressure during R, which are hallmarks of narcolepsy in mice, did not occur in HDC-KO, whereas they were observed in DM mice. Thus, these narcolepsy signs are neither caused nor abrogated by the absence of histamine. Conversely, the lack of histamine produced obesity in HDC-KO and to a greater extent also in DM. Moreover, the regularity of breath duration during R was significantly increased in either HDC-KO or DM relative to that in congenic wild-type mice. Defects of histamine transmission may thus modulate the metabolic and respiratory phenotype of murine narcolepsy.

Cataplexy and sleep disorders in Niemann-Pick type C disease.

Niemann-Pick disease type C (NP-C) is a rare and progressive autosomal recessive disease leading to disabling neurological manifestation and premature death. The disease is prone to underdiagnosis because of its highly heterogeneous presentation. NP-C is characterized by visceral, neurological, and psychiatric manifestation, and its clinical picture varies according to age at onset. Although cataplexy is one of its characteristic symptoms, particularly in the late infantile and juvenile form, sleep disturbances are described only exceptionally. A combination of splenomegaly, vertical supranuclear gaze palsy, and cataplexy creates a most useful suspicion index tool for the disease. In adolescent and adult patients, when intellectual deterioration progresses and emotional reactions become flat, cataplexy usually disappears. Pathological findings in the brainstem in NP-C mouse model are compatible with the patients' symptoms including cataplexy. The authors observed cataplexy in 5 (3 with late infantile and 2 with juvenile form) out of 22 NP-C cases followed up in the past 20 years.

Differences in brain morphological findings between narcolepsy with and without cataplexy.

OBJECTIVE: Maps of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) obtained by diffusion tensor imaging (DTI) can detect microscopic axonal changes by estimating the diffusivity of water molecules using magnetic resonance imaging (MRI). We applied an MRI voxel-based statistical approach to FA and ADC maps to evaluate microstructural abnormalities in the brain in narcolepsy and to investigate differences between patients having narcolepsy with and without cataplexy. METHODS: Twelve patients with drug-naive narcolepsy with cataplexy (NA/CA), 12 with drug-naive narcolepsy without cataplexy (NA w/o CA) and 12 age-matched healthy normal controls (NC) were enrolled. FA and ADC maps for these 3 groups were statistically compared by using voxel-based one-way ANOVA. In addition, we investigated the correlation between FA and ADC values and clinical variables in the patient groups. RESULTS: Compared to the NC group, the NA/CA group showed higher ADC values in the left inferior frontal gyrus and left amygdala, and a lower ADC value in the left postcentral gyrus. The ADC value in the right inferior frontal gyrus and FA value in the right precuneus were higher for NA/CA group than for the NA w/o CA group. However, no significant differences were observed in FA and ADC values between the NA w/o CA and NC groups in any of the areas investigated. In addition, no correlation was found between the clinical variables and ADC and FA values of any brain areas in these patient groups. CONCLUSIONS: Several microstructural changes were noted in the inferior frontal gyrus and amygdala in the NA/CA but not in the NA w/o CA group. These findings suggest that these 2 narcolepsy conditions have different pathological mechanisms: narcolepsy without cataplexy form appears to be a potentially broader condition without any significant brain imaging differences from normal controls.

Amygdala lesions reduce cataplexy in orexin knock-out mice.

Narcolepsy is characterized by excessive sleepiness and cataplexy, sudden episodes of muscle weakness during waking that are thought to be an intrusion of rapid eye movement sleep muscle atonia into wakefulness. One of the most striking aspects of cataplexy is that it is often triggered by strong, generally positive emotions, but little is known about the neural pathways through which positive emotions trigger muscle atonia. We hypothesized that the amygdala is functionally important for cataplexy because the amygdala has a role in processing emotional stimuli and it contains neurons that are active during cataplexy. Using anterograde and retrograde tracing in mice, we found that GABAergic neurons in the central nucleus of the amygdala heavily innervate neurons that maintain waking muscle tone such as those in the ventrolateral periaqueductal gray, lateral pontine tegmentum, locus ceruleus, and dorsal raphe. We then found that bilateral, excitotoxic lesions of the amygdala markedly reduced cataplexy in orexin knock-out mice, a model of narcolepsy. These lesions did not alter basic sleep-wake behavior but substantially reduced the triggering of cataplexy. Lesions also reduced the cataplexy events triggered by conditions associated with high arousal and positive emotions (i.e., wheel running and chocolate). These observations demonstrate that the amygdala is a functionally important part of the circuitry underlying cataplexy and suggest that increased amygdala activity in response to emotional stimuli could directly trigger cataplexy by inhibiting brainstem regions that suppress muscle atonia.

White and gray matter abnormalities in narcolepsy with cataplexy.

STUDY OBJECTIVES: The authors applied diffusion-tensor imaging including measurements of mean diffusivity (MD), which is a parameter of brain tissue integrity, fractional anisotropy (FA), which is a parameter of neuronal fiber integrity, and voxel-based morphometry, which is a measure of gray and white matter volume, to detect brain tissue changes in patients with narcolepsy-cataplexy. DESIGN: N/A. PATIENTS: Patients with narcolepsy-cataplexy (n = 16) and age-matched healthy control subjects (n = 12) were studied. INTERVENTIONS: Whole cerebral MD, FA measures, and the volumes of the gray and white matter compartments were analyzed using statistical parametric mapping. MEASUREMENT AND RESULTS: Significant MD increases and concomitant FA decreases were localized in the fronto-orbital cortex (P < 0.001) and the anterior cingulate (FA, P < 0.001; MD, P = 0.03) in narcolepsy-cataplexy. Additional MD increases without FA changes were detected in the ventral tegmental area, the dorsal raphe nuclei (P < 0.001), and the hypothalamus (P < 0.01). FA signal decreases were observed in the white matter tracts of the inferior frontal and inferior temporal cortices of narcolepsy-cataplexy patients (P < 0.001). Brain volume loss was evident in focal areas of the inferior and superior temporal cortices (P < 0.001) and the cingulate (P = 0.038). CONCLUSIONS: Areas of increased diffusivity in the hypothalamus appear consistent with hypocretinergic cell loss reported in narcolepsy-cataplexy. Signal abnormalities in the ventral tegmental area and the dorsal raphe nuclei correspond to major synaptic targets of hypocretin neurons that were associated with the regulation of the sleep-wake cycle. Brain tissue alterations identified in the frontal cortex and cingulate are crucial in the maintenance of attention and reward-dependent decision making, both known to be impaired in narcolepsy-cataplexy.

Analysis of cortical thickness in narcolepsy patients with cataplexy.

STUDY OBJECTIVES: To investigate differences in cortical thickness in narcolepsy patients with cataplexy and control subjects. DESIGN: Cortical thickness was measured using a 3-D surface-based method that enables more accurate measurement in deep sulci and localized regional mapping. SETTING: University hospital. PATIENTS AND PARTICIPANTS: We enrolled 28 patients with narcolepsy and cataplexy and 33 age-and sex-matched control subjects. INTERVENTIONS: Cortical thickness was measured using a direct method for calculating the distance between corresponding vertices from inner and outer cortical surfaces. MEASUREMENTS AND RESULTS: We normalized cortical surfaces using 2-D surface registration and performed diffusion smoothing to reduce the variability of folding patterns and to increase the power of the statistical analysis. Localized cortical thinning in narcolepsy patients with cataplexy was found in orbitofrontal gyri, dorsolateral and medial prefrontal cortexes, insula, cingulate gyri, middle and inferior temporal gyri, and inferior parietal lobule of the right and left hemispheres at the level of a false discovery rate P<0.05. No significant local increases in cortical thickness were observed in narcolepsy patients. A significant negative correlation was observed between the narcolepsy patients' scores on the Epworth Sleepiness Scale and the cortical thickness of the left supramarginal gyrus. CONCLUSIONS: Cortical thinning in narcolepsy patients with cataplexy in localized anatomic brain regions may serve as a possible neuroanatomic mechanism of the disturbances in attention, memory, emotion, and sleepiness.

Localized loss of hypocretin (orexin) cells in narcolepsy without cataplexy.

STUDY OBJECTIVES: Narcolepsy with cataplexy is characterized by a loss of approximately 90% of hypocretin (Hcrt) neurons. However, more than a quarter of narcoleptics do not have cataplexy and have normal levels of hypocretin in their cerebrospinal fluid, raising the possibility that their disease is caused by unrelated abnormalities. In this study we examined hypocretin pathology in narcolepsy without cataplexy. DESIGN: We examined postmortem brain samples, including the hypothalamus of 5 narcolepsy with cataplexy patients; one narcolepsy without cataplexy patient whose complete hypothalamus was available (patient 1); one narcolepsy without cataplexy patient with anterior hypothalamus available (patient 2); and 6 normal brains. The hypothalamic tissue was immunostained for Hcrt-1, melanin-concentrating hormone (MCH), and glial fibrillary acidic protein (GFAP). MEASUREMENTS AND RESULTS: Neither of the narcolepsy without cataplexy patients had a loss of Hcrt axons in the anterior hypothalamus. The narcolepsy without cataplexy patient whose entire brain was available for study had an overall loss of 33% of hypocretin cells compared to normals, with maximal cell loss in the posterior hypothalamus. We found elevated levels of gliosis with GFAP staining, with levels increased in the posterior hypothalamic nucleus by (295%), paraventricular (211%), periventricular (123%), arcuate (126%), and lateral (72%) hypothalamic nuclei, but not in the anterior, dorsomedial, or dorsal hypothalamus. There was no reduction in the number of MCH neurons in either patient. CONCLUSIONS: Narcolepsy without cataplexy can be caused by a partial loss of hypocretin cells.

Cataplexy: an affair of pleasure or an unpleasant affair?

Narcolepsy, cataplexy and emotions form an intriguing triad that fascinates sleep researchers. A novel aspect of narcoleptic patients' behaviours now appears depending on the emotional valence of the context: how can we explain the fact that narcoleptic patients may experience pleasant-triggered (e.g. laughing) cataplexy as well as unpleasant-related drawback performance (Tucci, V., Stegagno, L., Vandi, S., Ferrillo, F., Palomba, D., Vignatelli, L., Ferini-Strambi, L., Montagna, P., Plazzi, G., Emotional information processing in patients with narcolepsy: a psychophysiologic investigation, Sleep 26 (2003) 558-564; Khatami, R., Birkmann, S., Bassetti, C.L., Amygdala dysfunction in narcolepsycataplexy, J. Sleep Res. 16 (2007) 226-229)? With this in mind we postulate that narcolepsy with cataplexy is a complex sleep disorder that, among others, affects the modulation of emotions at different levels: structural, cellular and molecular.

Weight loss in narcolepsy patients treated with sodium oxybate.

INTRODUCTION: Narcolepsy is often associated with increased body weight. Sodium oxybate has efficacy in many narcolepsy symptoms. The purpose of this study was to evaluate the effects of sodium oxybate on weight in patients with narcolepsy. METHODS: Charts from three centers of all patients with narcolepsy who had been using sodium oxybate for at least 3 months were reviewed. Patients in whom anti-cataplexy medications were added or withdrawn or wake-promoting medications added after the start of sodium oxybate were excluded from further analysis. In the remainder, pre-sodium oxybate and, most recently, on-sodium oxybate weights were compared using Student's t-tests. Sodium oxybate dose and duration of therapy were also noted. RESULTS: A total of 54 patients meeting inclusion criteria were identified. Of these 54, 33 (61%) were women; the mean age was 48.3 years. The mean dose of sodium oxybate was 6.9g/night and the duration of therapy was 25 months. The mean pre-sodium oxybate weight was 78.3 (+/-15.7)kg. The most recent on-sodium oxybate weight was 74.9 (+/-15.1, p=0.003). The average weight loss was 3.4kg, whereas the maximum was 30.9kg. CONCLUSIONS: This study suggests that treatment of patients with narcolepsy with sodium oxybate can result in weight loss.

Agenesis of the corpus callosum associated with narcolepsy-cataplexy.

We describe a 24-year-old man with episodes of intense desire to sleep for periods ranging from 2min to 3h, episodes of generalized weakness and inability to speak without alteration of consciousness, frequent hypnagogic hallucinations during sleep and occasionally transient paralysis of limbs upon awakening. Brain MRI demonstrated elevation of the third ventricle, a characteristic lack of depiction of the corpus callosum and extension of the bihemispheric fissure to the third ventricle. We assume that structural changes of the base of frontal lobes, diencephalon and brainstem, can be accountable for symptomatic narcolepsy and cataplexy.

Evaluation of hypothalamic-specific autoimmunity in patients with narcolepsy.

An autoimmune-mediated mechanism is considered the most probable etiology for narcolepsy. However, this hypothesis remains unproven. Since narcolepsy is characterized by dysfunction of the hypothalamic hypocretinergic (orexinergic) system, we evaluated the presence of hypothalamic-specific antibodies in sera and CSF of 25 hypocretin-deficient and 6 non-deficient narcoleptic patients by immunohistochemistry and analyzing a screening of a rat cDNA expression hypothalamic library. There was no hypothalamic-specific reactivity in serum or CSF by inmmunohistochemistry. The screening of the hypothalmic library detected some reactive clones but not a common reactivity. Our study did not find any evidence of hypothalamic-specific autoimmunity in narcolepsy.

Characterization of the spontaneous and gripping-induced immobility episodes on taiep rats.

In 1989, we described a new autosomic-recessive myelin-mutant rat that develops a progressive motor syndrome characterized by tremor, ataxia, immobility episodes (IEs), epilepsy, and paralysis. taiep is the acronym of these symptoms. The rat developed a hypomyelination, followed by demyelination. At an age of 7-8 months, taiep rats developed IEs, characterized electroencephalographically by REM sleep-like cortical activity. In our study, we analyzed the ontogeny of gripping-induced IEs between 5 and 18 months, their dependence to light-dark changes, sexual dimorphism, and susceptibility to mild stress. Our results showed that IEs start at an age of 6.5 months, with a peak frequency between 8.5 and 9.5 months. IEs have two peaks, one in the morning (0800-1000 h) and a second peak in the middle of the night (2300-0100 h). Spontaneous IEs showed an even distribution with a mean of 3 IEs every 2 h. IEs are sexually dimorphic being more common in male rats. The IEs can be induced by gripping the rat by the tail or the thorax, but most of the IEs were produced by gripping the tail. Mild stress produced by i.p. injection of physiological saline significantly decreased IEs. These results suggested that IEs are dependent on several biological variables, which are caused by hypomyelination, followed by demyelization, which causes alterations in the brainstem and hypothalamic mechanisms responsible for the sleep-wake cycle regulation, producing emergence of REM sleep-like behavior during awake periods.

In vivo evidence of neuronal loss in the hypothalamus of narcoleptic patients.

A dysfunction of the orexin (hypocretin) system in the hypothalamus has recently been linked to the pathogenesis of narcolepsy. The authors used in vivo proton MR spectroscopy to assess the N-acetylaspartate (NAA) content in the hypothalamus of narcoleptic patients. Hypothalamic NAA/creatine-phosphocreatine was reduced in narcoleptic patients compared with control subjects (p < 0.01). Hypothalamic neuronal loss/damage is a central pathogenetic feature in narcolepsy.

Drugs to interfere with orexins (hypocretins).

Orexins (hypocretins) are bioactive peptides linking arousal, appetite and neuroendocrine-autonomic control. Dysfunction of the orexin system is associated with narcolepsy-cataplexy. Here, we review drugs interfering with orexins directly such as novel selective orexin receptor agonists and antagonists, as well as drugs interfering with orexins indirectly such as those used for the treatment of narcolepsy-cataplexy, and pharmacological targets within the complex network of endogenous neurohumoral signals integrated and relayed by the orexin system. These include amines, acetylcholine, purines, GABA and glutamate, as well as nutritional-metabolic, circadian-photic, immunological and neuroendocrine-peptidergic influences. Basic and clinical evaluation of drugs interfering with the orexin system will lead to a better understanding of the molecular prerequisites that control behavioral state, stress responses, energy homeo- stasis and survival, and yield therapeutic advances for the treatment of narcolepsy and other disorders of sleep, eating, mood and memory.