A Quiet Revolution for Those Prone to Nodding Off. The New York Times reviews advances in the treatment of narcolepsy, especially modulation of the neurotransmitter orexin by the first of a promising new class of drugs which may have much broader potential to modify fatigue and sleep disturbances. Surprisingly, the new drug, Xyrem, contains the compound GHB (gamma-hydroxybutyrate), which has gained notoriety as a “date-rape drug.” The developers of Xyrem plan to distribute it by a novel mechanism to preclude its diversion into recreational use, sidestepping the abuse that is virtually crippling other medically essential but highly abusable drugs like Oxycontin. An added dividend from this article is the news, which which I had been unacquainted, that narcolepsy appears to be an autoimmune disease. Autopsies of narcoleptics show severe deficits in orexin-containing neurons in the CNS, suggesting they have been destroyed. While narcolepsy is not strictly a psychiatric disorder and thus out of my purview, it is of course true that disorders in sleep regulation and architecture are prominent in psychiatric illness, and I’m sure that the new discoveries about the role of orexin will have psychiatric applications. By the way, narcolepsy involves not only sudden sleep attacks but some other extraordinary — and frightening to patients — syptoms, including cataplexy (sudden loss of muscle tone, often in conjunction with emotional arousal, which can lead for example to people literally falling down laughing), hypnagogic and hypnopompic hallucinations (bizarre distortions in the perception of reality when on the point of falling asleep or awakening, often terrifying, which represent the intrusion of REM sleep into wakeful consciousness) and sleep paralysis, also terrifying. Some think, by the way, that the sleep paralysis of narcoleptic conditions may be the basis for alien abduction experiences.