Case Study: Dr. J is a 55-year-old neurosurgeon who had recently gone through a divorce and was involved in tense negotiations with his hospital over his schedule. For the last six months, he had been unable to fall asleep, or would have long periods of "semi-wakefulness."
As he stared at the ceiling, he was filled with regrets about his marriage, worries about his finances, and fears that, in his perpetually drowsy state, he could make a mistake that would harm a patient.
Dr. J tried a prescription sleep medication, but saw only minimal improvement. He was forced to give up emergency call duties—which meant a dock in pay and a blow to his self-esteem.
When his physician referred him to me, I began cognitive-behavioral therapy. In the sleep field, CBT, which involves educating patients about sleep, establishing good "sleep hygiene" or daily habits, and teaching patients to challenge thoughts and beliefs that are causing them anxiety, is the gold standard. It's more effective over the long term than medications. (In my practice, if CBT doesn't seem to be getting at the deeper psychological issues that led to the patient's sleep problems, I may also do psychodynamic-oriented therapy.)
During a five-session program, Dr. J learned about aspects of sleep that were not covered during his medical training. Though sleep affects our bodies and minds in countless ways, budding doctors—often sleep-deprived themselves—are not told much about the factors that set and disrupt the sleep-wake cycle.
Working on a bright computer screen at night, for example, sends signals to your body that it's time to be alert. I taught Dr. J to power down at least an hour before bedtime.
Dr. J was especially helped when I challenged his inaccurate ideas about how much sleep he was getting. Many insomniacs underestimate the amount; just knowing that he was likely getting more shut-eye than he thought quelled some of his anxiety.
I also taught him to accept stressful situations as a natural part of life. A high achiever, Dr. J had thought of himself as a superhuman of sorts. That made it hard for him to believe that he had limitations suddenly made apparent by his personal and professional troubles. Reframing his problems as normal and manageable disrupted the persistent "worry, can't sleep, then worry about not sleeping" pattern.
ID: Characterized by sleep attacks (an irresistible and uncontrollable desire to fall asleep at inappropriate times), cataplexy (a sudden loss of voluntary muscle control), sleep paralysis (an inability to move or speak while regaining consciousness after REMsleep), and hypnagogic hallucinations (vivid and often frightening hallucinations while half-asleep).
Prevalence: Narcolepsy with cataplexy affects about .02-.18 percent of the population in the U.S. and Western Europe.
Treatment: Stimulant medication for daytime sleepiness and sleep attacks, nighttime medication to aid the consolidation of sleep and to control cataplexy, and cognitive-behavioral therapy.
Case Study: Mary is a 64-year-old unemployed secretary whose life was deeply and negatively affected by undiagnosed narcolepsy. It was impossible for her to stay awake in class as a teenager, so her teachers gave her detention and barely let her graduate. Her self-esteem was low since her friends and family saw her as lazy and unproductive.
Over the years, Mary was fired from several jobs after falling asleep or, alarmingly, falling down and being unable to move for several minutes. As is typical for narcoleptics, Mary noticed that the episodes tended to occur when she was angry, startled, or in the middle of a laughing fit. So she started to suppress her emotions, which further alienated her from family and friends.
Mary was finally diagnosed after her physician referred her to me. I worked with her doctor to put her on a nighttime sleeping aid and a mild daytime stimulant. I taught her basic sleep-hygiene rules, making sure she was going to bed at a regular time and in a comfortable, quiet bedroom.
Once this comprehensive treatment was in full swing, Mary began functioning much better and started looking for part-time work.
Narcolepsy is clearly a biological condition, and yet it has affected her identity and her way of relating to other people so much that it mirrors a psychological disorder. Mary still finds it difficult to let herself laugh at jokes or get appropriately angry when faced with an unjust situation. It's a deeply entrenched pattern that we're trying to break via psychotherapy sessions.
To at last realize that she's not an inadequate person, but rather someone who has been struggling with a serious condition, is a relief for Mary, but she harbors a lot of sadness over her life's many misunderstandings and missed opportunities.
ID: Getting out of bed and moving around or engaging in other complex behaviors while in an altered state of consciousness.
Prevalence: As high as 17 percent among children, with a peak between eight and twelve years of age. About 4 percent of adults sleepwalk.
Treatment: A brief course of a benzodiazepine or antidepressant can help treat severe cases. Hypnosis can help consolidate one's sleep, making sleepwalking less likely.
Case Study: Jim is a 29-year-old building manager. One night when he was about 8 years old, his parents noticed that he was not in bed. When they found him, he was walking straight down the middle of the street. Similar episodes occurred at random times and caused his parents a great deal of anxiety.
After college, Jim's sleepwalking continued on an occasional basis and was frightening to his wife, who once found him sitting in the car with the motor running, staring blankly out the window. Jim came to realize that he sleepwalked when he was under stress.
When his supervisor pressured him to work more hours and take on greater responsibility, Jim got several tablets of a well-known sleep medication from a friend, out of desperation. The first night he tried a pill he slept very well, so he took one again the next night and fell into a deep sleep. When he woke up, he was in a police car on the way to the local station.
Only later was he told that he had driven to his company's apartment complex and used his master key to enter one apartment after the other. Following his release from jail he contacted his doctor, who recommended a comprehensive sleep evaluation.
While in the lab he didn't sleepwalk at all, so I don't have objective confirmation of his diagnosis. I'm now helping him cope with his stress and have asked him to put in safety measures to prevent him from getting out of the house and into his car. I've started using hypnosis with Jim, in the hope that it will deepen his sleep and prevent his bizarre unconscious escapades.
ID: Sleep-related abnormal sexual behaviors. These are variants of confusional arousals (mental or behavioral confusion upon waking up) and sleepwalking. They can include anything from masturbating in one's sleep to unwittingly initiating sex with a partner.
Prevalence: Unknown, because only a few scientific articles on the condition have been published.
Treatment: The condition can in some cases be related to a seizure disorder, in which case antiseizure medication is the best treatment. Otherwise sleep education and CBT can help improve overall sleep and prevent episodes.
Case Study: Tom is a 40-year-old high school teacher. His wife's 17-year-old niece had moved to their town to attend college and stayed with the couple while she hunted for an apartment. On the third night after moving in, she awoke to find Tom standing over her with his hand under her shirt. She was extremely upset and called the police.
When the police arrived they found Tom somewhat disoriented and contrite. He insisted that he had done nothing wrong. As he awaits trial, his lawyer is preparing a sexsomnia defense. Meanwhile, he's getting behavioral sleep training from me to try to prevent similar episodes. I can't say for sure whether Tom sexually assaulted his niece knowingly or not, but the police report is consistent with sleepwalking behavior: Tom was bewildered and mystified, not angrily denying the behavior as a criminal would likely do.
Other sexsomnia cases I've treated involve patients beginning to perform sexual acts on their partners but with a glassy, faraway look in their eyes that was off-putting. These patients often have to sleep in another room so as not to disturb their partners, though one person confessed that marital sex was better for him during his partner's sexsomnia episodes than when his partner was awake! In several cases, drinking alcohol before going to bed seemed to spur on episodes of sexsomnia.
ID: Incubus attacks are a form of sleep paralysis with hypnagogic (occurring upon awakening or falling asleep) hallucinations.
Prevalence: Recurrent episodes afflict about 4 percent of the population. Fifteen to 40 percent of the U.S. population will experience at least one episode of sleep paralysis . These attacks are more common in younger people and slightly more frequent in women than men.
Treatment: Supportive counseling with cognitive-behavioral therapy to improve sleep consolidation. When sleep is consolidated (not interrupted by stints of waking up and falling back asleep) incubus attacks are less likely to occur.
Case Study: Martha is a 37-year-old paralegal secretary. She was recently divorced and living alone in an apartment when she awoke one night to find herself unable to move. She gradually noted the presence of someone or something in the room. Desperate to get away, she struggled to move but without success. To her horror, she saw an evil-looking creature sitting in the far corner of her room. Struggling to breathe, she was face-to-face with a threatening demon. Finally she seemed to be able to breathe again. She gradually got out of bed, with a deep sense of dread.
Martha could hardly stand being in her apartment, and came to me for psychotherapy. Though she hasn't yet had a second incubus attack, she remains haunted by the experience and has not been able to let go of her belief that she was visited by a demon. In fact, I'm treating her similarly to the way I treat patients with post-traumatic stress disorder.
The scientific explanation for an incubus attack is simply that the patient's sleep is fragmented (perhaps due to extreme stress) so that part of the brain is in the REM phase of sleep while the other is awake. This causes the patient to feel the paralysis of REMsleep in a real, conscious way, and yet because they are also dreaming, the mind makes up a story to explain the sensation—such as a creature sitting on one's chest.
Martha had a strict religious upbringing that probably made her more susceptible to her interpretation. But patients I've had who fully accepted my explanation and did not believe in supernatural events were still shaken to the core by their incubus attacks.
Delayed Sleep Phase Disorder
ID: This is a disorder of the circadian (24-hour) sleep-wake cycle, which results in going to sleep and waking up more than two hours later than a conventional schedule would dictate.
Prevalence: Between 7 and 16 percent of the population has DSPD; most sufferers are teens and young adults.
Treatment: Either the gradual shifting back of bed- and wake times until a desired sleep schedule is reached or chronotherapy, in which patients go to sleep and get up 2-3 hours later each day for several days until they arrive at their ideal bedtime. Morning use of a bright light box to signal that it's time to wake up and possibly the use of melatonin at bedtime to promote sleep.
Case Study: Joe is a 16-year-old high school student whose sleep disorder had gotten so bad that he wasn't attending classes at all. It had all begun the previous year when his parents divorced, and he lived for several months with an older brother who didn't enforce bedtime rules.
Joe started exchanging text messages with an insomniac friend and played online games against opponents on the other side of the planet. By the time he moved back in with a parent, he was staying up until 3 a.m. and was incapable of getting up with the alarm.
I wrote a letter asking his school to grant him mercy while I started chronotherapy treatment. Over the next six days, he went to bed three hours later and got up three hours later each day. He rapidly moved his bedtime from 5 a.m. to 11 p.m.
He also exposed himself to a bright light in the morning while getting ready for school. He was able to finish 11th grade with his classmates.
Night owls are particularly vulnerable to falling into DSPD, since their circadian rhythm is already a little out of sync with our early-bird society. It's not surprising that Joe's problems began with the divorce of his parents; emotional upheaval often triggers sleep problems of all kinds.
John Cline, Ph.D., is a psychologist at the Sleep Disorders Centers of Connecticut and Waterbury Hospital Regional Sleep Lab. He also teaches psychiatry at Yale University.
10 TIPS FOR GETTING YOUR Zs
- Limit evening alcohol to two drinks, preferably before 8 p.m.
- No more than 2 cups of coffee a day and none after 2 p.m.
- Exercise 20 to 30 minutes a day, preferably in the late afternoon.
- Keep the bedroom on the cool side.
- Try to expose yourself to bright light in the morning.
- Keep the bedroom quiet and dark.
- Orient the clock face away from you.
- Have a light complex-carbohydrate snack about an hour before bedtime.
- Avoid drinking liquids after 8 p.m.
- Buy a bed large enough that you won't be disturbed by a partner's movements.
Find more sleep tips online by PT bloggers at blogs.psychologytoday.com:
Sleepless in America By John Cline, Ph.D.
Sleep Newzzz By Michael J. Breus, Ph.D.
Sleeping Angels By Dennis Rosen, M.D.