As a clinical psychologist who specializes in sleep disorders, I've seen everyone from those who chase
sleep each night to no avail to those who become unrecognizable characters once they enter never-never land. Here's a guided tour through some of my most memorable case files. (Details have been changed to protect patients' confidentiality.)
ID: Trouble falling asleep and staying asleep.
Prevalence: The condition affects about a third of Americans and is a persistent problem for 10 percent of the population.
Treatment: Sleep medication and/or cognitive-behavioral therapy.
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.
Narcolepsy
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.
