THE MYSTERY. Do sleep problems cause psychiatric disease? Or is it the other way around? Sleep problems are an extremely common feature of all psychiatric disorders, while the medications used to treat psychiatric conditions can cause insomnia, daytime sleepiness, and restless legs.
The Case of the Woman on Stress Leave
When I first see certain patients, I notice that they look intensely sad, and I know that no matter what tests I do or what medical problems I find, I might never get to the root of their problems. Such was the case with a woman in her sixties who had been referred to me because she had severe sleepiness. I studied her appearance for clues that might shed light on the cause of her problem. She was roughly fifty pounds overweight and poorly groomed; her hair was uncombed and her clothes were ill fitting and old. The expression on her face was sad and withdrawn.
Her doctor suspected that her daytime sleepiness might be caused by sleep apnea, so he sent her to me for evaluation. She did have the common symptoms of sleep apnea. She snored, stopped breathing during sleep, and was overweight. But there was more. Many nights she experienced severe restlessness and difficulty falling asleep.
When I asked her about her work, she explained that she was on medical disability—stress leave. She had been a senior executive at a bank, in charge of the loan department, but was now unable to work. She blamed her current situation on the poor economy and a nervous breakdown; her doctor was treating her for depression. She was also convinced that if her poor nighttime sleep and daytime sleepiness could be treated, all her problems would go away. It turned out that her treatment for severe depression involved several medications that could both disrupt her nighttime sleep and make her sleepy during the day. But she might also have a sleep disorder such as sleep apnea that could worsen her depression. I knew that this was going to be a tough case.
Her sleep test showed that she moved a great deal during sleep and she stopped breathing about six times an hour. Although her breathing pattern improved when she was tested while being treated with continuous positive airway pressure, her sleep was still unstable, partly because of excessive movements. I knew the cause of her sleep-breathing disorder, but the solution for the movements would be more difficult.
Mental Disorders and Sleep
Mental disorders of various severity are very common, and they often coexist with sleep disorders or cause sleep problems. In a survey of European countries published in 2011 it was shown that over a third of the total European population suffers from a mental disorder of some sort. The two most frequent were anxiety disorders (affecting 14 percent of the population) and depression (affecting 6.9 percent of the population). The report also found that insomnia affected 7 percent of the population.
The costs of treating mental disorders are huge. Another European study in 2011 reported the costs to society of mental and sleep disorders. The cost in billions of euros broke down as follows: addiction, 65.7; anxiety disorders, 74.4; mood disorders, 113.4; psychotic disorders, 93.9; and sleep disorders, 35.4.
Symptoms of a mental disorder and sleep problems are often interwoven. Sleep disturbance is a very common occurrence in mental illnesses, and the disturbed sleep, in turn, can cause daytime sleepiness and other symptoms, which can then worsen the symptoms of the mental disorder. In fact, disturbed sleep can itself cause a mental disorder. Furthermore, some of the symptoms of sleep disorders are similar to the symptoms seen in psychiatric conditions, and many people with sleep disorders are misdiagnosed as having a mental condition.
To confuse matters even further, the drugs used to treat psychiatric conditions frequently cause sleep disturbance. Often it is very difficult to figure out the source of a particular symptom. Medications used to treat depression, for example, can cause restless legs syndrome (see Chapter 11), and drugs that treat schizophrenia can cause weight gain, which in turn may cause sleep apnea (Chapter 12).
The category “psychiatric illness” or “mental illness” lumps together many conditions in which patients experience changes in mood, perception of reality, thought processes, or behavior. Traditionally, these were not considered medical disorders but were classified as disorders of the mind. We now know that several of these conditions are caused by biochemical abnormalities involving the brain, and treatment often involves correcting the biochemical abnormalities.
The important association between sleep and mental illness cannot be overstated. A 2016 study found that people with any mental disorder who reported disturbed sleep were more likely to have suicidal thoughts or to plan or attempt suicide.
The mental disorders we most often see at the sleep clinic in association with sleep problems are disorders of mood (such as depression and bipolar disorder), disorders of thought (such as schizophrenia), and anxiety disorders (including panic disorder and posttraumatic stress disorder, which is often seen in military veterans).
Disorders of Mood
Mood disorders are broken into two general types, depression and bipolar disorder. People with depression feel sad most of the time even when there is no apparent reason for the feeling. In children and teenagers, depression sometimes manifests as irritability instead of sadness. Some people have a condition called dysthymia in which there is a chronic depressed mood, but it is not severe enough to be classified as a major depression.
DEPRESSION
A previous diagnosis of depression is particularly common in female patients who come to the sleep clinic. In my practice, about 21 percent of women referred for sleep apnea were being treated for depression, compared to only 7 percent of men referred for the same condition. About 8 percent of North American adults can expect to have severe depression at some time in their lives. Most of those affected will be women. It is important to note, however, that many of the patients being treated for depression were not depressed. They were sleepy, and they had been misdiagnosed.
Links between sleep and depression are very strong. Insomnia is present in about 75 percent of depressed patients, and daytime sleepiness is present in about 40 percent of young depressed adults. Insomnia and sleepiness affect quality of life, and have been reported to be a risk factor for suicide. Depression is a very serious condition, and most depressed people have sleep problems.
Depression in adolescents. In my clinic I have seen many children being treated for depression who were referred because of insomnia or excessive daytime sleepiness. Before puberty, boys and girls experience about the same rates of depression. Between the ages of eleven and thirteen, however, there is a dramatic rise in the rate of depression in girls. By age fifteen, girls are twice as likely as boys to have been depressed. The stresses of adolescence, including physical, emotional, and hormonal changes, seem to affect girls more. Female high school students have higher rates of depression, anxiety disorders, and eating disorders than their male counterparts. The reason for this difference is, at least in part, related to hormones.
A 2016 study found that disturbed sleep in depressed children may be a predictor of suicidal behavior. It is important to stress that at times patients might be misdiagnosed as having depression. Sleepiness, an important symptom of narcolepsy and sleep apnea, has been mischaracterized in some patients as a symptom of depression, for example. Similarly, some teenagers whose circadian clock has changed so that they are sleepy later at night (see Chapter 8) and have to be dragged out of bed in the morning have been misdiagnosed with depression. Imagine carrying a diagnosis you do not have for the rest of your life!
Depression in women. Sex hormones can cause fluctuations in mood that can lead to depression. These hormonally related fluctuations occur during the menstrual cycle (discussed in Chapter 3), during pregnancy and the time following childbirth (Chapter 4), and in the time immediately before, during, and after menopause (Chapter 5). Some women experience severe mood and physical changes associated with the menstrual cycle. Symptoms include irritability, depressed feelings, and physical changes such as bloating, tender or painful breasts, and cramps. This is premenstrual syndrome (PMS). The symptoms are worse during the days before menstruation starts. When the mood changes are severe, the disorder is called premenstrual dysphoric disorder (PMDD). All these conditions can lead to sleep disruption.
Mood swings are also common in pregnancy, and some pregnant women might become depressed. Women who are trying to become pregnant or who are infertile can be under great stress, but there is no evidence that stress alone leads to depression. Nor is there evidence that having an abortion leads to depression.
The days and weeks that follow giving birth are a high-risk time for women who have had a major psychiatric illness. Some women experience postpartum depression, an extreme mood disorder that requires medical intervention. Such women often have had symptoms or a history of depression before they became pregnant. Motherhood, with all its demands and stresses, increases the risk of depression.
Although menopause is a time when women’s hormone levels are changing drastically, it rarely leads to depression. Many menopausal women can have sleep problems, however, because of symptoms such as hot flashes.
Hormonal differences offer a partial explanation of why depression is so much more common in women than men, but some scientists also believe that the greater stresses that many women face are another factor. These stresses can include having major responsibilities both at home and at work, being a single parent, trying to make ends meet financially, and being the main care-giver for children and/or aging or sick parents. Many of my women patients who have had sleep problems related to depression were in the process of divorce or were in a poor relationship. Others had children who had marital or other problems. Rates of depression are highest among men and women who are separated or divorced and lowest among those who are married. The quality and stability of a marriage can play a role in depression. Sometimes depression in women is related to a lack of intimacy and a confiding relationship; sometimes it is linked to frequent or severe marital disputes. Women in unhappy marriages have very high rates of depression.
Depression in men. Although depression is less common among men than women, the sheer number of cases still places depression in men as a public health problem. Is there a link between depression and sleep problems? A 2016 study of men found that those with severe restless legs syndrome were very likely to have depression. One important study followed students graduating from the Johns Hopkins University School of Medicine (classes 1948–1964), all men, for up to forty-five years. This study found that those who had insomnia during school were much more likely to develop depression starting about fifteen years after graduation.
I have seen many male patients with insomnia who are victims of the economic recession that started in 2008. Many lost their jobs, or their businesses went bankrupt. Often their minds race when they are trying to sleep because they are worried about their financial situation.
Depression and aging. Depression is not a normal part of aging. Most older people lead satisfying lives and are not depressed. Though there is a perception that they suffer from empty-nest syndrome when their children leave home, research has not confirmed that this situation is a likely indicator of depression.
Sleep problems related to depression. People with depression suffer from a variety of sleep problems. More than half have insomnia; others have trouble staying asleep, or they wake up early in the morning and have trouble falling back to sleep. Because they might be very sleepy during the day, they might take a long nap or drink excessive amounts of caffeinated beverages, both of which could inhibit their nighttime sleep.
Research from Germany published in 2011 showed that people with insomnia were twice as likely to develop depression as people with no sleep complaints. Research from France reported that same year showed that insomnia symptoms, daytime sleepiness, and the use of sleeping pills can each increase the risk of developing depression in the elderly. Research from Japan published in 2010 reported that difficulty falling asleep (but not being able to stay asleep or waking up very early in the morning) could predict the development of depression. Thus sleep disturbance can lead to depression, or be a marker that depression may occur.
About one in five adults in the United States who complain of insomnia are diagnosed with depression. In some people depression manifests as over-sleeping. About one-third of all people who experience insomnia will have depression sometime in their lives, as will a quarter of those who have daytime sleepiness. Half of patients with both symptoms will have depression at some point in their lives. Thus, there is a very strong correlation between depression and poor sleep. In fact, one of the symptoms used by the National Institute of Mental Health in the diagnosis of depression is insomnia or excessive sleepiness.
I have seen many cases in which stress in the workplace was the cause of severe insomnia. One of my patients was an air traffic controller who was no longer able to deal with the stress of her job. She became clinically depressed, could not sleep, and nodded off while working. She had to go on disability.
Symptoms of depression. According to guidelines published by the National Institute of Mental Health, if three to five or more of the following symptoms are present for more than two weeks, they may indicate depression.
· Persistent sad, anxious, or “empty” feelings
· Feelings of hopelessness or pessimism
· Feelings of guilt, worthlessness, or helplessness
· Irritability or restlessness
· Loss of interest in activities or hobbies that were once pleasurable, including sex
· Fatigue and decreased energy
· Difficulty concentrating, remembering details, and making decisions
· Insomnia, early morning wakefulness, or excessive sleeping
· Overeating or appetite loss
· Thoughts of suicide or suicide attempts
· Aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment
Treatment of sleep problems related to depression. I am not a psychiatrist. I see hundreds of people a year who have sleep problems who are also depressed, and if I believe that their sleep problems are caused by depression I recommend they see a psychiatrist or a psychologist. Most medical practitioners use medications to treat depression. More than twenty-five different types of antidepressants are available, and between 60 and 80 percent of people with depression respond favorably to one or more of these medications. It may take several weeks or months of treatment before progress becomes apparent. Sometimes the sleep problem will resolve itself before the mood improves and sometimes after.
Doctors who treat depressive patients with antidepressants might also add a hypnotic medication in the form of a sleeping pill (see Chapter 20). Some antidepressants produce side effects that affect sleep, such as insomnia, excessive sleepiness, or difficulty falling asleep because of symptoms of restless legs syndrome. A patient who is prescribed an antidepressant that keeps him or her awake might be advised to take the medication in the morning. Similarly, if a person is given an antidepressant whose side effect is to make the user sleepy, it might be better to take the medication at night. After evaluating a patient who has been referred to me for insomnia, I sometimes recommend that the doctor prescribing the medications reconsider the drugs being prescribed or change the timing of when the patient takes the medication.
Antidepressant medications. The older antidepressant medications are the tricyclics (examples include amitriptyline and imipramine) and monoamine oxidase inhibitors (MAOIs; examples include phenelzine). These act by increasing the levels of neurotransmitters in the brain (mainly serotonin and norepinephrine), which improves communication between brain cells. It is believed that abnormal levels of neurotransmitters contribute to depression.
Newer medications that primarily affect serotonin levels in the brain and are thought to improve levels of neurotransmitters are selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).
Another newer class of antidepressants that are thought to improve levels of neurotransmitters are the serotonin and norepinephrine reuptake inhibitors (SNRIs), which include venlafaxine (Effexor) and duloxetine (Cymbalta).
Other newer drugs that affect levels of brain chemicals are bupropion (Wellbutrin), trazadone (Deseryl), nefazodone (Serzone), and mitrazipine (Remeron).
Generally speaking, the newer medications have different—but fewer—side effects from the older medications. Drugs that affect serotonin levels, for example, may cause sexual dysfunction (decreased interest in sex, decreased bodily response during sex, and decreased ability to orgasm), whereas with MAOIs there might also be a drop in blood pressure, weakness, dizziness, or weight gain.
Before taking these drugs, patients should keep in mind that several of the antidepressants I have listed (especially the newer ones) can have insomnia or daytime sleepiness as a side effect. Some might have weight gain (which can cause sleep apnea) as a side effect. Patients being treated for depression who experience major sleep problems should review the benefits and drawbacks of their medications with their doctor.
Herbal products. Although few doctors prescribe herbal medications, public interest has grown for treating both depression and anxiety with natural products. One plant that is widely used in some European countries to treat depression is Saint John’s wort (Hypericum perforatum). A 2015 analysis of studies of its use concluded that there is some benefit, but the effect appears to be modest compared to a placebo. The U.S. Food and Drug Administration advised the public that Saint John’s wort appears to affect the way the body handles certain drugs, including some used to treat AIDS, and could reduce the effectiveness of certain oral contraceptives and anticoagulants. Alternative treatments, though “natural,” are not always safe. Patients should tell their doctor if they are using a herbal treatment for depression.
Other types of therapy. Many patients do not want to see a psychiatrist, and they prefer not to take pills. Several types of psychotherapy are used to treat depression without medication. In these treatments, people talk with a therapist to understand and solve (or at least cope with) problems that might have an impact on their depression. I frequently refer such patients for cognitive behavioral therapy (see Chapter 19). Behavioral therapists, who are often psychologists, help people unlearn the behavioral and thought patterns that could be causing or aggravating their depression. Such treatments can also prevent insomnia from becoming chronic. With cognitive behavioral therapy, patients learn to change negative attitudes and behaviors that contribute to or maintain depression. Doctors might also combine psychotherapy with medications.
While most depression responds to medication, if this does not work, for some severely depressed patients electroconvulsive treatment can be highly effective. In this treatment, doctors induce a seizure while the patient is anesthetized. Why this treatment works is totally unknown. While it has been maligned, it can be lifesaving in a severely depressed patient. The main side effects are related to memory, mild headaches, and muscle pains. Another treatment currently being investigated is a device that stimulates the brain with magnetic waves. The jury is still out as of late 2016 on the usefulness of this treatment.
Because depression is so common and along with its treatment so frequently causes sleep problems, it is important that people being treated for depression make sure the doctor is aware of any sleep difficulties they already have or develop after starting a treatment.
BIPOLAR DISORDER
People with bipolar disorder, also called manic depressive disorder, have features of both depression and mania. When the patient is in a depressive phase, the symptoms are similar to those of depression. During a manic phase, however, the patient might feel inappropriately elated and appear to have boundless energy; patients in this phase might also do inappropriate things such as going on spending sprees. Bipolar disorder has been classified as having two types:
Bipolar I Disorder: defined by manic or mixed manic depressive episodes or severe manic symptoms
Bipolar II Disorder: defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.
Bipolar disorder often causes severe sleep problems when people are in their manic phase. Some scientists theorize that an abnormal circadian system might play a role. Recent research shows that variations in the genes that control the circadian clock might affect the rate of suicide in these patients. Patients with bipolar disease sometimes have a great deal of difficulty falling asleep at night, and their days and nights might switch. People might report that they do not need as much sleep as they did and that they feel terrific after only two or three hours of sleep. When people switch from the depressed phase to the manic phase (sometimes even before the switch), they experience several days of very poor sleep. Some patients claim they do not sleep at all during this time. Additionally, in what has been called a mixed state of bipolar disorder, patients have mania and depression simultaneously. Almost all these patients have a sleep problem, because it is likely that the chemical changes that are affecting their mood are also affecting the parts of the brain controlling sleep.
Symptoms of mania. The mania symptoms commonly found in patients with bipolar disorder listed below were adapted from the National Institute of Mental Health guidelines.
Mood Changes
Feeling very “up,” “high,” or elated
Having a lot of energy
Feeling “jumpy” or “wired”
Being agitated, irritable, or “touchy”
Behavioral Changes
Having increased activity levels
Having trouble sleeping
Becoming more active than usual
Talking very fast about many different things
Feeling as if their thoughts are going very quickly
Thinking they can do a lot of things at once
Doing risky things, such as spending a lot of money or having reckless sex
Treatment of sleep problems in bipolar disorder. Doctors often prescribe medications to treat bipolar disorder. The treatments, however, might make patients sleepy—very sleepy—and might have potentially severe side effects. When patients have a severe manic episode (in Bipolar I) they could require hospitalization.
Lithium carbonate, a mood stabilizer, is the most widely used medication to treat bipolar disorder. If depression is also a major problem, the doctor might also prescribe an antidepressant. Treatment with lithium has two important effects on sleep that patients need to keep in mind. First, lithium may lead to an underactive thyroid gland, which could cause sleepiness, weight gain, and even sleep apnea. Second, some studies have suggested that lithium can slow the body clock, setting patients on a night-owl schedule (see Chapter 8).
Aripiprazole (Abilify), an antipsychotic agent, has been approved by the FDA for treatment of several mental disorders, including schizophrenia and bipolar disorder, and as an additional treatment for major depression when other antidepressants are not effective.
Valproic acid or divalproex sodium (Depakote) is generally as effective as lithium for treating bipolar disorder. Lamotrigine (Lamictal), another anti-epilepsy (anticonvulsant) drug, is also used to treat bipolar disorder. Other anti-convulsants are sometimes prescribed for treating bipolar disorder, including topiramate (Topamax), gabapentin (Neurontin), and oxcarbazepine (Trileptal).
Valproic acid, lamotrigine, gabapentin, and several other anticonvulsant medications, as well as aripiprazole, can increase the risk of suicidal thoughts and behaviors; people taking these drugs should be closely monitored for symptoms of depression, suicidal thoughts or behavior, or unusual changes in mood or behavior. The FDA has warned people taking these medications to not make any changes in their treatment without talking to their doctor. All the anticonvulsant drugs can make the patient sleepy, which can be a help at night but is less helpful if the sleepiness persists after the patient awakens.
A SAD TALE (OR IS IT SSAD?)
In 1976 Norman Rosenthal moved from South Africa to the United States to train in psychiatry. He noticed in himself that during the winter, especially in the morning darkness, he felt his energy level plummet; when spring arrived and the mornings brightened, his energy level soared. After research and collaboration with scientists working on the circadian system in 1984, he published the first article on seasonal affective disorder (SAD). Just as sleep apnea was not a new disease when it was first diagnosed in the mid-1960s, SAD did not suddenly appear in the 1980s. That the seasons can have a major effect on the body has been known for centuries. (The body of a hibernating bear, for example, changes dramatically before the winter.)
Rosenthal described a group of patients with SAD, most of whom had bipolar disease, whose depression worsened during the winter months (starting in October–December in the Northern Hemisphere). Their symptoms were severe daytime sleepiness, excessive eating, and a craving for carbohydrates. These symptoms improved as the days lengthened in the spring.
For some patients, the symptoms of depression worsen or appear only when nights are longer (during the winter), which is why the condition has been called winter depression. SAD is thought to be not a separate condition but a variant of clinical depression. A milder form has been called subsyndromal seasonal affective disorder (SSAD).
The number of people with SAD increases in areas closer to the North and South Poles, where there is the least amount of daylight in the winter. More cases of SAD have been reported in Alaska (almost 10 percent of the population) than Florida (less than 2 percent of the population). Women are more likely to have SAD than men.
What causes SAD? It is not simply the amount of daylight exposure. Recent research suggests that susceptibility to SAD could be related to variations in genes responsible for the production of a pigment called melanopsin. Specialized cells in the eye contain the pigment, which is light sensitive, and are believed to play a role in resetting the body’s circadian clock. This may explain why some northern populations (for example, people of Icelandic descent in Iceland and Canada) are less likely to develop SAD than southern populations.
Why do patients with SAD gain weight? Some researchers have introduced the phrase “circadian desynchrony” to describe the mismatch between an individual’s circadian clock and the world he or she lives in. Patients with SAD spend more time in bed awake; it takes them more time to fall asleep; and they have poor sleep quality. The combination of factors can affect several hormone systems, including those involved in appetite control and metabolism. People with SAD often gain weight during the winter months. Reduced sleep time changes the levels of hormones that control appetite (leptin and ghrelin) and can negatively impact the way the cells in the body respond to the hormone insulin. These changes can lead to weight gain.
Treatments have been developed for SAD patients that focus on exposing them to longer periods of bright light. Starting in October and throughout the winter season (in the Northern Hemisphere) a thirty-minute exposure to bright light (natural sunlight or a “light box”) can be effective in treating or preventing SAD. A lower intensity and duration of exposure to blue-enriched light has also been effective. Antidepressants might be prescribed when depressive symptoms are present. Some doctors prescribe the hormone melatonin. A new antidepressant compound, agomelatine, which is available in some countries though not the United States, might be effective. This medication stimulates melatonin receptors in the brain and antagonizes serotonin receptors. No scientific evidence exists at this writing that either melatonin or agomelatine has a positive effect on SAD.
SAD can be a serious disorder. Some sufferers have had thoughts of suicide. People exhibiting significant symptoms of SAD must seek professional help. It has been reported that light therapy can lessen suicidal thoughts in patients with SAD. People with SAD should consult a clinician who is familiar with all aspects of treating SAD and should follow the treatment recommendations of their clinician. People with SAD should not treat themselves.
Disorders of Thought: Schizophrenia
Schizophrenia is a devastating illness affecting roughly 1 percent of the world’s population. A high suicide rate is associated with schizophrenia, and in spite of marked improvements in treatment, about 20 percent of affected people are incapacitated by the illness. Those who do not require intensive treatment often require many visits to their health care providers and might need hospitalization.
Causes and symptoms of schizophrenia. People with schizophrenia have problems in how their brain deals with thoughts, problems with the content of the thoughts themselves (delusions), and the belief that their delusions are real. In other words, their thinking process becomes illogical, disorganized, and sometimes repetitive. They might experience either delusions (false, unchangeable, and irrational beliefs) or hallucinations (sensations, sounds, sights, touches, tastes, and smells that are not present). Hearing voices that other people do not hear is the most common type of hallucination in schizophrenia, as was depicted in the movie A Beautiful Mind. People with schizophrenia might start to believe that they are being followed, persecuted, robbed, or poisoned. They might develop bizarre behavior or ignore personal hygiene.
People with schizophrenia have extremely abnormal sleep patterns. Their dreams can be terrifying, and it can take them hours to fall asleep. They are also likely to have nightmares. I will always remember the videotape of one patient we saw who had awakened during the night with a terrible hallucination, delusion, or nightmare; he started hitting his own head to try to stop the terrible thoughts. Several of the patients I have seen have become nocturnal: they are awake at night and asleep during the daytime, and they come to the clinic complaining of insomnia. Though the sleep problems in people with schizophrenia are severe, they can often be treated.
Treatment of sleep problems in schizophrenia. As with the other mental disorders, the treatment focuses on the underlying schizophrenia problem. There are excellent medications specific for this condition now available that help control the disease. Almost all schizophrenic patients I’ve seen in the sleep disorders center were already being treated for their schizophrenia but still had sleep problems. They were convinced that if their sleep problem could be solved the schizophrenia would go away. Unfortunately, this is not the case. Though some medications used to treat schizophrenia also help to improve the patient’s sleep, the sleep does not usually become completely normal. But because it can improve sleep, doctors sometimes prescribe the medication to be taken at bedtime.
A large number of schizophrenic patients have other sleep problems as well, such as obstructive sleep apnea or a movement disorder. It is estimated that over 50 percent of outpatients with schizophrenia are at high risk of having obstructive sleep apnea. This might in part be related to the fact that some medications used to treat schizophrenia cause weight gain, and this increases the risk of having sleep apnea. Since the medications also cause sleepiness, doctors might not consider whether the patient has developed sleep apnea, so patients or their families should describe the symptoms carefully. Schizophrenic patients who develop obstructive sleep apnea are treated in the same way other patients with the disorder are treated.
We have also had patients at the sleep clinic who had narcolepsy but were misdiagnosed as having schizophrenia and treated for this condition instead. One young teenager was even hospitalized in a psychiatric ward. Narcolepsy is a disorder in which people have vivid dreams at sleep onset, but they generally recognize that the images they have are dreams and are not real (see Chapter 13). The schizophrenic patient, when untreated, believes the hallucinations to be real.
Anxiety Disorders
Tomorrow’s the big day: You are about to propose a toast at your best friend’s wedding, to be interviewed for a job, to take a final exam, to go onstage in a musical, to take your first overseas plane trip. You are trying to fall asleep but you cannot because you have butterflies in your stomach and your heart is pounding. It is normal to feel nervous or anxious in such stressful situations, and the feeling usually goes away as soon as you stand up for the toast, sit down for the interview or exam, step onto the stage, or fasten your seatbelt. For some people, however, these feelings of fear and dread come on at the wrong time and in the wrong place. Feelings of anxiety take over their lives and prevent them from performing important—or even daily—tasks and activities. These feelings are brought on by an anxiety disorder.
A 2016 study reported that about 16.6 percent of adults worldwide will have an anxiety disorder in their lifetime. These disorders are twice as common in women than men. They include panic disorder, generalized anxiety disorder, social phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. All these disorders can be treated, but they can worsen if they are left untreated. Medications (most often antidepressants, sometimes anti-anxiety drugs), psychotherapy, and cognitive behavioral treatment are the most common treatments. Patients with these disorders, even when they have sleep complaints, are best treated by a psychiatrist. The medications commonly prescribed for anxiety disorders, used at bedtime, could help alleviate the insomnia.
PANIC DISORDER
Your heart is beating fast, you are breathing deeply, you are sweating and shaking, time seems to be standing still, and you feel dizzy. You might have chest pain or tingling in your fingers. You feel as if you are about to die. You have these episodes over and over again, yet the doctor never finds anything abnormal during your checkups. When people have these symptoms for more than a month, they are usually diagnosed with a panic disorder.
Sufferers of panic attacks usually connect them with the situations in which they occur. This can lead to a fear of a particular situation, which the person then tries to avoid. More than half of people with panic disorders awaken with nighttime panic attacks, and many develop a fear of falling asleep. Waking up at night afraid of dying is a terrifying symptom. When such patients come to the sleep clinic, we might screen them for a sleep disorder (patients with sleep apnea might awaken in a panic), but if they don’t have a sleep disorder we refer them to a psychiatrist.
GENERALIZED ANXIETY DISORDER
You are always worried about your job, family, or health, even when all seem to be well. You have trouble controlling the worrying. This problem is common in both women and men, and it usually begins to affect people in their early twenties. Most people with generalized anxiety disorder have trouble sleeping because they can’t stop worrying at bedtime; added to their other worries will be worry about not falling asleep. Fifty to 75 percent of these patients have difficulties with sleep.
SOCIAL PHOBIA
You are afraid of being embarrassed or humiliated and are uncomfortable in situations that involve social interactions or that might draw attention to you. You experience extreme shyness in meetings, at parties, in the classroom, or even at a restaurant. Students with this phobia might start cutting classes. Other patients might develop panic attacks. Some might start depending on alcohol to relax, and that can result in a new set of problems. About 20 percent of these patients have insomnia.
OBSESSIVE-COMPULSIVE DISORDER (OCD)
This disorder, which affects about 2 percent of the world’s population at some time, has two types of symptoms. Obsessions are thoughts or ideas that even the patient will sometimes admit are “crazy,” “silly,” “pointless,” “stupid,” or make no sense. In spite of knowing that the thoughts are irrational, the person cannot seem to keep from thinking about them. Compulsions are behaviors that occur in response to the obsessions. For example, the person might believe (have the obsession) that the gas burner has been left on and will keep checking the burner (the compulsion) over and over again. The compulsions are usually repeated each time in exactly the same way. People with OCD do not usually have sleep problems unless they are worrying at night or their obsession leads them to compulsive behavior at night. This might include repeated checking to make sure the doors are locked, the windows are closed, the baby is breathing, or the water faucets are turned off. There are medications that can treat OCD. Antidepressant drugs that affect brain levels of serotonin have been shown to improve symptoms in some patients. Medications approved by the FDA for use in the treatment of OCD include the following antidepressants: clomipramine (Anafranil), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft).
POSTTRAUMATIC STRESS DISORDER (PTSD)
Almost seventy years after being liberated from a concentration camp, a Holocaust survivor still wakes up almost every night with nightmares. A woman is brutally raped and she relives the horror every night in her dreams. About 10 to 30 percent of people who have been involved in a traumatic event develop PTSD.
This disorder, now called posttraumatic stress disorder, has had other names over the years, including “shell shock” and “battle fatigue.” People develop PTSD after experiencing or witnessing something horrible and reacting with intense fear, helplessness, or horror. It is common in both the military and civilian populations. PTSD sufferers replay the terrible events frequently, often awakening from nightmares in a sweat with their hearts thumping, sometimes screaming. Some patients exhibit symptoms of panic disorder. Such patients may develop a fear of falling asleep. Many combat veterans have sleep apnea, and many (perhaps most) have PTSD. Some of these veterans will have claustrophobia (due to past experience with gas and other masks) and will thus have difficulty tolerating the CPAP treatment. Some combat veterans even years after discharge from service will awaken at night and “patrol” their dwelling.
Despite its association with the military, PTSD is twice as common among women as men in the general population. When a patient is referred to the sleep clinic for insomnia, sometimes the assessment identifies the cause as a very traumatic event. These patients need psychiatric care. A study published in 2012 showed that a medication called prazosin (a drug originally introduced to treat high blood pressure) along with cognitive behavior therapy (see Chapter 19) were effective for many patients in treating the sleep disturbances in PTSD.
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The patient told me that she had put on a great deal of weight, a side effect of one of the medications she was taking because she was severely depressed and had considered suicide. Some antidepressants cause restlessness before and during sleep and increase movements during sleep, which was the problem that was uncovered in her sleep test. Additionally, one of the medications that she was using for anxiety had a side effect of making her extremely sleepy during the day. Because she needed these medications for her psychiatric condition, we could not suggest that she stop using them. I suggested instead that we treat the mild sleep apnea with CPAP. I also recommended that her psychiatrist consider adjusting her medication in the hope of minimizing side effects. The problem was that the sleep disorder was not the cause of her psychiatric disorder. The medications she took for her psychiatric disorder were having profound adverse effects on her sleep. Her sleep was unlikely to improve significantly until the darkness of her depression finally lifted.
Psychiatric conditions often result in sleep problems. Many of these psychiatric conditions are more commonly found in women, so sleep disorders tend to be common in women with these conditions. But addressing the psychiatric problem with medications can exacerbate the patient’s sleep problems. Sometimes there is no easy solution to a patient’s sleep problems.