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Questions
of the Week
January
Through March, 1999
January 4, 1999
Q Last week
you were discussing "hypersomnia" and I believe that my
nephew may have this. He will fall asleep and tell me that he is
dreaming and he can do this while we are in the midst of a
conversation. Is there any other condition that would cause
this?"
A Narcoloepsy is defined when there have been
at least three months of sudden onset and irresistible sleep which can
be characterized by cataplexy (sudden bilateral loss of muscle tone,
most frequently in intensely emotional situations) and/or sudden sleep
paralysis or hallucinations at the beginning (hypnogogic) or endings (hypnopompic)
of sleep cycles. Such individuals find an irresistible urge for sleep
often precipitated by an emotional event and will report either
paralysis or hallucinations at the onset or closure of sleep. This
differs from primary hypersomnia and often has a neurological basis
and is not typically implicated with clinical depression.
January 11, 1999
Q You have
been discussing sleep problems for several weeks. Well, I have a
problem that is probably like a lot of people. I work shifts for my
company, and the shifts are always changing. I am tired most of the
time and do not have energy to do much of anything except for work. Is
there an "official" name for this, and is this an issue I
should discuss with my supervisor?"
A Circadian
Rhythm Sleep Disorder is most often divided into three major subtypes:
a pattern of delayed sleep onset and then late awakening with
inability to bring this into a normal pattern. This is called delayed
sleep phase type. Threre is also jet lag type that which occurs in
individuals who travel frequently across time zones as part of their
work. Shift Work Type refers to individuals who are working during
normal sleep cycle and attempting to force sleep during the normal
waking hours. There is also what is referred to as unspecified type
for sleep wake schedule disorders that arise as a resilt of other
irregular sleep wake patterns.
Your company is likely
highly invested in productivity. They are also likely invested in
industry health and safety concerns. Explaining to your supervisor any
problems you are having with attention, concentration and coordination
as a result of this sleep rhythm disturbance may help them assist you
in finding a schedule within which you can work.
January 18, 1999
Q This is
more of an academic question. I have never known anyone who sleep
walked. Does this really occur or are people who report this as a
problem just attention-seeking?"
A
Sleepwalking Disorder is diagnosed when an individual arises from bed,
often during the first third of a major sleep episode, and walks
about. The individual, during the episode, has a blank, often
expressionless, face and may be unresponsive to others communicating
although in some instances the sleep walking individual will
verbalize. The individual is awakened with great difficulty and is
amnestic for the event. Although 1-7% of the adult population may have
had a sleepwalking episode, sleep walking disorder is less common.
Investigations indicate that from 1/10 to 1/3 of children have had a
sleepwalking episode. There has been some indication that breathing
related sleep disorders and sleepwalking and between migraine
headaches and sleepwalking.
January 25, 1999
Q We are
having a very difficult time with our son. He is seven years old,
wakes up screaming during the night, most nights, but he does not seem
to recall a dream just wakes up screaming, thrashing about and seems
wild. He calms down but by then we are pretty upset, and the whole
household is away? What could this be?"
A Sleep
Terror Disorder presents as someone awakening with signs of fear and
shortness of breath, rapid heat beat and most often a scream of
terror. Recall of the dream is not common with children although
adolescents and adults may recall the dream content and this most
often occurs in the first third of a sleep cycle. In adults this may
be associated with other psychological problems, but in children,
other problems are not as common. In children it usually subsides by
adolescence. In adults, it most often occurs in early adulthood and is
more likely to be chronic. It is also common for this to occur in
families. These individuals are more likely to awaken/calm with
difficulty in comparison to those with Nightmare Disorder who most
often are easier to calm.
The first concern would be to insure that other problems are not the
cause of these symptoms such as other disease or metabolic problem.
Evaluation by the child's pediatrician and psychologist would be the
place to start.
February 1, 1999
Q You have
been discussing sleep for several weeks. I have the strangest sleep
problem. At the beginning of the academic year here at college, I just
cannot sleep. I stay up until 3am or 4am and then fall asleep briefly
before class. I am tired all day. After the semester, around the first
of the year, I then begin having this sensation that I cannot get
enough sleep. I go to bed at about 8pm and sleep through my first
class, come home during the afternoon and nap and on weekends I'll
sleep most of the time. I also have been gaining wait, snacking a lot
and it seems to take me hours to memorize even small amounts of
material for my classes. Actually, there are other problems as well,
but that may be enough to ask this question. Any thoughts?"
A Insomnia
(inability to sleep) and hypersomnia (need for excessive sleep)
associated with psychological problems such as major depressive
disorder can account for almost half of the cases seen in sleep
centers. Biploar disorder, anxiety disorders, panic disorder and other
conditions can create problems with problems with sleep onset, sleep
maintenance or the above mentioned hypersomnia. Such individuals may
appear haggard during the day. Among many groups, it is more
acceptable to discuss problems with sleep than problems with anxiety
and mood.
You mention several other
symptoms that may suggest problems with mood and/or anxiety such as
problems with concentration, memory and a change in eating with
associated weight gain. Assuming that these symptoms are not related
to a substance (prescribed or not prescribed) that you are taking, and
that you have seen your family physician and have no physical disease
or condition creating this problem, you may wish to be seen by a
consulting psychologist at the Student Health Center. Perhaps the most
important aspect is the onset of the problem when school starts and a
change as soon as Christmas vacation ends.
February 8, 1999
Q I gather
that all sleep disorders are psychological and that they are not
caused by physical illness?"
A Insomnia
(inability to sleep) and hypersomnia (need for excessive sleep) and
parasomnia (abnormal behavior during sleep cycles) can all arise from
physical disorders and conditions. There are degenerative neurological
disorders such as Parkinson's Disease, cerebral vascular disease
caused by lesions to the upper brain stem, thyroid conditions, viral
or bacterial infections, pulmonary diseases and muculoskeletal
diseases which result in pain.
In any disease or illness
state, the patient and the doctor need to look at both the
psychological precursors and aftermath of the physical illness upon
the individual as well as the impact of the illness itself upon
physical functioning including sleep.
February 15, 1999
Q I think
my sleep disorder is caused by pain. I take a drug called Vicodin for
pain, and it really makes me drowsy, but I still do not sleep well,
and I think this is because my underlying pain is still there."
A As noted
last week, insomnia (inability to sleep) and hypersomnia (need for
excessive sleep) and parasomnia (abnormal behavior during sleep
cycles) can arise from prescrived medication or other drug taken and
can result from the intoxication of the drug or from the withdrawal
from the drug. These are not primary sleep disorders in that they
would not occur if the individual were not taking the prescribed
medication or other drug. The drugs used to treat anxiety (anxiolytic
drugs) such as the benzodiazepines (Eg. Valium, Ativan, etc) and drugs
that are used to treat pain (the narcotic analgesia like Percocet,
Vicodin, Lorcet, etc) are know to disrupt sleep. And since withdrawal
can extend over a long period of time, the sleep disorder may occur
weeks after the cessation of the drug.
In the case you describe, it was unclear as to how much of the pain
relieving drug you have been taking, whether you nap during the day,
and/or whether you awaken as the drug wears off or merely have
disrupted sleep pattern caused by the drug itself.
February 22, 1999
Q I am
married to a man who regularly picks fights with other men, becomes
enraged when his car does not start and will kick in the fenders and
doors, and has become so upset at a restaurant that he has thrown food
on customers. We have had countless confrontations by the police and
although he has never been sent to jail, I feel that this is going to
happen. Is this a brain tumor or something?"
A There is
often an underlying personality disorder that accompanies a disorder
called Intermittent Explosive Disorder which is, itself, considered a
disorder of impulse. Such individuals are prone to aggressive
outbursts when under stress. They may perceive the stress as threat,
frustration, insult, vulnerability or any combination of the above.
Some of these individual have unusual EEG (brain) wave patterns or
changes in brain chemistry. There may also be "soft"
neurological findings, but the disorder is considered to arise from
poor control of impulse when needs or demands are not met. As the
individual accumulates a series of experiences in which such behaviors
are tolerated, often beginning early in life, the behavior continues.
The threat to individuals and property can be substantial. There are
those for which this pattern of behavior suddenly emerges. The person
is often upset, guilt-laden and remorseful after the rage filled
episode even though there may be a sense of relief after the aggresive
outburst.
March 1, 1999
Q I have a
daughter who must be a kleptomaniac. She repeatedly shoplifts makeup
and clothing and has twice been caught. She states that it is
"fun and better than paying for things." I do not know if
this is something of which she has control, but she seems so calm to
be doing it and to be caught. We accessed your website and have
contacted one fo the doctors, but do you thing she is a
kleptomaniac?"
A True
kleptomania is a disorder of impulse control. The individual feels
that he/she cannot resist the impulse to steal objects that are not
needed for personal use or are stolen for their monetary value. The
patient will describe tension prior to stealing the object and a sense
of relief and gratification after the theft has been perpetrated. This
is not to be confused with those who steal out of anger and vengence
or who do so due to delusional (false) beliefs.
In the case you describe, your daughter has personal use for the items
and prides herself with the defiance that is expressed by the theft.
This does not fit the criteria for kleptomania, and there may be
several other factors as work such as the perception that she exists
outside of conventional social boundaries. You mention having located
a doctor through the American Academy, and I encourage you to follow
through with any scheduled apppointments.
March 8, 1999
Q My son
has twice been arrested for starting fires. Once he burned his car and
the other time he burned his home. I suspected that these were no
accidents because his focus was not on the losses but on the insurance
money. I suggested that his attorney investigate whether he is a
pyromaniac because of this fire setting. Is that possible?"
A Pyromania
is an impulse control disorder in which the individual purposefully
and recurrently sets fire for the pleasure derived from the fire
itself, not for the monetary gain or social protest. The individual
experiences tension or emotional arousal before setting the fire and
relief after the act is completed. They are fascinated with fire, show
appreciable curiosity and interest (will read, discuss, collect items,
etc). Such individuals often will participate in the aftermath of the
fire started such as assisting firefighters, assisting victims or
attracted to watching the impact of what they have done. This does not
appear to be what you are describing if I correctly understand what
has occurred. You seem to indicate that your son's behavior has been
for monetary gain. A psychologist in your community can evaluate your
son and provide him with a clearer understanding of why this behavior
is occurring.
March 15, 1999
Q My
husband buys lottery tickets, our vacations are to Las Vegas or
Atlantic City, his free time is spent with some unsavory men with whom
he bets, and although he has vowed to stop, he returns to betting and
bets even more. We have already lost one home, and our daughter
dropped out of school in order to help support the family. Is this a
gambling addition?"
A
Pathological gambling is an impulse control disorder in which the
individual is preoccupied with wagering, and the amount of the wager
increases in order that the person achieve a greater sense of
excitement. When the individual attempts to refrain from gambling,
he/she becomes irritable even when attempting to reduce the amount of
the gambling. The gambling becomes a means of escaping from negative
moods (e.g., anxiety, depression, etc), and following loss, the
individual feels driven to pursue catching up with the losses. Such
individuals lie to their families, their employers and their treating
psychologist. They may engage in illegal acts such as embezzlement and
fraud to maintain their gambling, and they will not only rely upon
others to help them financially but will exploit others and ruin
relationships.
If this describes, to some
extent, the problems you are confronting, and your husband is not in
care, attempt to involve him in care and to access gamblings
annonymous and other organizations. If he is already in care, be
certain that part of that care involves the doctor having access to
the extent and impact of this gambling behavior. Doctors can become
pawns in a patient's pathological gambling.
March 22, 1999
Q My
daughter began playing with and then pulling her eyebrows and her
eyelashes, later her hair until she had left large areas with no hair.
This has continued even though she states that she wishes it were
something she did not do. I read somewhere that this is called
"trick or" something, not sure, and do not know what to do
about it."
A
Trichotillomania is defined as increased state of tension prior to
pulling ones hair and sense of relief when pulling out the hair. The
person derives satisfaction or gratification even though they may
express that they wish there were not performing the act.The
individual may derive pleasure from extracting hair on any or all
areas of the body. Inflammation, infection and areas of hair depletion
are the most common findings. And while it is equally common among
males and females in childhood, it appears to be more common in
females in adulthood. Some of the commonly used treatments for
obsessive-compulsive behaviors, and, indeed, some clinics appear to
deal very well with this disorder, and often the patient is motivated
to find a means not to engage in the behavior.
March 29, 1999
Q "We
have a girl at school who I think is anorexic. She is very skinny,
eats very little and is always running or working out. She does not
hang out with us much, and I wonder if I am correct and if her parents
even notice."
A Anorexia
Nervosa - can be separated into two types: the restricting type in
which the individual dangerously limits food intake but does not binge
eat or purge (self-induced vomiting or use of laxatives, diuretics,
enemas, etc), and the binge-eating/purging type. In both cases there
is a refusal to maintain a minimally normal body weight, and the
individual weighs less than 85% of ideal body weight. The individual
has an intense fear of weight gain or obesity even though they present
to others as markedly underweight. Such individuals deny the severity
of their condition, and they have a disturbance in perception as to
the appearance of their body. In females this is often accompanied by
the absence of menstrual cycle. The dangers are apparent since the
body is deprived of needed nutrients and the use of purging procedures
can increase the health hazards.
It is not inappropriate to discuss your concern with your classmate
and/or to discuss any concern for the health and safety of a classmate
with the school psychologists assigned to your school. They are
trained to observe and address such problems.
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