"I only sleep 2 hours a night"

[randomdoc1]

We've all encountered this in practice. Curious to know what you all make of patients saying this. One patient wanted to see me after seeing another provider, she was on all at the same time: lorazepam, temazepam, belsomra, seroquel, and mirtazapine (and only claims she's getting 2hrs of sleep a day). I have a few hypotheses:
1) Patient substantially underestimates how much they sleep
2) Unrealistic expectations of sleep aid (i.e. it is normal to wake up in the night-we all do, I believe from my sleep medicine rotation I was told the normal human circadian rhythm tends to average 25hrs so it is normal to have variations night to night in how we sleep)
3) Very poor adherence to sleep hygiene (napping and not including that in the history, caffeine, cigarettes, screen time, etc.).
I believe most patients have enough intellectual functioning to be able to accurately monitor how much time they are actually asleep, so I'm not sure why we get such a gross underestimate sometimes or what gets a patient to say this. I see a higher proportion of patients with borderline personality disorder making such claims, but not all of course. Like @whopper said, I started to encourage patients to use a device like a fitbit to accurately monitor what their patterns are. Interestingly, some become very resistant and some even flat out say "I do eventually get tired and crash during the day." At the end of the day, I encourage CBT-I and discuss the evidence base for treating insomnia. If they desire, I also let them know there are sleep specialists but they will probably not recommend much more beyond what I've provided.

Sleep is an interesting topic in psychiatry.

---

Members don't see this ad.

 

[WisNeuro]

I'd wager it's a mix of all three in most people. It's always fun to read the sleep apnea eval of someone who claims that they can only sleep like 2 hours a night, but then they have no problem logging 5ish hours in a sleep lab, where most people would have a more difficult time sleeping. I have also encountered the more frequent than it should be oxycodone+mirtazapine+quetiapine+xanax+flexeril patient who says that they have difficulty sleeping, when I am more concerned about them ever waking up again.

 

[deleted480308]

I'd wager it's a mix of all three in most people. It's always fun to read the sleep apnea eval of someone who claims that they can only sleep like 2 hours a night, but then they have no problem logging 5ish hours in a sleep lab, where most people would have a more difficult time sleeping. I have also encountered the more frequent than it should be oxycodone+mirtazapine+quetiapine+xanax+flexeril patient who says that they have difficulty sleeping, when I am more concerned about them ever waking up again.

Yeah, I’m 100% suspecting bs when someone tells me they avg 1-2 hrs/night.

 

[WisNeuro]

Yeah, I’m 100% suspecting bs when someone tells me they avg 1-2 hrs/night.

I'm willing to believe it if it's acute, or intermittent. But am very skeptical when they claim it's a years-long pattern. Much of the time I'm able to get collateral informant data that suggest that while they may wake up several times a night and sleep in 1-2 hour chunks, between the night time and napping during the day, they're closer to 7-8.

 

[randomdoc1]

fit bit to the rescue. The truth comes out. Have it monitor 24/7. That's one thing I learned in sleep medicine, the monitors they used outpatient were very telling and told a totally different story.

 

[WisNeuro]

fit bit to the rescue. The truth comes out. Have it monitor 24/7. That's one thing I learned in sleep medicine, the monitors they used outpatient were very telling and told a totally different story.

What about patients with REM movement disorders with the Fitbit stuff?

 

[winniehoney]

Wait, don't surgery residents get by with 2 hours of sleep a night? So I don't see what's the problem.

 

[Indodo]

Wait, don't surgery residents get by with 2 hours of sleep a night? So I don't see what's the problem.

Not every night. Certainly not for years.

 

[PsyDr]

Psychologist, so different. But I when I encounter people who say "I don't sleep, ever.", I

1) Offer them an "out" by going over how it's almost impossible to describe what you're doing when you're unconscious.
2) Explain that sleep deprivation is a serious matter.
3) Explain to them that they do not demonstrate the known neurological correlates of prolonged sleep deprivation.
4) Explain to them that the last time medicine had someone who didn't sleep for 11 days, the Navy showed up and took them away.
5) Explain that we will go from a conservative approach to aggressive.
6) First we will get a sleep log.
7) If they can't do that, then I will offer a fitbit or similar.
8) If they can't do that, we will need a full sleep study.
9) Explain that much like hypertension, we need to measure things so we can treat them. In sleep, this is a sleep study.
10) Explain that if polysomnography shows that they really aren't sleeping for this long, we need to run expensive genetic tests on them and their family, and we need to call the CDC.

 

[Indodo]

Psychologist, so different. But I when I encounter people who say "I don't sleep, ever.", I

1) Offer them an "out" by going over how it's almost impossible to describe what you're doing when you're unconscious.
2) Explain that sleep deprivation is a serious matter.
3) Explain to them that they do not demonstrate the known neurological correlates of prolonged sleep deprivation.
4) Explain to them that the last time medicine had someone who didn't sleep for 11 days, the Navy showed up and took them away.
5) Explain that we will go from a conservative approach to aggressive.
6) First we will get a sleep log.
7) If they can't do that, then I will offer a fitbit or similar.
8) If they can't do that, we will need a full sleep study.
9) Explain that much like hypertension, we need to measure things so we can treat them. In sleep, this is a sleep study.
10) Explain that if polysomnography shows that they really aren't sleeping for this long, we need to run expensive genetic tests on them and their family, and we need to call the CDC.

The behavioral approach is already being done and the approach is probably overly aggressive with meds.
The other thing is that we don't do sleep studies for insomnia.
Genetic tests after one PSG? Looking for what? FFI? Why call the CDC?

When patients say all these meds aren't working, I say okay, lets slowly stop them first and get to a healthier natural sleep.
People don't die from insomnia except with mania/FFI.
Stick with CBT-I.

 

[randomdoc1]

3) Explain to them that they do not demonstrate the known neurological correlates of prolonged sleep deprivation.

What are those? Just curious so I can run over it with my patients. Find it hard to believe they are working a full time job and perky looking despite 2h of sleep a night and not acutely manic.

10) Explain that if polysomnography shows that they really aren't sleeping for this long, we need to run expensive genetic tests on them and their family, and we need to call the CDC.

That's awesome.

 

[PsyDr]

Here you go:

Gulevich, G., Dement, W., & Johnson, L. (1966). Psychiatric and EEG observations on a case of prolonged (264 hours) wakefulness. Arch Gen Psychiatry, 15(1), 29-35.

Ross, J. J. (1965). NEUROLOGICAL FINDINGS AFTER PROLONGED SLEEP DEPRIVATION. Arch Neurol, 12, 399-403.

IIRC, tactile agnosia developed very early.

 

[PsyDr]

The behavioral approach is already being done and the approach is probably overly aggressive with meds.
The other thing is that we don't do sleep studies for insomnia.
Genetic tests after one PSG? Looking for what? FFI? Why call the CDC?

When patients say all these meds aren't working, I say okay, lets slowly stop them first and get to a healthier natural sleep.
People don't die from insomnia except with mania/FFI.
Stick with CBT-I.

1) I'm sure the AASM would be interested to know we don't do sleep studies for insomnia, as their guidelines specifically state that polysomnography is indicated for insomnia "....when initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic),...." .

2) The median life expectancy for FFI following onset of symptoms is like 7 months. People absolutely die from insomnia. It just very very very very very rare. If this is documented, it would be a decent idea to start working it up fast.

3) My point is, and has been, that obtaining accurate information is necessary to treat. Patient give inaccurate information all the damn time (e.g., caloric intake, alcohol consumption, etc). The DSM5 recognizes this in their AUD's use of labs (e.g., GGT) and their recommendation for neuropsych testing in the neurocognitive disorders. Ignore the motivations and collusions. Documenting increasing attempts to get information, attempting to get objective data in the face of unreliable informants, all while taking the patient's complaints seriously, is a pretty decent idea.

 

[birchswing]

I'd wager it's a mix of all three in most people. It's always fun to read the sleep apnea eval of someone who claims that they can only sleep like 2 hours a night, but then they have no problem logging 5ish hours in a sleep lab, where most people would have a more difficult time sleeping. I have also encountered the more frequent than it should be oxycodone+mirtazapine+quetiapine+xanax+flexeril patient who says that they have difficulty sleeping, when I am more concerned about them ever waking up again.

I'm was the opposite--sleep 7-9 hours a night but with suspected apnea. Went to sleep lab and despite my best efforts only slept 30 minutes. Was diagnosed with insomnia! I told them I can't even sleep in a hotel the first night, let alone with all these things on me and people waiting for me to fall asleep.

 

[clausewitz2]

1) I'm sure the AASM would be interested to know we don't do sleep studies for insomnia, as their guidelines specifically state that polysomnography is indicated for insomnia "....when initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic),...." .

2) The median life expectancy for FFI following onset of symptoms is like 7 months. People absolutely die from insomnia. It just very very very very very rare. If this is documented, it would be a decent idea to start working it up fast.

3) My point is, and has been, that obtaining accurate information is necessary to treat. Patient give inaccurate information all the damn time (e.g., caloric intake, alcohol consumption, etc). The DSM5 recognizes this in their AUD's use of labs (e.g., GGT) and their recommendation for neuropsych testing in the neurocognitive disorders. Ignore the motivations and collusions. Documenting increasing attempts to get information, attempting to get objective data in the face of unreliable informants, all while taking the patient's complaints seriously, is a pretty decent idea.

I mostly agree with you, but minor point: I don't think there is good reason to believe that insomnia per se is what kills people in FFI as opposed to an epiphenomenon of the havoc wrought by the culprit prion.

 

[PsyDr]

I mostly agree with you, but minor point: I don't think there is good reason to believe that insomnia per se is what kills people in FFI as opposed to an epiphenomenon of the havoc wrought by the culprit prion.

I imagine you are correct. Outside of the genotyping, the diagnostic criteria for FFI has some tautological and nonspecific stuff. Randy Gardner demonstrated ataxia, astereognosis, hallucinations, cognitive changes, and affect changes. Reportedly these returned to baseline after . So are these neurobehavioral signs due to the sleep deprivation or the prions affecting the same structures? Or is this just an extension of the entire idea of the mind as an epiphenomenom of the brain?

 

[Stagg737]

I'm willing to believe it if it's acute, or intermittent. But am very skeptical when they claim it's a years-long pattern. Much of the time I'm able to get collateral informant data that suggest that while they may wake up several times a night and sleep in 1-2 hour chunks, between the night time and napping during the day, they're closer to 7-8.

I've actually got a patient like that right now where it's legit. Complaining of sleeping ~1 hour per night for 3-4 nights then gets a night where he sleeps ~4 hours, rinse, repeat. He's been on the medicine floor for about 2 weeks and we've got documentation of this. Check his previous 2 hospitalizations (one was ~2 years ago) and same thing was recorded. No one previously addressed it (and we are now as we treat his other issue). Patient is not manic and feels worn out all the time but is pretty alert.

It's really odd, though I do agree that most of the time when patients make this claim they're not reporting accurately.

fit bit to the rescue. The truth comes out. Have it monitor 24/7. That's one thing I learned in sleep medicine, the monitors they used outpatient were very telling and told a totally different story.

Only thing I'd caution is that fitbits can be easily tricked if a person relaxes enough. I used to do this and my fit bit was recording 8-9 hours of sleep per night, but I felt like it was a huge overestimate. Laid in bed one night and just listened to some music for about 2 hours and just relaxed. Was 100% certain I was awake the whole time and my fit bit recorded I was sleeping for about 1.5 of those hours because it just tracks heart rate (and temp in more advanced ones). So they're not always the greatest method of monitoring sleep, especially in the people who really do just lay there relaxed but can't actually get to sleep.

 

[Indodo]

1) I'm sure the AASM would be interested to know we don't do sleep studies for insomnia, as their guidelines specifically state that polysomnography is indicated for insomnia "....when initial diagnosis is uncertain, treatment fails (behavioral or pharmacologic),...." .

2) The median life expectancy for FFI following onset of symptoms is like 7 months. People absolutely die from insomnia. It just very very very very very rare. If this is documented, it would be a decent idea to start working it up fast.

3) My point is, and has been, that obtaining accurate information is necessary to treat. Patient give inaccurate information all the damn time (e.g., caloric intake, alcohol consumption, etc). The DSM5 recognizes this in their AUD's use of labs (e.g., GGT) and their recommendation for neuropsych testing in the neurocognitive disorders. Ignore the motivations and collusions. Documenting increasing attempts to get information, attempting to get objective data in the face of unreliable informants, all while taking the patient's complaints seriously, is a pretty decent idea.

I would love to see a link to see where the AASM recommends PSGs for insomnia. Im serious. I am not aware that this is an indication.
Like I said EXCEPT for FFI/mania. Outside of that. It isn't rare, it doesn't happen. Like a previous post said, even in FFI (also in mania) it isn't the insomnia that kills you.
So again, why would you call the CDC? or do expensive genetic tests after 1 psg?

For your 3rd point. It sounds like the OP is already doing those things. My approach is always to do the simple things first. Like stop all these meds if they arent working.

 

[NicMouse64]

Psychologist, so different. But I when I encounter people who say "I don't sleep, ever.", I

1) Offer them an "out" by going over how it's almost impossible to describe what you're doing when you're unconscious.
2) Explain that sleep deprivation is a serious matter.
3) Explain to them that they do not demonstrate the known neurological correlates of prolonged sleep deprivation.
4) Explain to them that the last time medicine had someone who didn't sleep for 11 days, the Navy showed up and took them away.
5) Explain that we will go from a conservative approach to aggressive.
6) First we will get a sleep log.
7) If they can't do that, then I will offer a fitbit or similar.
8) If they can't do that, we will need a full sleep study.
9) Explain that much like hypertension, we need to measure things so we can treat them. In sleep, this is a sleep study.
10) Explain that if polysomnography shows that they really aren't sleeping for this long, we need to run expensive genetic tests on them and their family, and we need to call the CDC.

How do you check the data on these devices? I am curious as I do some research with EHR interfaces and different wearable devices.

 

[WisNeuro]

I would love to see a link to see where the AASM recommends PSGs for insomnia. Im serious. I am not aware that this is an indication.
Like I said EXCEPT for FFI/mania. Outside of that. It isn't rare, it doesn't happen. Like a previous post said, even in FFI (also in mania) it isn't the insomnia that kills you.
So again, why would you call the CDC? or do expensive genetic tests after 1 psg?

For your 3rd point. It sounds like the OP is already doing those things. My approach is always to do the simple things first. Like stop all these meds if they arent working.

JCSM - Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults

 

[PsyDr]

I would love to see a link to see where the AASM recommends PSGs for insomnia. Im serious. I am not aware that this is an indication.
Like I said EXCEPT for FFI/mania. Outside of that. It isn't rare, it doesn't happen. Like a previous post said, even in FFI (also in mania) it isn't the insomnia that kills you.
So again, why would you call the CDC? or do expensive genetic tests after 1 psg?

For your 3rd point. It sounds like the OP is already doing those things. My approach is always to do the simple things first. Like stop all these meds if they arent working.

1) Here you go:

Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med, 4(5), 487-504.

On page 487, bottom right. Feel free to download it yourself from AASM, Pubmed, or your institutional source of preference.

If you wanna get more information, the DSM5 also says "The use of biological validators is now embodied in the DSM-5 classification
of sleep-wake disorders..." (pg 362).

2) If you look at my post, I was referring to when a patient says they don't sleep ever. I was not referring to the OP's situation. I also never said One PSG. In any case, Sleeping 2hrs does not happen for long. If evolution could have done that, it would have. And every military and industry that relies upon human performance would have invested a ton into this research. There are almost no psycho/pathophysiologies where this occurs. The literature base shows that this doesn't last more than a few days before people show neurological signs. Absent such signs, we are left with a few possibilities in order of likelihood:

A. The most likely is that the patient is unaware of how much they are sleeping or they are lying for whatever purposes. If this is the case, then their self report is unreliable. One cannot treat on unreliable information. So objective data is needed. Not much different than how UDS are used in pain med clinics or why sleep logs are used in inpatient settings. If they are lying, then being subjected to an objective test will be untenable for them. This gives the provider an out. "I will not prescribe without a sleep study". If they are unaware of how much they are sleeping, objective data can be used to further the therapeutic alliance "You said that you slept 2 hrs, but this data shows that you slept 9hrs. Do you think you're misunderstanding sleep or are you trying to tell me you're tired or ?".

B. The patient has a bipolar variant, where mania has somehow persisted forever. Again, I would imagine the experts would wanna see that.
C. The patient has FFI, and their life expectancy is months. I dunno about how slow you work up something with a prognosis of less than a year.

 

[randomdoc1]

Only thing I'd caution is that fitbits can be easily tricked if a person relaxes enough. I used to do this and my fit bit was recording 8-9 hours of sleep per night, but I felt like it was a huge overestimate. Laid in bed one night and just listened to some music for about 2 hours and just relaxed. Was 100% certain I was awake the whole time and my fit bit recorded I was sleeping for about 1.5 of those hours because it just tracks heart rate (and temp in more advanced ones). So they're not always the greatest method of monitoring sleep, especially in the people who really do just lay there relaxed but can't actually get to sleep.

Hmm...I wonder how the actigraphy used in sleep clinics measures to what is available for patients to purchase? Either, way, definitely still agree with @PSYDR. Getting an objective and clearer picture, more helpful information is important to getting a more accurate diagnosis with helps direct care. Even if the patient is laying and some gets accidentally recorded as sleep, sometimes actigraphy has been very telling about what exactly their lifestyle habits are. For example, people really should lead structured and somewhat active lives. Not having that I'm sure does not help sleep either and is further evidence towards poor sleep hygiene. I loved it when I was on sleep medicine and they used the actigraphy, it was so helpful for literally every single case.

 

[Liquid8]

I think the true 1-2 hour/night sleeper is pretty rare. If we rule out physical issues – OSA or chronic pain conditions; then things like poor sleep hygiene (like waking up and checking digital devices), daytime naps, inappropriate use of caffeine, alcohol or illicit drug are often part of the picture, especially if there is an escalation in sleep medication requests. My general take on the latter is that if you’re using them for more than 3-4 days they are unlikely to be effective, if a patient claims it doesn’t work it should be stopped, and increasing the dose beyond normal limits simply saturates the relevant receptors resulting in more side effects, no increase in efficacy and a higher predisposition to dependence. Fortunately the majority of my private patients aren’t keen on getting addicted to anything so can easily be reasoned with in this manner.

One thing that needs to be clarified is if they do sleep 1-2 hours for a few nights and end up crashing afterwards. I have one patient who reported 2-3 hours a night, but it was due to working ridiculous amounts of hours and having to be up to participate in international teleconferences. Every week she’d crash for about 16 hours and start again, and the chronic sleep deprivation had been going on for so number of years that she had become used to it. Once she left that position, her sleep normalised but it took a few months.

If someone remains insistent on something to help but z-drugs and benzos (except xanax) are ineffective and they aren't willing or capable of making any lifestyle changes, then I won’t hesitate to trial an atypical AP – which usually gets a reported as being too effective and they’ve slept 12+ hours through.

If I bring people into hospital and they claim poor sleep, I can verify this by the night nursing notes as well as ask the patients if they can remember how often the nursing staff came into check on them. I know that the nurses do hourly checks, so if they can’t recall this happening it’s safe to assume that they have just misinterpreted how much sleep they have had.

 

[futuredo32]

I think the true 1-2 hour/night sleeper is pretty rare. If we rule out physical issues – OSA or chronic pain conditions; then things like poor sleep hygiene (like waking up and checking digital devices), daytime naps, inappropriate use of caffeine, alcohol or illicit drug are often part of the picture, especially if there is an escalation in sleep medication requests. My general take on the latter is that if you’re using them for more than 3-4 days they are unlikely to be effective, if a patient claims it doesn’t work it should be stopped, and increasing the dose beyond normal limits simply saturates the relevant receptors resulting in more side effects, no increase in efficacy and a higher predisposition to dependence. Fortunately the majority of my private patients aren’t keen on getting addicted to anything so can easily be reasoned with in this manner.

One thing that needs to be clarified is if they do sleep 1-2 hours for a few nights and end up crashing afterwards. I have one patient who reported 2-3 hours a night, but it was due to working ridiculous amounts of hours and having to be up to participate in international teleconferences. Every week she’d crash for about 16 hours and start again, and the chronic sleep deprivation had been going on for so number of years that she had become used to it. Once she left that position, her sleep normalised but it took a few months.

If someone remains insistent on something to help but z-drugs and benzos (except xanax) are ineffective and they aren't willing or capable of making any lifestyle changes, then I won’t hesitate to trial an atypical AP – which usually gets a reported as being too effective and they’ve slept 12+ hours through.

If I bring people into hospital and they claim poor sleep, I can verify this by the night nursing notes as well as ask the patients if they can remember how often the nursing staff came into check on them. I know that the nurses do hourly checks, so if they can’t recall this happening it’s safe to assume that they have just misinterpreted how much sleep they have had.

At the hospital where I moonlight, the nurses stick their head in the door and take a quick peek. If the person is laying there in the dark wide awake, they are documented as sleeping.

 

[clausewitz2]

At the hospital where I moonlight, the nurses stick their head in the door and take a quick peek. If the person is laying there in the dark wide awake, they are documented as sleeping.

I think the point was actually that if the nurses poke their heads in and the patient doesn't remember them doing this, they were probably asleep.

 

[OldPsychDoc]

Usual inpatient conversation:
Pt: I haven't slept at all since I got here.
OPD: The nursing report logged you at 7 hours sleep.
Pt: I was just lying there.
OPD: So we check on you every 15 minutes here--if you are awake and hear or see them, just lift up your hand and wave so we know you're awake. Most of our patients like you are too polite, and don't let us know. But if you're not sleeping, we want to know.

Follow-up conversation next day:
(There is none. It never fails. They aren't awake and they aren't waving.)

 

[randomdoc1]

Ditto to much of what was said above. There is a sleep wellness clinic that seems to be evidence based and they may be able to work with some of my cases who only "sleep 2 hours a night." I believe they do indeed offer actigraphy and then the conversation stops there. We can't keep throwing pills if we don't have an accurate picture of what is going on. I almost take offense at patients who claim this. I remember when I first had my son and I had to be up every 2-3 hours, if lucky I got 5hrs straight of sleep. IT.....DROVE.....ME.....NUTS. I was definitely getting some clear psychiatric symptoms and I looked nowhere as alert, calm, and collected as some of these patients who continue to report to work and are performing just fine. Doesn't help when some therapists call you and ask why you aren't "fixing their sleep, they are only getting 2hrs of sleep a night." Total bs.

As an aside, isn't sleep deprivation used as a form of torture in some settings?

 

[psych_pa]

Doesn't help when some therapists call you and ask why you aren't "fixing their sleep, they are only getting 2hrs of sleep a night." Total bs.

The therapists question your prescribing methods?

 

[watto]

If you are interested in the topic of sleep state misperception, I recommend the work of Allison Harvey. She has some good practical interventions including registering difference between actigraphy and perception, and behavioral experiments to demonstrate ability to function during the day no matter what happened the night before.

There is a correlation with depression and anxiety. Makes sense - salience detection deficits probably there with over-attribution and attention to negative inputs.

Some have found higher frequency EEG waves intruding into NREM 1 and 2 in these folks, which may reflect a state of awareness during sleep.

It's interesting stuff. I see these folks in my CBT for Insomnia practice all the time.

 

[aim-agm]

Another facet might be what stage of sleep they are spending time in. At least I was taught that in Stage I sleep there is a degree of awareness of surroundings and no recognition of the fact of being asleep (i.e. if someone lapsed into Stage I sleep and you woke them up, they would deny ever being asleep). Would it make sense that some patients spend an extended amount of time in early sleep and honestly having the experience of having very limited sleep?

 

[watto]

Another facet might be what stage of sleep they are spending time in. At least I was taught that in Stage I sleep there is a degree of awareness of surroundings and no recognition of the fact of being asleep (i.e. if someone lapsed into Stage I sleep and you woke them up, they would deny ever being asleep). Would it make sense that some patients spend an extended amount of time in early sleep and honestly having the experience of having very limited sleep?

Yes, though this also happens in NREM 2 in insomniacs - here is a good Harvey review on sleep state misperception that references the old Rechtschaffen study where insomniacs interpreted sleep as wakefulness 10 minutes after onset of the first sleep spindle:

(Mis)Perception of Sleep in Insomnia: A puzzle and a resolution