By Brandon R. Peters, M.D.
Poor sleep can profoundly affect the lives of teenagers. As summer draws to a close and school-aged children gear up to return to class, it is helpful to pause and recognize the importance of quality sleep. In order to achieve this, as this clinical case demonstrates, some youth may need help from a sleep specialist.
A 14-year-old boy, who we will call John, came to my office complaining of insomnia and hallucinations. At his first visit, he reported that when he goes to sleep he can't stop thinking about random things. During the school year, he was going to bed at 9-10 p.m. It would take him hours to fall asleep. He often couldn't get to sleep until 2 a.m. He had tried melatonin and Benadryl with little benefit.
Even when John finally got to sleep, his night was disturbed. He was getting up one or two times to urinate. He was a very restless sleeper, often getting sweaty at night. He would wake with heart palpitations and a racing heartbeat. He also has had episodes of sleepwalking, but never leaves the house. He may have occasional nightmares. He was never noted to snore or have pauses in his breathing during sleep. His mornings were a source of frustration for him and his parents.
He had to get up at 6:30 a.m. in order to get to school on time. As a result, John figured that he was getting 3.5 to four hours of sleep most nights. When his parents tried to awaken him, he would want to return to sleep. He would complain of a headache or stomachache. He often wanted to stay in bed until 10 or 11 a.m., which he typically did on the weekends. He was missing school and his grades were suffering. From the sixth to eighth grades John's school performance had undergone a steady decline: falling from As and Bs initially to Cs and Ds by the time of his visit.
When he got home from school in the afternoon, he would crash early, taking naps that lasted for hours several days per week. His parents became concerned about his psychiatric health. He has had some mild anxiety and rare panic attacks, and they wondered if his sleep patterns were due to depression. He had attention problems at school and the possibility of ADD was entertained. Most significantly, John was having visual and auditory hallucinations during the day. He might hear someone screaming. He was enrolled in a university program to identify and support teens at risk of developing schizophrenia.
John had previously been a healthy boy. He had no health problems beyond asthma and a neck injury after a fall. He used only an inhaler medication and ibuprofen for headaches. His mother and sister were also night owls. When asked privately, he denied the use of all illicit drugs.
His examination revealed a tall, thin boy with normal vital signs. During the interview, John would often become inattentive to the conversation. He had a deviated nasal septum and swelling in the nose suggestive of allergies. His tongue was crowded in his mouth with gaps in the sides of his bite. His Epworth sleepiness score, a subjective measure of excessive sleepiness, was elevated at 10.
How do we conceptualize his symptoms and findings in order to effectively treat his conditions? His sleep pattern is classic for someone with delayed sleep phase syndrome (DSPS) and he was enrolled in the cognitive behavioral therapy for insomnia (CBTI) to correct this. DSPS can cause profound insomnia and early morning sleepiness. Some of his symptoms later in the day were hypothesized to be due to sleep deprivation. Unable to get to sleep, and forced out of bed to get to school on time, he was incurring extreme sleep deprivation. This can contribute to mood problems, naps, and increase the risk of hallucinations. In fact, some 80 percent of normal people will hallucinate with sleep deprivation, mostly these misperceptions are visual in nature.
Moreover, his sleepiness, nocturia (peeing at night), sleepwalking, and ADD symptoms could relate to sleep apnea that contributes to sleep fragmentation. His episodes of abnormal attention and behavior lacked stereotypy, or consistency in their occurrence, but epilepsy was also part of the differential diagnosis. It was recommended that he undergo a formal sleep study with extra monitoring for seizures.
Through the course of five weeks of CBTI, he began to experience significant improvements in his insomnia and daytime function. The first week, John's initial sleep log showed it was taking him on average 280 minutes to fall asleep when he was going to bed at 9:55 p.m. He was getting four hours of total sleep. His sleep efficiency, a measure of total sleep time divided by total time in bed, was an abysmal 41 percent. By the end of his therapy, he was falling asleep in 22 minutes, getting more sleep overall, and his sleep efficiency had improved to 87 percent.
By the end of his CBTI program, he had completed his diagnostic sleep study. This demonstrated that he had pediatric sleep apnea. His breathing was disturbed 4.3 times per hour, causing him to fragment his sleep. In children and adolescents, more than 1 breathing disruption per hour is considered to be abnormal. He did not have seizures or any other abnormalities noted. It was recommended that he initiate treatment for sleep apnea.
Given that John had already gone through his major growth spurt, his treatment options differed from those that would be offered to a younger child. Tonsillectomy and orthodontic treatments would be ineffective. Instead, his allergies were treated and he began to use continuous positive airway pressure (CPAP). This device maintains the airway through a constant flow of air delivered through a face mask and allows deeper sleep to occur. He used it for six weeks and recently returned to discuss his experience.
The timing of his sleep continues to be improved by maintaining a regular sleep schedule and getting 15 minutes of morning sunlight upon awakening. He is sleeping better through the night and wakes feeling more refreshed. He no longer wakes to urinate and is not sweating at night. He is less sleepy during the day and now only rarely takes short naps. He is more attentive and his mood has noticeably improved. With better sleep, his hallucinations have completely resolved, and any considerations of significant psychiatric illness have been put aside.
School starts for John in a few weeks. He is now in a position to excel. It is my heartfelt hope that all children and teens will get the attention and support they need to sleep better and be at their best. If help is needed, start by reaching out to your pediatrician who can provide a referral to sleep specialists near you. Let's make it a great school year.
Kryger, MH et al. "Principles and Practice of Sleep Medicine." Elsevier, 5th edition, pp. 502-503.
Peters, B.R. "Can Sleep Deprivation Cause Hallucinations." Sleep Disorders, About.com, 2014.
Peters, B.R. "Delayed Sleep Phase Syndrome in Teenagers." Sleep Disorders, About.com, 2014.
Peters, B.R. "What Is Cognitive Behavioral Therapy for Insomnia (CBTI)?" Sleep Disorders, About.com, 2014.
Brandon R. Peters, M.D., is the writer on sleep for About.com, a neurology-trained sleep medicine specialist in Novato, Calif., and consulting assistant professor at the Stanford Center for Sleep Sciences and Medicine. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: sleep.stanford.edu.