About 1% of the world’s population is affected by schizophrenia. It can be a difficult mental health issue to treat, as patients try to get by in a world in which they have difficulty determining what is real and what is not real. Schizophrenia affects men and women equally, and the onset is usually during the second decade of life.
Schizophrenia’s cause is unknown. There is no medical test to diagnose the illness. There appears to be a genetic predilection, and environmental factors may also play a role. The clinical diagnosis is usually based on symptoms, which may include bizarre behaviors, hallucinations, flat affect, delusions and trouble sleeping.
I remember the first schizophrenic patient that I saw in our clinic. She was in her twenties and complained of difficulty sleeping. Her affect was such that I was suspicious for schizophrenia, but she had not listed this in her medical history. After a few minutes of conversation, I was sure there was some sort of mental health issues. I asked her if she had ever been diagnosed with a mental illness and she said no. When I asked about a family history of mental illness, she said she has a “crazy aunt.”
The patient complained that she could not sleep, and reported that she was up for days at a time. I wondered if she could be bipolar and experiencing mania. After more conversation, I decided to ask her if she ever had hallucinations when she is trying to sleep. The patient responded that she sees someone every night in her kitchen. When I asked her if this presence ever spoke to her, she said that it does. When I asked what the voice would say, she said that it tells her what a bad person she is.
Since the patient gave no history, I asked her for the name of her primary-care provider. Unfortunately, the patient had only visited the office once for an unrelated problem and the provider had little information to offer. The patient was set up for a sleep study as I continued to try to contact her family.
During the polysomnogram, the patient appeared relatively quiet until she sat straight up in her bed and started yelling at someone who was not in the room. During sleep studies, patients are videotaped. There was clearly no one in the room, and her brain waves showed she was not asleep. She yelled obscenities and told the imagined intruder to leave. Then she lay back down and stared at the ceiling for a long time before eventually falling asleep.
Patients with schizophrenia often complain of difficulty sleeping, and the severity can give insight into whether their illness is sufficiently treated. Most will complain of difficulty initiating and maintaining sleep. During psychotic episodes or relapse, schizophrenics may experience total sleeplessness, which can make their illness worse.
Although it may be difficult, it is important to treat insomnia in these patients. People with mental health disorders sometimes forget to take their medication. Also, you have to consider any other medications, including antipsychotics, when deciding on a sleep medication. It is good idea to work closely with their psychiatrist or treating physician to find the right balance. Even with medication, a patient with schizophrenia may still deal with insomnia and may also report nightmares.
Our situation was unusual, as most schizophrenic patients would have been under treatment before coming to our office. I was able to find a family member who wasn’t particularly helpful, but confirmed that the patient had been diagnosed with schizophrenia in the past. The family said they were attempting to manage her symptoms holistically.
The patient was prescribed quetiapine (Seroquel, AstraZeneca), which helped keep the “intruder” from showing up in her kitchen at night. She reported she was sleeping much better. I then counseled her about schizophrenia at length and why it was important to manage her symptoms.
Remember that patients with mental health issues can have severe sleep issues. It is important to both their physical and mental health that they are treated. This can be difficult, because this population may often call complaining that their sleep aids are not working and demand different medication or increased doses. This could be a sign that their illness is undertreated. Speak to their family and psychiatrist for further insight.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.