Fiona Barwick, PhDClinical Associate Professor Department of Psychiatry and Behavioral Sciences Sleep Medicine Division Stanford Medicine
Inspiration for Specializing in Sleep Medicine
My original specialty was neuropsychology. I had been working at several VA hospitals with Veterans who returned from the wars in Iraq and Afghanistan with a significant number of problems. I assessed them with cognitive functioning and impact on daily life, and made some recommendations, but the reality is a lot of the veterans were also struggling with issues related to pain, sleep, and PTSD.
Neuropsychology is mostly about assessment rather than implementing recommendations. I wanted to be able to make a difference. I began to get training in how to treat PTSD, pain, and sleep issues from an evidence based perspective. I found myself interested in sleep because the intervention for sleep is one of the most effective. Depending on what other comorbidities exist, improving sleep can really make a difference in mood, anxiety, and quality of life.
Years after getting a position at Stanford’s Medical Center, I remain just as interested in sleep because it’s always a puzzle. There are many, many factors that impact sleep and trying to put the pieces together to make personalized recommendations remains just as fascinating for me today as when I first became interested.
Sleep Disorders and Psychiatric Conditions
Sleep disturbance is included as one of the diagnostic criteria in almost every psychiatric condition. Whether it’s depression, anxiety, PTSD, or bipolar disorder with schizophrenia. Even in certain psychiatric conditions where it’s not included, like ADHD, it is very common. So clearly sleep is a problem for every psychiatric disorder. What the research shows is that even when a psychiatric condition itself is treated successfully, the sleep problems persist. Because effective treatments exist for helping people with sleep, it should be screened for in every psychiatric disorder and it should be treated.
Sleep disorders must be treated, even apart from the psychiatric condition itself. Some of the research shows that when you treat sleep disorders successfully, some of the anxiety, depression, or trauma symptoms, like nightmares, start to decrease.
Sleep & Wakefulness Disorders
A variety of MDs, PhDs, PsyDs, both physicians and psychologists, work with patients who have sleep and wakefulness disorders. They need to work together to provide interdisciplinary care, which is important for any condition that has several factors affecting it. Of course, our MDs come from a variety of backgrounds like neurology, psychiatry, and pulmonology. The pulmonologist will treat the breathing difficulties. Neurologists can be especially knowledgeable about things like restless leg syndrome, periodic limb movements, REM behavior disorder, and narcolepsy. The psychologists are critical because insomnia often develops when people have other unrecognized sleep problems for a while. Understandably, patients become anxious when their sleep gets disrupted. They try all sorts of things to improve it, and nothing helps. So, they develop anxiety and then the insomnia on top of it is getting worse.
In addition, no one knows how sleep works: people don’t have a basic understanding. It’s not complicated, but it isn’t taught in school. It’s not even taught in medical schools or psychology programs. Interns, residents, and medical students get about 2 hours of sleep training in 4 years. This is a huge problem because even doctors who are finishing their training, unless they’re getting specialized training, may not be comfortable asking their patients about sleep, and they might not be comfortable with making recommendations. That’s why even though sleep problems are one of the most common symptoms reported in primary care settings, they are rarely asked about, rarely addressed. Practitioners just don’t know what to do. That’s apart from the fact that they don’t have a lot of time with patients, so trying to address this potential issue on top of everything else is virtually impossible.
Once you understand how sleep works, it’s no longer a big mystery why it might not be good one night, but better the next night. If you know the systems that affect sleep, you then know strategies to use to target those systems. Alcohol has a disruptiveness that is different for everyone. Some people are more sensitive, some people less, but if it leaves you awake or tossing and turning in the second half of the night, it can continue and worsen your sleep. When I go out for dinner I am aware that if I have a couple of glasses of wine, I will probably not have a good night’s sleep. But I’m not going to get upset about it. I’m not going to worry about it. It’s no longer this mystery. Human beings just don’t do well with uncertainty, and it can increase anxiety.
BRAINWeek for Sleep Specialists and Other Practitioners
Any sleep specialist is going to know how important sleep is, but let’s face it: sleep is related to everything. It impacts everything. To reiterate: for every psychiatric disorder, sleep disturbance is one of the criteria. Even people who don’t have psychiatric conditions can become more anxious and irritable when they lose sleep. Certainly, it can leave them feeling less alert, thinking less clearly. For people with neurological conditions, sleep disturbance is extremely common as well. I would suggest that everyone needs to understand how impactful sleep is. Everyone would benefit from understanding how sleep and circadian rhythms affect their area of specialty—whether psychiatry, neurology, cardiology, endocrinology—and understanding that there are effective treatments their patients will benefit from and that could help whatever associated condition is there. Since providers are not necessarily trained in sleep medicine, possible sleep disorders are not being screened for. Even if you do ask and your patient reports difficulty with sleep, you may not know what to do about it or where to send them. That’s not going to feel good. Most providers want to help their patients, and this is one of the biggest ways to help: By asking about sleep problems and knowing what to do.