For whom 'breakfast' was an oxy-moron.
For no sooner did he sleep,
Then he got up to eat,
and stayed full from midnight til morn.
"What seems to be the problem?" I ask.
"I sleep eat."
"Oh?" I raise my eyebrows slightly, indicating, 'that's interesting,' and hastily skim through her thick office chart. She has been seeing a psychiatrist on and off for years. Current diagnosis is "BiPolar Disorder, Depressed phase." Psychiatric medications -- Lamictal 100 mg bid, 100 mg Seroquel hs -- are evidently effective, as she is working and raising a family. I see somewhere on the pages that she is married and has two teen age sons.
"What do you mean? You eat while you sleep?"
"Yes, I get up at night and eat, but don't know it. I'm sleeping. Dr. Mandrake (her psychiatrist) thought I should see you."
This is both interesting and concerning. As a sleep specialist I see mainly people with snoring, trouble breathing during sleep, complaints of not getting enough sleep, restless legs, etc. When I come across people whose sleep problem seems related to a psychiatric disorder, I refer them to a psychiatrist. Now it was the other way around.
I search her chart for Dr. Mandrake's last note. Thankfully it was typed. He felt her weight gain was serious and possibly related to sleep walking and sleep eating, and that she should have a formal sleep study to "see if there are specific treatable abnormalities." I am one of two sleep specialists in our multispecialty group, and together we screen almost all patients who need a sleep study. Hence the consult. The referral makes sense, but will a sleep study help?
"Can you tell me more about this sleep eating? How long has it been going on?"
"I guess off and on for years."
"Well, do you do it every night?"
"No. My husband says I do it once a week or so. He leaves me alone."
"You mean he doesn't try to wake you?"
"Oh, no. My body knows where the food is. I just don't know I'm eating, because I am asleep." Her affect was flat, unalarmed. I inferred her answer to mean something like: 'Yea, I know I am grossly obese, what are you going to do about it, my doctor asked me to come here, I am obeying orders, ta da, ta da, ta da.'
"So why do you want to do anything about it?" I ask, pointedly.
"I'm gaining weight. I need to stop this eating during my sleep."
"How much weight have you gained, say over the past year."
"Last year, I don't know, I weighed maybe 200 lbs. The medicine makes me eat."
I reason that no one gets as fat as she is simply from sleep eating. She must eat all day. I remark, as both statement and question, "So maybe you also eat too much during the day, and that's why you're overweight?"
"I don't know."
Well, great, just great, I comment silently. Not only does she have psych problems, but she's also obese because she over eats and she's probably in big time denial about her food intake. Sleep eating -- if that's what she does -- just seems to be a bit player in her global dietary problem. But I am not displeased with the referral. Sleep eating is rare disorder; if anything, the consultation will compel me to learn more about it.
"Did you ever hurt yourself, getting up in your sleep and looking for food?"
"No there is always food lying around, in the bedroom or on the kitchen counter."
"So you sleep walk too? I mean you physically get out of bed and walk to find the food?"
"I guess so. My husband says I do."
"How about your kids? Did they sleep walk as children?"
"No, not as I can remember." Sleep walking is actually normal in children, and in some cases it can be familial, but this question is a dead end.
"And you haven't hurt yourself, sleepwalking and looking for food?"
"No, not so far. I just don't remember any of it, because I am asleep."
"And you always get back to bed? I mean, when you finally do wake up, you're always in your own bed?"
"Yes, me and the crumbs." She had a droll sense of humor.
"What kind of work do you do?"
"I'm a nurse's aid at Hopkins Nursing Home."
"What shift do you work?" I want to make sure we were dealing with a nocturnal problem. People who work at night and sleep during the day have a screwed up diurnal clock, and sleep studies are difficult to come by for those patients (most sleep labs are geared to night time studies only).
"7 a.m. to 3 p.m."
"Yes, about 40 hours every week."
"Do you ever fall asleep at work, or when driving a car, or during conversations with people?" Daytime sleepiness is a common sign of insufficient night time sleep. This question is formally addressed by the Epworth Sleepiness Scale, a short questionnaire which she would also answer in due time.
"No, not if I'm working or driving. Sometimes if I sit down after lunch, I'll nod off."
"Do you think you overeat during the day?"
"No I don't eat that much."
"Do you snack just before you go to bed?"
"Sometimes, but usually the last thing I eat is supper, about 7 p.m. Honestly, I don't eat that much all day."
Most morbidly obese patients remark that ehy 'don't eat that much'. But obesity, at its most basic, is simply a result of calories eaten > calories burned. She clearly has been eating more food than she uses up by metabolism.
"Well, how much do you think your weight gain is due to sleep eating, and how much to eating during the day?"
"I don't know. I think Dr. Mandrake is trying to figure that out."
People have been known to do strange things during sleep. Most of the strangeness stays confined to the bed (grinding teeth, kicking, talking, etc.), but a great deal also takes place out of bed -- sleep walking and sleep eating being two well-described oddities.
Is sleep eating a sleep disorder or an eating disorder? There are arguments both ways. It doess seem that people who 'sleep eat' are both overweight (because they eat too much during the day) and also have additional sleep disorders (such as sleep apnea or insomnia). But sleep eating is a specific diagnostic condition, technically a parasomnia, or 'abnormality around sleep'.
As sleep disorders go sleep apnea is rare, far, far less common than sleep apnea, insomnia, or restless legs syndrome. Like all sleep disorders, though, it is gaining in recognition as physicians more and more ask their patients "how do you sleep?"
A sleep eater is also a sleep walker or somnambulist (see following table). As such, the patient is prone to self-injury during an episode. Also, if sleep is interrupted during the night (from either sleep walking, or from associated disorders such as sleep apnea), they may feel tired and sleepy during the day.
Type of sleep disorder
Somnambulist, by Millais
Somnambulist, by Tamayo
Macbeth (Act 5, Scene 1):
Doctor, observing Lady Macbeth sleep walking: "You see, her eyes are open."
|Common and normal, up to 15% under age of puberty. Treatment: take steps to assure safety (e.g., alarms on bedroom door, removal of all sharp objects within reach, gates on stairs, etc.). Usually drugs not necessary.||Uncommon and abnormal, suggesting an underlying eating disorder; treatment: keep food out of reach|
|Uncommon and considered abnormal: perhaps affects 1% of population. Treatment: steps to assure safety (as with kids), plus drug treatment (see below)||Subset of sleep walkers and so is rare; patients often have manifest psychiatric problem. Treatment: Psychotherapy, behavior therapy, hypnosis; drug therapy (see below)|
|Dopaminergic drugs Sinemet (carbidopa and levodopa) and Mirapex (pramipexole); Benzodiazepine drug Klonopin (clonazepam)||Same|
|Sleep Walking, Somnambulism||Sleep Eating, sleep-related eating, nocturnal sleep-related disorder|
I was surprised Ms. Marschand never hurt herself. Here is what Talk About Sleep states about the condition:
I did some research of my own. As suspected, sleep eating is almost always reflection of an underlying psychological problem. The patients are usually overweight and have a history of dieting. The situation is worse if they go to bed hungry, as this causes them to binge at night. My patient had a history of depression and obesity -- conditions I do not treat.
Would there be any value in ordering a sleep study? Since she was sent by a psychiatrist, to a "sleep specialist", I felt the study should be done. It might uncover some other sleep-related problem more easily treatable than sleep walking and sleep eating. A cardinal rule of treatment is to look for underlying causes.
However, many of the associated causes are not sleep-related, and include drug abuse, nicotine withdrawal, hepatitis, damage to the satiety center in the brain (rare), and certain acute stresses. (Sleep 1991 Oct; 14(5): 419-431). Also, she needed to be checked for common medical problems, particularly diabetes and thyroid dysfunction.
The sleep study did reveal mild sleep apnea and disrupted sleep. She got up twice during the night to go to the bathroom, but both times the EEG showed that she was awake, not sleep walking. There was no apparent attempt to sleep walk (which would have been impossible anyway, because of all the attached wires). There were several other abnormalities on the study but, while interesting, they not shed much light on her sleep eating/sleep walking.
She is in my office a week later, for the follow up.
"How'd the sleep study go?"
"I don't know, they said to come talk to you."
"No, I mean from your side of it, did you sleep?"
"Oh, yea, but not as well as at home."
"Well, it showed some changes related more to your weight than anything else." Here I was referring to her mild sleep apnea, which did not require any specific treatment except the usual recommendation of weight loss. "And you didn't show any tendency to sleep walk."
She sits with stony silence, not really very curious about the study.
"Have you had any more sleep walking episodes since the study?"
"Not that I know of. At least my husband hasn't said so."
"Well, I sent a copy of the study report to Dr. Mandrake. When are you seeing him again?"
"Not until next month."
"OK. From my perspective there's not much more to do. See him and see what he thinks should be done."
So we had come full circle. She needed type of therapy I can't give, in the realm of stress management, psychotherapy, even possibly hypnosis (which has been tried in some cases). My 'sleep consult' was complete, and helpful in a negative way. Her sleep walking/sleep eating were not the root problem, but the manifestation of some other problem, much as fever is a manifestation of pneumonia. If you treat only fever with aspirin, and don't look for the cause, you will miss the pneumonia and its proper treatment. Of course this analogy is weak since there is no effective 'single' treatment for sleep eating.
I write a detailed note for Dr. Mandrake in the chart, but also made it a point to discuss the case with him in person.
Night Eating: Other Disorders of Sleep and Eating
Disorders not to be confused with sleep eating are binge eating before going to sleep and awakening during the night to eat. They are different from sleep eating simply because the subject is awake in each situation. Synonyms for both conditions are nocturnal bingeing, nighttime hunger, nocturnal eating, night eating syndrome, and the "Dagwood" syndrome, after the comic strip character who was always eating giant sandwiches at night.
These people seem unable to go to sleep with out food intake, and if awakened for any reason (such as to urinate) are compelled to eat more. Alternatively, they may awaken because of 'hunger', even though they have no caloric need. As a result, these people can also suffer insomnia or lack of sleep, as well as anxiety and depression.
Night eating can occur throughout the night. Whereas sleep eaters will eat anything edible, night eaters look for preferred foods. They are usually obese, and have psychologic or psychiatric conditions. Night eating can occur in children and adults, although it is rare after puberty.
Rarely, night eating can be due to low blood sugar or hypoglycemia. Any patient with this problem should see a physician to have a screening glucose tolerance test, and other metabolic studies as indicated. Beyond that, the problems underlying night eating are usually psychological, and should be dealt with as for true sleep eaters.
A week after her last visit I run into Dr. Mandrake at a quarterly staff meeting, and remind him of the case. "Did you happen to see the sleep report on your patient, Mrs. Marschand?"
"Oh yes, yes, thanks, that was helpful, I just wanted to make sure she didn't have any serious, treatable sleep disorder. I take it her mild sleep apnea doesn't bother you?"
"No, it's nothing I'd prescribe CPAP for, if that's what you mean. She just needs to lose weight, and that problem would also go away or at least get a lot better. What do you do for someone who sleep eats?"
"Not much, really. It's not a psychiatric disorder, I don't think it really has anything to do with her [BiPolar] depression. It's really an eating disorder. I already have her on [psych medications] and don't want to add another one. She actually may be eating more because of the meds, but they're helping her." The psychiatrist shrugs his shoulders, then adds: "The main thing, I think, is that she doesn't hurt herself when she goes for a sleep walk. But if she wants to eat a little at night, well, that's going to be hard to stop."
"Hmmm," I murmur, to which he responds:
"But it's a fascinating problem, don't you think?"