A Curious Case of Nighttime Eating
At Amen Clinics, we understand that “mental health” is really “brain health,” and for your brain to be healthy, you need a healthy body. If your brain is not healthy, then no matter what medications you take, you will not get better to the greatest degree possible. It’s basically like putting jet fuel in a broken-down car. It just doesn’t work.
What I like about the case study I am going to detail for you here is how beautifully it describes the importance of looking at underlying factors rather than just treating symptoms.
Jake: The Refrigerator Raider
This is the story of Jake and his wife Gen (names have been changed).
For 8 months, Gen had been suffering almost nightly with an eerily similar pattern. Between 2-4 a.m., Gen would feel Jake get up and go out to the kitchen where he would rummage through the pantry and refrigerator, eat messily like he was in a hot dog eating competition, then head back to the bedroom, leaving a trail of food and crumbs like Hansel and Gretel all the way back into their bed.
She would also notice a glazed look in his eyes, as if he was not all there, and was afraid to wake him out of it.
As understanding as she was, she was just not the kind of woman who fancied waking up next to a snoring partner in a bed full of crumbs with the first chore of the day having to be cleaning up after him.
Between his incessant snoring, messy night-time eating habits, and other issues, Gen was at her wit’s end and needed solutions. Fast. So, she recorded his bizarre sleeping behaviors on video, which is a great idea for a partner to do, and convinced him to come to see me.
In discussing his history, I learned that Jake was a 39-year-old veteran (served in Iraq and Afghanistan), with a medical history of obesity (body mass index 36), post-traumatic stress disorder (PTSD), alcohol abuse (in the past), vitamin D deficiency, hypothyroidism, and chronic pain.
The sleep complaints included snoring, nightly sleep-eating behaviors, excessive daytime sleepiness (Epworth Sleepiness Scale of 16), fatigue, non-refreshing sleep, and weight gain of over 40 pounds in the last 8 months.
Now it was time for me to solve the case.
Decoding Multiple Health Issues
As clinicians, it is very important that we understand how different health issues impact one another. This was very true in Jake’s case.
Jake was obese, which is a risk factor for obstructive sleep apnea (OSA). In this condition, the airway collapses and the tongue periodically falls back in the throat during sleep, closing off the airway and resulting in symptoms like snoring, tiredness, sleepiness, depression, lack of motivation, and concentration problems. It also puts a lot of strain on the heart, resulting in less blood flow to the brain and an increased risk of dementia, anxiety, heart attacks, high blood pressure, strokes, and sudden death.
Several times during the night, the brain can wake up (arousals) in order to trigger the muscles to breathe and get oxygen to the brain. Hence, sleep apnea also leads to excessive sleepiness, which can result in workplace and traffic accidents. It is estimated that 6,400 fatal accidents each year in the U.S. are attributed to sleep apnea. Frost & Sullivan calculated that the annual economic burden of undiagnosed sleep apnea among U.S. adults is approximately $149.6 billion. The estimated costs include $86.9 billion in lost productivity, $26.2 billion in motor vehicle accidents, and $6.5 billion in workplace accidents.
Jake’s sleep-related eating disorder is a form of parasomnia—any abnormal behaviors that occur during sleep—and involves binge eating during the sleep period. Typically, it is associated with minimal recollection or conscious control as well as weight gain. In some instances, sleep eating episodes may be caused by arousals related to untreated OSA that occur during sleep.
Other types of parasomnias—such as sleep talking, sleepwalking, or confusional arousals—can be a clue not just to sleep apnea, but also to chronic sleep deprivation. In sleep deprivation, we are concerned not only with the total amount of sleep somebody gets, but also the quality of that sleep. If you get 8 hours of sleep a night, but you have sleep apnea and are waking up tired, it is not adequate sleep. In fact, it is terrible sleep because every minute you are asleep with untreated OSA, your brain is suffocating. In some cases, parasomnias may be the result of something more serious, such as a seizure disorder.
We know that parasomnias like sleep eating disorder tend to occur most commonly in the transitional period between sleep and wakefulness.
Additionally, there was Jake’s PTSD to consider. When the nervous system is on high alert as it is in syndromes like PTSD, a person may tend to breathe heavily and blow off a lot of carbon dioxide. The brain can detect a drop in carbon dioxide and even trigger the muscles to stop breathing periodically to get the levels of carbon dioxide up to normal levels.
This is called central sleep apnea and is yet another way that the brain can be deprived of oxygen. The brain can then wake up, slip into the transitional zone between sleep and wakefulness, and trigger another parasomnia episode like sleepwalking and sleep eating.
Studies also suggest PTSD may be a risk factor for sleep disruption and sleep apnea, and treatment of OSA improves PTSD symptoms.
In Jake’s case, I had to look into the association between sleep apnea, PTSD, weight gain, sleepwalking, and sleep eating and how they perpetuate an unhealthy sleep cycle. In addition, a clinician must consider other factors, such as:
- Sleep deprivation (which can make your brain go into deeper stages of sleep to make up for lost sleep and can trigger arousals from deep sleep and parasomnias)
- Primary insomnia
- Medications (those that can affect REM or NREM sleep or cause sleep disruption independently or by worsening other sleep fragmentation disorders
- Co-morbid illnesses (such as low vitamin D, chronic pain, and other illnesses that can disrupt sleep)
To best serve our patients, we must be aware of how all these different factors may come together.
Pinpointing Jake’s Diagnosis
Let’s go back to Jake, whose main concern was his sleep-eating behaviors, which resulted in a weight gain of over 40 pounds. Gen’s main concerns were his snoring and sleep eating (which were destroying her sleep and ruining her mood), as well as his sleepwalking (which made her worry that Jake might hurt himself).
On reviewing details of Jake’s mental health history, as well as his sleep history, I discussed how sleep deprivation can worsen sleep disordered breathing (sleep apnea) and likewise, how sleep disordered breathing can lead to disrupted sleep, which can then perpetuate parasomnias like sleepwalking and sleep eating. Adding in Jake’s hyper-arousal (PTSD), which has been linked to an increased risk of sleep disordered breathing, compounded the sleep disruptions and consequent parasomnia (sleep eating), which in turn caused weight gain and worsened sleep disordered breathing.
Thus, my running hypothesis was that sleep-eating behaviors could be a secondary disorder of arousal due to severe sleep apnea.
To better understand Jake’s sleep patterns, I ordered a nocturnal polysomnography, a sleep study that involves the following:
- Sensors on the head to detect brain waves
- Belts on the chest and belly to detect breathing patterns
- A sensor to detect oxygen levels of the blood
- A microphone to detect snoring
- Sensors on the limbs to detect movements during sleep
- A sensor to detect body positioning
- Infrared video monitoring of the room
- A sensor near the nose to detect the temperature and pressure of the air going in and out of the nose.
Jake’s study demonstrated severe sleep apnea with an overall AHI (Apnea Hypopnea Index) of 108.3 events per hour. This means that Jake stopped breathing over 108 times an hour.
This is dangerous and requires immediate treatment because of the risks of untreated sleep apnea, as discussed previously.
I put Jake through another sleep test, in which different levels of CPAP (continuous positive airway pressure) are tried. Here, they monitor how many times the person stops breathing, as well as what pressures work best and are best tolerated. This device works because the pressure of the air delivered from the machine via tubing and a mask can keep the airway open and prevent its collapse.
The study concluded that pressures of between 8-14 cmH2O worked best to minimize the pauses in breathing. I hypothesized that if the sleep apnea was controlled adequately, there would be fewer arousals from sleep into sleepwalking and sleep eating. This would result in weight loss, which would further improve the sleep apnea. Controlling the sleep apnea would also improve his symptoms of PTSD.
I followed Jake for several months, making adjustments to his CPAP machine, getting downloads from the machine to make sure it was doing what it was supposed to be doing. In addition, I treated his PTSD independently and utilized a whole-brain approach to his health that included exercise, nutrition, targeted supplements, and cognitive behavioral therapy for insomnia.
Over time, he regained his energy, his symptoms of depression subsided, his concentration improved, his weight dropped, and his overall quality of life improved. His snoring was eliminated, and the nightly sleep-eating resolved for the most part, much to the delight of Gen, his patient wife.
Jake had his life back and had the tools he needed to be the father, husband, employee, family member, and friend that he wanted to be.
About the Author: Shane Creado, MD, Amen Clinics Chicago
Dr. Shane Creado is a board-certified psychiatrist and sleep medicine physician. He is also a sports psychiatrist and is on the Board of Directors of the International Society for Sports Psychiatry, as its Chairman of Memberships. Additionally, he has clinical experience with the veteran population, college mental health, exercise prescription and mental health, co-morbid psychiatric and sleep problems, CBT-Insomnia, alcohol recovery groups, MBSR (Mindfulness-Based Stress Reduction), administrative psychiatry, health care policy, cultural psychiatry, couples therapy, and regressive hypnosis. He uses the skills he acquired in these disciplines to holistically apply evidence-based medicine in the service of his patients. In his spare time, he likes to travel, write, act on stage, and play racquet sports.