National Sleep Foundation

Chapter 5: Circadian Rhythm Sleep Disorders

Case Study

Richard, the 32-year-old owner of an import-export business, was referred to the sleep clinic for insomnia and feeling chronically fatigued and unwell.

Patient History and Examination: About five years ago, Richard  inherited a family import-export business, which was failing. Struggling mightily to make his business profitable caused Richard a great degree of stress, which led to insomnia. Richard used his involuntary nighttime awakenings caused by the insomnia to conduct overseas calls and catch up on business-related paperwork. These activities extended Richard’s nocturnal wake times and resulted in daytime sleepiness, which he tried to address by taking naps during the day. After about six months of this sleep pattern, Richard found that neither his nocturnal sleep nor his daytime naps were refreshing; he was constantly exhausted, but rarely able to fall into a sound sleep.

History of Previous Illness: Stress related to his struggling business, see above.

Past Medical History: None significant.

Social History: Richard is single, and is almost exclusively focused on saving the family businessl he has no other hobbies and does not take vacations.

Family History: None relevant

Review of Sleep Pattern: Wrist actigraphy for one week demonstrated the occurrence of frequent short naps spread evenly throughout a 24-hour period, which added up to about 9 hours of total sleep per 24 hours. Body temperature, measured every two hours during actigraphy, did not follow any discernible circadian rhythm.

Evaluation and Diagnosis:  Richard was diagnosed with Irregular Sleep-Wake Type (IST) disorder,, and recommended to achieve one major sleep episode per 24 hours to help increase his sleep’s restorative quality and improve his daytime functioning.

Treatment and Follow-up:  Richard tried hard to reestablish a 24-hour, sleep-wake pattern on his own but was not successful. He then hired a friend to live with him and stop him from taking extended naps during the day; the friend also helped Richard to gradually restrict his time in bed to nighttime hours.

Three years later, Richard sleeps better; now, when he occasionally experiences insomnia, he does relaxation exercises or reads, rather than working. His improved sleep has helped Richard to rescue the business; now, when he has excessive work stress, which happens three or four times per year, he takes a hypnotic for no more than two to four weeks He feels better, and is much better able to manage his business than he was before his diagnosis. The business is thriving.