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There’s an ever-growing list of conditions with an evident but underexplored connection to shitty shuteye, such as OCD or chronic pain. It's time to add schizophrenia to the list.

Not only is its relationship with sleep poorly understood, but, according to a new psychiatry study from Australia, the recent surge in Cognitive Behavioral Therapy (CBT) also offers promising opportunities for clinically tailored, effective sleep therapy for people suffering from the common psychotic disorder. To design treatment for a problem, however, we need to understand it.  

Across the board, those diagnosed with mental illness experience disproportionately high rates of sleep issues, from general difficulty getting rest to severe and stubborn cases of insomnia, circadian rhythm disorders, nightmare disorders, sleep apnea and various parasomnias. But, research increasingly points to the futility of making generalizations about the connection between sleep and mental illness. Because, across the mental disorder spectrum, clinical populations wage their own battles with nocturnal demons. This certainly appears to be the case with schizophrenia.

The psychotic disorder affects more than two million Americans and typically shows up during late adolescence or early adulthood. Despite the misleading name and exaggerated depictions in pop culture, schizophrenia is not a split-personality disorder. (The "schizo” prefix refers to a "split" state of mind.)

Studies do show a link between schizophrenia and disturbed, disordered sleep.

Primary symptoms include abnormal social behavior, cognitive dysfunction and a disconnect from reality that manifests in hallucinations (seeing and hearing non-existent things) and delusions (holding paranoid, bizarre or irrational beliefs with conviction). Sadly, without treatment, people with schizophrenia often struggle to lead functional lives and face statistically high likelihoods of joblessness and homelessness. With treatment, typically antipsychotic medication, therapy and, in some cases, living assistance, schizophrenia can be manageable. But, it’s neither easy to have nor to study. The symptoms are multidimensional. The clinical population is diverse. And treatment doesn’t affect patients uniformly.

Studies do show a link between schizophrenia and disturbed, disordered sleep. The prevalence of insomnia among schizophrenia patients, according to a recent medical literature review, varies from 36 to 80 percent, depending on criteria for participation and definitions of insomnia. Clarity – if that wide numerical range provides any — basically stops there.

Schizophrenia studies may be challenging, but in this case, researchers say, they’re necessary. What's needed is studies that are better-tailored to the disease and the people who have it, that concern disorders other than insomnia, and which look at broken sleep as directly connected to the disorder rather than as a byproduct of lifestyle habits or medication.

For the study in question, published in the journal Psychiatric Quarterly, researchers at the University of Western Australia conducted in-depth, in person interviews with 14 schizophrenia patients about their relationship with rest. Previously, study authors explained, most sleep-schizophrenia analysis has been objective. By that, they mean physiological tests, including polysomnography (to measure sleep brain waves) and actigraphy (light exposure and body movement).

In this situation, and with so much to learn, the “why” matters as much as the “what.”

While assessments of Slow Wave Sleep and REM activity are useful to identify trends, they fail in at least one critical way: They aren’t developed for people with schizophrenia, and don’t provide insight into patients’ relationship with sleep. Given how little we know about the sleep-schizophrenia connection, and the degree to which disordered beliefs (e.g., paranoia) affect patients’ lives and well-being, analyzing brain waves based on an understanding of sleep in the general population may not be that meaningful or helpful to patients. In this situation, and with so much to learn, the “why” matters as much as the “what.”

“These methods provide insight into the type of sleep problems experienced by people living with severe mental illness,” study authors wrote, “they typically utilize a priori assumptions that the key features of sleep problems in psychosis can be described using a frame of reference derived from experiences in healthy people.”

The study, though admittedly small, produced interesting results. Here are some key findings:

  • All participants reported insomnia symptoms.
  • Eleven of 14 described sleep habits indicative of sleep-wake disorders and circadian dysfunction, including natural sleep schedules that deviate considerably from the norm.
  • Ten of 14 experienced symptoms or episodes of parasomnias, including nightmares, hallucinations, night terrors, sleep paralysis, sleepwalking, REM disturbances (acting out dreams) and night sweats.
  • Participants admitted to not telling doctors about their sleeping problems for fear of their complaints being interpreted as symptomatic of psychotic episodes and grounds for increased medication.
  • In discussing what they perceived as the root of their sleeping issues, participants continuously mentioned feeling a lack of control over the situation, as well as insurmountable anxiety, over-thinking, intrusive thoughts and hallucinations. “I mean trying to put sleep in a basket and stuff and saying 'this is what I want my sleep to be' and have it regulated and controlled is just berserk...bizarre I suppose," said one participant. "These processes are natural processes and have their own order. I can’t shape them or form them just by my own world.’’
  • They also felt medication interfered with normal sleep patterns.

Across the board, the findings pointed to trends in behavior and belief that doctors and therapists need to understand in prescribing medication and otherwise helping schizophrenia patients develop healthy sleep habits as part of a stable lifestyle.

Study authors particularly emphasized the degree to which participants reflected on anxiety, negative attitudes and beliefs about sleep. CBT addresses those exact issues and, based on a fair body of research, addresses them well. While CBT has shown promise for treating insomnia in the general sleep-disordered population, study authors believe it’s necessary to develop CBT courses tailored to the needs of schizophrenia patients to maximize their chance of success.