Training in the psychiatry of sleep disorders

Sleep disorders are common in psychiatric and non psychiatric consultations. Yet there is very little edu cation and training available to medical trainees in the UK. In this paper we describe our experience in a sleep laboratory during a part time six months attachment. We feel that a basic knowledge and experience in assessment, investigations and treatment of sleep dis orders and involvement in academic and research activities in this field should be considered to be a part of the psychiatric training schemes.

Sleep disorders are commonly encountered In psychiatric consultations and in general prac tice. In a general population survey 52% report a current or past sleep problem: most commonly insomnia (42%), nightmares (11%), excessive sleep (7%), and sleep walking (3%) (Bixler et al, 1979). These figures are even higher in popu lations seen by psychiatrists: 80% of patients referred to a liaison psychiatry service had a sleep disorder (Berlin et al, 1984). Yet, little at tention has been given to medical training in this area. A recent national survey of medical schools in the United States has shown that medical students receive on average two hours of edu cation on sleep disorder. Only 11 % of students are exposed to the clinical evaluation of sleep dis orders (Rosen et al, 1993). We could find no such information for United Kingdom medical schools, but our impression is that the amount of training in sleep disorders is no greater. The Royal College of Psychiatrists guidelines for general profes sional training do not include clinical experience in sleep disorders (Royal College of Psychiatrists, 1993). We describe our experience as registrars during a six month part time placement in sleep disorder as a part of the St George's Hospital Rotational Training Scheme in Psychiatry.

The setting
The placement is based at the sleep disorder unit at Atkinson Morley Hospital in Wimbledon, London. The unit receives referrals from all parts of the United Kingdom. It consists of a consultant psychiatrist, senior registrar in psychiatry, psy chiatric registrar, two sleep laboratory scientists and a statistician. The medical staff assess new referrals in an out-patient clinic. Appropriate patients are then admitted to the sleep labora tory for investigation. The sleep laboratory scien tists carry out polysomnographic recording over two nights. The statistician then produces a hypnogram which is a diagrammatic profile of the patient's night. Once the results are available the team develops a management plan for the patient. The patient returns to the out-patient clinic where the management plan is further discussed and explained. In addition to the clini cal work, there are regular academic meetings where both clinical and academic aspects of sleep disorders are discussed.

The experience
The post gave us the opportunity to see patients presenting with a range of sleep complaints: insomnia, hypersomnia, parasomnia and dis turbed sleep schedules. The out-patient assess ment involved a detailed history from the patient and, where appropriate, an additional informant. It was often possible to make a diagnosis on the basis of a precise history. This was then con firmed by the polysomnographic investigation. At other times, however, the polysomnograph would show unexpected organic abnormalities which would lead to different diagnoses. We became accustomed to thinking of sleep not as a separate entity but as being intimately related to the patient's waking life. We gained a unique insight into the morbidity associated with sleep disorder and the resulting social handicap. We learnt also to consider additional mental and physical dis orders, and their relationship to the presenting problem. Seeing hypnograms regularly gave us a first-hand knowledge of sleep architecture which could not be acquired from books. We learnt to manage sleep disorders; the treatments used ranged from simple measures on sleep hygiene to complex psychotherapy and the occasional use of drugs. We were able to relate psychodynamic factors seen in the history to the symptoms described and to abnormal sleep physiology. The intellectual discipline of precise history tak ing and detailed investigation appeared to be particularly rewarding when applied to sleep disorders.

Conclusions
Sleep disorders are associated with affective dis order, anxiety states, eating disorders, drug and alcohol abuse, and many physical disorders. It has been shown that the resolution of sleep disorders is associated with a reduction in the risk of developing other psychiatric disorders (Ford & Kamerow, 1989).
The specific skills gained during the attach ment are important to the general psychiatrist as sleep disorders are common and are responsible for considerable morbidity and may cause sig nificant social handicap. The dual psychological and physiological approach of the unit can be applied to a wide range of psychiatric disorders. The trainee can gain first-hand experience of the link between psychodynamic issues revealed in the out-patient assessment, disordered sleep architecture and psychological investigations. This is of great value when treating other patients encountered in psychiatric practice. We therefore suggest that a greater emphasis is placed on sleep disorders within psychiatric training. It would be appropriate for the Royal College of Psychiatrists to consider a knowledge of sleep disorders as an elective attribute of the trained psychiatrist.
We feel that the following elements should be specifically addressed within psychiatric training: (a) a basic knowledge of sleep and its re lationship with wakefulness; in particular the influence on sleep of mood, nutrition, activity, pharmacological agents, alcohol and illicit drugs (b) basic understanding of investigative procedures (polysomnography, relevant psychometry) and interpretation of their results (c) clinical experience in the assessment and treatment of common sleep problems (d) an understanding of the International Classification of Sleep Disorders (ICSD) (e) opportunities for research in the field.