The field of clinical sleep disorders blends naturally with clinical neuropsychology. Both specializations require intimate knowledge of neuroanatomy, working with tests and measurements, performing complex differential diagnosis, and integrating multiple methods to inform clinical judgment. Modern neuropsychologists need to stay informed about the role of sleep disorders in cognitive function, as only a fool would deny the influence of alertness, sleep quality, and hypnotic medication on test performance. For those readers who desire a crash course in sleep disorders, aided by rich graphic and Internet support, the Atlas of Clinical Sleep Medicine is just what the doctor (PhD) ordered. The Atlas is edited by Meir Kryger M.D., best known for his encyclopedic Principles and Practice of Sleep Medicine, now in its third edition. The 40 contributors are easily recognizable as prominent sleep researchers, including psychologists such as Thomas Roth and Hans Van Dongen.
Several chapters are particularly pertinent to our field. Biology of Sleep (Chapter 3) succinctly covers topics such as the brain's arousal and neurotransmitter systems, sleep drive, circadian timing, and control of REM sleep. The subchapter on brain blood-flow is supported by stunning graphics and charts. Normal Sleep (Chapter 4) provides the normative basis for distinguishing healthy from poor and abnormal sleep from the standpoint of ontogeny. In the context of a persistent postconcussion claim, symptoms of increased difficulty falling asleep and increased awakenings is not so deviant in somebody 70, but is reason for concern in a child of 12. Pharmacology (Chapter 5) provides useful tables summarizing important drug facts, such as the hypnotic medications most known for daytime (“hangover”) effects. This would help the neuropsychologist who suspects a role for drugs in that mildly deviant Trailmaking B score. Neurological Disease (Chapter 10) summarizes the sleep issues associated with many disorders. Conditions covered include narcolepsy, restless legs and periodic limb movements, epilepsy, Alzheimer's disease, Parkinson's disease, and Huntington's disease. More controversially, the chapter examines sleep in fibromyalgia and treats it as a valid diagnosis. But the sleep correlates of the syndrome have not been replicated, and the diagnosis itself was abandoned by its physician discoverer.
Several chapters are especially helpful to neuropsychologists who specialize in psychiatric and forensic referrals. Dreaming (Chapter 6) is brief, but the reader learns much about dream pathology, the psychological and neuropathological conditions that cause it, and the clinical features to look for. For example, dream impoverishment can be associated with alexithymia and various brain syndromes. In contrast, excessive dreaming is an indicator of drug withdrawal. Sleep and Psychiatric Disease (Chapter 16) is especially useful for advice on using sleep patterns to aid in the differential diagnosis of disorders from the depressive spectrum. A good rule of thumb is that hypersomnia is more predictive of bipolar depression, while insomnia indicates unipolar. Presentation and Diagnosis (Chapter 7) should prove very useful to full-time clinicians. Included are screening questions for insomnia and hypersomnia, symptom checklists, and self-report inventories (such as the Epworth Sleepiness Scale and Berlin Apnea Questionnaire). The Insomnia chapter (Chapter 9) is especially useful to readers who incorporate psychotherapy into their practice. It offers a complete guide to diagnosis, and advice on combining pharmacotherapy with cognitive-behavioral therapy.
Sleep apnea syndrome is to sleep disorder centers as mild head injury is to forensic neuropsychology: It dominates referral patterns and provides a reason for existence. Sleep Breathing Disorders (Chapter 11) is the longest chapter, and the focus is on polysomnographic interpretation. There are many pages of sleep epochs (a 30-s sleep sample) showing subtle and not-so-subtle abnormalities in respiratory effort and airflow, and many photos of noses, chins, and throats. This chapter is only for specialists wishing to seriously pursue a sideline in sleep disorders, but be forewarned: sleep medicine certification has been closed to neuropsychologists since 2005, when the American Board of Medical Specialties took over the formerly freestanding American Board of Sleep Medicine, a body originally founded with the help of experimental psychologists. This reviewer was “grandfathered in.”
The Atlas has a unique teaching feature that is cutting edge: Online searchable text and 68 patient videos. The inside front cover contains a scratch-off activation code, that when entered at www.expertconsult.com, allows the reader to access galleries of videotaped interviews and sleep studies. The most interesting videos include an MS patient with sleep apnea and hypnagogic hallucination, and another patient with Parkinson's disease who demonstrates rapid eye movement (REM) behavior disorder. Other videos show plain vanilla snoring and obstructive apnea. I wish this educational technology had been available when I took the sleep boards in the middle 1990s.
The Atlas of Sleep Medicine is the perfect reference book for the neuropsychologist who needs a crash course, or a quick reference guide, when coping with the sleep laboratory report appended to a referral sheet. One chapter contains a guide to digesting the standard score summary sheet. There is little neuropsychology in this book, except for some data tables and graphs showing vigilance test scores plotted against various sleep parameters. But the gains in fundamental knowledge and professional vocabulary when dealing with medical colleagues are worthwhile.
