Brit. 3. Psychiat.

(ig68), 114, 69-75

Hypersomnia
A Discussion of Psychiatric Implications Based on Three Cases

By ALEXANDER BONKALO

Epimenides, a Cretan poet of the 6th century or infiammations affecting the brain-stem, as
B.C., withdrew into a cave where he fell asleep; reviewed by Kleitman (is), Michaelis (20) and
he awoke 57 years later (@). This anecdote is Roth (22). Excessive abdominal girth may also
probably the first recorded case of hypersomnia. lead to somnolence, as seen in the Pickwickian
Sleeping Beauty, Rip Van Winkle and other syndrome identified by Burwell, Robin, Whaley
personalities of folklore and literature followed. and Bickelmann (i) and elaborated further by
Clinically valid contributions, however, first Drachman and Gumnit (@). The menarche or
appeared around the turn of this century. the menstrual cycle may be linked with hyper
Hypersomnia has been defined by Kleitman somnia, as shown by Jochims (13) and Lher
(15) as uncontrollable somnolence and patho mitte and Dubois (18) respectively. Sleep states
logically prolonged sleep, from which it is can develop on a psychogenic basis, e.g. after
sometimes difficult to arouse the sleeper, or to sudden intensive negative emotional experiences,
keep him awake for any length of time after he according to Roth (22), or as an avenue for
has been awakened. The reduction of con passive retreat from conflict and a means of
sciousness in hypersomnia is what appears to be withdrawing from action, as reported by Gold
normal sleep. It should therefore be differen stein and Giffin (i I). Michaelis (19) observed
tiated from conditions of impaired consciousness, hypersomnia, rather than insomnia, in cases of
such as coma, stupor, ictal or postictal confusion, endogenous depression.
and hypnotic or hysterical dissociation. A clinical pattern has emerged from the
Narcolepsy and hypersomnia are two diversity of forms, characterized by periodic
separate and distinct categories among the sleep somnolence and morbid hunger, first described
disorders. Narcoleptic attacks are sudden and by Kleine (14), then more specifically defined
imperative; the patient falls asleep on the spot, by Levin (i6), and eventually named the
and his sleep is of short duration, with immediate Kleine-Levin syndrome by Critchley and
alertness when awakened. In hypersomnia, sleep Hoffman (4). In a comprehensive study, Critch
is irresistible as in narcolepsy, but its onset is ley (@) has pointed out that in all genuine
more gradual. The patient has time to withdraw, cases the patients involved have been adolescent
even to go to bed in his accustomed manner. males. He also suggests that excessive eating in
His sleep is prolonged, lasting hours, days or this condition was compulsive and not due to
weeks. He can only with difficulty be aroused; morbid hunger. His criteria narrow the syn
on awakening he is drowsy, usually irritable, drome to a clinical entity referred to as peri
slow in mentation, even confused. Essentially, odic hypersomnia and megaphagia in adolescent
though this is somewhat over-simplified, the males. It becomes a matter of opinion whether
salient feature in narcolepsy is the need to fall this restricted category constitutes the Kleine
asleep; in hypersomnia, to keep on sleeping. Levin syndrome, or whether this term should be
Phenomena typically associated with narcolepsy used in a broader sense to include every case in
(cataplexy, sleep paralysis, hypnagogic hallu which periodic somnolence is associated with
cinations) are not present in hypersomnia. excessive eating. Recent reports by Gaffinek (s),
Hypersomnia is a syndrome which may be Gilbert (10) and Earle (6) have extended the
brought about by different conditions. Among limits of this syndrome, and have also added a
common causes are tumours, destructive lesions few female patients to the very small, and in
69
 70 HYPERSOMNIA: A DISCUSSION OP PSYCHIATRIC IMPLICATIONS

part controversial, roster of such cases. pounds. His body contours were softly moulded, giving
A special form of hypersomnia was called him an effeminate appearance which was accentuated by
bilateral gynaecomastia. Skeletal proportions and hair
the syndrome of sleep drunkenness (Schiaf distribution were masculine, and his genitalia were of
trzmkenheit) by Roth (22), and considered to be normal size. He had normal heterosexual phantasies and
a separate entity. Essentially it consists of pro interests. CliniCal investigations, including EEG, lumbar
tracted drowsiness in the morning after a corn CSF, air encephalogram, glucose tolerance tests, dee
trolyte study and serum protein assessments, gave normal
plete and deep night's sleep. Linked with this
results. Examinations during a sleep attack also resulted in
condition is a tendency toward dissociative essentially normal findings, except for massive defence
states due to incomplete wakefulness on pre reactions bilaterally and upgoing toes at the left side on
mature arousal. plantar testing, as well as eosinophilia (12 per cent.) and
Three cases of hypersomnia admitted to the episodic or continuous high amplitude 56cycles per
second slow waves occurring in both frontal and temporal
Toronto Psychiatric Hospital are here presented. leads in the EEG. From May to September i96o, detailed
observations and laboratory studies were carried out in
Case z hospitaL No sleep attack occurred during this period.
This i6-year-old boy had four sleep attacks between Serial EEG examinations resulted in poorly organized but
October 1959 and April 196o; the last one was observed essentially normal patterns. Daily BMR findings were
in hospital. Each sleep episode lasted 5 to 6 days, separated consistently low, ranging between o@
and 25.Remain
by normal intervals of 49, 87 and 62 days respectively. ing data were deemed to be within normal limits; they
Several weeks before the first attack he suffered a mild showedno periodic or episodic variations, beyond regular
flu-like
illness. daily rhythms.
Description of a Sleep Episode. The typical attack was Mental State. Between attacks, this boy's behaviour and
heralded by reluctance to get up in the morning. During personality did not differ essentially from others ofhis age.
thedaythepatient
wasslow, appeared He was co-operativeand friendly; though there was some
uncommunicative,
sleepy or in
a daze. His responses were monosyllabic, underlying hostility, he was able to establish good rapport,
often revealed anger or irritation. The followingday he with considerable warmth.
remained in bed, lying flat or curled up on his side, in a Psychological testing presented no evidenceofpathology.
state which appeared to be normal sleep, no different from Intelligence (WAIS) was average (verbal io8, perfor
his regular night sleep. Occasionally he became restless, mance 102, full scale io6). Personality profile (Cattell i6
banging his heels, turning and tossing in bed. During the PF) indicated submissiveness, timidity and lack of con
early phase he perspired excessively, his hands and feet cern. Projective tests suggested introversion, as well as
were cold and clammy; there was also moderate acrocyan anxiety about the environment generally and about
osis. He could be awakened for meals, he did go to the female authority specifically. Dynamically, the test results
washroom for eliminations; he was, however, drowsy, were interpreted as suggestive of inadequate defences in
mute or monosyllabic,
abruptand irritable
on such relationto an aggressive,hostilemother.
occasions.He ate and drank somewhat lessthan his usual Follow-up examination was carried out in June, 1966. In
dietthefirstday or two,butduringthelater daysofhis theinterim
thepatienthad had fouror fivesimilar
epi
period of somnolence he ate large amounts. He was sodes,
aboutone a year.Alloccurredin latespringor
resistiveand angry when awakened for clinicalexamina early summer. During this six-year period he functioned
tions, though fully oriented and rational. The condition of normally. He married and is well adjusted. He is now
almost continuous sleep lastedfor fivedays. On the sixth, grossly overweight; 5 ft. 8 in. tall, he weighs 205 pounds.
he was more spontaneous and spent some time out of bed, His gynaecomastia is less apparent; there are striae over
walking up and down and watching TV, though he his abdomen. Routine physical and laboratory tests gave
remained dazed and poorly communicative until towards normal results. He is generally satisfied, has no complaints
evening, when he became more alert and active. After one except for his sleep attacks, which occur about once a year
more day of gradual improvement he became fullyalert and whichhe accepts
asunavoidable.
and somewhat elated; he ate excessively at meals, with
sweets and candies in between; he was pleasant, friendly, Case 2
co-operative and well organized. In a day or two his This unmarried female office worker suffered eight sleep
mood, eating habits and general behaviour were back to attacks
betweentheagesofi6and 21 years.
Theirdates
his usual standards. and theirduration
were asfollows:
September,1936,4
Investigations.Personal and family history were unevent days;May, 1937,3 days;September,1937,8 days;
ful, except for manic-depressive illness in a maternal aunt. December, 1937, 8 days; March, 1939, 10 days; April,
@ His mother, now domineering and over-protective, 1939,8 days; October, ii days, and a mild
onein
attemptedabortion earlyin her pregnancyby taking i@o forwhich details are not available.
All episodes
quinine. He was a modelchild. There was no history of followed
thesame generalpattern:forno reasonthat
enuresis or other sleep disturbance, though he was a day couldbe ascertained
thepatientwould become listless,
wetter until age io. All his life he had been overweight. indifferent, and careless about her personal appearance;
@ At i6 his height was ft. 8 in. and he weighed 151 her appetite would diminish, she would complain of nausea
 BY ALEXANDER BONKALO 7'
and occasional vomiting. Within a few days she would when for several weeks during the summer he slept con
become very drowsy, progressing into sleep from which she tinuously throughout the day in spite of efforts to wake
could be roused with difficultyfor meals and toilet. Profuse him. When he did respond to arousal he was bad
sweating was noted during the sleep attacks. On arousal tempered and mean in disposition. During the fall in the
she had a muddled, dull look, often appeared irritable or same year, he became drowsy while working in a factory,
depressed, mildly confused at times, but not grossly dis and went home and slept more or less continuously for
oriented or irrational. Her food intake was classed from three days. At the age of 26, while in military service in
poor
to good
at different times, apparently improving England during the war, after a single glass of beer in a
as the spell progressed.After a variable period ofdays, she pub,
he did not remember anything for a day or two.
would suddenly snap
out ofitand be perfectly well. He was found by a policeman, apparently sleeping, on a
Neurological testing during the sleep attack recorded park bench. Taken to a hospital, he was discharged a
sluggishness of the right deep reflexes, but no essential week later without abnormal findings and with no diag
abnormalities. Repeated intensive clinical and laboratory nosed illness. Morning drowsiness continued, with
examinations between @937and @939,including an air episodic worsening. After the war he worked on the
study and early versions of EEG testing (in and out of assembly line in a refrigerator factory. According to a
attacks) resulted in normal findings. It was noted that report from his job, he was an efficient worker, cheerful
ergotamine tartrate, ephedrine, amphetamine and pheno and co-operative; the only fault to be found with him was
barbital, each tested separately, had no effect in relieving that periodically, for several consecutive days, he was late
attacks. No significant relationship was observed between arriving at work because of sleeping
in; it was also
the menstrual periods and the attacks. noted that he was always
hungry. Regrettably, the
This patient came from an insecure, unhappy home. notes failed to clarify the time relationship between his
Her father was a poor provider and a heavy drinker, hunger
and the episodes of sleeping
in.
repeatedly treated in mental hospitals. Two paternal In 1948, when he was 32, he was admitted to hospital
uncles and an aunt committed suicide.The mother was because of depression, precipitated by marital trouble
stable,
domineering
and over-protective.
The patient
was (personal discord). At the hospital it was hard to wake him
the youngest of three siblings. The eldest, a sister, was in the morning, and he was irritable if forcibly aroused.
emotionallystableand generallyhealthy.The second in He remained in a daze,and would frequently go back
thesibline, a brother, suffered drowsyepisodes, and is to sleep, with subsequent amnesia for activities carried out
presented belowindetail (Case3). in the dazed state of incomplete wakefulness. His appetite
As a childshesuffered acutenephritis and otitis media varied; occasionally he refused meals, at other times notes
followingmeasles, withresidual Her develop indicate
deafness. thathe ate largeamounts of food.Routine
ment was otherwise uneventful. She was described as a investigations
reported normalphysical findings. The EEG
likeable,
attractive person,proneto mood swingsand test noted some
sensitivity to hyperventilation and the
periods of anxiety; she was ambitious, presence of subharmonic
with strong loyal alpha activity in small amounts,
ties; basically, a sensible and able but no definite abnormalities.
person, who had Psychological examination
@ supported herself since youth working in stores and suggested superior intelligence (full scale IQ and no
offices. gross abnormalities. His developmental history was
In 950
and 1951 she had two more hospital ad essentially uneventful; he suffered no significant illnesses.
missions, at ages30 and 31,respectively, forreactiveHe was discharged four weeks later, improved, diagnosed
depression precipitated by a love affair. This illness had reactive
depression.
no direct
relationship
tohersleep
attacks,
thelast
ofwhich
occurred in 1940. At this time, again, physical and DISCUSSION
laboratory investigations, including EEG tests, resulted in
normal findings, except for bilateral conductive deafness The salient feature common to these cases
due to previous middle ear infection. Psychologicaltesting was the occurrence of irresistible drowsiness and
suggested superior general intelligence (full scale WAIS sleep, linked with pathological emotions and
IQ 122)and no thoughtdisorder or breakwithreality.
Projective tests suggested very high aspirational level,
vegetative irregularities. The leading abnormal
with a tendency to blame her family, her mother in manifestation was a condition which appeared
particular, for her own failures. Insecurity was noted, with to be true sleep: each patient subjectively fit
a great need for friendship but an inability to accept or sleepy; their appearance in the attack was very
trust it. She responded quickly to supportive psycho similar to that during their regular night sleep;
therapy, and was discharged
withthediagnosis
reactive
depression.
Shewasingoodhealth heardfrom they could be aroused from their condition; on
when last
in 1953. arousal, their drowsiness, perplexity and general
behaviour (e.g. yawning, stretching, etc.) were
Case3 in keeping with phenomena common to natural
This 32-year-Old male factory worker, brother of Case
awakening. Apart from hypersomnia, however,
2, had considerable difficulty waking up in the morning
since adolescence. Occasionally he would sleep until 5 the clinical picture as a whole differed consider
p.m.,ifleft alone.At theageof2! therewas an episode ably in each case.
72 HYPERSOMNIA:
Recurrent sleep episodes, linked with the
ingestion of large amounts of food and some
personality characteristics, class the first case in
the nosological syndrome referred to by Critch
ley (@) as periodic hypersomnia and mega
phagia in adolescent males. In 1962 the same
author recorded, from literature and from his
own observations, a total of 26 genuine cases
belonging to this category. From reports since
1962, the first case of Regli and
would also belong, and the further addition of
our patient as the 28th genuine case appears
justified. Evidently he also qualifies for the more
broadly defined category of the Kleine-Levin
syndrome.
It is of some interest that this patient suffered
a flu-like
illness a few weeks before the first
sleep attack. Among events which seemingly act
as precipitating factors, febrile illness was noted
in 5 cases out of the 26 collected by Critchley.
Our patient's eosinophilia, the intensive
sweating, the dysrhythmic EEG during the
sleep attack, as well as his chronic obesity,
gynaecomastia and abdominal striation should
be noted here. These findings may implicate
diencephalic dysfunction as part of the process.
The second patient showed periodic hyper
somnia from adolescence to 21 years of age. The
general pattern of the sleep attacks was very
similar to that seen in Case I, except that
gastric phenomena other than excessive food
intake were prominent, nausea and
occurred regularly during the early phase of each
attack, and only towards the end of the sleep
attacks did she eat goodmeals. Critchley (@)
observed in one of his patients that the excessive
eating was not due to excessive hunger. The
patient did not demand food he did not see, but
ate compulsively
every foodstuff in sight and
within reach. Critchley therefore suggested the
use of non-specific terms like megaphagia or
polyphagia instead of bulimia. He also suggested
that the nature of this symptom is in need of
thorough investigation, including studies on the
experience of satiety, on gastrointestinal peri
stalsis, and on metabolic functions. Our second
patientfurtherhighlights thisneed, as her
gastric phenomena may represent
the same symptom; her nausea and vomiting,
regularly linked with the sleep attack, may be
A DISCUSSION OF PSYCHIATRIC IMPLICATIONS
regarded as an equivalent ofthe condition which
leads to excessive eating in typical
cases. With
this qualification, this patient could be included
in the category of the Kleine-Levin syndrome as
an atypical
case.
The sleep disturbance followed a different
pattern in the third patient. His history does
include two occurrences at the age of 2 I years,
which appear compatible with two separate
Haynal (2 i) attacks of periodic hypersomnia. More im
portantly, this patient suffered in varying de
grees for many years from an exaggeration of the
normal sleep rhythm, with excessive sleep added
through grossly oversleeping in the morning. If
forcibly aroused after a full night's sleep, he was
irritable and carried out in a daze such
activities as getting dressed and having break
fast; often he went back to bed and continued
to sleep. On spontaneous awakening later, he
had amnesia regarding the earlier activities.
The pattern of disturbed sleep in this case
conforms with Roth's (22) syndrome of sleep
drunkenness. This pathological form of morn
ing drowsiness is characterized by considerable
resistance to arousal after a full night's sleep,
leading to a gross prolongation of regular
sleeping hours; meanwhile the 24-hour sleep
wakefulness rhythm continues, as the patient
maintains his alertness for the rest of the day,
following his spontaneous awakening at a late
hour. Roth also includes with this syndrome the
vomiting occurrence of twilightstates due to incom
plete awakening on enforced arousal.
The nosological position of pathological
morning drowsiness among the varieties of
hypersomnia is not yet clear. It may merely be a
formefrwte of the Kleine-Levin syndrome; there
are indications of this in our patient's personal
and family history. It can also appear as an
unusual sleep disorder in depression, as reported
by Michaelis (19). Moreover, there may be
cases where the exact sequence and causal
relationship of sleeping
in,maladjustment
and reactivedepression are blurred or
inseparably fused; the diagnostic label in such
a case may merely represent observer-bias.
Whether it is a symptomatic or a genuine entity,
a variant of this condition is distinct enough to warrant
clinical acceptance in its own right.
The term sleepdrunkenness, however, is
 BY ALEXANDER BONKALO 73
ambiguous as well as awkward. It was used to frequency in different members of a family:
denote morning drowsiness as a pathological narcolepsy, hypersomnia, various forms of
entity (22). It was also used with reference to psychoneurosis and psychosis, suicide, alcohol
impulsive acts, self.destructive or criminal in ism, endocrine disorders, obesity, congenital
nature, committed in the twilight state of semi blindness and enuresis.
wakefulness brought about by premature arous Psychogenic origin and the role of personality
al (12, 17, 23). For the sake ofclarity, it is pro factors in hypersomnia are much debated
posed herewith to apply the term diurnal hyper problems. Our patients' personalities, though
.comnia to cases showing pathologically prolonged different on the surface, did show certain
sleep with the 24-hour rhythm maintained, i.e. similarities at a deeper level. All three patients
to cases with pathological morning drowsiness. had strongly domineering mothers. All three had
Irresistible sleep to late hours in the morning high dependency needs, and some difficulties in
after a full night's sleep does become a clinical satisfying them because of ambivalence in their
problem if it seriously interferes with the relationships. All harboured deep-seated hos
requirements of everyday life, if it is symptomatic tilities, with also some demonstrable paranoid
of some other disease, or if abnormal waking aggression. Denial and passive withdrawal were
mechanisms are manifest. successful protective mechanisms in the first
The dissociative states due to incomplete patient. In the second and third cases, latent
awakening and leading to impulsive or irrational hostility and aggression were probably signifi
I behaviourhavebeenlabelledby Carrot,Velluz cant factors in the development of their depres
and Rigal (2) the syndrome of Elpenor in sive episodes and suicidal preoccupations.
reference to an incident in Homer's Odyssey.* A clear-cut separation of psychological and
This term is applicable to abnormal behaviour organic elements in the causation of hypersom
due to confusion on arousal from regular or nia is hardly possible; if attempted, it may merely
from hypersomnic sleep; it is also applicable reflect the investigator's personal proclivities.
whether the sleeper is sober or under the Psychologicalmotives,ifthey are not primarily
influence of alcohol, as were the legendary responsible, may be present as reinforcing
Elpenor and some of the cases described in the factors in every type of hypersomnia, though
literature. they enter most readily the diurnal form, as this
Of special interest is the familial occurrence appears to be mainly an accentuation of regular
of hypersomnia in Cases 2 and 3. In addition to sleep.
the sleep disorder in two of three siblings, this A transitory elimination of consciousness, as
family was loaded with psychopathology; suggested by Fenichel (8) is probably the archaic
chronic alcoholism and psychopathy were diag form of all repressions, and may serve as pro
nosed in the patients' father, three suicidal tection against the influx of too much anxiety
deaths occurred in the paternal sibling, and our producing stimulation, or it may be a total
hypersomnic patients themselves repeatedly protective response to a specific stress situation.
required treatment for depression. Pathologically Loss of consciousness, according to Fenichel,
loaded family settings are not unusual with whether it is fainting or sleep, may have an
hypersomnia, as well as with narcolepsy, unconscious meaning of its own. Such meanings
according to Roth (22). Among cases observed could include any libidinal needs, they may
by him or collected by him from literature, the represent death wishes against some other person
following conditions concurred with relative turned against oneself, or they may serve as
* Elpenor, a companion of Odysseus, while asleep on
distorted expression of hostile impulses of many
theroofofa house,
was awakenedby noise. kinds.
He suddenly
sprangup,and forgot
togo tothelongladder.
..butfell The possibility of causative somatic elementa
headlong from the roof and his neck was broken. . . and in hypersomnia is a controversial issue, except for
his spirit went down to the house of Hades.
Homer: The Odyss@y, trans. by A. T. Murray.Loeb
the grossly organic varieties with demonstrable
Classical Library (196o), I, 385. London: William pathology, located usually in the brain stem@
Heinernann Ltd. Certain findings in episodic, periodic or diurnal
 74 HYPERSOMNIA: A DISCUSSION OF PSYCHIATRIC IMPLICATIONS

forms strongly suggest the presence of significant of the latter syndrome, as she manifested, linked
organic factors among the causes. Such findings with the sleep attacks, gastric phenomena other
include the frequent concurrence of sleep dis than megaphagia. The third patient suffered
order and vegetative, hormonal or constitu from a syndrome which is essentially a patho
tional abnormalities in the same patient, or the logical exaggeration ofthe regular sleep rhythm;
frequent concentration ofsuch symptoms among the term diurnal hypersomnia is proposed as the
different members of his family. The striking name for this form of sleep disorder.
similarity of the clinical pattern in patients 3. The role of psychological and organic
showing the syndrome defined by Critchley (@) factors in hypersomnia is discussed. It is sugges
or the K.leine-Levin syndrome would also ted that the hypersomnia syndrome, manic
indicate significant organic pathogenic or depressive illness and periodic catatonia have
pathoplastic factors. Moreover, this syndrome elements in common, worthy of special atten
usually appears in patients with a reasonably tion, even beyond the nosological interest in
healthy and well adjusted personality. sleep disorders.
Beyond its inherent interest, the study of
hypersomnia has also heuristic value in psy AcxNowaaix@w.@rrs
chiatry. Elements which appear I wishtothankProfessor
in clusters in A. B. Stokes forhisvaluable
various forms of hypersomnia are more or less and stimulating interestinthiswork and hisadviceand
helpin theinvestigation ofCase i.For Cases2 and 3,
similarlycombined in certainother psychiatric retrospectively diagnosed from hospital files, I am indebted
syndromes. The concurrence of pathological to Dr. Mary V. Jackson.
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114, 77-84.

Alexander Bonkalo, M.D., Assistant Professor, University of Toronto, Department of P@ychiafry, Toronto,
Canada

(Received 31 October, 1966)

Hypersomnia: A Discussion of Psychiatric Implications Based on
Three Cases
ALEXANDER BONKALO
BJP 1968, 114:69-75.
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