The ''Narco-Sleep Thing''- Or Are Our Patients Getting Biased?

Sleep Medicine goes Hollywood, or at least the narcolepsy part of it.

Recently I was reminded of my profession while watching two movies I had rented from a local video store.

The one titled ``Gun Shy'' (Hollywood Pictures release) starred Liam Neeson as a burned-out Drug Enforcement Agency (DEA) undercover agent and Sandra Bullock as gastroenterologist. Neeson gets a strong sedative from his psychiatrist to overcome his symptoms of extreme fear and sleeplessness after being in the middle of gunmen frenzy several times due to his job. This makes him so sleepy that he falls asleep with a gun pointing toward his head in the middle of the next drug dealer showdown. Later in the movie Oliver Platt, who plays the counterpart as an also burned-out son-in-law of a Mafia Godfather, admires him: ``Either you are the coolest person I've ever met or maybe you have that Narco-Sleep Thing.'' At the end of the movie, Bullock helps both men to retire from their strenuous lives with some cash recovered from a failed drug deal and they live happily ever after.

The other movie, ``Deuce Bigalow, Male Gigolo'' (Touchstone Picture release), is produced by Adam Sandler and starred Saturday Night Live's Rob Schreiner as part time gigolo by accident. In this persiflage to ``American Gigolo'' Schreiner plays an aquarium cleaner who accidentally destroys the huge seawater aquarium of one of his clients, a very expensive male prostitute. To get the money for the repair cost of the aquarium, he steps in as part-time gigolo, while the real gigolo is on a trip to Europe and answers the request calls of his female clients. However, instead meeting his dream women, all the women he gets as clients are somehow physically challenged. One of them has a severe form of narcolepsy, and the major sketch of the movie is when she falls asleep while throwing a bowling bowl (movie fanatics like me have seen that slapstick before in other movies but it was never officially related to narcolepsy). At the end, it comes to the showdown with the real gigolo, and Schreiner wins it with the help of all his new female friends. He falls in love with one of them who has only one leg, and they live happily ever after. (Also, the girl with narcolepsy lives happily ever after.) The recommended treatment in the movie is not a stimulant but a football helmet, which protects her in any case of cataplectic crash down.

These both are quite funny movies (not as bad as criticized, and I can recommend them for lonely, dark, long winter nights), but what do they have to do with sleep medicine?

In my opinion, Hollywood movies have always, in one way or another, been a mirror of actual main streams in the society. People have caught up on any kind of sleep problems now in the last 15 years through reports in the media or through the endless number of advertisements for better mattresses, anti snoring devices, sleep clinics etceteras. And they respond to that what has gotten into their mind. More and more wives send their husbands with the straight diagnosis of sleep apnea to the doctor and not like in the old days simply complaining about snoring. ``My wife (or husband) says I have sleep apnea'' is a phrase we hear more and more often from patients. This is not a major problem. Asking for snoring, witnessed apneas and excessive daytime sleepiness or using a standard questionnaire leads pretty straight to a more ``clinical'' suspicion.

When patients come and say: ``Doctor I have the Narco-Sleep-Thing'' or ``Doctor I have narcolepsy. I am always so tired,'' experienced sleep specialists insist in such cases in their patient interview on questions about sleep behavior and snoring patterns before they send the patient to any expensive polysomnography or MSLT. However, some rookies (see also the editorial by Dement in the first issue of last year's Sleep and Breathing) might accept the patients self-diagnosis and refer him right away to an expensive and maybe avoidable polysomnography. In a few words, more and more patients are getting biased about their possible sleep disorder before they enter a doctor's office or a sleep clinic for the first time.

Is this a major problem? No! It just verifies the need for a clear and structured patient interview and for a maximum of sleep medicine education for students in medical school and for family physicians. Does this whole ``Narco-Sleep'' phenomenon have a positive aspect? Yes. We wanted the public to be aware of sleep disorders. Now the people are getting aware of sleep disorders and might it be through movies and not through sophisticated articles in sophisticated science sections of sophisticated daily newspapers.

A patient who in the beginning insists on his/her ``movie'' diagnosis, in my experience, needs more time to be interviewed. It is time-consuming to overcome bias and explain that sleep time might need extension or that a diagnostic test is needed to distinguish narcolepsy from sleep apnea. However, the patient who comes to the physician with a sleep complaint is a patient with a sleep problem, and it is important that these patients seek medical help. It is a goal to get the public's awareness about sleep problems. Now is not the time to worry about difficult patients. It is time to be happy that they come at all.