Case Report
Wearable watches, bands and rings that record sleep have increased in popularity. It is common for the sleeper to select such wearables for the convenience of a number corresponding to some aspect of their health such as sleep. The ease and immediacy of the sleep measurement is another advantage of the use of a wearable. Software/app correspondence to the accelerometer algorithm measurement provides a convenient chronicling of one’s health behaviors. Young adult sleep is generally of poor quality as the sleeper selects social activities and has responsibilities that collectively marginalize necessary sleep of six to seven hours [1]. In fact, this action of self-recording health data is encouraged as it represents a type of self-care or development of self-care that is needed for an individual. Further, a combination of measurements, for example, sleep or not along with heart rate levels is considered with some software guided interpretations about the individual’s sleep. However, a reactivity or in some cases an overreliance (similar to phone dependence to constantly check one’s social media) can develop. Extremes of both types may occur –such as assuming the reading is accurate or inaccurate can occur and sometimes direct the person’s assumptions about the health status of a behavior. This case study addresses this overreliance wearables for the measurement of sleep.
Case History
A 27 year old triracial patient identifying as a male presented to the Insomnia clinic with a ten month history of poor sleep in terms of sleep onset and sleep maintenance insomnia. He stated that he has had some work performance decline with small errors and omissions on tasks in his information systems fulltime job. He has stopped out of his regular golf on Saturday mornings, Trivia club on Wednesday nights and 12 inch softball league play. At home he has found evenings to become more of viewing television from the time he returns from work rather than reading, video game playing, and visiting with friends and family as he has regularly done. He takes a no-drowsiness formula over the counter medicine intermittently for his seasonal allergies. His BMI is 26. He denied medical conditions or recent surgeries. The patient wore prescription glasses and reported yearly optometry appointments. The patient lives alone in a one bedroom condominium he owns in a quiet residential community near his family and a few friends. He elaborated on his tension about his work performance as he has a new supervisor that while reasonable in managerial manner is implementing new company wide standards for various operations within the company that involve considerable new learning of software features for all the departments of the company that his job responsibilities dictate. He related that during University and Graduate school he thrived on new learning tasks but in this last year feels his sleep problems are getting in the way feeling a readiness for work. The patient wore the newest model of a wearable watch with an expanded screen.
Clinical Course
Assessment & Treatment: The patient was provided with basic facts about sleep and requested to track his sleep using a standard paper form used in the field. Structured interview results ruled out sleep disorders of Narcolepsy, Delayed Sleep Phase Delay, Restless Legs Syndrome and Parasomnias that are common in his age group. He did not have symptoms of Sleep Apnea. The Physical Exams findings were unremarkable for upper airway (i.e., no Mallampati rating) masses and all other areas of the Physical exam were normal. The patient did not use tobacco or recreational drugs; he drank alcohol at a mild level. The patient complied with a paper version of a sleep log and emailed his wearable sleep record. The paper sleep log finding concurred with the interview findings that he had good sleep hygiene with a regular wake up time, no napping, regular bedtime, no electronics/workouts/meals 1 to 2 hours, minimally before bedtime. He had a low level of bright light exposure in that he began his day due to his commute to the train and then trained into the office quite early in the morning. His work cubicle was composed of three walls and once arrived, he communicated electronically for the day with teams members, employee requests and other job tasks. Since the office was in an industrial park away from commerce, he brought his lunch to have at his desk each day. He worked extended hours and when he arrived home it was often dark.
Specifically, the sleep log indicated a thirty minute variance of times at bedtime and a regular wake time. He dined when he got home from work which, at times, was as late at 9pm. He showered at night and had his suit, breakfast items, lunch and briefcase packed each night so he could make the earliest train scheduled after his breakfast. The patient denied energy drink use. He had two cups of coffee in the morning and a caffeinated soda with his lunch and another soda, sometimes, in the mid-afternoon. Figure 1. Depicts the baseline and treatment weeks of total sleep time recorded. The patient described feeling awake for a long time until sleep and at times not sleeping at all. The patient reported that he continued to lay in bed through the whole night interval.
In the Cognitive Behavior Therapy for Insomnia (CBTi) sessions a focus on determining his sleep pattern, utilizing the behavior strategy of stimulus control to attend to non-novel stimulus as a means of de-activating the patient’s attention on their sleep, training in mindfulness relaxation to deaccelerate the patient’s arousal and the implantation of any needed changes in the patient’s sleep hygiene [1]. These therapeutic themes were addressed in each weekly session for six sessions in total. Between the sessions, the patient completed the sleep log and some worksheets related to the CBTi session theme. It is noted that sleep recordings are discrepant between the paper form and the wearable watch reporting.
From the onset, the patient expressed a puzzlement that his watch(wearable) recording depicted him sleeping, yet he felt miserable and was beginning to have a mounting sense of tension from the influence of his poor sleep on his daytime work performance. Despite this, he was insistent in the continued use of his watch (wearable) to record his sleep. He entered his food intake, exercise type and minutes and water intake daily on this watch. Several minutes of several session was devoted to the discussion of the reliability of the watch records. The recording of sleep or not is fairly accurate [2-4]. As the patient’s understanding of the sleep science basics, he becomes aware that he was likely in light sleep when he thought he was awake and since he was prohibited (I.e., CBTi requirement) to not check electronics as the screens stimulate the visual pathway and brain. Even to date, some of the wearables function as a black box with non-disclosed algorithms to sleep stages of light sleep, sleep, deep sleep and dream sleep [3].
Outcome of the Case
After completing the six weekly sessions of CBTi, the patient reported improved total sleep time, reduced time to fall asleep and a confidence in going to certain mundane activities if awake for more than thirty minutes in the middle of the night to deactivate his brain’s arousal level (i.e., Stimulus Control). He has reported a comfort level with his work performance and a general positive tone with the new responsibilities of his position. He has modulated his leisure activity schedule with a return to some 45% of the past activities he has done. He also implemented some activities of mental health self-care with organizing a lunch eating group, trying some new activities with co-workers (e.g., indoor rock climbing) so as know the person he is communicating with by computer in the workday. He continues to be dependent on his wearable as he enjoys receiving the immediate metric but has formulated a perspective to consider number and the possibility of poor reliability and validity [1,5,6]. He reports an overall general positive focus to his life.