Chapter 15: Sleep and Elimination Difficulties

Raskin examines sleep and elimination difficulties, two sets of problems that often straddle the line between everyday experiences and diagnosable disorders. Case studies such as Cassandra’s insomnia and Hubert’s narcolepsy illustrate how disruptive sleep problems can be, while Maribel’s enuresis and Arjun’s encopresis show how elimination issues impact childhood development and family stress. DSM-5-TR and ICD-11 classify sleep disturbances into insomnia disorders, hypersomnolence disorders, narcolepsy, and parasomnias, with ICD relocating sleep problems outside of “mental disorders” while DSM retains them. Parasomnias include sleepwalking, night terrors, REM sleep behavior disorder, nightmare disorder, and restless legs syndrome. Historical perspectives show how cultural views of sleep evolved, from segmented sleep in premodern Europe to today’s ideal of continuous rest. Biological explanations emphasize the sleep cycle, the hyperarousal theory of insomnia, neurotransmitters such as GABA, orexin (hypocretin), and the role of brain regions like the hypothalamus. Treatments include benzodiazepines, non-benzodiazepine Z-drugs (zolpidem, eszopiclone), orexin-receptor antagonists (suvorexant, lemborexant, daridorexant), modafinil and sodium oxybate for narcolepsy, melatonin, antihistamines, tricyclics, and antipsychotics. Psychological perspectives highlight Freud’s psychodynamic theory of dreams and nightmares, CBT for insomnia (CBT-I) using stimulus control, sleep restriction, and sleep hygiene, and behavioral therapies for elimination problems such as enuresis alarms and dry-bed training. CBT for encopresis combines laxatives, high-fiber diets, psychoeducation, reinforcement, and skills training. Psychodynamic and humanistic therapies interpret bedwetting and soiling as unconscious expressions of conflict, while narrative therapy famously externalizes problems such as “Sneaky Poo.” Sociocultural perspectives highlight how organizational injustice, poverty, racial disparities, caffeine, and screen time affect sleep, while bedwetting stigma and economic burden disproportionately affect disadvantaged families. Family systems therapy views a child’s bedwetting as an “identified patient” symptom masking parental conflict, while alternative therapies such as acupuncture show some promise in treating enuresis. Historical accounts reveal bizarre remedies from Pliny’s boiled mice to 19th-century electric-shock devices, while modern genetics research links enuresis to heritability and desmopressin targets vasopressin regulation. Ultimately, the chapter emphasizes that sleep and elimination difficulties are highly comorbid with other conditions, requiring clinicians to assess them in a broader biopsychosocial and cultural context.