“So, what’s changed?” I asked.

Steve grudgingly acknowledged that things had gotten worse over the past three years. Assertive and demanding by nature, in the past he had felt in control of his world. Now he was always on edge and prone to emotional outbursts. He was exhausted and had lost his motivation. He no longer enjoyed doing things he used to enjoy, a symptom known as anhedonia—Greek for “lack of pleasure.” He was more forgetful and not as accurate or productive as he had been, but he wondered if this was just a function of turning 55.

What Flipped the Switch?

It seemed clear that Steve’s surly and aggressive behavior reflected more than just an unpleasant disposition. A number of physical illnesses can cause such deteriorations in behavior. Leading contenders, alone and in combination, include endocrine disorders like thyroid disease and diabetes, cardiac disease, infectious diseases, neurological conditions, and cancer. But Steve’s primary care physician had given him a clean bill of health, other than moderate hypertension and a 20-pound weight gain over the past several years.

Next on my list was substance abuse, which is notorious for contributing to problematic behaviors. But Steve denied using illegal drugs, misusing prescription medications, or drinking excessively. His physical exam and lab work were consistent with this, as were his partners’ reports.

With the obvious physical illnesses and substance abuse ruled out, it was time to consider psychiatric disorders. It was possible that Steve had a personality disorder—a longstanding, maladaptive pattern of experiencing and interacting with the rest of the world. Steve’s interactions with me, the reports from his partners, and his history were all consistent with a personality disorder, or at least a worrisome exacerbation of some very negative personality traits.

But Steve’s personality had been the same since he was in college. While his aggressiveness didn’t necessarily make him a pleasant guy, it had served him well professionally. He also had friends and a wife of many years. So the evidence for a full-blown personality disorder was not strong. I needed to focus on what could have caused an exacerbation of his
pre-existing traits.

While several psychiatric problems, including depression, might explain Steve’s worsening behavior, his irritability, sad mood, decreased energy, and difficulty sleeping weren’t severe enough to make a conclusive diagnosis.

Too Little Air

It was with the exploration of Steve’s sleep problem that things got interesting. Sleep deprivation can have many physical and mental effects, including impaired cognitive and physical performance, increased errors, decreased immune response, and changes in mood. 

Disturbed sleep can be both a symptom and a cause of conditions such as depression, bipolar disorder, and changes in personality similar to Steve’s. In some studies, brain scans of severely sleep-deprived individuals are similar to those of psychopaths, people with an extreme form of antisocial personality disorder.

So I asked Steve about his sleeping. He fell asleep just fine, he said, but was restless during the night and woke up feeling unrested, usually with a headache.

“Do you snore?” I asked.

“Let’s put it this way,” Steve said. “I’ve had people pound on the walls of hotel rooms at night complaining that I was keeping them awake.”

“Does your wife ever notice that you stop breathing while you are sleeping?” 

“She flips out when that happens and pokes me to make sure I’m still alive.” 

Steve was describing classic symptoms of sleep apnea, a condition in which a
person either stops breathing entirely or has impaired airflow while sleeping, depriving the brain, and the rest of the body, of oxygen. Sleep apnea can cause hypertension, vascular problems, and cognitive and behavioral changes.

In the most common form of sleep apnea, obstructive sleep apnea, the upper airway becomes blocked as muscles relax during sleep; air being forced over the obstruction causes snoring. A variety of factors can cause the condition, including having a short, thick neck; gaining weight; and using substances that cause excessive sleepiness, like medications or alcohol. 

Not everyone with obstructive sleep apnea looks like Steve, but his physique fit the classic profile. Sleep apnea moved up on my list of possible diagnoses.

Steve’s primary care physician agreed to send Steve for a polysomnogram, an overnight study in a sleep laboratory in which the patient’s airflow, oxygen levels, muscle movements, heart rhythm, and brain waves are monitored. Steve expressed skepticism that he would be able to sleep in a strange place connected to all those machines. But he fell asleep easily and woke up only when the technician entered the room when his oxygen saturation level had repeatedly dropped to 85 percent. 

The technician had Steve put on a breathing mask connected to a machine that generates air pressure, helping to keep the airway open. This therapy, called continuous positive airway pressure, or CPAP, ensures that the brain gets enough oxygen. With CPAP in place, Steve’s oxygen saturation was fine. The sleep specialist recommended that Steve continue the treatment at home, and also that he lose some weight and avoid alcohol at bedtime. 

Two weeks later, Steve told me he had started feeling better almost immediately. He awoke feeling rested, his headaches were gone, and he felt more on top of things. His wife had even commented that he was calmer and less irritable.

I recommended that Steve return to work. I warned Bill that treatment for sleep apnea would not necessarily reverse Steve’s habit of treating others poorly, but it would give him more control over his behavior. I was hopeful that with clear expectations set on his behavior, the firm would see a new and improved Steve.

My hopes proved to be justified. Six months later, Steve’s mind was clearer, his work had improved, and he was back to mentoring the younger attorneys and serving his clients. 

Ronald Schouten is director of the Law & Psychiatry Service of the Massachusetts General Hospital and associate professor of psychiatry at Harvard Medical School, as well as co-author of Almost a Psychopath (2012). The cases described in Vital Signs are real, but names and certain details have been changed.