Loss of recall associated with automatic behaviour in narcolepsy

All participants consistently reported that automatic behaviour was associated with a loss of recall for a period of time. That is, while in automatic mode participants did not have conscious awareness of their actions and as a result were unable to describe what had occurred, often describing the episode as a ‘blank’ period. This feature of the phenomenon is not a new concept, with similar reports also found in the literature. Early research reported that individuals described an inability to recall events occurring only minutes to hours prior (Daniels, 1934; Ganado, 1958). The initial use of the terms 'amnesic states’ and ‘fugue – like episodes’ to describe automatic behaviour is also indicative that complete amnesia for the events of the episode is key to the syndrome. In other research, Guilleminault et al (1975) and Zorick et al (1979) noted that participants

In addition to loss of recall for the period of time in which automatic behaviour had occurred, in the current study individuals also had ‘amnesia’ for the act itself. That is, participants were not always aware of having had an episode. Even with a number of cues available to indicate that they had been in automatic mode (such as the presence of a ‘blank’ period or later finding the outcome of the automatic behaviour) many episodes went unnoticed. Often, it wasn’t until a family member or friend indicated that it had occurred that individuals became aware of an episode. In some instances, even after being told of the episode, some individuals would deny having completed the behaviour. Guilleminault et al (1975) observed similar reports from their participants. That is, upon questioning, participants denied having been ‘asleep’ even when obvious decrements in performance were evident and they were unable to recall what had just occurred. Together, this further supports the notion that when in this state individuals can have complete loss of conscious awareness, despite having conducted a number of activities.

The loss of recall associated with automatic behaviour may assist in explaining the subjective memory problems consistently reported in this population. Research has shown that although individuals with narcolepsy report diminished memory functions, assessment using objective measures, such as those found in a battery of memory tests, have been unable to demonstrated a memory deficit in this group (Hood & Bruck, 1996; Ollo et al, 1987; Rogers & Rosenberg, 1990). The reason for this discrepancy between subjective and objective measures of memory function continues to interest researchers. Hood and Bruck (1996; 1997) suggested that appropriate performance on objective memory tests in individuals with narcolepsy is associated with an individual’s ability to maintain wakefulness during testing periods (and therefore these testing situations do not

account for the effects of sleepiness on cognition). It may also be suggested that objective memory tests have limited external validity in relation to everyday memory performance. Alternatively, this self perceived impairment has been suggested to be associated with the way in which the individual appraises their memory functions (Hood & Bruck, 1996). Based on the current research, it is suggested that automatic behaviour may also play a key role in this issue.

In the current study, many participants reported that prior to their diagnosis, they experienced automatic behaviour, however given their lack of knowledge of their condition, they attributed these episodes to poor memory. It is possible that the high frequency of automatic behaviour and the associated failure to recall events could result in constant negative feedback in relation to one’s abilities and subsequently lowered self- efficacy of memory abilities. This is consistent with research by Hood and Bruck (1996), in which individuals with narcolepsy demonstrated significantly greater anxiety and less confidence in their memory abilities. In line with this finding, it is possible that reports of diminished capacity may be symptomatic of negative feedback or self evaluations from other aspects of life, such as failure to function at school, work or home. Together, the frequent inability to recall an event (as shown in automatic behaviour), plus negative feedback regarding memory functioning (associated with inability to function at work due to excessive daytime sleepiness and automatic behaviour) may distort the perception of their actual ability (measured to be within normal limits on objective measures). 6.2 Consequences of automatic behaviour in narcolepsy

occurred while in automatic mode. Similar to the literature, participants reported frequent errors while performing routine activities at home, work or while interacting in social situations (Guilleminault et al, 1975; Zorick et al, 1979). Previous research has demonstrated that errors are frequently associated with automatic behaviour, however, none have provided a classification of the types of errors that can occur. Rather, a description of the errors they observed was provided, such as, “they spoke jargon and wrote illegible scribble” (Ganado, 1958, p. 488). The current study was able to define and classify unsuccessful and successful actions in automatic behaviour. Errors were found to occur as a result of an omission or inappropriate sequencing of a step in a task; appropriate action using the inappropriate item/ environment (as often is the case when objects are misplaced); and perseverative actions. In addition to these errors, individuals were able to perform a simple behaviour that was context inappropriate, such as verbal responses not consistent with the topic of conversation. Finally, individuals were able to carry out appropriate actions while in automatic mode. As in the case with driving, a task that becomes quite automatic with experience, individuals were able to describe instances in which they had driven appropriately (to the best of their knowledge).

In cases where automatic behaviour resulted in errors, these were reported to occur as a consequence of an increase in the complexity to the task. That is, with the advent of a new step to consider, the individual would either regain full alertness, or continue in automatic mode and make an error in performance. This is consistent with previous research, which notes that automatic behaviour occurs when completing simple, routine behaviours (Guilleminault et al, 1975; Zorick et al, 1979).