Type 2: Sleepiness with high cognitive load

Similarly, all participants (N = 10) described experiencing automatic behaviour that was associated with feelings of sleepiness, which occurred when completing tasks with high cognitive load (Type 2). Participants described being stressed during these instances, as a result of feeling pressured to get many tasks completed.

“I find that if I’m trying to do too many things at once… you finish up with some interesting things happening.”[Participant A].

“Stress to get things done tends to have a lot of bearing on the amount of episodes of automatic behaviour that I have”. [Participant F].

Type 2 was also associated with individuals feeling sleepy and being aware of their sleepiness, but pushing on to get the task done. Participants reported that this was sometimes a conscious effort and a desire to complete a task. Alternatively the demands of work and family prevented them from taking the break they needed, and therefore automatic behaviour would occur.

“Started to write some notes, finding it hard to write, but kept going. By the third line I was not making sense, became ‘stupid’ and I had to give up. I was drifting into automatic behaviour but trying to retain consciousness to finish writing.”

[Participant D – Journal].

“She doesn’t push herself the way she did previously. And that’s when the automatic behaviour occurred previously, when she pushed herself further [pause] kept going” [Spouse - Participant G].

Participants reported that they believed that if they stopped and had a nap, the automatic behaviour would not occur.

“Getting a meal ready and knowing you’re tired and you just keep doing it because you want to get it done. It’s at these times where I need to stop.”

[Participant B].

“This episode was at stage one of automatic behaviour before my conscious switched off; if I was seated it would not have become automatic behaviour, I would have fallen asleep.”[Participant D – Journal].

The sleepiness associated with Type 1 and Type 2 was reported to be largely mediated by daily stimulant medication intake. All participants reported that daily medication intake had a large impact on the amount of automatic behaviour that occurred.

“My episodes of automatic behaviour are definitely when my medication time is wearing off.” [Participant D].

“It does get worse if I’ve forgotten to take my medication. I know that at about 10 o’clock in the morning I’m thinking, “why am I feeling like this?” and suddenly realise I haven’t taken anything” [Participant I].

As a consequence many believed that an effective way to control automatic behaviour was through appropriate management of medication.

“The only thing that really snaps me out I think is the medication.” [Participant

J].

“My sense of how I control automatic behaviour is partly medication, it could also be following a reasonable plan for sleep.” [Participant E].

“Once she got the tablets it seemed to control a lot of that (automatic behaviour).” [Spouse - Participant G].

Participants noted that if they did not take their medication appropriately this had an impact on their automatic behaviour for that day, and in the days following. That is, if they were to continue on without medication they would experience a rebound effect and be worse in the following days. This was also reported to occur when individuals did not take time to rest and sleep when they needed.

“I find it worse if usually the day before I’ve forgotten to take a dose of tablets… And it’s the next day that I seem to have more automatic behaviour.” [Participant

A].

“I think it’s worse on days following when I’ve taken insufficient medication.”

[Participant H].

“I can have 2 or 3 good days and bad days…I’ve sort of had to learn not to burn and bust because typically I used to feel good so I’d burn and then be crook for a week” [Participant F].

It may be noted here that according to the ESS (results presented in Table 1), participants reported a high propensity to fall asleep in the given scenarios, with scores falling within the clinically significant range according to Johns (1991) (scores greater than 16). However, when asked to complete the ESS thinking about their propensity to fall asleep when well medication, many scores fell below the clinically significant range. This supports the notion that stimulant medication had a large impact on participant’s ability to control sleepiness as well as their automatic behaviour.

4.2.3 Type 3: High cognitive load without sleepiness

The third instance in which automatic behaviour occurred was when participants were pressured to complete a task, but felt they were not sleepy or drowsy at the time (Type 3). This type of automatic behaviour was not described by all participants (N = 3).

“I’ll quite surprise myself sometimes that I must have had an episode because I haven’t felt drowsy.” [Participant J].

“I’ve had automatic behaviour when I’ve been well medicated and thought I was reasonably alert.” [Participant C].

“For this episode I was very well medicated and I believed that I was awake”

[Participant F – Journal].

It was interesting to note that the participants who experienced Type 3 automatic behaviour had higher ratings on the ESS than the other participants in the ‘on medication’ condition (in the ‘off medication’ condition ESS scores were comparable). That is, while the other participants received scores below the clinically significant level (below 16), only the three participants who reported Type 3 automatic behaviour received scores at or above this level (see Appendix C).

Finally, in both Type 2 and 3, participants believed that automatic behaviour occurred as a type of overload on the system.

“It’s almost like [pause] you can’t sort of process everything that’s happening…It’s a bit like a coping mechanism. That I can’t cope with two things at once” [Participant F].

“I reckon stress triggers it because it’s just like too much for your system to cope with. It just starts to happen whenever you are doing any common thing. After a while it just starts to overload.” [Participant B].

“If I’m trying to do a lot of things at once, um it’s sort of like an overload.”

[Participant H].