Obstructive Sleep Apnea

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Bilbo and Me, trying to get to the Smoky Mountain

jake

Imagine, a young father playing basketball with his buddies on a Sunday in the gym, joking around, slapping each others butts, (because, help us, that’s what they do!) Sweat is rolling down his face. Call him Jake. He’s heavier after three kids, but he’s trying to lose the baby weight. His wife has to wear earplugs to sleep, he sounds so loud in their bed. Jake has been playing hard for about thirty minutes. He’s feeling good. He never lost his touch. He’s with his same buddies from high school. They stay in contact. They’ve got each other’s backs. They’re running down the court. He’s guarding Tom and everyone’s diverted, running, heaving and breathing hard. Tom makes the shot and they’re all slapping each other’s butts. They are throwing the ball back into play and someone laughs at Jake. “Hey Jake! Get up!”

Obstructive Sleep Apnea (OSA) is a leading cause of early heart attack.

I wrote this out in what may seem almost tasteless detail only because this is how it happens. I wish it didn’t and I want it to stop. It is as horrible as you imagine. Jake dies. His wife and gorgeous kids are left to live life without his laughter and counsel and noisy snoring that his wife would do anything to have again. Jake’s community is man-down. Obstructive sleep apnea is a deadly sleep disorder.

CPAP is 99% effective when used to treat OSA. It works. It is just not always the easiest treatment to tolerate for many reasons. But it is worth fighting for. The fight for CPAP might look something like multiple visits to your primary care practitioner to get that referral to go through to your sleep lab. A referral is made, and silence, then made again, silence, then finally by the third or fifth try, it goes through. Or multiple visits to your sleep specialist, exchanging one sleep mask after another and then another until you finally find one that keeps a good seal on your face through the night. There are truly a mountain of barriers to compliance that you will trek across, more barriers than Bilbo encountered heading toward Smaug, and you’ll need as much courage.

Keep on!

Questions: To start with, how is your breathing, or your loved one’s? Did you know that you might have to walk such a circuitous trail toward being your own friend? Who else will do this for you?

Self-Care Tip: When you are deflected, when you get stuck in the moment of loss, pull back into the big picture. You are your own friend and it starts with Me.

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Sleep Is The Vital Sign Of Psychiatry

Yesterdays brief post, Just Go To Sleep, provoked and inspired many of us.  Perhaps it was its brevity, it’s mostly blank canvas in other words, that allowed for such freedom.  The comments ranged from major depressive disorder hypersomnia type, to insomnia related to anxiety.  We covered medication induced sleep, to parasomnias.  Some of us have to fight hard for our sleep time and others of us fight to get away from sleep.

I’ve covered a bit already on sleep in previous posts you can read if you want to review:

What I haven’t done is organize for you, as you did so well for me in your comments yesterday, the different reasons we sleep the way we do.  This isn’t a quick flick to show you but I will touch on Carl D’Agostino‘s question when talking about depression with increased sleep,

“Is our brain allowing us to escape the depression this way?”

English: Monitor of vital signs in intensive c...

(Photo credit: Wikipedia)

I love this question because it discloses simply by inquiry the full body involvement in the disease process of major depressive disorder.  Sleep is known as the vital signs of psychiatry.  It reflects what’s happening in the whole system, the whole person even down to a sore on your foot to the ravages of post traumatic stress disorder in your hypothalamus.  When sleep changes, we know to look into things.  There’s an investigation to be done.

 

 

We can, each of us, be part of the investigation:

  1. Maintain sleep hygiene.  Don’t indulge when we don’t want to go to bed.
  2. Observe our nights – is our sleep solid?
  3. If yes, is it restful?  Do we feel refreshed in the morning?  How is our day time energy?
  4. If not refreshing, why?  For example, do we snore?
  5. When do we have the most trouble – falling asleep, staying asleep, or falling back to sleep if we awaken?

When our sleep deteriorates, if nothing else has yet, we can bet it will soon if we don’t get our sleep restored.  Not everyone knows that during sleep, we heel, our hormones replenish and our memories consolidate.  Marie from blog-site, livingvictoriously, told us yesterday about her day time inattention after poor sleep,

“I have had nights with very little sleep that have left me feeling like I am unable to concentrate well the following day.” 

We all become a little drunk, disinhibited, inattentive and impulsive when we get little sleep.  Or opposite, as Carl described, with too much sleep we feel,

“vapid and uneventful.”  (Good word Carl, vapid.)

One of the sad times for me in clinic is when I meet a new patient who has suffered with insomnia for a long time along with another one or more combined brain illnesses and I fall into the, “what if’s?”  Knowing how much healing they would have gotten so long ago simply by getting sleep gets to me and I have to push it down and be grateful for the now, when I know they will find some relief.

Don’t minimize the role of sleep in our life.  Don’t minimize any changes in our sleep.  Take sleep seriously.  More serious than the rest of the stuff we usually ruminate over, like offenses taken, our appearance and the weight of our road bike.  If sleep changes, get a professional consultation.  If it doesn’t resolve, get another consultation and push and fight for your sleep.  It may be that health and lifestyle changes must happen.  Whatever it is, do it.  It is a friendly thing to do.

Questions:  What have you noticed about your whole body’s relationship to brain illness?  Has sleep been a part of it?  Did sleep harold any other important changes in your medical/emotional health?  Please tell us about it.

Self-Care Tip – Forget about sleep.  Just kidding.  Sleep well my friends.

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Where Does Courage Come From?

I want to do that, but I have no idea where I’m going to find the courage!

This is real folks.  People think this, say this, believe this and behave accordingly.  The other day, a young woman in her forties with a rolled scroll of precious problems including joint disease, extreme morbid obesity, nicotine dependence, depression, anxiety, obstructive sleep apnea, eczema, gastroesophageal reflux disease (GERD), heart palpitations, diabetes, hyperlipidemia and polycystic ovarian disease – this woman told me these words.

I have no idea where I’m going to find the courage!

Where does courage come from?  Is there an odds ratio, statistics, intuition barometer or what?  Where do we find courage?  (I am remembering the dear Lion in The Wizard of Oz.)

I see courage coming from our ability to make decisions.  Being able to decide comes from many paradigms, including my favorites as broken down through the biopsychosocial model (listed in no particular order):

  • Biological – temperament (genes or personality,) mental health/brain health (the brain being the organ we use to make decisions with,) developmental (the neurodevelopment of the brain is different at different ages,) things we put in our body (diet, illicit drugs, alcohol or nicotine,) medical illnesses, sleep issues, exercise, rash, ingrown toe-nail….
  • Psychological – self-control, coping skills, catastrophizing, negative thinking, thoughts, emotions, and behaviors….
  • Sociological – culture (including home, religion, race, gender,) stressors on our body, social support, God, interpersonal relationships (friends, marriage, kids, colleagues,) parenting, unemployment….

(WHEW!  Recovering my breath.)

Where do we find courage?

I drew a picture in the air for her psychological self,

17th century

Image via Wikipedia

I see you 100 pounds lighter, not smoking for the past six months at least, off of six of your twelve medications, your medical problem list shortened down to two or three.  You are able to feel pleasure again.  It is a real option for you.

If you don’t, I see you growing demented, paralyzed and dying from a heart attack.  I can’t say when these things will happen but they will happen if you don’t start taking care of yourself.

Where does courage come from?

For her biological self, I targeted the language of her temperament.  I remembered that we make decisions either through thought or feeling.  She was a “Feeler.”  I drew forth my light saber and went for the emotions.

You can do this!  Think of the gift you’d be giving yourself and to those you love.

For her sociological self, I talked about everyone in the family choosing with her, including husband.  Talking about how this changes the family culture, not to smoke together, setting boundaries with her husband to care for herself and thinking about getting other support networks like starting to go to church again or calling her pastor.

Question:  Where does courage come from for you?  Please tell me your story?

Self-Care Tip – Use your biopsychosocial model, that is to say all of what makes you you, to find your courage.  Be a friend to yourself.

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Celebrate Treatment and Live

Holding her breath, my niece swam the length of the pool underwater.  She popped up like an otter.  Slick, water rolling off of her like nothing in the world would bother her.  Click!  The timer showed her that she beat her record.  She was gasping but smiling like an olympian.

My niece would have liked to have added another lap before coming up for air but her body wouldn’t let her.  She needed to breath!  Have you seen the same thing happen in your spouse when they are sleeping?  They look like they are holding their breath doing laps and need to come up for air?  Gasp!  Ah!  Oxygen!  Sweet Oxygen!  Nothing like it.  This event when someone stops breathing for more than 10 seconds during sleep is called apnea.  When it happens more than 30 times in a night it is called Obstructive Sleep Apnea.  The gold standard for treatment is a machine that pushes air into the airway to keep it open – either bipap or cpap.

My patient is young, not obese, exercises regularly and looks healthy.  However, he has tested positive for Obstructive Sleep Apnea during a sleep study and has been prescribed cpap.  My patient used to wear it but frankly doesn’t feel sexy in it.  He feels like he’s wearing a jock-strap on his face.  My patient prefers to snore loudly, go silent, then gasp, over and over through his sleep rather than wear cpap.  No one had told my patient why he must wear cpap, nor did he look it up. We talked a little about his marriage and how he was happy at home.  We talked about school and how well he was performing.  Then we talked again about sleep apnea.  My patient didn’t know.  He didn’t know that he was gifting his wife with a future impotent man.  He didn’t know he was enjoying fewer an fewer functioning brain cells every day.  He didn’t know that he was gifting his children with his early death from heart attack.  He didn’t know that his anxiety might not be responding to his medications because his brain is screaming for oxygen.

Just thinking about his story made me take a deep breath and pray a prayer of gratitude for the air, oxygen, and life.  He did too.   We’ll see if he decides to use cpap or not over time.

In medicine, we can’t diagnose a primary emotional illness if someone has an ongoing medical disease that may be causing similar symptoms.  We need to be as sure as we can about where symptoms are coming from.  I liken it to a steam engine train chugging along, steam blowing out of the chimney.  The steam is what we see, but the onward movement of the train is the disease process.  Obstructive Sleep Apnea affects every cell, organ, system in our body because as it turns out, every bit of us needs oxygen to survive.  I’ve seen people after heart surgery, with no idea that they could have avoided all of that by simply using cpap.  I have been treating one woman now for 7 years for severe treatment resistant depression who is still not using cpap.

So many of the people I work with have sleep apnea.  They feel embarrassed and ashamed by it.  I’m not sure how to help them better but I’ll keep trying because their lives depend upon it.  To feel the sense of accomplishment my niece felt when she came up for air, “Ahhh!!”  Accepting treatment is that wonderful.  We could celebrate.  It’s all perspective.

Question:  Do you have any recommendations for those of us suffering and ashamed?

Self Care Tip #47 – Celebrate treatment and live.  Be a friend to yourself.