Sleep

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Sleep is a complex function.  it is not just biological, but also psychological and social. Your “daily residue;” everything that happened at work or whatever that day, combines with past traumas (which may have been dragged around since childhood) to create what may be disturbing dreams. Read more on Ways I Get Patients Off Of Sleeping Pills…

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I think it was in my first practice, straight out of residency, that I learned about sleep apnea.  He was a private patient, a man about 40, who had his sleep apnea treated when some enterprising ENT (Ear, Nose and Throat doctor) fried his too-large tonsils.

Within the day or two it took the surgery to heal, he came to the office to tell me that his symptoms of anxiety and depression were totally gone. Well, if I had trouble breathing, I would be anxious and depressed too.  You want to get that oxygen, continuously.

Even if the tests , which technology has simplified over the years, show that you’ve got plenty enough oxygen in your blood, the fear of losing oxygen has got to be significant.  I remember, even as a little kid, with hay fever attacks, what it felt like to gasp for air. I can only start to imagine what it is like for those who gasp for air in the middle of the night.

So at a later time, a different patient shows up, a 53 year old man, and he tells me he wants some Xanax or at least some Ativan.  I have someone count his respirations — 14 in a minute, not too bad. He is using the muscles in his neck to hike up his chest to breathe. He has recently stopped smoking, much to his credit, but still has a solid diagnosis of COPD, (chronic obstructive lung disease) and this guy got it in spades, but the question remains does he have sleep apnea?

We are lucky.  His diagnosis was confirmed by a sleep study.  This means someone had to watch and measure him all night. He is still shocked that I made the diagnosis just by asking questions.  Not that it is hard to tell what is going on.  I heard a little bit of wheezing without a stethoscope.

First things first — I was not going to prescribe anything that could depress his heart or breathing.  That meant no Xanax.  To say that he was not happy with me was — at best — a gross understatement.

Then I got up the guts to tell him the truth. “Until we treat your sleep apnea, your anxiety and depression are NOT going to get better.”

Now when I first started telling this to people, the relationship between depression and anxiety and sleep disorders may have been something someone could debate.  Not now.
Read more on Sleep Apnea Links To Depression, Anxiety…

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I remember traveling the U.S. looking for a residency — back then it was in neurological surgery.  My mother made me a detailed itinerary in a notebook which I clasped in my purse.  Cheap motels  awaited me in university cities when I arrived for my interviews. I mean, I never would have gone to all that trouble if I knew I was going to change specialties before long.

People asleep in airport waiting areasStill, my enthusiasm carried me through a route with too many time zone changes.  But I was young, single minded, rendered joyous and enthusiastic by my love of the brain.

I had a horror, as some of this was done in snowy regions at snowy times, of having to sleep in an airport.   I am delighted to report that I never had to – unlike our most recent holiday season,  when many people had to. Read more on Sleeping In The Airport…

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She was a 33 year old raven-haired exhausted woman who had probably been a beauty before she bore children, now aged 9, 6, and 4.  She wanted a renewal on her sleeping pills.  She did not want the antidepressant or anything else, just sleeping pills. She said that since the children all slept through the night, now she could, too.  She had not only a tubal ligation at her final pregnancy, but an ex-boyfriend who was no more than a distant memory.

Her last doctor, apparently a rarity, had actually started by prescribing the sleeping pills every third night. That had not lasted more than four weeks or so.  She wanted, and felt she “deserved,” sleep every night. She was convinced that was what the insurance doctors gave the rich people, so she was not going to let anybody skimp on her. Sleeping pills every night.  She would not have to think about anything other than keeping a bottle by her bed and getting it into her mouth.  Sleep would be automatic and life would be sweet.

The last doctor had been, to his credit, assertive enough to tell her that if this was what she wanted, she would be coming in every three months for the rest of her natural life on planet earth, to get sleeping pills. She thought that was just fine; that it was what everyone did and should do, since we had something as wonderful as sleeping pills in the world. Read more on Pharmaceutical Companies Are Stealing Our Dreams…

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Whenever I go into a new situation with a medical staff, the other psychiatrists seem to enjoy having me assess and treat people who have stumped them.  It doesn’t matter if it is a community mental health center, a VA facility, private HMO clinic, University hospital – whatever.  The favorite game is “Stump The Renegade Doctor.”

One challenge was a woman was 28 years old who was a little on the hypomanic side (meaning only a mild mood-swing toward the manic) and a little on the depressed side and a little paranoid — and a lot uncomfortable. She was informally and a tad sloppily dressed in clothes which nobody would have called “new” or “chic,” and her hair was a little messy.

She explained to me: “I can’t sleep.  I never get more than two or three hours in a night, with a lot of ups and downs and stuff.  I don’t know what is going on, but they already gave me all the medicines for sleep, and on me nothing works.”

Sleep disordersYeah, sure.  I suspected already that her problem had nothing to do with picking the “right” medicine, but people really do think that pills can fix anything psychiatric.  She had obviously had drilled into her head the idea that the right medicine would fix her. “They said you were good with pills, and you could figure me out,” she said.

I was flattered.  My colleagues generally won’t say such things to my face – they just dump their problem patients on me and go back to whatever they were doing.

I told her that first, we were going to talk about something called “sleep hygiene.”  She had never heard the words before and acted like I was talking a foreign language.  There are lots of things that can stop someone from sleeping, and lots of things that can help someone sleep. Read more on Sleep Problems Often Solved By Common Sense — Not Drugs…

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