Monday, September 26, 2011

Sleep Apnea - The Reluctant Psychoanalyst Gets Treatment:


To sleep, perchance to dream; ay, there’s the rub.  What if sleeping doesn’t go so well?  What if our dreams haunt us and we waken from them not curious but filled with worries – about what things we have to do the next day, and what we’ve forgotten…  This was my plight last winter.  It seemed to get better this summer.  Then one morning, I woke with a crick in my neck.  Must have slept on it funny.  But the crick didn’t go away and then, when I went for a jog, my whole upper back went out of whack.  Well, I went to my physiotherapist who specializes in soft tissue and cranial sacral therapies, but who is really a healer, and though she worked on my neck and back and they ended up feeling better than they had in months, she said that in the long run she couldn’t help me if I didn’t get the underlying problem attended to – which was: apnea.

Her diagnosis was based in part on my symptoms but also on my dreams.  She said that the neck problem was, she believed, caused by my desperate attempts to arch my back and neck in an effort to clear my breathing passages as I slept.  This was, she thought, a reaction to my throat collapsing on itself when I reached the deepest stages of sleep – about 4:30 in the morning.  I told her that I had been consistently waking then and that I had a terrible time getting back to sleep.  She proposed that the near suffocation of apnea could be mobilizing my autonomic nervous system, including cortisol, which then would lead me to awaken with a blast of energy that would attach itself to whatever anxieties I might have running around and keep me awake. 



As for the dreams, she noted that people with this disorder frequently dream of being in enclosed spaces.  This led me to remember a consistent bothersome theme in my dreams of being in a room or other space and finding that the way out was smaller than I could comfortably navigate.  Sometimes the door had shrunk, at others the only way out would be through a window.  Sometimes this was bothersome enough that it would wake me, at other times it just seemed like a distraction – I was able to crawl out of the room and keep on dreaming – and sleeping.

Interestingly, despite the small spaces being a consistent theme in my dreams, I had not been able to understand how they were related to the dynamic themes that the dream was representing from the rest of my life.  My physiotherapist’s explanation was that this was because they didn’t have a dynamic, psychological meaning, but they were representing a physiological state.  The dream was creating a symbol, but this symbol was intended to clue me into a threatening situation – suffocation - but I experienced this as a distraction – which was what the difficulty breathing was – if that’s indeed what it was – from the dream.  I don’t have a definitive diagnosis yet.  She referred me to a treater who has now referred me to another treater, and I am waiting for an appointment to be screened before I can go to a sleep lab, which I hear is a joyous experience.

So, why am I writing about this before the diagnosis is definitely made?  Well, in addition to being treated, I also went to a workshop given by a nationally acclaimed analyst at our local institute.  He presented in a number of forums, but his formal lecture was about the importance of including the entire experience of the analytic patient in the treatment – including, in the case he was discussing, attention deficit hyperactivity disorder (ADHD).  This would not seem to be something novel.  ADHD was a very popular diagnosis in the 90s, and is still widely seen.  There are widely accepted, though generally not curative treatments for it.  But analysts have blind spots.

Dr. Karl Menninger, a widely known analyst and thinker, used to maintain (as many others probably have) that when the only tool you have is a hammer, the whole world looks like a nail.  Psychoanalysis is a very powerful tool.  As the speaker said this weekend, it is used to treat people who come to our offices in pain.  It is such a powerful tool that it can help, over a period of time, people better understand their pain, where it comes from, and, eventually, learn what to do about it.   We can, however, come to see this tool as being so powerful that we overlook other means of ameliorating the condition of those who seek our help.  The presenter was urging us to avoid this trap.

My physiotherapist was practicing what the presenter preached.  She was seeing a patient in pain.  She was able, with her powerful and useful skill, to ameliorate that pain.  But she was also able to recognize that there was an ongoing stressor that was likely to continue to create the pain and that her treatment could not address that underlying problem.  The jury is still out on whether her hypothesis will be upheld.  But the approach she is taking is a laudable one.

My own psychoanalysis greatly helped me with sleep difficulties.  I would, at the time I began the treatment, awaken in the middle of the night – at one, two or three am and have difficulty going back to sleep.  As I learned about dreams, I became able to “catch” the dream I had been having, to reconstruct it, and to analyze the elements that had led me to awaken.  As I consciously worked on the problem that had been presented in coded form in the dream, I was frequently able to come up with a solution that led me to be able to return to sleep.  Sometimes I couldn’t accomplish that, but would pick up the dream in the middle somewhere and work, in a dream state, at coming up with a new, dream solution.  This new dream would mean that I was back asleep – problem temporarily solved.

Now, in the wake of a stressful year, I am having trouble sleeping again.  I tried to apply psychoanalytic principles to my symptoms.  As deep and wide as my analytic training may be, it did not include looking over the wall into the world of world of physical symptoms.  It did not occur to me that the symbols in my dreams might be based on them rather than psychic concerns.  I have to be careful that I don’t use my tool beyond its reach.  When someone with ADHD or apnea seeks a psychoanalytic treatment, the psychoanalysis can help improve his or her condition.  The lowered anxiety resulting from treatment leads to a decrease in the disruption that ADHD can cause.  The psychoanalysis may well help the apnea patient recover more quickly from an apnea moment to return to sleep.  That said, it does not eliminate, nor even explain, the underlying dysfunction, one that needs a different diagnosis and treatment to help the client achieve optimal functioning.

Post Script.  This was posted in 2011.  It is now 2015.  I did, indeed, have apnea - a painful night in the sleep lab proved this.  I have been successfully treated with a mouth appliance that forces my tongue forward and thus opens the breathing passage (see the description of that here).  It also stops my snoring, which the reluctant wife believes is worth the price of admission, which was pretty steep.  The other common treatment is a CPAP machine.  I tried this and, for me, it was like sleeping in a wind tunnel.  Maybe I would have gotten used to it in time, but thankfully the appliance has worked.

A couple of other things I have learned.  About a year after I began treatment, I looked back at my ratings of my sleep and my health when I sought treatment.  I was in bad shape, but once I got better I forgot how bad it was.  I was having heart palpitations and significant problems with attention and concentration.  A year later, I recalled that when prompted, but really had lost track of it.  I think that happens with our patients who are doing better and sometimes don't remember how bad it was when they weren't.

My sleep is not perfect now.  Especially when I am distressed about things at work, it can get pretty bad.  But I can also analyze my dreams, work on what is distressing me - which usually means facing something I would rather not - and the sleep will get better.  And I don't have dreams about being trapped in small spaces.  Just remembering them as I write this is enough to give me the Willies and to fear they will return, but they haven't.  I couldn't process my dream life in the ways that I am now  when the apnea was interfering with the sleep.  Then the stress related disruptions were much larger and addressing the problems did not lead to a return to sleeping well.  I think this, too, is part of the human condition.  Our various difficulties tend to be additive.  When we are not doing well in one area it contributes to difficulties elsewhere.  Yet another reason to do a very wide ranging diagnostic work up to identify multiple possible contributors to the presenting symptoms.

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