Saturday, December 31, 2011

Sleep Apnea - The Reluctant Psychoanalyst Gets Treatment (Cont.)

I posted some time ago about having been tentatively diagnosed with sleep apnea.  Since then I have: been to a dentist specializing in sleep appliances; seen a sleep physician; had a “sleep study” where I spent the night at a clinic with electrodes attached to my head; met with the sleep physician again; had another sleep study while using a CPAP machine; returned to the sleep dentist and had an appliance made; and dealt with the insurance industry.  What a nightmare!  Not so much the individual components (though the nights spent in the sleep clinic were among the worse night’s sleep I have ever had), but the amount of time that it has taken to have a treatment, the frustration of continuing to sleep poorly while knowing that a solution might be achievable, the out-of-pocket costs, and, ironically, the lack of dreams have all been part of the nightmare.

When I last posted, the diagnosis was still a hypothesis.  I was referred to the dental sleep specialist.  He evaluated me, had me fill out a brief self-report form and took X-Rays of my neck.  He explained that my symptoms were consistent with sleep apnea.  He further explained that the difficulty that leads to apnea is part of the paradoxical nature of sleep.  We need to relax our muscles in order to be able to sleep.  The danger, of course, is that if some muscles relax, our throats collapse and we can’t breathe.  This occurs with greater frequency as we gain weight and as we age – also something about my being tall contributes to the difficulty in maintaining the opening.  When the opening collapses, we panic, awaken in a fright with our adrenaline charging, and aren’t able to quickly get back to sleep.

Despite a presumptive diagnosis, the Dentist ordered a sleep study in order to definitively establish the diagnosis.  This required waiting for an intake meeting with the sleep physician, who explained what the sleep study would entail, then waiting for an opening at the sleep lab.  (Two months into the process, my secretary was concerned about her sleep, made a same day appointment to be evaluated at a different center and was in the sleep center for a study within two days, and then had the subsequent sleep study with the CPAP a week later – apparently different places work at different paces!) 

The folks at the sleep lab were very pleasant.  They applied electrodes to my scalp and to my legs, a band to measure respiration, and then had me sleep under video surveillance in a hotel bed.  A week or two later, the results showed that I had awakened from apnea events 15 times in the night, which suggested that I had a mild sleep apnea.  Consistent with my experience, I awoke from the last event about 4 am and did not return to sleep until it was time to wake at 6.  When I met with the physician again, he explained that this meant that I was not getting into the deep sleep that included REM and dreams and therefore was not dreaming at the usual rate.  By this time, school had been up and running again, I was anxious again, and I was not dreaming again – and his machines were supporting what I knew. 

The sleep doc recommended that I be fitted for a CPAP machine in addition to or perhaps in place of the dental appliance, so I scheduled for another sleep study, this time with the CPAP machine on.   When I went back for this, I was less than pleased.  The CPAP keeps the airways open by forcing air in through the mouth and nose.  Because I breathe through my mouth as well as my nose, I was fitted with a mask that covered most of my lower face – I looked like a WWII fighter pilot except that the mask was plastic instead of leather.  Sleeping with the machine on was like sleeping with your head sticking out the window of a car going down the road at about 60 miles an hour.  This was not a pleasant experience for me.  The sleep doc said that I would get used to it over time and claimed a higher success rate than for dental appliances.  The dentist stated that many could not tolerate the CPAP.  Ultimately, it took so long for the insurance to OK the CPAP that the dental appliance had already been made, and I decided to try that out before taking on the CPAP, paying for it, and wondering whether I would be able to tolerate it.

The dental appliance works by forcing the lower jaw forward in sleep and, in the process, moving the tongue forward.  This creates a larger breathing space at the back of the mouth – dramatically so.  In fact, when the appliance was put in place, I could feel how much easier it was to breathe while I was awake, something that seemed surprising to me.  The reluctant wife noticed immediately that I was not snoring and she has been able to dispose of the earplugs she has been using to protect her own sleep.  And especially immediately after starting to use the device, I was bombarded with dreams.  Likely this is related to something called REM rebound.  When we deprive laboratory animals of REM sleep for a night or two (Rats relax when they go into REM sleep so we can prevent REM by having them sleep on a very small island in water.  When they fall asleep, they roll off the island, get wet and wake up).  After having been deprived of REM, animals spend much more time in REM on subsequent nights, seemingly making up for lost time. 

My sleep pattern, in the weeks since getting the appliance, has changed dramatically.  I am dreaming again!  This means that I am waking up from those dreams – so there are unresolved issues that I can’t quite paper over in my sleep – but I am, by and large, able to get back to sleep after awakening – I think about the dream, perhaps analyze it, perhaps I pick up the thread of it and fall back asleep in it.  This doesn’t always work.  A couple of nights I have awakened and not been able to get back to sleep for a couple of hours, but this generally happens earlier in the night – at 1 or 2 – not at 4.  And the dream that awakened me has generally been disturbing – lately I’ve been dreaming, in whatever coded or not so coded fashion, about the state of my career and how dreary it is.  And this, combined with a laundry list of things that I must remember to do, can keep me up for some time.

I don’t know yet know over the long haul, how this will work out, but it seems to be a good start.  My jaw is a bit sore after having been forced into a new position and it has been very expensive.  I think more expensive than it needs to have been.  My regular dentist was appalled at what I was charged for the sleep device.  I think I will shop around next time (I saw one advertised on TV that was probably a glorified mouth guard for  $9.50), but this was also a lesson in what desperation will do to our willingness to pay for treatment.  The longer the treatment dragged out, the more I seemed willing to pay as I became more and more frustrated by not being able to do something basic to a psychoanalyst’s functioning – to sleep – and even more centrally - to dream.

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