Sleep and Dream Problems - Part 2

Sleep and Dream Pathologies

Most people experience bouts of troubled sleep and do so without too much difficulty. It’s rare for me to see a person whose presenting issue is only troubled sleep, rather, sleep and dreaming problems generally emerge as people share their issues with me.

Margo

Margo was severely agoraphobic. What is agoraphobia? People frequently mislabel agoraphobia as “fear of open spaces,” or “fear of leaving home.” These are certainly symptoms or features of agoraphobia, but technically agoraphobia is “fear of being in situations where escape is difficult or that a person would be unable to get help if things went wrong.”

Margo was an older, Caucasian widow. She had, in the past, been an active member of the LDS (or Mormon) Church, especially when her husband was alive, but her recent reticence to attend church precluded her interacting with other Church members. After years of disaffection, she became one of the older and forgotten members of the Mormon Church.

Margo’s son from her 40 year marriage did everything for her, grocery shopping, paid monthly bills, handled activities that she couldn’t do without help. He was good about her physical needs, but rarely visited or engaging her beyond superficial communication. He had a matter-of-fact disposition, not comfortable talking about anything that had to do with feelings or mood. Margo noted, “ My son has his own problems and I try not to get involved.” Over time, she had become disconnected from most others, even her neighbors. She told me in tearful tones when we first visited that she was excruciatingly lonely. Not surprising, she was also bored. Confined to long days watching television or reading.

What brought Margo to me? How did Margo get the courage to contact me and invite me, a total stranger, into her home and world?

The answer is a dream.

Margo was inactive and overweight. These two lifestyle issues were interconnected because she was aware that she used food for personal comfort. So, she not only ate poorly, she ate at irregular intervals and the quantity of food was too high for her aging metabolism. This precipitated a number of health conditions (like high blood pressure, marginal obesity, sleep apnea), it also encouraged immobility because with the excessive weight it was harder for her to get around.

Her declining health diminished her sleep quality. She would lay in bed for hours, tossing and turning, not able to sleep. When she did sleep, she never remained asleep, all kinds of things would wake her up. Strange noises in the house were an issue.

One night she had a disturbing dream. For Margo, the dream was a nightmare. She was in a graveyard. For whatever reason, she felt familiar in this setting, almost at ease, like it was her home. She was walking around the graveyard and noticed a gravestone. She recognized it was her gravestone. It was about that time that the wind began blowing her around and she realized that she was no longer in her body, but was part of the leaves in the graveyard. Someone was raking the leaves and she kept yelling that this person to stop and rescue her, but the person didn’t, the person just raked her up and stuffed her into a bag and started scrunching the bag and Margo was having a hard time breathing. She felt trapped and what she realized is that somehow her essence had gotten out of her dead body and was now part of the leaves and she didn’t have anyplace to go, no one to scream to for help, only the suffocating in this bag of leaves probably headed for a leaf shredder and once ground up she would no longer exist. She then woke and realized she was still herself, still alive, but was tangled up in her covers and had somehow twisted herself around so that the covers were wrapped around her head and neck. She said, “I’ve got to do something about my situation or I won’t be alive too much longer.” The next day she called my office.

Doctor I can’t sleep

Of the most common sleep pathologies, insomnia tops the list. Margo, in the previous story, would probably be diagnosed with insomnia.

What is insomnia?

What does it look like?

How do I know if I have insomnia?

These are all questions that deserve answers. The first, What is insomnia?, is a tricky question. The dictionary defines insomnia (Noun) as: (1) Inability to obtain sufficient sleep, especially when chronic; (2) difficulty in falling or staying asleep; (3) sleeplessness.

Insomnia is also a psychiatric diagnosis and the Diagnostic and Statistical Manual (DSM) for Mental Disorders has insomnia listed as a clinical sleep diagnosis. DSM gives a much more elaborated explanation of what it is: The subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.

The DSM doesn’t stop there, in fact, it lists criteria for Insomnia or attempts to describe it in operational terms, dissatisfaction with sleep quantity or quality:

• Difficulty initiating sleep

• Difficulty maintaining sleep, characterized by frequent awakenings or trouble returning to sleep after awakenings

• Early-morning awakening with inability to return to sleep

The specific sleep disturbance, insomnia, causes clinically significant distress or impairment in daytime functioning, as evidenced by at least one of the following:

• Fatigue or low energy

• Daytime sleepiness

• Impaired attention, concentration, or memory

• Mood disturbance

• Behavioral difficulties

• Impaired occupational or academic function

• Impaired interpersonal or social function

• Negative effect on caregiver or family functioning

The sleep difficulty feature must occur at least 3 nights per week, and be present for at least 3 months, and occur despite adequate opportunity for sleep.

If you think about this criteria more deeply, it does raise some perplexing issues, for example, there may be situations when there is not adequate opportunity for sleep. Let’s say you are a nurse in an Emergency Clinic that operates 24/7 and you are on both a regular 8-hour shift, but are also on call, so that there is not a space in time for you to get adequate sleep. So, you don’t get adequate sleep. You start experiencing some of the side effects of this poor sleep schedule. This is NOT insomnia. Insomnia is when the conditions for good sleep are present and for whatever reason, you are not getting adequate sleep. This is an internal intrapsychic problem. If poor sleep keeps up after you stop your crazy work schedule, then it isn’t the work schedule that’s causing poor sleep anymore, it, indeed, may be insomnia? If poor sleep is the consequence of a poor work schedule. It is treatable with behavioral strategies once your poor work schedule stops. I’ve seen emergency room doctors who complain to me that they are experiencing insomnia because of their hectic and ongoing busy schedule, but again, I would say that this is not insomnia, this is simply poor working conditions not conducive to sleep. Insomnia might make you more susceptible to poor sleep working schedules, but the schedules themselves are not the cause of the insomnia. Insomnia is caused from within the individual.

So, What Causes Insomnia?

This is a very tough question to answer because the answer hinges on the diagnostic criteria of insomnia. As this figure underscores, there are a lot of variables within the individual that can be insomnia causing, genetics (or family history) is one. I always ask, early on, whether a client can recall stories or memories of direct family members who suffer or suffered from insomnia. Again, the challenge here is that insomnia is not simply “inadequate sleep.” The reason for this is that as I have noted above, inadequate sleep can occur for a lot of reasons, probably the biggest reason isn’t insomnia (a psychiatric disorder which suggests underlying brain dysfunction, by definition), but poor sleeping conditions (an environmental issue that would be addressed if you improved the sleeping conditions). Perhaps one way to understand the term is to view insomnia as poor sleep because something internally is wrong with your circadian 8-hour on 16-hour off sleep cycle rhythms. “Dr. I’ve been sleeping 5 hours a night for years and I don’t feel like it’s a problem.” This is NOT a description of insomnia even though 5 hours of sleep, by research documentation, is not enough sleep for the body to renew itself. However, the person is not experiencing insomnia because the person does not perceive that anything is wrong or amiss with sleep.

There is really no one causal factor for Insomnia Disorder, rather, there are many components that can cause its onset or continuation:

• Stress and anxiety can make sleeping problematic, because they cause tension, as well as feelings of worry and overstimulation. This is insomnia due to anxious and ruminative thoughts.

• The individual may feel pessimistic toward sleeping over a period of time. This may make it harder to fall and stay asleep.

• Depression and other conditions including ruminative paranoia may spur insomnia.

• Changes in mood and hormones can cause insomnia.

• There are medical conditions including nasal allergies, chronic pain and arthritis that are associated with insomnia.

• Asthma, thyroid disorders and even acid reflux and chronic post-nasal drip can make sleeping uncomfortable and if this symptom is severe enough it can lead to insomnia.

• A whole range of medicines have insomnia as a side effect. Particularly, thyroid disease medicine and high blood pressure medicine can cause insomnia. But, if you take a drug that causes insomnia isn’t this a side-effect and not insomnia. Technically, the answer is yes, but if some aspect of insomnia is “internally-driven” then it is more likely to fall into the classical definition of insomnia.

As you might expect, there is a controversy about the nature of insomnia, What causes it? How is its cause related to treatment? Can it be “cured” or “eliminated”? How well do drugs work and are they a long-term approach to chronic insomnia?

I have a lot of experience studying and treating insomnia, but still, it baffles me. It is a clearly human condition. Animals won’t sleep if they are feeling threatened, but eventually they sleep and make up the loss. Humans seem to override this animal mechanism and can experience insomnia over an entire lifespan. And, of course, What are the long-term implications of a life of insomnia. It is true that chronic insomnia has been linked to the early emergence of dementia or Alzheimer’s disease in old age, but then again, just about everything has been found to be related to earlier onset of dementia, so this isn’t really something to fear.

I will discuss the treatment of insomnia later, but suffice it to say at this juncture that it is a large-scale human problem. Here are some statistic about insufficient sleep that I have abstracted from 2022 data:

• Almost half of all Americans say they feel sleepy during the day between three and seven days per week.

• About 35.2% of adults report sleeping on average for less than seven hours per night.

• Of major cities in the United States, Boulder, Colorado has the lowest percentage of adults who sleep less than seven hours per night, for the two cities with the highest rate of poor sleep are Camden, NJ and Detroit, MI, with 49.8% of adults in those cities reporting poor sleep.

• When compared to whites, black adults are almost are almost twice as likely to report poor sleep and are 60% more likely to report sleeping too much. 

• Women have a lifetime risk of insomnia that is 40% higher than men.

• 50% of pregnant women across age and race, experience insomnia-like symptoms.

• 8.2% of adults say they took medication to help them sleep at least four times in the past week.

• 80% of people who take prescription sleep medications say they experienced residual effects of the medication or poor sleep like oversleeping, feeling groggy during the day, or having a hard time concentrating the next day.

These statistics were taken from: National Sleep Foundation. (2020, March 7). The National Sleep Foundation’s 2020 Sleep in America® Poll Shows Alarming Level of Sleepiness and Low Levels of Action. Retrieved October 22, 2020.

Sleep Disorders Questionnaire

This questionnaire is a screening tool for physicians to assist in the evaluation of insomnia. Grade your answer by circling one number for each of the following questions:

Grading Scale 1=Never 2=Rarely 3=Occasionally 4=Most Nights/Days 5=Always

• Do you have trouble falling asleep? 1 2 3 4 5

• Do you have trouble staying asleep? 1 2 3 4 5

• 3. Do you take anything to help you sleep? 1 2 3 4 5

• 4. Do you use alcohol to help you sleep? 1 2 3 4 5

• 5. Do you have any medical conditions that disrupt your sleep? 1 2 3 4 5

• Have you lost interest in hobbies or activities? 1 2 3 4 5

• Do you feel sad, irritable, or hopeless? 1 2 3 4 5

• Do you feel nervous or worried? 1 2 3 4 5

• Do you think something is wrong with your body? 1 2 3 4 5

• Are you a shift worker or is your sleep schedule irregular? 1 2 3 4 5

• Are your legs restless and/or uncomfortable before bed? 1 2 3 4 5

• Have you been told that you are restless or that you kick in your sleep? 1 2 3 4 5

• Do you have any unusual behaviors or movements during sleep? 1 2 3 4 5

• Do you snore? 1 2 3 4 5

• Has anyone said that you stop breathing, gasp, choke in your sleep? 1 2 3 4 5

• Do you have difficulty staying awake during the day? 1 2 3 4 5

• DIAGNOSTIC DOMAINS: 1) Insomnia: Q1-5 2) Psychiatric Disorders: Q6-9 3) Circadian Rhythm Disorder: Q10 4) Movement disorders: Q11-12 5) Parasomnias Q13

• Grading of 3, 4 or 5 on any question, the patient likely suffers from insomnia. If they answer 3, 4 or 5 for two or more items and have significant daytime impairment the insomnia requires further evaluation and management.

Here is another instrument that I really like that focuses on Quality of Sleep. It’s probably a better assessment of insomnia per se.

INSOMNIA SEVERITY INDEX

Circle one:

• Difficulty falling asleep: 0=None 1=Mild 2=Moderate 3=Severe 4=Very Severe

• Difficulty staying asleep 0=None 1=Mild 2=Moderate 3=Severe 4=Very Severe

• Problems waking up too early 0=None 1=Mild 2=Moderate 3=Severe 4=Very Severe

• How satisfied are you with your current sleep pattern?

  0=Not at all 1=A little 2=Moderately 3=Dissatisfied 4=Very Dissatisfied

• How noticeable to others do you think your sleep problem is in terms of impairing the quality of your life?

  0=Not at all 1=A little 2=Moderately 3=Dissatisfied 4=Very Dissatisfied

• To what extent do you consider your sleep problems to interfere with your daily functioning (e g., daytime fatigue, mood, ability to function, concentration, mood memory) currently

  0=Not at all 1=A little 2=Moderately 3=Dissatisfied 4=Very Dissatisfied

Guidelines for Scoring/Interpretation: Add the scores for all seven items (questions 1 + 2 + 3 + 4 + 5 +6 + 7) = _______ your total score Total score categories: 0–7 = No clinically significant insomnia 8–14 = Subthreshold insomnia 15–21 = Clinical insomnia (moderate severity) 22–28 = Clinical insomnia (severe)

Parasomnias

There are so many sleep pathologies it will not be possible to describe them in this entry without making the entry length unreadably long or complex. The breadth and depth of the study of sleep pathologies is enormous, and although I’m very familiar with this literature, it makes sense to focus on the high-points or the topics that you might encounter in your everyday life. Parasomnias are one of those sleep issues that everyone encounters at one point in time or another.

What is a Parasomnia? (noun) a disorder characterized by abnormal or unusual behavior of the nervous system during sleep…"he's being treated for parasomnia at a sleep disorder clinic" In other words, the dictionary defers to the medical community for defining this word. The reason for this is that this word did not evolve in the general language, rather, it is a specialized word of value primarily to the subspecialty of medicine.

The dictionary defines parasomnia as:

By standard Diagnostic and Statistical Manual for Mental Disorder definition, parasomnia is: “…A sleep disorder that involves unusual and undesirable physical events or experiences that disrupt your sleep. A parasomnia can occur before or during sleep or during arousal from sleep. If you have a parasomnia, you might have abnormal movements, talk, express emotions or do unusual things. You are really asleep, although your bed partner might think you’re awake…”

A further refinement of the meaning of this word within medicine is to consider this disorder an REM/NREM sleep disorder (REM=Rapid Eye Movement). Or a disorder that is confined to a single stage of sleep. In this case, the individual is in a dream state or an REM state of sleep, but the body, for whatever reason, fails to inhibit bodily movement during this state of sleep. When this happens, the person acts out their dream.

There are unusual instances of parasomnia, for example, sleep-related abnormal sexual disorder: From Wikipedia: “…or sexsomnia, is a form of confusional arousal… Thereby, a person will engage in sexual acts while still asleep. It can include such acts as masturbation, inappropriate fondling [of oneself] or others, having sex with another person; and in more extreme cases, sexual assault. …These behaviors are unconscious, occur frequently without dreaming, and bring along clinical, social, and legal implications. Sexsomnia has a lifetime prevalence rate in the USA of 7.1% and an annual prevalence of 2.7%…

Parasomnias can be involuntary seld-related eating disorders (there is even a label SRED for this), of course, sleepwalking would be a parasomnia, sleep terrors (or Night Terrors) would be a parasomnia. Or, again, any human activity that occurs during sleep and during that period of time when a person should be frozen or anesthetized physiologically during what is otherwise known at the REM sleep stage. Catathrenia, for example is a syndrome that consists of… Wikipedia: ”breath holding and expiratory groaning during sleep…The sound is produced during exhalation as opposed to snoring which occurs during inhalation. It is usually not noticed by the person producing the sound but can be extremely disturbing to sleep partners…Bed partners generally report hearing the person take a deep breath, hold it, then slowly exhale; often with a high-pitched squeak or groaning sound.” Bed Wetting or Sleep Enuresis is a common parasomnia in children and adults.

The clinical features of a parasomnia are as follows:

• Male gender predilection

• Mean age of onset 50–65 years (range 20–80 years)

• Vocalization, screaming, swearing that may be associated with dreams

• Motor activity, simple or complex, that may result in injury to patient or bed-partner

• Occurrence usually in latter half of sleep period (REM sleep)

• May be associated with neurodegenerative disease

In my many years of practice, I’ve encountered people with parasomnia issues in all forms. It is sometimes associated with early-onset dementia and it can be a signficant pre-cursor for a dementia disorder in older persons (55 years and older). It is frequently observed in Veteran’s especially those suffering from long-term stress and PTSD under heavy battle-conflict conditions. There is a clear physiological explanation related to de-inhibition when this is the case.

The Case of Mark

Mark was a Veteran of the Marine Corp who spent two one-year tours in Afghanistan. His assignments were generally in small military units-teams, platoons, companies who were deployed to meet insurgency threat in towns and cities. Insurgents are based in villages and have little support, but they are lethal, embedded as regular members of villages and towns. Mark was in multiple firefights where he was “man on man” to identify and eliminate insurgent threat. It was a highly charged experience. He saw many people killed and wounded, the enemy, his friends, innocents (as he called them), and was directly responsible for shooting and killing multiple “insurgent threat targets” (which is the way he liked to describe it). In one instance, he described creeping up on five insurgents. It was in the early evening, he had penetrated their defenses and had crept up on them while they were standing behind a wall. He said he was almost caught off-guard at how obvious they were, defending this location, they were looking through the wall and away from him. Sitting targets, from his point-of-view. He said, it was surreal, almost like an rpg game. He wondered whether he should announce himself before he killed them all. He chose to play it safe. He was about 20 yards from these individuals, he stood up and had a clear line of sight, lifted his automatic weapon and that is when one of them turned around, startled, and then Mark said, “I just mowed them down, they didn’t have a chance…I probably put 15 bullets into each person, blood everywhere…I basically massacred these men, one actually smiled before he died…At the time, I was almost gleeful, because this was a tactically important site, at least for the moment, and I thought of myself as a hero, but then it hit me that just killed these guys in cold blood…It was my job…but it was a Hell of a job and I later regretted I had to do that…”

This was only one story of several that Mark related to me. For roughly two years, he lived like an animal, in fear that there would be retribution for all the insurgents he killed. “I killed men, women with guns, teenagers with guns, anyone who was a threat…but I kept thinking…one day the tables will be turned and I will be on the other side of this with the gun barrel pointing towards me…”

In fact, in one case, while the platoon was sleeping - they slept in dispersed groupings - an insurgent crept past the sentry, got into the platoon, was wearing a suicide bomb, and shot one marine before he blew himself up. Mark heard the explosion, and saw the aftermath. He said, “the explosion was like a big thud, everyone was immediately up and armed, it was ugly, one guy dead with a gunshot through the stomach and head, others injured from bomb shrapnel, guys moaning in pain, smoke everywhere, the smell of gunpowder, (it was a bomb with nails and debris in it that spewed in every direction…The guy that did it knew he was dead from the get-go…”

Mark never slept well while he was on his tours of duty. He said, “you never slept, always on edge, always alert, you walked around half the time in a sleep-deprived daze…”

Mark suffered from parasomnia. When he returned from Afghanistan he enrolled in college and started taking classes in engineering. He recalls one incident of parasomnia. “I’m not sure why it happened, but my roommate said that while I was sleeping, I jumped out of bed, pulled my gun from the nightstand, my roommate said it was so quick it was like one swift movement. I was yelling or goaning something, something gutteral…and loud… he said it was unintelligible, and the roommate stood up to calm me down and tried to gently push me back on the bed, with the gun and all, I guess he was scared, I grabbed hold of his neck…I guess I thought it was hand-to-hand combat, threw him on the ground…I guess I’m still pretty strong…took the gun in my hand and pushed the barrel on his forehead, he said he felt the steel barrel…and then he said he heard the hammer click off several shots…fortunately I don’t keep the gun loaded…but if it was loaded he would have been stone-cold dead…then I fell back on my bed and went back to an immobile sleep state…the roommate left that night while I was still sleeping and he…and I don’t blame him…no longer wanted anything to do with me…said I was a crazy..f####king asshole madman who shouldn’t be allowed to run around in a free society…He had no compassion for me or my issue….at the time, I didn’t think I had an issue…I don’t blame him…maybe I am what he says I am…at that time I thought that the only place I fit in was in the battlefield…and that’s a pretty isolated feeling…that’s when I started to look for help…psychiatric help, you know…”

Fortunately, this is the only time this incident occurred for Mark, and I saw Mark for quite a long time, so there was no way to really treat this, other than make sure that there wasn’t an easily accessible gun (locking his guns) when he was sleeping. But, this does underscore the real problematic nature of parasomnias and for people who are diagnosed with PTSD for whatever reason, the likelihood of this sleep dysfunction impacting every-day living is higher than in the normal population.

Restless Leg Syndrome

What is restless leg syndrome?

Restless Leg Syndrome is basically what it says: A disorder characterized by an unpleasant tickling or twitching sensation in the leg muscles when sitting or lying down, relieved only by moving the legs.

Restless Leg Syndrome (RLS) is not confined to a sleep issue per se., but the desire or autonomic impulse to move one’s legs makes falling asleep and staying asleep difficult for some people with RLS. In one study 88% of persons with RLS reported at least one sleep-related problem. RLS symptoms often appear shortly after laying down at night and the RLS sufferer will kick, squirm, or massage their legs to lessen the sensation. Some people with RLS are compelled to get out of bed and pace or stretch.

Most people with RLS also experience Periodic Limb Movement Disorder (PLMD). This disorder involves repetitive flexing or twitching of any limb (an arm or a leg) while asleep at night. It is different from RLS in that these movements are not accompanied by uncomfortable sensations and because they occur during sleep. Frequently people who suffer from PLMD are not aware that they are moving or twitching their limbs while asleep. They discover this, say, during a sleep study that involves an overnight hospital stay. However, PLMD-associated movements can cause a person to wake up and therefore can compound sleep issues.

There are temporary situations when RLS occurs. For example, during pregnancy about 20% of women complain of RLS. In these instances, the symptoms usually resolve after delivery.

Sitting or resting too much of the time are common triggers for RLS symptoms. Some substances, usually stimulants, can make symptoms worse. These include:

• Alcohol

• Caffeine

• Nicotine

• Medications, including certain drugs used to treat nausea, colds and allergies, and mental health conditions (Prozac). Adderall and Ritalin (two drugs for treating ADHD in adults often describe RLS as a common side effect).

Certainly, these substances are not advisable (and it would seem that common sense would preclude their use) too close to bedtime because they are very likely to have an adverse impact on sleep.

I bring these substances into the story here because this strongly suggests that both RLS and PLMD are likely neurologically derived. So, if a person is really troubled chronically by these issues, it makes sense to see a neurologist to get further evaluation.

Causes of RLS are Many

RLS is caused, like so many other mental health issues, by an imbalance in the neurotransmitter dopamine. Dopamine deficits in one area of the brain (the Nigra Striatal Pathway) can create this lack of controlled movement. There is probably a genetic link because half of sufferers report the same condition in blood-family members. Parent having the evening jitters. Women tend to get RLS more often than men and symptoms and not surprisingly, the symptoms worsen with age.

RLS has also be linked to low iron levels, though exactly how this is related to dopamine or if these are two separate causation pathways is not known. There are many simple things that could trigger temporary RLS including over-the-counter medications such as cold and flu remedies, antihistamines and some antidepressants. Symptoms can also be pre-cursors to chronic diseases such as kidney failure (where there can be problems with the body's iron and mineral levels), or Parkinson's disease that is known to be related to dopamine depletion. Stress or anxiety is always a possible reason for these abnormal movements to occur.

Sleep Apnea

I’m won’t go on about sleep pathology, although I could continue down the list and have almost a book-length entry, so I will present only one more. This is sleep apnea.

Why present sleep apnea? Because it is a gigantic issue in our contemporary society. You probably know someone who uses a CPAP (continuous positive airway pressure) machine, you may be using one yourself. Why? Because you suffer from sleep apnea, and although sleeping with a CPAP machine is a big hassle, having to hook yourself up to a machine and sleep with it every night, the implications of letting sleep apnea go untreated are substantial, particularly if you experience chronic sleep apnea and, going untreated, it is chronic (or probably getting worse) as you grow old.

What is sleep apnea? Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts while you are in a sleep state. If you snore loudly and feel tired even after a full night's sleep, if the circumference of your neck is large, and if you are overweight or obese, you probably have sleep apnea. Why? Because the mechanics of sleep apnea work in such a way that the more soft tissue (including fat tissue) that is around your trachea the more likely it is that in sleep, the trachea will collapse when this tissue relaxes and folds onto it (especially when you are lying in a prone position). Essentially, sleep apnea is slow and deliberate and systematic (while sleeping) suffocation.

I like the picture above because it is a crystal clear representation of the blocked airway issue that is at the root of sleep apnea. Why we were designed with a trachea (very small air canal) that winds to the back of our neck so that this ton of biological tissue lays on it when we are sleeping, God only Knows. But, at first blush, it seems, at least to me, like a very poor structural system for breathing while laying prone in sleep.

Wow! That’s serious. My answer is, yes it is serious. Even worse, we don’t have good strategies for altering these mechanics. There are some very experimental surgeries that cut out more space in this soft tissue or try to re-route the trachea in a less vulnerable area of the neck, but these surgeries have tons of side effects and they are risky themselves, so they are not widely employed.

What is the prevalence of sleep apnea? That depends on what grouping of the population your are evaluating.

In general: 3 to 7% for adult men and 2 to 5% for adult women in the overall population experience sleep apnea.

The prevalence of OSA in obese or severely obese patients is nearly twice that of normal-weight adults. People with mild OSA who gain 10% of their baseline normal weight are at a sixfold-increased risk of progression of OSA, and an equivalent weight loss can result in a more than 20% improvement in OSA. The highest prevalence of OSA is in obese children, under age 12, who have a 46% prevalence of OSA. That is; almost half of obese children have Obstructive Sleep Apnea (OSA).

The number one treatment for obesity is weight loss. Sure, there are a few drugs that work on the trachea and there is always the CPAP machine itself that eliminates the issue by forcing air through the trachea (these blocking fatty tissues are very soft and light), but if the goal is to eliminate or reduce OSA then weight loss is the best and most sure-fire approach.

What is a CPAP Machine?

A CPAP (continuous positive airway pressure) machine is a device that sits next to the sleeping individual. It is a relatively simple device, although the complexity (and the cost) comes in with the ongoing monitoring of the sleeping individual and the titrating of pressure as the need for airway pressure changes in any given night to keep the trachea pathway open. The goal here is to keep this airway open with as little forced air as possible.

CPAP machines are indeed, a hassle, especially if you are sleeping with a partner.

It makes things like sexual relationships, communication after going to bed, reading in bed, even the noise that these machines make can be annoying (although some of these machines are marvelously quiet). Most require electricity, and battery operated small machines exists for travel and such things as camping, but these are expensive costing close to a thousand dollars for the machine. Insurance generally pays for CPAP machines and the endless supply of expendables (tubing, mouthpieces, etc.) and they are hard working machines so they wear out every 3 to 5 years and need replacement.

Sleep Apnea is a Dangerous Disorder

Why go through this hassle to treat sleep apnea? Because it is a potentially lethal disorder and if it doesn’t kill you over time through deprived oxygenation to the brain, then it can impair you at an early age. The prevalence rate in untreated sleep apnea and dementia is much to high to think this is just chance occurrence. Probably the biggest issue is “stroke”. The prevalence rate of stroke in untreated sleep apnea. For example, among a national sample of sleep-disordered breathing persons with an apnea–hypopnea index of 20 or greater the risk of suffering a first-ever stroke over a 4 yr (unadjusted odds ratio, 4.31; 95% confidence interval, 1.31–14.15; p = 0.02). This amounts to a 20% increased likelihood of stroke in a four year period.