Healthcare Crisis: Sleep Disorders as a Microcosm of the Larger Problem (Part II)

Learning to know oneself is a major developmental stage in one’s maturation to adulthood. Strangely or not, the vast majority of individuals, men or women, spend the largest portion of their lives fighting this necessary objective. In part, this flaw in development is not always as self-inflicted as it may seem. Rather, the human condition itself has a built-in psychological system that encourages the formation of blind spots that serve to “protect” the individual from experiencing too much self-knowledge.

Leaving for the moment the potential psychological value of a blind spot, no better example than sleep apnea can explain how this phenomenon works. Sleep apnea operates within the confines of a very obvious blind spot—it occurs as you sleep— therefore you cannot know what is occurring in this subdued form of consciousness so different than waking experience. Eventually, though, clues take shape, and the individual hears from a bedpartner about breathing cessation, loud snoring, or unusually fitful sleep. How does the average person respond to such input? On the very first expression of these insights, would the individual declare, “Hmmm, that’s very interesting, I think I will call my doctor today and see if I can get scheduled for a sleep test”? We all know this response is exceedingly rare. Rather, it might take 10 to 40 years of repetition before the individual moves forward.

Let’s ramp up the symptoms and observe an exhausted individual during the day, suffering constant daytime sleepiness and tiredness, needing to nap routinely, needing more caffeine to drive safely and starting to suffer noticeable cognitive difficulties such as concentration and memory impairment. What would he do? Would he rush off to the local sleep center? Would he even bring the information to the attention of a primary physician? Or, would this person simply ramp up the amount of caffeine to “solve” the problem? Again, the greater tendency is to avoid facing the knowledge something is wrong; in fact, for the most part, the individual does not see something as “wrong.” Rather, a rationalization turns what seems wrong to something “normal” by designating these symptoms as a clear sign of aging, which undoubtedly is a normally occurring process. Yet, the person could just as easily be wrong, maybe dead wrong if the problem is due to undiagnosed and untreated sleep apnea. To be clear, sleep apnea causes faster aging.

Why do people function in a way that seems so counterproductive? Is it simply a matter of ignorance about sleep or sleep problems? Is it the lack of interest or attention to sleep issues in society that steers the individual away from closer scrutiny of such an obvious change in health status? While I believe the above points are relevant, valid, and part of the equation, the over-arching problem is that men and women of whatever age are not predisposed to knowing things about their own health. This self-imposed “ignorance” is due to the fear generated either acutely with a worrisome change in health status, or chronically when individuals are forced to face their own mortality. 

In the first instance of an acute change, do you know how many individuals suffer episodes of chest pain of a potential cardiac nature and yet choose not to seek care? We know the numbers are not inconsequential, because there are still patients who come to an emergency facility and declare they had chest pain several days earlier, yet only came for the visit because they continued to feel poorly ever since. At that point, we discover an EKG showing signs of a recent heart attack. Do such individuals not visit the doctor because of a stoical or dismissive attitude about pain? That is certainly a possibility. Is it also plausible that chest pain evokes images of racing ambulances, chaotic hospitals, dire intensive care units, CPR, and ultimately death? If someone has knowledge of these scenes through television, movies, or more importantly from the experiences of their own friends and family, it is not a stretch for these images to operate on a subconscious level and prevent the individual from seeking care. In effect, in this acute setting, patients are electing at some level not to use their self-awareness to make health decisions that would seem to offer more advantages than disadvantages. And, in so many of these scenarios, I would argue that fear prevents the individual from gaining this rational level of decision-making.

In the chronic setting, whatever the problem might be—prostate issues, fibroid tumors, mental illness, joint pain, high blood pressure and so on—patients understand that visiting a doctor increases the risk of hearing bad news, and most of us do not enthusiastically run to hear bad news! Fear prevents us from observing clarifying details about the changes in our health status so that we can avoid visiting the doctor. In this scenario an individual would only seek help once pain crosses a certain threshold, the pain supersedes the fear, or the pain turns fear into a motivator.

Even if we look at the converse scenario regarding the patient who goes to the doctor for every type of ache or pain, stomach ailment, low-grade infection, or headache to name just a few examples, we are still working in the same realm of emotion. These patients are often suffering what are called psychosomatic symptoms. This term means the symptom is real, not imaginary, but the symptom itself may be triggered by the patient’s inability to deal with their emotions or the symptom may be magnified by an emotional over-reaction to the sensations experienced from that symptom. As a worst-case scenario, imagine a person with chronic headaches who is convinced he has a brain tumor but all the tests return negative. Thus, fear doesn’t just drive these patients to seek care more than necessary, but most importantly the fear is acting to cloud their judgments so that they are unable to gather self-observations to distinguish when the pain is “the same old pain,” or whether the pain represents something new and different—a very good reason to see a doctor.

Let’s return to cardiac issues and contrast them with sleep issues to finish up Part II. Did you know that the overwhelming majority of patients who seek care for chest pain do not have cardiac problems? Usually, the most common causes of the pain are gastrointestinal issues such as indigestion, reflux or constipation, but the patient notices the problem more in the chest than the abdomen. Another common cause is rib or muscle pains, but the individuals often do not realize they were engaged in a physical activity like gardening, lifting an object, or straining a muscle in the shoulder while reaching for an object. For all the people that come to the emergency room for these issues, a whole lot more self-medicate at home and try to sort out the problem. But, the people who do come often fear the issue is cardiac, and because heart problems can always carry the unpleasant aura of being life-threatening, it makes sense to see more people in the emergency room for chest pain.

So, how many patients do you think come to the emergency room complaining of insomnia? Interestingly, while this scenario is rare, it can prove deadly as these individuals often develop severe and intense psychologically-driven sleeplessness which can lead to a state of panic and in many cases suicidal thoughts and behaviors. Again, fear is what drove them to the medical center, but it was also fear that prevented them from rationally taking steps to learn the well-described tendency for insomnia to spiral out of control in people who obsess about their insomnia.

To sum up, fear plays a crucial role in how people choose or not choose to see their health problems as well as how to act or not act to manage them. In the third and final part of this series, I want to delve deeper into this fear where we might discover elements that drive this strong emotion, and then we’ll turn our attention back to the discussion on the chaos and confusion found within our healthcare crisis and why a big part of the crisis is triggered by human fear.


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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