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WHY YOU CAN’T STAY AWAKE: MANAGEMENT OF APNEA

January 27th, 2011 Posted in Anti Depressants-Sleeping Aid | No Comments »

As we saw in the previous chapter, the options for drug therapy in the treatment of sleep apnea are few and relatively ineffective. Some drugs may be appropriate when central apnea is the problem, since they act to repair the mechanisms responsible for a malfunctioning respiratory drive. Protriptyline, for example, stimulates the muscles of the upper airway; it also decreases the time spent in REM sleep, thus minimizing the periods during which most severe OSA occurs. In OSA, however, the causes of the breathing disruption are usually of a physical nature, making drug therapy largely useless. Sleeping pills, commercial or prescription, are no solution. I have discussed the fact that use of sedatives may produce sleep but can also act to prevent the sleeper from waking up enough to begin breathing after an apnea attack. What’s more, such drugs suppress respiratory function even further—in some cases to the point of death.
By the same token, however, to delay treatment, or avoid it entirely, may be just as dangerous. Besides the health risks posed by apnea, such as hypertension and heart disease, there is the documented danger of death directly attributable to breathing problems.
There are options, however, which can provide varying measures of success but, like almost any medical treatment, have their share of drawbacks as well. As we have seen, most apnea is really a mixture of CSA and OSA. Thus the discussion of treatments here will focus on the latter, since in many cases remedying the obstruction will subsequently eliminate the cause of central apnea as well.
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WHAT’S THE RATE OF PEOPLE GET DIFFERENT MEDICAL TREATMENT FOR BDD?

January 20th, 2011 Posted in Anti Depressants-Sleeping Aid | No Comments »

People with BDD didn’t receive more than one third of all the treatments they requested. And they didn’t receive more than half of all the surgeries they requested. The most common reason is that the physician considered the treatment unnecessary (because the person looked fine) and didn’t provide it. So many people had to see a lot of doctors before they could find one who would finally agree to provide the requested treatment.
It can be very difficult, though, to turn down requests for surgery or other medical treatment. Some people with BDD suffer so greatly that it can be very hard to deny them the treatment they so desperately seek. “The doctors and they couldn’t turn me down because I was so miserable.” Another man said, “I can’t believe the doctor did liposuction because now I know I look fine. But I was so unhappy back then that he gave in and did it.”
One man thought he looked like an “alien” and believed he was the third ugliest person in the world (after Gomer Pyle and Tiny Tim). He’d gone to 3 dermatologists and 3 dentists, none of whom agreed to treat him. He’d also seen 16 plastic surgeons, all of whom turned him down. One surgeon told him that if he got all the surgery he wanted, he’d look “mutilated.” Finally, the 17th surgeon agreed to do a nose job, but the patient hated the result so much that he sued the surgeon. When I saw him he was so desperate for more surgery that he was planning to get into a massive car accident that would destroy his entire face.
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SLEEP PATTERNS: CIRCADIAN RHYTHMS ARE NOT THE SAME AS “BIORHYTHMS”

January 13th, 2011 Posted in Anti Depressants-Sleeping Aid | No Comments »

It might be well to note that circadian rhythms— a known and accepted physiological principle—are not the same as “biorhythms,” a fad that reached its peak in the 1970s. While circadian rhythms dominate our every bodily function, biorhythms were declared by some to be long-term cycles of physical and emotional health that could be traced back to the date of birth and, at least theoretically, used to project our performance on any given day. “Computers” designed to generate biorhythm charts appeared in shopping malls, restaurants, movie theater lobbies, and turnpike rest stops. In exchange for a quarter the machines purportedly warned people that they would reach a peak or a trough on such and such a day, that they should avoid driving or sexual contact, and so on—sort of a high-tech form of palm reading. Not surprisingly, biorhythms were dismissed as pop science by chronobiologists. In one study, for example, investigators compared reports of thirteen thousand on-the-job accidents, as well as eighty-five hundred airplane mishaps, with the so-called critical days supposedly predicted by the biorhythms of the workers and pilots. No correlation was found.
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SURGERY, DERMATOLOGIC TREATMENT, AND OTHER NONPSYCHIATRIC MEDICAL TREATMENT FOR BDD: DO THESE TREATMENTS WORK?

December 30th, 2010 Posted in Anti Depressants-Sleeping Aid | No Comments »

The answer to this question seems to be no—they usually don’t. In the study I’ve been describing of 250 people with BDD who received these treatments, 72% of the treatments resulted in no change in overall BDD severity.
Considering all types of nonpsychiatric treatment combined (“any treatment”), only 11.7% of all treatments improved overall BDD symptoms, and 16.3% were followed by worsening of overall BDD symptoms. Most often, BDD didn’t change. In my series of 200 additional people, even fewer treatments improved BDD: only 3.6% (91.0% led to no change, and 5.4% led to worsening). What about surgery, which is generally the most definitive and expensive treatment that’s received? In the study 18, 58.3%
Number of treatments received in each category: Any treatment: 453, surgery: 15, dermatologic treatment: 265, dental: 34, other medical: 17, paraprofessional: 22 of surgeries resulted in no change in BDD symptoms, and 24.3% were reported to make BDD symptoms worse. In other words, after surgery nearly one quarter of patients were even more preoccupied with the perceived appearance flaw, more distressed, and more impaired by their appearance concerns. Eighty five percent of treatments received from a dentist, 100% of other treatments received from other types of doctors (e.g., endocrinologist), and 91% of treatments received from a paraprofessional led to no change or worsening of BDD symptoms. It’s worth noting that surgery and dental treatments were particularly likely to worsen BDD symptoms.
Dr. Veale’s study, done in England, had similar results. He found that 81% of the 50 BDD patients he saw in a psychiatric setting were dissatisfied or very dissatisfied with the outcome of nonpsychiatric medical consultation or surgery. Repeated surgery tended to fuel increasing dissatisfaction. Although I didn’t ask patients about their satisfaction per se, it’s my impression that experiencing no change in the appearance concern—and certainly experiencing a worsening of this concern—causes people with BDD to feel quite dissatisfied. Sometimes the dissatisfaction is intense, leading to panic, despair, and sometimes even suicidal or violent behavior.
Although only some patients find that BDD gets worse after surgery or medical treatment, in some cases the outcome is extremely poor—even life-threatening. One man I saw who had multiple ear surgeries became suicidal and violent each time the bandages were removed after surgery, necessitating repeated emergency hospitalization. A young man whose surgeon turned him down for forehead surgery but who gave him some facial cream thought the cream created huge, dark spots on his face. He became so enraged over this that he went on a rampage around his parents’ house, threatening them with a hammer and splintering their furniture. A number of patients threatened to sue, or expressed fantasies of harming, their surgeon.
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PARASOMNIAS: SLEEPWALKING

December 23rd, 2010 Posted in Anti Depressants-Sleeping Aid | No Comments »

Perhaps the strangest of all sleep disorders is sleepwalking, more technically known as somnambulism. Many of us can recall incidents where we, or our relatives, were discovered wandering about the house, seemingly wide awake but behaving in bizarre, funny, or sometimes dangerous ways. Come morning, sleepwalkers are completely unaware of their nocturnal perambulations and frequently wince as others recount the tales of their outrageous activities.
Sleepwalking episodes are probably directly related to deep sleep. The most striking symptom of the condition, of course, is what researchers call intense autonomic activation—or, in layman’s terms, unconscious movement. Sleepwalking activity may last anywhere from five minutes to half an hour but usually less than ten minutes. Walkers wear blank expressions (and sometimes not much else). They seem indifferent to the environment, for example, ignoring freezing cold and traipsing barefoot in the snow. Physically awake but mentally asleep, they demonstrate only a minimal level of awareness and reactivity but do exhibit some skill in maneuvering around objects. They know they are walking down steps, for example, and can open doors or use tools appropriately. By and large, however, their activity is purposeless and clumsy; they are unable to play the piano, for instance, or to prepare a meal. Somnambulists’ eyes are open, but they don’t see. A sleepwalker may talk, more or less coherently.
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