Sleep apnea is a serious, potentially life-threatening breathing disorder that is characterized by brief, involuntary interruptions of breathing during sleep. There are two types of sleep apnea: obstructive and central. Obstructive sleep apnea, the most common type, occurs when air cannot ﬂow into or out of the person’s nose or mouth because of an obstruction caused by a relaxed and sagging tongue or a sagging uvula (the small piece of tissue that hangs from the center of the back of the throat) during sleep. Central sleep apnea, which is less common, occurs when the brain fails to send the proper signals to the muscles used in breathing to continue regular inhalation and exhalation during sleep.
During any given night, a person with sleep apnea may involuntarily stop breathing 20 to 30 times per hour. These pauses in breathing are usually accom- panied by snoring, although not everyone who snores has sleep apnea. The snor- ing occurs because, although the person continues to try to breathe, air cannot ﬂow easily in and out of the mouth. Choking also can occur.
During the pause in breathing, the person is unable to inhale oxygen and exhale carbon dioxide, resulting in increased levels of carbon dioxide in the blood. This increase in carbon dioxide alerts the brain to wake the person. Breathing often resumes with a loud snort or a gasp. The frequent arousal pre- vents the person from getting enough sleep and often causes early morning headaches and daytime drowsiness. Daytime concentration and performance suffer due to sleep deprivation.
Sleep apnea occurs in all age groups but is more common in men than in women. More than 12 million people in the United States are estimated to have the disorder. People most likely to have sleep apnea are those who snore loudly and also are overweight, have high blood pressure, or have a physical abnormal- ity inside the nose or upper airway. The problem appears to run in families, sug- gesting a possible genetic cause.
To diagnose sleep apnea, doctors use two tests, performed either at a sleep center or at home. One test is polysomnography, which records various body functions—such as the electrical activity of the brain, eye movement, muscle
activity, heart rate, and blood oxygen levels—during sleep. A test called the mul- tiple sleep latency test measures how fast a person falls asleep. (It takes most people 10 to 20 minutes to fall asleep; people who habitually fall asleep in fewer than 5 minutes are likely to require treatment for a sleep disorder.)
Treatment for sleep apnea depends on the underlying cause. Lifestyle changes are enough to reverse the disorder in some people. Such changes may include avoiding the use of alcohol, tobacco (see page 107), and sleeping pills, all of which can make the airway more likely to collapse during sleep. Overweight people can beneﬁt from losing weight (see page 73). People in whom sleep apnea occurs only when they sleep on their backs are advised to sleep on their sides. The most common treatment for the disorder is called continuous positive airway pressure, in which the person wears a mask over the nose during sleep so that pressure from an air blower can force air through the nasal passages. The process also helps prevent the airway from collapsing during sleep. Side effects may include nasal irritation and drying, facial skin irritation, sore eyes, headaches, and abdominal bloating. Dental appliances can reposition the lower jaw and tongue during sleep to reduce the risk of airway obstruction. Medica- tions are generally not effective for treating sleep apnea.
Some people with sleep apnea undergo surgery to increase the size of their airways. Common surgical procedures include removal of the adenoids (tissue at the back of the nasal cavity that helps the body ﬁght infection), tonsils, nasal polyps, or uvula and part of the soft palate. People with life-threatening sleep apnea may need a tracheostomy, in which a small hole is made in the windpipe and a tube is inserted through which air can ﬂow directly into the lungs while the person sleeps.
People who have narcolepsy experience such overwhelming daytime sleepi- ness—even after adequate sleep at night—that they become drowsy or fall asleep at inappropriate times and places during the day. Such “sleep attacks” can occur repeatedly during a given day and may come on without warning. Another classic symptom of narcolepsy is cataplexy (sudden episodes of loss of muscle function that cause the person to collapse suddenly or his or her neck to go limp). Sleep paralysis often occurs, preventing the affected person from moving while falling asleep or waking up. Some people also have vivid hallucinations while falling asleep. Such symptoms can seriously disrupt the person’s life and limit his or her activities.
Narcolepsy occurs in both men and women and can begin at any age. As many as 200,000 people are affected, although the problem is often underdiagnosed or misdiagnosed as depression, epilepsy, or side effects of medication. Doctors think that a disturbance in the normal order of sleep stages causes narcolepsy. Most people ﬁrst go through a stage of nonrapid eye movement (NREM) when
falling asleep, followed by a stage of rapid eye movement (REM), when dream- ing and muscle relaxation occur. In people with narcolepsy, these stages are reversed.
To diagnose narcolepsy, doctors perform two tests—polysomnography and the multiple sleep latency test (see page 356)—at a sleep center or at the per- son’s home.
There is no cure for narcolepsy, but certain treatments can relieve symptoms. Drugs called central nervous system stimulants (such as methylphenidate, dex- troamphetamine, or modaﬁnil) can help manage the excessive daytime sleepi- ness caused by narcolepsy. Antidepressants (such as amitriptyline or ﬂuoxetine) also are prescribed. An important part of treatment is scheduling short naps two to three times per day to help relieve daytime sleepiness. Some people with nar- colepsy and their families ﬁnd it helpful to join a support group where they can learn to deal with the emotional effects of the disorder, talk about occupational limitations, and ﬁnd out how to avoid situations that could cause injury.
Restless Legs Syndrome
Restless legs syndrome is a sleep disorder in which a person experiences unpleasant sensations in the legs. People who have this disorder often describe the sensations as creeping, crawling, tingling, pulling, or painful feelings in the calves, although the entire leg can be affected. These sensations can occur when the person lies down or sits for long periods, such as in bed, at a desk, or riding in a car. Moving, rubbing, or massaging the legs brings relief, at least brieﬂy. People with restless legs syndrome ﬁnd it difﬁcult to relax and fall asleep, often sleeping best during the morning hours. A lack of sufﬁcient sleep at night causes daytime drowsiness and affects performance at home and at work. Many people with restless legs syndrome have periodic limb movement, which is character- ized by involuntary jerking or bending leg movements that occur every 10 to 60 seconds during sleep.
The cause of restless legs syndrome remains unknown, but certain factors have been linked to the disorder. They include a family history of the disorder; pregnancy; low levels of iron in the blood; diseases such as kidney failure (see page 291), diabetes (see page 365), and rheumatoid arthritis (see page 309); and a high caffeine intake.
Both men and women can develop restless legs syndrome, which is more common and more severe among older people. An accurate diagnosis often depends on how well the person can describe his or her symptoms because there is no visible abnormality in the legs and there is no diagnostic test to detect the disorder. Mild cases of restless legs syndrome respond well to self-treatments such as taking a hot bath, massaging the legs, using a heating pad or an ice pack, exercising, and eliminating caffeine. More serious cases are treated with benzo- diazepines (such as clonazepam or diazepam) and opioids (such as codeine or
propoxyphene). These drugs do not cure restless legs syndrome but only treat the symptoms. Some people respond well to a nondrug treatment called transcu- taneous electric nerve stimulation (TENS), in which electrical stimulation is applied to the legs or feet for 15 to 30 minutes before bed to reduce leg jerking during sleep.
A psychosis is a serious mental disorder in which a person loses touch with real- ity and cannot tell whether he or she is having a real-life experience or an unreal one. The two most common types of psychosis are schizophrenia and delusional disorder.
Schizophrenia is a devastating brain disorder that can be extremely disabling. The ﬁrst signs of the disorder are often confusing and shocking to family and friends. Schizophrenia is characterized by profound disruptions in thought and emotion that can affect language, perception, and a person’s sense of self. It can produce a wide array of symptoms. Some symptoms, called positive symptoms, show an excess of or distortion in normal functioning. They include hearing voices or other hallucinations, delusions (such as the belief that radio or televi- sion programs are sending special messages directly to the affected person), dis- organized or incoherent speech, unpredictable agitation, purposeless and bizarre behavior, and catatonia (unawareness and rigid or unusual postures). So called negative symptoms reﬂect a loss of normal functioning. They include a ﬂat facial expression and tone of voice, a lack of speech ﬂuency, apathy, and the inability to begin or maintain any type of goal-oriented behavior. No single symptom deﬁnes the disorder, but rather a pattern of symptoms that is accompanied by difﬁculty holding a job or functioning in society. Several subtypes of schizo- phrenia, deﬁned by their predominant symptom, have been identiﬁed. For exam- ple, a person with paranoid schizophrenia is preoccupied by delusions or “hearing voices.”
Schizophrenia is often misunderstood. Many people mistakenly think that the disorder causes multiple personalities. Some people may fear that a person with schizophrenia is violent and dangerous, although most people affected with schizophrenia are not violent. The best way to think of schizophrenia is to com- pare a normal brain to a functioning telephone switching system in which the calls (in the form of perceptions) come in and are routed to the proper desti- nation. But in the brain of a person with schizophrenia, the switching system malfunctions. Incoming calls can be sent along the wrong pathway, leave the pathway, or arrive at the wrong destination. Incoming perceptions and outgoing messages become disorganized or blocked.
More than 2 million people in the United States have schizophrenia. It usually appears during young adulthood. Onset can be either sudden or gradual. Researchers have found that susceptibility to schizophrenia may be inherited, but there is also some evidence that impairment in fetal brain development may also have a role in the disorder. Many people with schizophrenia are severely disabled and stigmatized by the disorder, which affects their careers and rela- tionships.
Antipsychotic medications (such as haloperidol, thioridazine, or ﬂuphen- azine) are prescribed to treat the hallucinations and delusions that frequently occur and may also help improve emotional expression. Most of these medica- tions are taken by mouth, but seriously affected people may have to take them by injection. Antipsychotic medications can produce side effects such as muscle spasms, drowsiness, faintness, dry mouth, blurred vision, sensitivity to sunlight, and constipation. Some men who take these medications have difﬁculty with sexual function.
Only one person in ﬁve fully recovers from schizophrenia, and about 10 per- cent of affected people remain severely ill over long periods, even with treat- ment. In another 50 percent, symptoms improve, sometimes signiﬁcantly. Most people with schizophrenia will need treatment for the rest of their lives. Some people with schizophrenia may deny that they need medications and refuse to take them. Others forget to take their medications because of the disorganized thinking that is characteristic of the disease.
This behavior makes it difﬁcult to help a friend or family member who may be showing signs of schizophrenia. If you know someone who may have schizo- phrenia, you may be more successful in getting him or her to seek treatment by focusing on one symptom, such as depression or difﬁculty sleeping. Above all, try to maintain a caring, helpful manner when approaching someone who may have this type of psychotic disorder, since they often are anxious and suspicious of others.
Many people with schizophrenia have delusions (tenaciously held false beliefs), but not all people with delusions have schizophrenia. Doctors diagnose a person with a delusional disorder if he or she has a persistent delusion that involves a situation that could occur in daily life, such as being poisoned or followed, but shows no other signs of schizophrenia. Aside from the odd manifestations of the delusion, the person’s behavior is not unusual, and his or her functioning at home and work is not impaired.
Delusions fall into a number of distinct categories. The most common type of delusion is that of persecution by others. People with this type of delusional dis- order believe that their friends, family, or coworkers are conspiring to drug or spy on them or to ruin their reputations.
Another form of delusional disorder that is frequently encountered is delu- sional jealousy, in which the person takes everyday occurrences, such as a part- ner’s returning home a bit late from work, as evidence of unfaithfulness. Erotic delusions compel the affected person to believe that he or she is loved by some- one with high status, such as the president of the company he or she works for or a famous actor. People who have grandiose delusions believe that they have spe- cial powers that could save the world or cure a disease. Delusional disorder also can take the form of somatic delusions, in which the person thinks that there is something seriously wrong with his or her body—that it is misshapen, produces a foul odor, or has insects crawling on it.
The treatment of choice for a delusional disorder is drug therapy, but drugs are not always successful in treating the disorder. Delusions that persist for a long period can be difﬁcult for doctors to treat. If the affected person is unable to function in daily life, or if he or she poses a threat to himself or herself or others, the person will have to be hospitalized.
Living with a Person Who Has a Mental Disorder
About 51 million people in the United States have some form of emotional or mental disorder. Because mental illness is so common, many Americans cope with the day-to-day struggle of sharing a home with a person who is mentally ill. Living with a person who has a mental disorder can be challenging and stressful, and most family members are not adequately prepared for the experience. Many families also fear the stigma that still surrounds many types of mental illness. But effective treatments exist for many mental disorders, and help is readily available. The ﬁrst step in dealing with a loved one’s problems is to recognize the warning signs of a mental disorder:
• confused thinking
• long periods of depression
• extreme mood swings (from elation to sadness)
• high levels of fear, worry, or anxiety
• withdrawal from people and activities
• signiﬁcant changes in eating or sleeping habits
• delusions or hallucinations
• thoughts of suicide or homicide
• denying the existence of a problem
• unexplained physical illnesses
• substance abuse
The symptoms of many mental disorders are similar, so many families share the same experiences. The behaviors—including withdrawal, angry outbursts, or
disorganized speech—that characterize certain mental disorders can be shocking and embarrassing when performed in public. If you are in such a situation, remember that the person cannot help what he or she is doing. Try to encourage the person to move to a more private place until he or she is calm. Discuss with the person’s doctor what to do in such situations so that you can be prepared the next time.
To help ﬁght the stigma of mental illness, you can become an advocate for your loved one. Ask the doctor about the person’s speciﬁc needs and try to ﬁll them. For example, someone who has delusional disorder (see page 360) may be able to hold a job but may need an understanding boss who is willing to overlook the person’s delusional behavior as long as it does not interfere with work. Many people have misconceptions about mental illness; you can work to correct these misconceptions and help them change their attitudes and the way they interact with people who are mentally ill.
Many people who live with someone who has a mental disorder ﬁnd it helpful to join a support group. These groups offer a protective environment in which you can share your concerns and learn coping strategies from people who face similar challenges. If there is no local support group that deals with your partic- ular situation, consider starting one. Other people in similar situations may be happy to participate.
Family or individual counseling often beneﬁts partners or family members. A therapist or counselor familiar with the type of mental disorder involved can teach you about the disorder and suggest ways to handle typical situations you may encounter. Talk to a number of therapists before beginning counseling to ﬁnd one who is knowledgeable about the disorder and with whom you feel com- fortable.
Having a person with a mental disorder in the family alters the dynamics of family life. The affected person tends to become the focal point around which family life revolves. Caregivers or other family members can often feel slighted and overwhelmed, and may become resentful. Children, especially, can feel ignored. They also may feel embarrassed when an insensitive friend makes fun of the affected person. It is important to try to balance the needs of the person with the needs of the other members of your household. Plan special activities with the other members of your family—especially your children—to make them feel included and to draw you together as a family.
Caregivers can easily become overwhelmed by their responsibilities. Because of this, you should not attempt to handle everything yourself; the full responsi- bility of caregiving should never fall on one person. A caregiver who is on call
24 hours a day will burn out quickly. Schedule regular breaks from your care- giving duties. When you need an unscheduled break, arrange to have a depend- able relative or a friend ﬁll in for you.
Keep an updated list of things that need to be done. Identify as many people as possible who can provide help. Every member of your household can participate or contribute in some way. Ask your friends and relatives, too. Offer them choices from your list, such as doing chores, running errands, preparing meals, making telephone calls, and providing company. Be direct. Do not hesitate to ask for help whenever you need it.
If family members or friends cannot help, contact volunteer and community organizations, as well as your doctor and local hospitals and health organiza- tions. If you belong to a support group, ask the group members for suggestions. You also may want to hire a professional caregiver through a licensed home health agency, such as a visiting nurse association.
Caring for yourself is an essential part of being a caregiver. To succeed as a caregiver, it is vital that you follow a healthy lifestyle. Eat a nutritious, well- balanced diet (see page 4), exercise regularly (see page 11), do not smoke (see page 107), and get plenty of sleep. Try to limit your intake of caffeine and alco- hol. And be sure to use relaxation techniques (see page 119), such as meditation and deep-breathing exercises, to relieve stress.