A psychiatrist thinks an OSA patient has also hypochondria

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papzombie
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A psychiatrist thinks an OSA patient has also hypochondria

Post by papzombie » Mon Dec 05, 2016 12:11 pm

Dear all,

Asian nose, BMI = 26, living in Europe. I have had severe OSA (AHI = 40), 8 months on CPAP with super good AHI = 0.5, but am still tired (with all typical ex-OSA symptoms: memory, concentration, fatigue, quickly get anger, depression, slow thinking, slow in decision making, bad multi-tasking). I have been actively trying to look for the reasons. Now the psychiatrist thinks I have a hypochondriac, but I think I am only actively looking for the answer.

History with Hospital A with OSA
- First polysomnography (measuring many (10 ?) points on my body) in Feb 2016 found that I have severe OSA
- One night at that hospital sleeping with the CPAP, with only a pulse oxymeter on my finger to find out that 6 cm H2O is needed for the CPAP
- I complain that I still feel tired, then Hospital A agreed to increase to 8cm H2O.
- Since June 2016 I increase to 9cm H2O, and stay with it until now
- In Oct 2016 a MRI scan says that my brain is OK: no damage visible on that MRI.

History with my GP: I kept asking for more blood check (3 times this year)
- Vitamin D level: very low in June 2016, became later normal in October
- Other stuffs are normal: magnesium, ferritine, Vitamin B1, B12, B6, thyroid

History with Hospital B: where they treat my liver
- Since 2014 it was found that I have Hepatitis-B, and a bit high ALT & AST, a bit liver fatness.
- Nov 2016 a liver biopsy was done, seems normal, yet still they don't know why my ALT & AST was high
- Hospital B does not think that my liver problem is the source of my cognitive or mood problems.
- May 2017 will come back for a check.

Because I am still tired, I went to another hospital: Hospital C in November:
History with Hospital C
- With the WatchPAT-200 measuring my chest and finger, it was found that I wake up 2-3 times per hour, a total of 16 times on that night (8h30m on bed, 6h30m sleeping). Learning also that I have a huge problem at work that makes me think about it all the day, the sleep doctor in Hospital C thinks I have a psycho-physiological issue, and suggests a CBT-I (cognitive behavioral therapy for insomnia).
- I need to find someone specializing in CBT-I to work with.
- Since 2 month I don't have to deal with the problem at work anymore, but I still feel bad, so I am not sure if the "psycho-physiological issue" there is relevant.

History with a Psychiatry
- No sign of ADHD (unlike suggested by my GP)
- Suspected problems are: depression, anger disorder, anxiety disorder
- I was given the choice of Mirtazapine (3.5mg/day), Trazodone (light dose), or Quetiapine to treat those psychologist problems and also to help my sleep.
- I opted for Mirtazapine 3.5mg, used for 7 days, then increased to 7.5mg since 3 days. No clear sign of betterness.

I do video recording myself in later November:
- Each 15-20 minutes, I have a movement. Sometimes I just turn my neck, sometimes change sleep position
- About 30% of the time I move, then I scratch my face, or scratch my nose, or fix the position of the mask.
- I don't see leg or arm movements that are similar to a RLS or PLMD.
- Due to the strange video file format (.h264 file), I am not yet able to play those files correctly to be able to synchronize these movements with the events marked by my machine.

My observation relating to oxygen
- Window opening: I always need to open the window and room door a bit to have air ventilated, if the opening of those window/door is not enough, then I remember having more dream (either I have more dream, or I wake up more after dreaming and hence I remember that I have more dream), and in the morning I would feel more tired. My wife does not complain about the window not opened enough.
- Wearing mask while awake: In the evening if I wear the mask to work, then I have more concentration.

My remaining questions why I still have all problems
- Does the mask cause one part of my awakenings ?
- Can a possible Upper Airway Resistence wake me up ?
- Am I having an over sensitivity to oxygen ?
- Does a real Polysomnography with CPAP helps to synchronize my body movements to the awakenings ?
- Is there another reason than the psycho-physiologist issue ?

What my doctors think about me
- Doctors in Hospital A only care about OSA, they believe I must be fine now. One time I discussed about a possible UARS that my CPAP machine cannot detect, they think that OSA is also a sort of Upper Airways Resistence and that my AHI < 1.0 shows that I should not care about UARS. These doctors in Hospital A does not want to hear me anymore. They don't pay attention to my complain about window opening, and they find that very strange that I think wearing the mask helps my concentration.
- GP thinks I bother him too much with to many questions, he even thinks I have ADHD basing on my communication with him. That's why I was sent to a psychiatry.
- Psychologist and Psychiatrist in that Psychiatry first listened to me, seemed to be with me, think that I am intelligent. But then after hearing that I am not satisfied with many doctor's opinions and now want to do a Polysomnography with CPAP, together with the fact that I do video recording of my sleep, now they think I have a Hypochondriasis: "Even if it is because that currently the doctors don't know yet what cause your problem, or because there is a difference in opinion between doctor in this country and other European countries or US, what you show now make me think you might have a hypochondriasis". Both the GP and those psychologist/psychiatrist think that there is no reason to do a Polysomnography with CPAP, given that the WatchPAT has said I have 16 awakenings per night.

What do you think I should do ?

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Last edited by papzombie on Sat Dec 10, 2016 8:08 am, edited 14 times in total.
AHI = 0.7, wake up 3 times per hour, always tired

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 12:23 pm

Something additional: I always have a feeling of a pain on my chest upon waking up, and I could burp like after drinking 250ml Cocacola. This pain disappears after 15 minutes, not sure if that's aerophagia.

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AHI = 0.7, wake up 3 times per hour, always tired

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by 49er » Mon Dec 05, 2016 1:03 pm

Papzombie,

As one who has some unusual sleep issues that so far remain a mystery, I feel your pain big time. Do you have the option of seeing another doctor? If that is a possibility, what about keeping a strict symptom diary in the hopes that might motivate a doctor to look outside the box. Now, I am not sure how things work in your country but one negative I see in this recommendation for the US is that many doctors aren't interested in doing that.

You might have to speak to a staff member ahead of time to make sure this is something the doctor would work with you on. But if they are, it could be a very valuable diagnosis tool.

Regarding diet, have you tried a ketogenic diet as many people find it helps with excess sleepiness?

Finally, a certain percentage of people (not sure exact number but below 50%) find that even with optimized therapy, the excess sleepiness doesn't do away and give stimulants like Provigil a try. Might that be a possibility for you?

Best of luck.

49er

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by robysue » Mon Dec 05, 2016 1:31 pm

papzombie,

I am sorry that you are still having real problems.
papzombie wrote:Because I am still tired, I went to another hospital: Hospital C in November:
History with Hospital C
- With the WatchPAT-200 measuring my chest and finger, it was found that I wake up 2-3 times per hour, a total of 16 times on that night (8h30m on bed, 6h30m sleeping). Learning also that I have a huge problem at work that makes me think about it all the day, the sleep doctor in Hospital C thinks I have a psycho-physiological issue, and suggests a CBT-I (cognitive behavioral therapy for insomnia).
- I need to find someone specializing in CBT-I to work with.
- Since 2 month I don't have to deal with the problem at work anymore, but I still feel bad, so I am not sure if the "psycho-physiological issue" there is relevant.
I still think that pursuing the CBT-I is a good idea. The idea behind CBT-I is to figure out a way to teach your body to not wake up as much and your mind to not worry as much about the wakes that do happen.

I do video recording myself in later November:
- Each 15-20 minutes, I have a movement. Sometimes I just turn my neck, sometimes change sleep position
- About 30% of the time I move, then I scratch my face, or scratch my nose, or fix the position of the mask.
- I don't see leg or arm movements that are similar to a RLS or PLMD.
- Due to the strange video file format (.h264 file), I am not yet able to play those files correctly to be able to synchronize these movements with the events marked by my machine.
Turning over in bed and moving your head around are not necessarily signs that you are not sleeping well---particularly if the movement is isolated. I.e. If you change position and it's another good 20 minutes before you move again, then that may just be that you are an "active" sleeper---someone who just moves a lot when you're in Stage 2 sleep. (And Stage 2 sleep makes up about 50-60% of normal sleep.)

The face/nose scratching and mask fiddling could be an indicator that the mask's presence is triggering some possible spontaneous arousals. Or it could be that you just have an itchy nose and you'd be doing this in your sleep even without the mask.

I think the real way to get an idea on the number of actual wakes you have every night is to simply try turning the machine off and back on whenever you find yourself awake during the night. That won't track arousals, but it should get at closely approximating the number of real wakes.

History with a Psychiatry
- No sign of ADHD (unlike suggested by my GP)
- Suspected problems are: depression, anger disorder, anxiety disorder
- I was given the choice of Mirtazapine (3.5mg/day), Trazodone (light dose), or Quetiapine to treat those psychologist problems and also to help my sleep.
- I opted for Mirtazapine 3.5mg, used for 7 days, then increased to 7.5mg since 3 days. No clear sign of betterness.
Are there plans to increase the Mirtazapine further? Here in the states, the usual starting dose for Mirtazapine seems to be 15mg once a day at bedtime. But there's also a caution about using it if there are any liver problems.
My observation relating to oxygen
- Window opening: I always need to open the window and room door a bit to have air ventilated, if the opening of those window/door is not enough, then I remember having more dream (either I have more dream, or I wake up more after dreaming and hence I remember that I have more dream, in the morning I would feel more tired. My wife does not complain about the window opening.
- Wearing mask while awake: In the evening if I wear the mask to work, then I have more concentration.
I'm not sure why you think this is an oxygen problem. The room air and the side air contain the same concentration of oxygen. And the CPAP does not increase the oxygen in the air you breathe. It simply holds your airway open so that you don't have O2 desats caused by the collapse of your airway at night.

My guess is that you simply dislike "stale" or "stagnant" air, and having the window open allows for fresh air to come into your bedroom. It's not that the 'fresh' air has more oxygen; it's that the fresh air smells 'fresher' than the stale, stagnant room air. My guess is that what wakes you up when the window is not open is that you just get too hot since you are used to sleeping with the window open.

As for why wearing the mask while awake in the evening gives you better concentration? I haven't the foggiest idea. I suspect, however, that with the mask on you are not worry about your O2 levels dropping because you are breathing room air. Out of curiosity: Does opening the window of the room you are working in, but not using a CPAP mask while awake also help you concentrate in the evening?

My remaining questions why I still have all problems
- Does the mask cause one part of my awakenings ?
- Can a possible Upper Airway Resistence wake me up ?
- Am I having an over sensitivity to oxygen ?
- Does a real Polysomnography with CPAP helps to synchronize my body movements to the awakenings ?
- Is there another reason than the psycho-physiologist issue ?
If you are not totally comfortable when you are sleeping with the mask and some of that discomfort comes from stimuli coming from the machine, then the mask might be contributing to some spontaneous arousals.

Without examining a great deal of your wave flow data on a breath-by-breath level, there's no good way to automatically say UARS explains your on-going problems. On the other hand, there's also no way to eliminate that as a cause of your symptoms.

I don't know what you mean by "over sensitivity to oxygen" since all the air you are breathing has the same O2 content since you are NOT using an O2 concentrator as far as I know. I do think you may have a bit of a sensitivity to stale room air, most likely based on either "smell" (even if you can't identify it) or the desire to have moving air in your environment.

A real PSG with your CPAP may or may not "synchronize my body movements to the awakenings". But it should show whether you are still experiencing a large number of spontaneous arousals while using the machine.

"Is there another reason than the psycho-physiologist issue ?" Bad sleep has lots of causes. The CBT-I would help you get at whether any of your sleep related behaviors are making the problem worse than it needs to be.
What do you think I should do ?
Get the CBT-I started.

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 1:42 pm

49er wrote:Papzombie,

As one who has some unusual sleep issues that so far remain a mystery, I feel your pain big time.
Thanks for sharing the feeling
Do you have the option of seeing another doctor? If that is a possibility, what about keeping a strict symptom diary in the hopes that might motivate a doctor to look outside the box. Now, I am not sure how things work in your country but one negative I see in this recommendation for the US is that many doctors aren't interested in doing that.

You might have to speak to a staff member ahead of time to make sure this is something the doctor would work with you on. But if they are, it could be a very valuable diagnosis tool.
I still have the option, but this time I need to win (ie. to be rather sure that going to that doctor would help find something). Because so far I have got about 5 requests, but only 2 was fruitful (vitamin D shortage, or sleep in Hospital C finds that I wake up too much).

About making a strict symptom diary: i did have it, but the doctor don't seem to like reading it. Partly because they don't want to read English (not their mother tongue), or partly it's not their habit. I am afraid that if I show I make such a diary, I would be seen more Hypochondriac.
Regarding diet, have you tried a ketogenic diet as many people find it helps with excess sleepiness?

Finally, a certain percentage of people (not sure exact number but below 50%) find that even with optimized therapy, the excess sleepiness doesn't do away and give stimulants like Provigil a try. Might that be a possibility for you?
49er
I don't seem to be sleepy much after CPAP, only that I always have a feeling of not having slept enough: pressure at the forehead and top of the head, feel just weird. Why sleep not enough: the worst night (the night I wake up more often, remember more dream, feeling more tired immediately at waking up) is 100% correlated with the worst symptom of that weird feeling on my head; and the best night would only result in the slightest form of that weird feeling: a bit like I have drunk some alcohol early in the morning.

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by rick blaine » Mon Dec 05, 2016 1:59 pm

Hi papzombie,

If I read you correctly, (i) you were tired before being diagnosed with OSA and starting CPAP therapy, but you are still tired after, and in spite of, the CPAP therapy.

You also report (ii) various psychological changes - poor memory, trouble concentrating, irritability, and depression. And I especially note "air hunger" - the phrase I use for the feeling you have of the air needing to be "ventilated" by having the windows open.

And thirdly, I note that (iii) you've had numerous examinations and tests - none of which shows anything organic.

All of these together suggest that you might have hyper-ventilation syndrome, or HVS.

As a brief explanation - poor breathing habits, the kind which lead to an imbalance of blood gases - which imbalance, if it's 'kept up' long enough, can produce a whole range of symptoms, including the ones you list here.

The remedy is breathing exercises - which are best taught to you by a breathing physiologist - someone who sees you over a number of weeks, since you have to learn new breathing habits and make them automatic.

You might go back to your GP and gently suggest that HVS is another possible explanation - one that is at least worth checking out. And then he can refer you to a breathing physiologist, probably one who works in a hospital lung-function department, for an opinion.
Last edited by rick blaine on Mon Dec 05, 2016 2:15 pm, edited 3 times in total.

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by 49er » Mon Dec 05, 2016 2:02 pm

"""I don't seem to be sleepy much after CPAP, only that I always have a feeling of not having slept enough: pressure at the forehead and top of the head, feel just weird. Why sleep not enough: the worst night (the night I wake up more often, remember more dream, feeling more tired immediately at waking up) is 100% correlated with the worst symptom of that weird feeling on my head; and the best night would only result in the slightest form of that weird feeling: a bit like I have drunk some alcohol early in the morning.""

Ok, I am confused because in your initial post, you said, ""I live in Europe, have severe OSA, 8 months on CPAP with super good AHI, but am still tired (with all typical ex-OSA symptoms: memory, concentration, fatigue, quickly get anger, depression). I have been actively trying to look for the reasons. Now the psychiatrist thinks I have a hypochondriac, but I think I am only actively looking for the answer.""

I think the reason I am confused is during my rare good nights on the machine, even though I didn't sleep enough, the quality was so good that I still have good concentration and memory even though I had to take frequent breaks. I also didn't feel fatigue or depression.

But maybe my experience is different from yours.

Anyway, RobySue mentioned the CBT-I which you had talked about previously. Where are you with that?

49er

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 2:04 pm

Hi Robysue,
As always: thanks for reading me.

I'll answer you more fully, for now I'll explain the oxygen problem.

1) Opening window: In a sealed box, one person consumes O2 and emits CO2, the oxygen density is quickly decreased to zero. In another box, also sealed but with one small hole, that person consumes O2 quicklier than the small hole could provide, i.e. the oxygen density also decreases to zero, but more slowly. In both of the cases, the person would find the air "more and more heavy" because their lung works more heavily to get enough oxygen.

My room without opening the window enough is like that 2nd box to a sleeping person. I wake up feeling "heavy air", while an awake person (e.g. could be the same me) might find the room's air just normal. What could be the difference ? Probably: the sleeping lung pumps less than an awake lung. So a sleepy lung in a underventilated room would pump less oxygen to the blood.

2) Working with CPAP: probably that my lung sometimes subconsciously not pumps enough, then the increased air flow fix it. The same effect I find in the evening: breath deeply expressively (Taichi or Qigong or simply just some deep breath).

I have not yet observed the difference between with or without window opening, while I sit-and-work in the evening. But I do find walking outside while thinking help boost my brain productivity up to 2 times.

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by LSAT » Mon Dec 05, 2016 2:30 pm

papzombie wrote:Hi Robysue,
As always: thanks for reading me.

I'll answer you more fully, for now I'll explain the oxygen problem.

1) Opening window: In a sealed box, one person consumes O2 and emits CO2, the oxygen density is quickly decreased to zero. In another box, also sealed but with one small hole, that person consumes O2 quicklier than the small hole could provide, i.e. the oxygen density also decreases to zero, but more slowly. In both of the cases, the person would find the air "more and more heavy" because their lung works more heavily to get enough oxygen.

My room without opening the window enough is like that 2nd box to a sleeping person. I wake up feeling "heavy air", while an awake person (e.g. could be the same me) might find the room's air just normal. What could be the difference ? Probably: the sleeping lung pumps less than an awake lung. So a sleepy lung in a underventilated room would pump less oxygen to the blood.

2) Working with CPAP: probably that my lung sometimes subconsciously not pumps enough, then the increased air flow fix it. The same effect I find in the evening: breath deeply expressively (Taichi or Qigong or simply just some deep breath).

I have not yet observed the difference between with or without window opening, while I sit-and-work in the evening. But I do find walking outside while thinking help boost my brain productivity up to 2 times.
1. Lungs do not pump oxygen...the heart does
2. Why not wear an O2 sensor to measure your Oxygen levels at different times
3. Humidity can make air heavier

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 2:31 pm

@Robysue and 49er: I will start CBT-I soon.

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 2:38 pm

LSAT wrote: 1. Lungs do not pump oxygen...the heart does
2. Why not wear an O2 sensor to measure your Oxygen levels at different times
3. Humidity can make air heavier
Hi there
1. Sorry, I thought the lung filter O2 out of the air, gives it to the heart and then the heart pumps oxygen to the blood.
2. Yeah, good idea, I do measure O2 using a Pulse spirometry, measure various time with normal result. But I forgot using it with (1) Sleeping while window is not opened enough, (2) do some reading / watching movie in the evening
3. Humidity: would pay attention to it if I find a pattern relating to my symptoms.

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 2:54 pm

@ALL: Do you think what I experience is not real, or not that big ? Do I really have hypochondriasis like what the psychiatrist thinks ?

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Re: Hypochondriac: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 3:25 pm

robysue wrote:papzombie,
Turning over in bed and moving your head around are not necessarily signs that you are not sleeping well---particularly if the movement is isolated. I.e. If you change position and it's another good 20 minutes before you move again, then that may just be that you are an "active" sleeper---someone who just moves a lot when you're in Stage 2 sleep. (And Stage 2 sleep makes up about 50-60% of normal sleep.)
It is good to know it might be normal.
The face/nose scratching and mask fiddling could be an indicator that the mask's presence is triggering some possible spontaneous arousals. Or it could be that you just have an itchy nose and you'd be doing this in your sleep even without the mask.
I will make a video sleeping NOT with cpap, will be like a horror movie I guess:-).
I think the real way to get an idea on the number of actual wakes you have every night is to simply try turning the machine off and back on whenever you find yourself awake during the night. That won't track arousals, but it should get at closely approximating the number of real wakes.
I've set up the CPAP to my arm's reach, will see if I'll remember it tonight.
Are there plans to increase the Mirtazapine further? Here in the states, the usual starting dose for Mirtazapine seems to be 15mg once a day at bedtime. But there's also a caution about using it if there are any liver problems.
The pyschiatrist says low dosed Mirtazapine helps my sleep. Higher dose is to treat depression, and it might harm my sleep.
My guess is that you simply dislike "stale" or "stagnant" air, and having the window open allows for fresh air to come into your bedroom. It's not that the 'fresh' air has more oxygen; it's that the fresh air smells 'fresher' than the stale, stagnant room air. My guess is that what wakes you up when the window is not open is that you just get too hot since you are used to sleeping with the window open.
I don't know. About "stale"/ '"stagnant" or "used to fresh/cold air", then I have the following information: I grow up in a tropical country with a lot of air ventilation even in winter. When I moved to the colder part of Europe I started finding that I need window to open a bit, because windows here are so air-isolated.
As for why wearing the mask while awake in the evening gives you better concentration? I haven't the foggiest idea. I suspect, however, that with the mask on you are not worry about your O2 levels dropping because you are breathing room air. Out of curiosity: Does opening the window of the room you are working in, but not using a CPAP mask while awake also help you concentrate in the evening?
I answer you in my other post.

Without examining a great deal of your wave flow data on a breath-by-breath level, there's no good way to automatically say UARS explains your on-going problems. On the other hand, there's also no way to eliminate that as a cause of your symptoms.
Questions:
- The sleep doctor in Hospital C says the WatchPAT-200 is sensitive enough to also be able to detect UARS, and no UARS was found. Is that true ? Itamar website does not say so.
- The lung doctor in Hospital A says Apnea is also an Upper Airway Resistance, so when AHI is low it means UARS is also treated. I don't agree with him. Who is right here ? Or upon seeing that RERA is also low (~ 0.5), we can safely say UARS is not severe enough to cause my problem ?
A real PSG with your CPAP may or may not "synchronize my body movements to the awakenings". But it should show whether you are still experiencing a large number of spontaneous arousals while using the machine.
Question: Do you think a real PSG can do something to me that the WatchPAT-200 (measuring only the chest and the finger) cannot ?

"Is there another reason than the psycho-physiologist issue ?" Bad sleep has lots of causes. The CBT-I would help you get at whether any of your sleep related behaviors are making the problem worse than it needs to be.

Question: Do I need to purchase the Sleepio subscription ? It's 300 per year, a bit expensive.

Thanks.

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Re: Hypochondria: what my psychiatrist thinks I might have

Post by papzombie » Mon Dec 05, 2016 3:36 pm

rick blaine wrote: All of these together suggest that you might have hyper-ventilation syndrome, or HVS.
This is a good pointer, I have read https://en.wikipedia.org/wiki/Hyperventilation_syndrome, and will read more to see if it applies to me.

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robysue
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Re: Hypochondria: what my psychiatrist thinks I might have

Post by robysue » Mon Dec 05, 2016 4:40 pm

papzombie wrote: 1) Opening window: In a sealed box, one person consumes O2 and emits CO2, the oxygen density is quickly decreased to zero.
The box must be relatively small AND airtight for the O2 to drop close enough to 0 to be life threatening. Buildings are not airtight and your room is actually quite large. In other words, the problem that you are worrying about just make sense because you are not sleeping in a small enclosed, unventilated space like a cupboard or a refrigerator.
In another box, also sealed but with one small hole, that person consumes O2 quicklier than the small hole could provide, i.e. the oxygen density also decreases to zero, but more slowly. In both of the cases, the person would find the air "more and more heavy" because their lung works more heavily to get enough oxygen.
I'm not sure I fully understand what you are saying. If the hole in the box is not sufficient to provide proper ventilation, then I suppose death by suffocation might take a bit longer. But the analogy breaks down when we are talking about sleeping in an ordinary building in an ordinary bedroom which is not small enough or airtight enough to pose any kind of suffocation risk.

As for the air feeling "heavy"---that comes usually from whether there is a lot of humidity in the air rather than the O2 content of the air. The air on top of Mt. Everest so thin that it does not contain enough O2 to keep a human body properly oxygenated, but I don't think climbers describe the air as "too heavy". Conversely, the air in a dense hot jungle may feel oppressively heavy, but it has plenty of O2 to keep a human oxygenated.
My room without opening the window enough is like that 2nd box to a sleeping person.
The body requires less ventilation during sleep and that's why the tidal volume goes down and the respiratory rate slows when we're soundly asleep. The body maintains roughly the same SpO2 during sleep as wake because the decreased activity in the body uses up less O2. That actually means that our lungs are doing less work, not more, when we are asleep. Moreover, since the lungs are taking in less air (and oxygen) by volume in each breath while asleep, then in theory that would mean that it would take a longer time to deplete the O2 in a small, unventilated space while asleep as compared to when awake. But again, your bedroom is not a small, unventilated space: It's a room in an ordinary building.

I have not yet observed the difference between with or without window opening, while I sit-and-work in the evening.
Since you breath more deeply and use more oxygen when you are sitting and working as compared to when you are sleeping, and you don't have any sensation that the room's O2 being depleted when you are awake, I think you may have developed an unreasonable fear of suffocation while asleep at some point. One common source of "fear of suffocation while asleep" is untreated OSA since each OA is in fact a mini-suffocation event. It could be that your brain is having a very difficult time understanding that you are no longer in danger of suffocation (from an obstructive apnea) as long as you sleep with the CPAP.
2) Working with CPAP: probably that my lung sometimes subconsciously not pumps enough, then the increased air flow fix it. The same effect I find in the evening: breath deeply expressively (Taichi or Qigong or simply just some deep breath).
It is unlikely that your lungs fail to inhale enough oxygen when you are sleeping with the CPAP. But breathing too deeply for too long (hyperventilating) causes a whole host of problems because breathing too deeply for too long can mess up the CO2 levels in the blood by over depleting them. Symptoms of hyperventilation include feeling lightheaded, having a rapid heartbeat, and being short of breath. It also can lead to numbness or tingling in your hands or feet, anxiety, fainting, and sore chest muscles. It could be that the CPAP is encouraging you to hyperventilate a bit when you are awake and using it while trying to get to sleep or get back to sleep after a middle of the night wake.

I wake up feeling "heavy air", while an awake person (e.g. could be the same me) might find the room's air just normal. What could be the difference ? Probably: the sleeping lung pumps less than an awake lung. So a sleepy lung in a underventilated room would pump less oxygen to the blood.
The sleeping body needs less new O2 taken in on each breath to maintain the desired level SpO2 levels. So respiration slows down and tidal volume goes down when you fall asleep. Hence a sleeping body should be just as happy with the O2 content in the room's air as an awake body does.

If you wake up feeling like the air coming through the hose is "heavy" that could be a sign that you have the humidifier set too high. Not everybody's nose and upper airway likes sleeping in a jungle, and if you have the humidifier maxed out the excess humidity might be the cause of waking up feeling like the air is "heavy"

But I do find walking outside while thinking help boost my brain productivity up to 2 times.
A lot of people find this to be true. There is something about getting outside and being physically active that really helps the whole body, including the brain. In the US a lot of people will say that they're going for a walk "to clear their head". They don't mean to drain their sinuses; they mean to clear their mind and to help refocus their mind on whatever they want to focus on.

Finally I'll reiterate a point that someone else has made: If you are really worried that your SpO2 levels drop during sleep, get a recording oxymeter to find out whether they really drop or not. Make sure that the time on the oxymeter is properly synced with your CPAP's clock so that you can try to correlate any serious drops in SpO2 with obstructive events.

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