30.05.2014
Most of us understand what anxiety is; after all, we have all felt fear and uncertainty at some point in time.
Anxiety disorders encompass a variety of mental blocks and phobias which result in the patient becoming overwhelmed by a sense of fear, hopelessness and panic. It is common for people with sleep apnea to have various types of psychological problems like depression, irritability, reduced memory, focusing problems, etc.
A specific type of anxiety disorder called the General anxiety disorder (GAD – anxiety lasting for more than 6 months) is most frequently associated with sleep interruptions.
A sleep apnea patient is most likely to show symptoms of a panic attack (according to The Diagnostic and Statistical Manual of Mental Disorders) including excessive sweating, trembling of hands, choking or asphyxiation, nausea and vomiting, pain in the chest, inability to identify oneself, fear of loss of control, fear of dying (very common with apnea sufferers), etc. It was shown in a recent study involving 301 subjects showed that sleep apnea can be responsible for panic attacks in sleep, or nighttime panic disorder. One of the side effects of sleep apnea is lowering oxygen and increasing carbon dioxide levels in the blood. Sleep panic attacks are considered to be continuation of daytime feelings of extreme anxiety and stress. Though sleep apnea may not directly cause nighttime panic attacks, but the two conditions share a lot of common symptoms, to the extent that an apnea episode closely resembles a panic attack. It is also to be noted that carbon dioxide levels are higher than normal with people who have nighttime panic attacks, even when the individual does not suffer from sleep apnea.
While recurrent breathlessness associated with sleep apnea results in repeated awakenings for sleep, they are not associated with symptoms of great anxiety. Thus it is logical to conclude that when shallow breathing of sleep apnea causes oxygen depletion and increase of carbon dioxide levels, the result is an engulfing sense of fear and panic.
In any case, anxiety is a rather complicated mental condition which shows up by way of various emotional and physiological signs. It has been observed that people who have panic attacks in sleep have what is medically known as beta-adrenergic hyperresponsiveness (relates to excessive responses of certain receptors of the heart that results in palpitations, discomfort of the chest, etc). To understand how this happens you have to recall the different stages of sleep including light, REM sleep and the non-REM sleep or the deep restorative phase.
While CPAP therapy could have been the ideal choice for managing sleep apnea symptoms, it is rather difficult to treat a patient of panic attacks with this therapy because the sensation of claustrophobia after mask use may result in discontinuation.
Changing sleeping posture, sleep apnea dental appliances, sleep apnea pillows, etc are effective alternatives to CPAP usable by apnea patients who have panic attacks.


Over and above losing weight, quitting alcohol, altering sleeping position, etc the sleep apnea patient can simultaneously practice good sleep hygiene to get relief from the distressful symptoms. Primarily caused by either physical or mental stress, these feelings of fear, etc are mostly temporary.
Similarly, sleep apnea is also closely linked to panic attacks in sleep (also called nocturnal panic attacks).  This could explain the recurrence of anxiety during the day culminating in panic attacks at night for the apnea patient. This particular disorder shares a lot of common symptoms with sleep apnea, like tiredness, diminished ability to concentrate, irritability, etc.
This during diagnosis of nighttime panic disorder, a differential diagnosis (a process of diagnosing a disorder whichdoes not display any unique sign) of sleep apnea is necessary. This causes sleep interruption throughout the night.  A chain reaction sets in that are biochemical in origin, which along with the over-active nervous system makes one stressed, anxious and irritable.
While these people have chronic conditions, another 20 million have sleep problems which are temporary in nature.
Though no causal factors have yet been identified, there are a few medical conditions which increase the risk for developing panic disorders including panic attacks – and sleep apnea is one of them. In fact, 70% of those who experience daytime panic symptoms would experience them during sleep also.  The reason why they happen is not known but researchers have hypothesized on some possible factors.
Pauses in breathing not only cause drop in oxygen (responsible for fast breathing and the heart to beat faster), which leads to an increase of stress hormones. During diagnosis of panic attacks which occur during sleep, doctors usually check whether the patient is suffering from co-existent hypoglycemia, hyperthyroidism, any anxiety disorder related to trauma etc, but never relates sleep apnea with this condition.
However, sleep apnea is likely to be responsible for the onset of panic attacks because of the ailment’s impact on blood pressure and heart beats. Poor lifestyle choices and feeling stress often are two reasons why people develop anxiety disorders. Other than caffeine and stress, sleep apnea is capable of triggering nighttime panic attacks by releasing excess adrenalin when the upper airway collapses.
It over-relaxes the muscles of the throat, which in turn can collapse and block the airways during sleep. Therefore, patients who report symptoms of panic attacks should be tested for the sleep apnea, to rule out the ailment as a possible cause. Then they advise the patient to make some lifestyle modifications like giving up alcohol, caffeine, etc, followed by evaluating sleep apnea.


Undiagnosed sleep apnea can result in panic attacks sooner or later; thus it makes sense to get evaluated for sleep apnea if you experience any symptom.
For example, medications for inducing sleep, Cognitive Behavioral Therapy, relaxation techniques can reduce the symptoms of anxiety and panic disorders.  Meditation, doing physical exercise, effective time management, etc can be effective stress busters and improve quality of sleep. However, the same feelings, when they persist for 6 months or more and the condition deteriorates when left untreated, is often referred to as anxiety disorders. On the other hand a person who has panic attacks show symptoms which are very similar to signs displayed by an apnea patients. Additionally, when the tongue recedes back during breathing, choking the upper airway, the apnea patient wakes up with a jerk, mostly in a panic-ridden state. It has also been found that sleep apnea could worsen the symptoms of Post Traumatic Stress Disorder, yet another type of anxiety disorder.
These include current sleep problems, malfunctioning of the biochemical system, lifestyle factors, etc. Polysomnography, ECG, manometry and pH monitoring are some of the tests that can be performed to rule out the existence of this sleep disorder. This results in the individual not being allowed entry into the REM stage of sleep in the sleep cycle. He mentions that the cause of panic attacks may be caused when a person has either an over-sensitive suffocation monitoring system or a system which is not functioning optimally.
One study has shown that excess carbon dioxide affects that segment of the brain (amygdala) that is responsible for causing extreme fear as well as panic attacks.
But, at the same time, they are also hypersensitive to any external trigger that would result in release of adrenalin and may show heightened response with more severe anxiety, unusually high pulse rate, etc. Panic attacks usually happen when the person in the deepest phase of sleep, which is usually during the initial hours of sleep at night.
Alcohol essentially, bars the transit from non-REM stage to REM stage of sleep, which makes the environment conducive for panic attacks. While anxiety can result in sleep problems, research shows that major deprivation from sleep can also result in anxiety disorders.



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