Sunday, August 29, 2010

Sleep Apnea and Death Wish

Is sleep apnea an ultimate expression of Death Wish?
Yes, yes, I know scientists have shown its causes, beyond a shadow of doubt, to be physical, psychology therefore has no place in its etiology. Pulmonary scientists have shown that sleep apnea is merely a lack of muscle tone which occurs in apnea folks more strongly than normals, and this factor, along with overgrowth of soft tissues in the airway passage, explains the pathophysiology of Apnea. Why do I want to complicate the matter by bringing in such a funny concept as Death Wish into the equation?
And why would anyone have death wish in the first place? Don't we want to live forever, and what makes me think that this most primary of instincts - to cling tenaciously to dear life - is abandoned in sleep?
But I have a nagging feeling that sleep apnea which is closest thing to death perhaps may be a premature expression of the wish to die and to be free of the rigmarole of life.
In "Beyond the Pleasure Principle" Freud put forward the view that the ultimate purpose of all living organism is to die. Our drives/instincts are conservative in nature and their aim is to restore an earlier state. As soon as life arose - the first drive - it sought to undo the act and strove to restore the earlier inorganic state. It was the bombardment with a fresh trauma and creation of a fresh drive that prevented life from reaching its goal of death in a linear fashion. With addition of each fresh trauma and fresh drive, life became more and more complicated, with each drive seeking death in its own unique way. It is the cross-purposes of these different drives in their endeavor to reach death [eternal peace] which produces the clamor of life.
Sleep is a state of partial death. The real aim of sleep is to die completely. To do absolutely nothing. To give up all our tensions. But we cannot do that. Some basic activity, like the activities of respiration, circulation and temperature must still go on, while the rest of us lies there practically dead.
Yet, when life if hard and the tensions through the day high, in sleep the wish to give up all tensions completely, including breathing and heart activity, to give up the ghost entirely, becomes tempting.
It is this wholesale abandonment of tensions - the stressed man throwing off the yoke of all the cares and worries of the day - that is reflected in the drop in the tone of respiratory muscles. In milder cases in the form of snoring and in extreme cases as sleep apnea. Obesity and hypertension, themselves a reflection of unmanageable stresses of life, act as contributory factors.
Now it is a matter of everyday observation that when we are having a difficult time during the day we sleep poorly and we snore. There is a definite correlation between the loudness of a person's snoring and the stress he is having in his life. So perhaps all these factors obesity, hypertension, snoring and sleep apnea are end points of a person's inability to deal with the tensions of life.

Now do I have anything clinical to bolster such a hypothesis? Do I have dreams that show that in sleep we seek to be free of life's tension and wish for death?

Well, the theme of taking a journey -symbolizing the journey of life - and recoiling from it in horror is perhaps the most frequent dream of humans. And this typical dream, in all its variations, after interpretation, show in it, the two contrary wishes: to die and to cling on to life. The prototypical manifest content is generally framed in imageries such as taking a plane journey and being late for it and missing the flight or trying to reach one's childhood home but never quite making there, getting lost on the side roads, or taking a train journey but getting left behind on the platform or in a very interesting twist a patient of mine, a retired man in his Eighties, would dream of seeing himself back at work and working like a dog. The distress of having reached the end of one's life transposed to distress at having to once again live the drudgery of factory work.
Do I have dreams of a person who actually has Sleep apnea which can support the hypothesis?
One of my patient does have sleep apnea and it was very instructive as to how his dreams changed once he was put on C-pap machine and his apnea got treated.
And what was the change?
During his apnea day his dreams were very vivid and real. In fact they were so real that he would feel that he could actually bring back things from his dream to real life. Pieces of candy, a slice of pie, a mug of coffee; they would appear so real in the dream that he would have a feeling that all he had to do was to grab them and bring them out of his dream into the waking world.
There were other intense dreams as well. Dreams about his family when he was young, romping with his brothers in the countryside - he grew up in rural area, about being on a vacation in a resort hotel, gambling in casino.
Yes, there were dreams of falling off a bridge or drowning in water (fantasy of rebirth) and these pointed to the symbolic representation of death. But majority of dreams were of being intensely alive.
Now such dreams of being intensely alive contradicts the assumption that a common factor produces sleep apnea and the wish to take refuge in death away from life's tensions. In fact the apnea was accompanies by just the very opposite wishes - to be intensely alive. Is there anyway out of the difficulty?
Perhaps there is.
When the patient was asked about the affect accompanying the dreams of playing blackjack in casino and about romping with his brothers in the countryside, he admitted that while the visual pictures were those of enjoyment, the emotions accompanying them were unmistakably those of anxiety and distress.
So those dreams were not so much celebration of life as a denial of death and the dream was showing that "Oh no, you are not dying but you are in casino having time of your life. Or you are about to get a piece of the pie or you are once again a child and having fun with your brothers." So here we see the familiar element of wish fulfillment trying to reverse the fear of death by showing just its opposite - living life to the fullest. However, the wish fulfillment fails to reverse the distress/fear of death perhaps because it was fueled by the real situation of death - the actual apnea - and emotionally the patient continued to experience distress despite the visual imagery being that of enjoyment.
One last point. Since dreams of taking one's last journey and dying -and its denial by showing oneself busily engaged with life - are so universally present regardless whether the dreamer has sleep apnea or not, one must assume that whenever life frustrates us we dream of abandoning this world [and being reborn] and only when this wish becomes pathologically strong does it make a move from a purely psychic process to a psychosomatic one and gives rise to the disorder of Sleep Apnea.

1 comment:

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