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Steven Y Park, MD  
Male, 52
New York, NY

Specialties: Sleep-breathing disorders

Interests: Running, Baking, origami
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212-315-9058
New York, NY
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Do People Think You're Lazy?

Nov 23, 2008 - 54 comments
Tags:

laziness

,

airway resistance syndrome

,

sleepy

,

UARS

,

Sleep Apnea



More than a few times per month, I have patients comment that they think others perceive them as being lazy. Whether they like to "sleep in" or have trouble getting up in the mornings, or if they’re prone to taking naps in the afternoon, their sleepiness often elicits other’s perception of them as being lazy or unproductive. Add to this a saying from Proverbs: "Laziness brings on deep sleep, and the shiftless man goes hungry." Given that this type of work ethic runs deep in our modern day culture, it’s difficult to avoid being called lazy if you’re not the first one in the office and the last one to leave.  

However, laziness may have less to do with sleep than it does with how well one is breathing while they’re sleeping. Without assessing the latter, it would be wrong to assume the former.

Sleepy or Sleep Deprived?

Typically, most self professed "lazy" people don’t look forward to waking up in the morning. On more than one occasion, patients have complained that they "curse the mornings" when they have to get up. Often it takes multiple cups of coffee, or vigorous exercise, before they feel even somewhat functional. Naps are also a requisite for most of these people and almost all of them crash at night, completely exhausted by the time they get to bed. In the morning, they never feel refreshed—always feeling like they’ve slept only for a few hours.  

The other common misperception people have about other sleepy people is that they must have trouble sleeping or that they have insomnia. However, what many supposed "lazy" people suffer from is not usually due to insomnia—they can fall asleep just fine. In fact, many of these people fall asleep too easily. The difference is, these people just can’t wake up once they do fall asleep.  

So, if these people are not sleep deprived, sleeping more than their peers, why do these people seem so tired and "lazy" all the time? The true answer lies in how well they’re breathing while they’re sleeping.

To Breathe Or Not To Breathe

Many supposed "lazy" people that I see in my practice often have a sleep breathing problem called Upper Airway Resistance Syndrome (or UARS for short). This often occurs to those who have a smaller than average airway opening, or a bigger than average tongue to jaw size ratio. And for those who suffer from UARS, this is the primary reason why they’re not getting the deep and restful sleep that they truly need and desperately desire.  

It’s taken for granted that all humans have rigid, open windpipes that allow air to pass easily from the nose through the lungs. What’s unique about the human upper airway, however, is that due to our unique ability to talk, our voice boxes are much lower down, underneath the tongue, which forces the tongue to rotate backwards. This is fine when you’re awake, but when you’re on your back, the tongue and voice box falls back partially due to gravity. Furthermore, when you go into deep sleep, your throat and tongue muscles relax, then with a bit of deep inspiration, the tongue falls back completely to occlude the 1-2 mm airway space behind the tongue.

If you have UARS, a number of different scenarios can occur: the tongue falls back, and you can wake up after a few seconds, with you panting, in a sweat, your heart racing, and in a state of panic. Or you wake up from deep to light sleep only, never realizing that your sleep was disturbed.  

Also, if you stop breathing for 10 seconds or longer, and then wake up, then you just had an apnea or a "loss of breath" due to an obstructed airway. Five or more apneas per hour is in the range of having obstructive sleep apnea. But even if you stop breathing 20-30 times every hour, each lasting anywhere from 1-9 seconds, you’ll be told you don’t have any apneas, so therefore there’s nothing clinically wrong with you.  

This is the major conundrum many UARS patients find themselves in. Although they’re not found to have a clinically diagnosable problem, they still suffer from the same level of fatigue and exhaustion that many OSA patients experience. This may be why so many UARS patients are often mistaken for being lazy and not properly treated as someone who suffers from a sleep breathing problem.

Fighting While Sleeping

Another physiologic phenomenon that many UARS patients experience is that they’re constantly under a low grade state of stress or anxiety.Whether or not they feel this way while they’re awake, while they’re sleeping, their bodies are in a constant mode of "fight or flight." Both hormonally and neurologically, having UARS can put your body under enormous stress. Since you’re never able to reach a deep level of sleep, and stay in a sustained state of light sleep, your entire nervous system goes en guarde, and becomes hypersensitive. Even your emotions and senses are heightened, including your hearing, vision, taste, and smell. Simultaneously, you are exhausted all the time.

Also, in this constant state of readiness, blood is taken away from your gastrointestinal system, your reproductive organs, your skin or your hands and feet. This may be why so many people with UARS have cold hands or feet or suffer from a rash of gastrointestinal problems.

Laziness May Be a Virtue

But there is one positive side to all of this. Contrary to popular belief, I see many people with UARS who self proclaim themselves as being lazy, compensate for their chronic fatigue and lack of energy by becoming overachievers, being highly productive and creative in everything they do, going non-stop during the day, but crashing at night. They’re also much more attuned to their bodies, being proactive about their health, and taking care of whatever illnesses they have before they become huge problems.

However, there are those who can’t sustain this high energy lifestyle especially as they get older and they start gaining weight. What happens for many of these patients is that they now progress into a more severe form of sleep breathing problem like OSA.

So the next time you think you’re lazy or think that others perceive you this way, the way you feel and act may actually be due to chronic deep sleep deprivation and not a personality defect. Something else to sleep on.  

____________________________________________
Steven Y. Park, M.D., author of Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. Endorsed by New York Times best-selling authors Dr. Christiane Northrup, Dr. Dean Ornish, Dr. Mark Liponis, and Mary Shomon.

www.doctorstevenpark.com

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by Cherie762, Nov 23, 2008
that was very well written and informative doctor, thank you, I know Im not lazy but I do sleep a lot, I have hypothydoidism plus a recent bso medically induced menopause, I think both of those contribute to me feeling tired, thats a much better term than lazy as members of my family have called me, they just dont understand.

Best wishes to you ,
Cherie762

Avatar universal
by Steven Y Park, MDBlank, Nov 23, 2008
There are many reasons for being tired, and sometimes, either the patient or their family or peers perceive this as being lazy. Sleep inefficiency, no matter what the cause, can lead to chronic lack of energy. By the history you gave, you have many reasons for being tired. Menopause, either natural or medically induced, by lowering your progesterone levels (or altering the balance between progesterone and estrogen), can lead to worsening upper airway obstruction for reasons that I described in my article, The Male Menopause Myth (see bog posts). Hypothyroidism is another condition that in theory be aggravated by the elevated stress hormones due to sleep inefficiency. If you prefer to sleep on your side or stomach only, and if one of your parents snores heavily, you may want to consider undergoing a sleep consultation with an overnight sleep study to see if a sleep-breathing problem may be causing your fatigue issues. Take a look at two articles in my blog areas: Obstructive Sleep Apnea and Tired of Being Tired.

Avatar universal
by Rob2008, Nov 23, 2008
It was thought I had sleep apnea because I was experiencing severe fatigue and waking with tachycardia at night.   My sleep study showed 27 partial apneas per hour with the lowest o2 being only 89.    I tried CPAP and there was no difference in the way I felt, plus I can't deal with the mask.    Hopefully if I lose 50 pounds it'll go away.

Avatar universal
by Rob2008, Nov 23, 2008
Although, I still used to wake up tachycardic before I gained all this weight.  So I don't know

Avatar universal
by PlateletGal, Nov 25, 2008

Good post. I've read about UARS before. I guess since I have CFS, I can relate to people who have this condition. (fatigue... unrefreshing sleep).  I hope that your post will inspire more people to ask their physician about this condition. I will also keep this in the back of my mind for people who post in the EBV and CFS forums.

Avatar universal
by Steven Y Park, MDBlank, Nov 25, 2008
Rob2008,

You don't have to be overweight to have a sleep breathing problem. It's a good idea to lose the weight anyway, and most likely, your apneas will go away for the most part. However, you'll probably still be left with breathing obstructions that last for less than 10 seconds, so it doesn't get counted as apneas. Imagine if you stopped breathing for 5-8 and you woke up all of a sudden with your heart racing, sweaty, in a state of panic.

PlateletGal,

Thanks for the feedback. I have my own theories about CFS, but there's not enough time to discuss it fully in this forum. My feeling is that whether it's mononucleosis (EBV) or CFS, the end mechanism is unrefreshing sleep due to a chronic vicious cycle of poor breathing while sleeping. It's what starts the cycle that defines which diagnosis you get. For example, EBV viruses attack the body's lymphoid tissues and if you have relatively large tonsils to begin with, they become even bigger, causing more frequent obstructions while in deep sleep. This causes more inflammation in the throat, which aggravates more tonsil swelling. So if your anatomy is predisposed (more narrow jaw structures), and you develop any degree of inflammation, poor sleep quality will lat a lot longer than usual.

Avatar universal
by kat98503, Nov 25, 2008
I have used a CPAP machine for 5 years.  It was very hard to get used to the mask, but I made my self do it anyway.
The relief was so great after a few months, that I will not go anywhere without my CPAP.  I love the thing.  Now I feel, when I put on my mask, I am going to a wonderful, deep, special place.  i know I will wake up refreshed, as I did not do for 30 years.  I am extremely grateful.
Kat98503

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by stella5349, Nov 25, 2008
It's a great article - thank you for writing this.  I really think though more information should be researched on the hormonal imbalance vs- sleeping or "lazy" as written. More doctors should be taught the correlation of hormonal imbalances as "causes" and not rely so much on meds and lab numbers.

I went 6 years being Hashimoto hypothyroid exhausted - I slept - but didn't sleep good. I woke exhausted and walked through the day with an inability to function at all even 50%.

Without correct balance and not digging further into more labs - ( that has recently been done on me) - I was given a DX of fat - lazy and depressed by many doctors until finally I got the treatment I needed.

Dozens of doctors I went through with all the same diagnoises, until finally a new MD found I was undermedicated  hypothyroid Vit deficent and estrogen dominant.

For a month now I am regulated on all the right meds - supplements and YES - progestrone and I sleep correctly now. I wake refreshed and happy to start the day! It is a blessing to appreciate sleep they way it is intended to be! People comment on me looking 10 yrs younger and the "stress" is off my face now.

Sleeping correctly now after one simple test of meds - majority the progestrone I started a month ago - has rid me of all anxiety - overeating - "laziness". It has put crystal clear thinking back in my life which I appreciate everyday that I have back!

The SAME FSH -  LH tests were done repeatedly - along with TSH and other thyroid tests that came back "normal" for me with these previous "experts" - and in fact - I was - worse at times then when this new MD tested me  - and found I had issues with a "bad" level of TSH and Free testing along with a new DX of estrogen dominance.

I am not disclaiming your logic at all - I feel it is such good information -  I am very interested in the UARS information. What I do question is other doctors not considering the underlying conditons and treating the patient appropriately? Even specialist that claim their status as experts in these diseases will brush the patient off with a pocket full of meds and shoe them out the door telling them they are lazy - they need to diet - and they are depressed.

Who wouldn't be when you can't function?

SO many people suffer needlessly until they find a doctor willing to dig into their conditions and try other things (than Sleep / anxiety meds)  - which did nothing for me at all. Some sadly never find the answer they need and buy right into the fact that maybe the fat - lazy and depressed status IS really them - per those experts.

Again thanks for the article - you bring some very good points to the table for discussion.

Avatar universal
by Steven Y Park, MDBlank, Nov 25, 2008
Stella5349,

Thanks for bringing up an important issue. I agree, hormone imbalance is a major problem that's severely underdiagnosed because doctors rely too much on superficial blood test numbers. Many women (and men) are able to live (relatively) normal lives once these imbalances are found and addressed properly.

One interesting point to consider is that by definition, UARS causes a low-grade stress response. Physiologic stress has been shown to affect virtually every other hormone in the body. In particular, it suppresses TRH (or thyroid releasing hormone), and makes the cells less responsive to thyroid hormone and reproductive hormones, as well as altering your hormones that regulate appetite. It also raises your sugar levels. So in many cases, treating the appropriate deficiency can make a big difference for many people. By this line of reasoning, another way of treating (independently or concurrently with supplemental hormones) this is to allow people to breathe better at night so they can sleep better, lowering the stress response that can aggravate all these conditions.

Lastly, one very interesting fact about progesterone is that it is an upper airway muscle dilator. In other words, it promotes muscle tension and tone, and in particular the tongue muscle (genioglossus). As women slowly lose progesterone (or quickly during periods or after pregnancy), if you already have a narrowed airway behind the tongue, with further muscle relaxation, it falls back easier and you'll keep waking up from deep to light sleep, leading to inefficient sleep. This relative change (stress) in your body causes a nervous system reaction, or what's sometimes called vasomotor symptoms. This includes night sweats, hot flashes, weight gain, mood swings, irritability, and insomnia. Does this sound familiar? That's why HRT (which contains progesterone) helps women sleep better. These  same symptoms can occur in young men as well, especially if they're gaining weight. As their upper airways narrow more and more, they sleep less efficiently, and due to this relative change, experience all the symptoms that menopausal women undergo. Incidentally, I have many women who use a bioidentical progesterone cream that they rub daily on a soft part of their body, and this helps them out greatly.

There are many proposed reasons for estrogen dominance these days, including contraceptives, synthetic hormones, and BPA in bottles. But if your progesterone slowly diminishes naturally, you'll naturally become estrogen dominant, since estrogen hangs around a lot longer.




Avatar universal
by PlateletGal, Nov 26, 2008
Hi Dr. Park,

I agree.... poor sleep quality is often seen in many CFS patients. Ken Friedman, Ph.D. talks about this in one of his interviews. Dr. Friedman became involved with CFS research after his daughter was diagnosed with CFS. His daughter had a sleep study test done and they found out that she had over 200 waking episodes every night !!

I had my tonsils taken out (shortly after having mono... due to chronic throat infections). In 2002, I had a septoplasty done... due to chronic sinus infections. I still have unrefreshing sleep, but I am currently on a pathogen killing treatment that is restoring my health. I've posted some links below if you are interested. Personally I think I was genetically predisposed to having CFS. My mother has Sjogren's Syndrome and there are other people on her side of the family who also have autoimmune problems. I think what happens in someone with CFS, is similiar what happens to some people who have lyme disease. A person can be bitten by a tick and be infected by the bacteria... borrelia burgdorferi. However, they may not have any symptoms until years later... especially at a time when their health deteriorates.

So what are your recommendations for people with CFS ? (if you have time, that is). We also have hormone problems and I know many of us are on HRT. I was on it for a year, until I decided to do the treatment that I'm currently on.




sources:

http://phoenix-cfs.org/IntFriedmanPtINov07.htm --- Dr. Friedman's interview

http://www.cfids.org/archives/2002rr/2002-rr4-article01.asp --- sleep dysfunction in CFS

http://www.immed.org/illness/fatigue_illness_research.html --- infections found in CFS patients


Avatar universal
by Steven Y Park, MDBlank, Nov 26, 2008
There's a lot of great research on CFS. I think it's agreed by most experts that many different types of illnesses can cause or trigger CFS. Dr. Jacob Teitelbaum, a leading researcher in this area, also agrees that poor sleep is a major contributing component.

Interestingly, one consistent exam finding that I see is a narrowed upper airway, usually due to small jaws and dental crowding. This leads to the tongue taking up too much space and is susceptible to collapse when in deep sleep, especially when on your back. This is why almost invariably, people with CFS prefer not to or are unable to sleep on their backs. They compensate by sleeping on their sides or stomachs, until any simple cold, allergy or infection causes a sudden worsening in the upper airway anatomy, which starts a vicious cycle where there's more tongue obstruction, leading to microscopic reflux, leading to more inflammation, and so on.

This is why some people with EBV infections experience only mild symptoms, but others with small jaws or large tonsils are much more prone to the severe prolonged symptoms. Even if you don't have tonsils, there are various other situations that can trigger a similar event. Some will be found to have obstructive sleep apnea, but many won't, for reasons that I describe in my article on airway resistance syndrome.

I'm not discounting all the other great research on CFS, but this is one simple major mechanism that should always be considered in any workup for someone with this condition.

Avatar universal
by monotreme, Nov 26, 2008
Thanks so much for this information.  My husband has Primary progressive MS and has unrelenting fatigue.  He also has central hypogonadism and is on testosterone replacemnt therapy.  For the past three months, he has been snoring loudly and has been getting short of breath.  

During an endoscopy to repair a stricture, the GI doctor said that the anesthesiologist had some difficulty keeping his airway open while he was under the sedation, and that prior to the procedure, he was snoring loudly.  He suggested that my husband have a sleep study.

Can complications from MS weaken the chest muscles and cause some obstruction in the airways?  I am wondering if the snoring is causing the excessive daytime fatigue.  On weekends, he can sleep all afternoon and wake up feeling tired.

Thank you.

Avatar universal
by Steven Y Park, MDBlank, Nov 26, 2008
monotreme,

It sounds like your husband needs to undergo a sleep study. Obstructive sleep apnea is a problem due to muscle relaxation in the upper throat leading to obstruction. Even without MS, millions of people continue to have undiagnosed obstructive sleep apnea. As I've mentioned before, it can also suppress reproductive hormone levels. Hopefully, your husband will benefit significantly by undergoing proper treatment.

Avatar universal
by LLWB, Nov 27, 2008
Dr. Park,

For more years than I can remember, I am always tired. I never wake up full of energy, even after 8-9 hrs of sleep. I have been diagnosed with fibro, type 2 diabetes, diabetic neuropathy, deg osteo-arthritis, degen disc disease, I had chronic sinusitis, for which I had sinus surgery, and a deviated septum, for which I had a septoplasty. My ENT has to use a child's scope to look in my nose. I am short of breathe a lot of the time, and will be having lung function tests in the near future. (Dec 2) My Spirometry tests put me at lung age of 76. I'm 61. Yes I smoke. I am on multiple medications, including Phendimetrazine, for energy, and to help me stay awake. I drive for a living. Sometimes I absolutly can not stay awake. If I stop and sleep for 5-10 minutes, then I can stay awake for awhile. On weekends I can nap for 4-5hrs, and still go to bed and sleep for 8. What help can you recommend for me? Thank you for this column.

Avatar universal
by Steven Y Park, MDBlank, Nov 27, 2008
I sounds like you may have a sleep-breathing problem. Many of the medical conditions that you describe can be aggravated by, if not caused by sleep apnea. As for driving, it's been shown that sleep deprived people SEVERELY underestimate how impaired they are. There was a recent news show on TV where they sleep deprived people for only a few hours every night for consecutive days. When asked if they felt if they can drive, and all of them said yes. It was clear that they were not. It's also been shown that having untreated sleep apnea can be just as bad, if not worse than being legally drunk. I realize you drive for a living, but think about not only the danger to your own health, but also for the safety of others. In some state, it's illegal to drive while sleep deprived. Get it checked out by a sleep doctor.

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by Barb135, Nov 27, 2008
I ran across this article by accident and can't help but wonder if there's something here for me also.  For many years, I was tired all the time and every time I talked to my dr(s) about it, I was told that depression causes fatige, when I wasn't depressed, except because I had no energy!!  One dr insisted that I take anti-depressants, which only made me more tired so I felt like a zombie most of the time.  After going through this with more than one dr, my current dr, whom I've been seeing for several years finally agreed to have me tested for pernicious anemia because of burning and tingling in my hands, arms, feet and legs; and yes, I had it, so was started on B-12 shots.  That helped a lot, but I still didn't feel right and I know I was being looked at as a hypochondriac.  During this time I was gaining weight like mad (5 lbs or more every week or two).  Almost a year after I started the B-12 shots in Aug 2007, I finally got them to test my thyroid - hypo with TSH of 55.51   - started on synthroid, next TSH very low, so synthroid lowered, last TSH only slightly higher so synthroid was lowered more (currently 75 mcg daily).  During this time, I have often had bouts of fatigue.  I have to get up at 3:30 am, Mon-Fri so go to bed around 7:30 pm.  I almost always go to sleep very quickly, but I wake up around 9:30 or so and for the rest of the night, I only sleep very lightly and for very short periods at a time (usually an hour to hour 1/2 at a time) and have trouble falling asleep each time I wake up, so when it's all said and done, I probably only sleep for 4-5 hrs/night if that.

I am 59 yrs old, surgically menopausal 12 yrs ago.  Was on numerous HRT therapies for about 10 yrs, both before and after my hysterectomy.  For the past 10 years or so, I've had horrible night sweats and have basically been told that I need to "learn to live with it" - but the night sweats are often what wakes me up during the night and sometimes, I have to get up and change clothes, etc and of course by the time all that's done, I'm wide awake and unable to even consider going back to sleep.  I also have very bad acid reflux and on ocassion, wake up in the night gasping for breath because of the acid.  I have raised the head of my bed; but sometimes have to sleep almost sitting up in order to keep the acid from coming up into my throat.  In Oct and Dec '07, I had surgeries on my vocal cords due to Reinkes Edema.  Those surgeries went very well with complete recovery.  

Now I know I have pernicious anemia, hypothyroidism (but dr doesn't think it necessary to do tests to find out what causes it (Hashimotos, etc) and they won't even test free T-3, saying that's not necessary because it's only for research purposes anyway.  I have put on almost 40 pounds in less than 2 years and no matter what I eat or how much exercise I do, I can't lose it.  I finally talked them into letting me get checked for insulin resistance (blood sugars are pretty erratic most days) because diabetes runs rampant in my family.  They also agreed to check for adrenal function, but the only lab test for that was a fasting cortisol level, which as I understand it doesn't tell much. My cholesterol has also been high for the past year (since I gained all this weight) and all they want to do is put me another pill when I feel sure that it would go down if I could lose the weight.  

I have read a lot about how important a good night's sleep is for keeping a normal weight, etc and I can't remember the last time I went to bed and slept for more than a couple hours at a time.  I quit smoking about 1 1/2 yrs ago and have never had any type of sinus or other breathing problems.  A lot of times, I get very sleepy during the day and just have to stop and close my eyes for a short period, even though the B-12 shots and synthroid have gone a long way toward eliminating that; and yes, when I do this on weekends, my husband often makes comments that I'm being "lazy" or should "use my time more constructively".  

I am now being referred back to the ENT who did the surgeries on my vocal cords because I have something in my throat that feels like a lump (it's on the inside only and can't be felt from the outside) and I often feel like it's choking me.  I think this could be due to thyroid, but since the only tests they've ever run on my thyroid are TSH and free T-4, I really don't know.  I did mention estrogen levels to my dr's nurse practitioner and she blew me off almost before the words were out of my mouth because according to her, I am long past any concern for that.  

My question then would be: could the health problems I have be affecting my sleep, or is my sleep (or lack of) contributing to all the other things?  How does one go about getting drs to take these complaints seriously and order the proper diagnostic tests or referrals and not just throw another prescription at us and tell us to come back in 3 months for a follow up??  I can't stand being told one more time that I just need to eat less and better, exercise more and the weight will come off.

Avatar universal
by Steven Y Park, MDBlank, Nov 28, 2008
Barb135,

You're right, it's traditionally taught that depression can cause fatigue, or hypothyroidism can cause fatigue. However, almost everything you described can be attributed to a sleep-breathing problem. Even your acid reflux issues and throat problems can be aggravated by it. In light of your (surgically post-menopausal status), it's even more likely. Interestingly, it's been shown that women who wake up from night sweats are actually waking up from breathing pauses, and not from the night sweats. Take a look at my Male Menopause Myth Article (as well as the other articles on sleep apnea) for a further explanation. A simple sleep study should be able to tell you if you have this problem.

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by Rebecca_L, Nov 28, 2008
Why yes, I have been accused of being lazy on many occasions. I've always, as long as I can remember at least, awakened tired and unrefreshed. I am generally hyper-alert at night -- any little noise or particularly light will awaken me. I can't sleep on anything but my stomach. I know my mouth is small because dentists have complained about it, alhtough I've had my wisdom teeth pulled and I don't think my mouth is crowded. (I could be wrong though.) The big thing I was wondering about was the thyroid issue mentioned. My thyroid has been tested many times, starting when I was 16. It has always shown in the low, but still barely normal range. Now I have three small nodules on my goiter which started about 7 years ago after an extremely bad depression but have not grown since the depression was brought under control. I believe that the thyroid level I'm low in is the one that would trigger the goiters, so I'm not sure if thyroid supplements would be good or bad. Do you have any advice for me on that? I would consider a sleep test but I'm really paranoid about being asleep where people I don't know are awake and watching me. In fact, one of the reasons my Yorkie is my "therapy" dog is because I know she'll wake me up if anyone moves around my part of the house, so I can relax a little more when I want to sleep. (Of course that also disrupts my sleep since she is VERY good at her job of barking. lol) Oh, and several members of my family have sleep apnea. My uncle had grooves cut into his tongue because his airflow was so bad. I think (I could remember this wrong, though) that they had a hard time giving him a breathing tube before surgery which somehow prompted the need to put grooves in his tongue.

Avatar universal
by Steven Y Park, MDBlank, Nov 28, 2008
Rebecca_L,

Everything you described is compatible with sleep apnea, including your small jaw, being a light sleeper, stomach sleeping, and strong family history. The reason why you never wake up refreshed is because you can never get deep restorative sleep. As I've mentioned before, sleep apnea and the resultant elevated stress response can suppress your thyroid levels as well. Most endocrinologists will tell you that being on thyroid medications will not make your nodules go away (in the old days, they did think this way). But if your doctor wants to try years of on thyroid medications to see if you feel better, it may be worth a shot. But remember, even if it works, you may still have a sleep-breathing problem, which places you a risk for all the other medical conditions such as depression, anxiety, hypertension, and heart disease. Most people are very apprehensive about sleeping in a foreign bed with people watching, but it's rare that people are not able to sleep at all. If it's a major concern, they are now offering home-based sleep studies. Take a look at my other articles on obstructive sleep apnea and airway resistance syndrome.

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by motherofan18month, Nov 29, 2008
my mother & father both were diagnosed with sleep apnea (among other things) a few weeks ago i decided to coount how many hours i was sleeping and still being tired......after 10 days i concluding i was sleeping a total of 126 hours in a 240 hour period........should i go through a sleep study to see whether i have sleep apnea???????!!!

377012 tn?1283969035
by motherofan18month, Nov 29, 2008
sleeping this much is interfering with taking care of my son, husband, and house work....advice is GREATLY APPRECIATED!!!!

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by Rebecca_L, Nov 29, 2008
I'm curious, Dr. Park, could you tell us some of the possible/probable treatments for this? And should we just take our concerns to our general physician and go from there? I think that being able to go to sleep and sleep well would be heaven.

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by jondsam, Nov 29, 2008
Well I would just like to say that I am lazy.  Im not afraid to say it, not tired but lazy.  And not tired because im lazy, if that makes any sense :p

Avatar universal
by Steven Y Park, MDBlank, Nov 30, 2008
The best way to tell if you have obstructive sleep apnea or airway resistance syndrome is to undergo a sleep study. Some general physicians may not be aware of the importance of sleep on your health. In that case, you can see a sleep medicine doctor. There are many other additional factors that contribute to your sleep health besides a sleep-breathing problem—a sleep doctor can help you with all of these issues.




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by redheadaussie, Dec 01, 2008
You know this is all very interesting. I have been fighting what in my mind is a very obvious and chronic condition. I explain to the medical profession how I sleep wonderfully in hospital because I have an oxygen mask forcing into my lungs, lovely  fresh life giving breath. I go home and snore like a leopard tank, wake feeling like a proverbial and still I get told, do some exercise, lose some weight, (well, I'll be blowed, I lost 30 plus kilos and I STILL need to sleep half the day away and still even then wake from hearing my own snoring and feeling my own breathe trying to be forced out and wake in a panic) yatta yatta yatta
Had thyroid removed, slept the best I ever did in that wonderful terrifyingly skinny bed! Keep telling my GP and others to allow me a sleep study but, nooooooo.....I am going through all the gamut of every other test known to man and a dog! Today I had a cortisol and ACTH blood test. ( Fatigue of extreme nature may well be an adrenal insufficiency, we shall see!)  I refuse to be a lovely little furry critter anymore!
  I think my body is so stressed from the attacks of 'Oh my gawwwwwd...I can't breathe..wake uuuuuuup!' that I may well have damaged adrenals!
  Perchance I will print out your article and shove it under the nose of my "I studied for 7 years so call me God!" doctor, and see what comes of it.
Thanks for your fascinating articles!

Avatar universal
by Pooh40, Dec 01, 2008
There aren't very many symptoms and doctor problems mentioned here that I haven't been through in the past 10 years...being called lazy is the norm.  I refuse to accept that 'diagnosis' and will continue to fight the medical experts until I get what I need.

Fortunately, my current doctor 'allowed' me to try a sleep apnea mask after the respiratory test (not sure what it's called, but it's where you put the oxygen monitor on your finger overnight) showed that I had 20 apneas in a 7 hour period.  This is considered very low apnea, but I still wanted to try the mask to see the results.
I couldn't go to sleep with the usual style mask over the nose and all the straps around the head, etc.  It's rather a catch-22:  I can't sleep well because of being hyperaware of sounds, movements, light in the night, so I can't fall asleep with the mask in order to help alleviate these symptoms.  

However, the good news is that there is another style of apnea apparatus that is much lighter with fewer straps...two little, soft cone-shaped pieces fit into the nostrils and only two small straps go over the head.
Needless to say, I found this a little weird at first, but after just two tries, I am beginning to get used to it.  I'm hoping that within a few more nights I'll actually be able to fall asleep with it.  I am a side sleeper (no surprise there!), and can still be on my side with this new contraption.

The first time I put this on in the apnea office, I felt very claustrophobic, but I now turn the air flow on before placing it on my face and found that much more comfortable.  These newer machines also have a built-in humidifier, and I found the gentle flow of moist air a huge relief in itself.  

I've always felt like I couldn't get enough air through my nose and have been wearing the nasal strips for the past year - they actually did help somewhat, but that led me to believe that the machines would likely be even better.
I went from literally zero energy, couch-bound, unable to even make a sandwich for myself, to about 50% energy with the nasal strips, and I'm sure looking forward to going up to 100% with the sleep machine.
I wish everyone here the same progress.  Your posts and Doctor Park's information have been the first light in my tunnel for many years and I thank you all so very much.

Avatar universal
by Nicholas1838, Dec 01, 2008
I was diagnosed with sleep apnea years ago. I have had 5 different sleep studies in the last several years. The first one they found that I stopped breathing over 660 times in around six and half hours and had a very severe case.  My wife used to see me stop breathing at night in my sleep and I snore very badly. I ended up having the surgery where they cut out what was left of my tonsils and my uvula and opened up a deviated septum in my nasal passage. It was the worst most painful surgery I have ever had and it only slightly helped my problem. I have tried numerous CPAP and BIPAP machines and different masks but I just could not get used to them. I either feel like I am suffocating or I wake up in the morning with the mask pulled  off of my face and the machine still running. I finally gave up and just try to sleep when I can. To complicate matters I get bouts of insomnia and mania where I can sleep at all for a couple of days at time and I usually only go to bed much after one or two in the morning. Half the time I feel like I am a walking zombie and I have to drink coffee during the day just to stay awake which I know is only making my sleeping problem at night worse. I have even visited a sleep neurologist to no avail. I have been living like this for years, always fatigued and I never have any energy. My wife is constantly calling me lazy and unmotivated which is very unfair given my health condition. I appreciate your article and insight into the problem but for me I have given up hope and just live the way I live day to day and night by night.

Avatar universal
by RJ9999, Dec 01, 2008
I have a sleep problem but I don't believe it is mentioned here.   I wake up sometimes 10 times  night with dry mouth.  I apparently beathe through my mouth not my nose when I sleep.  My nose suts tight when I lay down forcing me to breath through my mouth.
I tried nose sprays which worked but became addictive where I needed it throughout the day.  So, I'm back to cronic dry mouth at night.
Is there away to correct this problem?

Avatar universal
by Steven Y Park, MDBlank, Dec 01, 2008
RJ9999,

Your problem can be easily treated by any local ear, nose or throat doctor. You have to breathe well through your nose to sleep well.

Avatar universal
by Sharon600, Dec 01, 2008
It's been suggested that I consider a sleep test and my 24 yr old daughter is going to be having one done in 2 weeks.  I have fbro, degen disc disease, periformis syndrome, recurrent shingles, IBS with constipation, I take thyroid medication and I've been taking ambien cr for the past 6 months in order to sleep.  I am sleeping with the medication but is it possible that I'm still not getting restorative sleep?  My daughter can not get up in the morning.  3 and 4 and 5 alarms don't even wake her.  She's always tired and has no energy.  She says she does dream a lot.  Does that mean she's getting good sleep?
Do a lot of people have a hard time going to sleep at the sleep labs?  I'm not sure I could fall asleep like I normally do at home.
Thanks for any and all your advise.
SA2


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by Dalubaba, Dec 02, 2008
I am on alprozalam since last 17yrs.Started with 0.25 mg. and now 0.75 mt.  I may have to increase to  1mg.I get 5 hours sleep with this regime.
I am hypo-thyrodic since last 35years.Have tinnitus as well and deafness. I am 78.I am trying to do away with the alprozalam.Any advice you give will be appreciated.

Avatar universal
by Steven Y Park, MDBlank, Dec 02, 2008
Sharon600,

It sounds like a sleep study is a good option for you. Regarding you daughter, the fact that she's dreaming a lot means that she's waking up a lot during REM sleep, when your muscles are most relaxed. When you wake up during REM, you'll remember your dreams vividly. The problem is that she can't stay in REM sleep.

FYI, I have a live teleseminar on "How to Beat Insomnia Without Medications" on Thursday 12/4 at 8 PM Eastern. I'll  be interviewing a renown sleep researcher, Dr. Gregg Jacobs. He's the author of the landmark Harvard study that showed that cognitive behavioral therapy is better than sleeping pills. To register and get the telephone call in information, go here: http://tinyurl.com/5q247f


Avatar universal
by fadingaway1946, Dec 02, 2008
Well here I am 61 and awake after only a couple of hours of sleep AGAIN and I will be falling asleep this afternoon. This is my routine everyday now. I can not take hormone replacements due to blood clot and vein problems. My mother and sister have Addisons Disease and thyroid problems. My tests show I don't have it.  I am on anti depressants, blood pressure and chlorestrol drugs and I am heading towards diabetes as I have gained a lot of weight. I have no energy and my family says I snore very loudly.
HELP please if you can as I'm always too tired to do anything it seems.

Avatar universal
by Lilmagic, Dec 02, 2008
You have opened my eyes to the fact that it is possible, nay probable, that I am sleep deprived. I am without doubt an 'I hate mornings' person. I know for a fact that I wake anything from 3or 4 times a night up to 20+ times. Often I just open my eyes, check the time and I'm away again, but on occasions I can then be awake for an hour or two.

I relish not having to get up in the mornings as I can doze till lunch time and can usually manage a long afternoon nap, as mong as I have the time to spare for it, otherwise I take pro-plus and just carry on, looking forward to bedtime. I love my bed, but I just wish I slept better, so maybe it's time I consulted my GP and tried to get a sleep study done to see if that will resolve my sleeping and other health issues such as depression, IBS and osteo-arthritic symptoms. If it did, I'd be soooooo happy!!!

lilmagic

Avatar universal
by Steven Y Park, MDBlank, Dec 02, 2008
To both fadingaway1946 and Lilmajic,

It sounds like both of you may benefit from a sleep medicine evaluation.

Avatar universal
by Foxylady5643, Dec 02, 2008
Hi Dr. Park,
I have been experiencing variety of different symtoms for over 1 1/2 now. I am a 27 year old female with no significant health history. I have been experiencing night sweats as part of my symtoms. Real night sweats, where I have to change clothe. I also have hot flashes during the day but at the same time I feel cold. I also have goose bumps pretty much all the time. I am always tired, fatigued and sleepy, always want to sleep. I had multiple tests done such as blood work to check my thyroid, ESR, CBC, hormone levels, vitamin D (which was very low). I also have cold hands and feet most of the time. I've had abdominal U/S, CXR, CT scans, MRI brain with no results. So eventually I was sent to a psychiatrist who put me on antidepressents which have not really helped (made me slightly less depressed about this problem but I still have my symtoms). I also have developed GI problems esp. being constipated (I don't know if this can be related to anything). This has been such a long road for me and I know you can't solve this just by this post but do you think this can be related to UARS? Any suggestions as to which doctor I should see?

Thank you

Avatar universal
by Corndog, Dec 02, 2008
Hi, Dr. Park.

Thanks for the good article. I started having trouble sleeping and extreme daytime sleepiness after a blow to the head with loss of consciousness. At first I didn't make the connection, and I am only assuming a connection now, as I can link the start of multiple problems (forgetfulness, foggy thinking, nystagmus, flashes of light, insomnia, extreme daytime sleepiness) with the concussion. At the time my doctor was adjusting my thyroid hormones (Hashimoto's), adding Cytomel. After the hormones were in balance, I felt less tired, but had difficulty sleeping at night and it was nearly impossible for me to stay awake in the day. I went to a sleep clinic for several overnight studies because obstructive apnea was suspected, but not found. I had low oxygen levels (as low as 83 for periods) and little to no REM or deep sleep. I also had that "frozen asleep" thing sometimes, where I woke up but couldn't move for a few seconds. I started taking Topamax for bipolar, and on the next sleep study, my oxygen levels at night were normal. I sleep better, and the nystagmus I had developed also went away. I take Provigil to help me stay awake in the day. If I forget it, it takes everything in me to get out of bed, and I fall asleep easily at the computer or on the phone. I never got a specific diagnosis, but I suspect narcolepsy or something similar. Once I ran out of Topamax and the nystagmus came back within a few days.

Yes, I sometimes feel lazy, and others have suggested that I am. I could sleep an entire day, even after taking 400 MG Provigil, if I let myself - easily, especially during a depressed phase.

I also have sarcoidosis and arthritis. I had menopause at age 39 (naturally) and use bioidentical progesterone cream.

Thanks again for the article.

Avatar universal
by Steven Y Park, MDBlank, Dec 03, 2008
Foxylady5643,

Your symptoms are definitely compatible with upper airway resistance syndrome. Your night sweats, hot flashes are what are called vasomotor symptoms, where you have some confusion of your involuntary nervous system. Take a look at my article on UARS and the Male menopause myth.

Avatar universal
by PlateletGal, Dec 06, 2008

This article was e-mailed me today (through co-cure.org). This was published in October 2008 :

Are patients with chronic fatigue syndrome just 'tired' or also 'sleepy'?

http://www.ncbi.nlm.nih.gov/pubmed/19021860?dopt=AbstractPlus

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by kiddthekatt, Dec 06, 2008
   Thank you so much for this article. I understand a little more about my some times, sleepless nights. I know that I am not a lazy person, but at times I feel absolutely unable to get a grip on what is keeping me awake at night. Since my dx with Fibro and cfs, I sleep more at night, a deeper restful sleep. But, when I m in a flare, sleep will not come. The pain of cramping burning muscles, the headaches and the feeling of just falling apart, literally falling apart, maes me feel as though I have little sticks holding my eyelids up. I didn't mention that I also use sleep medcation every night. Once again, thank you for your article.

Angel

Avatar universal
by Steven Y Park, MDBlank, Dec 06, 2008
PlateletGal,

Thanks for the link. I remember reading that article when it first came out. Here, it suggests that CFS patients are more tired than sleepy, and that there is a distinction.

kiddthekatt,

One thing that I'm beginning to suggest to all my CFS and fibromyalgia patients (in addition to their current medical regimen) is to try cognitive behavioral therapy (CBT) for imsomnia. Traditional CBT takes 4-6 session in person and may not be covered by insurance. However, in my last teleseminar with Dr. Gregg Jacobs, and insomnia expert, he's made his CBT program (which was tested at Harvard and shown to be better than taking sleeping pills) available online at a nominal cost. Although it's for insomnia, the main focus of the program is good sleep hygiene. I'm also going to recommend it for CPAP patients that are still struggling. Take a look at www.cbtforinsomnia.com.




Avatar universal
by meadow1, Dec 07, 2008
Thanks for your article, Dr. Park. I had not heard of UARS before, but have wondered if my 85 year old mom may have a sleep issue, other than simply aging. I've wondered tjat even more in the last 2 years, since I've become her caregiver. I know she has a mixture of issues: grief from my dad's passing two years back, allergies, and now some dementia. But she's often mentioned not feeling like she's slept, and now she mentions feeling like she's not awake soon after getting up (or maybe that's a dementia issue?). She sleeps relatively lightly, and has always snored. I've just wondered if the dementia would have developed as much if her sleep had been better. Are there any studies on dementia having any roots in sleep issues?

I have fibromyalgia, and have noticed how much better my mind works after a night of sleeping well.



Avatar universal
by Amjad67, Mar 04, 2009
I'm above 40 now and till date I was thinking that I am lazy by nature, but this article suddenly changed
my perception about my past and present. I always use to blame myself and think that may be its my
nature that I have adopted due to be habits, but I am so glad to know that its a medical phenomena.

I like the way you changed my thinking just in a few minutes.

Can we correct this problem thru treatment?

Amjad Ali

Avatar universal
by Steven Y Park, MDBlank, Mar 04, 2009
Amjad67,

Sleep-breathing problems don't explain everything, but it's such a common situation that it's worthwhile looking into if you do have some of the symptoms that I described above. The first thing to do is to see your doctor and make sure there's nothing else that could be causing your problems. Then the next step is to get an evaluation by a sleep medicine doctor. If you are chronically sleep deprived, and this is taken care of, I'm willing to bet that you'll feel much better.

meadow1,

Take a look at my article on sleep apnea and Alzheimer's.

Avatar universal
by shane669, Jun 02, 2009
It sound great, very useful information to share with readers that's amazing, I know that I am not a lazy person, but at times I feel absolutely unable to get a grip on what is keeping me awake at night. Since my dx with Fibro and cfs, I sleep more at night, a deeper restful sleep. But, when I m in a flare, sleep will not come. you can get more feedback from here:
http://lahealthandrejuvenation.com/

Avatar universal
by nomara, Jul 16, 2009
Hi Dr. Park,  I was diagnosed with severe sleep apnea a few months ago. The specialist feels that it has likely gone untreated for 10 or more years.   It took a very long time to get used to wearing the mask for the cpap.  Now that I am sleeping "successfully" most of the time (about a month now) I definitely feel better with more energy some days but not all.   I've even lost some weight without changing diet or exercise.  There are still many days where I feel exhausted and irritable.  I have had tests for diabetes, heart disease and hypothyroidism.  I've even seen a specialist about Fibromyalgia.  Thankfully I have not been diagnosed with any of that.  But,  I feel like I should be feeling %100 by now...am I being too impatient?   I'm only 42, have always been active with my children and I run a dog care business.  I've never lead a sedentery life or regularly eat unhealthy, why do I still feel so tired, achy and irritable?  I still have a lot of weight to lose but I coped so well even before I was diagnosed.  Should my GP order more tests?  Does my body have more repair to do before I'm back to "normal?"  Do I need to be more patient and allow more time to feel better?  I desperately want to feel like my old self again!
Thanks your article was very helpful!

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by wadeheather, Jul 16, 2009
Dr. Park,

I agree that it was a wonderful article, but I also have to contest that there are a lot of things that may make people feel lazy. There are a lot more symptoms than just sleep issues, or there are a lot of things that cause sleep issues.  Personally, I have chronic insomnia. I've been on a couple of diffent things. I go to work and have to talk to people with bright red eyes and huge circles, whether I've taken meds or not. I feel better if I sleep, but I still look like a piece of garbage.  

I have immediate relatives with RSL and apnea, but that is not my problem. Well, not that I know of.  I could only dream of how I slept and felt a few years ago. I think that being able to "assign" the problem to one thing or another is important, but for someone like me it remains  a fact of life. Sleep is a privilidge, not an absolute. It is what is it is, and we deal with it.

Avatar universal
by Steven Y Park, MDBlank, Jul 16, 2009
nomara,

I'm happy for you that you're able to use your CPAP machine. For some people, the results can be immediately dramatic, whereas in others it can take many months. Unfortunately, there are some that never feel any better despite using CPAP religiously. It sounds like you're in the right path. Just give it some more time, and if possible get your compliance data read and interpreted by your sleep doctor to make sure there are no other technical issues with your CPAP.

wadeheather,

I do agree with you that there are many other reasons that can make you feel tired, lethargic or just plain lazy. However, the point of my article is that a sleep-breathing problem is a major underlying treatable issue that is frequently treated as something else, and can take months or years before the real condition is diagnosed.

It's also interesting that you have chronic insomnia and have a family history of RLS and apnea. All three are commonly related. I even make an argument that a sleep-breathing problem (not necessarily sleep apnea) can present  in the early stages as chronic insomnia. In my experience, most people with chronic insomnia, RLS and sleep apnea have narrowed upper airway passageways, leading to inefficient sleep. I'm even willing to bet that you prefer not to sleep on your back, right?

I know this may sound controversial, but I don't separate people as either having or not having a sleep-breathing problem. All of us, even if we're "normal," are on a sleep-breathing continuum. It just make a lot more sense. I describe this new concept in my book, Sleep, Interrupted.


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by Sleepinbeauty, Jul 18, 2009
It was FINALLY suggested I do a night time sleep study after 8 + years of always feeling tired/never rested after 8/9 hours of sleep a night, falling asleep in the day,no energy to do anything but work and even that is a struggle.   I was told the typical things:  You are depressed, you need to lose weight, you are working to much, you are a typical young person(working ft/partying too much/not sleeping enough) etc.  I knew none of it was true.  I have been taking synthroid for my under active thyroid from the beginning so that was under control, have taken numerous anti depressions, was told I have CFS,  fibromyalgia and IBS.  Did the sleep study and NO I did not have sleep apnea.  I went back for the day time sleep study.....Found out I have Narcolepsy.  I see no mention of it here and even though it is not as common as Sleep apnea it has many of the same signs and symptoms.  Just wanted everyone that is having sleep issues to look into Narcolepsy.  It is often misunderstood and joked about but is a very real problem.  Narcolepsy is for life so the sooner you get it discovered the (hopefully) better your quality of life can be!

Avatar universal
by fedup100, Apr 12, 2011
Dr. Park,

Thank you for your article. I am suffering from multiple medical problems -- endometriosis, interstitial cystitis, allergies, asthma, thyroid disease, and recently I have been battling shingles. I used to be a good sleeper but over the past few years, I have developed severe insomnia. I suspect this is related to an adrenal problem as I also suffer from hashimoto's disease. My latest blood tests show that I have become anemic. Do I need to see a sleep specialist?  I fall asleep without any problems and sometimes I wake up within an hour of going to sleep. Sometimes I can go back gto sleep right away and sometimes I can not. Even so I wake up several times in the middle of the night. On a good night I can sleep 6 hours uninterrupted. I am a full time graduate student and this severe fatigue is really taking its toll on my academic performance. Lately, I have also been suffering from depression and anxiety. I believe my problems are rooted in my endocrine system, but even so I am wondering if a sleep study would help shed some light on what is going on with my health.

Thank you for your reply.

Avatar universal
by david_85, May 10, 2011
I'm having an issue of sleeping waay too much. I am sleeping for about 12hrs or more a day, i have trouble sleeping at night and waking up or getting out of bed. but when i do wake up i  wake up and get out of bed like at 2-4pm and that's an everyday thing. I am sleeping more then i am awake. Just the other day i had stood up for 24hrs just so that i can go to sleep at night but when i did i had went to sleep like at 9pm and woke up the next morning at 6pm and was still tired then went back to sleep at 11pm thinking i was gonna get up earlier but ended up wakeing up at 3pm. i dont know what to do about my sleeping issues. If you have any idea what is wrong with me please let me know or email me on david_alvarez85***@**** Thanks Dr. Park

Avatar universal
by Steven Y Park, MDBlank, May 10, 2011
fedup100 and david_85,

It sounds like both of you need to see a sleep specialist. Sleep-breathing problems are most commonly seen, but other conditions such as restless leg syndrome PLMD, and narcolepsy (see sleepinbeauty's response) can be occasionally found. It's important to remember that you can still stop breathing 20 to 30 times per hour and be told you don't have sleep apnea. Good luck.

Avatar universal
by halfpint1961, Jun 18, 2011
I keep blaming my age, job, ect....!  I am a R.N. that does private home care to preterm 3 year old twins, I am also just shy of 50 years old, I don't have the energy to keep up with the twins, I am not complaining because of their prematurity it is great seeing them so active, but trying to keep up with them, I am so exhausted in the evening that when I come home I go to bed using the excuse to watch my shows to "unwind" when in fact I am trying to sneak in a nap!  never had problems with sleep apnea, but have recently been experiencing restless leg syndrome, don't know, still thinking it is the age!

Avatar universal
by bcloud3, Dec 15, 2011
I am 44 years old male. I don't recall ever feeling refreshed in the morning, no matter how long I sleep. Last few years just always feel "lazy" and seems to be getting worse over time.  Diagnosed with OSA 2 years ago and started CPAP. Even though on the machine my apnea numbers now look good, I still don't feel refreshed after a nights sleep, and have much trouble with focus, memory, etc. during the day, affecting work performance, getting jobs around the house done, etc.  Everyone I talk to that are on CPAP sleak of how life-changing it is. I don't have that.  Have been on anti-depressants (currently 150mg Effexor) for 4 or 5 years. In the past 2-3 years have had alot bigger struggle with motivation regarding exercise, diet etc. Maybe just the age thing? Bottom line, while not totally non-functional, I can't imagine the way I feel most days could be considered normal. After reading some things on-line, have started to wonder about thyroid? I also suffer from tinnitis and have seen supposed info linking it with hypothyroidism. Is thyroid something I should have checked considering the OSA is technically fixed but not feeling any results?

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