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Why My Sp02 Numbers Drop Significantly While Sleeping? Is This Anxiety Or Panic Attacks?

Posted on Sun, 18 Nov 2012

Question: Hello Doctor:

Your opinion on the following health issue will be greatly valued and appreciated!!

Upon assuming the sleeping position(supine,left/right side) my Sp02 numbers drop significantly...from 96% to 91% and even further down than 90%. Recently when sleeping I am using an "oximeter alarm clock" to wake me up if drops are below 90%. Yesterday, the device woke me up 3-4 times between 11:30pm-1:30pm. When I woke and stood up...some form of cardiac arryhthmia took place and lasted for about 15-20minutes. This event was recorded on an event monitor given by my cardilologist. The ambulance was called...by the the paramedics came...the arrhythmia settled. I agreed to stay home and not go the emergency because a similar event had occured two days previously that resulted in me going and being dismissed from emergency.

I've been told that I suffer from anxiety/panic atttacks in the past...mostly happening at night and waking me during sleep or shortly after getting up from sleep. It is only recently that the significant drops in SpO2 during sleep/assuming sleeping positions were discovered by me through self experimentation by using an oximeter.

My question is if there is possibility that my previous so called "panic attacks" could have been caused by lower than normal previously unknown...SpO2 numbers and apneas events during sleep?

Is there such a thing as severe anxiety with normal SpO2 numbers? If so...could this type of "normal anxiety"...over the years if untreated....lead to significant SpO2 drops when in supine positions? Also could this anxiety eventually lead to major depression/apnea/arryhthmias?

If yes, how does psychiatry tackle this type of issue?

Thank you,
XXXXXXX

Answered by Dr. Jonas Sundarakumar (3 hours later)

Hello and welcome to Healthcare Magic. Thanks for your query.

I would be happy to assist you in clarifying your doubts. In order to understand your problem better, can you please provide the following details...

- What is the reason for being on an oximeter monitoring?
- Have you been diagnosed to have any cardiac or medical problem?
- You have also mentioned that you were given an event monitor by your cardiologist - what was the reason for the same?
- Have you had a thorough medical and cardiac evaluation? If so, what were the results / what was the doctor's opinion?
- Since when have you been having anxiety problems?
- Can you describe these 'attacks' in detail?
- How much are these symptoms affecting you? How functional are you now?
- Have you been on any medication for the anxiety / panic attacks?
- Have you suffered from any other psychological problems in the past?

Please get back to me with these details so that I will be able to guide you better.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Jonas Sundarakumar (13 hours later)

Hello Dr. Sundarakumar:

Thank you so much for you resposnse. I will answer all questions that you asked with honesty...straight forward...and also include any other additional information which I think may be important in your assessment.

1. REASON FOR OXIMETER: I purchased the small oximeter because during the night I can wake up with rapid heart rate and shortness of breath...I was finally curious to see if during or emidiately after these episodes if my oxygen levels were normal or there was something to be seen. Since I've been in the hospital many times with shorness of breath and rapid heart rate..... I suppose I wanted to self experiment with the oximeter. The paramedics who transported me to the the hospital during my second last visit to the emergency(last Thursday)...also saw the drops in SpO2 in their abmulance equipment during transpost to the hospital and commented something like "There is something physiological going on here...it not a case of simple anxiety/panic"...the problem or fact was...during these episodes...by the time the ambulance arrived and I went to hospital...all the vital signs were normal(perhaps because i was now standing in the vertical position most of the time). So the same old story from emergency..."your EKG, blood tests are normal...anxiety/panic...go home". Knowing all this new information now...i purchased a second small oximeter...this time with an alarm...I programmed it to wake me up if my SpO2 levels dropped below 90%...as mentined before....this device has been waking me up during sleep in the the past 2 day since I started to use it....again I did i do this? Because I am affraid that something might be going on physiologically that has not be detected since I now tend to believe the symptoms disappear by the time the ambulance gets here...by this time i am standing up. Doctor...now I need a straight forward answer from you :))....I am I able to bring down my SpO2 significantly during sleep psychologically? or something else has been haunting me in the past 20 years or so that has been dismissed as anxiety/panic/some depression? If this "something else" is there....could this be causing anxiety/panic/depression?

2. CARDIAC ISSUES: No diagnosis has been given for cardiac issues. I have had two Stress Echos in the past six months...all negative for heart disease..(actually there was another stress test that shoewed ST segmentdepression which was taken as a fasle positive). The recent arryhthmias? (One on Thursday one on Saturday)...are a new phenomenon. I went too the cardiologists office on Friday to pick up an event monitor(because the Thursday event scared me so much) as he had previously advised me to do so if anything new comes about. On Saturaday around 1:30 am..the second arryhthmia event happened and thankfully at leadt now it is recorded!!

3. TIME AND LENGTH OF ANXIETY: I started to notice anxiety around me when I first got married about 20 years ago. The first time I got a "panic attack" was when I woke up in the morning after a previous arguement with my ex-spouce during the night...she turned cold and it got me very upset...Life in this marriage was stressful(constant arguements, pressures, lovelessness, control issues etc.) Children came along..I started to feel more XXXXXXX and content in the situation but the arguements and coldness somehow remained. In 2009 I left the marriage because I did not want to expose the children to any more negativity and also I felt that I could not live in lovelessnes any longer...so it was pointless to stay just for the sake of staying....My ex spounce is living with the children in the house we bought...I am paying all the bills..... and I am staying with my parents for now. I have a new woman in my life...trying to make a life...but health issues and my ex wife not cooperating to have a peaceful resolution to the divorce makes things difficult. Also I believe she is involved in having my boy and eldest daughter in alienation against me...my 11 year old boy does not want visit any more...my eldest daughter (15 years old) seems to want to get on with her life(no calls were made to me after the children knew my recent health issues and emergency visits...feels like I dont even exist for the at times.) I only get visits from my youngest 9 year old daughter who is always enthused to be here every weekend. When my boy was only six...he came out with comments like..."Daddy mommy said she is going to trick you over and over again"...I thought this was so,so strange for him to say...so I even recorded what he said. I believe since my ex-wife found out that I am trying to have a life with someone else....there is involvement in turning the eldest children against me with false reasoning, accusations, manipulation and perhaps brainwashing. So overall there is lot of stress in my life at the moment as previously.

4. DESCTRIPTION OF ATTACKS:
a. Recent 2 attacks---Recent atttacks seem different...heart seems not to beat only fast...but aslo irregular...tightness across chest...and some sharp pain. Heart beat got as high as 160bpm(one got recorded). Happened during sleep or just about going to sleep.

b. Previous attacks during years---fast heart rate...felt like i was going to die...something terrible was going to happen. Mostly during sleep and few times on driving.

Other information regarding attacks: All attacks had subsided for about 15 years. The fisrt recent attack happened after some type of chest infection(lying in bed for two weeks---last March) and getting into arguement with a friend the previous night. At the same time I was also putting through my papers for divorce...which I found difficult and saddening at times for some reason. For some reason also I feel sadness when I think of my ex spouce but I know this is the right thing to do.

5. HOW BEING AFFECTED BY THESE SYMPTOMS?FUCTIONALITY?

These symptoms make it hard for me to carry on my daily activities...I suppose I fear the attacks because they have been so scary at times....I can get breatheless, hyperventilate and feel chest tightness throughout the day especially in stressful situations. I had some form of a hyperventilation attack after the fisrt appearance in court with my ex wife. I noticed that I tend to tighten my belly a lot...even now as I write this...especially infront of computer if I am involved in writing an intense letter etc. I do better at things if I have someone with me...and there is agorophobia there...tend to stay in house a lot more.

6. MEDICATION FOR ANXIETY/PANIC ATTTACKS: Took some previously when it all started...about 18 years ago...took some ativan? and/or lorazopam? as needed and stopped..It hepled so, so.....I did quite well without any medication especially as the children made me feel more content in the marriage. Currently i take some natural remedies to help me cope with all this as suggested by an MD who specializes in Conplementary Medicine( I take St. Johns Wort, Holy XXXXXXX Valerian). My regular MD has suggseted Veblafaxine...but I have not take this.

7. OTHER PSYCHOLOGICAL PROBLEMS IN PAST? I dont think that I have but my childhood years were not the best. Some important information which maybe of importance:Generally...did not have a good childhood----My father was way working...hardly interacted with me or my brother....my mother was very/still is very controlling..she hyperventilates quite a bit.....she had seen her brother assasssinated during civil war in Greece after the WWII...so I try to understand. I honestly believe she leaves a life of fear and that this fear transfers on...I find it very difficult at times having moved in with my parents again after my separation...it feels like a trap....it feels like it adds to my problem.

Last but not least...yes...there was sexual abuse during childhood back in Europe...as the father was absent and the mother was out working in the fields. I felt unprotected and of course, unloved etc. I am just wondering...is this the reason why i feel sorry for my ex-wife? Is the reason I found it difficult to leave a "toxic" marriage sooner?

Im I a bit overconcerned about my health? Probably....eapecially with the recent events...I think anyone with these experiences would be. There seems to be something physiological going on...I believe apnea for sure? Other things...possible...could this "monster" have many heads--possible.

Anyway...Dr. Sundarakumar...there you have it...all "true and from the heart"....looking forward to your response.

Thank you, XXXXXXX

Answered by Dr. Jonas Sundarakumar (19 hours later)

Hello again and thanks for the very detailed reply.

Before I give you my opinion, let me assure of two things:
1) I am perfectly able to understand how worrying and distressing your symptoms are to you and that I am considering them seriously.
2) My opinion is not biased based on your past history or any possible psychiatric diagnosis which you may have received in the past.

Now, your two most concerning issues are the drops in spo2 (sometimes below 90%) and the cardiac dysrythmias - both of which you feel are clear indicators of a physiological problem and also feel that cannot be explained in terms of a psychological problem such as panic attacks.

Let me first tell you that panic disorder does have a strong biological basis - and we have even been able to narrow down the pathology to the specific neuro-chemical imbalances in the brain. It is also well established and proven that panic disorder is a 'polysystemic' condition which does indeed alter the physiology of multiple systems in the body. Other than the psychological symptoms such as feeling anxious, apprehensive, fear of impending doom, etc., there are also multiple physiological changes which take place in the body during a panic attack, thereby producing multiple physical symptoms.

One of the main reasons, panic disorder can produce these multiple, definitive and characteristic physical symptoms is due to DYSAUTONOMIA or in other words autonomic dysregulation. This is the reason why it causes the rapid or irregular heart beat, hyperventillation, breathing difficulty, bowel discomfort, etc. etc.

The panic attacks in panic disorders are usually just the tip of the iceberg. Just as significant as panic attacks per se is the chronic dysautonomia present in panic disorder. A number of expressions of dysautonomia are often present for extended periods in panic disorder patients, even in the absence of XXXXXXX panic attacks. Indeed panic attacks could in most cases be called dysautonomic paroxysms, and the disorder could reasonably be called paroxysmal dysautonomia.

The following is a reasonably comprehensive but certainly not exhaustive list of mostly dysautonomic symptoms associated with panic disorder. Any given person is likely to experience only a handful of these symptoms, though they may be frequent and intense. The point of such an extensive list is to provide reassurance to someone diagnosed with panic disorder who is experiencing any of these very diverse symptoms that they can indeed be merely symptomatic of panic disorder
and not necessarily a sign that some other medical or biological condition is present.

Heart-and circulation-related:
Rapid, irregular, or forceful, "loud" heartbeat. Sensation of skipped heartbeats. Chest pain. Low or high blood pressure, often with remarkably wide swings.

Breathing-related:
Lowered oxygen level, elevated or lowered carbon dioxide level, under- and over-breathing, sensations of slow suffocation, sensations of inability to take a XXXXXXX or satisfying breath or to yawn, sensations of abdominal constriction of lungs, often worse when standing or floating chest-deep in water.

Muscle-, skin-, and nerve-related:
Jerking, trembling, twitching, spasm, tremor, rigidity, weakness, numbness, tingling, itching, feverishness, chills, hot flashes, "goose bumps XXXXXXX pins-and-needles, isolated "pin jabs XXXXXXX "jelly legs XXXXXXX "legs of lead XXXXXXX excessive or insufficient sweating, intolerance to heat, inability to stretch satisfyingly, flushing, a sudden whole-body, tactile and auditory "whoosh" sensation (either without external trigger or in reaction to minute sounds or other triggers).

Digestion-related:
Tightness in the throat, lump in the throat, sore throat, sensation of foreign object in throat, difficulty swallowing, reflux of acid or bile, nausea, vomiting, reflux asthma, reflux sinusitis, irregularity, spasms, burning or aching pain, bleeding, sensitivity to specific foods (triggering gut symptoms or symptoms from any of the other groups listed here), constipation, diarrhea, incontinence, urinary frequency, spastic bladder, excess secretion of bile, insufficient secretion of pancreatic enzymes.

Endocrine-related:
Abnormal fluctuations of epinephrine, norepinephrine, insulin, glucagon, renin, aldosterone, cholecystokinin, endorphins, and other endocrine substances. These are normally not noticed except through their expression in other symptoms.

So, as you can see, your symptoms such as cardiac dysrythmias and drops in spO2 are well known physiological signs of the dysautonomia associated with panic disorder. Moreover, your EKG, Echo and all blood tests are normal, which indicates that your cardio-vascular system is functioning normally.

So, please be assured that your psychological as well as physical symptoms, including the physiological changes which you have documented during the panic attacks are all typical of Panic Disorder. The fear or apprehension that you are going to get these attacks is also typical of Panic disorder and is called 'anticipatory anxiety'.

I would strongly suggest that you consult a psychiatrist for further treatment options for this. With appropriate treatment, I'm sure that these symptoms will get controlled. So, my sincere advise to you would be to start proper, regular treatment as early as possible, rather than spending your efforts in looking for a 'sinister' medical cause.

You have also mentioned that you are in the midst of a difficult time with regards to your family. Regarding your question, it is possible that your past childhood / traumatic experiences could have an impact on your later life relationships. Persons who have had sexual abuse in childhood can be more clingly or have more intense emotional attachments or have a exagerrated sense of abandonment / rejection when it comes to relationships. So, this could be a possible reason why you still feel sorry for your wife or were finding it difficult to end a 'toxic' relationship.

I hope I have clarified your doubts.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Jonas Sundarakumar (12 hours later)

Dr. Sundarakumar:

Thank you so much for your detailed and expert analysis indeed. I will definately will not hesitate to talk with a psychiatrist reagarding a possible treatment approach....I just want to rule out anything esle first. I am not looking for a "sinister" medical cause....i think the picture is clear...it is the significant drops in SpO2 while assuming the supine position awake/sleeping that buffles me. The explanation your delivered does satisfy my curiosity.

Today I saw the cardilologist regarding the "arrhythmia episodes"..he thinks all is normal and says posssibly a test might me needed to rule out a "hole in the heart".
He also suggested to book an appointment with a doctor that specializes in anxiety and sleep disorders. He wants to see a sleep study also. I thought this is a good idea to see if apnea is present....I do remember my ex wife telling me numerous times..."you stop breathing during sleep".

He was buffled when I told him my SpO2 numbers drop down when I assume the supine position. He asked for a demonstration. He took me to another room and I sat on a flat surface lying in the supine position. Within approxiately 10 minuttes my SpO2 raeding went as low as 92%. He said he did not have an explanation but found at the moment but found it "mysterious".

I would appreciate knowing the approach to treatment you would take.
I would greatly respect and value your expert opinion.

If it involves medication...how long would you have someone like me on medication? Would it be a lifetime thing or for a period of time and what medication in your opinion is the safest and best suited for this issue.

Thank you, XXXXXXX

Answered by Dr. Jonas Sundarakumar (12 hours later)

Hello again Mr. XXXXXXX and thanks for writing in.

A sleep study (polysomnography) would be a good idea to monitor these attacks and help you get a clearer picture. As regards managing the anxiety / panic attacks, there are effective treatment options - both in the form of medication and psychotherapy.

SSRI antidepressants like Escitalopram, Citalopram, Sertraline, Fluoxetine, etc are usually used as first line medication. Since these medication may take about a few weeks to gradually take full effect, other short term anti-anxiety medication can be used. Sometimes beta blockers like propranolol are also used for the management of the physical symptoms of anxiety like palpitations, tremors, etc. There are also many other medication like Buspirone, Flupentixol, Melitracin, etc. which have been proven to be effective anti-anxiety agents. The duration of treatment is variable from person to person. They are usually given for a minimum of 4 - 6 months, but may have to be continued for longer periods.

Other than medication, there are several good psychotherapy techniques like Cognitive Behaviou Therapy (CBT) which can give long lasting results. There are also relaxation therapies like controlled breathing, progressive muscle relaxation, applied relaxation, biofeedback, etc. which can help you deal with the physical manifestations of anxiety.

It's been proven that a combination medication and psychotherapy yields the best results. You psychiatrist would be able to suggest the best option for you, after a detailed assessment and discussion with you.

Wish you all the best.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Jonas Sundarakumar (13 hours later)

Hello Doctor Sundarakumar:

Thank you for your response. I will certainly consider treatment especially after the sleep study findings by the end of November. If I am suffering from severe apnea for the last 20 years or so...could this contribute to anxiety/panic attacks? or they could simply coexist? Could this cause anxiety/panic attacks?

I have attended some classes held by Prof. Artour Rakhimov who explains panic attacks somewhat different(see following youtube video--panic attack eplained between 8th-9th minutes). I don't mean to take too much of your time but since it relates to your field of expertise I would be curious and value your opinion regarding this view.

Thank you, XXXXXXX

Answered by Dr. Jonas Sundarakumar (9 hours later)

Hello again Mr. XXXXXXX and thanks for writing in.

Studies have shown that there is a higher incidence of a diagnosis of sleep apnea among patients with panic / anxiety disorders. This implies that there is indeed an "association" between sleep apnea and panic attacks. Now, whether these two disorders merely co-exist or whether they have a common or interlinked pathology is not clearly proven. However, it is possible that carbon-dioxide build up (during episodes of apnea) can trigger panic attacks.

I did go through the You Tube video of Prof. Rakhimov. It is actually a well known fact that there is a relation between anxiety disorders and hyperventillation. Hyperventillation is indeed a "panicogenic" agent. In fact, in clinical settings, where we teach behavioural techniques to patients with panic disorder, we use hyperventillation to demonstrate the triggering of a panic attack and teach them controlled breathing to prevent such triggers. The relationship between anxiety and hyperventillation is actually reciprocal. That is, increased anxiety can increase the respiratory rate and result in hyperventillation and hyperventillation in turn can trigger these anxiety / panic attacks. This is what many people with anxiety disorders go into a viscious cycle of chronic hyperventillation and anxiety problems.

This is why relaxation therapies such as controlled breathing, yoga, etc, are effective. Even in the biofeedback technique, patients are taught to be vigilant to the physical signs of mounting anxiety (like irregular breathing, hyperventillation, etc.) and immediately employ steps to relax - thereby avoiding a catastrophic build up of anxiety and breaking the viscious cycle that I mentioned earlier.

I hope I have clarified your doubts.

Best wishes,

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar