By Dr. Alex Dimitriu

You get an email from your boss asking you to meet later that day, and you immediately think you’ve done something wrong, and might get fired, then lose your home, then your marriage.

A lab result comes back slightly off, and you immediately think you might have some serious life-threatening malady, “what could this mean??” as you envision your funeral.

You believe in superstition or following certain rituals to make sure you either do well on a date, job interview, or upcoming exam. Not having your lucky pen or favorite shirt might spell failure.

When Daydreams Turn into Daymares

People daydream all the time, but certain people go down negative wormholes that can feel shockingly real. These fantasies can occur several times per day, leaving you feeling anxious or sick or tired or paralyzed in fear of some pending doom. In more intense experiences, out of desperation, people get compelled to action. They’ll call their doctor or boss for reassurance or lash out at someone close to them in an effort to unload a heavy burden of anxiety (which also makes people quite irritable, short tempered, and unemphatic, btw).

As a psychiatrist, I am privileged to hear about people’s inner dialogue all the time. I get a window into their thinking, and after seeing hundreds of patients, patterns become apparent, and certain solutions emerge as being highly effective. One pattern I see often in people who are either anxious, depressed, or have ADHD is the tendency to go down negative thought spirals. I have often called these “daymares,” as the daytime / daydream version of a nightmare. These can be rooted in reality, quite real, and quite scary.

Interestingly, anxious thoughts really come in 2 varieties – ones that are useful, and ones that are not. The immediate solution that has helped so many of my patients is asking one fundamental question:

Ask yourself: “What is the utility of this thought?”  2 possible outcomes emerge.

1 – Certain thoughts are useful. Like the thought that you might fail the upcoming exam or not meet the deadline for a work project if you don’t get working on it. Indeed. In those cases, you might listen to the anxious thought, and consider doing something about it. Some anxious thoughts have utility, they serve as healthy reminders to prepare or start getting something done. These thoughts are easier to work with because they are rooted in reality and have actionable steps that you have control to take. Important to emphasize here that these are real issues for which you are in a position to take useful action. This will differ greatly from the next type of thought.

2- Stabbing thoughts, or as previously described by Daniel Amen, “ANTS,” or automatic negative thoughts. I call these stabbing thoughts because it really is no different than stabbing yourself repeatedly with a fork. When faced with the question of “What is the utility of this thought,” these types of thoughts start to fail the test. There is often a greatly exaggerated outcome, and nothing you can do about it. If you can catch them, and label them for what they are, you might start to realize there is some tendency to poke yourself with a fork when there is nothing you can do about it. For some people, living in a state of stress or self-oppression becomes a default state. Patients of mine will sometimes wake in the morning and scan the news to find something to worry about. It is like stabbing yourself with a fork. Catch it and stop it. There is no utility to those thoughts, it’s your head messing with you.

“What if I drove off the cliff??” Lessons From OCD’s Intrusive Thoughts

We can learn a lot from people with high anxiety or OCD – because they often experience “intrusive negative thoughts,” which are more dramatic and easier to recognize. Let me give you some examples.

I’ve met a woman who while cutting fruit on a cutting board would have a sudden flash of cutting her husband’s throat with the knife. A nursing mother who would have a flash thought of throwing her infant at a wall when it was crying. A man who would often wonder what would happen if he jerked the steering wheel and drove the car off a cliffside road.

They were all ashamed and terrified of these thoughts and would never in their life act on them. But the more the thoughts scared them, the more they came back. Many of these patients were much improved just by talking to someone about it. By understanding that sometimes people get crazy thoughts, and the scarier they are, and the more you keep them secret, the more they come back to haunt you. You’d be amazed at how many people experience wild crazy fantasies or daymares like this if you ask. 99% know they would never act on it, but even a slight doubt can turn big and scary, “but what if…” The more the thoughts bite, the more they come back. Until you realize that the only thing you have to fear is fear itself. The thought is a fantasy that recurs because it gets your attention. Talk to your fears. Running never works.

Lastly, I want to point out a fascinating study which may also reveal the basis of some stabbing thoughts. The experiment looked at how people deal with boredom and found that “67% of men and 25% of women chose to inflict it on themselves rather than just sit there quietly and think.” Yes, people would rather painfully zap themselves with electricity than just sit there and think. Ref https://www.science.org/doi/10.1126/science.1250830.

Don’t Zap Yourself Repeatedly

Filter the thoughts, by asking about “what is the utility?” talk about them and identify and stop the useless ones in their tracks. Say to yourself, “I don’t entertain that type of thinking.” Mindfulness meditation, exercise, and journaling help. The RAIN method for dealing with these thoughts helps too. It stands for R- recognize the thought, A-accept the thought, I-investigate the thought, N- non-identification. Read more about RAIN here.

For more information, be sure to check out my post on “Bingeing on Negativity.”and also “Unwinding Anxiety,” by Judson Brewer is a great read on this topic.

If the negative thoughts are too much to handle (as is the case for depressed or significantly anxious people), or happen too often, speak to a professional soon.

By Alex Dimitriu MD

Finding an effective pharmacologic approach to alleviating obstructive sleep apnea (OSA) could revolutionize treatment of this complex, underdiagnosed, and life-threatening sleep disorder. Results of a study – the MARIPOSA trial — published in the October 2023 issue of the American Journal of Respiratory and Critical Care Medicine indicate a combination of two medications, oxybutynin, and atomoxetine, has been shown “clinically meaningful” in improving OSA.

The double-blind investigation involved more than 200 patients, including 176 who actually completed the four-week protocol. The drugs reportedly act together to increase what one physician describes as “the activity of the dilator muscles in the upper airways.” They do so by “activating the genioglossus muscle [a muscle of the tongue] with a synergic effect on the upper respiratory tract during sleep.”

Study authors report patients receiving the drug combination experienced significantly less sleep disturbance due to disruptions in their breathing and a higher quality of sleep. But neither medication taken alone proved effective and, in some cases, slightly worsened a person’s sleep disturbance score or lowered sleep quality, the scientists state. With CPAP compliance rates at about 50%, any alternative to improving airflow during sleep is a welcome addition to the field.

But No Pill Yet for the Problem–

No FDA-approved pharmaceutical treatment option currently exists for treatment of OSA, an issue that continues to spur ongoing drug investigations. The MARIPOSA trial is only the latest of a series of OSA-related pharmacologic studies published during the past several years. Some scientists have likened the hunt for an effective OSA drug to a “search for the Holy Grail.”

One report — in a 2022 issue of the Journal of Clinical Sleep Medicine — suggests reboxetine, a drug formerly used to treat depression, shows positive action in reducing the severity of OSA. The National Sleep Foundation indicates that, in July 2023, the FDA approved further testing of an investigational sleep apnea drug, IHL-42X, in phase II and phase III patient trials. Advanced by Icannex Healthcare, IHL-42X contains dronabinol and acetazolamide. Dronabinol is a synthetic cannabinoid with effects similar to compounds in the marijuana plant. Preliminary research shows IHL-42X can cut sleep apnea patients’ episodes of disruptive breathing by more than half, according to the Sleep Foundation.

Also being tested for potential efficacy in decreasing the severity of OSA is a combination of AD109 and AD504, under development by the pharmaceutical firm Apnimed.

All About Obstructive Sleep Apnea

OSA is characterized by the narrowing and obstruction of the upper airway during sleep, causing a person to stop breathing repeatedly. The term “apnea” or “apnoea” applies to the cessation of breathing for 10 seconds or longer. Symptoms include excessive snoring, awakening from sleep gasping, daytime sleepiness and fatigue, morning headaches and sore throat, and problems focusing. If untreated, the disorder increases a person’s risk for stroke, cardiovascular disease, heart failure, pulmonary arterial hypertension, and development of neurobehavioral issues like mood changes and depression. The disease also may eventually lead to poor dietary habits, lack of exercise, altered insulin resistance, and systemic inflammation.

Obesity, older age, genes, alcohol use, smoking, and anatomical issues like a deviated septum, mandibular hypoplasia, or enlarged tongue or tonsils are all factors that can promote occurrence of OSA. The disease tends to be more prevalent in men, and, according to health professionals, affects between 9 percent and 38 percent of adults in the United States and nearly a billion people worldwide.

Less Sleep Quality Most Concerning

Perhaps, one of the most disconcerting aspects of the disorder is its association with a decline in sleep duration, sleep hygiene, and overall quality.

A study just published in December 2023 by JAMA Network Open indicates OSA patients with “shorter objective sleep duration had higher risk for all-cause mortality independent of AHI [apnea-hypopnea index] compared with those sleeping at least seven hours.” The research involved 2,574 OSA patients, representing men and women from a variety of races. AHI measures the average number of apnea (breathing stops) or hypopneas (incidents of abnormally shallow breathing) a person experiences in an hour. In other words, according to the researchers, lack of sufficient sleep plays a much greater role in an OSA patient’s morbidity and mortality than simply the number of times the person experiences a breathing episode during sleep.

OSA’s negative impact on sleep architecture and hygiene is a prime impetus for doctors’ efforts to find effective medications.

Current OSA Treatment Options

Until now, treatment for OSA has been limited to use of electrical devices that exert continuous positive airway pressure (CPAP machines), which an estimated half of OSA patients have difficulty tolerating; custom-fitted oral appliances to push the jaw forward and alleviate airway obstruction; lifestyle changes and correction of underlying medical conditions like obesity and atrial fibrillation; positional therapy for keeping patients sleeping in their side; and surgical procedures to eliminate anatomical defects like enlarged tonsils and create more breathing space in the oropharynx. The oropharynx is that part of the throat connecting the mouth and the upper portion of the airway.

Experts warn of the long-term consequences of uncontrolled OSA. In fact, some speculate that sleep apnea may have been the ultimate cause of the 2016 death of Supreme Court Justice Antonin Scalia. But who should be screened for the disorder? Many OSA patients are either asymptomatic or report only vague symptoms like daytime fatigue that is unaccompanied by any other obvious signs.

Authors of a 2022 article on the website of the National Center for Biotechnology Information indicate universal OSA screening for asymptomatic individuals is not recommended. However, they advise people who experience excessive daytime sleepiness or are told by a bed partner that they snore loudly, choke or gasp during sleep, or seem to stop breathing multiple times should contact a physician.

A Few Tips

Although not all factors that increase the potential for developing OSA can be eliminated or controlled, people may reduce their risks. Among important steps to take:

• Get enough sleep – sleep apnea is worse when you are sleep deprived or exhausted. Stick to regular timing, and a cool, dark and quiet bedroom.
• Increase physical activity, especially if much of the time is spent sitting in an office or at home in front of a computer.
• Undergo treatment for hypertension, chronic nasal congestion and upper respiratory infections, and other conditions that contribute to OSA.
• Achieve a weight and body mass index appropriate to age and height.
• Reduce consumption of alcohol, particularly just before bedtime, and
• Eliminate smoking as part of an overall healthy lifestyle.
• Be careful driving and avoid doing so if you have any tendency to doze off. Speak with your doctor immediately if you have trouble staying awake during the day.

When it comes to our health, American philosopher and historian Will Durant, perhaps, said it best: We are what we repeatedly do. Excellence [good health] then, is not an act, but a habit.”

Aug 22, 2023 Dr. Dimitriu was published in Psychology Today in an article titled:

Aromatherapy May Lead to a 226% Boost in Cognition

You know those small vials of fragrant oils sometimes placed on a hotel pillow to calm a guest and improve sleep? Well, science says they work, even suggesting certain aromas can help build better brains—and memories—during sleep. Researchers writing in a July 2023 issue of Frontiers in Neuroscience contend “olfactory enrichment”—inhaling pleasant fragrances during sleep—influences brain function in ways that significantly improve cognition and boost memory.

Click HERE for the full article.

May 25, 2023 Dr. Dimitriu was published in Psychology Today in an article titled:

For ADHD, White Noise Could Be an Alternative to Medication

Could some types of noise potentially prove therapeutic for individuals with attention deficit hyperactivity disorder (ADHD)? Results of a growing number of recent studies indicate “yes,” despite past research showing that noise exposure, in general, impairs human cognitive performance, negatively affects patterns of brain activity, and damages mental and physical health. One online article boldly displays the headline White Noise May Be as Effective as Drugs for ADHD.

Click HERE for the full article.

April 4, 2023 Dr. Dimitriu was published in Psychology Today in an article titled:

Sleep Medications for Insomnia: Limitations and Alternatives

A study published recently (January 2023) in the Journal of Alzheimer’s Disease is the latest confirmation of prior scientific warnings about a potential association between certain prescribed sleeping aids, including benzodiazepines, “Z-hypnotic drugs,” and trazodone, and a significant risk of developing dementia—as high as 79 percent in Caucasian adults, ages 71-77. Additional research suggests these medications also are linked to other adverse effects, namely increased risk of falls and resulting fractures, memory loss, and confusion among older adults and safety concerns. An article appearing in a 2019 issue of Frontiers in Behavioral Neuroscience contends that commonly prescribed benzodiazepines for anxiety and sleep suppress the central nervous system and the brain’s awake response to danger, causing some study participants to sleep through loud fire alarms.

But if left untreated, disordered sleep, which involves difficulties falling asleep or remaining asleep during a seven- or eight-hour period, poses problems that can be as disconcerting as the effects of the drugs used to treat it. In Nature and Science of Sleep, for example, scientists indicate short-term consequences of insomnia include increased response to stress, emotional and mood disorders, and cognitive, memory, and performance deficits.

Click HERE for the full article.

January 11, 2023 Dr. Dimitriu was published in Psychology Today in an article titled:

Why Some Experts Believe Stress Can Aid Performance

“A little anxiety from time to time can be beneficial to task performance…[as] illustrated by the Yerkes-Dodson law, which states…performance is improved by anxiety until an optimum level of arousal is reached.” That quote, by psychologist and author Clifford B. Dobson as referenced in Yerkes-Dodson: A Law for All Seasons, might best explain why Garry Kasparov became World Chess Champion and John McEnroe won seven Grand Slam tennis championships by age 25, despite their performance stress.

Click HERE for the full article.

Oct 10, 2022 Dr. Dimitriu was published in Psychology Today in an article titled:

Perfection Is Unattainable: Aim for 80 Percent

Happiness is letting go of what you think your life is supposed to look like.

Twenty percent reduced productivity oftentimes leads to 50 percent more happiness. And, of course, once a goal is achieved and confidence gained, one always has the opportunity to raise the bar. Some super-successful patients of mine have said their gardener or maintenance worker seems happier than they are. Indeed, setting—and achieving—smaller goals can cause the brain to release dopamine, a neurotransmitter that makes a person feel good—even happy, and boost one’s self-esteem. Higher self-esteem enhances overall mental health.

Click HERE for the full article.