Am I Dying Read online

  We can’t always expect to feel like superheroes. Life is full of demands, and you’re probably not always clocking eight hours of sleep per night. Sometimes you just have to burn the candle at both ends for your disorganized, psychopathic boss, or wake up through the night to soothe your crying child.

  But do you feel tired all the time, for no apparent reason, despite seeming to get enough sleep? Different from the way you remember feeling years ago? The exact sensation is sometimes hard to describe, but people use terms like “run-down,” “exhausted,” “weak,” and “unfocused”—overall just not yourself. If your symptoms last longer than six months, they can be considered chronic. (Of note, having chronic fatigue does not necessarily mean you have the specific condition known as chronic fatigue syndrome.)

  It’s possible you just need more and higher-quality sleep than you’re getting. It’s also possible you have an underlying medical condition that’s draining your spirits. So which is it—a new mattress or a comprehensive medical workup?

  Take a Chill Pill

  Rockabye, baby . . . Are you sure you’re getting enough sleep? Just because your work colleagues can scrape by on six hours per night doesn’t mean you can too. There’s plenty of evidence that some people just need more sleep than others to function at peak performance. If your symptoms always improve by the end of a one- or two-week vacation—that is, enough time to pay down some sleep debt—then you probably just need to schedule more sleep during the work week.

  You’re out of fuel. Did you just start an extreme diet? Are you on an all-juice cleanse? Or did you completely and suddenly eliminate a major food group, like carbs? Your body may not be getting enough calories to function at full capacity. If you’re already fairly thin, you may not have a lot of reserves to burn. An extreme diet (major drop in calories) or a starve-and-binge diet (no food until nighttime, or eating only every other day) will make your energy supply inconsistent and often depleted. If you want to lose weight, aim for a realistic reduction in calories (10 to 20 percent below normal), spread evenly over the day’s meals.

  You need to push yourself harder. If you don’t get much regular physical activity, your body can get stuck in low-energy mode. Try to squeeze at least thirty minutes of fast walking or jogging into most days (ideally more than five times per week).

  Do you love piña coladas? Alcohol may help you fall asleep quickly, but as its sedating effect wears off, you’ll probably wake back up. It also increases urine production, causing dehydration and frequent overnight bathroom trips. Even if you’re not overtly hung over the next morning, you’ll still be in low gear. Limit yourself to one or two drinks whenever possible, with no more than three drinks on special occasions.

  You’re taking sleeping pills. Sleeping pills are usually long acting, to help you sleep through the whole night, but if you take them too late, you’ll face lingering effects the following morning. Take the pills when you first get in bed, and at least eight hours from the time you have to wake up. If you don’t want to take a pill until you’ve already tried to fall asleep on your own, ask your doctor for a shorter-acting medication. See the Quick Consult for more details.

  Your medications are dragging you down. Many medications—especially antihistamines (for allergies), pain relievers, antianxiety/antidepressant medications and some blood pressure medications (especially beta blockers)—can cause fatigue. If you’ve recently lost weight, you may need to reduce the doses of some medications. Look over your prescription regimen with your doctor; please don’t stop or change anything on your own!

  Make an Appointment

  You’ve been feeling depressed about your life or prospects. Depression can cause many different symptoms, including generalized fatigue, irritability, loss of interest in your usual activities, difficulty concentrating, changes in appetite or weight, loss of sex drive, and problems staying asleep. Remember, superheroes get depressed too. (Um, hello—Batman is super depressed!) If you think you could have depression, speak to your doctor about the many treatment options. They can make a huge difference in the quality of your life.

  Your neighbors complain about your snoring. And you live on four acres. Sleep apnea is a common condition in which your throat periodically closes down during sleep. The result is loud snoring and brief periods of apnea—not breathing—that wake you up for a few seconds. You can wake up literally hundreds of times per night and not remember the next morning. Unsurprisingly, you’ll be exhausted. If you’re a known snorer who wakes up feeling tired, and you’re also overweight, older than fifty, have a large neck, and/or have high blood pressure, you should definitely ask about a sleep study. If you do have sleep apnea, the available treatments can dramatically improve sleep quality and energy levels. Many people use a mask at night that supports breathing by blowing air into the lungs. If you’re overweight, shedding a few pounds may also significantly improve your symptoms.

  You’ve had severe fatigue for at least six months that is worse after exertion, and you don’t feel better after a full night’s sleep. Chronic fatigue syndrome/systemic exertion intolerance disease, or CFS/SEID, is not well understood and difficult to diagnose.

  You could have CFS/SEID if your energy has significantly decreased, your fatigue interferes with your overall functioning, and your fatigue has been present for more than six months. Sometimes CFS/SEID starts after a cold or other minor infection. The fatigue is usually worse right after exertion and doesn’t improve with sleep (you wake up not feeling refreshed). Other symptoms include poor attention, dizziness when getting up from a seated position, headache, and muscle/joint aches.

  If your doctor thinks you could have CFS/SEID, it’s important to first get tested for other causes of fatigue. Once those boxes have been checked and the diagnosis confirmed, the combination of talk therapy and an exercise plan may dramatically improve your life.

  You’ve had weight gain and constipation, and even though it’s the middle of summer, you always feel cold. Your thyroid gland, which helps regulate your body’s metabolism, may be running out of steam. A few simple blood tests can diagnosis hypothyroidism (a.k.a. underactive thyroid), which causes fatigue, weight gain, constipation, and cold intolerance. Most of the time, taking supplemental thyroid hormone is enough to bring your body back up to speed.

  You also feel short of breath and easily get winded. Your blood may not be delivering enough oxygen to your muscles and heart. The most common cause is anemia—not enough red blood cells—which can be diagnosed with a simple blood test. (Finding the cause of anemia can be more complicated and may involve a colonoscopy, since bleeding from the colon is a major cause, especially among older adults.) Other potential causes include heart disease, which affects blood delivery throughout your body, and lung disease, which interferes with the transfer of oxygen from air to your blood.

  You’re constantly peeing and drinking water. You may have diabetes, which occurs when your body runs out of (or stops responding to) insulin. As a result, your body can no longer normally process sugar, which gets stuck in your bloodstream. Your kidneys produce tons of urine to offload some of the sugar into your toilet. As a result, you become dehydrated, tired, and thirsty. If you’ve been having these symptoms, see your doctor as soon as possible—today, ideally—as you likely need treatment with insulin. If you’re feeling really lightheaded or nauseated, just head to the E.R.

  You’ve been experiencing recurrent fever, weight loss, and/or night sweats. An infection could be draining your body of energy without causing any other obvious symptoms. Some common culprits include heart infections (endocarditis), HIV infection, and tuberculosis. Certain cancers, such as lymphoma, can also present with these symptoms. See your doctor ASAP.

  You have known kidney disease, or you’re swollen and haven’t peed much in the past few days. Kidney failure causes many problems that can contribute to fatigue. For example, it causes anemia (lack of red blood cells), poor appetite, fluid in the lungs (which lowers oxygen levels), and the ac
cumulation of toxic, sedating chemicals. Additional signs of kidney failure include high blood pressure and swelling in your face or legs. If you don’t have known kidney problems but have been experiencing these symptoms, see your doctor right away. If you have known kidney disease, worsening fatigue may be a sign that you need to change medications or start dialysis.

  The whites of your eyes have turned yellow. Liver disease can cause jaundice (yellow eyes and skin), itchiness, and the accumulation of toxic chemicals that cause confusion, fatigue, and eventually full-blown coma. The first signs of liver-related confusion are subtle—fatigue, slow response time, short attention span, and irritability. Next up are disorientation, slurred speech, and stupor. One telltale sign of more advanced liver disease is the inability to keep your arms up and palms facing out, as if to stop traffic, for more than a few seconds without letting your hands flap downward. (By the time you reach this point, you’ll probably no longer be reading this book.) See your doctor today.

  Get to the E.R.

  You’re really groggy and confused for no clear reason. Okay, so if you’re in this state, you’re probably not reading this book. But perhaps you arrived at this paragraph on behalf of someone else. Many dangerous conditions can cause severe fatigue and confusion, including brain infection (encephalitis), stroke, drug overdose (for example, with painkillers), carbon monoxide poisoning, severe infection (sepsis), and more. Call an ambulance before it’s too late.

  Insomnia

  EDITED BY AMY ATKESON, M.D.

  Insomnia is defined as impaired daytime functioning that results from difficulty falling asleep, difficulty staying asleep, and/or waking up too early and being unable to fall back asleep. And if you’re still awake after reading that list, you just might have insomnia.

  Not everyone needs the exact same amount of sleep. If you’re one of the lucky few that can snooze for a few hours and then wake up feeling like a million bucks . . . well, we hope you’re enjoying your life as an investment banker or heart surgeon.

  If you’re like the rest of us, there may be some telltale signs you’re not catching enough Zs. If you drift off during quiet daytime moments (while watching television or riding the bus), have difficulty focusing, or generally feel forgetful, irritable, depressed, or anxious (like we did throughout all of medical school), you’d probably benefit from more time in the sack.

  Although insomnia is not itself lethal, it wreaks havoc on your mood, attention, metabolism, and immune system. It makes you snap at people who totally didn’t do anything wrong. (You monster!) It makes you eat more and gain weight. And it makes you do stuff that definitely can be lethal, like falling asleep at the wheel and crashing your car. Indeed, almost half of fatal truck crashes are related to driver sleepiness.

  So how do you know if you need to just cut back on the coffee or take a cab to the doctor for a detailed evaluation?

  Take a Chill Pill

  Your iPad is your teddy bear. The key to good sleep is good sleep hygiene—basically, an environment that promotes sleep. As a general rule, screens are terrible, even if you use apps to reduce blue light. Evict the television from your bedroom and leave your laptop, phone, and tablet somewhere else—even just outside your door, if necessary. Your bedroom should be for sleep and sex—not for working, reading, blogging, and gramming. If you really can’t part with your devices, then at least don’t charge them right next to your bed. The buzzes and bings are designed to grab your attention even as you should be powering down.

  Both sides of your pillow are hot. If you’re crashing on a straw mattress in a hot room without blinds that overlooks a busy train station . . . well, please don’t drive on the same highways as us. The ideal bedroom should be comfortable, cool (68 to 72°F), dark, and quiet. If splurging on a new air conditioner or white noise machine helps you get just thirty extra minutes of sleep per night, the money will have been well spent.

  You can’t keep a schedule. The brain’s circadian rhythm promotes wakefulness and sleepiness on a regular schedule. You’re not exactly jamming to your body’s rhythm if you hop into bed at a different time each night. Even if it requires setting an alarm for getting into bed, try to be consistent.

  You’re a power napper. If you can’t fall asleep at night, you definitely should not be napping during the day. You want sleepiness to build up as much as possible throughout the day, so you’re more prepared to doze when night finally arrives. Soldier through the fatigue, and soon you’ll be sleeping on a more regular schedule.

  You enjoy an adult beverage in the evening. It is (hopefully) obvious that drinking caffeinated beverages—like coffee, tea, soda, and energy drinks—in the afternoon or evening can cause insomnia. (Heads up: caffeine is also found in chocolate and many over-the-counter headache medications.) Alcoholic drinks, however, can also keep you tossing and turning. Although booze helps you zonk out, it also stimulates you later in the night as its sedating effect wears off. (It will also fill your bladder every few hours, waking you up for late-night trips to the toilet.)

  You’re constantly fretting. Trying to finish this book certainly kept us up at night! Stressing about work, family, finances, and all the other drama in your life keeps your mind racing when it should be resting. Let us know if this sounds familiar: You’re stressing about life, then you turn over and see how late it is, and now you’re stressing about not getting enough sleep, and boom! You’re in a vicious cycle. Reassure yourself that you will fall asleep at some point, and that you will make it through tomorrow. You always do. Try to further unchain your mind with meditation and focused deep breathing. Breathe in . . . 2, 3, 4 . . . breathe out . . . 2, 3, 4 . . . and repeat.

  Your bladder can’t wait until morning. If your bladder behaves during the day but acts up at night, the most likely explanation is that you’re just drinking too much fluid before bed. Cut yourself off at least two or three hours before bedtime. If, on the other hand, you’re peeing all the time, both day and night . . . well, urine trouble. (Get it?!) You could have an enlarged prostate (if you’re a man), a urinary tract infection, or a related problem. See the section on frequent urination for more details.

  You have dinner right before bed. Gorging on a heavy meal right before bedtime may lead to bloating and acid reflux, both of which will make you uncomfortable when you finally get between the sheets. Try to eat at least three hours before bedtime, so your stomach has plenty of time to empty.

  You’ve memorized the patterns on your ceiling. If you can’t fall asleep, don’t just lie in bed staring at the ceiling. Sleep specialists recommend you leave the bedroom and do something relaxing, like read a long-winded book, and not return to bed until your lids start to sag. This behavior sends the clear message to your brain that bed is for sleeping—not for reading, watching television, or even lying awake and worrying about falling asleep.

  Make an Appointment

  You’re long in the tooth. Half of adults over the age of sixty-five experience sleep dysfunction. The list of common indignities includes overactive bladder, chronic joint pain, dementia (which messes with the normal sleep–wake clock), and medications that affect sleep. Increased napping during the day also leads to problems falling asleep at night. Speak to your doctor (or read on) if there are specific issues interfering with your sleep, but general solutions include being more active, avoiding naps, and adjusting to the normal changes that come with age—namely, getting tired earlier and waking up earlier. Perhaps you’ll finally become that morning person who has already worked out, eaten breakfast, and mowed the lawn before anyone else rolls out of bed.

  You’re popping a new pill. Many medications can interfere with your sleep cycle. Common culprits include blood pressure medications like beta blockers (atenolol, metoprolol/Toprol) and alpha blockers (terazosin/Hytrin, tamsulosin/Flomax); decongestants (phenylephrine, pseudoephedrine); stimulants (methylphenidate/Ritalin); steroids (prednisone, hydrocortisone); and antidepressant medications known as selective serotonin reuptake inhibitors
, or SSRIs (fluoxetine/Prozac, escitalopram/Lexapro, citalopram/Celexa, sertraline/Zoloft). Of note, stopping these medications may briefly cause withdrawal symptoms, which can also include . . . you guessed it . . . insomnia. Please speak with your doctor before stopping or changing any medication.

  You wake up early and can’t fall back asleep. A major cause of early awakenings is depression. If your sleep problems are coupled with low mood, poor concentration, and a change in your appetite/weight, speak with your primary doctor as soon as possible. Another cause of early morning awakenings is excessive alcohol intake, so if the awakenings only occur after wild nights out, go easier on the tequila shots next time.

  You’re experiencing “the change.” During menopause, over one-third of women have difficulty sleeping. Hot flashes and night sweats will keep you up at night. The hormonal changes also distort your brain’s normal sleep cycle. Ask your doctor about the many treatment options, including replacement hormones.

  You have an inexplicable urge to move your legs and walk around. If you get a weird discomfort or tingling in your legs that improves when you walk around, you likely have restless legs syndrome. You probably also feel some relief early in the morning and finally sneak in a few good Zs. This curious disorder can occur on its own or as a result of another condition, like iron deficiency, kidney disease, neuropathy (nerve irritation), multiple sclerosis, and even pregnancy, or as a side effect from medications (including antihistamines, antidepressants, and antinausea medications). If you can’t stop dancing at night, see your doctor for a basic workup. You may also be able to settle down your legs by stretching them out and taking a hot shower before bed.

  You’ve tried every suggestion in the book, and you still can’t fall asleep. If you have impeccable sleep hygiene, take no suspicious medications, and don’t relate to any of the scenarios described above, see your doctor for a more thorough assessment, which may include blood tests and a sleep study.