In general it is considered bad form to diagnose celebrities with medical conditions, though there is no scarcity of pundits willing to engage in speculation. I avoid this muck for the most part, but occasionally an opportunity arises to use what we know about a “case” to educate people on possible missteps or misunderstandings on the diagnosis and treatment of sleep disorders.
Tiger Woods is a prime example. A great deal of superficial analysis has been written in the past few weeks, including a commentary on the Huffington Post where we learn Tiger suffers from a “sleep disorder” and “insomnia” and “a lack of sleep.” On CBS Sports we learn he is “resting and rehabilitating” due to recent back surgery and that he was mixing Vicodin and Xanax during the recent DUI arrest, which led to his acknowledgement of needing professional help to deal with the pain and sleep disorders. Heavy.com states that it was the mix of medications that caused the problem with driving, and made a point to deny that alcohol was in any way involved. And, finally, one commentator chose to criticize Woods in a forum post titled Tiger Woods now adds “sleep disorder” to his bag of excuses, which as a sleep medical professional infuriates me for the obvious reason that we do not look at sleep disorders as “excuses” for anything; we look at them as medical disorders in need of treatment.
With this backdrop, let’s review and discuss some of the past events in Tiger Woods’ life that serve as important reminders in evaluating and managing sleep disorders in our patients.
Much has been discussed about how the death of Wood’s father has impacted his career. His dad passed down a love and deep knowledge of golf, psychology, and the discipline needed to achieve. Earl Woods may have passed something else onto his son: a genetic predisposition for obstructive sleep apnea. Earl Woods had many physical characteristics of sleep apnea in terms of the apparent weight gain and cardiovascular disease to which he eventually succumbed at the age of 74 with his cause of death described as a heart attack.
Genetic predisposition for OSA and cardiovascular disease in family medical history are important indications to seek an evaluation at a sleep medical center. In fact, we often meet patients who come to the center specifically stating, “My dad suffered from high blood pressure (or had a stroke, or had a heart attack)…and I thought I should check out whether I might be suffering from sleep apnea.” These patients are very astute and often their concerns are justified as they invariably show obstructive sleep apnea or upper airway resistance syndrome in the sleep lab. And, as you might expect, they then become highly motivated to move forward with a trial of PAP therapy. Again, keep in mind their perspectives. They did not report cardiovascular diseases in themselves; but simple awareness of their genetic tendencies led them to a sleep center.
A second possible sign of a sleep disorder is Wood’s apparent nasal congestion. As an avid golfer, I have watched many of Wood’s tournaments and recall noticing signs of congestion including dark circles under his eyes during close-up photos or talking in a voice where you could hear some type of nasal blockage when he gave interviews. Apparently, the problem is so noticeable someone placed Woods on a list of 10 celebrities who suffer from allergies, and he was alleged to suffer from problems with pollen.
Nasal congestion is extremely common in OSA/UARS. Some sleep professionals theorise the irritation and inflammation emanating from an obstructed airway somehow seeds the tissues, making them ripe for chronic congestion in the form of rhinosinusitis. In previous posts we have attempted to establish some of the finer points regarding chronic congestion including the high probability that many OSA/UARS patients suffer from both allergic and nonallergic rhinitis, the latter a much more confusing condition to diagnose and treat. Not only must OSA/UARS recognize and deal with rhinitis of any form, eventually they must realize they will never obtain an optimal response to PAP therapy without aggressively resolving nasal congestion issues.
Much of the major media coverage on Woods described what appears to be a chronic case of insomnia and perhaps equally chronic use of sleep aids such as Ambien. There was particularly explosive incident involving a car crash in the middle of the night after which Woods was found sleeping in the car and was allegedly snoring per an eyewitness. Once again, we’re drawn back to the genetic predisposition for sleep apnea and how so many patients who present with insomnia and hypnotic dependency often have been masking the real culprit, OSA or UARS. In our publication in the Mayo Clinic Proceedings, as well as the accompanying video, we outline how more than 90% of patients taking prescription sleep drugs actually suffered from undiagnosed OSA or UARS.
One of the more interesting questions arising from Woods’ experiences is whether or not he has ever consulted with a sleep medical specialist. As we described in the Mayo Clinic Proceedings paper, nearly all patients were prescribed insomnia sleeping pills by primary care physicians, psychologists, or psychiatrists. Very few had previously visited sleep medical centers, and of the few that had consulted a sleep specialist, it was not unusual for them to declare they underwent a sleep study that came back negative, which often means the diagnosis of UARS was missed.
This intersection between insomnia and sleep apnea is a crucial take home message in analyzing cases like Tiger Woods’ and the more than 1000 patients in our paper from the Mayo Clinic Proceedings. It is not unusual for a patient to go 10 to 20 years on a regimen specifically devoted to medication as the primary therapeutic intervention before someone finally suggests a professional sleep evaluation. Even then, it would not be unusual for the patient to ignore the recommendation for years before finally agreeing to an overnight sleep study in a sleep lab. For any patient hooked on sleeping pills, a sleep test is imperative. If diagnosed with OSA or UARS there are a wide range of treatment options that offer hope and healing.
About the author
Dr Barry Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr. Krakow started in sleep research in 1988 and helped pioneer innovative therapies for chronic nightmare patients. Since 1995, he has practiced sleep medicine full-time and currently operates Maimonides Sleep Arts & Sciences, Ltd., a private sleep medical center specializing in the treatment of sleep disorders such as insomnia and sleep apnea in mental health patients. He is also principal investigator of the Sleep & Human Health Institute, a non-profit research center that focuses on the complex interplay between physiological and psychological sleep disorders.