Silent Partners: The Wives of Sleep Apneic Patients

Sleep 10(3):244-248, Raven Press, New York 1987, Association of Professional Sleep Societies Silent Partners: The Wives of Sleep Apneic Patients Rosalind D. Cartwright and Sara Knight Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, U.S.A. Summary: The wives of 10 male patients being treated for sleep apnea, obstructive type, were interviewed and given the Social Adjustment Scale (SAS) and Marital Satisfaction Inventory (MSI). The patients also completed an SAS and a Minnesota Multiphasic Personality Inventory (MMPI). These data were compared with those from a sample of divorced patients from the same pool. The married patients were significantly more depressed and socially isolated than were those divorced. Both marital partners showed poor adjustment in the Marital and Social/Leisure areas, and patients also showed poor adjustment in their Parental Role. Marriages do not necessarily represent social support but appear to be an added burden for sleep apneic patients. Key Words: Apnea-Marital relationship. The literature describing the physical symptoms of the sleep apneic patient is now extensive. The characteristic nocturnal snoring, apneic pauses during sleep respiration with accompanying episodes of oxygen de saturation and the consequent daytime hypersomnolence have all been well described (1). Recently, some attention has also been directed to the psychological side of this disorder. Cognitive deficits and depression have both been noted in some patients (2,3), and both have been implicated in the difficulty associated with engaging these patients in their treatment. Little attention has been paid to date to the effects of this disorder on social behavior, especially within the marital unit. Those clinicians who take a careful history are often told that one common factor responsible for bringing the patient to seek help is the wife's leaving the bedroom or asking the husband to sleep elsewhere due to the disruption of her sleep by his noisy breathing. Not only does sleep apnea separate the marriage partners for sleep time, but it also severely limits their shared social time due to the patient's inability to sustain evening wakefulness. Because of this clinical presentation, it seemed important to establish the impact of this disorder on the spouse and on the marriages of these patients. Accepted for publication December 1986. Address correspondence and reprint requests to Dr. Rosalind D. Cartwright, Rush-Presbyterian-St. Luke's Medical Center, 1753 West Congress Parkway, Chicago, IL 60612. 244

SILENT PARTNERS 245 SAMPLE Thirty male patients who were participating in an experimental treatment protocol were asked for permission to contact their wives for an interview and some testing. These patients had all been diagnosed by standard all-night clinical polysomnography as meeting the criteria for sleep apnea of the obstructive type (4). To participate in the marital study, patients had to be currently married and living with the spouse. This eliminated 8 of the sample, 1 who never married and 7 who were divorced or who separated and divorced during the course of the study. Four were eliminated because they refused to complete psychological testing, and 8 refused to allow their wives to participate or the wives themselves declined. The final sample of 10 couples studied may represent a bias toward better marriages in that these marriages have survived and both partners were willing to discuss the problems associated with the husband's sleep apnea. METHOD To achieve some appreciation of the personality difficulties these patients may present for a marriage partner, all patients were asked to complete a Minnesota Multiphasic Personality Inventory (MMPI). The 10 couples who signed informed consent for the marital study also each completed the Social Adjustment Scale (SAS) (5), and the wives responded to the Marital Satisfaction Inventory (MSI) (6) and were interviewed concerning the implications for them of the husband's sleep disorder. Table 1 describes the patients in the marital sample and compares them with the seven divorced patients for age and severity of apnea. Three wives reported that they and their husbands occupied separate bedrooms, 2 wives slept in separate beds in the same room, and 5 couples slept together. Seven wives responded that the husband's snoring interfered with their own sleep onset, 7 reported that it interfered with their sleep maintenance (5 reported that it interfered with both), and only 1 answered that neither onset nor maintenance was disturbed. Five responded that their reaction to the husband's snoring was" irritation"; three said their reaction was "worry." As reaction to the husband's daytime sleepiness, 2 wives said they were "lonely," 2 said they were "disappointed," 2 were "angry," 2 were "frustrated," and 1 was "irritated." With this background of affective response, the findings on the MSI and SAS are not surprising. Figures 1-3 show these data. Figure 1 shows that the husbands in the marital sample were more depressed (scale 2) (1 = 2.85, P <.05), had a tendency to have less energy (scale 9) (1 = 2.06, p <.10), TABLE 1. Age and severity of sleep apneic patients in married and divorced subgroup Age (yr) A + HI severity Mean SD Mean SD Married (n = 10) 48.0 12.3 55.9 38.0 Divorced (n = 7) 42.3 9.0 31.9 35.3 NS NS A + HI, apnea and hypopnea index.

246 R. D. CARTWRIGHT AND S. KNIGHT 1.Hs 2. D* 3. Hy 4. Pd 5. Mf 6. Pa 7. PI 8. Sc 9. Ma 10. Si** 70-------------------------------------------------- --r:.~=----7=,;;;;;----_-------...;... ~-- ~arried :~... -----"''=«''*''---/_/ c_. ~_ ~ ~ Divorced 40-------------------------------------------------- 30-------------------------------------------------- FIG. 1. MMPI T scores of married (n = 10) and divorced (n = 7) patients. Scales: 1. Hypochondriasis (Hs); 2. Depression (D); 3. Hysteria (Hy); 4. Psychopathic Deviate (Pd); 5. Masculinity-Femininity (MF); 6. Paranoia (Pa); 7. Psychasthenia (Pt); 8. Schizophrenia (Sc); 9. Hypomania (Ma); 10. Social Isolation (Sij. *p < 0.05; **p < 0.01. '. and were significantly more socially isolated (scale 0) (t = 3.43, p <.01) than were those patients who were divorced. These results must be interpreted with caution in light of the trend in the sample characteristic differences of the divorced group to be both younger and less severe in terms of Apnea + Hypopnea Index (A + HI), although neither of these differences reached statistical significance. On the basis of their three highest MMPI peaks, the married sample would be described as somewhat depressed and anxious (scale 2, Depression; scale 1, Hypochondriasis; and scale 3, Hysteria). Figure 2 compares the SAS of the husbands and wives (higher scores represent poorer adjustment). The graph shows that the two groups paralleled each other with peaks of disturbance for both in the Marital and Social/Leisure areas in contrast to Work as an area of satisfaction. The Marital Scale scores for 4 of the 10 husbands were higher (more disturbed) than the mean reported by Weisman and Bothwell (5) for 35 depressed patients during an acute episode. The husbands, unlike the wives, also had elevated scores for Parental Role and in adjustment in Family Unit subscales. Figure 3 2.6 2.4 2.2 2.0 1.8 1.6 " \ 1.4.. 1.0 'I. '. Husbands FIG. 2. Social adjustment scores of husbands and wives (n = 10).

SILENT PARTNERS 247 70 60 50 ~ wives 'f ~ ':! 8 7-0- T : - ~ 40 ~ normal sample 30 2 3 4 5 6 7 8 9 10 11 High score= less satisfaction FIG. 3. Marital satisfaction inventory scores for wives of sleep apnea patients (n = 10) and normative sample (n = 253). Scales: I. Conventionalization; 2. Global Distress; 3. Affective Communication; 4. Problem Solving/Communication; 5. Time Together; 6. Disagreement About Finances; 7. Sexual Dissatisfaction; 8. Role Orientation; 9. Family History of Distress; 10. Dissatisfaction With Children; II. Conflict Over Child-Rearing. shows the responses to the MSI completed by the wives, revealing some overall dissatisfaction with the marriage (scale 2). This is most clear in the Conflict Over Child Rearing (scale 11), on which scale 5 of the 10 wives' scores were elevated >lsd above the norm of 48. This complements the husbands' own SAS scores, showing problems in carrying out their parental role and their poor family unit adjustment. DISCUSSION Although the findings are based on a small sample and the study was not formally controlled, it appears that those sleep apnea patients who remain married have an added burden. This is consistent with reports that marriages act to exacerbate rather than to buffer the impact of chronic disease (7). For the most part, patients appear to be able to derive satisfaction from their work role. With their limited energy, however, the marriage and parental responsibilities are more than they can cope with. The result is that husbands and wives both find the marital situation and their social and leisure time to be areas of poor adjustment, with conflict over child-rearing being a focus for the wives' marital dissatisfaction. In contrast to a divorced group, the married patients are more depressed, socially isolated, and exhausted. Those who treat sleep apneic patients should be aware that the wives may also need support or direct help. They need to be educated about the disorder and made part of the treatment team since many of the treatments for these patients involve the wife's participation (weight control, alcohol reduction). Their help is often needed to observe if the patient has learned to sleep only in the lateral position or is sleeping supine (8). The wife cannot do this if she has removed herself to another room. She must be helped to obtain the sleep she needs to function while becoming involved as a partner in the patient's home care. Sleep apnea may well be a disorder ripe for a wives' support group movement equivalent to the AI-Anon group for partners or family members of alcoholics, because this disorder creates an extended stress on the marital and family unit, interfering as it does with both shared social and sleeping arrangements. The attendant marriage problems need to be recognized while the patient's sleep disorder is being brought under control. REFERENCES I. Guilleminault C, van den Hoed J, Mitler M. Clinical overview of the sleep apnea syndromes. In: Guilleminault C, Dement W, eds. Sleep apnea syndromes. New York: Liss, 1978:1-12.

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