Insomnia and Anxiety (Series in Anxiety and Related Disorders) (35 page)

of information very clearly, above the din of the other noise (Craske et al. 2005). In

the same way, physical cues can be meaningful information because of the fear that

they signal panic symptoms. This same process can occur in sleep. Craske’s manual

provides the example of a mother perceiving sounds from her new born baby out of

a sleep because of the meaning such sounds have for her. During sleep, there are a

variety of normal physical fluctuations in breathing, heart rate, and muscle activity

that may be perceived more easily in those predisposed to mistakenly think of

these symptoms as danger cues. Panic during the night is thus conceptualized the

same as panic during the day. As a result, psychoeducation focuses on the idea that

physical sensations do not pose a genuine threat. The homework assignment for

the first week is to monitor awareness of their experience as they wake out of sleep

in a panic. This can include thoughts, physiological sensations, or imagery.

In session 2, patients are taught about the physiology of anxiety and the auto-

nomic nervous system. They also receive a handout on sleep hygiene which details

the following sleep rules: (1) stay in bed for as long as sleep is needed but no longer,

(2) maintain a regular, consistent wake up time, and obtain exposure to bright light

during the day; (3) engage in quiet presleep activities such as reading or taking a

hot bath; (4) engage in regular late afternoon exercise; (5) maintain a comfortable

sleeping environment (e.g., no extremes in temperature, no noise etc.); (6) consider

a light bedtime snack (e.g., dairy or crackers); (7) limit caffeine, tobacco, or alcohol

use close to bedtime. The idea behind these recommendations is to optimize sleep

habits and decrease the likelihood of sleep deprivation; sleep deprivation is thought

Craske’s Nocturnal Panic Protocol

133

to increase sleep-related anxiety and increase susceptibility to panic (Mellman &

Uhde 1990; Roy-Byrne, 1986).

In session 3, patients are asked to undergo a voluntary hyperventilation experi-

ment to learn about the effects of overbreathing. This sets the stage for a breathing

retraining technique (BRT); a practice taught over the next few sessions. BRT

implements a counting procedure with the end goal of slowing breathing to three

seconds on the inhale and 3 on the exhale. Session 4 continues with BRT and also

focuses on restructuring thoughts about the overestimate of danger. Starting in

session 2, there is a focus on monitoring thoughts about panic, thus there is data

available during session 4 for discussion. The tendency toward overestimating risk

is presented as an exacerbating factor in panic. There is a careful exploration of

thoughts that overestimate the likelihood of danger and a countering of the overes-

timation of risk. Possible techniques include asking to: (1) treat such thoughts as

hypotheses for which data should be gathered to test if it is true; (2) generate a

list for what alternative possibilities exist; (3) consider whether there might be an

error in their assessment of risk; (4) estimate the “real” odds for something happening.

Unrealistic statements are challenged because they can turn
possibilities
into

certainties and thus create anxiety (Craske et al. 2005).

Session 5 continues the focus on cognitive restructuring; more specifically, the

tendency toward evaluating consequences as catastrophes. A countering technique

is taught, wherein the person is encouraged to critically evaluate the actual severity

of the situation and personal resources for coping with the presumed “catastrophe.”

For example, if someone is afraid of passing out upon awakening from a panic

attack, the focus may be on the fact that such an event would be unlikely, and if it

were to occur, it would be “time-limited and manageable.” Craske suggests that in

cases wherein the “catastrophe” involves truly significant loss (e.g., death), then

countering the probability overestimation (i.e., as presented in the preceding para-

graph) is more appropriate. Session 6 encourages experiencing feared physical

sensations (e.g., hyperventilation-related symptoms). The rationale for this strategy

is that the more people experience feared sensations, the less likely it is that they

will react with panic when experiencing them in the future. The therapist models a

series of exercises, and then the patient is invited to repeat the same exercises. For

each of the exercises, the person identifies: (1) the sensations experienced; (2) the

intensity of the sensations; (3) the intensity of anxiety; and (4) the similarity of the

experience to naturally occurring panic sensations.

Exercises

Shaking the head from side to side for 30 s

Running on the spot for 90 s

Holding one’s breath for as long as possible

Complete body muscle tension for 1 min or holding a pushup position for as long as possible

Spinning in a chair for 1 min

Hyperventilation for 1 min

Breathing through a straw (with nostrils held together) for 2 min or breath as slowly as possible

for 2 min

Focusing on a specific bodily sensation (e.g., swallowing) for 90 s

(continued)

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9 Other Issues in Managing the Sleep of Those with Anxiety

(continued)

Exercises

Focusing on a specific cognitive image (e.g., going crazy) for 90 s

Meditative relaxation (i.e., repeat a word like calm over and over) for 5 min

Quiet relaxation for several minutes interrupted by a buzzer sound

In addition, patients construct a hierarchy of feared/avoided activities (e.g., exer-

cising, saunas, drinking hot beverages) for exposure in future sessions. Sessions

7–10 primarily focus of cognitive restructuring, deconditioning, exploration and

exposure to avoided activities (from their hierarchy), and continued interoceptive

exposure. The final session focuses on the review and planning for termination.

While future studies are needed, Craske’s treatment appears to provide an effective

treatment for those with nocturnal panic.

Treating Claustrophobia Associated with Sleep Apnea Treatment

Sleep apnea is a fairly common disorder characterized by loud snoring and repeated

episodes of breathing interruptions occurring in sleep. Typically, these breathing

disturbances result in frequent arousals and contribute to poor sleep quality and

such daytime sequelae as overwhelming sleepiness, reduced concentration, mem-

ory dysfunction, cardiopulmonary complications, and impaired occupational and

social functioning. Although various treatment approaches may be considered for

the management of this condition, most diagnosed with moderate or severe sleep

apnea are treated with an apparatus known as a continuous positive airway pressure

device – CPAP. This apparatus consists of a nasal or oral/nasal mask. The mask is

attached via plastic hosing to an electric air pump designed to force

air into the airway during sleep in order to eliminate sleep-related breathing

disturbances. The compressed air flows into the airway and acts as a splint to hold

back the tongue and open the soft tissue obstructing the airway. When CPAP is

used, breathing becomes more regular, snoring stops, restful sleep is restored, and

daytime symptoms are reduced or alleviated entirely.

CPAP has proven very effective for eliminating sleep-related upper airway

obstruction, reducing excessive daytime somnolence (EDS), and improving cardio-

pulmonary function among patients with sleep apnea (Engleman & Wild, 2003;

Kribbs et al., 1993; Rauscher, Popp, Wanke, & Zwick, 1991; Sanders, Gruendl, &

Rogers, 1986). Unfortunately, many treated with CPAP fail to adhere to this therapy

(Beecroft, Zanon, Lukic, & Hanly, 2003; Engleman & Wild, 2003; Jenkins, Mrad,

& Walsh, 1991; Kribbs et al., 1993; Rauscher et al., 1991; Sanders et al., 1986).

Factors most often cited as contributing to CPAP intolerance include the cost and

inconvenience of the CPAP apparatus, the physical discomfort experienced from

wearing the CPAP mask, dryness in the nose and throat, and, in some cases, chronic

rhinitis associated with CPAP use. However, a substantial proportion of those who

fail CPAP therapy report panic or claustrophobic reactions to the nasal mask

Treating Claustrophobia Associated with Sleep Apnea Treatment

135

(Chasens, Pack, Maislin, Dinges, & Weaver, 2005; Means, 2002; Rolfe, Olson, &

Saunders, 1991). This is particularly the case in those who otherwise have a history

of claustrophobia or other severe anxiety disorders (e.g., panic disorder; PTSD).

Those with claustrophobic or panic reactions to CPAP typically report a pronounced

and uncomfortable sense of confinement and fears of suffocation while wearing

their CPAP masks. Attempts to wear CPAP while falling asleep only heighten this

anxiety and arousal, making it difficult if not impossible to fall asleep. Thus, despite

the important benefits of CPAP therapy, some may decline or reject this treatment

as a function of the enhanced anxiety and insomnia it causes them.

To the extent that anxiety and panic reactions to CPAP therapy actually represent

“phobic” responses to wearing the CPAP mask, such reactions should be treatable

with an anxiety deconditioning therapy such as desensitization or graded exposure.

Initial support for this contention comes from an early case study (Edinger &

Radtke, 1993), in which someone with history of claustrophobia and consequent

rejection of CPAP therapy was treated with a paradigm involving gradual exposure

and home-based practice with the CPAP apparatus. While this person was not using

CPAP at all when treatment began, he gradually became capable of using the CPAP

throughout each night’s sleep by the end of treatment. Follow-up with this person

showed continued CPAP use through an ensuing 6-year period. In a more recent

case series study (Means & Edinger, 2007), 11 people with pronounced anxiety

reactions to CPAP underwent graded exposure treatment to enhance their CPAP

tolerance/adherence. As a result of intervention, 8 (72.7%) of the 11 people showed

a pre-to-posttherapy increase in the number of nights they used CPAP, whereas 9

(81.8%) of the 11 showed pre-to-posttherapy increases in their hours on CPAP

when they actually used this apparatus. Although only 4 achieved a predetermined

desirable level of CPAP use, all but one showed improvements in either hours

of CPAP use or percent of nights CPAP was used. In addition to these promising

findings with adults, it is noteworthy that other investigators (Koontz, Slifer,

Cataldo, & Marcus, 2003; Rains, 1995) have successfully used similar graded

exposure therapies for acclimating children with significant anxiety to CPAP

therapy. Thus, despite the limited number of reports attesting to its efficacy, graded

exposure appears to be a promising and conceptually reasonable treatment for

addressing CPAP refusals resulting from the claustrophobic and panic reactions it

elicits in some people.

Treatment approach
: The treatment approach presented herein is based on the

strategies described in previous reports (Edinger & Radtke, 1993; Means &

Edinger, 2007). The primary treatment components include a series of graded

CPAP exposure exercises that are accomplished at each patient’s preferred pace via

homework assignments. The graded series of exposure exercises involve a gradual

introduction (or reintroduction) to CPAP usage to help people slowly acclimate

to CPAP and to reduce CPAP-related anxiety. The specific treatment employs a

standard exposure hierarchy that can be individually tailored for each person.

A sample hierarchy is provided in Table 9.1. As can be seen, the hierarchy requires

acclimation to holding the CPAP mask against the face and practice breathing with

136

9 Other Issues in Managing the Sleep of Those with Anxiety

Table 9.1
Sample CPAP exposure hierarchy

1. Connect the CPAP mask to the air compressor, turn it on, and hold the mask over your nose,

without strapping it to your head. Attempt to gradually increase the time you are able to

tolerate breathing through the CPAP mask until you can do so for at least 15 min without

anxiety.

2. Connect the CPAP mask to the air compressor, turn it on, and attach the mask to the

headgear. Practice wearing the mask with the headgear while you breathe through the CPAP

mask. Do this for increasing periods of time, starting with brief periods and building up to

30 min or more.

3. Connect the CPAP mask to the air compressor, turn it on, attach the mask to the headgear

and put the CPAP in place on your face with the headgear. Now practice taking short

daytime naps with the CPAP in place. Start with brief naps of 15 min or so and increase the

time up to 1 h as you feel able to do so.