Insomnia and Anxiety (Series in Anxiety and Related Disorders) (36 page)

4. Begin wearing CPAP at nighttime as originally prescribed. You may first try to wear it for a

portion of the night and then gradually increase your time on CPAP until you can tolerate it

for your full night of sleep

it without attaching it to the headgear and actually wearing the mask. Once the

person is comfortable with this step and can tolerate breathing with the CPAP in

this way for extended periods, the next step (i.e., practice breathing with the CPAP

while wearing the CPAP mask with the headgear) is introduced. Once the first

two steps of this hierarchy are mastered while awake, the next step involving using

CPAP during a brief daytime nap is introduced. After they are able to successfully

nap with CPAP for up to 1 h without anxiety or other difficulties, they are encour-

aged to begin using CPAP during the main sleep period at night time. Since patients

implement the graded exposure regimen independently in their homes, they are able

to progress at their own rates and may discontinue each practice session whenever

they choose to do so. These features provide patients a sense of control and safety

as treatment progresses and minimize chances for strong anxiety reactions that

might confound the treatment process.

Before beginning this treatment, it is useful to assess readiness and motivation

for treatment. Given the amount of “homework” involved in this therapy, those who

are not particularly interested in pursuing such treatment are generally not good

treatment candidates. However, because sleep apnea may have serious long-term

medical sequelae (cardiac disorders, increased risks for stroke, etc.) interventions

such a motivational interviewing (Aloia, Arnedt, Riggs, Hecht, & Borrelli, 2004)

may be a necessary prelude to graded CPAP exposure. It is also important to assess

comfort with the type of CPAP equipment he/she is using. For example, some may

report that their CPAP mask does not fit properly or is otherwise uncomfortable.

Others may complain that the CPAP air is too dry and irritates their airways. It is

important to know that such complaints can be addressed by providing choices

from the myriad of CPAP masks available on the market and by attaching a humidifier

unit to the CPAP air compressor. Such ancillary supplies can usually be obtained

from home healthcare companies that deliver the CPAP machine, so collaborating

with this vendor to resolve these issues can be beneficial to the overall CPAP

adherence intervention.

Treating Claustrophobia Associated with Sleep Apnea Treatment

137

When implementing the graded exposure treatment, it is useful to provide a gen-

eral rationale for the treatment. Most understand that gradual exposure to feared situ-

ations is an effective means of becoming more comfortable in such situations, so

describing CPAP exposure therapy in this context usually is helpful. We have found it

useful to present such rationale before introducing the specific treatment instructions

outlined above and in Table 9.2. Some are able to accept the treatment rationale and

follow through on the treatment instructions fairly independently and seemingly

require just one therapy visit. However, many if not most benefit from one or more

follow-up visits spaced at several week intervals from the initial visit. During follow-

up sessions, it is useful to consider subjective reports of increasing comfort with CPAP.

However, it is equally useful to monitor actual CPAP usage when possible particularly

during the latter stages of this treatment. Most current CPAP devices have internal

monitors that record actual time of usage, thus providing objective adherence informa-

tion. Although most readers will not likely have the means to access these data, it may

Table 9.2
Symptoms and characteristics of sleep disorders that warrant sleep specialty referral

Sleep disorder

Common symptoms and characteristicsa

Sleep apnea

Loud snoring

Observed breathing pauses during sleep/or

Gasping or choking in sleep

Excessive daytime sleepiness

Unrefreshing nighttime sleep and daytime naps

Awakening with a headache and/or dry mouth

Medical history may include hypertension or cardiac arrhythmia

Obesity is a common characteristic

Middle aged men most prone

Women more prone after menopause

Narcolepsy

Excessive daytime sleepiness

Periods of sudden muscular weakness coupled to strong emotion

Frightening images (hallucinations) at sleep onset or offset

Awakening from sleep with temporary paralysis

Insomnia complaints may or may not be present

Restless legs

Irresistible urges to move the legs

syndrome

Urges to move the legs often result from annoying sensations in the legs

such as crawling, tingling, drawing, or electric sensations

Symptoms more pronounced in the late afternoon and evening hours

Movement of legs or walking provides momentary relief

Night terrors

Sudden episodes of terror during sleep beginning with a loud cry or scream

Autonomic and behavioral manifestations of fear usually present during event

It is difficult to awaken the individual during the event

The individual is confused upon awakening from the event

There is often amnesia for the event on the following morning

Dangerous or self-injurious behaviors may occur during the event

Most such events occur during the first half of the sleep episode

aSymptoms and characteristics extracted from the International Classifications of Sleep Disorders,

2nd Edition: Diagnostic and Coding Manual (American Academy of Sleep Medicine, 2005)

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9 Other Issues in Managing the Sleep of Those with Anxiety

be useful to collaborate with the sleep laboratories or home healthcare companies that

respectively initially prescribe or set-up the CPAP unit. Usually, one or both of these

entities can access and print out reports summarizing the objective adherence data.

These data are particularly important for monitoring treatment outcomes since patients

often tend to over-report their CPAP usage (Grunstein & Sullivan, 2000). Such data

help corroborate the patients’ self-reports and aid in determining when treatment can

be terminated. Whereas no dose-response studies have been conducted to ascertain the

ideal number of follow-up sessions for this therapy, our clinical experience suggests

that those who respond to this therapy usually do so with one to four follow-up

sessions spaced at several week intervals.

Dream/Nightmare Rescripting

Nightmares, defined as disturbing dreams that awaken the sleeper, are emotionally

upsetting, sleep-disruptive phenomena that are highly pervasive in the general popu-

lation. Indeed, the lifetime prevalence of a nightmare experience likely approaches

100% (Nielsen & Zadra, 2005). For most individuals, nightmares are no more than

an occasional nuisance that have no clinically significant effects on their overall

sleep patterns or daytime functioning. However, 2–5% of younger adults and 1–2%

of older adults in the general population regard nightmares as a “current problem”

(Partinen, 1994). Whereas only about 4% of those patients seen in general medical

practices present nightmare complaints (Bixler, Kales, & Soldatos, 1979), night-

mares are commonly reported by psychiatric patients including those with depression

(Cartwright, Young, Mercer, & Bears, 1998), schizophrenia (Levin, 1998), substance

abuse issues (Cernovsky, 1985, 1986), and those who seek psychiatric care through

emergency room visits (Brylowski, 1990). Arguably, among the more affected

groups are those with posttraumatic stress disorders who display nightmare preva-

lence rates as high as 50–88% (Forbes, Phelps, & McHugh, 2001; Kilpatrick et al.,

1998; Neylan et al., 1998; Schreuder, van Egmond, Kleijn, & Visser, 1998). Thus,

nightmare complaints are relatively common among the general population at large and

especially among those with anxiety and other disorders.

The morbidity associated with nightmares can vary depending upon their fre-

quency, intensity, and the level of sleep disturbance and daytime anxiety they cause.

In milder forms, nightmares may cause occasional sleep disruption and lingering anxi-

ety or fear. In more protracted cases, nightmares may contribute to significant psycho-

logical distress and sleep impairment (Berquier & Ashton, 1992; Kales, Soldatos, &

Caldwell, 1980; Krakow, Tandberg, Scriggins, & Barey, 1995; Zadra & Dondri, 2000).

Nightmares may be viewed as exacerbating phenomena that contribute to the overall

perceived severity of such comorbid conditions as anxiety disorders, depression, and

PTSD (Berquier & Ashton, 1992; Kales et al., 1980; Krakow et al., 2002; Zadra &

Dondri, 2000). Often, learned sleep-preventing associations develop among nightmare

sufferers. For example, frequent and recurent nightmares may lead to fear of the bed/

bedroom, fear of going to sleep initially, or a fear of returning to sleep following a

Dream/Nightmare Rescripting

139

nightmare-induced awakening (Krakow et al., 2000). These fears in turn may lead to

sleep-disruptive practices such as keeping the TV and/or bedroom lights on throughout

the night or altering sleep schedules to reduce nightmare opportunities. Anecdotal

observations of combat veterans with PTSD often show such patterns as markedly

curtailing nighttime sleep and napping in the afternoon when dream and nightmare

propensity is reduced. When sleep becomes chronically disrupted by such practices,

notable ongoing daytime impairment including reduced concentration, excessive

sleepiness/fatigue, enhanced irritability, and mood disturbance may emerge. In turn,

the individual may suffer marked social and occupational functioning as a result. Thus,

nightmares often represent a clinically significant problem that merits effective man-

agement strategies.

Traditional views of nightmares posit that such phenomena are uncontrollable

processes emerging from the unconscious mind and represent unresolved conflicts

(Hartmann, 1984; Lansky, 1995; Mack, 1974) or unfinished business (Foa, Riggs,

Dancu, & Rothmaum, 1993) related to stressful or traumatic experiences. Although

this view implies that psychotherapy designed to produce conflict resolution should be

an effective nightmare therapy, this treatment approach currently has little empirical

support (Nielsen & Zadra, 2005). Since nightmares commonly occur in the context of

comorbid psychiatric conditions such as PTSD, some (Mack, 1974) have argued that

nightmares are merely secondary symptoms of a primary psychiatric disorder. Given

this view, it would be expected that effective treatment of the primary comorbid condi-

tion presumed to cause the nightmare(s) would resolve the nightmare problem.

However, at least one report showed that a substantial number of PTSD patients

continue to suffer from ongoing residual nightmares even after completing an intensive

3-month group program for their condition (Forbes, Creamer, & Biddle, 2001).

Hence, it is not apparent that these traditional conceptualizations of nightmares have

led to effective therapies for their amelioration.

Over the past several decades, clinicians and researchers have increasingly

adopted the view that nightmares are learned phenomena that merit their own

specific therapies. From this viewpoint, nightmares that emerge immediately

following a trauma or stressful event may initially serve a useful role by allowing

for helpful emotional processing and/or motivate the individual to alter behavior so

as to stay out of harm’s way (Krakow & Zadra, 2006). Those who show a proper

balance in their thoughts, emotions, and imagery surrounding the trauma are

thought to recover most effectively from traumatic events. However, some indi-

viduals may tend to “think too much and spend less time with their feelings and

images because the latter are more unpleasant and less manageable” (Krakow &

Zadra, 2006). In such individuals, nightmares persist over time as a habit and replay

over and over much like a broken record (Krakow & Zadra, 2006). Thus, night-

mares related to trauma can become a habit (Krakow, Hollifield et al., 2001). In

such cases, the nightmare persists as a noxious conditioned stimulus leading to

such conditioned responses as awakenings from bad dreams to reduce or avoid

unpleasant affect (Krakow, Johnston et al., 2001). Inasmuch as the awakenings

allow for “escape” from the noxious nightmares, such arousals are reinforced by the

momentary anxiety reduction they produce. This process, in turn, may contribute

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9 Other Issues in Managing the Sleep of Those with Anxiety

to unhelpful beliefs about sleep (i.e., sleeping leads to nightmares so sleep is not

safe) and the above-mentioned sleep safety and avoidance behaviors to minimize

nightmare exposure.