1. Coping with CPAP Wafaa El-Bahaey Prof. Of Psychiatry, Mansoura University 29-12-2011

2. Treatment for OSA Behavioral…weight reduction, position therapy Behavioral…weight reduction, position therapy Medical…CPAP, medication Medical…CPAP, medication Surgical Surgical

3. Why CPAP? 2% to 4% of adult population has OSA 2% to 4% of adult population has OSA Many patients who use CPAP are non- adherent Many patients who use CPAP are non- adherent CPAP use may lead to some physical & psychological problems. CPAP use may lead to some physical & psychological problems.

4. I dentify Problems with CPAP Treatment: A- Physical: Nasal congestion Nasal congestion Rhinorrhea Rhinorrhea Skin irritation Skin irritation Nasal dryness Nasal dryness Pressure leaks Pressure leaks B- Psychological: Feelings of anxiety & Claustrophobia Feelings of anxiety & Claustrophobia C- Social: Spouse distress Spouse distress

5. Factors Affecting Adherence to CPAP CPAP side effects CPAP side effects Apnea severity Apnea severity Social Variables Social Variables Psychological Variables Psychological Variables

6. …..Social Variables Individuals who live alone are less adherent to CPAP Individuals who live alone are less adherent to CPAP Individuals whose partners initiate treatment referrals are less adherent than those who initiate themselves. Individuals whose partners initiate treatment referrals are less adherent than those who initiate themselves. Approximately 50% of patients report they would discontinue CPAP if it negatively affected the sleep of their bed partner. Approximately 50% of patients report they would discontinue CPAP if it negatively affected the sleep of their bed partner. Thus, inclusion of the bed partner in any treatment program might increase adherence. Thus, inclusion of the bed partner in any treatment program might increase adherence. Hoy CJ, Venelle M, et al (1999). Can intensive support improve CPAP use in patients with SAHS? American Journal of Respiratory and Critical Care Medicine, 159, 1096-1100. Weaver TE, Maislin G, Dinges DF et al (2003). Self-efficacy in sleep apnea: Instrument Development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use CPAP. Sleep, 26, 727-732.

7. ….Psychological Variables Mood: controversial data about the impact of Depression Mood: controversial data about the impact of Depression Anxiety: more influential than depression Anxiety: more influential than depression Claustrophobia is reported in 11 to 28% of patients. Claustrophobia is reported in 11 to 28% of patients. Coping Coping Active positive coping strategies are markedly helpful Active positive coping strategies are markedly helpful

8. ….Psychological Variables Psychodynamic Theories: Psychodynamic Theories: A. Transtheoretical Model (TM): A. Transtheoretical Model (TM): state of Change state of Change B. Social Cognitive Theory (SCT) B. Social Cognitive Theory (SCT)

9. “States (steps) of Change” Precontemplation Precontemplation Contemplation Contemplation Preparation Preparation Action Action Maintenance Maintenance Termination Termination

10. Social Cognitive Theory (SCT) Two major factors influencing the likelihood that one will take preventive action: First, a person must believe that the benefits of performing the behavior outweigh the costs First, a person must believe that the benefits of performing the behavior outweigh the costs (i.e. positive vs negative outcome expectancies) (i.e. positive vs negative outcome expectancies) Second, the person must have a sense of self- efficacy with respect to performing the preventive behavior under a variety of circumstances." Second, the person must have a sense of self- efficacy with respect to performing the preventive behavior under a variety of circumstances."

11. How to improve coping?

12. Psychotherapeutic Modalities for Patients on CPAP I- Motivational I- Motivational II-Bahavioral techniques: II-Bahavioral techniques: gradual exposure and desensitization, relaxation techniques,…. gradual exposure and desensitization, relaxation techniques,…. III- Cognitive Behavioral Therapy (CBT) III- Cognitive Behavioral Therapy (CBT) A- Psychoeducation A- Psychoeducation B- Modelling (Coping Enhancement) B- Modelling (Coping Enhancement)

13. I- Motivational Enhancement Therapy Shannon L. O’Connor Christian, Mark S. Aloia Indications: Indications: Patients with OSA and supposed to be good responder to CPAP Patients with OSA and supposed to be good responder to CPAP

14. Steps of Motivational Enhancement Therapy: two face-to-face sessions, 1 week apart, and, two face-to-face sessions, 1 week apart, and, a follow-up phone call at 1 month interval. a follow-up phone call at 1 month interval.

15. Session 1: Patient Assessment of PAP during Titration Night A. Assessment of Motivation to Use PAP A. Assessment of Motivation to Use PAP B. Information Exchange: Video Clip of OSA Patient B. Information Exchange: Video Clip of OSA Patient C. Review of Patient’s Pre-Treatment (PSG) C. Review of Patient’s Pre-Treatment (PSG) D. Review of Symptoms D. Review of Symptoms E. Review of Mortality Graph E. Review of Mortality Graph F. Negotiate a Plan Based on the Patient’s Readiness and Confidence F. Negotiate a Plan Based on the Patient’s Readiness and Confidence G. Summary with highlights of the takehome G. Summary with highlights of the takehome message message

16. Session 1: Patient Assessment of PAP during Titration Night Takehome message: Takehome message: (1) patient concerns about health problems related to having untreated OSA; (1) patient concerns about health problems related to having untreated OSA; (2) patient reaction to feedback on the PSG; (2) patient reaction to feedback on the PSG; (3) medical conditions the patient may be at risk for with untreated OSA; (3) medical conditions the patient may be at risk for with untreated OSA; (4) benefits the patient experienced after using PAP; (5) motivation to use PAP; (4) benefits the patient experienced after using PAP; (5) motivation to use PAP; (6) patient goals. (6) patient goals.

17. Session 2: Patient’s Subjective Appraisal of Adherence to PAP 1. Patient concerns about symptoms of untreated OSA 1. Patient concerns about symptoms of untreated OSA 2. Potential barriers to PAP use 2. Potential barriers to PAP use 3. Patient benefits from PAP use 3. Patient benefits from PAP use 4. Current patient motivation and confidence 4. Current patient motivation and confidence 5. Specific steps the patient will take with regards to PAP use 5. Specific steps the patient will take with regards to PAP use 6. The patient’s ultimate goal 6. The patient’s ultimate goal 7. Additional resources the patient has identified that can be helpful. 7. Additional resources the patient has identified that can be helpful.

18. Session 2: Patient’s Subjective Appraisal of Adherence to PAP 1. Patient concerns about symptoms of untreated OSA 1. Patient concerns about symptoms of untreated OSA 2. Potential barriers to PAP use 2. Potential barriers to PAP use 3. Patient benefits from PAP use 3. Patient benefits from PAP use 4. Current patient motivation and confidence 4. Current patient motivation and confidence 5. Specific steps the patient will take with regards to PAP use 5. Specific steps the patient will take with regards to PAP use 6. The patient’s ultimate goal 6. The patient’s ultimate goal 7. Additional resources that can be helpful. 7. Additional resources that can be helpful.

19. II- Behavioral therapy: Exposure techniques Indications: Indications: Claustrophobia, anxiety, or panic symptoms which are related to: Claustrophobia, anxiety, or panic symptoms which are related to: a. wearing the mask (feeling restricted) and/or b. tolerating the air pressure (feeling suffocated)

20. III- Cognitive Behavioral Therapy to Increase Adherence to CPAP Delwyn Bartlett Model I: Psycho-education Model I: Psycho-education Model II: Modeling Model II: Modeling

21. Psycho-education Delwyn Bartlett provide information about: provide information about: 1. obstructive sleep apnea (OSA); 2. educate the patient on the most effective treatment, (CPAP); 3. educate the individual on the medical and psychiatric risks when OSA is not treated.

22. Thank You & Happy Dreams Thank You & Happy Dreams