Home Testing Model in Mental Health Patients: Part I Setting Up the Problem

I remember the first time I tried PAP therapy in 1993. There was a sense of an unwieldy, cumbersome and foreign object “plastered” to my face, and I was quite surprised I slept with it all night. I definitely did not sleep better that night, and I underwent several more brief trials with PAP during the ensuing decade, but never truly adapted and appreciated its value until 2002. Even though I was experiencing chronic daytime sleepiness and comprehended the rationale for using the device, the discomfort and awkwardness of the mask and pressurized airflow discouraged me from regular use. So, I tried nasal surgery with only slight benefit and then oral appliance therapy with considerable benefit 3-plus years before finally pushing myself to adapt to PAP therapy. Fortunately, many patients overcome these types of problems sooner than I was able to, but in my clinical experience I have found a great many similarities between my experiences and efforts to help mental health patients adapt to PAP therapy. 

When considering treatment for mental health patients, imagine a soldier who engaged in combat, who was exposed to an IED and suffered a chest injury causing difficulty breathing for hours. Or, imagine a rape victim who nearly suffocated while suffering an assault in her own bedroom. Or, finally, imagine a patient who survived a car accident in which he was trapped in the vehicle for an inordinate amount of time anxiously awaiting extraction. Can you picture how these individuals would feel the very first time they attempted PAP therapy?

One key to our understanding of these types of trauma patients is the phrase “the very first time.” Can these patients tolerate PAP therapy on first exposure? Many cannot, which suggests great care must be offered to mental health patients who may need to use the HST model. In general, the reason for the discomfort reported by mental health patients goes far beyond the relatively straightforward experiences of the so-called typical patient. Instead, for anxiety patients with a history of traumatic exposure (sometimes full-blown posttraumatic stress disorder or PTSD), a rational response is not immediately available when first putting on the mask while awake as well as when first waking up from sleep with it on the face. The struggle to use PAP may continue for weeks or months, because the contraption triggers anxiety due to their past histories of experiencing breathing difficulties during traumatic events. The same holds true for an asthmatic or other pulmonary patient currently experiencing poor control of breathing symptoms or ever-present, unpleasant memories of past episodes of poor control. Even anxiety or depression patients without obvious traumatic exposure may feel overwhelmed by the mask or the pressurized air sensations or both.

With this backdrop, one should ask how to help these types of patients initiate a PAP device. Although time is certainly a major factor in the long-term prognosis, the more pressing issue is the style of coaching these individuals must receive as a lead-up to using the device. The main options would include three typical procedures:

  • A simple desensitization program conducted by a sleep tech on the day of set-up following the home sleep test (HST) diagnostic study.
  • In the context of an HST setting or in a regular sleep lab setting, a PAP-NAP could provide a more advanced or elaborate desensitization.
  • The most prolonged coaching opportunity would occur with a full night titration study, which would likely commence with a lengthy desensitization prior to lights out. 

Which one of these three programs is right for a patient with a high probability for panicky or claustrophobic feelings emerging with first use of PAP device? And, by extension, which one of these programs is wrong for such a patient? In my opinion, it is the failing to ask the latter question that creates the opportunity for these patients to get off on the wrong foot. In particular, the most common misstep would lead to the rapid emergence of claustrophobic or panicky sensations in vulnerable patients.

These adverse effects, the feelings of claustrophobia and panic, are preventable in the large majority of at-risk patients, but these problems most often arise when a poorly trained sleep tech or one with very limited experiences in working with psychiatric patients provides a trauma patient only cursory instructions on using the auto-adjusting PAP device at home. The patient, having been unknowingly under-coached in the process, attempts to use PAP and rapidly develops claustrophobic or panicky sensations. These patients will commonly rip off the mask at bedtime or in the middle of the night with or without awareness of doing so.

What would prevent these episodes? Most importantly, from the get-go the sleep tech needs to sort out whether the patient’s anxieties revolve around the mask or the pressurized airflow or both. Surprisingly or not, most patients report one or the other; whereas, the most severe psychiatric patients will either report both, or worse, a sense of confusion about the process, such that he or she cannot describe a specific trigger to the discomfort and related feelings of distress. This is a common phenomenon in severely disturbed mental health patients, because they often lack the self-awareness or concentration abilities to sort out what is actually bothering them.

In the case of masks for such patients, we almost always start with nasal pillows no matter how obvious the need to resolve mouth breathing. The full face mask or the FFM and chinstrap combo is an absolute nonstarter for these patients. Even standard nasal masks may trigger claustrophobia. Now, in some cases, we will engage the patient in a discussion using a motivational interviewing technique to discern his or her definition or understanding of the problem of claustrophobia. Invariably, the patient reports difficulty with breathing, a sense of suffocation, or some other ill-defined anxiety about something placed on the face. For those who are aware of the breathing difficulties in this context of claustrophobia, we next ask, “what does PAP therapy do?” Because most patients can respond with words to the effect of “it gives you air to prevent you from not breathing,” a reasonable comment would be: “so, isn’t ironic that a device that gives you air could somehow take your breath away?” Again, individuals who can digest and absorb this fact usually respond with an “aha” moment, which in all likelihood indicates they do not suffer from true claustrophobia. Rather, they suffer from claustrophobic-like symptoms,l which they may be able to overcome with this degree of educational coaching. Unfortunately, those who struggle with this instruction may suffer from a more clear-cut form of claustrophobia, a type which would require more intensive desensitization with a psychotherapist or possibly an extended experience during a PAP-NAP with a sleep tech. 

Regarding pressurized airflow, at least two main and overlapping issues are likely to emerge, involving “control of breathing” and “hyperventilation.” Yet many sleep techs may have never received formal training or attained proficiency to help mental health patients who frequently run into these barriers. The first problem arises when patients attempt to synchronize their breathing with the PAP device, believing the effort to “control” one’s breathing is needed to adapt to the device. The second problem arises when the patient is not educated about the relationships between an anxiety-induced hyperventilation response and the resultant CO2 blow-off and subsequent worsening of breathing events. These problems are listed together, because they are interconnected both in how they emerge in susceptible patients and how they can be aborted early in the process.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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