sleep review


by Dr. Barry Krakow
| Sleep Review Magazine

The PAP-NAP: A Titration by Any Other Name

The PAP-NAP, a daytime desensitization and mini-titration procedure to help patients adapt to positive airway pressure therapy (PAP-T), has drawn much interest from the sleep medicine profession. Many sleep professionals have contacted Maimonides Sleep Arts & Sciences with questions about the procedure. These inquiries unexpectedly led to discussions about several problematic sleep lab practices, which from our perspective pointed to missed opportunities to optimize PAP-T adherence and outcomes.

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A New Home for Nightmare Treatment

behavioral-nightmareMilitary personnel returning from wars in Afghanistan and Iraq show increasing rates of post-traumatic stress disorder (PTSD) and post-traumatic nightmares. Media coverage of these two vexing mental health conditions is also intensifying and raising public awareness about the need for more effective therapeutic options. With growing attention focused on patients with nightmares, sleep centers have an opportunity to engage these patients. Successfully doing so hinges on applying a standard of care for nightmare assessment and treatment through behavioral sleep medicine specialists.

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2010-10Dr. Barry Krakow, PTSD Sleep Clinic founder, hopes the concept will catch on with others.

Is the Maimonides PTSD Sleep Clinic that opened in Albuquerque, NM, in March a vision of the future? Dr. Barry Krakow, its founder, certainly hopes so.

The clinic exists inside Krakow's already well-established Maimonides Sleep Arts & Sciences Ltd sleep center and nightmare treatment clinic, but is unique by focusing specifically on treating sleep disorders in patients with posttraumatic stress disorder (PTSD).

The occurrence of sleep disturbances such as nightmares and insomnia is, of course, one of the diagnostic criteria for PTSD, and the PTSD Sleep Clinic offers the cognitive behavioral therapy and imagery rehearsal therapy that researchers, including Krakow, have shown can ease nightmares in PTSD patients. However, they also take a holistic view of patients and ask what other factors might be disrupting the patients' sleep, including sleep-disordered breathing, restless leg syndrome, or circadian rhythm disorders.

Incoming chronic insomnia patients routinely undergo a sleep study at Maimonides, and Krakow says approximately 70% end up having an apnea-hypopnea index (AHI) greater than 5 and another 20% have upper airway resistance syndrome. In other words, about 90% of insomnia patients present with some form of comorbid sleep-disordered breathing, a condition Krakow, along with fellow researcher Dominic Melendrez, termed "complex insomnia" in 2001. Krakow sees similar rates among incoming PTSD patients, which may explain why the standard approach to treating PTSD-related sleep disturbance was not working for them, and why many of these patients report so much frustration in working on their sleep problems with many well-intentioned PTSD therapists.

"We ask our new PTSD patients how they arrived at our clinic and it is not unusual to get the raised eyebrow or turned down lip that says, ‘Boy, you don't know what it took to get here,'" Krakow says.

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Patients With Treatment-Resistant Insomnia Taking Nightly Prescription Medications for Sleep: A Retrospective Assessment of Diagnostic and Treatment Variables

The Primary Care Companion to the Journal of Clinical Psychiatry

Dr. Barry Krakow; Victor A. Ulibarri, BS; and Edward A. Romero, BS

Background: Some chronic insomnia patients who take nightly prescription medication achieve less than optimal results. The US Food and Drug Administration (FDA) and the American Academy of Sleep Medicine (AASM) recommend reevaluation of this type of patient to assess for potential psychiatric or medical causes to explain this “failure for insomnia to remit.”

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Enlisting patients as more active participants in their treatment.

In the years ahead as health care reform invades, infects, or inspires (take your pick) the medical community toward new models of practice, sleep medicine physicians and technologists must discover innovative treatment pathways. Currently, the most widely used sequence begins with a patient-physician clinic appointment to assess sleep complaints and develop a plan, which typically moves through testing in the sleep lab to long-term use of positive airway pressure therapy (PAP-T).

How effective is this system? Not so impressive judging by PAP-T adherence rates often hovering above 50%.

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Purpose: Current screening for obstructive sleep apnea (OSA) emphasizes self-reported snoring and other breathing symptoms. Nocturia, a symptom with a precise pathophysiological link to sleep apnea, has not been assessed as a screening tool for this common disorder of sleep respiration. In a large sample of adults presenting to area sleep centers, we aimed to determine the predictive power of nocturia for OSA and compare findings with other markers of OSA commonly used to screen for this disease.

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by Dr. Barry Krakow | Sleep Review Magazine

Creating the opportunity for sleep techs to provide more hands-on coaching.

Sleep technologists ordinarily spend 1,000 to 2,000 hours per year in face-to-face contact with patients trying out PAP therapy. Often, they know sleep patients as well as if not better than other providers who care for them. When effectively trained, sleep techs can engage patients to learn about their motivations, frustrations, and anxieties about PAP therapy.

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by Dr. Barry Krakow | Sleep Review Magazine | View Full Article

Restoring sleep through mental imagery.

The human capacity to picture things in the mind's eye is an extremely powerful tool. Imagine for a moment your response when someone asks for directions to your favorite restaurant. Most people do not suddenly generate a line-by-line list of MapQuest steps. Instead, the map is generated in the form of a brief "video" run-through of the streets and landmarks you pass along the way.

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by Dr. Barry Krakow |

THE STUDY OF VGONTZAS ET AL ON INSOMNIA AND HYPERTENSION ASSERTS THAT THE COMPLAINT OF INSOMNIA COUPLED WITH OBJECTIVELY DETERMINED short sleep duration (<5 or 5-6 h) increased risk for hypertension by 350% to 500% compared to individuals without insomnia who slept longer than 6 hours per night.1 The pathophysiology of insomnia and its related effects on the HPA axis as well as the hyperarousal described in Bonnet’s accompanying commentary2 are offered as likely pathways through which insomnia and hypertension might be linked. This outstanding work provides critically important information to the scientific literature in support of the emerging perspective that: the patho-physiological component of insomnia must be appreciated; healthcare providers must evaluate insomnia with greater precision; and, this complex medical and psychological condition must be treated more aggressively.



by Dr. Barry Krakow  | Sleep Review Magazine |  Download the PDF

Unconventional Wisdom

When talking with groups of sleep technologists about ways to achieve superior PAP therapy titration studies, I always ask, “What are the two most important factors in performing outstanding titrations?”

Let’s be clear, this is a trick question and rarely is it answered correctly, except by unusually savvy sleep technologists.

Many vote for the perfect mask and mask fitting; others are persuaded to find the right pressure delivery system; still others exclaim that titrations are more art than science, leading them to extol the virtues of careful observation and diligence as the real keys to success.

All these factors are highly relevant, but they are not the two most important factors. The next round of contributors move closer to the secrets of success but don’t quite get there: patients must be effectively desensitized to the mask as well as the pressurized airflow prior to starting the titration; patients must be thoroughly educated about their sleep breathing symptoms and how PAP therapy will correct the problem; and patient motivation must be thoroughly assessed, and, if lacking, then a healthy dose of support and encouragement must be provided to raise the motivational level.

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by Dr. Barry Krakow  | Sleep Review Magazine

Assessing your use of insomnia standards and guidelines.

When Sarah, a 52-year-old, nonobese woman sought a second opinion for her severe insomnia, our sleep lab inquired about previous workups. Two sleep centers offered her sleep hygiene instructions, cognitive-behavioral therapy, prescription sedatives, and recommendations for OTC sleep aids including antihistamines and melatonin. She embraced all these strategies to the best of her ability, but 5 years later she had little to show for her efforts. The last piece of advice she received—"you're probably depressed and should start antidepressants"—sent her scrambling through the Internet where she found our Web site, and then traveled 600 miles to our sleep medical center in Albuquerque, NM. More...

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by Dr. Barry Krakow | Clinical Psychiatry News | Download PDF

Imagery rehearsal therapy is a broad term for myriad cognitive-imagery treatments for chronic and potentially acute nightmare disorders. Several groups are researching specific brands of the therapy, and this modality is receiving substantial attention in two converging ways.  More...

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