ArticleClaustrophobic tendencies and continuous positive airway pressure therapy non-adherence in adults with obstructive sleep apnea
Introduction
Obstructive sleep apnea (OSA) is a highly prevalent sleep-related respiratory disorder affecting an estimated 2–4% of the adult population with significantly higher prevalence among obese adults.1, 2 Continuous positive airway pressure (CPAP) is the first-line medical treatment for OSA.3 Though CPAP is highly efficacious,4 the effectiveness of CPAP is limited by non-adherence.5, 6 Since 1994 when the seminal studies reporting CPAP non-adherence were published,7, 8, 9 many studies have examined factors of influence on CPAP adherence outcomes in the adult OSA population.10, 11 This body of literature has contributed to progress in the field for developing intervention strategies to enhance CPAP adherence; yet, there is relatively little empiric evidence that addresses common patient-described barriers to CPAP use, such as treatment-specific barriers.
One such treatment-specific barrier that is commonly encountered in the clinical setting and anecdotally discussed in the literature is claustrophobia. Claustrophobia is an anxiety disorder of specific phobia type in which individuals experience fear or avoid situations which involve enclosed places.12, 13 Claustrophobia includes components of fear of restriction and fear of suffocation.14 Anxiety disorders among adults with OSA are common15, 16 and evidence suggests that anxiety disorders and the fear of choking may be more prevalent in severe OSA17 and in those OSA adults with higher body mass index (BMI).18 As claustrophobia is an anxiety disorder that is associated with elevated anxiety sensitivity14 and anxiety disorders are prevalent among adults with OSA, it stands to reason that the prevalence of claustrophobia may be higher in adults with OSA than the general population.
Early studies of CPAP non-adherence identify claustrophobia as a self-reported barrier to CPAP treatment adherence19; less consistent users of CPAP were also identified as more frequently self-reporting claustrophobia as a treatment barrier.9 Since these early exploratory studies of CPAP non-adherence identified claustrophobia as a possible treatment-specific barrier, published reviews of OSA and CPAP adherence suggest claustrophobia is an important influential factor on CPAP adherence and an important clinical problem.20, 21, 22, 23 Yet to our knowledge, there are relatively few published studies that focus on claustrophobia in adults with CPAP-treated OSA24, 25 and only one that has systematically examined the relationship and influence of claustrophobia on CPAP non-adherence.26 Interestingly, two of these published reports focus on desensitization for claustrophobia albeit little is actually known about (1) the frequency of claustrophobia in the adult CPAP-treated population, or (2) if claustrophobia significantly contributes to CPAP non-adherence.
With the relative paucity of research that addresses claustrophobia and its potential influence on CPAP non-adherence, this secondary analysis of data from a prospective, longitudinal cohort study of newly-diagnosed OSA adults and newly-initiated CPAP treatment aimed to 1) determine frequency of claustrophobic tendencies in adults with OSA after one night of CPAP exposure in a sleep laboratory setting; and 2) determine if claustrophobic tendencies influence one week and one month CPAP non-adherence.
Section snippets
Methods
The data for this secondary analysis were derived from a previously reported, prospective, longitudinal cohort study that developed and tested a risk index (Index for Non-adherence to Positive Airway Pressure) for identifying adults with OSA at risk for CPAP non-adherence after one night of CPAP exposure in the sleep laboratory setting.27 The study was approved by the respective Institutional Review Boards at the two recruitment sites.
Results
The sample (n = 68) included obese (BMI 38.6 ± 9.9 kg/m2) middle-aged adults (49 ± 11.4 years) with severe OSA (AHI 36.7 ± 18.6 events/hour). Participants self-identified as non-Hispanic/Latino (93%) and of white race (90%; Table 1). Participants without complete CPAP-FAAS data for the secondary analysis included fewer adults with mild OSA (AHI 5–15 events/hour); there were no other significant differences between the participants with complete data for the secondary analysis (n = 68) and those
Discussion
The results of the secondary analysis of data from a prospective, longitudinal cohort study suggest that claustrophobic tendencies, as measured by the CPAP-FAAS, are prevalent among newly-diagnosed adults with moderate to severe OSA after one night of exposure to CPAP in the laboratory setting with 63% of the sample having claustrophobic tendencies (i.e., CPAP-FAAS score ≥ 25). In our study, females had significantly higher scores and greater frequency of claustrophobia than males. Higher body
Acknowledgments
The research described was supported by Grant Number K99NR011173 (Sawyer, AM, PI) and R00NR011173 (Sawyer, AM, PI) from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health. The investigators acknowledge Leon Sweer, MD for his contributions to the research at Penn State Hershey Medical Center's sleep center. The
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