Expert Interview: Dr. Emerson Wickwire On Cognitive Behavioral Therapy for CPAP

April 15, 2012

Dr. Emerson Wickwire currently serves as Sleep Medicine Program Director at Pulmonary Disease and Critical Care Associates in Columbia, Maryland. He also holds the rank of Assistant Professor, part-time, at the Johns Hopkins School of Medicine, where he completed a two-year postdoctoral fellowship in sleep. Dr. Wickwire is board certified both in behavioral sleep medicine by the American Board of Sleep Medicine and in cognitive and behavioral psychology by the American Board of Professional Psychology. He is a pioneer in interdisciplinary approaches to sleep medicine and maximizing human performance.

In this interview, Dr. Wickwire shares his wisdom about comprehensive approaches to managing sleep apnea, including cognitive-behavioral treatment to maximize success with CPAP .

Some of the questions include:

What are cognitive-behavioral treatments (CBT)?

Have cognitive-behavioral treatments been applied to sleep disorders?

What is the psychology of sleep apnea?

What factors influence PAP use?

What are Wickwire’s Four Pillars of CPAP Success?

What is a PAP adherence risk profile?

What CBT interventions have been tested to improve PAP adherence?

And much more…

Please fill in your contact information below to receive your free MP3 recording:

Written by Steven Park · Filed Under Expert Interviews | 4 Comments

Read AJ Jacobs’ Drop Dead Healthy: One Man’s Humble Quest for Bodily Perfection

April 15, 2012

AJ Jacobs, a senior editor for Esquire Magazine, interviewed me last year while working on his latest book project, Drop Dead Healthy: One Man’s Humble Quest for Bodily Perfection. The book is now out and was favorably reviewed by the New York Times. We talked extensively about his snoring and sleep apnea, and he underwent the entire diagnosis and treatment protocol, including CPAP. I just read sections of his book (including parts with me in it) and it’s hilarious!

If you’re not already familiar with Mr. Jacobs, he’s also the author of The Know-It-All: One Man’s Humble Quest to Become the Smartest Person in the World and The Year of Living Biblically: One Man’s Humble Quest to Follow the Bible as Literally as Possible. His current book, Drop Dead Healthy, is already #31 on Amazon’s best-seller list.

His book was endorsed by Dr. Mehmet Oz, and Timothy Ferriss (author of The 4-Hour Body). I strongly recommend that you read Mr. Jacobs’ book. But don’t stay up too late reading it—sleep deprivation can lead to premature aging.

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Obstructive Sleep Apnea And Intracranial Pressure

April 13, 2012

Guest blog by Deborah Wardly, MD

It seems to be a little known fact that obstructive sleep apnea (OSA) can cause an increase in intracranial pressure (ICP). In 1989 Jennum and Borgeson showed that individual apneas lead to an increase in ICP in addition to an increase in arterial pressure, but also that in patients with OSA, more than half of them have elevated ICP while awake in the morning, and the ICP in the morning is higher than it is in the evening. Since that time there have been a few papers addressing this phenomenon, but surprisingly less than one might expect, and probably as a result most doctors do not seem to be aware of the connection.

There is more information in the ophthalmology literature and this specialty seems to be knowledgable about the relationship between OSA and papilledema (swelling of the optic nerve head) as seen in pseudotumor cerebri. There are reports of patients with OSA and intracranial hypertension with papilledema showing improvement in disc edema and visual fields with the use of CPAP.

However there is less awareness of the condition of IIHWOP: idiopathic intracranial hypertension without papilledema. In IIHWOP the headache pattern may be identical to that of migraine, and in the absence of papilledema it may not be possible to diagnose it without a lumbar puncture for opening pressure. The diagnosis of this subset of IIH must be considered in order to detect it.

In IIH the symptoms include most prominently headache, which is worse in the morning, and can be increased by anything which increases ICP, like coughing or sneezing (a Valsalva). The pain can go into the neck and upper back, and may be felt behind the eyes. There can also be nausea and vomiting, as well as dizziness. Many patients have a symptom called pulsatile tinnitus, which is a whooshing sound in the ears synchronous with the pulse. Less frequently there can be numbness of the extremities, generalized weakness, and balance problems. The ICP can affect the cranial nerves, notably the sixth nerve, and as above can lead to swelling of the optic disc which may cause visual changes. IIH can even present with psychiatric symptoms: depression, anxiety, and rarely self injurious behavior and psychosis.

The classic presentation of a person with IIH is an obese woman in her 40s, prior to menopause. The IIH is found to improve if the woman loses weight.

However there is a recent association noted in men with IIH: they are more likely to have OSA and testosterone deficiency. Therefore in addition to OSA, hormones seem to play a role in whether a person develops IIH. There is also a suggestion in the literature that IIH may in some cases be related to a hypercoagulable state. This may explain its prominence in people with higher estrogen levels. We know that OSA promotes hypercoagulability, is made worse by obesity, and may cause morning headache. OSA also will improve with weight loss.

I hope the reader can see the correlation and overlap between the symptoms of intracranial hypertension and those of OSA. It is my impression that there is likely a significant amount of IIH that is unrecognized among patients with OSA, because the relationship between apnea and ICP is not well known. Could it be that the severe fatigue and other debilitating symptoms in UARS are actually a result of unrecognized intracranial hypertension? I also suspect that problems in making the diagnosis of OSA may lead to underdiagnosis of OSA as the cause of many recognized cases of IIH.

What is your experience? As physicians were you aware that OSA may cause ICP? Do you have patients with both OSA and IIH? Do you have OSA patients with many of the IIH symptoms who might need further evaluation? As a patient with OSA, do you see yourself in the description of IIH?

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Research Opportunity for CPAP Users ($375 Honorarium)

April 12, 2012

A research firm is seeking obstructive sleep apnea patients who are currently using CPAP therapy for a study in the New York area. Candidates must meet ONE of the following criteria:

Recently diagnosed and have been on CPAP therapy between 2 weeks to 3 months
Use CPAP therapy intermittently
Have stopped using CPAP therapy within the last 3 months.

It involves an interview and some homework. There will be a $375 honorarium if selected.

If you’re interested, please contact:

Shaughn Clark

267-507-2529

sclark@schlesingerassociates.com

This is a time sensitive matter, so please respond by the end of today, 4/12/12.

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My Quote in More Magazine About Alcohol and Sleep

April 7, 2012

Look for my quote in More Magazine about the effects of alcohol on sleep (under #3).

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Listen To My Interview About Snoring With Dr. Sosenko

April 6, 2012

Dr. Lydia Sosenko, a dentist specializing in sleep-breathing disorders in Illinois, interviews me for this 34 minute segment on snoring. You can listen to it or download it here. We talk about about the many dangers of snoring, how it’s a “dealbreaker” in many relationships, why sleep tests are very important, how common undiagnosed apnea really is, and much more!

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A Surprising Finding: Sleep Apnea Is Linked With Depression!

April 5, 2012

If you have sleep apnea, you’re more likely to suffer from depression. I can’t help but to be amazed that theses type of studies are still performed. I know that in the name of science, you have to show that there are statistical associations between two conditions that are thought to be related. But it’s like doing a study that shows that if you cut your hand, you’re more likely to bleed, or if you trip over an uneven sidewalk, you’re more likely to fall.

You don’t have to be a doctor to know that not sleeping well for extended periods can definitely cause you to feel depressed. The skeptics will then point out that there’s only a strong association between depression and sleep apnea, and that it doesn’t show that sleep apnea actually causes depression. Knowing how prevalent sleep apnea is in our society (most of it undiagnosed), it makes sense to at least think about obstructive sleep apnea before you make a diagnosis of depression and prescribe antidepressants. Unfortunately, even if a randomized placebo-controlled prospective study of thousands of patents showed that having untreated sleep apnea leads to higher rates of clinical depression, it’s unlikely that physicians will change the way they diagnose and treat depression.

Interestingly, most antidepressants suppress REM sleep. Coincidentally, REM sleep is when you’re most likely to have obstructions and apneas, due to complete muscle relaxation in your throat. So anything that lowers REM sleep will by definition lower your rate of apneas. In fact, there are published studies showing that REM sleep deprivation can be helpful for depression. Not having as many apneas could make you feel better during the day. I realize this may be an overly simplistic explanation, but it’s definitely something that the scientific community should think more about.

Come to think of it, there are no prospective randomized double-blinded placebo-controlled trials showing that drinking water cures dehydration. Millions of mothers are giving their children water every day to treat dehydration without FDA approval.

Written by Steven Park · Filed Under Blog | 2 Comments

Ask Dr. Park Teleseminar on Obstructive Sleep Apnea

April 4, 2012

In this Ask Dr. Park Teleseminar, I answer the following questions:

- I’ve had my CPAP machine for 5 years. Should I undergo another sleep study to see if anything has changed?

- Does palatal expansion work for people over 60?

- What do you think about Provent therapy?

- Is it possible to have a dental device lose its’ effectiveness without any weight gain?

- What’s your vision in the multidisciplinary approach to OSA treatment and comorbididies?

- Will restorative breathing correct OSA cases previously recommended for surgery?

- Can sleeping on your side be OK for sleep apnea?

- A recent Chinese study reported OSA in 27% of 5 to 12 year olds. In view of the obesity epidemic here in the US, is the incidence here in the US at least as high, if not higher?

- Should a person’s stuffy nose be addressed before OSA therapy?

- Does CPAP create “dependence,” so that surgical options later on may not work as well due to a weakened diaphragm or other muscles for breathing?

- Your opinion on the new implants (Pillar and hypoglossal nerve stimulation)

- Does sleeping on a 45 degree incline help with obstructive sleep apnea?

- What can be done to reduce the number of “getups” each night?

- What percentage of OSA is due to tongue collapse (vs. soft palate)?

And much, much more.

Click here to purchase the 60 minute MP3 recording.

Written by Steven Park · Filed Under Expert Interviews | 6 Comments

Early Puberty For Girls: A Sleep-Breathing Problem?

April 3, 2012

You may have seen reports about the epidemic of public hair and early breast development in 6 to 7 year old girls. A recent study published in Pediatrics revealed that by age 7, 10% of white girls, 23% of black girls, 15% of Hispanic girls, and 2% of Asian girls had started developing breasts. In this week’s New York Times Magazine, a writer profiles a young girl that developed pubic hair, tall stature, big feet, and a curvaceous body at age 6.

There’s a general consensus amongst pediatricians that early puberty is a growing problem and a number of factors are blamed. The obesity epidemic is thought to play a role, since excess fat is known to produce higher levels of endogenous estrogen. The most probable suspect is thought to be due to the presence of xenoestrogens, which are artificial chemicals in our food and water supply that has estrogen-like properties. The most well-known of these is bisphenol-A (BPA). Recently, the FDA rejected a motion by environmental groups to ban BPA, which is widely found in food containers. Most baby bottle manufacturers have voluntarily stopped using BPA in their products.

Xenoestrogens and other endocrine disruptors like PBA not only act to induce early puberty, but can also alter the optimal balance of reproductive hormones in a woman’s (and man’s) body. The idea have having too much estrogen (endogenous or exogenous) in your body has been coined estrogen dominance by Dr. John Lee. An important concept to emphasize is that too much estrogen (or estrogen-like molecules) can suppress progesterone, which can have significant detrimental effects on breathing, especially in post-pubertal women. Progesterone is an upper airway muscle stimulant, and increases tongue muscle tone. Post-menopausal women have lower levels of progesterone, and lower tongue muscle tone (genioglossus muscle), but when given progesterone, muscle tone increased significantly.

This is why many women sleep better when given hormone replacement therapy after menopause. In one study, the average apnea hypopnea index (AHI, or measure of obstructive sleep apnea severity) was over 50% lower in postmenopausal women taking hormones. I sometimes wonder if the incidence of sleep apnea in women shot up after women were advised to stop taking hormones many years ago due to increased cardiovascular risks. If more women have sleep apnea, then that in itself will significantly increase rates of cardiovascular disease, including heart attacks and strokes.

If these environmental effects are happening in adult women, think about what can occur in young children. There’s even suspicion that these chemicals can cause neuro-developmental delays in infants. If you already have a sleep-breathing problem, adding xenoestrogens can only make things worse. As far as I know, I’m not sure of any studies showing that xenoestrogens can cause sleep apnea, but it can be argued that anything that prevents proper facial growth and development can increase your risk for developing obstructive sleep apnea.

What do you think about this issue? Is it a real problem that’s not being addressed by the government, or is it an an overblown concern?

Written by Steven Park · Filed Under Blog | 1 Comment

New Innovations in Sleep Apnea Therapy: Live Presentation at the Manhattan AWAKE Group

March 31, 2012

Please join me for a live presentation on the newest innovations in sleep apnea therapy. I’ll be talking about hypoglossal nerve stimulation, Provent, and functional dental appliances at the Manhattan AWAKE group meeting on Wednesday, April 2nd at 6:15 PM. It takes place at 134 West 26th Street, 2nd Floor, New York, NY.

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