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By Jessica Fink, LCSW-S
“I just can’t wear that CPAP.”
Sleep professionals hear this constantly. Next comes the troubleshooting: Is the mask uncomfortable? Is there a leak? Is the pressure causing problems? Would a different interface help?
Those are important questions. But what happens after the patient has tried several masks, settings have been adjusted, and they have been encouraged to keep trying—to no avail?
At that point, it may be useful to ask a different question: What does “I can’t tolerate CPAP” actually mean for this patient?
In my behavioral sleep medicine practice, I come across very different answers. Some patients feel claustrophobic or suffocated. Some unknowingly remove the mask during the night. Some cannot imagine dating while wearing CPAP or worry their children will make fun of them. Others resent the unfairness of being diagnosed with a potentially chronic condition that may require lifelong treatment. I’ve even heard CPAP described as “trying to sleep with a snorkel on my face.”
These are not all the same problem, and they should not receive the same intervention.
First: Be Sure It Really Isn’t the Equipment
I encourage my patients to troubleshoot mechanical issues with their physician or durable medical equipment provider company first.
Mask leak, pressure problems, nasal obstruction, aerophagia, skin irritation, dryness, and interface discomfort are not psychological problems. Patients should not be encouraged to tolerate a correctable physical or technical problem.
But once we’ve reasonably exhausted technical causes, continuing to change equipment may have diminishing returns. At this point, it’s not about trying harder. We need to try differently.
When CPAP use continues to prove difficult, clinicians may need to look beyond the equipment and identify what is actually maintaining the problem.
“I Feel Like I’m Suffocating”
Claustrophobia is one of the clearest examples.
CPAP can trigger two fears commonly associated with claustrophobia: restriction and suffocation. The mask itself can create a feeling of being trapped, while breathing pressurized air may feel like an inability to breathe.
Avoidance perpetuates the problem, as with any phobia.
A patient puts on the mask, experiences a surge of anxiety, and takes it off. The anxiety decreases. That relief reinforces removing the mask, making it more likely that the patient will escape the situation the next time anxiety occurs.
This is where simply telling someone to keep trying may not be enough.
In my practice, I use graded exposure when claustrophobia or a conditioned anxiety response is interfering with CPAP use. We first identify exactly which elements of CPAP provoke anxiety and develop an exposure hierarchy from less distressing to more distressing experiences.
We start during the day. The patient practices holding the mask to their face for short bursts. Then we progress toward wearing the mask plus the straps, napping while wearing the device, and eventually sleeping with CPAP.
The purpose isn’t to force the patient to endure overwhelming anxiety. It is to provide repeated opportunities to learn that anxiety can be tolerated without immediately escaping from the mask.
Although graded exposure has a strong theoretical rationale and supportive case-level evidence for CPAP-related claustrophobia,1 rigorous controlled trials specifically evaluating CPAP desensitization remain limited.
“I Can’t Sleep With This Thing On”
Sometimes patients mean exactly what they say: they cannot sleep.
Obstructive sleep apnea and chronic insomnia coexist enough that the phenomenon got its own name: COMISA. Yet people may assume that once the apnea is treated, sleep should improve. Not always.
I tell my patients that CPAP is a breathing treatment, not an insomnia treatment. It keeps the airway open so they can breathe, but chronic insomnia may still require its own intervention. I explain to patients that they have two disorders and therefore need two treatments.
I look for evidence of comorbid insomnia in someone who says they can’t wear their CPAP. Symptoms like long stretches of wakefulness at the beginning or middle of the night, sleep anxiety, or efforts to compensate for a bad night point to comorbid insomnia, which heavily complicates positive airway pressure use.
If insomnia is also present, the problem may not be simply acclimating to the equipment. For someone who already spends long periods awake in bed worrying about sleep, it is difficult to imagine a less appealing instruction than: “Now put this weird thing on your face and try to sleep.”
Cognitive behavioral therapy for insomnia (CBT-I) improves insomnia in patients with COMISA. Whether it reliably improves CPAP adherence is less certain. One randomized clinical trial found improved CPAP acceptance and use when CBT-I was provided before the positive airway pressure therapy.2 In contrast, the MATRICS randomized trial found improved insomnia outcomes without significant improvement in CPAP adherence.3
In my practice, I generally address significant insomnia first and then work more directly on CPAP adherence. The goal of CBT-I, however, is to treat the insomnia—not simply to make someone more compliant with CPAP.
‘I Don’t Want This to Be My Life’
Some barriers have less to do with the mask itself than with what the mask represents.
A diagnosis of obstructive sleep apnea can mean confronting a chronic health condition and a treatment that may become part of someone’s nightly routine indefinitely.
Patients may worry about stigma. What happens when they start dating someone? What will a partner think? Will their children make jokes about the mask? Why should they have to deal with any of this when other people don’t?
Those aren’t pathological reactions. A person can understand perfectly well that CPAP is medically beneficial and still feel angry, embarrassed, disappointed, or resentful about needing it.
This is where adherence work may involve something different from troubleshooting or education: helping the patient make room for the reality that they dislike CPAP while still deciding what they want to do about their health.
Motivational approaches can be useful when ambivalence is central. A systematic review and meta-analysis of randomized trials found that motivational interviewing modestly improved CPAP adherence among patients at the start of treatment.4
But motivation should not automatically be assumed to be the problem. A highly motivated patient who panics when wearing a mask needs a different intervention from someone who remains unconvinced that treatment is worth the inconvenience.
‘No One Ever Explained This to Me’
One of the things that has surprised me since adding CPAP adherence work to my practice is how often patients arrive without feeling that they understand their diagnosis.
They may know they were diagnosed with sleep apnea and CPAP was recommended but have little understanding of what happened during the study or what terms such as apnea, hypopnea, AHI [apnea-hypopnea index], or RERA [respiratory effort-related arousal] mean.
As a psychotherapist, I have a luxury many medical professionals do not: time. My appointments are longer than a typical medical visit. When appropriate, I ask patients to send me their sleep study report and spend time helping them understand the terminology and the information already provided. I do not interpret the study medically or make medical recommendations.
Patients are often appreciative simply to have enough time to understand what all of this means.
Education is also part of evidence-based CPAP care. Research suggests that educational interventions can improve adherence, including studies in which patients were helped to see and better understand information from their own sleep studies. One randomized controlled study using polysomnography chart viewing found greater positive airway pressure use and adherence with enhanced education and follow-up.5 More recently, a randomized controlled trial using video of patients’ own sleep-disordered breathing events also found improved CPAP adherence.6
Education is an intervention unto itself. We are asking someone to persist with a treatment that can initially be uncomfortable, inconvenient, slow to produce noticeable benefits, burdensome to clean, and potentially lifelong.
It is much harder to persist with all of that when you don’t understand what you are treating or why.
What Does ‘I Can’t Tolerate CPAP’ Mean?
Behavioral and supportive interventions can improve CPAP adherence, but “behavioral intervention” doesn’t describe a single treatment.
- A patient with claustrophobia may benefit from graded exposure.
- A patient with chronic insomnia needs assessment and treatment for insomnia.
- A patient who doubts their ability to succeed may need opportunities to build mastery and self-efficacy.
- A patient who feels ambivalent about treatment may benefit from a motivational approach.
- A patient struggling with the emotional weight or stigma of a chronic illness may need space to address what CPAP represents.
- And a patient with an unresolved technical problem needs that problem fixed.
The common thread is not a particular intervention. It is better assessment.
“Why isn’t this patient using CPAP?” has a variety of answers—all pointing to different interventions.
References
1. Means MK, Edinger JD. Graded exposure therapy for addressing claustrophobic reactions to continuous positive airway pressure: a case series report. Behav Sleep Med. 2007;5(2):105-16.
2. Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019 Dec 24;42(12):zsz178.
3. Ong JC, Crawford MR, Dawson SC, et al. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep. 2020 Sep 14;43(9):zsaa041.
4. Crosby ES, Spitzer EG, Kavookjian J. Motivational interviewing effects on positive airway pressure therapy (PAP) adherence: A systematic review and meta-analysis of randomized controlled trials. Behav Sleep Med. 2023 Jul-Aug;21(4):460-87.
5. Saraç S, Afşar GÇ, Oruç Ö, et al. Impact of patient education on compliance with positive airway pressure treatment in obstructive sleep apnea. Med Sci Monit. 2017 Apr 13;23:1792-9.
6. Kim KT, Son NH, Cho YW. Effect of self-viewing of sleep-apnoea videos on positive airway pressure adherence in moderate to severe obstructive sleep apnoea: a prospective, parallel-group, randomised controlled trial. J Clin Sleep Med. 2025 Dec 22;22(1):7.
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