Is Insomnia Caused By Obstructive Sleep Apnea?

Common sleep medicine dogma states that chronic insomnia is a completely separate disorder from obstructive sleep apnea (OSA). But just like other seemingly disparate medical conditions, there’s increasing evidence that there may be a certain degree of overlap between these two conditions. It’s been shown that anywhere from 39 to 58% of patients with OSA also have insomnia. Conversely, up to 43% of older people with chronic insomnia were found to have undiagnosed sleep apnea.

It’s been stated that chronic insomnia and sleep apnea can co-exist together, but very few studies are saying the one could cause the other. To challenge this assumption, Dr. Barry Krakow and the Sleep and Human Health Institute is looking at the provocative theory that a large percentage of people with chronic insomnia have undiagnosed breathing problems during sleep.

I wrote in my book, Sleep, Interrupted, that almost every patient that I see with chronic insomnia has significantly narrow upper airways, and one or both parents snore heavily. Most chronic insomniacs prefer not to or absolutely can’t sleep on their backs, due to the tongue taking up relatively too much space within the confines of smaller jaws. When in deep sleep, especially when on their backs, the tongue can fall back due to gravity, and because of additional muscle relaxation, causes breathing pauses and an inability to stay asleep.

It’s also not surprising that most people with sleep maintenance insomnia keep waking up at various 90-120 minute intervals, usually around the same times. This makes sense since at the end of one sleep cycle, your muscles will be most relaxed. Not sleeping deeply can lead to chronic sleep deprivation, which causes adrenaline overload and a hyperactive nervous system, which you can’t shut down when you’re ready to go to sleep. This process can explain sleep onset insomnia. One recent study showed that sleep deprivation can even cause a kind of euphoria, which can lead to poor judgement and even addictive behaviors.

Maybe this is why cognitive behavioral therapy (CBT) for insomnia works very well, but not for everyone. There are numerous studies and personal experiences that confirm that treating the underlying sleep-breathing problem can fix the insomnia issues.

Granted, even if only 50% of people with chronic insomnia have obstructive sleep apnea, it’s likely that another 30 to 40% will have upper airway resistance syndrome (or UARS), which is a huge topic that has been discussed elsewhere.

What do you think about my suspicion?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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9 thoughts on “Is Insomnia Caused By Obstructive Sleep Apnea?

  1. Insomnia can occur with OSA when patients are thinking about things etc. as in psychophysioloigcal insomnia. When OSA/UARS occurs at the sleep-wake interface, it will awaken the sleep onset insomnia prone individual.

    I have had patients with sleep maintenance insomnia and early final awakenings that I found were attributable to OSA/UARS exacerbation or its sole presentation in REM sleep, more common in the middle and latter thirds of the night.

    I think treating the OSA/UARS is the key. If there is residual insomnia due to conditioning perhaps or if insomnia is a second disorder, and was not co-morbid with OSA/UARS, then it can be separately treated, with CBT or other modalities.

    That is my quick response based on my experience.

    Good question.



  2. Dr Park-
    Firstly, let me say, I love your website. It such a wealth of information. I have referred many people to it (including a few of my doctors!). I was diagnosis with OSA and UARS. I am curious about the link between addictive behaviors and UARS and/or OSA. The link I went to from your site did not elaborate on this. Is there any other article or study that provides more info?

  3. Ms. Ruiz,

    There are no studies that I’m aware of, but every time I see someone with OCD or anorexia/bulimia, in almost all cases, I see very small airways, especially in the space behind the tongue. In most cases, these people can never sleep on their backs, due to tongue collapse in deep sleep due to gravity and muscle relaxation. Parents of these people typically snore heavily, and often have significant cardiovascular disease. Perhaps the stress response of inefficient sleep, by heightening the nervous system, somehow changes brain behavior. It would be an interesting study to perform.

  4. I’m a veteran after 26 years, prior to retirement (4 years) I started having problems staying asleep. I have always thought that it was just a built in alarm clock from all the years of getting up early. I have also had back pain (lower) for over 9 years. After much coaxing from my wife complaining both about my snoring and getting up between 3 am and 4 am daily I had my first sleep study done. I was always a stomach sleeper until now. My first sleep study revealed the following: Obstructive apneas: NREM 3, REM 8, Central Apneas REM: 1 and 4 Hypopneas, this was done in 2008 in a take home study. My latest Sleep Study revealed OSA with the following: 52 scorable events mostly apneic, Apnea Hypopnea Index was 11, REM 37 and Oxygen saturation of less than or equal to 88%. The doctors recommendation was that I had insufficient Sleep Syndrome and apparent co morbid anxiety based mood disorder My question is should I have been looked at more seriously since I displayed all of the symptoms of OSA back in 2008? The service diagnosed me with Primary Insomnia. Can the majority of my sleep problems be contributed to OSA back in 2008 that was not diagnosed properly. When I read the information on your site regarding Chronic Insomnia there are many symptoms that were present to include: daytime sleepiness, drowsy driving, lower and upper back pain, arthritis, constantly thinking about getting up on time etc. I would really like to hear some feedback.

  5. I have suffered from chronic kidney pain on my left side due to kidney stones. I developed the kidney stones and chronic pain that never goes away on my left side for over 20 years. I was on active duty at the time. this has effected my sleep and my breathing I also had my nose broken twice in the military. I was diagnosed with obstructive sleep apnea and severe insomnia but the V.A has turned down my claim and no civilian doctors in san Diego Ca will challenge the V.A. how that for a kicker.

  6. I am a veteran with 20 years service. After returning from the Gulf War I had to report chest pains and numbness on the left side of my body. I also had symptoms of trouble sleeping and problems with memory. Diagnosis showed that I had undetermined cardiac problems and paralysis of my right hemi diaphragm.

    In 2008 after complaining about inability to go to sleep and trouble staying asleep I was referred for a Sleep Test. A Split Night Report was conducted and it was determined that I had an RDI/hr of 47.6. It was also determined that I had scored 10 on the Epworth scale. CPAP was issued.

    Symptoms continued and a second sleep study was conducted in Feb 2015. Analysis of the respiratory data demonstrated a respiratory disturbance index (RDI) of 57.1 per hour of sleep, the AHI was of 56.8 per hour of sleep. The respiratory events were more severe in supine sleep (67.2). The predominant respiratory disturbance consisted of hypopneas (209 events), and RERAs (1 Event), obstructive apneas (0 events), central apneas (11 events) and mixed apneas (5 events). Baseline oxygen saturation was 96%. Lowest oxygen saturation was 84.0% in REM sleep. Snoring was noted. There were a total of 203 periodic limb movements. This resulted in a PLM index of 51.3. There was 7 arousal associated with limb movements resulting in a PLMA index of 1.8 per hour.

    I was never told in the Army that I had a sleeping problem because they would state that those problems of sleeping disorder and memory problems would be corrected once they were able to correct my cardiac problems. During my time I had two (2) cardiac catheterizations, MRIs, CAT Scans, Nuclear testing and still no relieve from those two major issues and still sleep problems. Did I received the correct diagnosis of my problems and did the avoidance of testing my sleep problems be the result of my present state. Could I have had a sleep apnea problem in conjunction with my insomnia? Any feedback would be appreciated. Thank you.

  7. Mr. Vaca,

    It’s difficult to say which came first, but the point of the article is that insomnia and sleep apnea frequently coexist, and that you have to treat both simultaneously. Needless to say, not breathing well at night can definitely prevent you from falling or staying asleep. Knowing what we know now, all patients with heart disease should be screened and treated for obstructive sleep apnea.

  8. You make an interesting point about sleep deprivation and the resulting sympathetic activation causing difficulties with sleep onset. I have dealt with chronic insomnia, most notably sleep onset, for the majority of my adult life (I’m 30). For as long as I can remember into my childhood, I have never slept through an entire night and typically wake up several times. Because this I have done this for as long as I remember, I just assumed this was my normal sleep pattern. However in college I started having trouble falling asleep. I couldn’t attribute this to any stress. I was started on Ambien and have since been unable to stop taking it. I have tried several times. My primary care doctor assumed it was an underlying anxiety disorder and has tried treating me with Xanax, Lexapro, trazodone and Zoloft. I have never felt anxious and none of these treatments have really helped my insomnia. I saw a sleep medicine specialist who was also at a loss for the cause of my insomnia. At his suggestion I tried sleep cognitive behavior therapy with a psychologist. When this was unsuccessful, my sleep specialist suggested that I have an addiction to Ambien and to continue using it I had to take a drug test and sign a contract that I would not sell it to anyone. I did not object and starting thinking that maybe I did have something psychologically wrong with me. I saw a second psychologist who did a complete work up on me. In the end he could not find anything wrong with me and was appalled that I had never had a sleep study in all the years of struggling with insomnia. He told me that I reminded him of a patient he had a few years ago who struggled with insomnia and a sleep study revealed seizures in REM sleep. My dad and aunt have epilepsy so I sought the opinion of a second sleep specialist. She too was surprised that I never had a sleep study and ordered one. It turns out I have sleep apnea and have an average of 13 apneic episodes per hour and do not stay in REM sleep very long. I am relieved to finally have some answers. I understand that I so not fit the profile of someone with sleep apnea as I am thin and athletic, but I just wish someone had thought to test me 10 years ago when I first presented with insomnia. I am hoping that CPAP will finally give me some relief!