Is Insomnia Caused By Obstructive Sleep Apnea?

April 27, 2011

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?

6 Responses to “Is Insomnia Caused By Obstructive Sleep Apnea?”

  1. Ralph Downey III, Ph.D., DABSM. FAASM on April 27th, 2011 7:54 pm

    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. Insomnia | Sleep Deprivation on May 18th, 2011 4:30 pm

    […] Insomnia is a term that derives from the Latin language that literally means “No sleep”.  More than half of the population in the United States experience one or more symptoms of insomnia!   With this large number of people experiencing this disorder, it is clear that the number of causes is great as well.  Some causes could be stress, pain, hormone shifts, neurological disorders and many, many more.  While we know that insomnia is such a large scale problem in the United States, it is a sleep disorder that is directly related to sleep apnea.  It has been shown that almost 40% of older individuals with chronic insomnia have undiagnosed sleep apnea.  Conversely, anywhere from 40% – 60% of patients with Obstructive Sleep Apnea have insomnia.  Most people can know if they have possible insomnia by asking themselves these 2 questions; “Do I have trouble falling asleep?” or “Once I am asleep, do I have trouble staying asleep?”  These 2 questions hold a lot of truth to the realization that insomnia and sleep apnea are definitely related.  Also, a lot of patients who have insomnia usually have narrow upper airways which could also be a sign of obstructive sleep apnea. […]

  3. Christy Ruiz on January 26th, 2012 2:31 pm

    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?

  4. Steven Park on January 26th, 2012 8:55 pm

    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.

  5. Mr. M Lefe on February 24th, 2012 10:00 am

    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.

  6. Billy Blue Layman on November 10th, 2014 3:03 am

    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.

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