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?

It’s estimated that up to 50% of people suffer from insomnia occasionally, and about 10% have chronic insomnia. There are a lot of reasons that can cause insomnia, from stress to medical conditions to external factors such as excessive noise. Yet, the most conditioned response from people whenever they can’t fall asleep is to take a sleeping pill. Unfortunately, this is not the best solution for most people.

In Search of the Best Sleep Remedy

Prescriptions for sleeping pills are at record volumes (56 million in 2008). In times of either emotional or financial stress, symptoms of insomnia rise, and so do prescriptions for sleeping pills. But how effective are they? A recent study funded by the National Institutes of Health (NIH) in 2005 showed that sleeping pills decreased the time it took to fall asleep by 18 minutes, and increased total sleep time by 28 minutes per night, on average. Pharmaceutical company funded studies show much more optimistic results, but there’s definitely a wide range of opinions within the sleep community regarding effectiveness of prescription sleep aids. Not to mention the various known side effects such as daytime drowsiness, sleep walking and sleep eating. Also, as with many studies, many people in the placebo arm also had significantly improved results.

In my experience with patients, sleeping pills are a hit or miss. The results vary depending on the individual. It’s safe to say that some people are much more susceptible than others without very many side effects. The same goes for the various natural supplements, herbs and remedies that are recommended, such as warm milk, L-theanine, valerian and melatonin. Regardless of whether or not there’s scientific evidence over which one works or doesn’t work, if it works for you, you can keep taking it, as long as there are no major side effects. Preferably, you should take a non-prescription medication, as they tend to have less side effects. The one exception is the over the counter sleep aid ingredient, diphenhydramine, which is the main ingredient in Benadryl. It’s also included alone or in combination with many other brand names. This ingredient is a strong antihistamine (used for allergies) that also can make you drowsy. Some elderly who use it have experienced  mental status changes as well as other various side effects. 

There have been many studies using melatonin. Melatonin is a natural hormone that your body produces more of as you fall asleep. Darkness causes melatonin to increase and sunlight stimulates receptors in your eyes that cause it to drop. Results for the use of melatonin as a sleep aid have generally been positive, but somewhat conflicting. Ramelteon is a recently introduced melatonin-like chemical that stimulates melatonin receptors in the brain. Results show that, in general, although it does help, it’s not as effective the standard sleep aids. 

Another recent study showed that valerian was not better than placebo in treating insomnia. This contradicts a number of my patients that swear by valerian. Again, studies report statistical averages, which lumps together people who respond with people that don’t. 

Simple Steps to Resolve Insomnia

For most people, practicing routine beneficial sleep habits is all you’ll need to avoid taking pills or medications. Setting aside at least 30 minutes to wind down and do something relaxing is one way. Avoiding anything stimulating (such as playing video games, surfing the internet, checking email, or even exercising) can help you fall asleep faster. 

Everyone has different sleep needs, so don’t stress if you can’t get 8 hours of sleep. People need anywhere from 6-8 hours of sleep to function normally. It’s also important to get out of bed within 30 minutes every morning, even on the weekends. Try to get outdoors and get exposed to sunlight. This helps to strengthen your sleep clock. 

If you’re not drowsy within 30 minutes of getting into bed, get out and do something that’s quiet and relaxing, until you feel drowsy. Try to reduce the total time in bed to match the total time you actually sleep. If you’re tired during the day, try taking a short nap in the mid to late afternoon. 

Try practicing relaxation techniques and breathing exercises such as meditation or yoga, especially before going to bed. Use the bed for sleep and sex only—don’t read, watch TV, or work on your computer while in bed. 

Lastly, don’t exercise too close to bedtime. Leave about 2-3 hours after exercising before going to bed. Elevation of core body temperature will keep you from falling asleep. As body temperature drops, you’ll feel more drowsy.

Various practitioners will tout one natural herb or supplement as being helpful for insomnia, but as I’ve pointed out previously, not everyone will benefit significantly. However, even if it works, as long as you’re not treating what’s causing your insomnia, it’s definitely going to come back. In some cases, there may be an underlying medical condition that could be presenting as insomnia. Many people with insomnia, for instance, actually have obstructive sleep apnea.  That’s why taking a pill, although it seems like the path of least resistance, will only worsen the situation in the long run.

If you currently rely on sleeping pills every night to help you fall asleep, or you feel tired and lethargic no matter what steps you take, then it’s time to see a doctor about your insomnia problem. 

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Cognitive Behavioral Therapy or CBT is a drug free therapy that has been effective in treating many people with insomnia.  Click here to find out how you can access the download to my interview, How to Beat Insomnia Without Medications, with Dr. Gregg Jacobs, the leading authority on the treatment of insomnia and the first to develop a drug-free program for insomnia proven more effective than sleeping pills.
 

GABA is one of numerous neurotransmitters in the brain that sends messages from one part of the brain to another. High GABA levels are associated with a calming, relaxing effect, whereas low levels are associated with anxiety and stress. Conventional wisdom says that if this is true, let’s increase GABA levels with supplements. The same can be said for various other neurotransmitters, hormones or vitamins that we use as supplements. In many cases, replacing what’s missing can certainly help, but you’re still not addressing what’s actually causing the lowering of these substances. 

If you look in the research literature (and on the internet), you’ll see many studies linking stress and low GABA levels. Another study showed that practicing yoga increases GABA. This is why any method or discipline that is calming or relaxing can raise your GABA levels. So it’s not a lack of GABA that gives you insomnia, per se, but there’s something else that is causing insomnia and low GABA levels.

This is a problem that we see with almost every area of modern medicine, where we’re great at finding associations, but not very good at solving the root of the problem. 

The common thread with all these studies goes back to stress. Yes, we have many different types of stress in our lives that can lead to insomnia (financial, work, family, poor diets, toxins, etc.), but what I’m suggesting is the possibility that due to our unique upper airway anatomy, all of us are somewhat susceptible to physiologic stress due to an inability to breathe properly at night. External stresses (psychologic, emotional and physical) can also aggravate this internal, physiologic stress.

The extreme end of this spectrum that I describe is called obstructive sleep apnea. But even if you’re "normal," having a narrowed upper airway anatomy can predispose you to microbstructions and arousals, leading to a physiologic state of hyperarousal. These people won’t officially meet the criteria for sleep apnea. Many of these people will also not be able to sleep on their backs, since that’s when the tongue falls back the most, due to gravity.

If you measure neurotransmitter levels in these patients, of course they’ll have abnormalities. This is why chronic insomnia is linked later in life to so many other medical conditions such as depression, diabetes, hypertension, and heart disease. Notice that these are all complications of obstructive sleep apnea. 

This is not to say that we should stop everything we do to treat insomnia. Cognitive Behavioral Therapy (CBT) is a great way to calm the mind and develop good sleep habits. It’s even been found to work better than sleeping pills. My only concern is what happens to these people many decades later, even if their insomnia is initially cured.

If you’ve read my book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, I stated my opinion that in my experience, almost all people with insomnia have narrowed upper air passageways, especially behind the tongue. Some will have undiagnosed sleep apnea, but many will have instead something called upper airway resistance syndrome. This is a variation or precursor to sleep apnea where the length of time of each breathing pause is not long enough to be called an apnea. Because of the multiple pauses in breathing in deep sleep, a low-grade stress response is created which causes the insomniac’s mind to race or think about stress-related issues before going to bed. Their nervous systems are edgy and en garde all the time. No wonder it’s hard to fall asleep, especially if you’ve had a stressful day.

I’ve also experienced multiple instances where treating an underlying sleep-breathing problem also significantly improves insomnia symptoms as well.

You may be asking by now, "why do sleeping pills or cognitive behavioral therapy work?" The older type sleep aids were generally tranquilizers and only helped to numb the nervous system so that you can fall asleep faster. But these medications did nothing to prevent the sleep-breathing pauses. The newer medications don’t have as much of the sedating properties, but it’s very controversial that they even make any significant difference. Although industry supported studies find significant  improvements in sleep scores using sleeping pills, non-industry supported studies show that these same sleeping pills only increase total sleep time by only 5-10 minutes. 

Cognitive behavioral therapy (CBT) is another underused option that has been shown to work much better than sleeping pills in general. CBT works by re-programming your thinking and behavior about sleep to promote good sleep hygiene and habits. 

CBT will work to some degree even if you have an underlying sleep-breathing problem because you’re addressing the physiologic stress-aggravting end result of the breathing problems that occur during sleep. Multiple micro-arousals from deep sleep to light sleep due to tongue muscle relaxation can definitely aggravate stress and anxiety problems.

This process also confirms other recent findings that report increased rates of depression and heart disease later in life in people with insomnia earlier on in life.

The main purpose of Dr. Krakow’s study tries to determine what percent of insomniacs have undiagnosed obstructive sleep apnea. Although not part of the study, it would be interesting to perform upper airway endoscopic exams like what I describe, to confirm what I describe in this post. 

Here’s my question to all insomniacs: Do you prefer to sleep on your back, side or stomach? If you prefer your side or stomach, there’s your answer.

I realize that they didn’t choose purely insomniacs, but their premise in designing the study was to determine how to approach someone with both insomnia and a mild sleep-breathing disorder. They also noted that most patients who have mild sleep-breathing problems also have insomnia, are women, and are thin and don’t fit the typical sleep apnea profile. 

This study is one more in the daily to weekly studies that are published that only serves to strengthen the sleep-breathing paradigm that I describe in my book. I realize it’s controversial to say that most of insomnia is actually a breathing issue, but take a look at all the studies that show that having insomnia places you at a higher risk for developing depression, diabetes, and heart disease later in life—all complications of obstructive sleep apnea. Of course CBT is still very useful and should be recommended much more often than offered currently. In addition, good sleep hygiene is still the gold standard and must be tried first. Unfortunately, our medical establishment’s obsession to search for the magic bullet to insomniacs to sleep better without all the side effects will dominate treatment recommendations for years to come.