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Is Insomnia Really A Sleep-Breathing Problem?
Sleep doctors have always thought of insomnia as a behavioral or stress aggravated issue, and the standard ways of treating this all-too-common condition is to either give sleeping pills or have the patient undergo cognitive behavioral therapy. However, a recent study directed by Dr. Barry Krakow at the Sleep and Human Health Institute is looking at the possibility that insomnia may actually be caused by a sleep-breathing problem, such as obstructive sleep apnea.
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.
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.
Views: 104
Replies to This Discussion
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Permalink Reply by Kate Gartland on
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Maybe my brain isnt connected but I dont understand the relationship between position of sleeping and the rest of the article. Meaning if I sleep on my side I probably have the narrowed airways? I had a sleep study done (it was exhausting, I woke up so many times with that damn probe by my nose)... they said no apnea. I snore loud enough to set off fire alarms... no one can share a room with me... I apparently have restless legs at night... but no apnea.
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Permalink Reply by Steven Y. Park, MD on
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Kate,
By definition, all modern humans have potentially narrowed airways due to our ability to talk and from a slight narrowing of our jaws. While sleeping on our backs, our tongues fall back partially in all people. But if your jaw is smaller than usual, then the tongue falls back more than usual, and when you add deep sleep (due to muscle relaxation), you'll snore or stop breathing. People wit these issues naturally compensate by sleeping on their sides. It sounds like you do have a sleep-breathing problem, but your pauses are not long enough to call apneas.
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Permalink Reply by RichM on
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Dr. Park, I am interested in what you thoughts are about if there is any link with insomnia and CSA. Since my auto accident that happen in Feb 2007 I have had insomnia along with a number of other issues including victualer (spelling) balance and ringing in the ears along with another problem that requires me to now ware FM hearing aids by phonak. I also since the accident have double vision and need to add number 20 prisms in both sides of my glasses along with short term memory problems. My past sleep study now shows that I have CSA's along with my OSA'a and now require a bipap with a backup rate. I only get approx 3-4 hrs sleep and that is mostly broken up. I use a a m series auto bipap right now till my new machine gets ordered and I use it most every night and still have insomnia. I am still on pain meds and to top it all off this past aug I was in the hospital for pulmonary embolisms so I have to be on coumadin so I can not take the nerve block shots till I get off of that med so I have to stay on the pain meds. It like a viscous circle what ideas do you have.
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Dr Park, I have always preferred to sleep on my tummy as far back as I can remember. My sleep problems didn't begin until a whiplash in 1994. I was in a 2 hour sleep/wake cycle for several years after. I had trouble both getting to sleep AND staying asleep. Ambien DOES get me to sleep w/in a few minutes. But it was only good for 4-5 hours and then I was awake. I never tried Ambien CR.
Of course, I have COPD which can throw a wrench in things. I did successfully utilize postional sleep training so that I no longer even these many years later sleep on my tummy (neck pain w/head turned for tummy sleeping). I just used knotted sox basted to my PJ fronts.
I've progressed thru CPAP to bi-level VPAP due to the COPD. I still have difficulty accepting that the whiplash wasn't a contributory cause of my sleep problems despite an eventual Dx of mild OSA. OSA doesn't explain the forward head carriage I now have since the whiplash (because I didn't have enough sense to let them transport me to ER and didn't have enough sense to go to the doctor until 2 weeks later - too late for a neck brace to do any good). Still I can accept the change in favored sleep position as a contributory cause as well.
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Permalink Reply by Dawn on
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Hi Dr. Park
I agree that insomnia can be a symptom of sleep apnea. Here is my story:
I used to have horrible insomnia, even as a kid. I used to only fall asleep on my side. I was diagnosed with sleep apnea two years ago (at age 42) and what a difference a machine can make. I actually look forward to falling asleep now. With the cpap on I usually can fall asleep within five minutes and I usually stay asleep. I can even sleep on my back, which at first with the cpap felt very unnatural.
In addition to insomnia, I also have always been a restless sleeper. Before being diagnosed and treated, I used to thrash around in my sleep something terrible. My husband commented that immediately with treatment with the cpap, that the position I fall asleep in is the position I wake up in. He says I just fall asleep and stay the way I fell asleep. When I was a kid both of my Grandmothers would complain that I would kick them something awful in my sleep when I would stay with them.
When I was a kid I not only was an insomniac and a restless sleeper, I was also a sleep walker. One time I was found sleep walking down the street until a neighbor brought me home. My parents had to put locks on the doors high enough out of my reach as I would also unlock the doors in my sleep.
I think I outgrew sleep walking, but the restless sleep and insomnia remained until I was successfully treated for sleep apnea. I honestly believe all the symptoms I had dating back to my childhood are the result of some form of airway obstruction during sleeping. The last two years have been wonderful!
Thanks for all of your information.
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I have always suffered from insomnia.....I am currently taking trazadone for sleep and I have recently been diagnosed with sleep apnea.....I am still struggling with my mask.....but, I am determined to get over this hurdle as I am tired of being tired all the time....wish me luck and I need to purchase your book.
Thanks
Belinda
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Interesting, Dr Park! I was a tummy sleep all my life as far back as I can remember until a whiplash in 1994. I haven't been able to sleep on my tummy since then. And my sleep problems began at that time. Trouble getting to sleep. Trouble staying asleep. Very common to sleep 2 hours, awake 2 hours, sleep 2 hour, awake 2 hour, sleep 2 hours all night long. The only good sleep I got was from 6 to 8:30 AM IF I could sleep during that time. Because I was working full time it wasn't often I could sleep during those hours. BUT - even if those were the only 2 - 2 1/2 hours of sleep I got I felt more rested than a full night's "sleep" that didn't include those 2 - 2 1/2 hours. On the other hand, Ambien would get me 4 hours sleep. But no more (never tried Ambien CR). If I added regular strength Tylenol (not the PM) I would get an additional 1-2 hours. Since the Tylenol helped I assumed I had some aches and pains issues I wasn't fully aware of since my doctors said there was nothing in Tylenol to relax and help w/sleep.
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Sorry. I forgot I had replied to this. Color me red-faced. It popped up again and I just replied w/o reading past the original post. Duh.
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Permalink Reply by RockRpsgt on
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Dr. Park I can understand how this could affect terminal and maintenance insomniacs, but I do not see a connection with Initial or psychophysiological insomniacs. I mean these types of insomniacs actually think that they can't sleep, or they think to much about life, or not sleeping so they can't sleep. You can't be aroused awake if you never fall asleep. What about idiopathic insomnia. I guess being sleep deprived messing with your circadian rythm could cause a chemical imbalance. I am just not seeing the full connection. I am very interested in this study and thanks for the link to the site.
Steven Y. Park, MD said:Kate,
By definition, all modern humans have potentially narrowed airways due to our ability to talk and from a slight narrowing of our jaws. While sleeping on our backs, our tongues fall back partially in all people. But if your jaw is smaller than usual, then the tongue falls back more than usual, and when you add deep sleep (due to muscle relaxation), you'll snore or stop breathing. People wit these issues naturally compensate by sleeping on their sides. It sounds like you do have a sleep-breathing problem, but your pauses are not long enough to call apneas.
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