Chest
Volume 137, Issue 6, June 2010, Pages 1449-1463
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POSTGRADUATE EDUCATION CORNER
CONTEMPORARY REVIEWS IN SLEEP MEDICINE
Insomnia and Sleep-Related Breathing Disorders

https://doi.org/10.1378/chest.09-1485Get rights and content

Insomnia disorder and obstructive sleep apnea are the two most common sleep disorders among adults. Historically, these conditions have been conceptualized as orthogonal, or insomnia has been considered a symptom of sleep apnea. Insomnia researchers have sought to exclude participants at risk for sleep-related breathing disorders (SRBD), and vice versa. In recent years, however, there has been a growing recognition of co-occurring insomnia disorder and SRBD and interest in the prevalence, consequences, and treatment of the two conditions when they co-occur. Although plagued by inconsistent diagnostic criteria and operational definitions, evidence from clinical and research samples consistently suggests high rates of comorbidity between the two disorders. More important, insomnia disorder and SRBD have additive negative effects. To date, only a few studies have explored the combined or sequential treatment of the conditions. Results support the importance of an integrated, interdisciplinary approach to sleep medicine. This article reviews the empirical literature to date and provides clinical recommendations as well as suggestions for future research.

Section snippets

Insomnia Disorder and Obstructive Sleep Apnea: Definition, Prevalence, Costs

Insomnia, characterized by difficulty initiating or maintaining sleep, early morning awakening, or nonrestorative sleep, is the most common sleep complaint among adults4 and perhaps the second most frequent health complaint after pain.5 Approximately 30% of adults in the United States experience occasional transient insomnia, and prevalence estimates for chronic insomnia range from 9% to 12%.6, 7 Insomnia disorder is positively correlated with age and negatively correlated with employment,

Cause

Although the cause of chronic insomnia is unknown, the disorder is most often conceptualized within a biopsychosocial framework. Physiologic abnormalities, including increased activity in the CNS and hyperarousal of the hypothalamic-pituitary axis (HPA)22 and proinflammatory cytokines, as well as personality traits such as anxious temperament, predispose individuals to react negatively to stress, the most common precipitating cause of insomnia disorder.5 Following a period of acute sleep

Co-occurrence of Insomnia Disorder and OSA

Several recent reviews have concluded that insomnia disorder and OSA are likely to coexist in sleep clinic patients.1, 2, 3 For example, a number of reports have documented high rates of insomnia complaints among patients referred for evaluation of SRBD (Table 1). All but one have relied on paper and pencil assessment of insomnia complaints. Smith et al33 required a daytime complaint and Insomnia Severity Index5 score ≥ 15, complaint duration of >6 months, and sleep-onset latency (SOL) or wake

Assessment

Whereas PSG is typically required to confirm the diagnosis of OSA, the foundation of insomnia disorder assessment is a thorough sleep history.54 At a minimum, providers should evaluate the type of insomnia complaints; the onset, frequency, and duration; sleep schedule and sleep-wake patterns on both weekdays and weekends; the sleep environment, including temperature, light, and noise; sleep behaviors such as diet, exercise, and bedroom activities; sleep-related beliefs and expectations

Treatment of OSA

For patients with mild SRBD, conservative treatment approaches include weight loss and mechanical interventions such as using a “tennis ball shirt” (ie, with a tennis ball sewn into the back) to avoid sleeping in the supine position. Careful monitoring of symptoms progression is essential. However, once SRBD has progressed beyond the mild stage, most OSA patients are currently treated using one of three approaches. Customized oral mandibular repositioning devices represent the next least

Treatment of Comorbid Insomnia and OSA

Despite the empirically supported treatments for insomnia disorder and OSA when they occur in isolation, less in known about how to treat the two disorders when they co-occur. In the most methodologically rigorous study treating combined insomnia disorder and OSA, Guilleminault et al87 randomized 30 patients matched for age, BMI, and gender to either group CBT-I followed by surgery, or surgery followed by CBT-I. At 3 months, participants were reassessed and then assigned to the alternative

Clinical Recommendations

Providing clinical recommendations regarding the co-occurrence of insomnia disorder and SRBD is challenging, controversial, and not supported by large clinical trials. Nonetheless, it is clear that a substantial number of patients experience insomnia disorder and OSA simultaneously, that patients treated for both conditions show the greatest improvement, and that sleep medicine patients will benefit from improved clinical care.

  • Standard practice should be to screen clinically for both SRBD

Conclusions and Future Directions

Clinicians and researchers have become increasingly aware of the frequent co-occurrence and additive negative consequences of insomnia disorder and SRBD. Extant literature lacks consistent assessment protocols and diagnostic criteria, and there remains a paucity of systematic evaluation regarding the relationship between the two disorders. More thorough evaluation of the comorbidity and consequences of the two disorders in population and clinical samples is required. Nonetheless, it is clear

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Wickwire has served as a scientific consultant for Health Media. Dr Collop has reported no potential conflicts of interest with any companies/organizations whose products or services may be discussed in this article.

Other contributions: We thank the reviewers for their helpful observations.

References (114)

  • C Guilleminault et al.

    Chronic insomnia, postmenopausal women, and sleep disordered breathing: part 1. Frequency of sleep disordered breathing in a cohort

    J Psychosom Res

    (2002)
  • B Krakow et al.

    Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD

    Biol Psychiatry

    (2001)
  • B Krakow

    An emerging interdisciplinary sleep medicine perspective on the high prevalence of co-morbid sleep-disordered breathing and insomnia

    Sleep Med

    (2004)
  • EO Bixler et al.

    Insomnia in central Pennsylvania

    J Psychosom Res

    (2002)
  • HE Persson et al.

    Sleep deprivation worsens obstructive sleep apnea. Comparison between diurnal and nocturnal polysomnography

    Chest

    (1996)
  • MO Summers et al.

    Recent developments in the classification, evaluation, and treatment of insomnia

    Chest

    (2006)
  • EJ Stepanski et al.

    Emerging research on the treatment and etiology of secondary or comorbid insomnia

    Sleep Med Rev

    (2006)
  • KL Lichstein

    Secondary insomnia: a myth dismissed

    Sleep Med Rev

    (2006)
  • MK Means et al.

    Relaxation therapy for insomnia: nighttime and day time effects

    Behav Res Ther

    (2000)
  • AG Harvey et al.

    An open trial of cognitive therapy for chronic insomnia

    Behav Res Ther

    (2007)
  • C Guilleminault et al.

    Chronic insomnia, premenopausal women and sleep disordered breathing: part 2. Comparison of nondrug treatment trials in normal breathing and UARS post menopausal women complaining of chronic insomnia

    J Psychosom Res

    (2002)
  • MA Machado et al.

    Clinical co-morbidities in obstructive sleep apnea syndrome treated with mandibular repositioning appliance

    Respir Med

    (2006)
  • J Collen et al.

    Clinical and polysomnographic predictors of short-term continuous positive airway pressure compliance

    Chest

    (2009)
  • CJ Lettieri et al.

    Sedative use during CPAP titration improves subsequent compliance.: a randomized, double-blinded, placebo-controlled trial

    Chest

    (2009)
  • DA Bradshaw et al.

    An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea

    Chest

    (2006)
  • Wickwire E, Smith M, Collop N. Insomnia in other sleep disorders: breathing disorders. In: Sateia M, Buysse D, eds....
  • National Institutes of Health

    NIH state-of-the-science conference statement on manifestations and management of chronic insomnia in adults

    NIH Consens Sci Statements

    (2005)
  • CM Morin

    Insomnia: Psychological Assessment and Management

    (1993)
  • S Ancoli-Israel et al.

    Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I

    Sleep

    (1999)
  • DE Ford et al.

    Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?

    JAMA

    (1989)
  • LA Gellis et al.

    Socioeconomic status and insomnia

    J Abnorm Psychol

    (2005)
  • GK Zammit et al.

    Quality of life in people with insomnia

    Sleep

    (1999)
  • DJ Taylor et al.

    Comorbidity of chronic insomnia with medical problems

    Sleep

    (2007)
  • DJ Taylor et al.

    Insomnia as a health risk factor

    Behav Sleep Med

    (2003)
  • RJ Ozminkowski et al.

    The direct and indirect costs of untreated insomnia in adults in the United States

    Sleep

    (2007)
  • M Daley et al.

    The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers

    Sleep

    (2009)
  • JK Walsh et al.

    The direct economic costs of insomnia in the United States for 1995

    Sleep

    (1999)
  • MK Stoller

    Economic effects of insomnia

    Clin Ther

    (1994)
  • NM Punjabi

    The epidemiology of adult obstructive sleep apnea

    Proc Am Thorac Soc

    (2008)
  • C Iber et al.

    The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology, and Technical Specifications

    (2007)
  • T Young et al.

    The occurrence of sleep-disordered breathing among middle-aged adults

    N Engl J Med

    (1993)
  • MR Shepertycky et al.

    Differences between men and women in the clinical presentation of patients diagnosed with obstructive sleep apnea syndrome

    Sleep

    (2005)
  • RL Ellen et al.

    Systematic review of motor vehicle crash risk in persons with sleep apnea

    J Clin Sleep Med

    (2006)
  • N Collop

    The effect of obstructive sleep apnea on chronic medical disorders

    Cleve Clin J Med

    (2007)
  • KL Lichstein et al.

    Insomniacs' perceptions of cognitive versus somatic determinants of sleep disturbance

    J Abnorm Psychol

    (1980)
  • PE Peppard et al.

    Longitudinal study of moderate weight change and sleep-disordered breathing

    JAMA

    (2000)
  • S Redline et al.

    Studies in the genetics of obstructive sleep apnea. Familial aggregation of symptoms associated with sleep-related breathing disturbances

    Am Rev Respir Dis

    (1992)
  • AB Newman et al.

    Progression and regression of sleep-disordered breathing with changes in weight: the Sleep Heart Health Study

    Arch Intern Med

    (2005)
  • C White et al.

    Alcohol increases sleep apnea and oxygen desaturation in asymptomatic men

    Am J Med

    (1981)
  • DW Wetter et al.

    Smoking as a risk factor for sleep-disordered breathing

    Arch Intern Med

    (1994)
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