Insomnia and OSA

  • Elizabeth E. Sita
  • Hrayr P. Attarian


Obstructive sleep apnea (OSA) and chronic insomnia are two of the most common sleep disorders, and they coexist frequently in the same patient. Although OSA is associated with drowsiness and chronic insomnia with hyperarousal, they both can lead to cognitive issues and fatigue. They also have been associated with higher incidence of cardiovascular morbidities. The shared mechanism among the complications associated with both disorders is likely the overactivation of the hypothalamic-pituitary-adrenal axis. Chronic insomnia can be a symptom of OSA, and it can also interfere with an OSA patient’s ability to tolerate CPAP, the gold standard for treatment. CPAP can ameliorate the insomnia symptoms of someone with OSA, and cognitive behavioral therapy for insomnia can improve CPAP adherence. Therefore it is important for clinicians to recognize the overlap between these two disorders and the impact both have on the patient’s overall well-being.


Obstructive sleep apnea Insomnia CBT-I CPAP Apnea-hypopnea index (AHI) Hypothalamic-pituitary axis 


  1. 1.
    Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379:1129–41.CrossRefGoogle Scholar
  2. 2.
    Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29:1155–73.CrossRefGoogle Scholar
  3. 3.
    Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. J Am Med Assoc. 2004;291:2013–6.CrossRefGoogle Scholar
  4. 4.
    Guilleminault C, Eldridge FL, Dement WC. Insomnia with sleep apnea: a new syndrome. Science. 1973;181:856–8.CrossRefGoogle Scholar
  5. 5.
    Krakow B, Melendrez D, Ferreira E, et al. Prevalence of insomnia symptoms in patients with sleep disordered breathing. Chest. 2001;120:1923–9.CrossRefGoogle Scholar
  6. 6.
    Bailes S, Rizzo D, Baltzan M, Grad R, Pavilanis A, Creti L, et al. Manifestations of insomnia in sleep apnea: implications for screening and treatment. Behav Sleep Med. 2015;14:429–41.CrossRefGoogle Scholar
  7. 7.
    Subramanian S, Guntupalli B, Murugan T, Bopparaju S, Chanamoul S, Casturi L, et al. Gender and ethnic differences in prevalence of self-reported insomnia among patients with obstructive sleep apnea. Sleep Breath. 2011;15:711–5.CrossRefGoogle Scholar
  8. 8.
    Cronlein T, Geisler P, Langguth B, Eichhammer P, Jara C, Pieh C, et al. Polysomnography reveals unexpectedly high rates of organic sleep disorders in patients with prediagnosed primary insomnia. Sleep Breath. 2012;16:1097–103.CrossRefGoogle Scholar
  9. 9.
    Krakow B, Ulibarri VA, McIver ND. Pharmacotherapeutic failure in a large cohort of patient with insomnia presenting to a sleep medicine center in laboratory: subjective pretest predictions and diagnoses. Mayo Clin Proc. 2014;89:1608–20.CrossRefGoogle Scholar
  10. 10.
    Vozoris NT. Sleep apnea-plus: prevalence, risk factors, and association with cardiovascular diseases using United States population-level data. Sleep Med. 2012;13:637–44.CrossRefGoogle Scholar
  11. 11.
    Gupta MA, Knapp K. Cardiovascular and psychiatric morbidity in obstructive sleep apnea (OSA) with insomnia (sleep apnea plus) versus obstructive sleep apnea without insomnia: a case-control study from a nationally representative US sample. PLoS One. 2014;9(3):e90021.CrossRefGoogle Scholar
  12. 12.
    Krakow B, Melendrez D, Ferreira E, Clark J, Warner TD, Sisley B, et al. Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest. 2001;120:1923–9.CrossRefGoogle Scholar
  13. 13.
    Sivertsen B, Bjornsdottir E, Overland S, Salo P. The joint contribution of insomnia and obstructive sleep apnoea on sickness absence. J Sleep Res. 2013;22:223–30.CrossRefGoogle Scholar
  14. 14.
    Bjornsdottir E, Janson C, Gislason T, Sigurdsson JF, Pack AI, Gehrman P, et al. Insomnia in untreated sleep apnea patients compared to controls. J Sleep Res. 2012;22:131–8.CrossRefGoogle Scholar
  15. 15.
    Krell SB, Kapur VK. Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath. 2005;9:104–10.CrossRefGoogle Scholar
  16. 16.
    Yang C, Liao Y, Lin C, Chou S, Wang E. Psychological and behavioral factors in patients with comorbid obstructive sleep apnea and insomnia. J Psychosom Res. 2011;70:355–61.CrossRefGoogle Scholar
  17. 17.
    Mercer JD, Bootzin RR, Lack LC. Insomniacs’ perception of wake instead of sleep. Sleep. 2002;25:564–71.CrossRefGoogle Scholar
  18. 18.
    Lichstein KL, Thomas SJ, Woosley JA, Geyer JD. Co-occurring insomnia and obstructive sleep apnea. Sleep Med. 2013;14:824–9.CrossRefGoogle Scholar
  19. 19.
    Series F, Roy N, Marc I. Effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects. Am J Respir Crit Care Med. 1994;150:481–5.CrossRefGoogle Scholar
  20. 20.
    Persson HE, Svanborg E. Sleep deprivation worsens obstructive sleep apnea: comparison between diurnal and nocturnal polysomnography. Chest. 1996;109:645–50.CrossRefGoogle Scholar
  21. 21.
    Beneto A, Gomez-Siurana E, Rubio-Sanchez P. Comorbidity between sleep apnea and insomnia. Sleep Med Rev. 2009;13:287–93.CrossRefGoogle Scholar
  22. 22.
    Krakow B, Melendrez D, Lee SA, Warner TD, Clark JO, Sklar D. Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath. 2004;8:15–29.CrossRefGoogle Scholar
  23. 23.
    Krakow B, Melendrez D, Sisley B, Warner TD, Krakow J, Leahigh L, et al. Nasal dilator strip therapy for chronic sleep-maintenance insomnia and symptoms of sleep-disordered breathing: a randomized controlled trial. Sleep Breath. 2006;10:16–28.CrossRefGoogle Scholar
  24. 24.
    Machado MA, de Carvalho LB, Juliano ML, Taga M, do Prado LB, do Prado GF. Clinical co-morbidities in obstructive sleep apnea syndrome treated with mandibular repositioning appliance. Respir Med. 2006;100:988–95.CrossRefGoogle Scholar
  25. 25.
    Wickwire E, Schumacher J, Richert A, Baran A, Roffwarg H. Combined insomnia and poor CPAP compliance: a case study and discussion. Clin Cas Stud. 2008;7:267–86.CrossRefGoogle Scholar
  26. 26.
    Wickwire EM, Smith MT, Birnbaum S, Collop NA. Sleep maintenance insomnia complaints predict poor CPAP adherence: a clinical case series. Sleep Med. 2010;11:772–6.CrossRefGoogle Scholar
  27. 27.
    Bjornsdottir MS, Janson C, Sigurdsson JF, Gehrman P, Perlis M, Juliusson S, et al. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013;36:1901–9.CrossRefGoogle Scholar
  28. 28.
    Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663–7.CrossRefGoogle Scholar
  29. 29.
    Luyster FS, Buysse DJ, Strollo PJ. Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med. 2010;6:196–204.PubMedPubMedCentralGoogle Scholar

Suggested Reading

  1. Luyster FS, Buysse DJ, Strollo PJ. Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and research. J Clin Sleep Med. 2010;6:196–204.PubMedPubMedCentralGoogle Scholar
  2. Sweetman AM, Lack LC, Catcheside PG, Antic NA, Chai-Coetzer CL, Smith SS, et al. Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev. 2017;33:28–38.CrossRefGoogle Scholar
  3. Wickwire EM, Collop NA. Insomnia and sleep-related breathing disorders. Chest. 2010;137:1449–63.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Elizabeth E. Sita
    • 1
  • Hrayr P. Attarian
    • 2
  1. 1.Department of PsychiatryNorthwestern MedicineChicagoUSA
  2. 2.Department of NeurologyNorthwestern MedicineChicagoUSA

Personalised recommendations