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Comorbid Insomnia and Sleep Disordered Breathing

  • SLEEP DISORDERS (S CHOKROVERTY, SECTION EDITOR)
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Opinion statement

Sufficient evidence has accumulated to warrant conceptualization of comorbid insomnia and sleep disordered breathing (SDB) as a distinct clinical syndrome. As such, diagnostic and treatment approaches should be founded on an integrated and multidisciplinary approach with equivalent clinical attention and priority given to both insomnia and respiratory aspects of patients’ presenting complaints. Several well established and effective treatments exist for both insomnia and SDB. Although questions of optimal treatment combination and sequence remain to be examined, current evidence provides preliminary guidance regarding the sequential or concurrent management of insomnia and sleep disordered breathing when comorbid. Unsatisfactory response to pharmacotherapy or cognitive-behavioral therapy for chronic insomnia should trigger evaluation for comorbid sleep-related breathing disturbance prior to more aggressive or off label pharmacotherapy. Presence and course of insomnia symptoms should be monitored closely in SDB patients with persistence of insomnia symptoms following SDB treatment prompting targeted treatment of insomnia. Aggressive treatment of insomnia prior to or in combination with SDB treatment may be particularly indicated in situations where insomnia is suspected to interfere with diagnosis or treatment of SDB. Insomnia and sleep disordered breathing appear to uniquely contribute to the morbidity of patients with this comorbidity. With this in mind, active engagement and monitoring of SDB and insomnia will often be necessary to achieve optimal outcomes.

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References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  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. Comprehensive review of the literature examining all facets of the relationship between insomnia and sleep disordered breathing as comorbid conditions.

    PubMed  Google Scholar 

  2. Wickwire EM, Collop NA. Insomnia and sleep-related breathing disorders. Chest. 2010;137:1449–63. Comprehensive review of the literature examining all facets of the relationship between insomnia and sleep disordered breathing as comorbid conditions.

    Article  PubMed  Google Scholar 

  3. Wickwire EA. Combined insomnia and poor CPAP compliance a case study and discussion. Clin Case Stud. 2008;7:267–86.

    Article  Google Scholar 

  4. Smith S, Sullivan K, Hopkins W, Douglas J. Frequency of insomnia report in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS). Sleep Med. 2004;5:449–56.

    Article  PubMed  Google Scholar 

  5. Ram S, Seirawan H, Kumar SKS, Clark GT. Prevalence and impact of sleep disorders and sleep habits in the United States. Sleep Breath. 2010;14:63–70.

    Article  PubMed  Google Scholar 

  6. Guilleminault C, Eldridge F, Dement W. Insomnia with sleep apnea: a new syndrome. Science. 1973;181:856–8.

    Article  PubMed  CAS  Google Scholar 

  7. Guilleminault C. Sleep apnoea-insomnia. Nurs Times. 1974;70:1708–9.

    PubMed  CAS  Google Scholar 

  8. Guilleminault C, Palombini L, Poyares D, Chowdhuri S. 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;53:617–23.

    Article  PubMed  Google Scholar 

  9. Guilleminault C, Davis K, Huynh NT. Prospective randomized study of patients with insomnia and mild sleep disordered breathing. Sleep. 2008;31:1527–33.

    PubMed  Google Scholar 

  10. Krakow B, Melendrez D, Lee S, Warner T, Clark J, Sklar D. Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath. 2004;8:15–29.

    Article  PubMed  Google Scholar 

  11. Krell SB, Kapur VK. Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath. 2005;9:104–10.

    Article  PubMed  Google Scholar 

  12. Chung KF. Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea. Respiration. 2005;72:460–5.

    Article  PubMed  Google Scholar 

  13. Gooneratne NS, Gehrman PR, Nkwuo JE, Bellamy SL, Schutte-Rodin S, Dinges DF, et al. Consequences of comorbid insomnia symptoms and sleep-related breathing disorder in elderly subjects. Arch Intern Med. 2006;166:1732–8.

    Article  PubMed  Google Scholar 

  14. Yang CM, Liao YS, Lin CM, Chou SL, Wang EN. Psychological and behavioral factors in patients with comorbid obstructive sleep apnea and insomnia. J Psychosom Res. 2011;70:355–61.

    Article  PubMed  Google Scholar 

  15. Ong J, Kong A, Lederman M, Park M, Crisostomo M, Cvengros J, et al. Developing clinical profiles and a multidisciplinary approach for patients with OSA and comorbid insomnia. Sleep. 2012;35:A244.

    Google Scholar 

  16. Glidewell RN, Roby EK, Orr WC. Is insomnia an independent predictor of obstructive sleep apnea? J Am Board Fam Med. 2012;25:104–10.

    Article  PubMed  Google Scholar 

  17. Glidewell RN, Moorcroft WH, Lee-Chiong Jr T. Comorbid Insomnia: reciprocal relationships and medication management. Sleep Med Clin. 2010;5:627–46.

    Article  Google Scholar 

  18. Glidewell R, Roby E, Orr W. The course of insomnia prior to and following treatment of obstructive sleep apnea. Sleep. 2010;33:A171.

    Google Scholar 

  19. Cao M, Guilleminault C, Kushida C. Clinical features and evaluation of obstructive sleep apnea and upper airway resistance syndrome. In: Kryger M, Roth T, Dement W, editors. Principles and practices of sleep medicine. 5th ed. St. Louis: Elsevier; 2010. p. 1206–18.

    Google Scholar 

  20. Guilleminault C, Kirisoglu C, Poyares D, Palombini L, Leger D, Farid-Moayer M, et al. Upper airway resistance syndrome: a long-term outcome study. J Psychiatr Res. 2006;40:273–9.

    Article  PubMed  Google Scholar 

  21. Björnsdóttir E, Janson C, Gíslason T, Sigurdsson JF, Pack AI, Gehrman P, et al. Insomnia in untreated sleep apnea patients compared with controls. J Sleep Res. 2011. doi:10.1111/j.1365-2869.2011.00972.x. Article first published online 12 October 2011.

    PubMed  Google Scholar 

  22. 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.

    Article  PubMed  CAS  Google Scholar 

  23. Lichstein KL, Riedel BW, Lester KW, Aguillard RN. Occult sleep apnea in a recruited sample of older adults with insomnia. J Consult Clin Psychol. 1999;67:405–10.

    Article  PubMed  CAS  Google Scholar 

  24. Krakow B, Romero E, Victor A, Kikta S. Prospective assessment of nocturnal awakenings in a case series of treatment-seeking chronic insomnia patients: a pilot study of subjective and objective causes. Sleep. 2012;35:1685–92.

    PubMed  Google Scholar 

  25. 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.

    Article  PubMed  Google Scholar 

  26. Kapur VK, Baldwin CM, Resnick HE, Gottlieb DJ, Nieto FJ. Sleepiness in patients with moderate to severe sleep-disordered breathing. Sleep. 2005;28:472–7.

    PubMed  Google Scholar 

  27. Pieh C, Bach M, Popp R, Jara C, Crönlein T, Hajak G, et al. Insomnia symptoms influence CPAP compliance. Sleep Breath. 2012. doi:10.1007/s11325-012-0655-9. Article first published online 4 February 2012.

    Google Scholar 

  28. 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.

    Article  PubMed  Google Scholar 

  29. Mysliwiec V, Gill J, Lee H, Baxter T, Pierce R, Barr TL, et al. Sleep disorders in U.S. military personnel: a high rate of comorbid insomnia and obstructive sleep apnea. Chest. 2013;36:167–74.

    Google Scholar 

  30. Kribbs NB, Pack AI, Kline LR, Smith PL, Schwartz AR, Schubert NM, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147:887–95.

    Article  PubMed  CAS  Google Scholar 

  31. Weaver TE, Kribbs NB, Pack AI, Kline LR, Chugh DK, Maislin G, et al. Night-to-night variability in CPAP use over the first three months of treatment. Sleep. 1997;20:278–83.

    PubMed  CAS  Google Scholar 

  32. Aloia MS, Arnedt JT, Stanchina M, Millman RP. How early in treatment is PAP adherence established? Revisiting night-to-night variability. Behav Sleep Med. 2007;5:229–40.

    Article  PubMed  Google Scholar 

  33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington DC: American Psychiatric Publishing; 2013.

  34. NIH State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults statement. J Clin Sleep Med. 2005;1:412–21.

    Google Scholar 

  35. Littner M, Hirshkowitz M, Kramer M, Kapen S, Anderson WM, Bailey D, et al. Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep. 2003;26:754–60.

    PubMed  Google Scholar 

  36. Edinger JD, Wyatt JK, Stepanski EJ, Olsen MK, Stechuchak KM, Carney CE, et al. Testing the reliability and validity of DSM-IV-TR and ICSD-2 insomnia diagnoses: results of a multitrait-multimethod analysis. Arch Gen Psychiatry. 2011;68:992–1002.

    Article  PubMed  Google Scholar 

  37. Krakow B, Warner T, Melendrez D, Krakow J, Sisley B. Nasal dilator strip therapy for chronic sleep. Maintenance insomnia: a case series. Sleep Breath. 2004;8:133–40.

    Article  PubMed  Google Scholar 

  38. 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.

    Article  PubMed  Google Scholar 

  39. Ong JC, Crisostomo MI. The more the merrier? Working towards multidisciplinary management of obstructive sleep. Apnea and comorbid insomnia. J Clin Psychol. 2013. doi:10.1002/jclp.21958. This article outlines a multidisciplinary process for optimal management of comorbid insomnia and sleep disordered breathing. It also provides a succinct and thoughtful discussion of the critical issues regarding diagnosis and management of this comorbidity.

    PubMed  Google Scholar 

  40. Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006;29:1031–5.

    PubMed  Google Scholar 

  41. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J, et al. Practice parameters for the treatment of snoring and obstructive sleep. Apnea with oral appliances: an update for 2005. Sleep. 2006;29:240–3.

    PubMed  Google Scholar 

  42. Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006;29:375–80.

    PubMed  Google Scholar 

  43. Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010;33:1408–13.

    PubMed  Google Scholar 

  44. Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379:1129–41.

    Article  PubMed  Google Scholar 

  45. Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep. 2006;29:1415–9.

    PubMed  Google Scholar 

  46. Berry RB, Patel PB. Effect of zolpidem on the efficacy of continuous positive airway pressure as treatment for obstructive sleep apnea. Sleep. 2006;29:1052–6.

    PubMed  Google Scholar 

  47. Guilleminault C. Benzodiazepines, breathing, and sleep. Am J Med. 1990;88:25S–8S.

    Article  PubMed  CAS  Google Scholar 

  48. Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA, et al. Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med. 2009;151:696–702.

    Article  PubMed  Google Scholar 

  49. Lettieri CJ, Collen JF, Eliasson AH, Quast TM. Sedative use during continuous positive airway pressure titration improves subsequent compliance: a randomized, double-blind, placebo-controlled trial. Chest. 2009;136:1263–8.

    Article  PubMed  Google Scholar 

  50. Bradshaw D, Ruff G, Murphy D. An oral hypnotic medication does not improve continuous positive airway pressure compliance in men with obstructive sleep apnea. Chest. 2006;130:1369–76.

    Article  PubMed  Google Scholar 

  51. Rosenberg R, Roach JM, Scharf M, Amato DA. A pilot study evaluating acute use of eszopiclone in patients with mild to moderate obstructive sleep apnea syndrome. Sleep Med. 2007;8:464–70.

    Article  PubMed  Google Scholar 

  52. Morin C. Psychological and behavioral treatment of insomnia I: approaches and efficacy. In: Kryger M, Roth T, Dement W, editors. Principles and practices of sleep medicine. 5th ed. St. Louis: Elsevier; 2010. p. 866–83.

    Google Scholar 

  53. Morin CM. Combined therapeutics for insomnia: should our first approach be behavioral or pharmacological? Sleep Med. 2006;7:S15–9.

    Article  PubMed  Google Scholar 

  54. Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301:2005–15.

    Article  PubMed  CAS  Google Scholar 

  55. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;151:1172–80.

    PubMed  CAS  Google Scholar 

  56. Wickwire EM, Collop NA. Insomnia and sleep-related breathing disorders. Chest. 2010;137:1449–63.

    Article  PubMed  Google Scholar 

  57. Gulley C, Hwang D, Ho S, Petrilla J, Chang N, Chang J, et al. Effectiveness of a single-session cognitive behavioral therapy program in a large group setting for insomnia and impact on healthcare utilization. Sleep. 2013;36:A192–3.

    Google Scholar 

  58. Ritterband LM, Thorndike FP, Gonder-Frederick LA, Magee JC, Bailey ET, Saylor DK, et al. Efficacy of an internet-based behavioral intervention for adults with insomnia. Arch Gen Psychiatry. 2009;66:692–8.

    Article  PubMed  Google Scholar 

  59. Espie CA, Kyle SD, Williams C, Ong JC, Douglas NJ, Hames P, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012;35:769–81.

    PubMed  Google Scholar 

  60. Espie CA, Barrie LM, Forgan GS. Comparative investigation of the psychophysiologic and idiopathic insomnia disorder phenotypes: psychological characteristics, patients' perspectives, and implications for clinical management. Sleep. 2012;35:385–93.

    PubMed  Google Scholar 

  61. Morin CM, Gaulier B, Barry T, Kowatch RA. Patients' acceptance of psychological and pharmacological therapies for insomnia. Sleep. 1992;15:302–5.

    PubMed  CAS  Google Scholar 

  62. Vincent N, Lionberg C. Treatment preference and patient satisfaction in primary insomnia. Sleep. 2001;24:411–7.

    PubMed  CAS  Google Scholar 

  63. McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs. pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74:595–602.

    Article  PubMed  Google Scholar 

  64. Barbini B, Bertelli S, Colombo C, Smeraldi E. Sleep loss, a possible factor in augmenting manic episode. Psychiatry Res. 1996;65:121–5.

    Article  PubMed  CAS  Google Scholar 

  65. Colombo C, Benedetti F, Barbini B, Campori E, Smeraldi E. Rate of switch from depression into mania after therapeutic sleep deprivation in bipolar depression. Psychiatry Res. 1999;86:267–70.

    Article  PubMed  CAS  Google Scholar 

  66. Kaplan KA, Harvey AG. Behavioral treatment of insomnia in bipolar disorder. Am J Psychiatry. 2013;170:716–20.

    Article  PubMed  Google Scholar 

  67. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1:862–5.

    Article  PubMed  CAS  Google Scholar 

  68. Strohl KP, Redline S. Nasal CPAP therapy, upper airway muscle activation, and obstructive sleep apnea. Am Rev Respir Dis. 1986;134:555–8.

    PubMed  CAS  Google Scholar 

  69. Buchanan P, Grunstein R. Positive airway pressure treatment for obstructive sleep apnea-hypopnea syndrome. In: Kryger M, Roth T, Dement W, editors. Principles and practices of sleep medicine. 5th ed. St. Louis: Elsevier; 2010. p. 1233–49.

    Google Scholar 

  70. Barnes M, Houston D, Worsnop CJ, Neill AM, Mykytyn IJ, Kay A, et al. A randomized controlled trial of continuous positive airway pressure in mild obstructive sleep apnea. Am J Respir Crit Care Med. 2002;165:773–80.

    Article  PubMed  Google Scholar 

  71. Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev. 2003;7:81–99.

    Article  PubMed  Google Scholar 

  72. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5:173–8.

    Article  PubMed  Google Scholar 

  73. Suratt P, Turner B, Wilhoit S. Effect of intranasal obstruction on breathing during sleep. Chest. 1986;90:324–9.

    Article  PubMed  CAS  Google Scholar 

  74. Todorova A, Schellenberg R, Hofmann HC, Dimpfel W. Effect of the external nasal dilator Breathe Right on snoring. Eur J Med Res. 1998;3:367–79.

    PubMed  CAS  Google Scholar 

  75. Pevernagie D, Hamans E, Van Cauwenberge P, Pauwels R. External nasal dilation reduces snoring in chronic rhinitis patients: a randomized controlled trial. Eur Respir J. 2000;15:996–1000.

    Article  PubMed  CAS  Google Scholar 

  76. Hoffstein V, Mateika S, Metes A. Effect of nasal dilation on snoring and apneas during different stages of sleep. Sleep. 1993;16:360–5.

    PubMed  CAS  Google Scholar 

  77. Djupesland PG, Skatvedt O, Borgersen AK. Dichotomous physiological effects of nocturnal external nasal dilation in heavy snorers: the answer to a rhinologic controversy? Am J Rhinol. 2001;15:95–103.

    Article  PubMed  CAS  Google Scholar 

  78. Amaro A, Duarte F, Jallad R, Bronstein M, Redline S, Lorenzi-Filho G. The use of nasal dilator strips as a placebo for trials evaluating continuous positive airway pressure. Clinics. 2012;67:469–74.

    Article  PubMed  Google Scholar 

  79. Powell N, Riley R. Surgical management for obstructive sleep-disordered breathing. In: Kryger M, Roth T, Dement W, editors. Principles and practices of sleep medicine. 5th ed. St. Louis: Elsevier; 2010. p. 1250–65.

    Google Scholar 

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Conflict of Interest

Robert N. Glidewell is the owner of and receives a regular salary from Behavioral Sleep Medicine, LLC, which provides CBT-I at a private clinic and through a contract with National Jewish Health, and Behavioral Sleep Medicine Specialists, which provides CBT-I, and receives compensation on a contract basis for providing CBT-I services.

Human and Animal Rights and Informed Consent

This article does not contain any studies with animal subjects performed by the author. With regard to the author’s research cited in this paper, all procedures were followed in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 and 2008.

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  1. Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Sleep and Behavioral Health Sciences Section, National Jewish Health, Denver, CO, USA

    Robert N. Glidewell PsyD, CBSM

  2. Behavioral Sleep Medicine, LLC, Colorado Springs, CO, 80907, USA

    Robert N. Glidewell PsyD, CBSM

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Correspondence to Robert N. Glidewell PsyD, CBSM.

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Glidewell, R.N. Comorbid Insomnia and Sleep Disordered Breathing. Curr Treat Options Neurol 15, 692–703 (2013). https://doi.org/10.1007/s11940-013-0259-0

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