Sleep apnoea and insomnia: What’s the link?

Types of insomnia

1. Acute insomnia: This is classed as a few weeks or nights of poor sleep. “These temporary sleep issues are often triggered by external forces, such as stressful situations, jetlag or major life events,” says Josh. Anyone who’s lain awake after a long-haul flight or when worrying about work may well sympathise!
2. Chronic insomnia: In this case the sleep disturbances last for longer than three months, with sleep difficulties occurring at least three days per week².

However, the categorisation doesn’t stop there – we can also break down insomnia according to the way people experience it:

3. Onset insomnia: When someone takes a long time to go to sleep
4. Maintenance insomnia: When someone wakes up during the night and struggles to get back to sleep – this may happen multiple times
5. Complex insomnia: A combination of the two above categories

What causes insomnia?

“As we’ve seen, insomnia is a catch-all term for multiple types of sleep (or lack of sleep!) issues,” says Josh, “so it can be challenging to determine one root cause.”

However, if we look a bit more closely at the circumstances of an individual reporting sleep problems, we can assess if the insomnia is primary or secondary – which basically means whether it is linked to another health issue or not:

Primary: Not linked to a health issue – think back to the triggers for acute insomnia and things such as noise at night or too much light in the bedroom.

Secondary: Linked to a health issue or medical condition, pain, and/or the use of certain medications or drugs.

Who gets insomnia?

“Insomnia doesn’t discriminate, anyone can develop it,” says Josh. However, there are three Ps that can play a part in whether someone experiences insomnia: Predisposition and Precipitating and Perpetuating factors – as Josh explains:

“Certain factors that may predispose someone to having insomnia include being female, being older, or having an underlying health condition such as diabetes, heart disease, kidney disease or high blood pressure.”

“But such predispositions are just one part of the story,” says Josh. “If someone has chronic insomnia there’s often a combination of precipitating factors (such as stressful life events) and perpetuating factors (ongoing behaviours that maintain a disrupted sleep rhythm – like excessive napping, or working shifts) contributing to it.”

So what about sleep apnoea – can that be a risk factor for insomnia too?

Comorbidity: having insomnia and sleep apnoea together

Josh explains: “There is a condition called COMISA, which stands for comorbid insomnia with sleep apnoea – and there’s thought to be a two-step circular relationship at play here.”¹⁰

1. OSA leads to disrupted sleep with heightened nocturnal arousal (basically waking up more easily during the night), often leading to anxiety around sleeping – a precipitating
2. The patient then sees their opportunities for sleep are reduced, and sleep remains fragmented – so they experience a ‘double whammy’ of less sleep, plus continued poor quality sleep.

The result? “It’s quite often that I see patients with untreated OSA who have an anxiety around sleeping because they know there’s a health risk and they don’t see any benefit from sleeping when they wake in the morning,” says Josh.

Treatment for OSA

There are several treatment options for sleep apnoea – including lifestyle changes or wearing a mandibular advancement device (an oral appliance a bit like a gumshield) at night. Sometimes surgery is recommended, although it’s not usually the first line of treatment as it’s an invasive procedure that doesn’t promise a positive outcome.

The ‘gold standard’ treatment for sleep apnoea is CPAP therapy¹².

CPAP stand for continuous positive airway pressure, because that’s what a CPAP machine delivers. During CPAP therapy, the sleep apnoea patient wears a mask attached to the device. The device sends a steady stream of pressurised air to the mask – breathing in this air while they sleep helps keep the patient’s airways open, preventing apnoeas.

The benefits of CPAP therapy include more daytime energy¹³, a more positive mood¹⁴, clearer mind¹⁴ and – music to the ears of people who also have insomnia – better sleep.

Anxiety around sleep

However, Josh warns that if a patient has gone a long time without treatment for either their insomnia or sleep apnoea, they may have developed some of those perpetuating factors we talked about earlier – such as anxiety around sleep, which could hamper their progress.

“Often in the clinic patients who are new to treatment may feel that wearing a mask is only going to increase their anxiety around sleep,” says Josh. “However, with the right guidance from a qualified professional, they can see dramatic improvements to both elements of their sleeping issues.”

“This is why it can often be important for a patient to seek cognitive behavioural therapy for insomnia (CBT-i) as an adjunct to their CPAP therapy.”

Cognitive behavioural therapy for insomnia (CBT-i)

CBT-i aims to help change the way you think about sleep in general and has been shown to be effective for both chronic and comorbid insomnia^15,16. During structured CBT-i sessions you’ll speak to a trained counsellor, who will help guide you towards a more positive mindset and address any underlying issues that may be stopping you getting enough sleep. They may also show you relaxation techniques. You will usually need to have around four to six sessions to see a difference, and will be set ‘homework’ to do between appointments to boost your progress.

Other treatments for insomnia

While CBT-i is normally the first course of treatment recommended for someone with insomnia, you doctor may also suggest other treatments, depending on your situation. For example they may ask you to try natural remedies or prescribe medications, known as hypnotics. It’s worth noting that most of these types of medicine are for short-term use (for example in cases of jetlag), and you would need to be weaned off any sleep aid medication before starting a course of CBT-i, as no practitioner should be doing CBT-i while a patient is using hypnotic medication.