Today Barry Krakow MD pushed this question in an article at Baystreet. From the article:
“Researchers at the Sleep and Human Health Institute and Maimonides Sleep Arts and Sciences, Ltd investigated drug failure in 1210 chronic insomnia patients and found 91% of those who completed sleep studies actually suffered from previously undiagnosed sleep apnea, a critical factor likely to be aggravating their insomnia.”
How does this happen?
Insomniacs often find many reasons to explain their sleep problems. Doctors can be misdirected by their insomniac patients’ cues as well.
Generally, many patients believe they can’t sleep because of stress and anxiety, or pain, or because they have to use the bathroom all night. And while these are all good indications that insomnia is present, there are a number of other things to consider.
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- Insomnia is often the sign of another underlying condition. It isn’t often considered a stand-alone diagnosis (though it can be).
- When patients are getting out of bed frequently at night, it might not be because they have to use the restroom excessively. Sleep apnea forces arousal from sleep, and the body responds by sending out stress hormones, which in turn stimulate the bladder, leaving the woken person to believe they are using the restroom because their bladder is full. However, it isn’t always full, but it could leave someone feeling that way because of the stress response following the apnea events they aren’t aware they’re having. This can lead to the bathroom urgency they experience, not necessarily caused by a full bladder itself.
- People really do not know how much they actually sleep at night. As a sleep technologist, I can tell you first hand that the vast majority of my patients sleep most of the night and yet they leave the lab feeling like they didn’t sleep at all. Sleep state misperception, otherwise known as paradoxical insomnia, is a subjective sense of never having slept despite objective evidence to the contrary.
From Psychology Today: “[S]leep studies have revealed that people sometimes have great difficulty accurately estimating how long it takes them to fall asleep and just how long they are awake during the night. People who misperceive the sleep state they are in just aren’t good at making these estimates. This is most likely due to high levels of arousal that keep the brain more active even during sleep and make judgments of wakefulness versus sleep difficult.”
- Patients using multiple kinds of medications for multiple health issue, including for sleep, may still feel they can’t sleep and, ultimately, the interactions of all these medications may truly be to blame. However, doctors aren’t always in the know about what’s in their patients’ medicine cabinets, or they may not be aware of the side effects of additional nutraceuticals, vitamins or supplements their patients are taking because patients may not tell their doctors about these added treatments.
Also important to consider: the most popular approach to treating insomnia is pharmaceutical, which might be part of the problem. Many prescribed sleep aids can actually worsen or lead to apnea. The good news is that some, though not all, sleep health professionals redirect insomnia patients to cognitive behavior therapists instead of, or in conjunction with, prescription sleep aids to see whether behavioral approaches might be more long-lasting and healthy for them. This is one way to avoid adding the complication of apnea.
- Patients with chronic disease may often blame all of their symptoms on their single diagnosis (“it’s the MS,” or “I have insomnia because of my chemo side effects,” for instance). Again, this might be true, but it’s just as likely that patients will have multiple conditions, including the presence of restless legs or sleep-disordered breathing, in tandem with other health problems. Doctors may accept this reasoning without looking into the problem further as they aren’t often well-versed in sleep health (on average, MDs spend about 1 hour of their entire medical school training learning about sleep).
If you factor in these pieces of the puzzle, the broader picture of insomnia as a primary condition becomes a little more murky.
Typically, complaints of insomnia do not automatically send patients to sleep labs for overnight studies. However, with the growing number of patients at higher risk for sleep apnea (due to obesity, heart disease, diabetes, pulmonary disease or hypertension), it probably makes better sense to have an overnight sleep study to rule out apnea before tossing out insomnia as merely behavioral in origin. It is possible, of course, to have both, and for different reasons.
It’s important to note that patients who are at higher risk for sleep apnea don’t generally qualify for overnight home studies because of the general complexity of their health.
If you have insomnia, please open up this discussion with your doctor. The best way to isolate the root cause of any health problem is to sit down and work as a team, and that means insomniacs need to ask for help and demand answers, and doctors need to investigate all the possibilities until the root causes are discovered, and then initiate treatment.
This will mean more tests, more questions, and closer looks at all medications including over-the-counter supplements, but it will also mean getting to the root of your insomnia so you can best treat it.