Recent research suggests that those with stubborn insomnia—who have not responded to a variety of drugs and therapies—may not have insomnia at all.
Another stealthy sleep disorder, obstructive sleep apnea (OSA), may actually be to blame.
What the latest research tells us
Albuquerque sleep researcher Dr. Barry Krakow has long suspected a connection between insomnia and sleep-breathing disorders.
His team at the Sleep and Human Health Institute and Maimonides Sleep Arts & Sciences conducted research to identify why over 1200 chronic insomniacs seemed to be failing their drug therapies.
The Mayo Clinic report of his findings in 2014 showed overwhelming evidence (at 80 to 90 percent of subjects tested) that those insomniacs were actually suffering from undiagnosed sleep apnea.
The patients they studied had been using sleep aids for periods of at least 4 years and had suffered from more than a decade's worth of insomnia.
This was groundbreaking research and Krakow's findings have already influenced the way insomnia is identified, diagnosed, and treated by sleep specialists today.
However, more study is needed to further clarify whether insomnia might also be to blame for creating the proper conditions for the secondary development of sleep apnea, a question researchers have yet to answer.
The problem of diagnosing insomnia
Most sleep physicians rely on a patient's history and subjective reports of sleeplessness to diagnose them with insomnia, unless there are clear indicators in their visit to the doctor's office that suggest a sleep study is in order to rule out other sleep disorders.
Those indicators include, among other things, high blood pressure, obesity, atrial fibrillation, and reports from witnesses describing sleep breathing struggles for the patient.
However, a person who is not overweight, has no sleep partner to witness their nocturnal breathing patterns, and does not have hypertension or cardiac arrhythmias may slip through the cracks and never see the interior of a sleep clinic (or even be asked to take home a sleep apnea test). They may be diagnosed with insomnia when, in fact, they have an occult (hidden) case of sleep apnea or other sleep disorder.
Instead of pursuing treatment for sleep apnea, they may be given medications or prescribed cognitive behavior therapy to manage their sleeplessness. Imagine their dismay, then, when therapy doesn't work and they still have problems with sleep fragmentation all night long.
An additional problem: many sleep aids used to treat insomnia have a negative impact on sleep-disordered breathing. That is to say, those with sleep apnea who take sedatives to fall asleep will further aggravate sleep apnea.
When sleep apnea masquerades as insomnia
When apneas occur, they force the brain to arouse the person from sleep on a recurring basis so that person can consciously breathe to correct deficiencies in blood oxygen that have reached critical mass.
Much of the time, these arousals are not noticed by the person who is sleeping; they show up in sleep studies as shifts from deeper stages of sleep to more shallow sleep—shifts that patients never notice.
In these cases, the person can suffer from deficits in sleep quality every time they bypass deeper stages in sleep architecture due to frequent awakenings.
In addition, when people with sleep apnea do fully awaken in the night, they might find that their heart is pounding, probably due to the reductions in blood oxygen which force a release of stress hormones into the bloodstream to awaken them. This can lead to difficulty returning to sleep, and anxiety over repeated awakenings, which can also amplify the struggle with falling back to sleep.
When to suspect your sleep problem may not be insomnia
There are specific symptoms that point to the possibility that what you and your doctor have thought of as insomnia all this time might actually be a case of sleep apnea.
If you have to rise frequently to use the restroom, you may not have a bladder problem, but an apnea problem. Most insomniacs, after all, don't lose sleep due to trips to the bathroom.
When you arouse from an apnea, it's because your bloodstream has been flooded with stress hormones to wake you up so that you will breathe consciously.
That shift in blood chemistry also increases the kidneys' urine production and stimulates the bladder to report the need to be voided. You feel the need to go, but in truth, you really don't need to, it just feels like you do.
Often, people will resort to unconscious "mouth breathing" as the body attempts to introduce more oxygen during the process of respiration. The outcome is that you'll awaken with a dry mouth, which is not a typical insomnia symptom.
Sore, scratchy throat
If you awaken with a perpetual scratchy throat, it may be the result of loud snoring. The upper airway resistance caused by snoring, upper airway resistance syndrome (UARS), or sleep apnea can lead to forceful intakes of air between obstructions, and this ongoing friction can lead to a sore throat. This isn't a typical concern for someone suffering from insomnia.
The shifts in blood chemistry that occur as the result of sleep apnea cause more than just an oxygen deficit, but an increase in the amount of carbon dioxide in the brain, which you normally expel through exhalation. This buildup creates shifts in the vascular system that ultimately put pressure on the cerebral vascular system, which causes you to wake up with a headache.
Someone who has insomnia may also wake up with a headache due to sleep deprivation. In addition, the lack of sleep caused by insomnia can amplify pain perception; when an insomniac goes to bed with a headache, not sleeping may actually worsen the pain.
This is not usually the case for people with sleep apnea; they don't have a headache all night long, but simply wake up with one.
Taking action to differentiate insomnia from sleep apnea
Most people with insomnia never connect it with other health conditions they might have, nor do they understand how certain medications can make it hard to sleep.
As many as 80 percent of insomniacs are aware they snore or have other sleep breathing issues, and yet they never think that the two could be related.
If you can't fall asleep easily, can't maintain sleep for very long, or wake up frequently all night, you are describing the symptoms common to both insomnia and sleep apnea.
For those with long-lasting insomnia that's resistant to every attempt made to treat it, it might be a good time to reconsider the root cause of your sleeplessness to ensure you shouldn't actually be treating a different problem.
A trip to your primary care physician or sleep specialist is in order. Not getting adequate sleep, or having only poor quality sleep, can negatively impact your quality of life and lead to additional chronic health problems.
Sleep & Human Health Institute