Under such circumstances, the two conditions appear to interact. Sleep medicine professionals have long recognized that chronic insomnia and OSA often occur in the same individual. The reasons for chronic insomnia and OSA, disparate sleep disorders, sharing the same health consequences remain unclear. Although the pathophysiology of OSA is believed to differ from that of chronic insomnia, they share the health consequences of hypersomnolence and fatigue, hypertension and cardiovascular disease, impaired glucose tolerance and diabetes, and anxiety and depression. Its prevalence, like that of chronic insomnia, varies with the source, but it may also be as high as 1 in 3 adults. It is widely hypothesized to be a disorder of sleep fragmentation by recurrent arousals and oxygen desaturation resulting from obstructed breathing (known as the sleep fragmentation paradigm of OSA). Obstructive sleep apnea (OSA) is recognized to be a disorder of inspiratory fluttering (hypopnea, snoring, and silent inspiratory airflow limitation) or collapse with complete occlusion of the pharyngeal airway (obstructive apnea) during sleep. Because stress is believed to have a pathophysiologic role in chronic insomnia, it is not surprising that patients with chronic insomnia experience the health consequences of chronic stress, including hypersomnolence and fatigue, hypertension and cardiovascular disease, impaired glucose tolerance and diabetes, and anxiety and depression. The prevalence of chronic insomnia varies with the source, but it may affect 1 in 3 adults. It is widely hypothesized to be a disorder of physiologic hyperarousal (also termed somatic arousal, the term we use throughout this report), a state of chronic stress characterized by increased sympathetic nervous system (SNS) activity.
Therefore, when chronic insomnia and obstructive sleep apnea occur in one individual, aggressive treatment of obstructive sleep apnea may lead to a reduction in chronic stress that causes the patient’s chronic insomnia to remit.Ĭhronic insomnia is a state of delayed sleep onset and poor sleep maintenance lasting more than 6 months. Among patients with obstructive sleep apnea, the stress response is directed at inspiratory airflow limitation during sleep (hypopnea, snoring, and inaudible fluttering of the throat). These three cases lend support to the hypothesis that chronic insomnia and obstructive sleep apnea share a pathophysiology of chronic stress. The patient with bipolar disorder also experienced complete remission of his symptoms of depression during the 1 year he was followed postoperatively. All three patients subsequently underwent maxillomandibular advancement to treat mild obstructive sleep apnea and experienced prolonged, complete resolution of somatic arousal, chronic insomnia, and fatigue. None of the patients received treatment for insomnia. One patient experienced a modest improvement in her somatic arousal, insomnia severity, and fatigue with autotitrating nasal continuous positive airway pressure, but the other two did not tolerate nasal continuous positive airway pressure. Polysomnography revealed that each patient also had mild obstructive sleep apnea, despite only one snoring audibly. Our three Caucasians patients each presented with severe, chronic insomnia associated with somatic arousal and fatigue occurring either alone, in association with bipolar disorder, or with temporomandibular joint syndrome. This report of three cases describes patients with both chronic insomnia and obstructive sleep apnea in whom the chronic insomnia remitted with no specific treatment following treatment of obstructive sleep apnea with maxillomandibular advancement. Although the two disorders seem different, they predispose to the same long-term, stress-related illnesses, and when they occur in the same individual, each affects the other’s response to treatment they interact. Obstructive sleep apnea is thought to result from obstructive respiratory events causing arousals, sleep fragmentation, and recurrent oxygen desaturation. Chronic insomnia is thought to result from stress-related physiologic hyperarousal ( somatic arousal) that makes it difficult for an individual to fall or stay asleep. Chronic insomnia and obstructive sleep apnea are both common sleep disorders.
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