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Steven Y Park, MD  
Male, 47
New York, NY

Specialties: Sleep-breathing disorders

Interests: Running, Baking, origami
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Is Insomnia Really A Sleep-Breathing Disorder?

Feb 09, 2009 - 30 comments
Tags:

Insomnia

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cbt

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Sleep Apnea

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upper airway resistance synd

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sleep breathing



Sleep doctors have always thought of insomnia as a behavioral or stress aggravated issue, and the standard ways of treating this all-too-common condition is to either give sleeping pills or have the patient undergo cognitive behavioral therapy. However, a recent study directed by Dr. Barry Krakow at the Sleep and Human Health Institute is looking at the possibility that insomnia may actually be caused by a sleep-breathing problem, such as obstructive sleep apnea.

If you’ve read my book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, I stated my opinion that in my experience, almost all people with insomnia have narrowed upper air passageways, especially behind the tongue. Some will have undiagnosed sleep apnea, but many will have instead something called upper airway resistance syndrome. This is a variation or precursor to sleep apnea where the length of time of each breathing pause is not long enough to be called an apnea. Because of the multiple pauses in breathing in deep sleep, a low-grade stress response is created which causes the insomniac’s mind to race or think about stress-related issues before going to bed. Their nervous systems are edgy and en garde all the time. No wonder it’s hard to fall asleep, especially if you’ve had a stressful day.

I’ve also experienced multiple instances where treating an underlying sleep-breathing problem also significantly improves insomnia symptoms as well.

You may be asking by now, "why do sleeping pills or cognitive behavioral therapy work?" The older type sleep aids were generally tranquilizers and only helped to numb the nervous system so that you can fall asleep faster. But these medications did nothing to prevent the sleep-breathing pauses. The newer medications don’t have as much of the sedating properties, but it’s very controversial that they even make any significant difference. Although industry supported studies find significant improvements in sleep scores using sleeping pills, non-industry supported studies show that these same sleeping pills only increase total sleep time by only 5-10 minutes.

Cognitive behavioral therapy (CBT) is another underused option that has been shown to work much better than sleeping pills in general. CBT works by re-programming your thinking and behavior about sleep to promote good sleep hygiene and habits.

CBT will work to a significant degree even if you have an underlying sleep-breathing problem because you’re addressing the physiologic stress-aggravting end result of the breathing problems that occur during sleep. Multiple micro-arousals from deep sleep to light sleep due to tongue muscle relaxation can definitely aggravate stress and anxiety problems.

This process also confirms other recent findings that report increased rates of depression and heart disease later in life in people with insomnia earlier on in life.

The main purpose of Dr. Krakow’s study tries to determine what percent of insomniacs have undiagnosed obstructive sleep apnea. Although not part of the study, it would be interesting to perform upper airway endoscopic exams like what I describe, to confirm what I describe in this post.

Here’s my question to all insomniacs: Do you prefer to sleep on your back, side or stomach? If you prefer your side or stomach, there’s your answer.

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by Haddock_Entrap_Propulasion , Feb 10, 2009
Do your ideas regarding the cause of insomnia apply to people ho have it as a -result- of depression?  

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by Aussie_AK, Feb 11, 2009
This is an extreemly interesting question. I have had insomnia problems most of my life. I was born 8 weeks pre-mature and have suffered asthma as a child and depression as an adult. I am currently suffering PND and am having sleep problems.....I also like to sleep on my stomach because I find it hard to fall asleep on my back......I would love to hear more about your thoughts on this topic :)

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by insomniac66, Feb 12, 2009
I have insomnia, if you couldn't tell by the name! I also have sleep apnea...amongst other things.

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by lysah, Feb 12, 2009
my husband has been diagnosed with sleep apnea, but like 90 percent of the population who were given the mask as only treatment he cant stand it and wont wear it. could he have this problem you are talking about. 3 of my 4 kids have had adnoids out and seem to breathe much better at night.. thanks lysah

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by Xaminer, Feb 12, 2009
I appreciate this article.  I have wondered sometimes if my early morning awakening is due more to a breathing problem than a depressive disorder.  I take 75-100 mg. of trazodone at night to help me stay asleep or go back to sleep if I awake & have for years.  Of course I won't wear a mask at night if it is the problem but I may check it out as there is a sleep center fairly close by & would be covered by insurance plan.  I generally sleep on my stomach or side-what does it mean?

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by Xaminer, Feb 12, 2009
I've also been told I snore.  

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by Steven Y Park, MDBlank, Feb 12, 2009
Thanks everyone for your great comments.


Kage-no-Taren,

What I'm suggesting is the possibility that an underlying sleep-breathing disorder is what's causing or aggravating insomnia AND depression. I realize it's a controversial statement, but worth considering based on all the studies that I've seen and written about.

Aussie_AK,

Take a look at some of my other articles, especially the one on upper airway resistance syndrome. I also have much more information on my bog at http://www.doctorstevenpark.com. My book is the most comprehensive source of information on this entire topic.

lysah,

There are other options, but in most cases, there's much more that can be done with CPAP. You just need medical providers that take the time to help you and your husband through the process. Don't give up.

Xaminer,

It's highly likely that you have a sleep-breathing disorder. Anything that relaxes your nervous system, by relaxing your muscles, can make your sleep-breathing problem worse. You will naturally wake up after a while when you stop breathing, but by taking a sedative, you're preventing the arousals, so you can stay longer in an obstructive state, depriving your heart and your brain of more oxygen. You're sleeping on your side/stomach to compensate for your tongue falling back due to gravity, but it's not good enough. Take a look at my other articles on sleep apnea, upper airway resistance syndrome, and anxiety and sleep position.




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by Lexie211, Feb 13, 2009
Hi,

Just last week I found out that I am not sleeping very well, I would suddenly wake up and being frightened out of my sleep and could not go back to sleep after a very long time. I took Dr Chase Nerve food and found out I slept a little better.  Want to know if its my nerves or should I continue to take the Nerve food.

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by Steven Y Park, MDBlank, Feb 13, 2009
Lexie211,

What you describe could be due to a number of different reasons. If you feel like the supplement you mention helps, you can continue using it, but at a certain point, you should stop it to see if the episodes return. My bias it to figure out what's causing it rather than covering it up with any pill.

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by ginger899, Feb 14, 2009
When I wake up in the morning I could always go back to sleep again, no problem. My breathing is deep and regular, and relaxed. Of course I can't because if I did I would sleep to midday! But at night I often find it hard to go to sleep. I tried deep breathing but it doesn't help. It's as if I'm too awake to go to sleep, and changing from one thing to another is difficult, but when I've already been sleeping (ie the morning) it's SO easy to sleep then! Do you think this could be sleep breathing disorder? Or something else?

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by Steven Y Park, MDBlank, Feb 14, 2009
ginger899,

What you describe is classic insomnia. But to know if you truly have the upper airway anatomy is to look inside your throat with a camera. Do you sleep on your back, side or stomach? When years of wake up, are you refreshed?

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by TELLJohnson, Feb 14, 2009
I feel like something blocking on my throat, I have mucus from my throat and nose coming out, and after mucus come out, my throat is very dry and something blocking my throat, what do you think it is? thanks TELL

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by Aussie_AK, Feb 15, 2009
Hi Dr Park,

You are amazing! Thank you for your reply :)

I have looked at your site and read most of your blogs/articles and I am fascinated. I have spoken to my mum who told me that as well as being 8 weeks premi I had sleep apnea as a baby - so there you go!! I often find myself holding my breath, and I am a mouth breather & have a small mouth! I am also prone to panic attacks and have a "worrier" type personality.

I am a fit, 27 year old female on the thin side - like your article suggests, not the typical sleep Apnea profile. I am in the children's fitness industry in Australia - so I am pretty active and exercise regularly. I am also very positive about life - so the depression is purely clinical and I am very aware of my thoughts.

I have heaps of other info about me that may be of use to some of your studies.........  Very strange stuff happened to me after giving birth to my first child that might help link some of your thoughts.....After reading your articles I think you might find it very interesting. Put it this way - no doctors in Australia had experienced these side effects in women after giving birth!

I think what you do is fantastic - keep up the great work! Where can I get a copy of your book in Australia?

Aussie_AK

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by Steven Y Park, MDBlank, Feb 15, 2009
As you'll see from reading my book, my inspiration for writing the book and my entire sleep-breathing paradigm came from my wife's experiences after her first two pregnancies. By knowing this information and taking proactive measures, my wife is doing much better now after the birth of our third child one month ago.

You can order the book through my website—just click on the book cover picture.

I've love to hear more about what happened after your first child.

Thanks for your comments.

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by Steven Y Park, MDBlank, Feb 15, 2009
Aussie_AK,

You can also order through Amazon.com, but one reader in Denmark commented that it took forever, since it was shipped from Australia ;-)

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by uk2, Feb 15, 2009
Hi

I've heard sleep problems are the main cause of fibromyalgia which i have, my rheumy gave me requip to take at night a parkinson med so promote sleep he said if i could get into stage 4 sleep i would feel more refreshed, the body needs deep sleep to restore its muscles and organs and thats why people with fibro have sleep problems i either wake ever 2 hrs, or go to sleep and then at 2 am and stay awake yet i can sleep in the morn not that i do as i dont want to disrupt my sleep pattern but sometimes i have to go back to sleep once my 3 kids go back to school just for 2 hrs or i'd be a wreck!

sam

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by ginger899, Feb 15, 2009
Thanks Dr Park. (No WAY do I want a camera down my throat!)....unless things were very desperate!  I start off sleeping on my back because I can really relax more like that and stretch out. I have a very very low pillow with only neck support, so I lay quite straight. I like that, hate to have my head bent forward! During the night, I change positions and wake up many times on left side. Mostly I feel ok in the morning if I've had 6-9 hours sleep. I just wish I felt the same at bedtime that I feel in the morning (cocooned and sleepy and warm and always ready to sleep more!) I've had another thought.....maybe I'm just lazy???

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by Steven Y Park, MDBlank, Feb 15, 2009
ginger899,

Some people naturally like to sleep on their backs, regardless of their anatomy. Bending your head back will open up your airway automatically. Bending your head forward closes off your airway. This to normal for all humans. You may be interested in my earlier article on laziness and my thoughts on why people may have these thoughts:

http://www.medhelp.org/user_journals/show/43324



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by Aussie_AK, Feb 16, 2009
Hi Dr Park,

OK here is what happened:

After being induced and having a 7.5 hour labour straight after induction, to tell you the truth I found the whole process terrifying and traumatic, I was a total wreck. I had lost 5kg from my pre-pragnancy weight and was just skin and bone.

I was unable to urinate and had to be cathaterised 4 times after the birth. Apparently urinry retention is not common after birth and the nurses had never come accross it before. It made me so sick - it makes you feel like you have the flu, and all shaky (much like mastitis, which I have now had 7 times!).

I was so stressed out I was unable to sleep for 10 days straight (about 2 hours a night with sleeping tablets).

3 weeks after the birth I started to hear a strange sound in my left ear. It was like a generator a low hum that was all comsuming and so loud I went crazy. It really made me so upset and angry. Some nights after I did manage some sleep it would dissapear only to reappear in the afternoon - starting off like a generator - slow to start then speed up over about 1 hour.

This went on for about 3 months - and I really did not think I could cope. I saw an ENT who did not know what it was and said it might be breast feeding and preganacy related?

During this time I also managed to get an anaphalactic reaction to a food I always eat (pasta) so I am not sure if it was an anaphalactic reaction or just something else that was strange!

My body keeps doing weird things - like coming out in bruises all over my legs!

This is happening to someone who is very fit and healthy and eats a nutritious balanced diet!!

Slowly my sleep is improving - and I am trying very hard to get off the sleeping tablets (I only take 1/4 of a normasin if I can't sleep) and last night after reading all your info I slept without anything!! YAY!!!!!

So there you go - strange stuff (especially the ear thing).

Let me know if you can make any sense of this!!

Aussie_AK








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by nrecovery, Feb 16, 2009
hello doctor, one question...i take up to 300mg of trazadone at nite for my sleep problems. is that too much?? it helps. my directions are to only take up to 150mg. that dosnt help. i also take a roserem with the trazadone. but, i still wake up about every hour. and, eventually just get up after only  4and, a half to 5 hours of sleep. thank you.

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by aheneve, Feb 16, 2009
Interesting series of posts.  I have insomnia and have had it as long as I can remember.  Hard to fall asleep, once asleep difficult to wake up.  Occasionally (1-2x a week) wake up startled with a gasp, sometimes wake myself up snoring.  I understand UARS, my Father has this as well and uses a CPAP mask.  There's no way I'll ever use one myself.

So this is interesting, but what is one supposed to do about it?  Wearing a mask is not a solution, its just an annoying treatment for an unsolved problem.  What about having my tonsils or adenoids out?  Would that help?  Is there anyway to incresae the size of the upper respiratory pathways either surgically or by some other means?

Thanks

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by coolheat, Feb 17, 2009
Hi Dr. Park:
I have undergone the sleep study and indeed have severe sleep apnea. I have been using C-PAP for several years. However, I also have what I consider a psychologically based insomnia which originated in a stressful situation several years ago. The situation was resolved, but the insomnia remained. I have tried a variety of remedies for the insomnia, including ambien, lunesta, behavior/relaxation techniques, valerian, melatonin, anti-histamines, and most recently, 10 mg elavil. So far, the elavil is the most successful, as I can actually get back to sleep if I wake up to use the bathroom. I am actually sleeping pretty well. The others methods I tried varied from partially effective: ambien; to outright useless: behavioral techniques, relaxation, and "natural" stuff like valerian. By the way, all this insomnia took place before and DURING my use of C-PAP.
In addition, I have moderate to severe chronic persistent NON-allergic asthma, with frequent bouts of bacterial bronchitis. Most of the time, it does not effect my sleeping, but during an exacerbation I may have to use albuterol (a stimulent) and other nebbed bronchiodialtors (stimulents), as well as large does of prednisone and/or solu-medrol IV (in ER or hosp). During these flare-ups, I can kiss sleep goodbye! In a fight between elavil and prednisone...the prednisone wins (and NO sleep).
Thanks!
coolheat
www.myspace.com/gaylemyrnamuzak

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by cobainsdomain, Feb 18, 2009
There is also a recent study i learned of in college, however i cannot for the life of me remember who by.  It basically is saying that before artificial light, our modern sleep schedule didn't exist.

Basically that for some people it was normal to wake up randomly throughout the night, for work, or because of sounds or surroundings.  They believe that not everyone is mean't for a full nights sleep, that some people are wired for short periods of sleep followed by periods of being awake in between.

It was actually extremely interesting, and i think everyone should read a little into it...

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by aheneve, Feb 18, 2009
Hmm.  After re-reading my post with some time in between, I might want to clarify it.  The downside of UARS and sleep apnia is increased risk of heart disease, excess tiredness compared to others, and waking up startled from a personal health perspective.  Socially, the problem is snoring loud or otherwise.

The only solutions I see are C-PAP and I once heard about a shirt with a tennis ball sewed into the back so you will always sleep on your side.  Given these alternatives, I'll take the increased risk of heart disease (who wants to live forever anyway) and the snoring is someone else's problem. If my girlfriend or someone else complains, if camping or on travel, I just tell them that if they'd just breathe with me, they'd be asleep in no time.  :)

So that leaves me wondering if there is another more acceptible solution that would provide a "solution" to the problem instead of things that would just be more annoying than the problem in the first place.  With C-PAP I would not sleep AT ALL and I know I'd take that shirt off and throw it across the room.

[To answer the Dr.s initial question, I fall asleep on my back and then switch to my side during the night and basically toss and turn usually ending up on my back when I wake up.]

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by CareerLady, Mar 04, 2009
I feel like I sleep a lot better on my stomach. It's hard on my back to do that, though, so I spend most of the first part of the night on either side. When I fall asleep on my back, I inevitably wake up very quickly, almost as soon as I fall asleep.

I have been diagnosed with a sleep-breathing disorder. With apnea= 1, hypopnea = 2, and RERA = 148 during 6 hours, I think I am living proof that UARS is a distinct disorder from apnea. Thanks for all your support, Dr. Park.

My doctors don't seem to fully understand (I am on #3) but I am working away on treatment and learning. I am using CPAPas much of the night as I possibly can, not having my success, and trying to figure out what's next.

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by Steven Y Park, MDBlank, Mar 04, 2009
aheneve,

Ultimately, sleep apnea and UARS are due to anatomic jaw narrowing. Obesity is the end result. So you can be thin and not even snore and have sleep apnea. Although all the formal treatment options for sleep apnea are not too appealing, you shouldn't reject them even without trying them. It also sounds like you haven't been tested for it either. I've had many patients that were very reluctant, but ended up liking CPAP.

Ultimately, it's your life, but sooner or later it will affect someone else. Whether it affects a spouse or children, or killing someone by dozing at the wheel (it's been shown that untreated sleep apnea diminished your reaction times to levels worse than being legally drunk), you have a responsibility to others. Plus your snoring will sleep deprive your bedpartner, potentially leading to relationship issues.

There are alternative besides CPAP, but not until you first get diagnosed and you actually try CPAP if you have it. The tennis ball option rarely works. Another option if you have the right anatomy is a dental device that pulls your lower jaw forward while you sleep. The last option is surgery. This is a huge and controversial topic in itself, but if done properly for the right reasons in the right areas of the upper airway, it does work. Take a look at my articles on sleep apnea and UARS.


CareerLady,

Treating UARS is a challenge, since various devices either on the face or inside the mouth can CAUSE more arousals than they help. Rarely, some people respond to CPAP, but in general, it's very unusual because of your hypersensitive nervous system. Dental devices that pull the lower jaw forward may be another good option for some people. If you want to try an inexpensive mouth guard that I use as a screening device, Somnoguard or Puresleep are two options. If you respond to either of these, you can then invest in the more formal, adjustable and comfortable dental devices. Surgery is also an option, but one of last resort.  

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by Tsukiakage, Mar 26, 2009
Is it possible that this could cause a person to wake up randomly in the night, almost every night after 5 hours of sleep? It's almost like clockwork for me. It's been going on for 2 weeks now and I really wish that I could get back on a normal sleep schedule.

It's actually causing me to have anxiety attacks - which is something I have never suffered from before.

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by Steven Y Park, MDBlank, Mar 26, 2009
Tsukiakage,

You're probably entering a deeper stage of sleep at the 5 hour mark. Are you dreaming when you wake up? One sleep cycle is about 90 to 120 minutes, so after 2-3 cycles, you'll start to enter longer periods of REM sleep, when your muscles will relax the most, and that's when you're most likely to stop breathing and wake up suddenly. These episodes can lead to what may seem like panic or anxiety attacks, as well as to heighten your nervous system, and making you more tired. Something must have changed with your life for you to have this new problem (increased weight, stress, change in eating schedule, or nasal congestion, etc.)

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by Mercman1292, May 08, 2009
Great info Dr. Park!  2 weeks ago I started waking up after dreaming I couldn't breathe.  This would typically occur 2 hrs after falling asleep.  Then, like clock work, every 2 hrs after that, I would wake up with the same sensation.  I am 39 years old and have been a sound sleeper for 39 years.  I loved sleep.  Now, I get 2 hr wake up calls!  I suspect it is allergy related because pollen is off the charts here & my sinus' feel slight pressure and I have post nasal drip going on.  It freaked me out the first time it happended and I ended up with a panic attack (which I've never had before) which made it worse.  Now that I have figured out what is going on, I can't seem to shake it.  At least I don't have the panic attacks any more.   I still wake up every 2 hrs.  When I wake up, I feel like I'm in a fog and there is a tingly sensation in my skin and feels like blood rushing through my head.  Then I calm myself and fall back asleep to go thru it again in 2 hrs.  I wake up with very dry nasal passages after about 5-6 hrs of this.  Then I'm up for the day.  I want to get back to normal so any help would be appreciated.  

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by jawpainhelp, Jun 08, 2011
Two weeks ago, I heard about a doctor who treats sleep and breathing disorders, craniofacial pain and tmj disorders. His name is Elliott J. Alpher. Dr. Alpher has been treating craniofacial pain disorders with conservative, non-invasive methods for over 30 years.

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