Insomniacs wake up and go from zero to 60 in about two seconds. Not only are they wide awake, but they may suffer racing thoughts, heart palpitations, anxiety, stress worries, all because they’ve been jarred out of their sleep to being fully alert.
Normally we gradually ascend from slumber into waking consciousness in the morning with or without coffee.
So why would you suddenly wake up at night unless something was waking you up?
This clue would have explained insomnia, but was ignored for a long time.
Research does show that insomniacs lineup the usual list of suspects to explain awakenings: anxiety, stress, worries, racing thoughts, but even insomniacs know they are asleep before they wake up.
So they don’t know with certainty, why they’re waking up and they remain perplexed about being fully alert in the middle of the night.
We researched insomniacs in the sleep lab and monitored them before, during and after these awakenings. And the results were breathtaking.
Not only did they wake up more times than normal sleepers, but they suffered hundreds of many awakenings, what we call arousals. They were fracturing their sleep and destroying their sleep quality.
And if you’re ready for snooze flash number two: 90% of their awakenings and arousals were caused by… (please take a deep breath)
That’s what they didn’t do. Their breathing was compromised and obstructed because they suffered from obstructive sleep apnea. The same condition that fueled my insomnia 20 years ago.
On this graphic, you will see the three main breathing events of sleep apnea:
At the top is normal breathing: smooth, rounded, curves up and down, suggesting breathing in and out.
At the bottom is the apnea – a flat line, complete suffocation as your throat collapses. Obviously anyone would awaken from that blockage.
Next are the hypopneas – a 50% reduction.
And then the flow limitation – a 25% reduction.
All of these breathing events can awaken you. Insomniacs have more of the moderate type.
So perhaps you’re asking would a 25% reduction in your breathing wake you up?
Well, let’s try this experiment. Go ahead, put your hands out in front of you. Just take a moment. Now bring them up to your throat and start choking yourself about 25…
Okay. You get the picture.
Breathing is good, Not breathing is life threatening. Which explains where all the skepticism comes about this theory, because how could you possibly wake up all night long from a breathing problem and not know about it?
Well, consider the case of severe sleep apnea. They suffer hundreds of suffocations all night long, complete loss of their breathing.
When do they seek help at a sleep center?
Only after someone in their bedroom freaks out, watching and listening to them not breathe.
And the afterwards, do they seek help a few months later? No.
How about a few years later? No, only after suffering a life threatening disorder for about a decade, might they seek help.
So if the worst case doesn’t get it, how would insomniacs detect the problem when they only suffer this more moderate breathing disruption that still wakes them up?
This recognition gap caused us to delay our understanding of the link between insomnia and sleep breathing problems.
Now we comprehend that so many insomniacs suffered two disorders in one. The psychological side is easy to see: you’re awake, but the physiological side is hidden from you because you are asleep.
This radical paradigm shift in knowledge demands a new term to designate the complexity of this problem.
So we call it complex insomnia, which indicates the need for in-depth, physiological testing, an overnight sleep study to identify and diagnose what’s waking you up.
For any diehard skeptics still out there, we’ve got one final and astonishing piece to the puzzle.
Remember insomniacs make trips to the bathroom and complain about it. That’s called nocturia.
Snooze flash number three: Who would have thought it sleep apnea causes nocturia.
Sleep apnea pushes excess blood flow into your heart all night long. The heart responds by releasing a natural diuretic, making the kidneys work overtime throughout the night.
So sleep apnea causes insomnia and nocturia. Actually a very nice two for one deal when it comes to treatment.
There are three levels of therapy to treat sleep breathing.
First, focus on nasal breathing, nasal saline rinses, neti pot washes, prescription nasal sprays will eradicate chronic congestion.
Last, we strongly recommend nasal strips because we studied insomniacs with moderate sleep breathing symptoms. And 75% of them reported a decrease in insomnia just by using the nasal strip on a nightly basis.
Next, oral mandibular advancement devices or oral appliance therapy. Like the type provided to me by Dr. Meade.
These are becoming first-line therapy. They gently anchor onto your dental arches and thrust the jaw forward, opening the airway permitting more air through and eradicating the majority of your breathing events.
Last is PAP therapy – Positive Airway Pressure, the gold standard. Most know it as CPAP. The C stands for continuous or constant pressure breathing in and breathing out. And that’s the problem.
You probably know someone who’s failed CPAP because they couldn’t tolerate breathing out against that constant pressure.
Mental health patients and insomnia patients can’t tolerate CPAP. They develop panic attacks, claustrophobia, and even traumatizing experiences so harmful to them, they will drop out of care for a few years just after brief exposure to CPAP.
Unfortunately, some insurance carriers and even some sleep centers do not recognize these side effects and instead blame patients for not using CPAP.
Fortunately, technology has found a better way. In 2005, we switched all of our patients over to bi-level devices, dual pressure: high-pressure when you breathe in and low pressure when you breathe out.
This matches your natural breathing pattern. They’re even advanced bi- level devices that monitor your breathing and adjust pressures all night long.
Last, sleep technology has expanded with numerous masks that can fit into your nose, over your nose or as full face masks. And there are mask liners that enhance comfort.